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Cocco M, Campo G, Guiducci V, Casella G, Cavazza C, Cerrato E, Sacchetta G, Moreno R, Menozzi A, Amat Santos I, Díez Gil JL, Scarsini R, Picchi A, Vadalà G, Pilato G, Colaiori I, Barbierato M, Arioti M, Pavasini R, Lanzilotti V, Menozzi M, Varbella F, Erriquez A, Biscaglia S. Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction With or Without ST-Segment Elevation. J Am Coll Cardiol 2024:S0735-1097(24)07984-1. [PMID: 39217557 DOI: 10.1016/j.jacc.2024.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/26/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The effectiveness of complete revascularization is well established in patients with ST-segment elevation myocardial infarction (STEMI), but it is less investigated in those with non-ST-segment elevation myocardial infarction (NSTEMI). OBJECTIVES This study aimed to assess whether complete revascularization, compared with culprit-only revascularization, was associated with consistent outcomes in older patients with STEMI and NSTEMI. METHODS In the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease) trial, 1,445 older patients with myocardial infarction (MI) were randomized to culprit-only or physiology-guided complete revascularization, stratified by STEMI (n = 256 culprit-only vs n = 253 complete) and NSTEMI (n = 469 culprit-only vs n = 467 complete). The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. The key secondary outcome included a composite of cardiovascular death or MI at 1 year. RESULTS In the overall study population, physiology-guided complete revascularization reduced both primary and key secondary outcomes. The primary outcome occurred in 54 (21.1%) STEMI patients randomized to culprit-only vs 41 (16.2%) STEMI patients of the complete group (HR: 0.75; 95% CI: 0.50-1.13) and in 98 (20.9%) NSTEMI patients randomized to culprit-only vs 72 (15.4%) NSTEMI patients of the complete group (HR: 0.71; 95% CI: 0.53-0.97), with negative interaction testing (P for interaction, 0.846). Similarly, no signal of heterogeneity with respect to the initial clinical presentation was observed for the key secondary endpoint (P for interaction, 0.654). CONCLUSIONS Physiology-guided complete revascularization, compared with culprit-only revascularization, provided consistent benefit across the whole spectrum of patients with MI. (FIRE [Functional Assessment in Elderly MI Patients With Multivessel Disease]; NCT03772743).
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Affiliation(s)
- Marta Cocco
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy.
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda USL-IRCCS Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia, Italy
| | | | | | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital ASLTO3, Rivoli, Turin, Italy
| | | | - Raul Moreno
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain, Instituto de Investigación Hospital La Paz (IDIPAZ), University Hospital La Paz, Madrid, Spain
| | | | - Ignacio Amat Santos
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - José Luis Díez Gil
- Centro de Investigation Biomedica end Red en Enfermedades Cardiovasculares, Cardiology Department, H. Universitario y Politécnico La Fe, Valencia, Spain
| | - Roberto Scarsini
- Azienda Ospedaliero Universitaria Integrata di Verona, Verona, Italy
| | - Andrea Picchi
- Cardiovascular Department, Azienda Unità Sanitaria Locale (USL) Toscana Sud-Est, Misericordia Hospital, Grosseto, Italy
| | - Giuseppe Vadalà
- Azienda Ospedaliero Universitaria Policlinico Paolo Giaccone, Palermo, Italy
| | - Gerlando Pilato
- Department of Interventional Cardiology, San Giovanni Di Dio Hospital, Agrigento, Italy
| | - Iginio Colaiori
- Cardiology Unit, Ospedale Santa Maria Goretti, Latina, Italy
| | - Marco Barbierato
- Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell'Angelo, Mestre, Venice, Italy
| | - Manfredi Arioti
- Ospedale Santa Maria delle Croci, ASL Romagna, Ravenna, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | | | - Mila Menozzi
- Cardiovascular Department, Infermi Hospital, Rimini, Italy
| | - Ferdinando Varbella
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital ASLTO3, Rivoli, Turin, Italy
| | - Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
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2
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Bianchini E, Basile M, Bianchini F, Zito A, Romagnoli E, Aurigemma C, Paraggio L, Lunardi M, Laborante R, Fracassi F, Montone RA, Leone AM, Biondi-Zoccai G, Trani C, Burzotta F. Multivessel revascularization in non-ST segment elevation acute coronary syndromes: A systematic review and meta-analysis of 182,798 patients. Int J Cardiol 2024; 413:132392. [PMID: 39067526 DOI: 10.1016/j.ijcard.2024.132392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 06/12/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Patients experiencing non-ST segment elevation acute-coronary-syndromes (NSTE-ACS) often present with multivessel-coronary-artery-disease (MVD). An immediate complete multivessel revascularization (MVR) - within the index hospitalization - may be considered the default therapeutic strategy, although its risk-to-benefit profile has not been definitively established through dedicated clinical trials. METHODS A systematic review and meta-analysis, adhering to MOOSE and PRISMA guidelines, was conducted to assess studies comparing immediate MVR versus a conservative culprit-only revascularization (COR) in NSTE-ACS with MVD. The main endpoints were all-cause death, major adverse cardiovascular events (MACE) and non-fatal myocardial infarction (MI). The incidence of any revascularization or further percutaneous-coronary-interventions (PCIs) were also collected. The primary analyses for the main endpoints were conducted on propensity-matched groups only. RESULTS A total of 22 studies (182,798 patients) were identified. 7 studies, encompassing 11,372 patients, were included in the primary analysis of propensity score-matched groups. Immediate MVR significantly increased (28%) survival (OR 0.72, 95% CI 0.58-0.90, P < 0.01) along with a 35% reduction in MACE (OR 0.65, 95% CI 0.47-0.88, P = 0.01) and a 60% decrease in MI (OR 0.40, 95% CI 0.25-0.63, P < 0.01) during a mean 3-years follow-up compared to the propensity score-matched COR group. Results were consistent in the unmatched analyses. CONCLUSIONS This meta-analysis supports an immediate MVR for improving clinical outcomes in patients with NSTE-ACS and MVD as compared to a conservative immediate COR. These data prompt further evaluations regarding optimal strategies in the pursuit of MVR, including patient selection, revascularization modality, and assessment methods of revascularization completeness.
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Affiliation(s)
- Emiliano Bianchini
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mattia Basile
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Bianchini
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Zito
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Lazzaro Paraggio
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Mattia Lunardi
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Renzo Laborante
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Fracassi
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy; Center of Excellence in Cardiovascular Sciences, Ospedale Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Carlo Trani
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy.
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Shanmuganathan M, Nikolaidou C, Burrage MK, Borlotti A, Kotronias R, Scarsini R, Banerjee A, Terentes-Printzios D, Pitcher A, Gara E, Langrish J, Lucking A, Choudhury R, De Maria GL, Banning A, Piechnik SK, Channon KM, Ferreira VM. Cardiovascular Magnetic Resonance Before Invasive Coronary Angiography in Suspected Non-ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Imaging 2024:S1936-878X(24)00196-7. [PMID: 38970595 DOI: 10.1016/j.jcmg.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND In suspected non-ST-segment elevation myocardial infarction (NSTEMI), this presumed diagnosis may not hold true in all cases, particularly in patients with nonobstructive coronary arteries (NOCA). Additionally, in multivessel coronary artery disease, the presumed infarct-related artery may be incorrect. OBJECTIVES This study sought to assess the diagnostic utility of cardiac magnetic resonance (CMR) before invasive coronary angiogram (ICA) in suspected NSTEMI. METHODS A total of 100 consecutive stable patients with suspected acute NSTEMI (70% male, age 62 ± 11 years) prospectively underwent CMR pre-ICA to assess cardiac function (cine), edema (T2-weighted imaging, T1 mapping), and necrosis/scar (late gadolinium enhancement). CMR images were interpreted blinded to ICA findings. The clinical care and ICA teams were blinded to CMR findings until post-ICA. RESULTS Early CMR (median 33 hours postadmission and 4 hours pre-ICA) confirmed only 52% (52 of 100) of patients had subendocardial infarction, 15% transmural infarction, 18% nonischemic pathologies (myocarditis, Takotsubo and other forms of cardiomyopathies), and 11% normal CMR; 4% were nondiagnostic. Subanalyses according to ICA findings showed that, in patients with obstructive coronary artery disease (73 of 100), CMR confirmed only 84% (61 of 73) had MI, 10% (7 of 73) nonischemic pathologies, and 5% (4 of 73) normal. In patients with NOCA (27 of 100), CMR found MI in only 22% (6 of 27 true MI with NOCA), and reclassified the presumed diagnosis of NSTEMI in 67% (18 of 27: 11 nonischemic pathologies, 7 normal). In patients with CMR-MI and obstructive coronary artery disease (61 of 100), CMR identified a different infarct-related artery in 11% (7 of 61). CONCLUSIONS In patients presenting with suspected NSTEMI, a CMR-first strategy identified MI in 67%, nonischemic pathologies in 18%, and normal findings in 11%. Accordingly, CMR has the potential to affect at least 50% of all patients by reclassifying their diagnosis or altering their potential management.
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Affiliation(s)
- Mayooran Shanmuganathan
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Chrysovalantou Nikolaidou
- Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Matthew K Burrage
- Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Alessandra Borlotti
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Rafail Kotronias
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Roberto Scarsini
- Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Abhirup Banerjee
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Dimitrios Terentes-Printzios
- Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Alex Pitcher
- Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Edit Gara
- Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Jeremy Langrish
- Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Andrew Lucking
- Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Robin Choudhury
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Giovanni Luigi De Maria
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Adrian Banning
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Stefan K Piechnik
- Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Keith M Channon
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Vanessa M Ferreira
- Acute Vascular Imaging Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, National Institute for Health and Care Research Oxford Biomedical Research Centre, Oxford British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom; Oxford University Hospitals National Health Service Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom.
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Balmforth C, Whittington B, Tzolos E, Bing R, Williams MC, Clark L, Corral CA, Tavares A, Dweck MR, Newby DE. Translational molecular imaging: Thrombosis imaging with positron emission tomography. J Nucl Cardiol 2024:101848. [PMID: 38499227 DOI: 10.1016/j.nuclcard.2024.101848] [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: 12/29/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/20/2024]
Abstract
A key focus of cardiovascular medicine is the detection, treatment, and prevention of disease, with a move towards more personalized and patient-centred treatments. To achieve this goal, novel imaging approaches that allow for early and accurate detection of disease and risk stratification are needed. At present, the diagnosis, monitoring, and prognostication of thrombotic cardiovascular diseases are based on imaging techniques that measure changes in structural anatomy and biological function. Molecular imaging is emerging as a new tool for the non-invasive detection of biological processes, such as thrombosis, that can improve identification of these events above and beyond current imaging modalities. At the forefront of these evolving techniques is the use of high-sensitivity radiotracers in conjunction with positron emission tomography imaging that could revolutionise current diagnostic paradigms by improving our understanding of the role and origin of thrombosis in a range of cardiovascular diseases.
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Affiliation(s)
- Craig Balmforth
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - Beth Whittington
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Evangelos Tzolos
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rong Bing
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Laura Clark
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Carlos Alcaide Corral
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Adriana Tavares
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Marc Richard Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David Ernest Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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5
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Bujak K, Rinaldi R, Vidal-Cales P, Montone RA, Diletti R, Gąsior M, Crea F, Sabaté M, Brugaletta S. Immediate versus staged complete revascularization in acute coronary syndrome: A meta-analysis of randomized controlled trials. Int J Cardiol 2023; 393:131397. [PMID: 37769973 DOI: 10.1016/j.ijcard.2023.131397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Clinical guidelines recommend a complete revascularization (CR) in patients with acute coronary syndromes (ACS) and multivessel disease (MVD). However, its optimal timing is unclear. The aim of this meta-analysis was to compare the clinical outcomes following immediate versus staged CR in ACS. METHODS PubMed and Scopus were searched until March 2023 for randomized controlled trials (RCTs) comparing immediate versus staged CR. The primary endpoint was major adverse cardiovascular event (MACE) at the longest follow-up. Secondary outcomes were all-cause death, cardiovascular death, myocardial infarction (MI), any unplanned revascularization, target-vessel revascularization (TVR), and stent thrombosis. Safety outcomes were major bleeding, contrast volume, procedure duration, and length of hospitalization. RESULTS Eight RCTs were included (3559 patients, weighted mean follow-up 12.5 months). There were no differences in the primary endpoint (OR 0.74, 95%CI: 0.54-1.01) and in the secondary endpoints of death, and stent thrombosis between the two CR strategies. Immediate CR was associated with a lower risk of recurrent MI (OR 0.51, 95% CI 0.34-0.76), any unplanned revascularization (OR 0.59, 95%CI: 0.43-0.80), and TVR (OR 0.61, 95% CI 0.45-0.84) compared to staged CR. Immediate CR was also associated with lower total contrast volume and shorter total procedure duration and hospitalization length compared to staged CR without differences in major bleedings. CONCLUSION No difference was found between immediate and staged CR regarding MACE, or deaths rates at one year. Immediate CR may be associated with a lower risk of recurrent MI and unplanned coronary revascularization than staged CR.
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Affiliation(s)
- Kamil Bujak
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Riccardo Rinaldi
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Pablo Vidal-Cales
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rocco Antonio Montone
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Roberto Diletti
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Konst RE, Parker M, Bhatti L, Kaolawanich Y, Alenezi F, Elias-Smale SE, Nijveldt R, Kim RJ. Prognostic Value of Cardiac Magnetic Resonance Imaging in Patients With a Working Diagnosis of MINOCA-An Outcome Study With up to 10 Years of Follow-Up. Circ Cardiovasc Imaging 2023; 16:e014454. [PMID: 37582156 DOI: 10.1161/circimaging.122.014454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/07/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Patients with a working diagnosis of myocardial infarction with unobstructed coronary arteries (MINOCA) represent a heterogeneous cohort. The prognosis could vary substantially depending on the underlying cause. Although cardiac magnetic resonance (CMR) is considered a key diagnostic tool in these patients, there are limited data linking the CMR diagnosis with the outcome. METHODS This study is a prospective outcomes registry of consecutive patients presenting with a working diagnosis of MINOCA who were clinically referred for CMR at an academic hospital from October 2003 to February 2020. We assessed the relationships between the prespecified CMR diagnoses of acute myocardial infarction (AMI), myocarditis, nonischemic cardiomyopathy (NICM), normal CMR study, and major adverse cardiac events (MACEs). RESULTS Of 252 patients, the CMR diagnosis was AMI in 63 (25%), myocarditis in 33 (13%), NICM in 111 (44%), normal CMR in 37 (15%), and other diagnoses in 8 (3%). A specific nonischemic cause was diagnosed allowing true MINOCA to be ruled-out in 57% of the cohort. During up to 10 years of follow-up (1595 patient-years), MACE occurred in 84 patients (33%), which included 64 deaths (25%). The unadjusted cumulative 10-year rate of MACE was 47% in AMI, 24% in myocarditis, 50% in NICM, and 3.5% in patients with a normal CMR (Log-rank P<0.001). The CMR diagnosis provided incremental prognostic value over clinical factors including age, gender, coronary artery disease risk factors, presentation with ST-elevation, and peak troponin (incremental χ² 17.9, P<0.001); and patients with diagnoses of AMI, myocarditis, and NICM had worse MACE-free survival than patients with a normal CMR. CONCLUSIONS In patients with a working diagnosis of MINOCA, CMR allows ruling-out true MINOCA in over half of the patients. CMR diagnoses of AMI, myocarditis, and NICM are associated with worse MACE-free survival, whereas a normal CMR study portends a benign prognosis.
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Affiliation(s)
- Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands (R.E.K., S.E.E.-S., R.N.)
- Duke Cardiovascular Magnetic Resonance Center (R.E.K., M.P., L.B., Y.K., F.A., R.J.K.), Duke University Medical Center, Durham, NC
| | - Michele Parker
- Duke Cardiovascular Magnetic Resonance Center (R.E.K., M.P., L.B., Y.K., F.A., R.J.K.), Duke University Medical Center, Durham, NC
| | - Lubna Bhatti
- Duke Cardiovascular Magnetic Resonance Center (R.E.K., M.P., L.B., Y.K., F.A., R.J.K.), Duke University Medical Center, Durham, NC
| | - Yodying Kaolawanich
- Duke Cardiovascular Magnetic Resonance Center (R.E.K., M.P., L.B., Y.K., F.A., R.J.K.), Duke University Medical Center, Durham, NC
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (Y.K.)
| | - Fawaz Alenezi
- Duke Cardiovascular Magnetic Resonance Center (R.E.K., M.P., L.B., Y.K., F.A., R.J.K.), Duke University Medical Center, Durham, NC
| | - Suzette E Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands (R.E.K., S.E.E.-S., R.N.)
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands (R.E.K., S.E.E.-S., R.N.)
| | - Raymond J Kim
- Division of Cardiology (F.A., R.J.K.), Duke University Medical Center, Durham, NC
- Department of Radiology (R.J.K.), Duke University Medical Center, Durham, NC
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7
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Tzolos E, Bing R, Andrews J, MacAskill MG, Tavares AAS, Macnaught G, Clark T, Mills NL, Fujisawa T, Nash J, Dey D, Slomka PJ, Koglin N, Stephens AW, Deutsch MA, van Beek EJR, Williams MC, Hermann S, Hugenberg V, Dweck MR, Newby DE. Noninvasive In Vivo Coronary Artery Thrombus Imaging. JACC Cardiovasc Imaging 2023; 16:820-832. [PMID: 36526577 DOI: 10.1016/j.jcmg.2022.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/16/2022] [Accepted: 10/06/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The diagnosis and management of myocardial infarction are increasingly complex, and establishing the presence of intracoronary thrombosis has major implications for both the classification and treatment of myocardial infarction. OBJECTIVES The aim of this study was to investigate whether positron emission tomographic (PET) and computed tomographic (CT) imaging could noninvasively detect in vivo thrombus formation in human coronary arteries using a novel glycoprotein IIb/IIIa receptor antagonist-based radiotracer, 18F-GP1. METHODS In a single-center observational case-control study, patients with or without acute myocardial infarction underwent coronary 18F-GP1 PET/CT angiography. Coronary artery 18F-GP1 uptake was assessed visually and quantified using maximum target-to-background ratios. RESULTS 18F-GP1 PET/CT angiography was performed in 49 patients with and 50 patients without acute myocardial infarction (mean age: 61 ± 9 years, 75% men). Coronary 18F-GP1 uptake was apparent in 39 of the 49 culprit lesions (80%) in patients with acute myocardial infarction. False negative results appeared to relate to time delays to scan performance and low thrombus burden in small-caliber distal arteries. On multivariable regression analysis, culprit vessel status was the only independent variable associated with higher 18F-GP1 uptake. Extracoronary cardiac 18F-GP1 findings included a high frequency of infarct-related intramyocardial uptake (35%) as well as left ventricular (8%) or left atrial (2%) thrombus. CONCLUSIONS Coronary 18F-GP1 PET/CT angiography is the first noninvasive selective technique to identify in vivo coronary thrombosis in patients with acute myocardial infarction. This novel approach can further define the role and location of thrombosis within the heart and has the potential to inform the diagnosis, management, and treatment of patients with acute myocardial infarction. (In-Vivo Thrombus Imaging With 18F-GP1, a Novel Platelet PET Radiotracer [iThrombus]; NCT03943966).
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Affiliation(s)
- Evangelos Tzolos
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - Rong Bing
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jack Andrews
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark G MacAskill
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Adriana A S Tavares
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Gillian Macnaught
- Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Tim Clark
- Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer Nash
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Damini Dey
- Departments of Medicine (Division of Artificial Intelligence in Medicine) and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Piotr J Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine) and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Marcus-Andre Deutsch
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, University Hospital Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Edwin J R van Beek
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Sven Hermann
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Verena Hugenberg
- Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine-Westphalia Bochum, University Hospital of the Ruhr University, Bad Oeynhausen, Germany
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
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8
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Ohashi H, Kuramitsu S, Takashima H, Matsuo H, Horie K, Terai H, Kikuta Y, Ishihara T, Saigusa T, Sakamoto T, Suematsu N, Shiono Y, Asano T, Tsujita K, Masamura K, Doijiri T, Sasaki Y, Ogita M, Kurita T, Matsuo A, Harada K, Yaginuma K, Sonoda S, Amano T, Yokoi H, Tanaka N. Five-Year Outcomes After Fractional Flow Reserve-Guided Deferral of Revascularization in Infarct-Related Artery Lesions. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100632. [PMID: 39130706 PMCID: PMC11307784 DOI: 10.1016/j.jscai.2023.100632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/28/2023] [Accepted: 03/09/2023] [Indexed: 08/13/2024]
Abstract
Background Little evidence is available about the long-term safety of fractional flow reserve (FFR)-guided deferral of revascularization in infarct-related artery (IRA) lesions, especially when measuring FFR in the late setting after myocardial infarction (MI). This study aimed to assess the long-term outcomes after deferral of revascularization in IRA lesions based on FFR assessed in the late phase of post-MI. Methods From the J-CONFIRM registry (Long-Term Outcomes of Japanese Patients With Deferral of Coronary Intervention Based on Fractional Flow Reserve in Multicenter Registry), data on 1447 lesions (1263 patients) were divided into 2 groups: the IRA and non-IRA groups. The primary study end point was the cumulative 5-year incidence of target vessel failure (TVF), such as cardiac death, target vessel-related MI, and clinically driven target vessel revascularization. Results Of the 1447 lesions, 138 (9.5%) were classified into the IRA group. The median duration of FFR measurement was 716 days after MI. The frequency of visual-functional mismatches (ie, FFR >0.80 and percent diameter stenosis ≥50% or FFR ≤0.80 and percent diameter stenosis <50%) was comparable between the IRA and non-IRA groups (31.9% vs 36.3%). The cumulative 5-year incidence of TVF did not differ between the groups (9.2% vs 11.8%; inverse probability-weighted hazard ratio, 1.18, 95% confidence intervals, 0.48-2.91, P = .71). Similar results were observed irrespective of regional wall motion assessed by ultrasonic cardiography and acute MI type. Conclusions The 5-year TVF rate did not differ between the IRA and non-IRA lesions when deferring revascularization guided by FFR in the late setting of post-MI.
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Affiliation(s)
- Hirofumi Ohashi
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Shoichi Kuramitsu
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Kazunori Horie
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Japan
| | - Hidenobu Terai
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Yuetsu Kikuta
- Department of Cardiology, Fukuyama Cardiovascular Hospital, Fukuyama, Japan
| | | | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Nobuhiro Suematsu
- Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Taku Asano
- Department of Cardiology, St Luke’s International Hospital, Tokyo, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Tatsuki Doijiri
- Department of Cardiology, Yamato Seiwa Hospital, Yamato, Japan
| | - Yohei Sasaki
- Department of Cardiology, Chidoribashi Hospital, Fukuoka, Japan
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Akiko Matsuo
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Ken Harada
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, Japan
| | - Kenji Yaginuma
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Shinjo Sonoda
- Department of Cardiovascular Failure Therapy, Saga University, Saga, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Hiroyoshi Yokoi
- Department of Cardiology, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - J-CONFIRM Investigators
- Department of Cardiology, Aichi Medical University, Aichi, Japan
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Japan
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
- Department of Cardiology, Fukuyama Cardiovascular Hospital, Fukuyama, Japan
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
- Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
- Department of Cardiology, St Luke’s International Hospital, Tokyo, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiology, Nakamura Hospital, Echizen, Japan
- Department of Cardiology, Yamato Seiwa Hospital, Yamato, Japan
- Department of Cardiology, Chidoribashi Hospital, Fukuoka, Japan
- Department of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, Japan
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
- Department of Cardiovascular Failure Therapy, Saga University, Saga, Japan
- Department of Cardiology, Fukuoka Sanno Hospital, Fukuoka, Japan
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
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9
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Diletti R, den Dekker WK, Bennett J, Schotborgh CE, van der Schaaf R, Sabaté M, Moreno R, Ameloot K, van Bommel R, Forlani D, van Reet B, Esposito G, Dirksen MT, Ruifrok WPT, Everaert BRC, Van Mieghem C, Elscot JJ, Cummins P, Lenzen M, Brugaletta S, Boersma E, Van Mieghem NM. Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomised trial. Lancet 2023; 401:1172-1182. [PMID: 36889333 DOI: 10.1016/s0140-6736(23)00351-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND In patients with acute coronary syndrome and multivessel coronary disease, complete revascularisation by percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. We aimed to investigate whether PCI for non-culprit lesions should be attempted during the index procedure or staged. METHODS This prospective, open-label, non-inferiority, randomised trial was done at 29 hospitals across Belgium, Italy, the Netherlands, and Spain. We included patients aged 18-85 years presenting with ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndrome and multivessel (ie, two or more coronary arteries with a diameter of 2·5 mm or more and ≥70% stenosis based on visual estimation or positive coronary physiology testing) coronary artery disease with a clearly identifiable culprit lesion. A web-based randomisation module was used to randomly assign patients (1:1), with a random block size of four to eight, stratified by study centre, to undergo immediate complete revascularisation (PCI of the culprit lesion first, followed by other non-culprit lesions deemed to be clinically significant by the operator during the index procedure) or staged complete revascularisation (PCI of only the culprit lesion during the index procedure and PCI of all non-culprit lesions deemed to be clinically significant by the operator within 6 weeks after the index procedure). The primary outcome was the composite of all-cause mortality, myocardial infarction, any unplanned ischaemia-driven revascularisation, or cerebrovascular events at 1 year after the index procedure. Secondary outcomes included all-cause mortality, myocardial infarction, and unplanned ischaemia-driven revascularisation at 1 year after the index procedure. Primary and secondary outcomes were assessed in all randomly assigned patients by intention to treat. Non-inferiority of immediate to staged complete revascularisation was considered to be met if the upper boundary of the 95% CI of the hazard ratio (HR) for the primary outcome did not exceed 1·39. This trial is registered with ClinicalTrials.gov, NCT03621501. FINDINGS Between June 26, 2018, and Oct 21, 2021, 764 patients (median age 65·7 years [IQR 57·2-72·9] and 598 [78·3%] males) were randomly assigned to the immediate complete revascularisation group and 761 patients (median age 65·3 years [58·6-72·9] and 589 [77·4%] males) were randomly assigned to the staged complete revascularisation group, and were included in the intention-to-treat population. The primary outcome at 1 year occurred in 57 (7·6%) of 764 patients in the immediate complete revascularisation group and in 71 (9·4%) of 761 patients in the staged complete revascularisation group (HR 0·78, 95% CI 0·55-1·11, pnon-inferiority=0·0011). There was no difference in all-cause death between the immediate and staged complete revascularisation groups (14 [1·9%] vs nine [1·2%]; HR 1·56, 95% CI 0·68-3·61, p=0·30). Myocardial infarction occurred in 14 (1·9%) patients in the immediate complete revascularisation group and in 34 (4·5%) patients in the staged complete revascularisation group (HR 0·41, 95% CI 0·22-0·76, p=0·0045). More unplanned ischaemia-driven revascularisations were performed in the staged complete revascularisation group than in the immediate complete revascularisation group (50 [6·7%] patients vs 31 [4·2%] patients; HR 0·61, 95% CI 0·39-0·95, p=0·030). INTERPRETATION In patients presenting with acute coronary syndrome and multivessel disease, immediate complete revascularisation was non-inferior to staged complete revascularisation for the primary composite outcome and was associated with a reduction in myocardial infarction and unplanned ischaemia-driven revascularisation. FUNDING Erasmus University Medical Center and Biotronik.
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Affiliation(s)
- Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Wijnand K den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium
| | | | - Rene van der Schaaf
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Manel Sabaté
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Raúl Moreno
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos, Genk, Belgium
| | | | - Daniele Forlani
- Department of Cardiology, Santo Spirito Hospital, Pescara, Italy
| | - Bert van Reet
- Department of Cardiology, AZ Turnhout, Turnhout, Belgium
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Maurits T Dirksen
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | | | | | | | - Jacob J Elscot
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Paul Cummins
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Mattie Lenzen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Salvatore Brugaletta
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Eric Boersma
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands.
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10
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Abstract
Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an important subtype of myocardial infarction (MI) that occurs in approximately 6-8% of patients with spontaneous MI who are referred for coronary angiography. MINOCA disproportionately affects women, but men are also affected. Pathogenesis is more variable than in MI with obstructive coronary artery disease (MI-CAD). Dominant mechanisms include atherosclerosis, thrombosis, and coronary artery spasm. Management of MINOCA varies based on the underlying mechanism of infarction. Therefore, systematic approaches to diagnosis are recommended. The combination of invasive coronary angiography, multivessel intracoronary imaging, provocative testing for coronary spasm, and cardiac magnetic resonance imaging provides the greatest diagnostic yield. Current clinical practice guidelines for the secondary prevention of MI are based largely on data from patients with MI-CAD. Thus, optimal medications after MINOCA are uncertain. Clinical trials focused on the treatment of patients with MINOCA are urgently needed to define optimal care.
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Affiliation(s)
- H R Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA;
| | - N R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA;
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11
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Wang KL, Meah MN, Bularga A, Singh T, Williams MC, Newby DE. Computed tomography coronary angiography in non-ST-segment elevation myocardial infarction. Br J Radiol 2022; 95:20220346. [PMID: 36017975 PMCID: PMC9733606 DOI: 10.1259/bjr.20220346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/15/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022] Open
Abstract
Electrocardiography and high-sensitivity cardiac troponin testing are routinely applied as the initial step for clinical evaluation of patients with suspected non-ST-segment elevation myocardial infarction. Once diagnosed, patients with non-ST-segment elevation myocardial infarction are commenced on antithrombotic and secondary preventative therapies before undergoing invasive coronary angiography to determine the strategy of coronary revascularisation. However, this clinical pathway is imperfect and can lead to challenges in the diagnosis, management, and clinical outcomes of these patients. Computed tomography coronary angiography (CTCA) has increasingly been utilised in the setting of patients with suspected non-ST-segment elevation myocardial infarction, where it has an important role in avoiding unnecessary invasive coronary angiography and reducing downstream non-invasive functional testing for myocardial ischaemia. CTCA is an excellent gatekeeper for the cardiac catheterisation laboratory. In addition, CTCA provides complementary information for patients with myocardial infarction in the absence of obstructive coronary artery disease and highlights alternative or incidental diagnoses for those with cardiac troponin elevation. However, the routine application of CTCA has yet to demonstrate an impact on subsequent major adverse cardiovascular events. There are several ongoing studies evaluating CTCA and its associated technologies that will define and potentially expand its application in patients with suspected or diagnosed non-ST-segment elevation myocardial infarction. We here review the current evidence relating to the clinical application of CTCA in patients with non-ST-segment elevation myocardial infarction and highlight the areas where CTCA is likely to have an increasing important role and impact for our patients.
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Affiliation(s)
| | - Mohammed N Meah
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Trisha Singh
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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12
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Rabbat MG, Kwong RY, Heitner JF, Young AA, Shanbhag SM, Petersen SE, Selvanayagam JB, Berry C, Nagel E, Heydari B, Maceira AM, Shenoy C, Dyke C, Bilchick KC. The Future of Cardiac Magnetic Resonance Clinical Trials. JACC Cardiovasc Imaging 2022; 15:2127-2138. [PMID: 34922874 DOI: 10.1016/j.jcmg.2021.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 05/17/2021] [Accepted: 07/27/2021] [Indexed: 01/13/2023]
Abstract
Over the past 2 decades, cardiac magnetic resonance (CMR) has become an essential component of cardiovascular clinical care and contributed to imaging-guided diagnosis and management of coronary artery disease, cardiomyopathy, congenital heart disease, cardio-oncology, valvular, and vascular disease, amongst others. The widespread availability, safety, and capability of CMR to provide corresponding anatomical, physiological, and functional data in 1 imaging session can improve the design and conduct of clinical trials through both a reduction of sample size and provision of important mechanistic data that may augment clinical trial findings. Moreover, prospective imaging-guided strategies using CMR can enhance safety, efficacy, and cost-effectiveness of cardiovascular pathways in clinical practice around the world. As the future of large-scale clinical trial design evolves to integrate personalized medicine, cost-effectiveness, and mechanistic insights of novel therapies, the integration of CMR will continue to play a critical role. In this document, the attributes, limitations, and challenges of CMR's integration into the future design and conduct of clinical trials will also be covered, and recommendations for trialists will be explored. Several prominent examples of clinical trials that test the efficacy of CMR-imaging guided pathways will also be discussed.
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Affiliation(s)
- Mark G Rabbat
- Division of Cardiology, Loyola University Chicago, Chicago, Illinois, USA; Division of Cardiology, Edward Hines Jr VA Hospital, Hines, Illinois, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - John F Heitner
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Alistair A Young
- Department of Biomedical Engineering, King's College London, London, United Kingdom
| | - Sujata M Shanbhag
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom; National Institute for Health Research Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Joseph B Selvanayagam
- College of Medicine, Flinders University of South Australia, Department of Cardiovascular Medicine, Flinders Medical Centre, Southern Adelaide Local Health Network, and Cardiac Imaging Research Group, South Australian Health and Medical Research Institute, Adelaide, South Australia
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, and British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, United Kingdom
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, Klinikum der Johann Wolfgang Goethe-Universitat Frankfurt, Frankfurt am Main, Germany
| | - Bobak Heydari
- Stephenson Cardiac Imaging Centre and Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, and Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alicia M Maceira
- Cardiovascular Unit, Ascires Biomedical Group, and Department of Medicine, Health Sciences School, UCH-CEU University, Valencia, Spain
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Christopher Dyke
- Division of Cardiology, National Jewish Health, Denver, Colorado, USA
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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13
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Meah MN, Bularga A, Tzolos E, Chapman AR, Daghem M, Hung JD, Chiong J, Taggart C, Wereski R, Gray A, Dweck MR, Roobottom C, Curzen N, Kardos A, Felmeden D, Mills NL, Slomka PJ, Newby DE, Dey D, Williams MC. Distinguishing Type 1 from Type 2 Myocardial Infarction by Using CT Coronary Angiography. Radiol Cardiothorac Imaging 2022; 4:e220081. [PMID: 36339063 PMCID: PMC9627233 DOI: 10.1148/ryct.220081] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 01/25/2023]
Abstract
Purpose To determine whether quantitative plaque characterization by using CT coronary angiography (CTCA) can discriminate between type 1 and type 2 myocardial infarction. Materials and Methods This was a secondary analysis of two prospective studies (ClinicalTrials.gov registration nos. NCT03338504 [2014-2019] and NCT02284191 [2018-2020]) that performed blinded quantitative plaque analysis on findings from CTCA in participants with type 1 myocardial infarction, type 2 myocardial infarction, and chest pain without myocardial infarction. Logistic regression analyses were performed to identify predictors of type 1 myocardial infarction. Results Overall, 155 participants (mean age, 64 years ± 12 [SD]; 114 men) and 36 participants (mean age, 67 years ± 12; 19 men) had type 1 and type 2 myocardial infarction, respectively, and 136 participants (62 years ± 12; 78 men) had chest pain without myocardial infarction. Participants with type 1 myocardial infarction had greater total (median, 44% [IQR: 35%-50%] vs 35% [IQR: 29%-46%]), noncalcified (39% [IQR: 31%-46%] vs 34% [IQR: 29%-40%]), and low-attenuation (4.15% [IQR: 1.88%-5.79%] vs 1.64% [IQR: 0.89%-2.28%]) plaque burdens (P < .05 for all) than those with type 2. Participants with type 2 myocardial infarction had similar low-attenuation plaque burden to those with chest pain without myocardial infarction (P = .4). Low-attenuation plaque was an independent predictor of type 1 myocardial infarction (adjusted odds ratio, 3.44 [95% CI: 1.84, 6.96]; P < .001), with better discrimination than noncalcified plaque burden and maximal area of coronary stenosis (C statistic, 0.75 [95% CI: 0.67, 0.83] vs 0.62 [95% CI: 0.53, 0.71] and 0.61 [95% CI: 0.51, 0.70] respectively; P ≤ .001 for both). Conclusion Higher low-attenuation coronary plaque burden in patients with type 1 myocardial infarction may help distinguish these patients from those with type 2 myocardial infarction.Keywords: Ischemia/Infarction, CT Angiography, Quantitative CTClinical trial registration nos. NCT03338504 and NCT02284191 Supplemental material is available for this article. © RSNA, 2022.
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Affiliation(s)
- Mohammed N. Meah
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Anda Bularga
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Evangelos Tzolos
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Andrew R. Chapman
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Marwa Daghem
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - John D. Hung
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Justin Chiong
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Caelan Taggart
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Ryan Wereski
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Alasdair Gray
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Marc R. Dweck
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Carl Roobottom
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Nick Curzen
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Attila Kardos
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Dirk Felmeden
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Nicholas L. Mills
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Piotr J. Slomka
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - David E. Newby
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
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14
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Demirkiran A, van der Hoeven NW, Janssens GN, Lemkes JS, Everaars H, van de Ven PM, van Pouderoijen N, van Cauteren YJM, van Leeuwen MAH, Nap A, Teunissen PF, Hopman LHGA, Bekkers SCAM, Smulders MW, van Royen N, van Rossum AC, Robbers LFHJ, Nijveldt R. Left ventricular function, strain, and infarct characteristics in patients with transient ST-segment elevation myocardial infarction compared to ST-segment and non-ST-segment elevation myocardial infarctions. Eur Heart J Cardiovasc Imaging 2022; 23:836-845. [PMID: 34195800 PMCID: PMC9159742 DOI: 10.1093/ehjci/jeab114] [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] [Received: 04/15/2021] [Accepted: 05/19/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS This study aims to explore cardiovascular magnetic resonance (CMR)-derived left ventricular (LV) function, strain, and infarct size characteristics in patients with transient ST-segment elevation myocardial infarction (TSTEMI) compared to patients with ST-segment and non-ST-segment elevation myocardial infarctions (STEMI and NSTEMI, respectively). METHODS AND RESULTS In total, 407 patients were enrolled in this multicentre observational prospective cohort study. All patients underwent CMR examination 2-8 days after the index event. CMR cine imaging was performed for functional assessment and late gadolinium enhancement to determine infarct size and identify microvascular obstruction (MVO). TSTEMI patients demonstrated the highest LV ejection fraction and the most preserved global LV strain (longitudinal, circumferential, and radial) across the three groups (overall P ≤ 0.001). The CMR-defined infarction was less frequently observed in TSTEMI than in STEMI patients [77 (65%) vs. 124 (98%), P < 0.001] but was comparable with NSTEMI patients [77 (65%) vs. 66 (70%), P = 0.44]. A remarkably smaller infarct size was seen in TSTEMI compared to STEMI patients [1.4 g (0.0-3.9) vs. 13.5 g (5.3-26.8), P < 0.001], whereas infarct size was not significantly different from that in NSTEMI patients [1.4 g (0.0-3.9) vs. 2.1 g (0.0-8.6), P = 0.06]. Whilst the presence of MVO was less frequent in TSTEMI compared to STEMI patients [5 (4%) vs. 53 (31%), P < 0.001], no significant difference was seen compared to NSTEMI patients [5 (4%) vs. 5 (5%), P = 0.72]. CONCLUSION TSTEMI yielded favourable cardiac LV function, strain, and infarct-related scar mass compared to STEMI and NSTEMI. LV function and infarct characteristics of TSTEMI tend to be more similar to NSTEMI than STEMI.
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Affiliation(s)
- Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Nina W van der Hoeven
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Gladys N Janssens
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jorrit S Lemkes
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Nikki van Pouderoijen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | | | | | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Paul F Teunissen
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Luuk H G A Hopman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | | | - Martijn W Smulders
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Lourens F H J Robbers
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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15
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Siddiqui AJ, Omerovic E, Holzmann MJ, Böhm F. Association of coronary angiographic lesions and mortality in patients over 80 years with NSTEMI. Open Heart 2022; 9:openhrt-2021-001811. [PMID: 35101898 PMCID: PMC8804677 DOI: 10.1136/openhrt-2021-001811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/09/2022] [Indexed: 01/16/2023] Open
Abstract
Objective Coronary angiography (CA) and percutaneous coronary intervention (PCI) is of great importance during non-ST-segment elevation myocardial infarction (NSTEMI) management. Coronary artery lesions and their association to mortality in elderly patients with NSTEMI was investigated. Methods Patients >80 years of age who underwent CA at index NSTEMI during 2011–2014 were included. Data were collected from the Swedish Coronary Angiography and Angioplasty Registry and Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registries. Coronary lesions were categorised into; one vessel disease (1VD), multi-vessel disease (MVD) and left main disease (LMD) and 0%–49% stenosis grade were considered as controls. Cox regression was used to estimate HRs for all-cause mortality associated with coronary lesions. Survival benefit was determined after PCI and in relation to if revascularisation was complete or incomplete and any complications in the Cath lab was assessed. Results Five thousand seven hundred and seventy patients with history of CA and PCI were included, 10% had normal coronary arteries, 26% had 1VD, 50% MVD and 14% LMD. Mortality was higher in patients with 1VD, MVD and LMD: HR 1.8 (1.3–2.5), HR 2.2 (1.6–3.0) and HR 2.8 (2.1–3.9), respectively. PCI were treated in 84% of 1VD, 73% MVD, and 54% in LMD. Survival was higher with PCI HR 0.85 (0.73–0.99). MVD had lower adjusted mortality HR 0.71 (0.58–0.87) compared with patients with MVD who did not undergo PCI. Complications and mortality were higher in patients with LMD both during CA and PCI, HR 2.9 (1.1–7.6) and HR 4.5 (1.6–12.5). Conclusion Coronary lesions (>50% stenosis) are strong predictors of mortality in elderly patients with NSTEMI. MVD is common and PCI treatment is associated with increased survival.
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Affiliation(s)
- Anwar J Siddiqui
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Felix Böhm
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska Institutet, Stockholm, Sweden
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16
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Wa MELK, Silva KD, Pareek N, Perera D. Coronary Revascularization and Out-of-hospital Cardiac Arrest: Past, Present and Future. Heart Int 2021; 15:94-102. [PMID: 36277833 PMCID: PMC9524604 DOI: 10.17925/hi.2021.15.2.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/24/2021] [Indexed: 03/07/2024] Open
Abstract
Cardiologists and the cardiac catheter laboratory have key roles to play in the management of patients after out-of-hospital cardiac arrest (OHCA). Although immediate catheter laboratory activation is the standard of care in cardiogenic shock and ST elevation myocardial infarction, the majority of patients will present without these features and with an uncertain diagnosis. Even in the latter, early assessment and invasive management may be beneficial, but this is counterbalanced by significant resource utilization, potential to cause harm and the possibility that any diagnostic or therapeutic gains are offset by a poor neurological outcome. Past consensus on the management of the OHCA patient without ST elevation or cardiogenic shock is being challenged by emerging results from new trials in this field. Further randomized trials are ongoing, and are expected to deliver robust data from over 4,000 patients, allowing us to further refine the optimal management strategy in this challenging cohort. This article describes the benefits and pitfalls of a strategy of immediate coronary angiography in these patients, examines the recently published COACT and TOMAHAWK trials in detail, and describes a framework with which to approach the patient after resuscitated OHCA, based on the available evidence to date.
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Affiliation(s)
- Matthew E Li Kam Wa
- Cardiovascular Division, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
| | - Kalpa De Silva
- Cardiovascular Division, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
| | - Nilesh Pareek
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
- King’s College Hospital, King’s College Hospital NHS Foundation Trust, London, UK
| | - Divaka Perera
- Cardiovascular Division, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
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17
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Singh T, Chapman AR, Dweck MR, Mills NL, Newby DE. MINOCA: a heterogenous group of conditions associated with myocardial damage. Heart 2021; 107:1458-1464. [PMID: 33568434 DOI: 10.1136/heartjnl-2020-318269] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) was first described over 80 years ago. The term has been widely and inconsistently used in clinical practice, influencing various aspects of disease classification, investigation and management. MINOCA encompasses a heterogenous group of conditions that include both atherosclerotic and non-atherosclerotic disease resulting in myocardial damage that is not due to obstructive coronary artery disease. In many ways, it is a term that describes a moment in the diagnostic pathway of the patient and is arguably not a diagnosis. Central to the definition is also the distinction between myocardial infarction and injury. The universal definition of myocardial infarction distinguishes acute myocardial infarction, including those with MINOCA, from other causes of myocardial injury by the presence of clinical evidence of ischaemia. However, these ischaemic features are often non-specific causing diagnostic confusion, and can create difficulties for patient management and follow-up. The purpose of this review is to summarise our current understanding of MINOCA and highlight important issues relating to the diagnosis, investigation and management of patients with MINOCA.
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Affiliation(s)
- Trisha Singh
- British Heart Foundation Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
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18
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Rafaeli IR, Kireeva AY, Rogatova AN, Azarov AV, Semitko SP. Prognostic Value of Residual Coronary Artery Lesions on the SYNTAX Scale in Patients with Acute Myocardial Infarction without SТ Segment Elevation in the Mid-Term Period. ACTA ACUST UNITED AC 2021; 61:36-43. [PMID: 34397340 DOI: 10.18087/cardio.2021.7.n1501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/27/2021] [Indexed: 11/18/2022]
Abstract
Aim To study the effect of residual coronary injury after a percutaneous coronary intervention (PCI), as evaluated with the SYNTAX scale (residual SYNTAX score, RSS), on the mid-term prognosis for patients with non-ST elevation acute myocardial infarction (NSTEMI) and also to determine threshold RSS values for patients at high and low risk of adverse cardiac events.Material and methods A single-center, retrospective study was performed. From 421 patients with NSTEMI after PCI with stenting, 169 patients were selected who originally had multivessel coronary disease and who had undergone a repeated inpatient examination, including mid-term (11.7±3.0 mos.) coronary angiography. The endpoints were recurrent clinical manifestations of angina, repeat revascularization (RR), unstable angina (UA), recurrent acute myocardial infarction (AMI), cardiac death, and also a composite endpoint (major adverse cardiac events, MACE) that included UA, recurrent AMI, and cardiac death. After revealing a significant direct correlation between RSS and the probability of recurrent AMI, UA, MACE, or RR (p <0.05) using the ROC analysis, we have established threshold RSS values that divided patients into groups with high and low risk of the cardiac events listed above.Results For a significantly high risk of recurrent AMI (area under the curve, AUC 0.79±0.05; 95 % confidence interval, CI 0.68-0.89; р=0.048), the threshold RSS score was 8 (sensitivity 100 %, specificity 70.9 %). For UA and MACE, the RSS scores were both 3 (AUC 0.68±0.5; 95 % CI 0.58-0.79; p=0.005 and AUC 0.71±0.05; 95 % CI 0.61-0.8; p=0.001, respectively). The probability of UA during the observation period with RSS >3 was 4.07 times higher and that of MACE was 5.23 times higher than with RSS<3 (95 % CI 1.44-11.49; р=0.01 and 95 % CI 1.88-14.53; р=0.001, respectively).Conclusion The study demonstrated a significant, direct correlation between the RSS and the risk of adverse cardiac events in patients with NSTEMI during one year of observation. Specific threshold values were obtained, which may help in choosing both the extent of revascularization and the tactics for postoperative management of patients.
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Affiliation(s)
- I R Rafaeli
- Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - A Yu Kireeva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - A N Rogatova
- Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - Al V Azarov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - S P Semitko
- Sechenov First Moscow State Medical University (Sechenov University), Moscow
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19
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Kite TA, Ladwiniec A, Arnold JR, McCann GP, Moss AJ. Early invasive versus non-invasive assessment in patients with suspected non-ST-elevation acute coronary syndrome. Heart 2021; 108:500-506. [PMID: 34234006 DOI: 10.1136/heartjnl-2020-318778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/22/2021] [Indexed: 11/04/2022] Open
Abstract
Non-ST-elevation acute coronary syndrome (NSTE-ACS) comprises a broad spectrum of disease ranging from unstable angina to myocardial infarction. International guidelines recommend a routine invasive strategy for managing patients with NSTE-ACS at high to very high-risk, supported by evidence of improved composite ischaemic outcomes as compared with a selective invasive strategy. However, accurate diagnosis of NSTE-ACS in the acute setting is challenging due to the spectrum of non-coronary disease that can manifest with similar symptoms. Heterogeneous clinical presentations and limited uptake of risk prediction tools can confound physician decision-making regarding the use and timing of invasive coronary angiography (ICA). Large proportions of patients with suspected NSTE-ACS do not require revascularisation but may unnecessarily undergo ICA with its attendant risks and associated costs. Advances in coronary CT angiography and cardiac MRI have prompted evaluation of whether non-invasive strategies may improve patient selection, or whether tailored approaches are better suited to specific subgroups. Future directions include (1) better understanding of risk stratification as a guide to investigation and therapy in suspected NSTE-ACS, (2) randomised clinical trials of non-invasive imaging versus standard of care approaches prior to ICA and (3) defining the optimal timing of very early ICA in high-risk NSTE-ACS.
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Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Ladwiniec
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - J Ranjit Arnold
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alastair J Moss
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
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20
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Iqbal MB. Nonculprit Disease in Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. JACC Cardiovasc Interv 2021; 14:1079-1081. [PMID: 33933389 DOI: 10.1016/j.jcin.2021.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/15/2021] [Accepted: 03/30/2021] [Indexed: 11/20/2022]
Affiliation(s)
- M Bilal Iqbal
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada; Royal Jubilee Hospital, Victoria, British Columbia, Canada; Centre for Cardiovascular Innovation, University of British Columbia, British Columbia, Canada.
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21
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Balbi MM, Scarparo P, Tovar MN, Masdjedi K, Daemen J, Den Dekker W, Ligthart J, Witberg K, Cummins P, Wilschut J, Zijlstra F, Van Mieghem NM, Diletti R. Culprit lesion detection in patients presenting with non-ST elevation acute coronary syndrome and multivessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 35:110-118. [PMID: 33839051 DOI: 10.1016/j.carrev.2021.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE Identification of the culprit lesion in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) allows appropriate coronary revascularization but may be unclear in patients with multivessel coronary disease (MVD). Therefore, we investigated the rate of culprit lesion identification during coronary angiography in NSTE-ACS and multivessel disease. METHODS/MATERIALS Consecutive patients presenting with NSTE-ACS and MVD, between January 2012 and December 2016 were evaluated. Coronary angiograms, intravascular imaging, and ECGs were analyzed for culprit lesion identification. Long-term clinical outcomes in terms of major adverse cardiac events (MACE) and mortality were reported in patients with or without culprit identification. RESULTS A total of 1107 patients with NSTE-ACS and MVD were included in the analysis, 310 (28.0%) with unstable angina and 797 (72.0%) with non-ST elevation myocardial infarction. The culprit lesion was angiographically identified in 952 (86.0%) patients, while no clear culprit lesion was found in 155 (14.0%) patients. ECG analysis allowed to predict the location of the culprit vessel with low sensitivity (range 28.4%-36.7%) and high specificity (range 90.6%-96.5%). Higher lesion complexity was associated with inability to identify the culprit. Intravascular imaging was applied in 55 patients and helped to identify the culprit lesion in 53 patients (96.4%). There was no difference in all-cause mortality (21.4% vs. 25.8%, p = 0.24) and MACE (39.2% vs. 47.6%, p = 0.07) between the cohorts with or without culprit lesion identification by angiography. CONCLUSIONS The culprit lesion appeared unclear by coronary angiography in >10% of patients with NSTE-ACS and MVD. Complementary invasive imaging substantially enhanced the diagnostic accuracy of culprit lesion detection.
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Affiliation(s)
- Matthew Mercieca Balbi
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Paola Scarparo
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Maria Natalia Tovar
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Kaneshka Masdjedi
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Wijnand Den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jurgen Ligthart
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Karen Witberg
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Paul Cummins
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands.
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22
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van Cauteren YJM, Smulders MW, Theunissen RALJ, Gerretsen SC, Adriaans BP, Bijvoet GP, Mingels AMA, van Kuijk SMJ, Schalla S, Crijns HJGM, Kim RJ, Wildberger JE, Heijman J, Bekkers SCAM. Cardiovascular magnetic resonance accurately detects obstructive coronary artery disease in suspected non-ST elevation myocardial infarction: a sub-analysis of the CARMENTA Trial. J Cardiovasc Magn Reson 2021; 23:40. [PMID: 33752696 PMCID: PMC7983380 DOI: 10.1186/s12968-021-00723-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 02/02/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Invasive coronary angiography (ICA) is still the reference test in suspected non-ST elevation myocardial infarction (NSTEMI), although a substantial number of patients do not have obstructive coronary artery disease (CAD). Early cardiovascular magnetic resonance (CMR) may be a useful gatekeeper for ICA in this setting. The main objective was to investigate the accuracy of CMR to detect obstructive CAD in NSTEMI. METHODS This study is a sub-analysis of a randomized controlled trial investigating whether a non-invasive imaging-first strategy safely reduced the number of ICA compared to routine clinical care in suspected NSTEMI (acute chest pain, non-diagnostic electrocardiogram, high sensitivity troponin T > 14 ng/L), and included 51 patients who underwent CMR prior to ICA. A stepwise approach was used to assess the diagnostic accuracy of CMR to detect (1) obstructive CAD (diameter stenosis ≥ 70% by ICA) and (2) an adjudicated final diagnosis of acute coronary syndrome (ACS). First, in all patients the combination of cine, T2-weighted and late gadolinium enhancement (LGE) imaging was evaluated for the presence of abnormalities consistent with a coronary etiology in any sequence. Hereafter and only when the scan was normal or equivocal, adenosine stress-perfusion CMR was added. RESULTS Of 51 patients included (63 ± 10 years, 51% male), 34 (67%) had obstructive CAD by ICA. The sensitivity, specificity and overall accuracy of the first step to diagnose obstructive CAD were 79%, 71% and 77%, respectively. Additional vasodilator stress-perfusion CMR was performed in 19 patients and combined with step one resulted in an overall sensitivity of 97%, specificity of 65% and accuracy of 86%. Of the remaining 17 patients with non-obstructive CAD, 4 (24%) had evidence for a myocardial infarction on LGE, explaining the modest specificity. The sensitivity, specificity and overall accuracy to diagnose ACS (n = 43) were 88%, 88% and 88%, respectively. CONCLUSION CMR accurately detects obstructive CAD and ACS in suspected NSTEMI. Non-obstructive CAD is common with CMR still identifying an infarction in almost one-quarter of patients. CMR should be considered as an early diagnostic approach in suspected NSTEMI. TRIAL REGISTRATION The CARMENTA trial has been registered at ClinicalTrials.gov with identifier NCT01559467.
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Affiliation(s)
- Yvonne J M van Cauteren
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Martijn W Smulders
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | | | - Suzanne C Gerretsen
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Bouke P Adriaans
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | | | - Alma M A Mingels
- Department of Clinical Chemistry, Maastricht UMC+, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology & Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Simon Schalla
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Raymond J Kim
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, NC, USA
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jordi Heijman
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Sebastiaan C A M Bekkers
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
- Maastricht University Medical Center, P. Debyelaan 25, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
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23
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Kumar V, Weerakoon S, Dey AK, Earls JP, Katz RJ, Reiner JS, Shaw LJ, Blankstein R, Mehta NN, Choi AD. The evolving role of coronary CT angiography in Acute Coronary Syndromes. J Cardiovasc Comput Tomogr 2021; 15:384-393. [PMID: 33858808 DOI: 10.1016/j.jcct.2021.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/01/2021] [Accepted: 02/14/2021] [Indexed: 12/11/2022]
Abstract
In the United States, non-obstructive coronary disease has been on the rise, and each year, nearly one million adults suffer myocardial infarction, 70% of which are non-ST-segment elevation myocardial infarction (NSTEMI). In addition, approximately 15% of patients suffering NSTEMI will have subsequent readmission for a recurrent acute coronary syndrome (ACS). While invasive angiography remains the standard of care in the diagnostic and therapeutic approach to these patients, these methods have limitations that include procedural complications, uncertain specificity in diagnosis of the culprit lesion in patients with multi-vessel coronary artery disease (CAD), and challenges in following coronary disease over time. The role of coronary computed tomography angiography (CCTA) for evaluating patients with both stable and acute chest pain has seen a paramount upshift in the last decade. This paper reviews the established role of CCTA for the rapid exclusion of obstructive plaque in troponin negative acute chest pain, while exploring opportunities to address challenges in the current approach to evaluating NSTEMI.
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Affiliation(s)
- Vishak Kumar
- Division of Cardiology, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Shaneke Weerakoon
- Division of Cardiology, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Amit K Dey
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - James P Earls
- Division of Cardiology, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Richard J Katz
- Division of Cardiology, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Jonathan S Reiner
- Division of Cardiology, Interventional Cardiology Laboratory, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | | | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nehal N Mehta
- Division of Cardiology, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrew D Choi
- Division of Cardiology, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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24
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The Trials and Tribulations of Conducting Stress CMR Quantitative Analysis Studies. JACC Cardiovasc Imaging 2020; 13:2558-2560. [DOI: 10.1016/j.jcmg.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022]
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25
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Abdelrahman KM, Chen MY, Dey AK, Virmani R, Finn AV, Khamis RY, Choi AD, Min JK, Williams MC, Buckler AJ, Taylor CA, Rogers C, Samady H, Antoniades C, Shaw LJ, Budoff MJ, Hoffmann U, Blankstein R, Narula J, Mehta NN. Coronary Computed Tomography Angiography From Clinical Uses to Emerging Technologies: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 76:1226-1243. [PMID: 32883417 PMCID: PMC7480405 DOI: 10.1016/j.jacc.2020.06.076] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/08/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022]
Abstract
Evaluation of coronary artery disease (CAD) using coronary computed tomography angiography (CCTA) has seen a paradigm shift in the last decade. Evidence increasingly supports the clinical utility of CCTA across various stages of CAD, from the detection of early subclinical disease to the assessment of acute chest pain. Additionally, CCTA can be used to noninvasively quantify plaque burden and identify high-risk plaque, aiding in diagnosis, prognosis, and treatment. This is especially important in the evaluation of CAD in immune-driven conditions with increased cardiovascular disease prevalence. Emerging applications of CCTA based on hemodynamic indices and plaque characterization may provide personalized risk assessment, affect disease detection, and further guide therapy. This review provides an update on the evidence, clinical applications, and emerging technologies surrounding CCTA as highlighted at the 2019 National Heart, Lung and Blood Institute CCTA Summit.
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Affiliation(s)
- Khaled M Abdelrahman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marcus Y Chen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amit K Dey
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Renu Virmani
- Department of Pathology, CVPath Institute, Gaithersburg, Maryland
| | - Aloke V Finn
- Department of Pathology, CVPath Institute, Gaithersburg, Maryland
| | - Ramzi Y Khamis
- Vascular Sciences Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Andrew D Choi
- Division of Cardiology and Department of Radiology, The George Washington University School of Medicine, Washington, DC
| | - James K Min
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | | | | | | | - Habib Samady
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Leslee J Shaw
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York
| | - Matthew J Budoff
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jagat Narula
- Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, New York
| | - Nehal N Mehta
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
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26
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Schelbert EB, Iyer AM, Miller CA. Detecting the Prevalent Vulnerable Phenotype of Unrecognized Myocardial Infarction: Another Benefit of CMR Stress Testing. J Am Coll Cardiol 2020; 76:958-960. [PMID: 32819470 DOI: 10.1016/j.jacc.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Erik B Schelbert
- UPMC Cardiovascular Magnetic Resonance Center, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Heart and Vascular Institute, UPMC, Pittsburgh, Pennsylvania.
| | - Arun M Iyer
- UPMC Cardiovascular Magnetic Resonance Center, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Heart and Vascular Institute, UPMC, Pittsburgh, Pennsylvania
| | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom; Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, United Kingdom; Wellcome Centre for Cell-Matrix Research, Division of Cell-Matrix Biology & Regenerative Medicine, School of Biology, Faculty of Biology, Medicine & Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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27
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Affiliation(s)
- Rong Bing
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Marc Richard Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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