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Allwood RP, Papadakis M, Androulakis E. Myocardial Fibrosis in Young and Veteran Athletes: Evidence from a Systematic Review of the Current Literature. J Clin Med 2024; 13:4536. [PMID: 39124802 PMCID: PMC11313657 DOI: 10.3390/jcm13154536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/29/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Exercise is associated with several cardiac adaptations that can enhance one's cardiac output and allow one to sustain a higher level of oxygen demand for prolonged periods. However, adverse cardiac remodelling, such as myocardial fibrosis, has been identified in athletes engaging in long-term endurance exercise. Cardiac magnetic resonance (CMR) imaging is considered the noninvasive gold standard for its detection and quantification. This review seeks to highlight factors that contribute to the development of myocardial fibrosis in athletes and provide insights into the assessment and interpretation of myocardial fibrosis in athletes. Methods: A literature search was performed using the PubMed/Medline database and Google Scholar for publications that assessed myocardial fibrosis in athletes using CMR. Results: A total of 21 studies involving 1642 endurance athletes were included in the analysis, and myocardial fibrosis was found in 378 of 1595 athletes. A higher prevalence was seen in athletes with cardiac remodelling compared to control subjects (23.7 vs. 3.3%, p < 0.001). Similarly, we found that young endurance athletes had a significantly higher prevalence than veteran athletes (27.7 vs. 19.9%, p < 0.001), while male and female athletes were similar (19.7 vs. 16.4%, p = 0.207). Major myocardial fibrosis (nonischaemic and ischaemic patterns) was predominately observed in veteran athletes, particularly in males and infrequently in young athletes. The right ventricular insertion point was the most common fibrosis location, occurring in the majority of female (96%) and young athletes (84%). Myocardial native T1 values were significantly lower in athletes at 1.5 T (p < 0.001) and 3 T (p = 0.004), although they had similar extracellular volume values to those of control groups. Conclusions: The development of myocardial fibrosis in athletes appears to be a multifactorial process, with genetics, hormones, the exercise dose, and an adverse cardiovascular risk profile playing key roles. Major myocardial fibrosis is not a benign finding and warrants a comprehensive evaluation and follow-up regarding potential cardiac disease.
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Affiliation(s)
- Richard P. Allwood
- Sports Cardiology Department, Baker Heart and Diabetes Institute, Melbourne 3004, Australia
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St George’s, University of London, London SW17 0RE, UK;
| | - Emmanuel Androulakis
- Cardiovascular Clinical Academic Group, St George’s, University of London, London SW17 0RE, UK;
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2
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Fernández-Friera L, García-Alvarez A, Oliva B, García-Lunar I, García I, Moreno-Arciniegas A, Gómez-Talavera S, Pérez-Herreras C, Sánchez-González J, de Vega VM, Rossello X, Bueno H, Fernández-Ortiz A, Ibañez B, Sanz J, Fuster V. Association between subclinical atherosclerosis burden and unrecognized myocardial infarction detected by cardiac magnetic resonance in middle-aged low-risk adults. Eur Heart J Cardiovasc Imaging 2024; 25:968-975. [PMID: 38426763 PMCID: PMC11210973 DOI: 10.1093/ehjci/jeae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/13/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
AIMS Evidence on the association between subclinical atherosclerosis (SA) and cardiovascular (CV) events in low-risk populations is scant. To study the association between SA burden and an ischaemic scar (IS), identified by cardiac magnetic resonance (CMR), as a surrogate of CV endpoint, in a low-risk population. METHODS AND RESULTS A cohort of 712 asymptomatic middle-aged individuals from the Progression of Early SA (PESA-CNIC-Santander) study (median age 51 years, 84% male, median SCORE2 3.37) were evaluated on enrolment and at 3-year follow-up with 2D/3D vascular ultrasound (VUS) and coronary artery calcification scoring (CACS). A cardiac magnetic study (CMR) was subsequently performed and IS defined as the presence of subendocardial or transmural late gadolinium enhancement (LGE). On CMR, 132 (19.1%) participants had positive LGE, and IS was identified in 20 (2.9%) participants. Individuals with IS had significantly higher SCORE2 at baseline and higher CACS and peripheral SA burden (number of plaques by 2DVUS and plaque volume by 3DVUS) at both SA evaluations. High CACS and peripheral SA (number of plaques) burden were independently associated with the presence of IS, after adjusting for SCORE2 [OR for 3rd tertile, 8.31; 95% confidence interval (CI) 2.85-24.2; P < 0.001; and 2.77; 95% CI, 1.02-7.51; P = 0.045, respectively] and provided significant incremental diagnostic value over SCORE2. CONCLUSION In a low-risk middle-aged population, SA burden (CAC and peripheral plaques) was independently associated with a higher prevalence of IS identified by CMR. These findings reinforce the value of SA evaluation to early implement preventive measures. CLINICAL TRIAL REGISTRATION Progression of Early Subclinical Atherosclerosis (PESA) Study Identifier: NCT01410318.
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Affiliation(s)
- Leticia Fernández-Friera
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- HM CIEC MADRID (Centro Integral de Enfermedades Cardiovasculares), Hospital Universitario HM Monteprincipe, HM Hospitales, Av. de Montepríncipe, 25, 28660 Boadilla del Monte, Madrid, Spain
- CIBERCV, Madrid, Spain
- Universidad Camilo Jose Cela, Castillo de Alarcón, 49, 28692 Villafranca del Castillo, Madrid, Spain
| | - Ana García-Alvarez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- CIBERCV, Madrid, Spain
- Cardiology Department, Hospital Clinic Barcelona-IDIBAPS. Universitat de Barcelona, Barcelona, Spain
| | - Belen Oliva
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
| | - Inés García-Lunar
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- CIBERCV, Madrid, Spain
- Cardiology Department, Hospital Universitario La Moraleja, Madrid, Spain
| | - Iris García
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
| | - Andrea Moreno-Arciniegas
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- Cardiology Department, IIS-Hospital Universitario Fundación Jiménez Díaz, Av. de los Reyes Católicos 2, 28040 Madrid, Spain
| | - Sandra Gómez-Talavera
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- Cardiology Department, IIS-Hospital Universitario Fundación Jiménez Díaz, Av. de los Reyes Católicos 2, 28040 Madrid, Spain
| | | | | | | | - Xavier Rossello
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- Cardiology Department, Hospital Universitari Son Espases-IDISBA, Palma de Mallorca, Spain
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- CIBERCV, Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, and i+12 Research Institute, Madrid, Spain
| | - Antonio Fernández-Ortiz
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- CIBERCV, Madrid, Spain
- Cardiology Department, Hospital Clínico San Carlos, Universidad Complutense, IdISSC, Madrid, Spain
| | - Borja Ibañez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- CIBERCV, Madrid, Spain
- Cardiology Department, IIS-Hospital Universitario Fundación Jiménez Díaz, Av. de los Reyes Católicos 2, 28040 Madrid, Spain
| | - Javier Sanz
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- Mount Sinai Fuster Heart Hospital, New York, NY, USA
| | - Valentín Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro 3, 28029, Madrid, Spain
- Mount Sinai Fuster Heart Hospital, New York, NY, USA
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3
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Cavus E, Schneider JN, di Carluccio E, Ziegler A, Haack A, Ojeda F, Chevalier C, Jahnke C, Riedl KA, Radunski UK, Twerenbold R, Kirchhof P, Blankenberg S, Adam G, Tahir E, Lund GK, Muellerleile K. Unrecognized myocardial scar by late-gadolinium-enhancement cardiovascular magnetic resonance: Insights from the population-based Hamburg City Health Study. J Cardiovasc Magn Reson 2024; 26:101008. [PMID: 38341145 PMCID: PMC10944257 DOI: 10.1016/j.jocmr.2024.101008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/19/2023] [Accepted: 02/03/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The presence of myocardial scar is associated with poor prognosis in several underlying diseases. Late-gadolinium-enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging reveals clinically silent "unrecognized myocardial scar" (UMS), but the etiology of UMS often remains unclear. This population-based CMR study evaluated prevalence, localization, patterns, and risk factors of UMS. METHODS The study population consisted of 1064 consecutive Hamburg City Health Study participants without a history of coronary heart disease or myocarditis. UMS was assessed by standard-phase-sensitive-inversion-recovery LGE CMR. RESULTS Median age was 66 [quartiles 59, 71] years and 37% (388/1064) were females. UMS was detected in 244 (23%) participants. Twenty-five participants (10%) had ischemic, and 217 participants (89%) had non-ischemic scar patterns, predominantly involving the basal inferolateral left-ventricular (LV) myocardium (75%). Two participants (1%) had coincident ischemic and non-ischemic scar. The presence of any UMS was independently associated with LV ejection fraction (odds ratios (OR) per standard deviation (SD) 0.77 (confidence interval (CI) 0.65-0.90), p = 0.002) and LV mass (OR per SD 1.54 (CI 1.31-1.82), p < 0.001). Ischemic UMS was independently associated with LV ejection fraction (OR per SD 0.58 (CI 0.39-0.86), p = 0.007), LV mass (OR per SD 1.74 (CI 1.25-2.45), p = 0.001), and diabetes (OR 4.91 (CI 1.66-13.03), p = 0.002). Non-ischemic UMS was only independently associated with LV mass (OR per SD 1.44 (CI 1.24-1.69), p < 0.001). CONCLUSION UMS, in particular with a non-ischemic pattern, is frequent in individuals without known cardiac disease and predominantly involves the basal inferolateral LV myocardium. Presence of UMS is independently associated with a lower LVEF, a higher LV mass, and a history of diabetes.
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Affiliation(s)
- Ersin Cavus
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany, Hamburg, Germany.
| | - Jan N Schneider
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Eleonora di Carluccio
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Cardio-Care, Medizincampus Davos, Davos, Switzerland
| | - Andreas Ziegler
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Cardio-Care, Medizincampus Davos, Davos, Switzerland; School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Alena Haack
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Celeste Chevalier
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Charlotte Jahnke
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Katharina A Riedl
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany, Hamburg, Germany
| | - Ulf K Radunski
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany, Hamburg, Germany; University Center of Cardiovascular Science, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Enver Tahir
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Gunnar K Lund
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Kai Muellerleile
- Department of Cardiology, University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany, Hamburg, Germany
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4
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Kawasaki NK, Suhara T, Komai K, Shimada BK, Yorichika N, Kobayashi M, Baba Y, Higa JK, Matsui T. The role of ferroptosis in cell-to-cell propagation of cell death initiated from focal injury in cardiomyocytes. Life Sci 2023; 332:122113. [PMID: 37739163 PMCID: PMC10591893 DOI: 10.1016/j.lfs.2023.122113] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Abstract
AIMS Ferroptosis has grown in importance as a key factor in ischemia-reperfusion (I/R) injury. This study explores the mechanism underlying fibrotic scarring extending along myofibers in cardiac ischemic injury and demonstrates the integral role of ferroptosis in causing a unique cell death pattern linked to I/R injury. MAIN METHODS Cadaveric hearts from individuals who had ischemic injury were examined by histological assays. We created a novel model of inducing cell death in H9c2 cells, and used it to demonstrate ferroptotic cell death extending in a cell-to-cell manner. Ex vivo Langendorff-perfused hearts were used alongside the model to replicate cell death extension along myofibers while also demonstrating protective effects of a ferroptosis inhibitor, ferrostatin-1 (Fer-1). KEY FINDINGS Human hearts from individuals who had I/R injury demonstrated scarring along myofibers that was consistent with mouse models, suggesting that cell death extended from cell-to-cell. Treatment with Ras-selective lethal 3 (RSL3), a ferroptosis inducer, and exposure to excess iron exacerbated cell death propagation in in vitro models, and inhibition of ferroptosis by Fer-1 blunted this effect in both settings. In ex vivo models, Fer-1 was sufficient to reduce cell death along the myofibers caused by external injury. SIGNIFICANCE The unique I/R injury-induced pattern of cell death along myofibers requires novel injury models that mimic this phenomenon, thus we established new methods to replicate it. Ferroptosis is important in propagating injury between cells and better understanding this mechanism may lead to therapeutic responses that limit I/R injury.
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Affiliation(s)
- Nicholas K Kawasaki
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA
| | - Tomohiro Suhara
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA; Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Kyoko Komai
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA; Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan
| | - Briana K Shimada
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA
| | - Naaiko Yorichika
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA
| | - Motoi Kobayashi
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA
| | - Yuichi Baba
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA; Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
| | - Jason K Higa
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA
| | - Takashi Matsui
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoa, HI, USA.
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5
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Qiao J, Zhao P, Lu J, Huang L, Ma X, Zhou X, Xia L. Cardiac involvement in patients 1 year after recovery from moderate and severe COVID-19 infections. Front Cardiovasc Med 2022; 9:1009637. [PMID: 36386376 PMCID: PMC9646443 DOI: 10.3389/fcvm.2022.1009637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background Some patients suffered persistent cardiac symptoms after hospital discharge following COVID-19 infection, including chest tightness, chest pain, and palpitation. However, the cardiac involvement in these patients remains unknown. The purpose of this study was to investigate the effect of COVID-19 infection on the cardiovascular system after 1 year of recovery in patients hospitalized with persistent cardiac symptoms. Materials and methods In this prospective observational study, a total of 32 patients who had COVID-19 (11 diagnosed as severe COVID-19 and 21 as moderate) with persistent cardiac symptoms after hospital discharge were enrolled. Contrast-enhanced cardiovascular magnetic resonance (CMR) imaging was performed on all patients. Comparisons were made with age- and sex-matched healthy controls (n = 13), and age-, sex- and risk factor-matched controls (n = 21). Further analysis was made between the severe and moderate COVID-19 cohorts. Results The mean time interval between acute COVID-19 infection and CMR was 462 ± 18 days. Patients recovered from COVID-19 had reduced left ventricular ejection fraction (LVEF) (p = 0.003) and increased extracellular volumes (ECVs) (p = 0.023) compared with healthy controls. Focal late gadolinium enhancement (LGE) was found in 22 (68.8%) patients, mainly distributed linearly in the septal mid-wall or patchily in RV insertion point. The LGE extent in patients with severe COVID-19 was higher than that in patients with moderate COVID-19 (p = 0.009). Conclusion This 1-year follow-up study revealed that patients with persistent cardiac symptoms, after recovering from COVID-19, had decreased cardiac function and increased ECV compared with healthy controls. Patients with COVID-19 predominately had a LGE pattern of septal mid-wall or RV insertion point. Patients with severe COVID-19 had greater LGE extent than patients with moderate COVID-19.
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Affiliation(s)
- Jinhan Qiao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peijun Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianyao Lu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Huang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoling Ma
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyue Zhou
- MR Collaboration, Siemens Healthineers Ltd., Shanghai, China
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Liming Xia,
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Litmanovich D, Hurwitz Koweek LM, Ghoshhajra BB, Agarwal PP, Bourque JM, Brown RKJ, Davis AM, Fuss C, Johri AM, Kligerman SJ, Malik SB, Maroules CD, Meyersohn NM, Vasu S, Villines TC, Abbara S. ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease: 2021 Update. J Am Coll Radiol 2022; 19:S1-S18. [PMID: 35550795 DOI: 10.1016/j.jacr.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Management of patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD) relies heavily on imaging for determining or excluding presence and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions, as well as course of management and long-term prognosis. In patients with no known ischemic heart disease, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing and presence of myocardial ischemia. In patients with known ischemic heart disease, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. This document summarizes the recent growing body of evidence on various imaging tests and makes recommendations for imaging based on the available data and expert opinion. This document is focused on epicardial CAD and does not discuss the microvascular disease as the cause for CAD. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Diana Litmanovich
- Harvard Medical School, Boston, Massachusetts; and Chief, Cardiothoracic imaging Section, Beth Israel Deaconess Medical Center.
| | - Lynne M Hurwitz Koweek
- Panel Chair, Duke University Medical Center, Durham, North Carolina; Panel Chair ACR AUG committee
| | - Brian B Ghoshhajra
- Panel Vice-Chair, Division Chief, Cardiovascular Imaging, Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Prachi P Agarwal
- Division Director of Cardiothoracic Radiology and Co-Director of Congenital Cardiovascular MR Imaging, University of Michigan, Ann Arbor, Michigan
| | - Jamieson M Bourque
- Medical Director of Nuclear Cardiology and the Stress Laboratory, University of Virginia Health System, Charlottesville, Virginia; Nuclear cardiology expert
| | - Richard K J Brown
- University of Michigan Health System, Ann Arbor, Michigan; and Vice Chair of Clinical Operations, Department of Radiology and Imaging Sciences, University of Utah
| | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois; American College of Physicians; and Associate Vice-Chair for Quality, Department of Medicine, University of Chicago
| | - Cristina Fuss
- Oregon Health & Science University, Portland, Oregon; SCCT Member of the Board; Section Chief Cardiothoracic Imaging Department of Diagnostic Radiology, Oregon Health & Science University; ABR OLA Cardiac Committee; and NASCI Program Vice-Chair
| | - Amer M Johri
- Queen's University, Kingston, Ontario, Canada; Cardiology Expert; and ASE Board Member
| | | | - Sachin B Malik
- Division Chief Thoracic and Cardiovascular Imaging, Director of Cardiac MRI, Director of MRI, VA Palo Alto Health Care System, Palo Alto, California and Stanford University, Stanford, California
| | | | - Nandini M Meyersohn
- Fellowship Program Director, Massachusetts General Hospital, Boston, Massachusetts
| | - Sujethra Vasu
- Director, Cardiac MRI and Cardiac CT, Wake Forest University Health Sciences, Winston Salem, North Carolina; Society for Cardiovascular Magnetic Resonance
| | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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7
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Hirschberg K, Braun SM, Paul O, Ochs M, Riffel J, Andre F, Salatzki J, Lebel J, Luu J, Hillier E, Finster M, Vago H, Merkely B, Katus HA, Friedrich MG. The diagnostic accuracy of truncated cardiovascular MR protocols for detecting non-ischemic cardiomyopathies. Int J Cardiovasc Imaging 2022; 38:841-852. [PMID: 34751885 PMCID: PMC11129993 DOI: 10.1007/s10554-021-02462-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022]
Abstract
Cardiovascular magnetic resonance imaging is one of the most important diagnostic modalities in the evaluation of cardiomyopathies. However, significant limitations are the complex and time-consuming workflows and the need of contrast agents. The aim of this multi-center retrospective study was to assess workflows and diagnostic value of a short, contrast agent-free cardiac magnetic resonance protocol. 160 patients from Heidelberg, Germany and 119 patients from Montreal, Canada with suspected cardiomyopathy and 20 healthy volunteers have been enrolled. Scans were performed at a 1.5Tesla or 3Tesla scanner in Heidelberg and at a 3Tesla scanner in Montreal. We used single-slice T1 map only. A stepwise analysis of images has been performed. The possible differential diagnosis after each step has been defined. T1-values and color-encoded T1 maps significantly contributed to the differential diagnosis in 54% of the cases (161/299); the final diagnosis has been done without late gadolinium enhancement images in 83% of healthy individuals, in 99% of patients with dilated cardiomyopathy, in 93% of amyloidosis patients, in 94% of patients with hypertrophic cardiomyopathy and in 85% of patients with hypertensive heart disease, respectively. Comparing the scan time with (48 ± 7 min) vs. without contrast agent (23 ± 5 min), significant time saving could be reached by the short protocol. Subgroup analysis showed the most additional diagnostic value of T1 maps in amyloidosis and hypertrophic cardiomyopathy or in confirmation of normal findings. In patients with unclear left ventricular hypertrophy, a short, non-contrast protocol can be used for diagnostic decision-making, if the quality of the T1 map is diagnostic, even if only one slice is available.
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Affiliation(s)
- K Hirschberg
- Heart and Vascular Center, Semmelweis University, Városmajor utca 68, Budapest, 1122, Hungary.
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Sz M Braun
- Heart and Vascular Center, Semmelweis University, Városmajor utca 68, Budapest, 1122, Hungary
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
| | - O Paul
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
| | - M Ochs
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
| | - J Riffel
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
| | - F Andre
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
| | - J Salatzki
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
| | - J Lebel
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | - J Luu
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | - E Hillier
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
| | - M Finster
- Heart and Vascular Center, Semmelweis University, Városmajor utca 68, Budapest, 1122, Hungary
| | - H Vago
- Heart and Vascular Center, Semmelweis University, Városmajor utca 68, Budapest, 1122, Hungary
| | - B Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor utca 68, Budapest, 1122, Hungary
| | - H A Katus
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
| | - M G Friedrich
- Department of Cardiology, Angiology and Pneumonology, University Hospital Heidelberg, Heidelberg, Germany
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
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Yang Z, Xu R, Wang JR, Xu HY, Fu H, Xie LJ, Yang MX, Zhang L, Wen LY, Liu H, Li H, Yang ZG, Guo YK. Association of myocardial fibrosis detected by late gadolinium-enhanced MRI with clinical outcomes in patients with diabetes: a systematic review and meta-analysis. BMJ Open 2022; 12:e055374. [PMID: 35017252 PMCID: PMC8753417 DOI: 10.1136/bmjopen-2021-055374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE This meta-analysis assessed the associations of myocardial fibrosis detected by late gadolinium-enhanced (LGE)-MRI with the risk of major adverse cardiac and cerebrovascular events (MACCEs) and major adverse cardiac events (MACEs) in patients with diabetes. DESIGN Systematic review and meta-analysis reported in accordance with the guidelines of the Meta-analysis of Observational Studies in Epidemiology statement. DATA SOURCES We searched the Medline, Embase and Cochrane by Ovid databases for studies published up to 27 August 2021. ELIGIBILITY CRITERIA Prospective or respective cohort studies were included if they reported the HR and 95% CIs for MACCEs/MACEs in patients with either type 1 or 2 diabetes and LGE-MRI-detected myocardial fibrosis compared with patients without LGE-MRI-detected myocardial fibrosis and if the articles were published in the English language. DATA EXTRACTION AND SYNTHESIS Two review authors independently extracted data and assessed the quality of the included studies. Pooled HRs and 95% CIs were analysed using a random effects model. Heterogeneity was assessed using forest plots and I2 statistics. RESULTS Eight studies with 1121 patients with type 1 or type 2 diabetes were included in this meta-analysis, and the follow-up ranged from 17 to 70 months. The presence of myocardial fibrosis detected by LGE-MRI was associated with an increased risk for MACCEs (HR: 2.58; 95% CI 1.42 to 4.71; p=0.002) and MACEs (HR: 5.28; 95% CI 3.20 to 8.70; p<0.001) in patients with diabetes. Subgroup analysis revealed that ischaemic fibrosis detected by LGE was associated with MACCEs (HR 3.80, 95% CI 2.38 to 6.07; p<0.001) in patients with diabetes. CONCLUSIONS This study demonstrated that ischaemic myocardial fibrosis detected by LGE-MRI was associated with an increased risk of MACCEs/MACEs in patients with diabetes and may be an imaging biomarker for risk stratification. Whether LGE-MRI provides incremental prognostic information with respect to MACCEs/MACEs over risk stratification by conventional cardiovascular risk factors requires further study.
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Affiliation(s)
- Zhi Yang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
- Department of Radiology, Chengdu Fifth People's Hospital, Chengdu, Sichuan, China
| | - Rong Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Jia-Rong Wang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Hua-Yan Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Hang Fu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Ling-Jun Xie
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Meng-Xi Yang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Lu Zhang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Ling-Yi Wen
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Hui Liu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Hong Li
- Key Laboratory of Obstetrics & Gynecology and Pediatric Disease and Birth Defects of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
| | - Zhi-Gang Yang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, Sichuan University West China Second University Hospital, Chengdu, China
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9
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Old Age and Myocardial Injury in ST-Segment Elevation Myocardial Infarction. Am J Med Sci 2021; 362:592-600. [PMID: 34563496 DOI: 10.1016/j.amjms.2021.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/20/2020] [Accepted: 06/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known about the causality and pathological mechanism underlying the association between old age and myocardial injury in patients with ST-segment elevation myocardial infarction (STEMI). We evaluated the association between old age and myocardial injury in STEMI patients undergoing primary percutaneous coronary intervention (PCI) using cardiovascular magnetic resonance imaging (CMR). METHODS A total of 279 patients with STEMI who underwent primary PCI and CMR were enrolled. Of these, 52 patients were over the age of 70 years (18.6%, Age ≥70 group) and 227 patients were under the age of 70 years (81.4%, Age <70 group) at STEMI occurrence. We compared myocardial infarct size on CMR according to age at STEMI occurrence and performed inverse probability of treatment weighting. RESULTS On CMR analysis, myocardial infarct size on CMR tended to be greater in the Age ≥70 group than in the Age <70 group (21.2 ± 10.2% versus 19.5 ± 11.1%; p = 0.072). After performing inverse probability of treatment weighting adjustment, myocardial infarct size was significantly greater in the Age ≥70 group compared with the Age <70 group (22.6 ± 10.4% versus 19.6 ± 11.1%; p = 0.001). Subgroup analysis of patients older than 70 years revealed no significant difference in myocardial infarct size according to sex (20.1 ± 11.5% in females versus 20.4 ± 9.9% in males; p = 0.901). CONCLUSIONS Despite appropriate coronary revascularization, old age was associated with greater extent of myocardial injury in STEMI patients.
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Yang Z, Fu H, Li H, Wang JR, Xu HY, Xie LJ, Yang MX, Zhang L, Yang ZG, Guo YK. Late gadolinium enhancement is a risk factor for major adverse cardiac events in unrecognised myocardial infarction without apparent symptoms: a meta-analysis. Clin Radiol 2020; 76:79.e1-79.e11. [PMID: 33012499 DOI: 10.1016/j.crad.2020.07.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/28/2020] [Indexed: 02/08/2023]
Abstract
AIM To assess the prognostic role of unrecognised myocardial infarction (UMI) detected at late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMRII). MATERIALS AND METHODS Electronic databases including PubMed, EMBASE, Medline, and Cochrane were searched systematically for studies exploring the predictive value of UMI detected by LGE-CMRI for major adverse cardiac events (MACEs) and all-cause mortality in patients without apparent symptoms. Pooled hazard ratios (HRs) along with their 95% confidence intervals (CIs) were obtained from a random-effects model. Subgroup analyses were performed according to the different participants and outcomes. RESULTS Eight studies (2,009 participants) were identified comprising 442 patients with UMI detected at LGE-CMRI and 1,567 without UMI. The presence of UMI on LGE was associated with a significantly increased risk for MACEs (HRs: 3.44, 95% CI: 2.06 to 5.75; p<0.001) and all-cause mortality (HRs: 2.43, 95% CI: 1.00 to 5.87; p=0.05). In the subgroup analysis, the presence of UMI on LGE remained significantly associated with the risk of MACEs in patients with suspected coronary artery disease (HRs: 3.82, 95% CI: 2.49 to 5.85; p<0.01) and diabetes mellitus (HRs: 4.97, 95% CI: 3.02 to 8.18; p<0.01). CONCLUSION The presence of UMI detected by LGE-CMRI is associated with an increased risk of MACEs and all-cause mortality in patients without symptoms. LGE-CMRI could provide important prognostic information and guide risk stratification in patients with UMI.
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Affiliation(s)
- Z Yang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China; Department of Radiology, Chengdu Fifth People's Hospital, Chengdu, China
| | - H Fu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - H Li
- Key Laboratory of Obstetrics & Gynecology and Pediatric Disease and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - J-R Wang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - H-Y Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - L-J Xie
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - M-X Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - L Zhang
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Z-G Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China.
| | - Y-K Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China.
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11
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Domenech-Ximenos B, Sanz-de la Garza M, Prat-González S, Sepúlveda-Martínez A, Crispi F, Duran-Fernandez K, Perea RJ, Bijnens B, Sitges M. Prevalence and pattern of cardiovascular magnetic resonance late gadolinium enhancement in highly trained endurance athletes. J Cardiovasc Magn Reson 2020; 22:62. [PMID: 32878630 PMCID: PMC7469354 DOI: 10.1186/s12968-020-00660-w] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intensive endurance exercise may induce a broad spectrum of right ventricular (RV) adaptation/remodelling patterns. Late gadolinium enhancement (LGE) has also been described in cardiovascular magnetic resonance (CMR) of some endurance athletes and its clinical meaning remains controversial. Our aim was to characterize the features of contrast CMR and the observed patterns of the LGE distribution in a cohort of highly trained endurance athletes. METHODS Ninety-three highly trained endurance athletes (> 12 h training/week at least during the last 5 years; 36 ± 6 years old; 53% male) and 72 age and gender-matched controls underwent a resting contrast CMR. In a subgroup of 28 athletes, T1 mapping was also performed. RESULTS High endurance training load was associated with larger bi-ventricular and bi-atrial sizes and a slight reduction of biventricular ejection fraction, as compared to controls in both genders (p < 0.05). Focal LGE was significantly more prevalent in athletes than in healthy subjects (37.6% vs 2.8%; p < 0.001), with a typical pattern in the RV insertion points. In T1 mapping, those athletes who had focal LGE had higher extracellular volume (ECV) at the remote myocardium than those without (27 ± 2.2% vs 25.2 ± 2.1%; p < 0.05). CONCLUSIONS Highly trained endurance athletes showed a ten-fold increase in the prevalence of focal LGE as compared to control subjects, always confined to the hinge points. Additionally, those athletes with focal LGE demonstrated globally higher myocardial ECV values. This matrix remodelling and potential presence of myocardial fibrosis may be another feature of the athlete's heart, of which the clinical and prognostic significance remains to be determined.
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Affiliation(s)
- B Domenech-Ximenos
- Radiology Department, Hospital Clinic, Barcelona, Spain.
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
| | - M Sanz-de la Garza
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - S Prat-González
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - A Sepúlveda-Martínez
- Barcelona Center for Maternal-Fetal and Neonatal Medicine Hospital Clínic and Hospital Sant Joan de Deu, Barcelona University, CIBER-ER, Barcelona, Spain
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico - Universidad de Chile, Santiago de Chile, Chile
| | - F Crispi
- Barcelona Center for Maternal-Fetal and Neonatal Medicine Hospital Clínic and Hospital Sant Joan de Deu, Barcelona University, CIBER-ER, Barcelona, Spain
| | - K Duran-Fernandez
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - R J Perea
- Radiology Department, Hospital Clinic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - B Bijnens
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- BCN Medtech, Universitat Pompeu Fabra, Barcelona, Spain
- ICREA, Barcelona, Spain
| | - M Sitges
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
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12
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Churchill TW, Baggish AL. Cardiovascular Care of Masters Athletes. J Cardiovasc Transl Res 2020; 13:313-321. [PMID: 32189198 DOI: 10.1007/s12265-020-09987-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/11/2020] [Indexed: 01/31/2023]
Abstract
Masters athletes (MA), men and woman older than 35 years who participate in competitive athletics, is a rapidly growing population that is increasingly encountered in clinical cardiovascular practice. Although the high levels of exercise typically performed by MA confer numerous health advantages, no amount of exercise confers complete immunity from cardiovascular disease. The review was written to cover the clinical management of MA with cardiovascular disease. Focus is dedicated to four of the most common clinical scenarios including atrial fibrillation, myocardial fibrosis, coronary artery disease, and dilation of the ascending aorta.
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Affiliation(s)
- Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Harvard Medical School, Yawkey Suite 5B, 55 Fruit Street, Boston, MA, 02114, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Harvard Medical School, Yawkey Suite 5B, 55 Fruit Street, Boston, MA, 02114, USA.
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13
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Schuijf JD, Ambale-Venkatesh B, Kassai Y, Kato Y, Kasuboski L, Ota H, Caruthers SD, Lima JAC. Cardiovascular ultrashort echo time to map fibrosis-promises and challenges. Br J Radiol 2019; 92:20190465. [PMID: 31356106 PMCID: PMC6849674 DOI: 10.1259/bjr.20190465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022] Open
Abstract
Increased collagen, or fibrosis, is an important marker of disease and may improve identification of patients at risk. In addition, fibrosis imaging may play an increasing role in guiding therapy and monitoring its effectiveness. MRI is the most frequently used modality to detect, visualize and quantify fibrosis non-invasively. However, standard MRI techniques used to phenotype cardiac fibrosis such as delayed enhancement and extracellular volume determination by T1 mapping, require the administration of gadolinium-based contrast and are particularly difficult to use in patients with cardiac devices such as pacemakers and automatic defibrillators. Therefore, such methods are limited in the serial evaluation of cardiovascular fibrosis as part of chronic disease monitoring. A method to directly measure collagen amount could be of great clinical benefit. In the current review we will discuss the potential of a novel MR technique, ultrashort echo time (UTE) MR, for fibrosis imaging. Although UTE imaging is successfully applied in other body areas such as musculoskeletal applications, there is very limited experience so far in the heart. We will review the established methods and currently available literature, discuss the technical considerations and challenges, show preliminary in vivo images and provide a future outlook on potential applications of cardiovascular UTE.
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Affiliation(s)
- Joanne D Schuijf
- Global RDC, Canon Medical Systems Europe BV, Zoetermeer, The Netherlands
| | | | - Yoshimori Kassai
- CT-MR Solution Planning Department, CT-MR Division, Canon Medical Systems, Otawara, Japan
| | - Yoko Kato
- Department of Cardiology, Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA
| | | | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | | | - João AC Lima
- Department of Cardiology, Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA
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14
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Acharya T, Aspelund T, Jonasson TF, Schelbert EB, Cao JJ, Sathya B, Dyke CK, Aletras AH, Sigurdsson S, Thorgeirsson G, Eiriksdottir G, Harris T, Launer LJ, Gudnason V, Arai AE. Association of Unrecognized Myocardial Infarction With Long-term Outcomes in Community-Dwelling Older Adults: The ICELAND MI Study. JAMA Cardiol 2019; 3:1101-1106. [PMID: 30304454 DOI: 10.1001/jamacardio.2018.3285] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Importance Cardiac magnetic resonance (CMR) imaging can identify unrecognized myocardial infarction (UMI) in the general population. Unrecognized myocardial infarction by CMR portends poor prognosis in the short term but, to our knowledge, long-term outcomes are not known. Objective To determine the long-term outcomes of UMI by CMR compared with clinically recognized myocardial infarction (RMI) and no myocardial infarction (MI). Design, Setting, and Participants Participants of the population-based, prospectively enrolled ICELAND MI cohort study (aged 67-93 years) were characterized with CMR at baseline (from January 2004-January 2007) and followed up for up to 13.3 years. Kaplan-Meier time-to-event analyses and a Cox regression were used to assess the association of UMI at baseline with death and future cardiovascular events. Main Outcomes and Measures The primary outcome was all-cause mortality. Secondary outcomes were a composite of major adverse cardiac events (MACE: death, nonfatal MI, and heart failure). Results Of 935 participants, 452 (48.3%) were men; the mean (SD) age of participants with no MI, UMI, and RMI was 75.6 (5.3) years, 76.8 (5.2) years, and 76.8 (4.7) years, respectively. At 3 years, UMI and no MI mortality rates were similar (3%) and lower than RMI rates (9%). At 5 years, UMI mortality rates (13%) increased and were higher than no MI rates (8%) but still lower than RMI rates (19%). By 10 years, UMI and RMI mortality rates (49% and 51%, respectively) were not statistically different; both were significantly higher than no MI (30%) (P < .001). After adjusting for age, sex, and diabetes, UMI by CMR had an increased risk of death (hazard ratio [HR], 1.61; 95% CI, 1.27-2.04), MACE (HR, 1.56; 95% CI, 1.26-1.93), MI (HR, 2.09; 95% CI, 1.45-3.03), and heart failure (HR, 1.52; 95% CI, 1.09-2.14) compared with no MI and statistically nondifferent risk of death (HR, 0.99; 95% CI, 0.71-1.38) and MACE (HR, 1.23; 95% CI, 0.91-1.66) vs RMI. Conclusions and Relevance In this study, all-cause mortality of UMI was higher than no MI, but within 10 years from baseline evaluation was equivalent with RMI. Unrecognized MI was also associated with an elevated risk of nonfatal MI and heart failure. Whether secondary prevention can alter the prognosis of UMI will require prospective testing.
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Affiliation(s)
- Tushar Acharya
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Thor Aspelund
- Department of Medicine, University of Iceland, Reykyavik, Iceland
| | | | - Erik B Schelbert
- Heart and Vascular Institute of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane J Cao
- The Heart Center, St Francis Hospital, State University of New York at Stony Brook, Stony Brook
| | - Bharath Sathya
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Anthony H Aletras
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | - Tamara Harris
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | - Lenore J Launer
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | | | - Andrew E Arai
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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15
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Abstract
The first population-based cohort study in Uppsala with the aim to study cardiovascular disease was initiated in 1970 (ULSAM). This cohort of 2300 middle-aged men has since then been followed in a longitudinal fashion for almost 50 years. This study has been followed by the PIVUS study, investigating 1000 men and women at ages 70, 75, and 80. A very detailed examination has also been performed in 500 subjects aged 50 years, the POEM study. In recent years, a high-throughput study conducted in 13000 subjects has also been performed, named EpiHealth. Uppsala also collects data in 5,000 subjects in the nationwide SCAPIS study. Taken together, these cardiovascular-oriented studies constitute a very rich source for cardiovascular epidemiological research in Uppsala. This review summarizes the design of these studies and highlights some of the important results published based on data from these studies.
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Affiliation(s)
- Lars Lind
- Department of Medical Sciences, Uppsala University, Sweden
- CONTACT Lars Lind E-mail: Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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16
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Weir-McCall J, Bonnici-Mallia M, Ramkumar P, Nath A, Houston J. Whole-body magnetic resonance angiography. Clin Radiol 2019; 74:3-12. [DOI: 10.1016/j.crad.2018.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 04/10/2018] [Accepted: 05/29/2018] [Indexed: 01/01/2023]
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17
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Omori T, Kurita T, Dohi K, Takasaki A, Nakata T, Nakamori S, Fujimoto N, Kitagawa K, Hoshino K, Tanigawa T, Sakuma H, Ito M. Prognostic impact of unrecognized myocardial scar in the non-culprit territories by cardiac magnetic resonance imaging in patients with acute myocardial infarction. Eur Heart J Cardiovasc Imaging 2018; 19:108-116. [PMID: 28950314 DOI: 10.1093/ehjci/jex194] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/10/2017] [Indexed: 11/14/2022] Open
Abstract
Aims Unrecognized myocardial scar by late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) is strongly associated with cardiac event in patients with stable coronary artery disease. The purpose of this study was to evaluate the prognostic impact of unrecognized non-infarct-related LGE (non-IR-LGE) in patients with acute myocardial infarction (AMI). Methods and results We studied 269 patients with a first clinical episode of AMI underwent cardiac MRI within 6 weeks after onset (209 men; age, 66 ± 12 years). LGE, cine MRI and T2-weighted imaging were obtained to evaluate the presence and extent of LGE and to evaluate cardiac function. Major adverse cardiac events (MACE) were defined as cardiovascular death, non-fatal AMI, unstable angina requiring revascularization, fatal arrhythmia, and heart failure. Unrecognized non-IR LGE was observed in 13.0% of patients. During follow-up periods (median, 22 months; range, 3-95 months), 8.9% of patients experienced MACE in this study. In addition, 22.9% of patients with unrecognized non-IR LGE and 6.8% of patients without unrecognized non-IR-LGE experienced MACE (P < 0.01). The presence of unrecognized non-IR LGE predicted MACE with a hazard ratio of 3.45 (95% confidential interval, 1.03-11.47; P < 0.01). In addition, unrecognized non-IR LGE was the strongest independent predictors of MACE with a hazard ratio of 3.30 by the Cox proportional hazards model (P < 0.01). In contrast, angiography-proven multi-vessel disease and transmural extent of infarct-related LGE were not independently associated with MACE. Conclusion Among patients with a first clinical episode of AMI, unrecognized non-IR myocardial scar provides incremental prognostic value for predicting MACE beyond that of common clinical, angiographic and functional variables.
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Affiliation(s)
- Taku Omori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Akihiro Takasaki
- Department of Cardiology, Matsusaka Central Hospital, 102 Kawai, Matsusaka 515-8566, Japan
| | - Tomoyuki Nakata
- Department of Cardiology, Nagai Hospital, 29-29 Nishimarunouchi, Tsu 514-8508, Japan
| | - Shiro Nakamori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Naoki Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Kakuya Kitagawa
- Department of Radiology, Mie University Graduate School of Medicine, 2-174 Edobashi Tsu 514-8507, Japan
| | - Kozo Hoshino
- Department of Cardiology, Nagai Hospital, 29-29 Nishimarunouchi, Tsu 514-8508, Japan
| | - Takashi Tanigawa
- Department of Cardiology, Matsusaka Central Hospital, 102 Kawai, Matsusaka 515-8566, Japan
| | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School of Medicine, 2-174 Edobashi Tsu 514-8507, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
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Cha MJ, Kim SM, Kim Y, Kim HS, Cho SJ, Sung J, Choe YH. Unrecognized myocardial infarction detected on cardiac magnetic resonance imaging: Association with coronary artery calcium score and cardiovascular risk prediction scores in asymptomatic Asian cohort. PLoS One 2018; 13:e0204040. [PMID: 30216389 PMCID: PMC6138379 DOI: 10.1371/journal.pone.0204040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/01/2018] [Indexed: 11/29/2022] Open
Abstract
Background To investigate the association between unrecognized myocardial infarction (UMI) assessed with cardiac magnetic resonance (CMR) and coronary artery calcium (CAC) and cardiovascular risk prediction scores in asymptomatic Asian subjects. Materials and methods Total 872 asymptomatic subjects without prior cardiovascular event (male:female, 817:55; age, 53.88 ± 5.91) who underwent both CMR and CAC scoring CT were included. UMI were accessed and framingham risk score (FRS) and ASCVD (atherosclerotic cardiovascular disease) risk score by ACC/AHA were calculated. Results Late gadolinium enhancement indicating UMI was noted in 23 of 872 subjects (2.64%), but only three of them showed ECG abnormality (13.04%). Subjects with UMI showed higher CAC scores, FRS, and ASCVD scores than those without UMI (p < .001, p = .011 and p = .024, respectively). The prevalence of UMI differed significantly according to the CAC scores as follows: 1% in CAC = 0 (4/403), 1% in 1 ≤ CAC <100 (2/293), 6.1% in 100 ≤ CAC < 400 (7/114) and 14.5% in CAC ≥ 400 (9/62), respectively (p < .001). Receiver operating characteristics (ROC) analysis by using CAC score demonstrated an area under the curve (AUC) of 0.816 (95% confidence interval (CI), 0.780–0.848; p < .0001) for predicting UMI, which is superior to FRS [AUC, 0.712; 95% CI, 0.671–0.751; p = .009] and ASCVD risk score [AUC, 0.689; 95% CI, 0.648–0.729; p = .036]. Conclusion The prevalence of UMI increases with increasing burden of CAC and FRS. CAC score is a good discriminator for UMI, superior to FRS and ASCVD score, in asymptomatic population.
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Affiliation(s)
- Min Jae Cha
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
- Cardiovascular Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
- * E-mail:
| | - Yiseul Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Hyun Su Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Soo Jin Cho
- Center for Health Promotion, Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
| | - Jidong Sung
- Division of Cardiology, Department of Medicine, Sungkyunkwan University School of Medicine, Prevention & Rehabilitation Center, Heart Vascular & Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
- Cardiovascular Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
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Nordenskjöld AM, Hammar P, Ahlström H, Bjerner T, Duvernoy O, Lindahl B. Unrecognized myocardial infarction assessed by cardiac magnetic resonance imaging is associated with adverse long-term prognosis. PLoS One 2018; 13:e0200381. [PMID: 29979788 PMCID: PMC6034881 DOI: 10.1371/journal.pone.0200381] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/24/2018] [Indexed: 11/23/2022] Open
Abstract
Background Unrecognized myocardial infarctions (UMIs) are common. The study is an extension of a previous study, aiming to investigate the long-term (>5 year) prognostic implication of late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) detected UMI in patients with suspected stable coronary artery disease (CAD) without previously diagnosed myocardial infarction (MI). Methods In 235 patients with suspected stable CAD without previous MI, LGE-CMR imaging and coronary angiography were performed. LGE with a subendocardial component detectable in more than one imaging plane was required to indicate UMI. The stenosis grade of the coronary arteries was determined, including in the artery supplying an infarcted area. Stenosis ≥70% stenosis was considered significant. Patients were followed for 5.4 years in mean regarding a composite endpoint of cardiovascular death, MI, hospitalization due to heart failure, stable or unstable angina. Results UMI were present in 58 of 235 patients (25%). Thirty-nine of the UMIs were located downstream of a significant coronary stenosis. During the follow-up 40 patients (17.0%) reached the composite endpoint. Of patients with UMI, 34.5% (20/58) reached the primary endpoint compared to 11.3% (20/177) of patients with no UMI (HR 3.7, 95% CI 2.0–6.9, p<0.001). The association between UMI and outcome remained (HR 2.3, 95% CI 1.2–4.4, p = 0.012) after adjustments for age, gender, extent of CAD and all other variables univariate associated with outcome. Sixteen (41%) of the patients with an UMI downstream of a significant stenosis reached the endpoint compared to four (21%) patients with UMI and no relation to a significant stenosis (HR 2.4, 95% CI 0.8–7.2, p = 0.12). Conclusion The presence of UMI was independently associated with an increased risk of cardiovascular events during long-term follow up.
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Affiliation(s)
- Anna M. Nordenskjöld
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- * E-mail:
| | - Per Hammar
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Håkan Ahlström
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Tomas Bjerner
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Olov Duvernoy
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
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Eijsvogels TMH, Oxborough DL, O'Hanlon R, Sharma S, Prasad S, Whyte G, George KP, Wilson MG. Global and regional cardiac function in lifelong endurance athletes with and without myocardial fibrosis. Eur J Sport Sci 2017; 17:1297-1303. [PMID: 28910586 DOI: 10.1080/17461391.2017.1373864] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The aim of the present study was to compare cardiac structure as well as global and regional cardiac function in athletes with and without myocardial fibrosis (MF). Cardiac magnetic resonance imaging with late gadolinium enhancement was used to detect MF and global cardiac structure in nine lifelong veteran endurance athletes (58 ± 5 years, 43 ± 5 years of training). Transthoracic echocardiography using tissue-Doppler and myocardial strain imaging assessed global and regional (18 segments) longitudinal left ventricular function. MF was present in four athletes (range 1-8 g) and not present in five athletes. MF was located near the insertion points of the right ventricular free wall on the left ventricle in three athletes and in the epicardial lateral wall in one athlete. Athletes with MF demonstrated a larger end diastolic volume (205 ± 24 vs 173 ± 18 ml) and posterior wall thickness (11 ± 1 vs 9 ± 1 mm) compared to those without MF. The presence of MF did not mediate global tissue velocities or global longitudinal strain and strain rate; however, regional analysis of longitudinal strain demonstrated reduced function in some fibrotic regions. Furthermore, base to apex gradient was affected in three out of four athletes with MF. Lifelong veteran endurance athletes with MF demonstrate larger cardiac dimensions and normal global cardiac function. Fibrotic areas may demonstrate some co-localised regional cardiac dysfunction, evidenced by an affected cardiac strain and base to apex gradient. These data emphasize the heterogeneous phenotype of MF in athletes.
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Affiliation(s)
- Thijs M H Eijsvogels
- a Research Institute for Sports and Exercise Sciences , Liverpool John Moores University , Liverpool , UK.,b Department of Physiology , Radboud University Medical Center , Nijmegen , Netherlands
| | - David L Oxborough
- a Research Institute for Sports and Exercise Sciences , Liverpool John Moores University , Liverpool , UK
| | - Rory O'Hanlon
- c St. Vincent's University Hospital and The Blackrock Clinic , Dublin , Ireland
| | - Sanjay Sharma
- d Department of Heart Muscle Disorders and Sports Cardiology , St. Georges Hospital , London , UK
| | - Sanjay Prasad
- e Department of Cardiac Magnetic Resonance Imaging , Royal Brompton and Harefield National Health Service Trust , London , UK
| | - Greg Whyte
- a Research Institute for Sports and Exercise Sciences , Liverpool John Moores University , Liverpool , UK
| | - Keith P George
- a Research Institute for Sports and Exercise Sciences , Liverpool John Moores University , Liverpool , UK
| | - Mathew G Wilson
- f ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital , Doha , Qatar
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21
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Weir-McCall JR, Fitzgerald K, Papagiorcopulo CJ, Gandy SJ, Lambert M, Belch JJ, Cavin I, Littleford R, Macfarlane JA, Matthew SZ, Nicholas RS, Struthers AD, Sullivan FM, Waugh SA, White RD, Houston JG. Prevalence of unrecognized myocardial infarction in a low-intermediate risk asymptomatic cohort and its relation to systemic atherosclerosis. Eur Heart J Cardiovasc Imaging 2017; 18:657-662. [PMID: 27550660 PMCID: PMC5439404 DOI: 10.1093/ehjci/jew155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 06/29/2016] [Indexed: 12/18/2022] Open
Abstract
AIMS Unrecognized myocardial infarctions (UMIs) have been described in 19-30% of the general population using late gadolinium enhancement (LGE) on cardiac magnetic resonance. However, these studies have focused on an unselected cohort including those with known cardiovascular disease (CVD). The aim of the current study was to ascertain the prevalence of UMIs in a non-high-risk population using magnetic resonance imaging (MRI). METHODS AND RESULTS A total of 5000 volunteers aged >40 years with no history of CVD and a 10-year risk of CVD of <20%, as assessed by the ATP-III risk score, were recruited to the Tayside Screening for Cardiac Events study. Those with a B-type natriuretic peptide (BNP) level greater than their gender-specific median were invited for a whole-body MR angiogram and cardiac MR including LGE assessment. LGE was classed as absent, UMI, or non-specific. A total of 1529 volunteers completed the imaging study; of these, 53 (3.6%) were excluded because of either missing data or inadequate LGE image quality. Ten of the remaining 1476 (0.67%) displayed LGE. Of these, three (0.2%) were consistent with UMI, whereas seven were non-specific occurring in the mid-myocardium (n = 4), epicardium (n = 1), or right ventricular insertion points (n = 2). Those with UMI had a significantly higher BNP [median 116 (range 31-133) vs. 22.6 (5-175) pg/mL, P = 0.015], lower ejection fraction [54.6 (36-62) vs. 68.9 (38-89)%, P = 0.007], and larger end-systolic volume [36.3 (27-61) vs. 21.7 (5-65) mL/m2, P = 0.014]. Those with non-specific LGE had lower diastolic blood pressure [68 (54-70) vs. 72 (46-98) mmHg, P = 0.013] but no differences in their cardiac function. CONCLUSION Despite previous reports describing high prevalence of UMI in older populations, in a predominantly middle-aged cohort, those who are of intermediate or low cardiovascular risk have a very low risk of having an unrecognized myocardial infarct.
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Affiliation(s)
- Jonathan R. Weir-McCall
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | - Kerrie Fitzgerald
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | - Carla J. Papagiorcopulo
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | | | - Matthew Lambert
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | - Jill J.F. Belch
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | - Ian Cavin
- NHS Tayside Medical Physics, Ninewells Hospital, Dundee, UK
| | - Roberta Littleford
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | | | - Shona Z. Matthew
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | | | - Allan D. Struthers
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
| | - Frank M. Sullivan
- Department of Research and Innovation, North York General Hospital, University of Toronto, Toronto, UK
| | | | - Richard D. White
- Department of Clinical Radiology, University Hospital of Wales, Cardiff, UK
| | - J. Graeme Houston
- Department of Cardiovascular and Diabetes Medicine, College of Medicine, Ninewells Hospital, University of Dundee, Level 7, Dundee DD1 9SY, UK
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Affiliation(s)
- João A.C. Lima
- From the Division of Cardiology, Department of Medicine, Johns Hopkins Hospital and School of Medicine, Baltimore, MD
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23
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van de Schoor FR, Aengevaeren VL, Hopman MTE, Oxborough DL, George KP, Thompson PD, Eijsvogels TMH. Myocardial Fibrosis in Athletes. Mayo Clin Proc 2016; 91:1617-1631. [PMID: 27720455 DOI: 10.1016/j.mayocp.2016.07.012] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/15/2016] [Accepted: 07/15/2016] [Indexed: 12/17/2022]
Abstract
Myocardial fibrosis (MF) is a common phenomenon in the late stages of diverse cardiac diseases and is a predictive factor for sudden cardiac death. Myocardial fibrosis detected by magnetic resonance imaging has also been reported in athletes. Regular exercise improves cardiovascular health, but there may be a limit of benefit in the exercise dose-response relationship. Intense exercise training could induce pathologic cardiac remodeling, ultimately leading to MF, but the clinical implications of MF in athletes are unknown. For this comprehensive review, we performed a systematic search of the PubMed and MEDLINE databases up to June 2016. Key Medical Subject Headings terms and keywords pertaining to MF and exercise (training) were included. Articles were included if they represented primary MF data in athletes. We identified 65 athletes with MF from 19 case studies/series and 14 athletic population studies. Myocardial fibrosis in athletes was predominantly identified in the intraventricular septum and where the right ventricle joins the septum. Although the underlying mechanisms are unknown, we summarize the evidence for genetic predisposition, silent myocarditis, pulmonary artery pressure overload, and prolonged exercise-induced repetitive micro-injury as contributors to the development of MF in athletes. We also discuss the clinical implications and potential treatment strategies of MF in athletes.
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Affiliation(s)
- Freek R van de Schoor
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vincent L Aengevaeren
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maria T E Hopman
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David L Oxborough
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Keith P George
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | | | - Thijs M H Eijsvogels
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands; Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK; Division of Cardiology, Hartford Hospital, Hartford, CT.
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24
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Ramos R, Albert X, Sala J, Garcia-Gil M, Elosua R, Marrugat J, Ponjoan A, Grau M, Morales M, Rubió A, Ortuño P, Alves-Cabratosa L, Martí-Lluch R. Prevalence and incidence of Q-wave unrecognized myocardial infarction in general population: Diagnostic value of the electrocardiogram. The REGICOR study. Int J Cardiol 2016; 225:300-305. [PMID: 27744207 DOI: 10.1016/j.ijcard.2016.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diagnosis of unrecognized myocardial infarction (UMI) remains an open question in epidemiological and clinical studies, inhibiting effective secondary prevention of myocardial infarction. We aimed to determine the prevalence and incidence of Q-wave UMI in asymptomatic individuals aged 35 to 74years, and to ascertain the positive predictive value (PPV) of asymptomatic Q-wave to diagnose UMI. METHODS Two population-based cross-sectional studies were conducted, in 2000 (with 10-year follow-up) and in 2005. A baseline electrocardiogram was obtained for each participant. Imaging techniques (echocardiography, cardiac magnetic resonance imaging, and myocardial perfusion single-photon emission computerized tomography) were used to confirm UMI in patients with asymptomatic Q-wave. RESULTS The prevalence of confirmed Q-wave UMI in the 5580 participants was 0.18% (95% confidence interval [CI]: 0.10-0.33) and the incidence rate was 27.1 Q-wave UMI per 100,000person-years. The proportion of confirmed Q-wave UMI with respect to all prevalent MI was 8.1% (95% CI: 4.4-14.2). The PPV of asymptomatic Q-wave to diagnose Q-wave UMI was 29.2% (95% CI: 18.2-43.2%) overall, but much higher (75%, 95% CI: 40.9-92.9%) in participants with 10-year CHD risk ≥10%, compared to lower-risk participants. CONCLUSION Opportunistic identification of asymptomatic Q-waves by routine electrocardiogram overestimates actual Q-wave UMI, which represents 8% to 13% of all myocardial infarction in the population aged 35 to 74years. This overestimation is particularly high in the population at low cardiovascular risk. In epidemiological studies and in clinical practice, diagnosis of a pathologic Q-wave in asymptomatic patients requires detailed analysis of imaging tests to confirm or rule out myocardial necrosis.
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Affiliation(s)
- Rafel Ramos
- ISV Research Group, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain; Department of Medical Sciences, School of Medicine, University of Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Catalan Institute of Health (ICS), Girona, Spain.
| | - Xavier Albert
- Department of Medical Sciences, School of Medicine, University of Girona, Spain; Coronary Unit and Cardiology, Hospital Josep Trueta, Girona, Biomedical Research Institute, Girona (IdIBGi), ICS, Catalunya, Spain; Doctoral Program in Public Health and Biomedical Research Methods, Autonomous University of Barcelona, Spain
| | - Joan Sala
- Department of Medical Sciences, School of Medicine, University of Girona, Spain; Coronary Unit and Cardiology, Hospital Josep Trueta, Girona, Biomedical Research Institute, Girona (IdIBGi), ICS, Catalunya, Spain
| | - Maria Garcia-Gil
- ISV Research Group, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain; Department of Medical Sciences, School of Medicine, University of Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Catalan Institute of Health (ICS), Girona, Spain
| | - Roberto Elosua
- Registre Gironí del COR (REGICOR) Group, Cardiovascular, Epidemiology and Genetics Research Group (EGEC), Municipal Institute for Medical Research (IMIM), Barcelona, Spain
| | - Jaume Marrugat
- Registre Gironí del COR (REGICOR) Group, Cardiovascular, Epidemiology and Genetics Research Group (EGEC), Municipal Institute for Medical Research (IMIM), Barcelona, Spain
| | - Anna Ponjoan
- ISV Research Group, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain; Girona Biomedical Research Institute (IDIBGI), Catalan Institute of Health (ICS), Girona, Spain
| | - María Grau
- Registre Gironí del COR (REGICOR) Group, Cardiovascular, Epidemiology and Genetics Research Group (EGEC), Municipal Institute for Medical Research (IMIM), Barcelona, Spain
| | - Manel Morales
- Coronary Unit and Cardiology, Hospital Josep Trueta, Girona, Biomedical Research Institute, Girona (IdIBGi), ICS, Catalunya, Spain
| | - Antoni Rubió
- Department of Nuclear Medicine, Hospital Josep Trueta, Girona, Biomedical Research Institute, Girona (IdIBGi), ICS, Catalunya, Spain
| | - Pedro Ortuño
- Department of Diagnostic Radiology, Hospital Josep Trueta, Girona, Biomedical Research Institute, Girona (IdIBGi), ICS, Catalunya, Spain
| | - Lia Alves-Cabratosa
- ISV Research Group, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain; Girona Biomedical Research Institute (IDIBGI), Catalan Institute of Health (ICS), Girona, Spain
| | - Ruth Martí-Lluch
- ISV Research Group, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Catalunya, Spain; Girona Biomedical Research Institute (IDIBGI), Catalan Institute of Health (ICS), Girona, Spain
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Zhao X, Zhang Y, Sun Y, Sun L, Cai R. Assessment of myocardial viability with delayed-enhancement MRI in coronary artery disease: A correlative study with coronary artery stenosis using digital subtraction angiography. Exp Ther Med 2016; 12:2285-2289. [DOI: 10.3892/etm.2016.3590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 04/13/2016] [Indexed: 11/05/2022] Open
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Barbier CE, Themudo R, Bjerner T, Johansson L, Lind L, Ahlström H. Long-term prognosis of unrecognized myocardial infarction detected with cardiovascular magnetic resonance in an elderly population. J Cardiovasc Magn Reson 2016; 18:43. [PMID: 27430315 PMCID: PMC4950686 DOI: 10.1186/s12968-016-0264-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/30/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Individuals with unrecognized myocardial infarctions (UMIs) detected with cardiovascular magnetic resonance (CMR) constitute a recently defined group whose prognosis has not been fully evaluated. However, increasing evidence indicate that these individuals may be at considerable cardiovascular risk. The aim of the present study was to investigate the prognostic impact of CMR detected UMIs for major adverse cardiac events (MACE) in community living elderly individuals. METHODS Late gadolinium enhancement CMR was performed in 248 randomly chosen 70-year-olds. Individuals with myocardial infarction (MI) scars, with or without a hospital diagnosis of MI were classified as recognized MI (RMI) or UMI, respectively. Medical records and death certificates were scrutinized. MACE was defined as cardiac death, non-fatal MI, a new diagnosis of angina pectoris, or symptom-driven coronary artery revascularization. RESULTS During follow-up (mean 11 years) MACE occurred in 10 % (n = 18/182) of the individuals without MI scars, in 20 % (n = 11/55) of the individuals with UMI, and in 45 % (n = 5/11) of the individuals with RMI, with a significant difference between the UMI group and the group without MI scars (p = 0.045), and between the RMI group and the group without MI scars (p = 0.0004). Cardiac death and/or non-fatal MI occurred in 15, 5, and 3 of the individuals in the NoMI, UMI, and RMI group respectively. Hazards ratios for MACE adjusted for risk factors and sex were 2.55 (95 % CI 1.20-5.42; p = 0.015) for UMI and 3.28 (95 % CI1.16-9.22; p = 0.025) for RMI. CONCLUSIONS The presence of a CMR detected UMI entailed a more than double risk for MACE in community living 70-year-old individuals.
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Affiliation(s)
| | - Raquel Themudo
- />Department of Radiology, Uppsala University Hospital, Uppsala, 751 85 Sweden
| | - Tomas Bjerner
- />Department of Radiology, Uppsala University Hospital, Uppsala, 751 85 Sweden
| | - Lars Johansson
- />Department of Radiology, Uppsala University Hospital, Uppsala, 751 85 Sweden
| | - Lars Lind
- />Department of Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Håkan Ahlström
- />Department of Radiology, Uppsala University Hospital, Uppsala, 751 85 Sweden
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27
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Themudo R, Johansson L, Ebeling-Barbier C, Lind L, Ahlström H, Bjerner T. The number of unrecognized myocardial infarction scars detected at DE-MRI increases during a 5-year follow-up. Eur Radiol 2016; 27:715-722. [DOI: 10.1007/s00330-016-4439-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 12/22/2022]
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28
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Nordenskjöld AM, Hammar P, Ahlström H, Bjerner T, Duvernoy O, Eggers KM, Fröbert O, Hadziosmanovic N, Lindahl B. Unrecognized myocardial infarctions detected by cardiac magnetic resonance imaging are associated with cardiac troponin I levels. Clin Chim Acta 2016; 455:189-94. [DOI: 10.1016/j.cca.2016.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
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Baldassarre LA, Raman SV, Min JK, Mieres JH, Gulati M, Wenger NK, Marwick TH, Bucciarelli-Ducci C, Bairey Merz CN, Itchhaporia D, Ferdinand KC, Pepine CJ, Walsh MN, Narula J, Shaw LJ. Noninvasive Imaging to Evaluate Women With Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2016; 9:421-35. [PMID: 27056162 PMCID: PMC5486953 DOI: 10.1016/j.jcmg.2016.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 12/18/2022]
Abstract
Declines in cardiovascular deaths have been dramatic for men but occur significantly less in women. Among patients with symptomatic ischemic heart disease (IHD), women experience relatively worse outcomes compared with their male counterparts. Evidence to date has failed to adequately explore unique female imaging targets and their correlative signs and symptoms of IHD as major determinants of IHD risk. We highlight sex-specific anatomic and functional differences in contemporary imaging and introduce imaging approaches that leverage refined targets that may improve IHD risk prediction and identify potential therapeutic strategies for symptomatic women.
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Affiliation(s)
| | - Subha V Raman
- The Ohio State University College of Medicine, Columbus, Ohio
| | - James K Min
- Weill Cornell Medical College, New York, New York
| | | | - Martha Gulati
- The University of Arizona College of Medicine, Tucson, Arizona
| | | | | | | | | | - Dipti Itchhaporia
- Hoag Memorial Hospital Presbyterian Hospital, Newport Beach, California
| | | | - Carl J Pepine
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia.
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Weir-McCall JR, Duce SL, Gandy SJ, Matthew SZ, Martin P, Cassidy DB, McCormick L, Belch JJF, Struthers AD, Colhoun HM, Houston JG. Whole body cardiovascular magnetic resonance imaging to stratify symptomatic and asymptomatic atherosclerotic burden in patients with isolated cardiovascular disease. BMC Med Imaging 2016; 16:18. [PMID: 26923316 PMCID: PMC4770697 DOI: 10.1186/s12880-016-0121-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 02/16/2016] [Indexed: 12/25/2022] Open
Abstract
Background The aim of this study was to use whole body cardiovascular magnetic resonance imaging (WB CVMR) to assess the heart and arterial network in a single examination, so as to describe the burden of atherosclerosis and subclinical disease in participants with symptomatic single site vascular disease. Methods 64 patients with a history of symptomatic single site vascular disease (38 coronary artery disease (CAD), 9 cerebrovascular disease, 17 peripheral arterial disease (PAD)) underwent whole body angiogram and cardiac MR in a 3 T scanner. The arterial tree was subdivided into 31 segments and each scored according to the degree of stenosis. From this a standardised atheroma score (SAS) was calculated. Cine and late gadolinium enhancement images of the left ventricle were obtained. Results Asymptomatic atherosclerotic disease with greater than 50 % stenosis in arteries other than that responsible for their presenting complain was detected in 37 % of CAD, 33 % of cerebrovascular and 47 % of PAD patients. Unrecognised myocardial infarcts were observed in 29 % of PAD patients. SAS was significantly higher in PAD patients 24 (17.5-30.5) compared to CAD 4 (2–11.25) or cerebrovascular disease patients 6 (2-10) (ANCOVA p < 0.001). Standardised atheroma score positively correlated with age (β 0.36 p = 0.002), smoking status (β 0.34 p = 0.002), and LV mass (β -0.61 p = 0.001) on multiple linear regression. Conclusion WB CVMR is an effective method for the stratification of cardiovascular disease. The high prevalence of asymptomatic arterial disease, and silent myocardial infarctions, particularly in the peripheral arterial disease group, demonstrates the importance of a systematic approach to the assessment of cardiovascular disease.
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Affiliation(s)
- Jonathan R Weir-McCall
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK. .,NHS Tayside Clinical Radiology, Ninewells Hospital, Dundee, DD1 9SY, UK. .,Division of Cardiovascular and Diabetic Medicine, Level 7, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Suzanne L Duce
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK
| | - Stephen J Gandy
- NHS Tayside Clinical Radiology, Ninewells Hospital, Dundee, DD1 9SY, UK.,NHS Tayside Medical Physics, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Shona Z Matthew
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK
| | - Patricia Martin
- NHS Tayside Clinical Radiology, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Deirdre B Cassidy
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK
| | - Lynne McCormick
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK
| | - Jill J F Belch
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK
| | - Allan D Struthers
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK
| | - Helen M Colhoun
- Division of Population Health Sciences, Medical Research Institute, The Mackenzie Building, University of Dundee, ᅟ, DD2 4BF, UK
| | - J Graeme Houston
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, ᅟ, DD1 9SY, UK.,NHS Tayside Clinical Radiology, Ninewells Hospital, Dundee, DD1 9SY, UK
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Gränsbo K, Almgren P, Nilsson PM, Hedblad B, Engström G, Melander O. Risk factor exposure in individuals free from cardiovascular disease differs according to age at first myocardial infarction. Eur Heart J 2016; 37:1977-81. [DOI: 10.1093/eurheartj/ehw026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 01/20/2016] [Indexed: 02/01/2023] Open
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Nordenskjöld AM, Hammar P, Ahlström H, Bjerner T, Duvernoy O, Eggers KM, Fröbert O, Hadziosmanovic N, Lindahl B. Unrecognized Myocardial Infarction Assessed by Cardiac Magnetic Resonance Imaging--Prognostic Implications. PLoS One 2016; 11:e0148803. [PMID: 26885831 PMCID: PMC4757080 DOI: 10.1371/journal.pone.0148803] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 01/22/2016] [Indexed: 11/17/2022] Open
Abstract
Background Clinically unrecognized myocardial infarctions (UMI) are not uncommon and may be associated with adverse outcome. The aims of this study were to determine the prognostic implication of UMI in patients with stable suspected coronary artery disease (CAD) and to investigate the associations of UMI with the presence of CAD. Methods and Findings In total 235 patients late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) imaging and coronary angiography were performed. For each patient with UMI, the stenosis grade of the coronary branch supplying the infarcted area was determined. UMIs were present in 25% of the patients and 67% of the UMIs were located in an area supplied by a coronary artery with a stenosis grade ≥70%. In an age- and gender-adjusted model, UMI independently predicted the primary endpoint (composite of death, myocardial infarction, resuscitated cardiac arrest, hospitalization for unstable angina pectoris or heart failure within 2 years of follow-up) with an odds ratio of 2.9; 95% confidence interval 1.1–7.9. However, this association was abrogated after adjustment for age and presence of significant coronary disease. There was no difference in the primary endpoint rates between UMI patients with or without a significant stenosis in the corresponding coronary artery. Conclusions The presence of UMI was associated with a threefold increased risk of adverse events during follow up. However, the difference was no longer statistically significant after adjustments for age and severity of CAD. Thus, the results do not support that patients with suspicion of CAD should be routinely investigated by LGE-CMR for UMI. However, coronary angiography should be considered in patients with UMI detected by LGE-CMR. Trial Registration ClinicalTrials.gov NTC01257282
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Affiliation(s)
- Anna M Nordenskjöld
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Per Hammar
- Department of Radiology, Västmanland Hospital Västerås, Västerås, Sweden
| | - Håkan Ahlström
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Tomas Bjerner
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Olov Duvernoy
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Kai M Eggers
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | | | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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McAreavey D, Vidal JS, Aspelund T, Eiriksdottir G, Schelbert EB, Kjartansson O, Cao JJ, Thorgeirsson G, Sigurdsson S, Garcia M, Harris TB, Launer LJ, Gudnason V, Arai AE. Midlife Cardiovascular Risk Factors and Late-Life Unrecognized and Recognized Myocardial Infarction Detect by Cardiac Magnetic Resonance: ICELAND-MI, the AGES-Reykjavik Study. J Am Heart Assoc 2016; 5:JAHA.115.002420. [PMID: 26873683 PMCID: PMC4802464 DOI: 10.1161/jaha.115.002420] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Associations of atherosclerosis risk factors with unrecognized myocardial infarction (UMI) are unclear. We investigated associations of midlife risk factors with UMI and recognized MI (RMI) detected 31 years later by cardiac magnetic resonance. Methods and Results The Reykjavik Study (1967–1991) collected serial risk factors in subjects, mean (SD) age 48 (7) years. In ICELAND‐MI (2004–2007), 936 survivors (76 (5) years) were evaluated by cardiac magnetic resonance. Analysis included logistic regression and random effects modeling. Comparisons are relative to subjects without MI. At baseline midlife evaluation, a modified Framingham risk score was significantly higher in RMI and in UMI versus no MI (7.4 (6.3)%; 7.1 (6.2)% versus 5.4 (5.8)%, P<0.001). RMI and UMI were more frequent in men (65%, 64% versus 43%; P<0.0001). Baseline systolic and diastolic blood pressure were significantly higher in UMI (138 (17) mm Hg versus 133 (17) mm Hg; P<0.006; 87 (10) mm Hg versus 84 (10) mm Hg; P<0.02). Diastolic BP was significantly higher in RMI (88 (10) mm Hg versus 84 (10) mm Hg; P<0.02). Cholesterol and triglycerides were significantly higher in RMI (6.7 (1.1) mmol/L versus 6.2 (1.1) mmol/L; P=0.0005; and 1.4 (0.7) mmol/L versus 1.1 (0.7) mmol/L; P<0.003). Cholesterol trended higher in UMI (P=0.08). Serial midlife systolic BP was significantly higher in UMI versus no MI (β [SE] = 2.69 [1.28] mm Hg, P=0.04). Serial systolic and diastolic BP were significantly higher in RMI versus no MI (4.12 [1.60] mm Hg, P=0.01 and 2.05 [0.91] mm Hg, P=0.03) as were cholesterol (0.43 [0.11] mmol/L, P=0.0001) and triglycerides (0.3 [0.06] mmol/L, P<0.0001). Conclusions Midlife vascular risk factors are associated with UMI and RMI detected by cardiac magnetic resonance 31 years later. Systolic blood pressure was the most significant modifiable risk factor associated with later UMI.
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Affiliation(s)
| | - Jean-Sébastien Vidal
- AP-HP, Hôpital Broca, Service de Gérontologie I, and Université Paris Descartes, Sorbonne Paris cité, Paris, France
| | - Thor Aspelund
- The Icelandic Heart Association, Kopavogur, Iceland University of Iceland, Reykjavik, Iceland
| | | | | | | | - Jie J Cao
- National Heart Lung and Blood Institute, NIH, Bethesda, MD
| | - Gudmundur Thorgeirsson
- The Icelandic Heart Association, Kopavogur, Iceland University of Iceland, Reykjavik, Iceland
| | | | - Melissa Garcia
- Laboratory of Epidemiology, Demography, and Biometry, Intramural Research Program, National Institute on Aging, NIH, Bethesda, MD
| | - Tamara B Harris
- Laboratory of Epidemiology, Demography, and Biometry, Intramural Research Program, National Institute on Aging, NIH, Bethesda, MD
| | - Lenore J Launer
- Laboratory of Epidemiology, Demography, and Biometry, Intramural Research Program, National Institute on Aging, NIH, Bethesda, MD
| | - Vilmundur Gudnason
- The Icelandic Heart Association, Kopavogur, Iceland University of Iceland, Reykjavik, Iceland
| | - Andrew E Arai
- National Heart Lung and Blood Institute, NIH, Bethesda, MD
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Bogaert J, Eitel I. Role of cardiovascular magnetic resonance in acute coronary syndrome. Glob Cardiol Sci Pract 2016; 2015:24. [PMID: 26779508 PMCID: PMC4614331 DOI: 10.5339/gcsp.2015.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 04/30/2015] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Bogaert
- KU Leuven - University of Leuven, Department of Imaging and Pathology, Leuven, Belgium
| | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology, Angiology, Intensive care medicine), Lübeck, Germany
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35
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Hammar P, Nordenskjöld AM, Lindahl B, Duvernoy O, Ahlström H, Johansson L, Hadziosmanovic N, Bjerner T. Unrecognized myocardial infarctions assessed by cardiovascular magnetic resonance are associated with the severity of the stenosis in the supplying coronary artery. J Cardiovasc Magn Reson 2015; 17:98. [PMID: 26585508 PMCID: PMC4653938 DOI: 10.1186/s12968-015-0202-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 11/08/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A previous study has shown an increased prevalence of late gadolinium enhancement cardiovascular magnetic resonance (LGE CMR) detected unrecognized myocardial infarction (UMI) with increasing extent and severity of coronary artery disease. However, the coronary artery disease was evaluated on a patient level assuming normal coronary anatomy. Therefore, the aims of the present study were to investigate the prevalence of UMI identified by LGE CMR imaging in patients with stable angina pectoris and no known previous myocardial infarction; and to investigate whether presence of UMI is associated with stenotic lesions in the coronary artery supplying the segment of the myocardium in which the UMI is located, using coronary angiography to determine the individual coronary anatomy in each patient. METHODS In this prospective multicenter study, we included patients with stable angina pectoris and without prior myocardial infarction, scheduled for coronary angiography. A LGE CMR examination was performed prior to the coronary angiography. The study cohort consisted of 235 patients (80 women, 155 men) with a mean age of 64.8 years. RESULTS UMIs were found in 25% of patients. There was a strong association between stenotic lesions (≥70% stenosis) in a coronary artery and the presence of an UMI in the myocardial segments supplied by the stenotic artery; it was significantly more likely to have an UMI downstream a stenosis ≥ 70% as compared to < 70% (OR 5.1, CI 3.1-8.3, p < 0.0001). 56% of the UMIs were located in the inferior and infero-lateral myocardial segments, despite predominance for stenotic lesions in the left anterior descending artery. CONCLUSION UMI is common in patients with stable angina and the results indicate that the majority of the UMIs are of ischemic origin due to severe coronary atherosclerosis. In contrast to what is seen in recognized myocardial infarctions, UMIs are predominately located in the inferior and infero-lateral myocardial segments. TRIAL REGISTRATION The PUMI study is registered at ClinicalTrials.gov (NCT01257282).
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Affiliation(s)
- Per Hammar
- Västmanland County Hospital Västerås, Department of Radiology, Västerås, S-72189, Sweden.
- Department of Radiology, Oncology and Radiation Science, Uppsala University, S-75185, Uppsala, Sweden.
| | - Anna M Nordenskjöld
- Department of Cardiology, Örebro University Hospital, S-70182, Örebro, Sweden.
| | - Bertil Lindahl
- Uppsala Clinical Research Centre, S-75237, Uppsala, Sweden.
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, S-75105, Sweden.
| | - Olov Duvernoy
- Department of Radiology, Oncology and Radiation Science, Uppsala University, S-75185, Uppsala, Sweden.
| | - Håkan Ahlström
- Department of Radiology, Oncology and Radiation Science, Uppsala University, S-75185, Uppsala, Sweden.
| | | | | | - Tomas Bjerner
- Department of Radiology, Oncology and Radiation Science, Uppsala University, S-75185, Uppsala, Sweden.
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Turkbey EB, Nacif MS, Guo M, McClelland RL, Teixeira PBRP, Bild DE, Barr RG, Shea S, Post W, Burke G, Budoff M, Folsom AR, Liu CY, Lima JA, Bluemke DA. Prevalence and Correlates of Myocardial Scar in a US Cohort. JAMA 2015; 314:1945-54. [PMID: 26547466 PMCID: PMC4774246 DOI: 10.1001/jama.2015.14849] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Myocardial scarring leads to cardiac dysfunction and poor prognosis. The prevalence of and factors associated with unrecognized myocardial infarction and scar have not been previously defined using contemporary methods in a multiethnic US population. OBJECTIVE To determine prevalence of and factors associated with myocardial scar in middle- and older-aged individuals in the United States. DESIGN, SETTING, AND PARTICIPANTS The Multi-Ethnic Study of Atherosclerosis (MESA) study is a population-based cohort in the United States. Participants were aged 45 through 84 years and free of clinical cardiovascular disease (CVD) at baseline in 2000-2002. In the 10th year examination (2010-2012), 1840 participants underwent cardiac magnetic resonance (CMR) imaging with gadolinium to detect myocardial scar. Cardiovascular disease risk factors and coronary artery calcium (CAC) scores were measured at baseline and year 10. Logistic regression models were used to estimate adjusted odds ratios (ORs) for myocardial scar. EXPOSURES Cardiovascular risk factors, CAC scores, left ventricle size and function, and carotid intima-media thickness. MAIN OUTCOMES AND MEASURES Myocardial scar detected by CMR imaging. RESULTS Of 1840 participants (mean [SD] age, 68 [9] years, 52% men), 146 (7.9%) had myocardial scars, of which 114 (78%) were undetected by electrocardiogram or by clinical adjudication. In adjusted models, age, male sex, body mass index, hypertension, and current smoking at baseline were associated with myocardial scar at year 10. The OR per 8.9-year increment was 1.61 (95% CI, 1.36-1.91; P < .001); for men vs women: OR, 5.76 (95% CI, 3.61-9.17; P < .001); per 4.8-SD body mass index: OR, 1.32 (95% CI, 1.09-1.61, P = .005); for hypertension: OR, 1.61 (95% CI, 1.12-2.30; P = .009); and for current vs never smokers: 2.00 (95% CI, 1.22-3.28; P = .006). Age-, sex-, and ethnicity-adjusted CAC scores at baseline were also associated with myocardial scar at year 10. Compared with a CAC score of 0, the OR for scores from 1 through 99 was 2.4 (95% CI, 1.5-3.9); from 100 through 399, 3.0 (95% CI, 1.7-5.1), and 400 or higher, 3.3 (95% CI, 1.7-6.1) (P ≤ .001). The CAC score significantly added to the association of myocardial scar with age, sex, race/ethnicity, and traditional CVD risk factors (C statistic, 0.81 with CAC vs 0.79 without CAC, P = .01). CONCLUSIONS AND RELEVANCE The prevalence of myocardial scars in a US community-based multiethnic cohort was 7.9%, of which 78% were unrecognized by electrocardiography or clinical evaluation. Further studies are needed to understand the clinical consequences of these undetected scars.
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Affiliation(s)
- Evrim B. Turkbey
- Radiology and Imaging Sciences, National Institutes of Health,
Maryland, MD
- Department of Radiology and Radiological Sciences, Johns Hopkins
University, Maryland, MD
| | - Marcelo S. Nacif
- Radiology and Imaging Sciences, National Institutes of Health,
Maryland, MD
| | - Mengye Guo
- Department of Biostatistics, University of Washington, Washington,
WA
| | | | | | - Diane E. Bild
- Patient-Centered Outcomes Research Institute, Washington, DC
| | - R. Graham Barr
- Departments of Medicine and Epidemiology, Columbia University, New
York, NY
| | - Steven Shea
- Departments of Medicine and Epidemiology, Columbia University, New
York, NY
| | - Wendy Post
- Department of Cardiology, Johns Hopkins University Maryland,
MD
| | - Gregory Burke
- Division of Public Health Sciences, Wake Forest University Health
Sciences, Winston-Salem, NC
| | - Matthew Budoff
- Division of Cardiology, Los Angeles Biomedical Research Institute at
Harbor-UCLA Medical Center, Torrance, CA
| | - Aaron R. Folsom
- Division of Epidemiology and Community Health, University of
Minnesota, Minneapolis, MN
| | - Chia-Ying Liu
- Radiology and Imaging Sciences, National Institutes of Health,
Maryland, MD
| | - João A Lima
- Department of Radiology and Radiological Sciences, Johns Hopkins
University, Maryland, MD
- Department of Cardiology, Johns Hopkins University Maryland,
MD
| | - David A. Bluemke
- Radiology and Imaging Sciences, National Institutes of Health,
Maryland, MD
- Department of Radiology and Radiological Sciences, Johns Hopkins
University, Maryland, MD
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Xiao W, Ye P, Cao R, Yang X, Bai Y, Wu H. Urine Albumin Excretion Is Associated with Cardiac Troponin T Detected with a Highly Sensitive Assay in a Community-Based Population. PLoS One 2015; 10:e0135747. [PMID: 26301504 PMCID: PMC4547701 DOI: 10.1371/journal.pone.0135747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/26/2015] [Indexed: 02/04/2023] Open
Abstract
Background Urine albumin excretion is an important predictor of adverse cardiovascular events. Minimally elevated levels of serum cardiac troponin T (cTnT), a marker of cardiomyocyte micronecrosis, can be detected with high sensitivity cTnT (hs-cTnT) assays. The purpose of this study was to investigate the relationship between alterations in albuminuria and serum hs-cTnT levels in a community-based population. Methods We examined the association between the urine albumin/creatinine ratio (UACR) and hs-cTnT levels in 1354 participants without overt cardiovascular disease in a community-based, cross-sectional study in Beijing, China. Results With the highly sensitive assay, cTnT levels were detectable in 90.5% of our subjects. The median (interquartile range) concentrations of hs-cTnT were 7 (5–10) pg/mL. After adjustment for several factors, UACR (odds ratio: 1.40; 95% confidence interval: 1.08–1.65; P = 0.002) was associated with a higher likelihood of elevated hs-cTnT (≥14 pg/ mL), whereas the relationship between UACR and a higher presence of detectable hs-cTnT (≥ 3 pg/ mL) was not significant. In addition, a fully adjusted logistic regression analysis revealed that compared with participants in the lowest UACR quartile, those in the highest quartile had a 2.43- fold (95% CI: 1.25–5.08; P = 0.006) increased risk of elevated hs-cTnT. Conclusions Higher urine albumin excretion is associated with elevated hs-cTnT among persons without clinically evident cardiovascular disease, suggesting that albuminuria may be a potential risk factor for subclinical cardiovascular disease in the general population.
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Affiliation(s)
- Wenkai Xiao
- Department of Geriatric Cardiology, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, China
| | - Ping Ye
- Department of Geriatric Cardiology, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, China
- * E-mail:
| | - Ruihua Cao
- Department of Geriatric Cardiology, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, China
| | - Xu Yang
- Department of Geriatric Cardiology, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, China
| | - Yongyi Bai
- Department of Geriatric Cardiology, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, China
| | - Hongmei Wu
- Department of Geriatric Cardiology, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing, 100853, China
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Abstract
Since 1948, epidemiology studies played an important role in understanding cardiovascular disease and afforded an opportunity to learn about newer diagnostic tests. In 2000, the MESA Study incorporated several advanced cardiovascular imaging modalities including cardiac magnetic resonance imaging (MRI) and coronary artery calcium scans. The decade of follow-up enabled prognosis studies, an important step beyond association studies. In brief, left ventricular hypertrophy by cardiac MRI predicted incident heart failure and stroke. In the MESA Study, coronary artery calcium was a better predictor of coronary artery disease end points than the non-contrast-enhanced MRI scan. In the ICELAND MI substudy of the AGES-Reykjavik Study, a contrast-enhanced MRI scan detected many more unrecognized myocardial infarctions (MIs) (UMIs) than detected by electrocardiography and documented these UMI had adverse prognostic significance. Thus, cardiac MRI has been successfully incorporated into large population studies and shown added value over conventional measurements of cardiovascular disease.
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Affiliation(s)
- Andrew E Arai
- National Heart, Lung and Blood Institute, National Institutes of Health, US Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD, 20892-1061, USA,
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Abstract
Fibrotic remodelling of the extracellular matrix is a healing mechanism necessary immediately after myocardial injury. However, prolonged increase in myocardial fibrotic activity results in stiffening of the myocardium and heralds adverse outcomes related to systolic and diastolic dysfunction, as well as arrhythmogenesis. Cardiac MRI provides a noninvasive phenotyping tool for accurate and easy detection and quantification of myocardial fibrosis by probing the retention of gadolinium-contrast agent in myocardial tissue. Late-gadolinium enhancement (LGE) cardiac MRI has been used extensively in a large number of studies for measurement of myocardial scarring. T1 mapping, a fairly new technique that can be used to identify the exact T1 value of the tissue, provides a direct measurement of the extracellular volume fraction of the myocardium. In contrast to LGE, T1 mapping can be used to measure diffuse myocardial fibrosis and differentiate between disease processes. In this Review, we describe the basic principles of imaging myocardial fibrosis using contrast-enhanced MRI and summarize its use for prognostic purposes.
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Affiliation(s)
- Bharath Ambale-Venkatesh
- Department of Radiology, Johns Hopkins University, 600 North Wolfe Street, Blalock 524D1, Baltimore, MD 21287, USA
| | - João A C Lima
- Department of Cardiology and Radiology, Johns Hopkins University, 600 North Wolfe Street, Blalock 524D1, Baltimore, MD 21287, USA
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40
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Barbier CE, Themudo R, Bjerner T, Johansson L, Lindahl B, Venge P, Lind L, Ahlström H. Cardiac troponin I associated with the development of unrecognized myocardial infarctions detected with MRI. Clin Chem 2014; 60:1327-35. [PMID: 25062810 DOI: 10.1373/clinchem.2014.222430] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Late enhancement MRI (LE-MRI) and cardiac troponin I (cTnI) are sensitive methods to detect subclinical myocardial injury. We sought to investigate the relation between plasma concentrations of cTnI measured with a high-sensitivity assay (hs-cTnI) and the development of unrecognized myocardial infarctions (UMIs) detected with LE-MRI. METHODS After approval from the ethics committee and written informed consent were obtained, LE-MRI was performed on 248 randomly selected community-living 70-year-old volunteers and hs-cTnI was determined with a highly sensitive premarket assay. Five years later these individuals were invited to a second LE-MRI, and 176 of them (82 women, 94 men), who did not have a hospital diagnosis of MI, constitute the present study population. LE-MR images were analyzed by 2 radiologists independently and in a consensus reading, blinded to any information on previous disease or assessments. RESULTS New or larger UMIs were detected in 37 participants during follow-up. Plasma concentrations of hs-cTnI at 70 years of age, which were mainly within what is considered to be the reference interval, were related to new or larger UMIs at 75 years of age with an odds ratio of 1.98 per 1 unit increase in ln-transformed cTnI (95% CI, 1.17-3.35; P = 0.010). Plasma concentrations of hs-cTnI at 70 years of age were associated with the volumes of the UMIs detected at 75 years of age (P = 0.028). CONCLUSIONS hs-cTnI in 70-year-old community-living women and men was associated with the development of MRI-detected UMIs within 5 years.
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Affiliation(s)
| | - Raquel Themudo
- Department of Radiology, Uppsala University, Uppsala, Sweden
| | - Tomas Bjerner
- Department of Radiology, Uppsala University, Uppsala, Sweden
| | - Lars Johansson
- Department of Radiology, Uppsala University, Uppsala, Sweden; Astrazeneca, Gothenburg, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Venge
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Lind
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Håkan Ahlström
- Department of Radiology, Uppsala University, Uppsala, Sweden
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Katz MY, Kusakari Y, Aoyagi H, Higa JK, Xiao CY, Abdelkarim AZ, Marh K, Aoyagi T, Rosenzweig A, Lozanoff S, Matsui T. Three-dimensional myocardial scarring along myofibers after coronary ischemia-reperfusion revealed by computerized images of histological assays. Physiol Rep 2014; 2:2/7/e12072. [PMID: 25347856 PMCID: PMC4187547 DOI: 10.14814/phy2.12072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Adverse left ventricular (LV) remodeling after acute myocardial infarction is characterized by LV dilatation and development of a fibrotic scar, and is a critical factor for the prognosis of subsequent development of heart failure. Although myofiber organization is recognized as being important for preserving physiological cardiac function and structure, the anatomical features of injured myofibers during LV remodeling have not been fully defined. In a mouse model of ischemia-reperfusion (I/R) injury induced by left anterior descending coronary artery ligation, our previous histological assays demonstrated that broad fibrotic scarring extended from the initial infarct zone to the remote zone, and was clearly demarcated along midcircumferential myofibers. Additionally, no fibrosis was observed in longitudinal myofibers in the subendocardium and subepicardium. However, a histological analysis of tissue sections does not adequately indicate myofiber injury distribution throughout the entire heart. To address this, we investigated patterns of scar formation along myofibers using three-dimensional (3D) images obtained from multiple tissue sections from mouse hearts subjected to I/R injury. The fibrotic scar area observed in the 3D images was consistent with the distribution of the midcircumferential myofibers. At the apex, the scar formation tracked along the myofibers in an incomplete C-shaped ring that converged to a triangular shape toward the end. Our findings suggest that myocyte injury after transient coronary ligation extends along myofibers, rather than following the path of coronary arteries penetrating the myocardium. The injury pattern observed along myofibers after I/R injury could be used to predict prognoses for patients with myocardial infarction.
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Affiliation(s)
- Monica Y Katz
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Yoichiro Kusakari
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Hiroko Aoyagi
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Jason K Higa
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Chun-Yang Xiao
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ahmed Z Abdelkarim
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Karra Marh
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Toshinori Aoyagi
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Anthony Rosenzweig
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Scott Lozanoff
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Takashi Matsui
- Department of Anatomy, Biochemistry & Physiology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
Magnetic resonance (MR) imaging plays an important role in evaluation of various aspects of myocardial infarction (MI). MR imaging is useful in establishing the diagnosis of acute MI, particularly in patients who present with symptoms of MI but outside the diagnostic time frame of altered cardiac enzyme levels or with clinical features of acute MI but without an angiographic culprit lesion. MR imaging is valuable in establishing a diagnosis of chronic MI and distinguishing this condition from nonischemic cardiomyopathies, mainly through use of delayed-enhancement patterns. MR imaging also provides clinicians with several prognostic indicators that enable risk stratification, such as scar burden, microvascular obstruction, hemorrhage, and peri-infarct ischemia. The extent and transmurality of scar burden have been shown to have independent and incremental prognostic power over a range of left ventricular function. The extent of scarring at MR imaging is an important predictor of successful outcome after revascularization procedures, and extensive scarring in the lateral wall indicates poor outcome after cardiac resynchronization therapy. Scar size at MR imaging is also a useful surrogate end point in clinical trials. Finally, MR imaging can be used to detect complications of MI, such as aneurysms, pericarditis, ventricular septal defect, thrombus, and mitral regurgitation. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.335125722/-/DC1.
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Affiliation(s)
- Prabhakar Rajiah
- Cardiothoracic Imaging Section, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Electrocardiographic Q-wave "remodeling" in reperfused ST-segment elevation myocardial infarction: validation study with CMR. JACC Cardiovasc Imaging 2013; 5:1003-13. [PMID: 23058067 DOI: 10.1016/j.jcmg.2012.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 02/03/2012] [Accepted: 02/14/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the evolution in Q-wave expression during the first 5 years after a primary, successfully reperfused ST-segment elevation myocardial infarction (MI), using cardiac magnetic resonance (CMR) for infarct location, and to depict changes in infarct size and left ventricular remodeling over time. BACKGROUND In the absence of QRS confounders, abnormal Q waves are usually diagnostic of myocardial necrosis. It is hypothesized that Q-wave regression after MI could be related to smaller infarct sizes. Late gadolinium enhancement accurately depicts MI of any age. METHODS Forty-six MI patients underwent electrocardiography and CMR at 1 week (baseline), 4 months, 1 year, and 5 years post-infarction. Conventional CMR parameters were analyzed, and infarct presence, location, and size were assessed using late gadolinium enhancement CMR. Infarct locations were anterior or nonanterior (inferior and/or lateral), using late gadolinium enhancement CMR as a reference. For each time point, patients were classified as having a diagnostic/nondiagnostic electrocardiogram (ECG) using the European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation consensus criteria for previous Q-wave infarct. RESULTS At baseline, 11 patients (23%) did not meet the criteria for Q-wave MI. Non-Q-wave infarcts were significantly smaller than Q-wave infarcts (p < 0.0001). All anterior Q-wave infarcts (n = 17) were correctly localized, whereas in 7 of 19 nonanterior Q-wave infarcts, the location or extent of the infarct was misjudged by electrocardiography. At 4-month/1-year follow-up, in 10 patients (3 anterior/7 nonanterior), the ECG became nondiagnostic. The ECG remained nondiagnostic at 5-year follow-up. A cutoff infarct size of 6.2% at 1 year yielded a sensitivity of 89% and a specificity of 74% to predict the presence or absence of Q waves. CONCLUSIONS The incidence of nondiagnostic ECGs for previous MI using the current European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation criteria is substantial and increases with time post-infarction from 23% immediately post-infarction to 44% at 5-year follow-up.
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Levitan EB, Gamboa C, Safford MM, Rizk DV, Brown TM, Soliman EZ, Muntner P. Cardioprotective medication use and risk factor control among US adults with unrecognized myocardial infarction: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Vasc Health Risk Manag 2013; 9:47-55. [PMID: 23404361 PMCID: PMC3569379 DOI: 10.2147/vhrm.s40265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Individuals with unrecognized myocardial infarction (UMI) have similar risks for cardiovascular events and mortality as those with recognized myocardial infarction (RMI). The prevalence of cardioprotective medication use and blood pressure and low-density lipoprotein cholesterol control among individuals with UMI is unknown. METHODS Participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who were recruited between May 2004 and October 2007 received baseline twelve-lead electrocardiograms (n = 21,036). Myocardial infarction (MI) status was characterized as no MI, UMI (electrocardiogram abnormalities consistent with MI without self-reported history; n = 949; 4.5%), and RMI (self-reported history of MI; n = 1574; 7.5%). RESULTS For participants with no MI, UMI, and RMI, prevalence of use was 38.4%, 44.4%, and 75.7% for aspirin; 18.0%, 25.8%, and 57.2% for beta blockers; 31.7%, 38.7%, and 55.0% for angiotensin converting enzyme inhibitors or angiotensin receptor blockers; and 28.1%, 33.9%, and 64.1% for statins, respectively. Participants with RMI were 35% more likely to have low-density lipoprotein cholesterol < 100 mg/dL than participants with UMI (prevalence ratio = 1.35, 95% confidence interval 1.19-1.52). Blood pressure control (,140/90 mmHg) was similar between RMI and UMI groups (prevalence ratio = 1.03, 95% confidence interval 0.93-1.13). CONCLUSION Although participants with UMI were somewhat more likely to use cardioprotective medications than those with no MI, they were less likely to use cardioprotective medications and to have controlled low-density lipoprotein cholesterol than participants with RMI. Increasing appropriate treatment and risk factor control among individuals with UMI may reduce risk of mortality and future cardiovascular events.
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Affiliation(s)
- Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0022, USA.
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Turkbey EB, Nacif MS, Noureldin RA, Sibley CT, Liu S, Lima JAC, Bluemke DA. Differentiation of myocardial scar from potential pitfalls and artefacts in delayed enhancement MRI. Br J Radiol 2013; 85:e1145-54. [PMID: 23091294 DOI: 10.1259/bjr/25893477] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Delayed enhancement cardiac magnetic resonance (DE-CMR) imaging is used increasingly to identify and quantify focal myocardial scar. Our objective is to describe factors used in the interpretation of DE-CMR images and to highlight potential pitfalls and artefacts that mimic myocardial scar. Inversion recovery gradient recalled echo sequence is commonly accepted as the standard of reference for DE-CMR. There are also alternative sequences that can be performed in a single breath-hold or with free breathing. Radiologists need to be aware of factors affecting image quality, and potential pitfalls and artefacts that may generate focal hyperintense areas that mimic myocardial scar.
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Affiliation(s)
- E B Turkbey
- Radiology and Imaging Sciences, National Institutes of Health/Clinical Center, Bethesda, MD 20892, USA
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Ordovas KG, Higgins CB. Delayed contrast enhancement on MR images of myocardium: past, present, future. Radiology 2011; 261:358-74. [PMID: 22012903 DOI: 10.1148/radiol.11091882] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Differential enhancement of myocardial infarction was first recognized on computed tomographic (CT) images obtained with iodinated contrast material in the late 1970s. Gadolinium enhancement of myocardial infarction was initially reported for T1-weighted magnetic resonance (MR) imaging in 1984. The introduction of an inversion-recovery gradient-echo MR sequence for accentuation of the contrast between normal and necrotic myocardium was the impetus for widespread clinical use for demonstrating the extent of myocardial infarction. This sequence has been called delayed-enhancement MR and MR viability imaging. The physiologic basis for differential enhancement of myocardial necrosis is the greater distribution volume of injured myocardium compared with that of normal myocardium. It is now recognized that delayed enhancement occurs in both acute and chronic (scar) infarctions and in an array of other myocardial processes that cause myocardial necrosis, infiltration, or fibrosis. These include myocarditis, hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, and other myocardial conditions. In several of these diseases, the presence and extent of delayed enhancement has prognostic implications. Future applications of delayed enhancement with development of MR imaging and CT techniques will be discussed.
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Affiliation(s)
- Karen G Ordovas
- Department of Radiology, UCSF Medical Center, 505 Parnassus Ave, Room L308, Box 0628, San Francisco, CA 94143-0628, USA
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Barbier CE, Nylander R, Themudo R, Ahlström H, Lind L, Larsson EM, Bjerner T, Johansson L. Prevalence of unrecognized myocardial infarction detected with magnetic resonance imaging and its relationship to cerebral ischemic lesions in both sexes. J Am Coll Cardiol 2011; 58:1372-7. [PMID: 21920267 DOI: 10.1016/j.jacc.2011.06.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 04/26/2011] [Accepted: 06/07/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the prevalence of unrecognized myocardial infarction (UMI) detected with magnetic resonance imaging (MRI) and whether it is related to cerebral ischemic lesions on MRI in an elderly population-based cohort. BACKGROUND There is a correlation between stroke and recognized myocardial infarction (RMI) and between stroke and UMI detected with electrocardiography, whereas the prevalence of stroke in subjects with MRI-detected UMI is unknown. METHODS Cerebral MRI and cardiac late-enhancement MRI were performed on 394 randomly selected 75-year-old subjects (188 women, 206 men). Images were assessed for cerebral ischemic lesions and myocardial infarction (MI) scars. Medical records were scrutinized. Subjects with MI scars, with or without a hospital diagnosis of MI, were classified as RMI or UMI, respectively. RESULTS UMIs were found in 120 subjects (30%) and RMIs in 21 (5%). The prevalence of UMIs (p = 0.004) and RMIs (p = 0.02) was greater in men than in women. Men with RMI displayed an increased prevalence of cortical and lacunar cerebral infarctions, whereas women with UMI more frequently had cortical cerebral infarctions (p = 0.003). CONCLUSIONS MI scars are more frequent in men than in women at 75 years of age. The prevalence of RMI is related to that of cerebral infarctions.
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Khan AM, Litt H, Ferrari V, Han Y. Cardiac Magnetic Resonance Imaging in Ischemic Heart Disease. PET Clin 2011; 6:453-73. [DOI: 10.1016/j.cpet.2011.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Turkbey EB, Backlund JYC, Genuth S, Jain A, Miao C, Cleary PA, Lachin JM, Nathan DM, van der Geest RJ, Soliman EZ, Liu CY, Lima JAC, Bluemke DA. Myocardial structure, function, and scar in patients with type 1 diabetes mellitus. Circulation 2011; 124:1737-46. [PMID: 21947298 DOI: 10.1161/circulationaha.111.022327] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND We report relationships between cardiovascular disease risk factors and myocardial structure, function, and scar in patients with type 1 diabetes mellitus in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study. METHODS AND RESULTS Cardiac magnetic resonance was obtained in 1017 patients with type 1 diabetes mellitus. Gadolinium cardiac magnetic resonance was also obtained in 741 patients. The mean age was 49±7 years; 52% were men; and mean duration of diabetes mellitus was 28±5 years. Associations of cardiovascular disease risk factors with cardiac magnetic resonance parameters were examined with linear and logistic regression models. History of macroalbuminuria was positively associated with left ventricular mass (by 14.8 g), leading to a significantly higher ratio of left ventricular mass to end-diastolic volume (by 8%). Mean hemoglobin A(1c) levels over the preceding 22 years were inversely associated with end-diastolic volume (-3.0 mL per unit mean hemoglobin A(1c) percent) and stroke volume (-2.3 mL per unit mean hemoglobin A(1c) percent) and positively related to the ratio of elevated left ventricular mass to end-diastolic volume (0.02 g/mL per unit). The overall prevalence of myocardial scar was 4.3% by cardiac magnetic resonance and 1.4% by clinical adjudication of myocardial infarction. Both mean hemoglobin A(1c) (odds ratio, 1.5 [95% confidence interval, 1.0-2.2] per unit) and macroalbuminuria (odds ratio, 3.5 [95% confidence interval, 1.2-9.9]) were significantly associated with myocardial scar and traditional cardiovascular disease risk factors. CONCLUSIONS In addition to traditional cardiovascular disease risk factors, elevated mean hemoglobin A(1c) and macroalbuminuria were significantly associated with alterations in left ventricular structure and function. The prevalence of myocardial scar was 4.3% in this subcohort of DCCT/EDIC participants with relatively preserved renal function. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00360893 and NCT00360815.
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Affiliation(s)
- Evrim B Turkbey
- National Institutes of Health Clinical Center, National Institute of Biomedical Imaging and Bioengineering, Bethesda, MD 20892, USA
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Figtree GA, Lønborg J, Grieve SM, Ward MR, Bhindi R. Cardiac magnetic resonance imaging for the interventional cardiologist. JACC Cardiovasc Interv 2011; 4:137-48. [PMID: 21349451 DOI: 10.1016/j.jcin.2010.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 09/10/2010] [Accepted: 09/17/2010] [Indexed: 01/04/2023]
Abstract
Cardiac magnetic resonance imaging is a noninvasive technique for assessing heart structure and function without the need for ionizing radiation. Its ability to precisely outline regions of myocardial ischemia and infarction gives it an important role in guiding interventional cardiologists in revascularization. Its ability to characterize and precisely quantify abnormal regurgitant flow volumes or abnormal shunts also makes it a valuable tool for many noncoronary interventions. This review will discuss the evidence for cardiac magnetic resonance in guiding complex therapies in the catheter laboratory, as well as practical issues that need to be addressed to allow the application of this powerful tool to an increasing number of our patients.
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Affiliation(s)
- Gemma A Figtree
- North Shore Heart Research Group, Kolling Institute, University of Sydney, Sydney, Australia
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