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Tornvall P, Beltrame JF, Nickander J, Sörensson P, Reynolds HR, Agewall S. How to Use Cardiac Magnetic Resonance Imaging in Myocardial Infarction With Nonobstructive Coronary Arteries. Circ Cardiovasc Imaging 2024; 17:e016463. [PMID: 39012944 DOI: 10.1161/circimaging.123.016463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
The working diagnosis Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA) is being increasingly recognized with the common use of high-sensitivity troponins and coronary angiography, accounting for 5% to 10% of all acute myocardial infarction presentations. Cardiac magnetic resonance (CMR) imaging is pivotal in patients presenting with suspected MINOCA, mainly to delineate those with a nonischemic cause, for example, myocarditis and Takotsubo syndrome, from those with true ischemic myocardial infarction, that is, MINOCA. The optimal timing for CMR imaging in patients with suspected MINOCA has been uncertain and, until recently, not been examined prospectively. Previous retrospective studies have indicated that the diagnostic yield decreases with time from the acute event. The SMINC studies (Stockholm Myocardial Infarction with Normal Coronaries) show that CMR should be performed early in all patients with the working diagnosis of MINOCA, with the possible exception of patients who are clearly identified as having Takotsubo syndrome as determined by echocardiography. In addition to CMR imaging, other investigations of importance in selected patients may be pulmonary artery computed tomography to exclude pulmonary embolism, optical coherence tomography to identify plaque disruption, and acetylcholine provocation to identify coronary artery spasm. Imaging of patients with the working diagnosis MINOCA, which is centered on CMR together with supplemental investigations, results in a clear diagnosis in approximately three-quarters of the patients. This is a good example of personalized medicine, because a correct diagnosis will not only increase the satisfaction of the individual patient but also result in optimizing treatment without harming the patient.
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Affiliation(s)
- Per Tornvall
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden (P.T.)
| | - John F Beltrame
- University of Adelaide, Central Adelaide Local Health Network, Basil Hetzel Institute, Australia (J.F.B.)
| | - Jannike Nickander
- Department of Molecular Medicine and Surgery (J.N.), Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Peder Sörensson
- Department of Medicine Solna (P.S.), Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York (H.R.R.)
| | - Stefan Agewall
- Clinical Science, Oslo University, Norway (S.A.)
- Karolinska Institutet Danderyd Hospital, Stockholm, Sweden (S.A.)
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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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Hirono K, Ichida F. Left ventricular noncompaction: a disorder with genotypic and phenotypic heterogeneity-a narrative review. Cardiovasc Diagn Ther 2022; 12:495-515. [PMID: 36033229 PMCID: PMC9412206 DOI: 10.21037/cdt-22-198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/21/2022] [Indexed: 01/10/2023]
Abstract
Background and Objective Left ventricular noncompaction (LVNC) is a cardiomyopathy characterized by excessive trabecular formation and deep recesses in the ventricular wall, with a bilaminar structure consisting of an endocardial noncompaction layer and an epicardial compacted layer. Although genetic variants have been reported in patients with LVNC, understanding of LVNC and its pathogenesis has not yet been fully elucidated. We addressed the latest findings on genes reported to be associated with LVNC morphogenesis and possible pathologies to understand the diverse spectrum between genotype and phenotype in LVNC. Also, the latest findings and issues related to the diagnosis of LVNC were summarized. Methods This article is written as a commentary narrative review and will provide an update on the current literature and available data on common forms of LVNC published in the past 30 years in English through to May 2022 using PubMed. Key Content and Findings Familial forms of LVNC are frequent, and autosomal dominant mode of inheritance has been predominantly observed. Several of the candidate causative genes are also mutated in other cardiomyopathies, suggesting a possible shared molecular and/or cellular etiology. The most common gene functions were sarcomere function whereas genes in mice LVNC models were involved in heart development. Echocardiography and cardiac magnetic resonance imaging (CMR) are useful for diagnosis although there are no unified criteria due to overdiagnosis of imaging, poor consistency between techniques, and lack of association between trabecular severity and adverse clinical outcomes. Conclusions This review reflects the current lack of clarity regarding the pathogenesis and significance of LVNC and showed the complexity of imaging diagnostic criteria, interpretation of the role of LVNC as a cause, and uncertainty regarding the specific genetic basis of LVNC.
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Affiliation(s)
- Keiichi Hirono
- Department of Pediatrics, Graduate School of Medicine, University of Toyama, Toyama, Japan
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare, Tokyo, Japan
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Gorecka M, McCann GP, Berry C, Ferreira VM, Moon JC, Miller CA, Chiribiri A, Prasad S, Dweck MR, Bucciarelli-Ducci C, Dawson D, Fontana M, Macfarlane PW, McConnachie A, Neubauer S, Greenwood JP. Demographic, multi-morbidity and genetic impact on myocardial involvement and its recovery from COVID-19: protocol design of COVID-HEART-a UK, multicentre, observational study. J Cardiovasc Magn Reson 2021; 23:77. [PMID: 34112195 PMCID: PMC8190746 DOI: 10.1186/s12968-021-00752-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although coronavirus disease 2019 (COVID-19) is primarily a respiratory illness, myocardial injury is increasingly reported and associated with adverse outcomes. However, the pathophysiology, extent of myocardial injury and clinical significance remains unclear. METHODS COVID-HEART is a UK, multicentre, prospective, observational, longitudinal cohort study of patients with confirmed COVID-19 and elevated troponin (sex-specific > 99th centile). Baseline assessment will be whilst recovering in-hospital or recently discharged, and include cardiovascular magnetic resonance (CMR) imaging, quality of life (QoL) assessments, electrocardiogram (ECG), serum biomarkers and genetics. Assessment at 6-months includes repeat CMR, QoL assessments and 6-min walk test (6MWT). The CMR protocol includes cine imaging, T1/T2 mapping, aortic distensibility, late gadolinium enhancement (LGE), and adenosine stress myocardial perfusion imaging in selected patients. The main objectives of the study are to: (1) characterise the extent and nature of myocardial involvement in COVID-19 patients with an elevated troponin, (2) assess how cardiac involvement and clinical outcome associate with recognised risk factors for mortality (age, sex, ethnicity and comorbidities) and genetic factors, (3) evaluate if differences in myocardial recovery at 6 months are dependent on demographics, genetics and comorbidities, (4) understand the impact of recovery status at 6 months on patient-reported QoL and functional capacity. DISCUSSION COVID-HEART will provide detailed characterisation of cardiac involvement, and its repair and recovery in relation to comorbidity, genetics, patient-reported QoL measures and functional capacity. CLINICAL TRIAL REGISTRATION ISRCTN 58667920. Registered 04 August 2020.
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Affiliation(s)
- Miroslawa Gorecka
- Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
| | - Gerry P. McCann
- University of Leicester and The NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences and British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Vanessa M. Ferreira
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford Centre for Clinical Magnetic Resonance Research, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - James C. Moon
- Institute of Cardiovascular Science, University College London, London, UK
| | - Christopher A. Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College London, BHF Centre of Excellence and the NIHR Biomedical Research Centre at Guy’s and St. Thomas’ NHS Foundation Trust, The Rayne Institute, St. Thomas’ Hospital, London, UK
| | - Sanjay Prasad
- National Heart and Lung Institute, Imperial College, London, UK
| | - Marc R. Dweck
- University of Edinburgh and British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol NIHR Cardiovascular Research Centre, University of Bristol and University Hospitals Bristol and Weston NHS Trust, Bristol, UK
| | - Dana Dawson
- Department of Cardiology, Aberdeen Cardiovascular and Diabetes Centre, Aberdeen Royal Infirmary and University of Aberdeen, Aberdeen, UK
| | - Marianna Fontana
- Division of Medicine, Royal Free Hospital, University College London, London, UK
| | - Peter W. Macfarlane
- Electrocardiology Core Laboratory, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford Centre for Clinical Magnetic Resonance Research, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John P. Greenwood
- Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
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Ordovas KG, Baldassarre LA, Bucciarelli-Ducci C, Carr J, Fernandes JL, Ferreira VM, Frank L, Mavrogeni S, Ntusi N, Ostenfeld E, Parwani P, Pepe A, Raman SV, Sakuma H, Schulz-Menger J, Sierra-Galan LM, Valente AM, Srichai MB. Cardiovascular magnetic resonance in women with cardiovascular disease: position statement from the Society for Cardiovascular Magnetic Resonance (SCMR). J Cardiovasc Magn Reson 2021; 23:52. [PMID: 33966639 PMCID: PMC8108343 DOI: 10.1186/s12968-021-00746-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/17/2021] [Indexed: 01/09/2023] Open
Abstract
This document is a position statement from the Society for Cardiovascular Magnetic Resonance (SCMR) on recommendations for clinical utilization of cardiovascular magnetic resonance (CMR) in women with cardiovascular disease. The document was prepared by the SCMR Consensus Group on CMR Imaging for Female Patients with Cardiovascular Disease and endorsed by the SCMR Publications Committee and SCMR Executive Committee. The goals of this document are to (1) guide the informed selection of cardiovascular imaging methods, (2) inform clinical decision-making, (3) educate stakeholders on the advantages of CMR in specific clinical scenarios, and (4) empower patients with clinical evidence to participate in their clinical care. The statements of clinical utility presented in the current document pertain to the following clinical scenarios: acute coronary syndrome, stable ischemic heart disease, peripartum cardiomyopathy, cancer therapy-related cardiac dysfunction, aortic syndrome and congenital heart disease in pregnancy, bicuspid aortic valve and aortopathies, systemic rheumatic diseases and collagen vascular disorders, and cardiomyopathy-causing mutations. The authors cite published evidence when available and provide expert consensus otherwise. Most of the evidence available pertains to translational studies involving subjects of both sexes. However, the authors have prioritized review of data obtained from female patients, and direct comparison of CMR between women and men. This position statement does not consider CMR accessibility or availability of local expertise, but instead highlights the optimal utilization of CMR in women with known or suspected cardiovascular disease. Finally, the ultimate goal of this position statement is to improve the health of female patients with cardiovascular disease by providing specific recommendations on the use of CMR.
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Affiliation(s)
| | | | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol, UK
- Bristol National Institute of Health Research (NIHR) Biomedical , Research Centre, Bristol, UK
- University Hospitals Bristol, Bristol, UK
- University of Bristol, Bristol, UK
| | - James Carr
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Vanessa M Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Luba Frank
- Medical College of Wisconsin, Wisconsin, USA
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Center, Athens, Greece
- Kapodistrian University of Athens, Athens, Greece
| | - Ntobeko Ntusi
- University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital, Cape Town, South Africa
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio C.N.R., Pisa, Italy
| | - Subha V Raman
- Krannert Institute of Cardiology, Indiana University, Indianapolis, USA
| | - Hajime Sakuma
- Department of Radiology, Mie University School of Medicine, Mie, Japan
| | - Jeanette Schulz-Menger
- harite Hospital, University of Berlin, Berlin, Germany
- HELIOS-Clinics Berlin-Buch, Berlin, Germany
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Sörensson P, Ekenbäck C, Lundin M, Agewall S, Bacsovics Brolin E, Caidahl K, Cederlund K, Collste O, Daniel M, Jensen J, Y-Hassan S, Henareh L, Hofman-Bang C, Lyngå P, Maret E, Sarkar N, Spaak J, Winnberg O, Ugander M, Tornvall P. Early Comprehensive Cardiovascular Magnetic Resonance Imaging in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries. JACC Cardiovasc Imaging 2021; 14:1774-1783. [PMID: 33865778 DOI: 10.1016/j.jcmg.2021.02.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/12/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The objective of the SMINC-2 (Stockholm Myocardial Infarction With Normal Coronaries 2) study was to determine if more than 70% of patients with myocardial infarction with nonobstructed coronary arteries (MINOCA), investigated early with comprehensive cardiovascular magnetic resonance (CMR), could receive a diagnosis entirely by imaging. BACKGROUND The etiology of MINOCA is heterogeneous, including coronary, cardiac, and noncardiac causes. Patients with MINOCA, therefore, represent a diagnostic challenge where CMR is increasingly used. METHODS The SMINC-2 study was a prospective study of 148 patients with MINOCA imaged with 1.5-T CMR with T1 and extracellular volume mapping early after hospital admission, compared to 150 patients with MINOCA imaged using 1.5-T CMR without mapping techniques from the SMINC-1 study as historic controls. RESULTS CMR was performed at a median of 3 (SMINC-2) versus 12 (SMINC-1) days after hospital admission. In total, 77% of patients received a diagnosis with CMR imaging in the SMINC-2 study compared to 47% in the SMINC-1 study (p < 0.001). Compared to SMINC-1, CMR in SMINC-2 detected higher proportions of myocarditis (17% vs. 7%; p = 0.01) and takotsubo syndrome (35% vs. 19%; p = 0.002) but similar proportions of myocardial infarction (22% vs. 19%; p = 0.56) and other cardiomyopathies (3% vs. 2%; p = 0.46). CONCLUSIONS The results of the SMINC-2 study show that 77% of all patients with MINOCA received a diagnosis when imaged early with CMR, including advanced tissue characterization, which was a considerable improvement in comparison to the SMINC-1 study. This supports the use of early CMR imaging as a diagnostic tool in the investigation of patients with MINOCA. (Stockholm Myocardial Infarction With Normal Coronaries [SMINC]-2 Study on Diagnosis Made by Cardiac MRI [SCMINC-2]; NCT02318498).
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Affiliation(s)
- Peder Sörensson
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
| | - Christina Ekenbäck
- Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden; Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Magnus Lundin
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Stefan Agewall
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elin Bacsovics Brolin
- Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, Stockholm, Sweden; Department of Radiology, Capio St: Görans Hospital, Stockholm, Sweden
| | - Kenneth Caidahl
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Kerstin Cederlund
- Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, Stockholm, Sweden; Department of Radiology, Södertälje Hospital, Södertälje, Sweden
| | - Olov Collste
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden
| | - Maria Daniel
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Jens Jensen
- Department of Radiology, Capio St: Görans Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Shams Y-Hassan
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Loghman Henareh
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hofman-Bang
- Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden; Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Patrik Lyngå
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Eva Maret
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Nondita Sarkar
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Spaak
- Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden; Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Oscar Winnberg
- Department of Radiology, Capio St: Görans Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden; Kolling Institute, Royal North Shore Hospital, Sydney, Australia; Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Per Tornvall
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
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7
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Emrich T, Kros M, Schoepf UJ, Geyer M, Mildenberger P, Kloeckner R, Wenzel P, Varga-Szemes A, Düber C, Münzel T, Kreitner KF. Cardiac magnetic resonance imaging features prognostic information in patients with suspected myocardial infarction with non-obstructed coronary arteries. Int J Cardiol 2020; 327:223-230. [PMID: 33309758 DOI: 10.1016/j.ijcard.2020.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/14/2020] [Accepted: 12/02/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND To assess the prognostic implications of cardiac magnetic resonance imaging (CMR) in patients with clinical suspicion of myocardial infarction with non-obstructed coronary arteries (MINOCA). METHODS A total of 145 patients (58 ± 15 years, 97 men) were retrospectively enrolled in this single-center, longitudinal observational study. All patients underwent CMR including cine, edema-sensitive, and late gadolinium enhancement acquisitions, within a median of 3 days after cardiac catheterization. Follow-up was performed by medical records chart review and phone interviews; the median follow-up time was 4.2 years. The primary endpoint was defined as a combination of death, stroke, new onset of congestive heart failure, recurrent hospitalization, or the need for an invasive cardiac procedure. RESULTS In 143 (98.6%) cases, CMR revealed the following cardiac pathologies: myocarditis (n = 48, 33.1%), structural cardiomyopathies (n = 40, 27.6%), "true" myocardial infarction (n = 22, 15.1%), hypertensive heart disease (n = 19, 13.1%), and Tako-Tsubo cardiomyopathy (n = 14, 9.7%). Only two patients (1.4%) had a normal CMR examination. There were significant prognostic differences between different etiologies, e.g. myocarditis and Tako-Tsubo cardiomyopathy had a more favorable prognosis then structural cardiomyopathies. Age, end-diastolic volume index and time-to-CMR showed significant association with the primary endpoint in multi-variate Cox regression. CONCLUSIONS CMR performed early after the onset of clinical symptoms allows discrimination between acute myocardial injury from "true" MINOCA in patients presenting with chest pain and elevated cardiac biomarkers, thereby helping to identify the underlying pathology in suspected MINOCA and allowing risk stratification based on the established diagnosis. Furthermore, CMR parameters allow for improved prediction of adverse events compared to clinical and laboratory parameters.
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Affiliation(s)
- Tilman Emrich
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz; Langenbeckst. 1, 55131 Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Langenbeckst. 1, 55131 Mainz, Germany; Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive, Charleston, 29425, SC, USA
| | - Max Kros
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz; Langenbeckst. 1, 55131 Mainz, Germany
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive, Charleston, 29425, SC, USA.
| | - Martin Geyer
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckst. 1, 55131 Mainz, Germany
| | - Philipp Mildenberger
- Department of Medical Biometry, Epidemiology and Informatics, University Medical Center Mainz, Langenbeckst. 1, 55131 Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz; Langenbeckst. 1, 55131 Mainz, Germany
| | - Philip Wenzel
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Langenbeckst. 1, 55131 Mainz, Germany; Center for Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckst. 1, 55131 Mainz, Germany
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Drive, Charleston, 29425, SC, USA
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz; Langenbeckst. 1, 55131 Mainz, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Langenbeckst. 1, 55131 Mainz, Germany; Center for Cardiology, Cardiology I, University Medical Center Mainz, Langenbeckst. 1, 55131 Mainz, Germany
| | - Karl-Friedrich Kreitner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz; Langenbeckst. 1, 55131 Mainz, Germany
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Bucciarelli-Ducci C, Ostenfeld E, Baldassarre LA, Ferreira VM, Frank L, Kallianos K, Raman SV, Srichai MB, McAlindon E, Mavrogeni S, Ntusi NAB, Schulz-Menger J, Valente AM, Ordovas KG. Cardiovascular disease in women: insights from magnetic resonance imaging. J Cardiovasc Magn Reson 2020; 22:71. [PMID: 32981527 PMCID: PMC7520984 DOI: 10.1186/s12968-020-00666-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
The presentation and identification of cardiovascular disease in women pose unique diagnostic challenges compared to men, and underrecognized conditions in this patient population may lead to clinical mismanagement.This article reviews the sex differences in cardiovascular disease, explores the diagnostic and prognostic role of cardiovascular magnetic resonance (CMR) in the spectrum of cardiovascular disorders in women, and proposes the added value of CMR compared to other imaging modalities. In addition, this article specifically reviews the role of CMR in cardiovascular diseases occurring more frequently or exclusively in female patients, including Takotsubo cardiomyopathy, connective tissue disorders, primary pulmonary arterial hypertension and peripartum cardiomyopathy. Gaps in knowledge and opportunities for further investigation of sex-specific cardiovascular differences by CMR are also highlighted.
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Affiliation(s)
- Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol National Institute of Health Research (NIHR) Biomedical Research Centre, University Hospitals Bristol and University of Bristol, Bristol, UK
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital Lund, Lund University, Getingevägen 5, SE-22185 Lund, Sweden
| | | | - Vanessa M. Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Luba Frank
- University of Texas Medical Branch, Galveston, TX USA
| | | | | | | | - Elisa McAlindon
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
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9
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Hausvater A, Smilowitz NR, Li B, Redel-Traub G, Quien M, Qian Y, Zhong J, Nicholson JM, Camastra G, Bière L, Panovský R, Sá M, Gerbaud E, Selvanayagam JB, Al-Mallah MH, Emrich T, Reynolds HR. Myocarditis in Relation to Angiographic Findings in Patients With Provisional Diagnoses of MINOCA. JACC Cardiovasc Imaging 2020; 13:1906-1913. [DOI: 10.1016/j.jcmg.2020.02.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/14/2020] [Indexed: 12/26/2022]
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10
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Batlle JC, Kirsch J, Bolen MA, Bandettini WP, Brown RKJ, Francois CJ, Galizia MS, Hanneman K, Inacio JR, Johnson TV, Khosa F, Krishnamurthy R, Rajiah P, Singh SP, Tomaszewski CA, Villines TC, Wann S, Young PM, Zimmerman SL, Abbara S. ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome. J Am Coll Radiol 2020; 17:S55-S69. [PMID: 32370978 DOI: 10.1016/j.jacr.2020.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 12/17/2022]
Abstract
Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Juan C Batlle
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida.
| | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | | | - W Patricia Bandettini
- National Institutes of Health, Bethesda, Maryland; Society for Cardiovascular Magnetic Resonance
| | | | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joao R Inacio
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas V Johnson
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology Expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear Cardiology Expert
| | | | | | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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11
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Harris JM, Brierley RC, Pufulete M, Bucciarelli-Ducci C, Stokes EA, Greenwood JP, Dorman SH, Anderson RA, Rogers CA, Wordsworth S, Berry S, Reeves BC. A national registry to assess the value of cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention pathway activation: a feasibility cohort study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Cardiovascular magnetic resonance (CMR) is increasingly used in patients who activate the primary percutaneous coronary intervention (PPCI) pathway to assess heart function. It is uncertain whether having CMR influences patient management or the risk of major adverse cardiovascular events in these patients.
Objective
To determine whether or not it is feasible to set up a national registry, linking routinely collected data from hospital information systems (HISs), to investigate the role of CMR in patients who activate the PPCI pathway.
Design
A feasibility prospective cohort study.
Setting
Four 24/7 PPCI hospitals in England and Wales (two with and two without a dedicated CMR facility).
Participants
Patients who activated the PPCI pathway and underwent an emergency coronary angiogram.
Interventions
CMR either performed or not performed within 10 weeks of the index event.
Main outcome measures
A. Feasibility parameters – (1) patient consent implemented at all hospitals, (2) data extracted from more than one HIS and successfully linked for > 90% of consented patients at all four hospitals, (3) HIS data successfully linked with Hospital Episode Statistics (HES) and Patient Episode Database Wales (PEDW) for > 90% of consented patients at all four hospitals and (4) CMR requested and carried out for ≥ 10% of patients activating the PPCI pathway in CMR hospitals. B. Key drivers of cost-effectiveness for CMR (identified from simple cost-effectiveness models) in patients with (1) multivessel disease and (2) unobstructed coronary arteries. C. A change in clinical management arising from having CMR (defined using formal consensus and identified using HES follow-up data in the 12 months after the index event).
Results
A. (1) Consent was implemented (for all hospitals, consent rates were 59–74%) and 1670 participants were recruited. (2) Data submission was variable – clinical data available for ≥ 82% of patients across all hospitals, biochemistry and echocardiography (ECHO) data available for ≥ 98%, 34% and 87% of patients in three hospitals and medications data available for 97% of patients in one hospital. (3) HIS data were linked with hospital episode data for 99% of all consented patients. (4) At the two CMR hospitals, 14% and 20% of patients received CMR. B. In both (1) multivessel disease and (2) unobstructed coronary arteries, the difference in quality-adjusted life-years (QALYs) between CMR and no CMR [‘current’ comparator, stress ECHO and standard ECHO, respectively] was very small [0.0012, 95% confidence interval (CI) –0.0076 to 0.0093 and 0.0005, 95% CI –0.0050 to 0.0077, respectively]. The diagnostic accuracy of the ischaemia tests was the key driver of cost-effectiveness in sensitivity analyses for both patient subgroups. C. There was consensus that CMR leads to clinically important changes in management in five patient subgroups. Some changes in management were successfully identified in hospital episode data (e.g. new diagnoses/procedures, frequency of outpatient episodes related to cardiac events), others were not (e.g. changes in medications, new diagnostic tests).
Conclusions
A national registry is not currently feasible. Patients were consented successfully but conventional consent could not be implemented nationally. Linking HIS and hospital episode data was feasible but HIS data were not uniformly available. It is feasible to identify some, but not all, changes in management in the five patient subgroups using hospital episode data. The delay in obtaining hospital episode data influenced the relevance of some of our study objectives.
Future work
To test the feasibility of conducting the study using national data sets (e.g. HES, British Cardiovascular Intervention Society audit database, Diagnostic Imaging Dataset, Clinical Practice Research Datalink).
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. This study was designed and delivered in collaboration with the Clinical Trials and Evaluation Unit, a UK Clinical Research Collaboration-registered clinical trials unit that, as part of the Bristol Trials Centre, is in receipt of NIHR clinical trials unit support funding.
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Affiliation(s)
- Jessica M Harris
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Rachel C Brierley
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chiara Bucciarelli-Ducci
- National Institute for Health Research (NIHR) Bristol Cardiovascular Research Unit, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephen H Dorman
- National Institute for Health Research (NIHR) Bristol Cardiovascular Research Unit, Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sunita Berry
- NHS England, South West Clinical Networks and Senate, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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12
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Abanador-Kamper N, Kamper L, Castello-Boerrigter L, Haage P, Seyfarth M. MRI findings in patients with acute coronary syndrome and unobstructed coronary arteries. ACTA ACUST UNITED AC 2019; 25:28-34. [PMID: 30582569 DOI: 10.5152/dir.2018.18004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The underlying diagnosis in patients with acute coronary syndrome (ACS) and unobstructed coronary arteries remains a diagnostic challenge. We analyzed the value of magnetic resonance imaging (MRI) in this clinical setting. METHODS A total of 213 patients with ACS and unobstructed coronary arteries underwent MRI within a median of 2 days after initial presentation. Clinical, laboratory, and MRI data were analyzed. A consensus diagnosis was established for each case by an independent panel after reviewing the individual clinical, laboratory, and MRI data. Standardized interviews to determine patient outcomes were carried out after a median follow-up of 24 months. Clinical events were defined as a composite of death, stroke, myocardial infarction or recurrence of Takotsubo syndrome (TTS), new onset of heart failure with a left ventricular ejection fraction (LVEF) <30%, and occurrence of a new left ventricular thrombus formation. RESULTS Final diagnoses included acute myocardial infarction (AMI) (40%), acute myocarditis (24%) and TTS (33%). In 3% of patients, nonspecific findings lead to an indeterminate diagnosis. Patients with TTS showed a significantly impaired LVEF during the index event (50% vs. 60% in AMI and 60% in myocarditis, P = 0.001). The extent of myocardial edema was most pronounced in patients with TTS (13.4%±11.4 vs. 4.6%±7.9 in AMI and 1.8%±2.7 in myocarditis, P < 0.001). TTS patients had the highest event rate (16.9%). CONCLUSION Our study emphasizes the diagnostic utility of timely MRI in patients with ACS and unobstructed coronary arteries. We found a high prevalence of TTS patients, who had poorer outcomes compared with patients with a final diagnosis of AMI or myocarditis.
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Affiliation(s)
- Nadine Abanador-Kamper
- Department of Cardiology, HELIOS University Hospital, Wuppertal, Germany; Center for Clinical Medicine, University Faculty of Health, Witten/Herdecke, Germany
| | - Lars Kamper
- Department of Diagnostic HELIOS University Hospital, Wuppertal, Germany; Center for Clinical Medicine University Faculty of Health, Witten/Herdecke, Germany
| | | | - Patrick Haage
- Center for Clinical Medicine,University Faculty of Health, Witten/Herdecke, Germany
| | - Melchior Seyfarth
- Center for Clinical Medicine,University Faculty of Health, Witten/Herdecke, Germany
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13
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Myocardial Infarction With No Obstructive Coronary Artery Disease: Angiographic and Clinical Insights in Patients With Premature Presentation. Can J Cardiol 2018; 34:468-476. [DOI: 10.1016/j.cjca.2018.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/16/2017] [Accepted: 01/01/2018] [Indexed: 12/13/2022] Open
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14
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Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimský P. [2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.]. Eur Heart J 2018; 39:119-177. [PMID: 29457615 DOI: 10.1093/eurheartj/ehx393] [Citation(s) in RCA: 6056] [Impact Index Per Article: 1009.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Borja Ibanez
- Department of Cardiology, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.
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15
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Tornvall P, Brolin EB, Caidahl K, Cederlund K, Collste O, Daniel M, Ekenbäck C, Jensen J, Y-Hassan S, Henareh L, Hofman-Bang C, Lyngå P, Maret E, Sarkar N, Spaak J, Sundqvist M, Sörensson P, Ugander M, Agewall S. The value of a new cardiac magnetic resonance imaging protocol in Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) - a case-control study using historical controls from a previous study with similar inclusion criteria. BMC Cardiovasc Disord 2017; 17:199. [PMID: 28738781 PMCID: PMC5525301 DOI: 10.1186/s12872-017-0611-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/22/2017] [Indexed: 12/22/2022] Open
Abstract
Background Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is common with a prevalence of 6% of all patients fulfilling the diagnosis of myocardial infarction. MINOCA should be considered a working diagnosis. Cardiac Magnetic Resonance (CMR) imaging has recently been suggested to be of great value to determine the cause behind MINOCA. The objectives of this paper are to describe the rationale behind the second Stockholm Myocardial Infarction with Normal Coronaries (SMINC-2) study and to discuss the protocol for investigation of MINOCA patients in the light of the recently published position paper from the European Society of Cardiology. Methods The SMINC-2 study is an open non-randomised study using historical controls for comparison. The primary aim is to prove that MINOCA patients investigated with the latest CMR imaging technique can achieve a diagnosis in 70% of all cases entirely by imaging. By including 150 patients we will have >80% chance to prove that the diagnostic accuracy can be improved by 20 absolute % with a p-value of less than 0.05 when compared with CMR imaging in the SMINC-1 study. Furthermore, in addition to invasive coronary angiography, coronary arteries are evaluated by computed tomography angiography to investigate coronary causes and questionnaires are used to describe Quality-of-Life (QoL). By January 1st 2017, 75 patients have been included. Discussion Whether CMR imaging can provide a diagnosis to an adequate proportion of MINOCA patients is unknown. Well-defined inclusion and exclusion criteria will be used to compare a MINOCA cohort from the population with an appropriate control group. Positive results are likely to influence future guidelines of the management of MINOCA. Furthermore, the study will give mechanistic insights into MINOCA in particular in patients with “true” myocardial infarction and describe QoL in this vulnerable group of patients. Trial registration Clinical Trials NCT02318498.
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Affiliation(s)
- Per Tornvall
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
| | - E B Brolin
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - K Caidahl
- Molecular Medicine and Surgery, Karolinska Hospital, Stockholm, Sweden
| | - K Cederlund
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - O Collste
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - M Daniel
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - C Ekenbäck
- Clinical Sciences Danderyd Hospital, Karolinska Hospital, Stockholm, Sweden
| | - J Jensen
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - S Y-Hassan
- Medicine Huddinge, Karolinska Hospital, Stockholm, Sweden
| | - L Henareh
- Medicine Huddinge, Karolinska Hospital, Stockholm, Sweden
| | - C Hofman-Bang
- Clinical Sciences Danderyd Hospital, Karolinska Hospital, Stockholm, Sweden
| | - P Lyngå
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - E Maret
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - N Sarkar
- Medicine Solna, Karolinska Hospital, Stockholm, Sweden
| | - J Spaak
- Clinical Sciences Danderyd Hospital, Karolinska Hospital, Stockholm, Sweden
| | - M Sundqvist
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - P Sörensson
- Medicine Solna, Karolinska Hospital, Stockholm, Sweden
| | - M Ugander
- Molecular Medicine and Surgery, Karolinska Hospital, Stockholm, Sweden
| | - S Agewall
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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16
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Panovský R, Borová J, Pleva M, Feitová V, Novotný P, Kincl V, Holeček T, Meluzín J, Sochor O, Štěpánová R. The unique value of cardiovascular magnetic resonance in patients with suspected acute coronary syndrome and culprit-free coronary angiograms. BMC Cardiovasc Disord 2017; 17:170. [PMID: 28659139 PMCID: PMC5490179 DOI: 10.1186/s12872-017-0610-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 06/22/2017] [Indexed: 12/11/2022] Open
Abstract
Background Patients with chest pain, elevated troponin, and unobstructed coronary disease present a clinical dilemma. The purpose of this study was to investigate the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in a cohort of patients with suspected acute coronary syndrome (ACS) and unobstructed coronary arteries. Results Data files of patients meeting the inclusion criteria in two cardiology centres were searched and analysed. The inclusion criteria included: 1) thoracic pain suspected with ACS; 2) a significant increase in the high-sensitive Troponin T value; 3) ECG changes; 4) coronary arteries without any significant stenosis; 5) a CMR examination included in the diagnostic process; 6) an uncertain diagnosis before the CMR exam; and 7) the absence of known CMR and contrast media contraindications. Special attention was paid to the benefits of CMR in determining the final diagnosis. In total, 136 patients who underwent coronary angiography for chest pain were analysed. The most frequent underlying causes were myocarditis (38%) and perimyocarditis (18%), followed by angiographically unrecognised acute myocardial infarction (18%) and Takotsubo cardiomyopathy (15%). The final diagnosis remained unclear in 6% of the patients. The contribution of CMR in determining the final diagnosis determination was crucial in 57% of the patients. In another 35% of the patients, CMR confirmed the suspicion and, only 8% of the CMR examinations did not help at all and had no influence on diagnosis or treatment. Conclusion CMR provided a powerful incremental diagnostic value in the cohort of patients with suspected ACS and unobstructed coronary arteries. CMR is highly recommended to be incorporated as an inalienable part of the diagnostic algorithms in these patients.
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Affiliation(s)
- Roman Panovský
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic. .,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic.
| | - Júlia Borová
- The Department of Cardiology, Heart Centre, Hospital Podlesi, Trinec, Czech Republic
| | - Martin Pleva
- The Department of Cardiology, Heart Centre, Hospital Podlesi, Trinec, Czech Republic
| | - Věra Feitová
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The Department of Medical Imaging, St. Anne's Faculty Hospital and Masaryk University, Brno, Czech Republic
| | - Petr Novotný
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Vladimír Kincl
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Tomáš Holeček
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The Department of Medical Imaging, St. Anne's Faculty Hospital and Masaryk University, Brno, Czech Republic
| | - Jaroslav Meluzín
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Ondřej Sochor
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Radka Štěpánová
- International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czech Republic
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