1
|
Vyas R, Changal KH, Bhuta S, Pasadyn V, Katterle K, Niedoba MJ, Vora K, Dharmakumar R, Gupta R. Impact of Intramyocardial Hemorrhage on Clinical Outcomes in ST-Elevation Myocardial Infarction: A Systematic Review and Meta-analysis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100444. [PMID: 39132339 PMCID: PMC11307811 DOI: 10.1016/j.jscai.2022.100444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 08/13/2024]
Abstract
Background Intramyocardial hemorrhage (IMH) occurs after ST-elevation myocardial infarction (STEMI) and has been documented using cardiac magnetic resonance imaging. The prevalence and prognostic significance of IMH are not well described, and the small sample size has limited prior studies. Methods We performed a comprehensive literature search of multiple databases to identify studies that compared outcomes in STEMI patients with or without IMH. The outcomes studied were major adverse cardiovascular events (MACE), infarct size, thrombolysis in myocardial infarction (TIMI) flow after percutaneous coronary intervention (PCI), left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), and mortality. Odds ratios (ORs) and standardized mean differences with corresponding 95% CIs were calculated using a random effects model. Results Eighteen studies, including 2824 patients who experienced STEMI (1078 with IMH and 1746 without IMH), were included. The average prevalence of IMH was 39%. There is a significant association between IMH and subsequent MACE (OR, 2.63; 95% CI, 1.79-3.86; P < .00001), as well as IMH and TIMI grade <3 after PCI (OR, 1.75; 95% CI, 1.14-2.68; P = .05). We also found a significant association between IMH and the use of glycoprotein IIb/IIIa inhibitors (OR, 2.34; 95% CI, 1.42-3.85; P = .0008). IMH has a positive association with infarct size (standardized mean difference, 2.19; 95% CI, 1.53-2.86; P < .00001) and LVEDV (standardized mean difference, 0.7; 95% CI, 0.41-0.99; P < .00001) and a negative association with LVEF (standardized mean difference, -0.89; 95% CI, -1.15 to -0.63; P = .01). Predictors of IMH include male sex, smoking, and left anterior descending infarct. Conclusions Intramyocardial hemorrhage is prevalent in approximately 40% of patients who experience STEMI. IMH is a significant predictor of MACE and is associated with larger infarct size, higher LVEDV, and lower LVEF after STEMI.
Collapse
Affiliation(s)
- Rohit Vyas
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio
| | - Khalid H. Changal
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio
| | - Sapan Bhuta
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Vanessa Pasadyn
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Konrad Katterle
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | | | - Keyur Vora
- Department of Medicine and Cardiovascular Institute, Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rohan Dharmakumar
- Department of Medicine and Cardiovascular Institute, Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rajesh Gupta
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio
| |
Collapse
|
2
|
Li K, Zhang B, Zheng B, Zhang Y, Huo Y. Reperfusion Strategy of ST-Elevation Myocardial Infarction: A Meta-Analysis of Primary Percutaneous Coronary Intervention and Pharmaco-Invasive Therapy. Front Cardiovasc Med 2022; 9:813325. [PMID: 35369319 PMCID: PMC8970601 DOI: 10.3389/fcvm.2022.813325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background Pharmaco-invasive therapy (PIT), combining thrombolysis and percutaneous coronary intervention, was a potential complement for primary percutaneous coronary intervention (pPCI), while bleeding risk was still a concern. Objectives This study aims to compare the efficacy and safety outcomes of PIT and pPCI. Methods A systematic search for randomized controlled trials (RCTs) and observational studies were conducted on Pubmed, Embase, Cochrane library, and Scopus. RCTs and observational studies were all collected and respectively analyzed, and combined pooled analysis was also presented. The primary efficacy outcome was short-term all-cause mortality within 30 days, including in-hospital period. The primary safety outcome was 30-day trial-defined major bleeding events. Results A total of 26,597 patients from 5 RCTs and 12 observational studies were included. There was no significant difference in short-term mortality [RCTs: risk ratio (RR): 1.14, 95% CI: 0.67–1.93, I2 = 0%, p = 0.64; combined results: odds ratio (OR): 1.09, 95% CI: 0.93–1.29, I2 = 0%, p = 0.30] and 30-day major bleeding events (RCTs: RR: 0.44, 95% CI: 0.07–2.93, I2 = 0%, p = 0.39; combined results: OR: 1.01, 95% CI: 0.53–1.92, I2 = 0%, p = 0.98). However, pPCI reduced risk of in-hospital major bleeding events, stroke and intracranial bleeding, but increased risk of in-hospital heart failure and 30-day heart failure in combined analysis of RCTs and observational studies, despite no significant difference in analysis of RCTs. Conclusion Pharmaco-invasive therapy could be an important complement for pPCI in real-world clinical practice under specific conditions, but studies aiming at optimizing thrombolysis and its combination of mandatory coronary angiography are also warranted.
Collapse
Affiliation(s)
- Kaiyin Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bin Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First hospital, Beijing, China
- *Correspondence: Bo Zheng,
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First hospital, Beijing, China
- Yan Zhang,
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| |
Collapse
|
3
|
Milenkina SG, Belogurov AA, Delver EP, Staroverov II. [Pharmacoinvasive Approach to the Treatment of Acute ST-Segment Elevation Myocardial Infarction. Current State of the Problem]. ACTA ACUST UNITED AC 2020; 60:62-69. [PMID: 32245356 DOI: 10.18087/cardio.2020.1.n699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/29/2019] [Indexed: 11/18/2022]
Abstract
The articled focused on the pharmacoinvasive approach to the treatment of acute ST-segment elevation myocardial infarction. Current guidelines prioritize the primary transcutaneous coronary intervention. However, in both the Russian Federation and other countries, there are some peculiarities (logistic issues, specific aspects of infrastructure of medical facilities), which may hamper timely conduction of the endovascular treatment. In such cases, the thrombolytic therapy subsequently supplemented with transcutaneous coronary intervention would appear the most effective strategy aimed at the earliest recovery of coronary perfusion. The authors provided results of major studies that used such approach and the effect of using the thrombolytic therapy with recombinant prourokinase, a Russian third generation thrombolytic drug.
Collapse
Affiliation(s)
| | | | - E P Delver
- Russian Medical Research Center of Cardiology
| | | |
Collapse
|
4
|
Siddiqi TJ, Usman MS, Khan MS, Sreenivasan J, Kassas I, Riaz H, Raza S, Deo SV, Sharif H, Kalra A, Yadav N. Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction. Am J Cardiol 2018; 122:542-547. [PMID: 30205885 DOI: 10.1016/j.amjcard.2018.04.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 12/24/2022]
Abstract
ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.
Collapse
Affiliation(s)
| | | | | | | | - Ibrahim Kassas
- Division of Cardiology, New York University School of Medicine, New York, New York
| | - Haris Riaz
- Division of Cardiology, Cleveland Clinic, Cleveland Ohio
| | - Sajjad Raza
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Salil V Deo
- Department of Cardiac Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Hasanat Sharif
- Department of Cardiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ankur Kalra
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Neha Yadav
- Division of Cardiology, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
| |
Collapse
|
5
|
Roifman I, Ghugre NR, Vira T, Zia MI, Zavodni A, Pop M, Connelly KA, Wright GA. Assessment of the longitudinal changes in infarct heterogeneity post myocardial infarction. BMC Cardiovasc Disord 2016; 16:198. [PMID: 27741939 PMCID: PMC5064965 DOI: 10.1186/s12872-016-0373-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 09/30/2016] [Indexed: 11/17/2022] Open
Abstract
Background Infarct heterogeneity, as assessed by determination of the peri-infarct zone (PIZ) by cardiac magnetic resonance imaging, has been shown to be an independent predictor for the development of cardiac arrhythmias and mortality post myocardial infarction (MI). The temporal evolution of the PIZ post MI is currently unknown. Thus, the main objective of our study was to describe the temporal evolution of the PIZ over a 6 month time period in contemporarily managed ST elevation myocardial infarction (STEMI) patients. Further, given the poor prognosis associated with microvascular obstruction (MVO) post STEMI, we sought to compare the temporal evolution of the PIZ in patients with and without MVO. We hypothesized that patients with MVO would show a relative persistence of PIZ over time when compared to those without MVO. Methods Twenty-one patients post primary percutaneous coronary intervention were enrolled and treated with evidence based therapy. Each patient had three cardiac MRI scans at 48 h, 3 weeks and 6 months post infarction. Repeated Measures Analysis of Variance (ANOVA) was used to assess the evolution of core infarct size and peri-infarct zone size across the three time frames. Results The patients in this study were predominantly male, with ~40 % LAD territory infarction and a mean LVEF of 46 ± 7 %. Core infarct size and PIZ size both decreased significantly across the three time frames. The presence of microvascular obstruction (MVO), a known adverse prognostic factor, influenced PIZ size. Both patients with and without MVO had a significant reduction in core infarct size over time. Patients with MVO did not have a significant change in PIZ size over time (11.9 ± 6.8 %, 12.2 ± 7.5 %, 10.7 ± 6.6 % p = 0.77). In contrast, non-MVO patients did have a significant decrease in PIZ size over time (7.0 ± 5.5 %, 7.1 ± 6.5 %, 2.7 ± 2.6 %, p = 0.01). Conclusions Peri-infarct zone size, like core infarct size, varies depending upon the timing of measurement. Patients with MVO displayed a persistence of the PIZ over time.
Collapse
Affiliation(s)
- Idan Roifman
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.
| | - Nilesh R Ghugre
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Tasnim Vira
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada
| | - Mohammad I Zia
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada
| | - Anna Zavodni
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Division of Cardiothoracic Imaging, Department of Medical Imaging, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Mihaela Pop
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, The University of Toronto, Toronto, ON, Canada
| | - Graham A Wright
- Sunnybrook Research Institute, Schulich Heart Program, Sunnybrook Health Sciences Centre and the University of Toronto, 2075 Bayview Avenue, room M 315b, Toronto, ON, M4N-3M5, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
6
|
Cambios en el tratamiento y el pronóstico del síndrome coronario agudo con la implantación del código infarto en un hospital con unidad de hemodinámica. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.12.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
7
|
Cordero A, López-Palop R, Carrillo P, Frutos A, Miralles S, Gunturiz C, García-Carrilero M, Bertomeu-Martínez V. Changes in Acute Coronary Syndrome Treatment and Prognosis After Implementation of the Infarction Code in a Hospital With a Cardiac Catheterization Unit. ACTA ACUST UNITED AC 2016; 69:754-9. [PMID: 26979766 DOI: 10.1016/j.rec.2015.12.021] [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: 09/15/2015] [Accepted: 12/04/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Emergency care systems have been created to improve treatment and revascularization in myocardial infarction but they may also improve the management of all patients with acute coronary syndrome. METHODS A comparative study of all patients admitted with acute coronary syndrome before and after implementation of an infarction protocol. RESULTS The study included 1210 patients. While the mean age was the same in both periods, the patient group admitted after implementation of the protocol had a lower prevalence of diabetes mellitus and hypertension but more active smokers and higher GRACE scores. The percentage of ST-segment elevation acute coronary syndrome (29.8%-39.5%) and coronary revascularizations (82.1%-90.1%) significantly increased among patients admitted with acute coronary syndrome, and primary angioplasty became routine (51.9%-94.9%); there was also a reduction in time to catheterization and an increase in early revascularization. The mean hospital stay was significantly shorter after implementation of the infarction protocol. In-hospital mortality was unchanged, except in high-risk patients (38.8%-22.4%). After discharge, no differences were observed between the 2 periods in cardiovascular mortality, all-cause mortality, reinfarction, or major cardiovascular complications. CONCLUSIONS After implementation of the infarction protocol, the percentage of patients admitted with ST-segment elevation acute coronary syndrome and the mean GRACE score increased among patients admitted with acute coronary syndrome. Hospital stay was reduced, and primary angioplasty use increased. In-hospital mortality was reduced in high-risk patients, and prognosis after discharge was the same in both periods.
Collapse
Affiliation(s)
- Alberto Cordero
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain.
| | - Ramón López-Palop
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Pilar Carrillo
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Araceli Frutos
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Sandra Miralles
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Clara Gunturiz
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - María García-Carrilero
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Vicente Bertomeu-Martínez
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| |
Collapse
|
8
|
Prognostic value of dipyridamole stress cardiac magnetic resonance in patients with known or suspected coronary artery disease: a mid-term follow-up study. Eur Radiol 2015; 26:2155-65. [PMID: 26515549 DOI: 10.1007/s00330-015-4064-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 10/04/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Dipyridamole stress cardiac magnetic resonance (CMR) evaluates the key phases (perfusion and wall motion) of the ischemic cascade. We sought to determine the prognostic value of dipyridamole stress-CMR in consecutive patients symptomatic for chest pain. METHODS Seven hundred and ninety-three consecutive patients symptomatic for chest pain underwent dipyridamole stress-CMR and were followed up for 810 ± 665 days. Patients were classified in group 1 (no- reversible ischemia), group 2 (stress perfusion defect alone), and group 3 [stress perfusion defect plus abnormal wall motion (AWM)]. End points were "all cardiac events" (myocardial infarction, cardiac death and revascularization) and "hard cardiac events" (all cardiac events excluding revascularization). RESULTS One hundred and ninety-five (24 %) all cardiac events and 53 (7 %) hard cardiac events were observed. All and hard cardiac event rates in groups 1, 2, and 3 were 11 %, 49 %, 69 % and 4 %, 8 %, 21 %, respectively, with a higher rate in group 2 vs. group 1 (p<0.01) and group 3 vs. groups 1 and 2 (p<0.01). Multivariate analysis showed the presence of late gadolinium enhancement and stress perfusion defect plus AWM as independent predictors of all and hard cardiac events. CONCLUSIONS Dipyridamole stress-CMR improves prognostic stratification of patients through differentiation between the different components of the ischemic cascade. KEY POINTS • Dipyridamole stress cardiac magnetic resonance helps to assess coronary artery disease. • Novel technique to study the key phases of myocardial ischemia. • Combined assessment of perfusion and motion defects. • Dipyridamole stress imaging has additional value for predicting cardiac events.
Collapse
|
9
|
Khan JN, Razvi N, Nazir SA, Singh A, Masca NGD, Gershlick AH, Squire I, McCann GP. Prevalence and extent of infarct and microvascular obstruction following different reperfusion therapies in ST-elevation myocardial infarction. J Cardiovasc Magn Reson 2014; 16:38. [PMID: 24884638 PMCID: PMC4041906 DOI: 10.1186/1532-429x-16-38] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/14/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Microvascular obstruction (MVO) describes suboptimal tissue perfusion despite restoration of infarct-related artery flow. There are scarce data on Infarct Size (IS) and MVO in relation to the mode and timing of reperfusion. We sought to characterise the prevalence and extent of microvascular injury and IS using Cardiovascular magnetic resonance (CMR), in relation to the mode of reperfusion following acute ST-Elevation Myocardial Infarction (STEMI). METHODS CMR infarct characteristics were measured in 94 STEMI patients (age 61.0 ± 13.1 years) at 1.5 T. Seventy-three received reperfusion therapy: primary percutaneous coronary-intervention (PPCI, n = 47); thrombolysis (n = 12); rescue PCI (R-PCI, n = 8), late PCI (n = 6). Twenty-one patients presented late (>12 hours) and did not receive reperfusion therapy. RESULTS IS was smaller in PPCI (19.8 ± 13.2% of LV mass) and thrombolysis (15.2 ± 10.1%) groups compared to patients in the late PCI (40.0 ± 15.6%) and R-PCI (34.2 ± 18.9%) groups, p <0.001. The prevalence of MVO was similar across all groups and was seen at least as frequently in the non-reperfused group (15/21, [76%] v 33/59, [56%], p = 0.21) and to a similar magnitude (1.3 (0.0-2.8) v 0.4 [0.0-2.9]% LV mass, p = 0.36) compared to patients receiving early reperfusion therapy. In the 73 reperfused patients, time to reperfusion, ischaemia area at risk and TIMI grade post-PCI were the strongest independent predictors of IS and MVO. CONCLUSIONS In patients with acute STEMI, CMR-measured MVO is not exclusive to reperfusion therapy and is primarily related to ischaemic time. This finding has important implications for clinical trials that use CMR to assess the efficacy of therapies to reduce reperfusion injury in STEMI.
Collapse
Affiliation(s)
- Jamal N Khan
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Naveed Razvi
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Sheraz A Nazir
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Nicholas GD Masca
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Iain Squire
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| |
Collapse
|
10
|
Merlos P, López-Lereu MP, Monmeneu JV, Sanchis J, Núñez J, Bonanad C, Valero E, Miñana G, Chaustre F, Gómez C, Oltra R, Palacios L, Bosch MJ, Navarro V, Llácer A, Chorro FJ, Bodí V. Long-term prognostic value of a comprehensive assessment of cardiac magnetic resonance indexes after an ST-segment elevation myocardial infarction. ACTA ACUST UNITED AC 2014; 66:613-22. [PMID: 24776329 DOI: 10.1016/j.rec.2013.01.016] [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: 09/19/2012] [Accepted: 01/10/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION AND OBJECTIVES A variety of cardiac magnetic resonance indexes predict mid-term prognosis in ST-segment elevation myocardial infarction patients. The extent of transmural necrosis permits simple and accurate prediction of systolic recovery. However, its long-term prognostic value beyond a comprehensive clinical and cardiac magnetic resonance evaluation is unknown. We hypothesized that a simple semiquantitative assessment of the extent of transmural necrosis is the best resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction. METHODS One week after a first ST-segment elevation myocardial infarction we carried out a comprehensive quantification of several resonance parameters in 206 consecutive patients. A semiquantitative assessment (altered number of segments in the 17-segment model) of edema, baseline and post-dobutamine wall motion abnormalities, first pass perfusion, microvascular obstruction, and the extent of transmural necrosis was also performed. RESULTS During follow-up (median 51 months), 29 patients suffered a major adverse cardiac event (8 cardiac deaths, 11 nonfatal myocardial infarctions, and 10 readmissions for heart failure). Major cardiac events were associated with more severely altered quantitative and semiquantitative resonance indexes. After a comprehensive multivariate adjustment, the extent of transmural necrosis was the only resonance index independently related to the major cardiac event rate (hazard ratio=1.34 [1.19-1.51] per each additional segment displaying>50% transmural necrosis, P<.001). CONCLUSIONS A simple and non-time consuming semiquantitative analysis of the extent of transmural necrosis is the most powerful cardiac magnetic resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction.
Collapse
Affiliation(s)
- Pilar Merlos
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | | | - Jose V Monmeneu
- Unidad de Resonancia Magnética Cardiaca, ERESA, Valencia, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Clara Bonanad
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Ernesto Valero
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Fabián Chaustre
- Centro de Biomateriales e Ingeniería Tisular, Universidad Politécnica de Valencia, Valencia, Spain
| | - Cristina Gómez
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Ricardo Oltra
- Unidad de Cuidados Intensivos, Hospital Clínico Universitario, Valencia, Spain
| | - Lorena Palacios
- Unidad de Cuidados Intensivos, Hospital Clínico Universitario, Valencia, Spain
| | - Maria J Bosch
- Unidad de Cardiología, Hospital de La Plana, Villarreal, Castellón, Spain
| | - Vicente Navarro
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Angel Llácer
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Francisco J Chorro
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain
| | - Vicente Bodí
- Servicio de Cardiología, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Valencia, Spain.
| |
Collapse
|
11
|
Falcão FJDA, Alves CMR, Barbosa AHP, Caixeta A, Sousa JMA, Souza JAM, Amaral A, Wilke LC, Perez FCA, Gonçalves Júnior I, Stefanini E, Carvalho AC. Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment. Clinics (Sao Paulo) 2013; 68:1516-20. [PMID: 24473509 PMCID: PMC3840375 DOI: 10.6061/clinics/2013(12)07] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 06/20/2013] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients.
Collapse
Affiliation(s)
| | | | | | - Adriano Caixeta
- Department of Cardiology, Universidade Federal de São Paulo, São PauloSP, Brazil
| | | | | | - Amaury Amaral
- Secretaria de Saúde do Município de São Paulo, São PauloSP, Brazil
| | | | | | | | - Edson Stefanini
- Department of Cardiology, Universidade Federal de São Paulo, São PauloSP, Brazil
| | | |
Collapse
|
12
|
Valor pronóstico a largo plazo del análisis completo de los índices de resonancia magnética cardiaca tras un infarto de miocardio con elevación del segmento ST. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2013.01.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
13
|
|
14
|
Fernández-Friera L, García-Álvarez A, Ibáñez B. Imagining the future of diagnostic imaging. ACTA ACUST UNITED AC 2012; 66:134-43. [PMID: 24775390 DOI: 10.1016/j.rec.2012.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 10/01/2012] [Indexed: 01/21/2023]
Abstract
Cardiovascular imaging has become essential to achieving a better understanding of cardiovascular diseases. Due to the advent of new technology and the refinement of existing technologies, imaging's role has extended into the biological, functional, and hemodynamic diagnosis of multiple pathophysiologic processes. Current and future trends in cardiovascular imaging will focus on improving early diagnosis of vascular disease, so as to be able to promote cardiovascular health, and on its development as a useful tool in clinical decision-making. Imaging is also increasingly used to quantify the effect of novel therapies. The rapid development of molecular imaging and fusion imaging techniques improves our understanding of cardiovascular processes from the molecular and cellular points of view and makes it possible to design and test new preventive interventions. The proliferation and integration of imaging techniques in different clinical areas and their role in "translational imaging" plays an important part in the implementation of personalized therapeutic and preventive management strategies for patients with cardiovascular disease.
Collapse
Affiliation(s)
- Leticia Fernández-Friera
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) - Imaging in Experimental Cardiology Laboratory (IExC Lab), Madrid, Spain; Servicio de Cardiología, Hospital Universitario Montepríncipe, Madrid, Spain
| | - Ana García-Álvarez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) - Imaging in Experimental Cardiology Laboratory (IExC Lab), Madrid, Spain; Servicio de Cardiología, Hospital Clínic, Barcelona, Spain
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) - Imaging in Experimental Cardiology Laboratory (IExC Lab), Madrid, Spain; Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain.
| |
Collapse
|
15
|
Cuantificación del área miocárdica en riesgo: validación de puntuaciones angiográficas coronarias con métodos de resonancia magnética cardiovascular. Rev Esp Cardiol 2012; 65:1010-7. [DOI: 10.1016/j.recesp.2012.04.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 04/13/2012] [Indexed: 11/17/2022]
|
16
|
Analysis of post-infarction salvaged myocardium by cardiac magnetic resonance. Predictors and influence on adverse ventricular remodeling. Rev Esp Cardiol 2012; 65:634-41. [PMID: 22579424 DOI: 10.1016/j.recesp.2012.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 01/29/2012] [Indexed: 01/01/2023]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate by cardiovascular magnetic resonance those factors related to the amount of salvaged myocardium after a myocardial infarction and its value in predicting adverse ventricular remodeling. METHODS One hundred eighteen patients admitted for a first ST elevation myocardial infarction (primary angioplasty, 65 patients; a pharmacoinvasive strategy, 53 patients) underwent magnetic resonance (6 [5-8] days and 6 months; n=83). The myocardial salvage index was quantitatively assessed as the percentage of area at risk (T2-weighted sequences) not showing late enhancement. RESULTS Myocardial salvage index >31% (median) was associated with a shorter time to reperfusion (153 min vs 258 min), a lower rate of diabetes (12% vs 32%), shorter time to magnetic resonance, and better cardiovascular parameters (P<.05 for all analyses). There were no significant differences depending on the reperfusion method. In a logistic regression analysis, delayed reperfusion (odds ratio=0.42 [0.29-0.63]; P<.0001), diabetes (odds ratio=0.32 [0.11-0.99]; P<.05) and a longer time to the performance of magnetic resonance (odds ratio=0.86 [0.76-0.97]; P<.05) were independently related to a lower probability of a myocardial salvage index >31%. Predictors of increased left ventricular end-systolic volume at 6 months were the number of segments showing an extent of transmural necrosis >50% (odds ratio =1.51 [1.21-1.90]; P<.0001) and left ventricular end-systolic volume at one week (odds ratio=1.12 [1.06-1.18]; P<.0001). CONCLUSIONS Cardiovascular magnetic resonance enables the quantification of the salvaged myocardium after myocardial infarction. The celerity with which reperfusion therapy is administered constitutes its most important predictor. The possible effect of a delay in the performance of magnetic resonance on myocardial salvage needs to be confirmed. Salvaged myocardium does not improve the value of magnetic resonance for predicting adverse remodeling.
Collapse
|
17
|
Lejos del ensayo clínico… cerca de nuestra realidad. Rev Clin Esp 2011; 211:579-80. [DOI: 10.1016/j.rce.2011.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 07/04/2011] [Indexed: 11/23/2022]
|
18
|
Ruiz-Nodar JM, Feliu E, Sánchez-Quiñones J, Valencia-Martín J, García M, Pineda J, Martín P, Mainar V, Bordes P, Heras S, Quintanilla MA, Sogorb F. [Minimum salvaged myocardium after rescue percutaneous coronary intervention: quantification by cardiac magnetic resonance]. Rev Esp Cardiol 2011; 64:965-71. [PMID: 21784571 DOI: 10.1016/j.recesp.2011.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Accepted: 04/28/2011] [Indexed: 02/01/2023]
Abstract
INTRODUCTION AND OBJECTIVES When fibrinolysis fails in patients with ST elevation myocardial infarction, they are referred for a rescue percutaneous coronary intervention (PCI). However, there is still no evidence of how much myocardium potentially at risk we can actually salvage after rescue PCI. METHODS Fifty consecutive patients. Cardiac magnetic resonance was performed within 6 days. Myocardial necrosis was defined by the extent of abnormal late enhancement, myocardium at risk by extent of edema, and the amount of salvaged myocardium by the difference between myocardium at risk and myocardial necrosis. Finally, myocardial salvage index (MSI) resulted from the fraction (area-at-risk minus infarct-size)/area-at-risk. RESULTS The mean time elapsed between pain onset and fibrinolitic agent administration was 176 ± 113 min; time lysis-rescue=PCI 209 ± 122 min; time pain onset-PCI = 390 ± 152 min. The area at risk was 37% ± 13% and infarct size 34.5% ± 13%. Salvaged myocardium was 3% ± 4% and MSI 9 ± 8. Salvaged myocardium and MSI were similar between patients with the artery open on arrival at the catheterization lab (Thrombolysis in Myocardial Infarction [TIMI] 3) and those with TIMI flow ≤ 2 (3.3% ± 3.6% and 8.2 ± 6.9 in TIMI 0-2 vs 3.0% ± 3.7% and 10.8 ± 10.9 in TIMI 3; P=.80 and 0.31, respectively). No significant difference was observed between patients who went through rescue PCI within a shorter time and those with longer delay times. CONCLUSIONS The myocardial salvage after rescue PCI quantified by cardiac magnetic resonance is very small. The long delay times between pain onset and the opening of the infarct-related artery with PCI are most probably the reason for such a minimal effect of rescue PCI.
Collapse
Affiliation(s)
- Juan M Ruiz-Nodar
- Departamento de Cardiología, Hospital General Universitario de Alicante, Alicante, España
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|