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Troger F, Klug G, Poskaite P, Tiller C, Lechner I, Reindl M, Holzknecht M, Fink P, Brunnauer EM, Gizewski ER, Metzler B, Reinstadler S, Mayr A. Mitral annular disjunction in out-of-hospital cardiac arrest patients-a retrospective cardiac MRI study. Clin Res Cardiol 2024; 113:770-780. [PMID: 38602567 PMCID: PMC11026248 DOI: 10.1007/s00392-024-02440-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Mitral annular disjunction (MAD), defined as defective attachment of the mitral annulus to the ventricular myocardium, has recently been linked to malignant arrhythmias. However, its role and prognostic significance in patients requiring cardiopulmonary resuscitation (CPR) remain unknown. This retrospective analysis aimed to describe the prevalence and significance of MAD by cardiac magnetic resonance (CMR) imaging in out-of-hospital cardiac arrest (OHCA) patients. METHODS Eighty-six patients with OHCA and a CMR scan 5 days after CPR (interquartile range (IQR): 49 days before - 9 days after) were included. MAD was defined as disjunction-extent ≥ 1 mm in CMR long-axis cine-images. Medical records were screened for laboratory parameters, comorbidities, and a history of arrhythmia. RESULTS In 34 patients (40%), no underlying cause for OHCA was found during hospitalization despite profound diagnostics. Unknown-cause OHCA patients showed a higher prevalence of MAD compared to definite-cause patients (56% vs. 10%, p < 0.001) and had a MAD-extent of 6.3 mm (IQR: 4.4-10.3); moreover, these patients were significantly younger (43 years vs. 61 years, p < 0.001), more often female (74% vs. 21%, p < 0.001) and had fewer comorbidities (hypertension, hypercholesterolemia, coronary artery disease, all p < 0.005). By logistic regression analysis, the presence of MAD remained significantly associated with OHCA of unknown cause (odds ratio: 8.49, 95% confidence interval: 2.37-30.41, p = 0.001) after adjustment for age, presence of hypertension, and hypercholesterolemia. CONCLUSIONS MAD is rather common in OHCA patients without definitive aetiology undergoing CMR. The presence of MAD was independently associated to OHCA without an identifiable trigger. Further research is needed to understand the exact role of MAD in OHCA patients.
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Affiliation(s)
- Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Paulina Poskaite
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Eva-Maria Brunnauer
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Elke R Gizewski
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Sebastian Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Troger F, Kremser C, Pamminger M, Reinstadler SJ, Thurner GC, Henninger B, Klug G, Metzler B, Mayr A. Functional aortic valve area differs significantly between sexes: A phase-contrast cardiac MRI study in patients with severe aortic stenosis. Int J Cardiol Heart Vasc 2024; 51:101357. [PMID: 38356930 PMCID: PMC10863308 DOI: 10.1016/j.ijcha.2024.101357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
Background Aortic stenosis (AS) is one of the most prevalent valvular heart-diseases in Europe. Currently, diagnosis and classification are not sex-sensitive; however, due to a distinctly different natural history of AS, further investigations of sex-differences in AS-patients are needed. Thus, this study aimed to detect sex-differences in severe AS, especially concerning flow-patterns, via phase-contrast cardiac magnetic resonance imaging (PC-CMR). Methods Forty-four severe AS-patients (20 women, 45 % vs. 24 men, 55 %) with a median age of 72 years underwent transthoracic echocardiography (TTE), cardiac catheterization (CC) and CMR. Aortic valve area (AVA) and stroke volume (SV) were determined in all modalities, with CMR yielding geometrical AVA via cine-planimetry and functional AVA via PC-CMR, the latter being also used to examine flow-properties. Results Geometrical AVA showed no sex-differences (0.91 cm2, IQR: 0.61-1.14 vs. 0.94 cm2, IQR: 0.77-1.22, p = 0.322). However, functional AVA differed significantly between sexes in all three modalities (TTE: p = 0.044; CC/PC-CMR: p < 0.001). In men, no significant intermethodical biases in functional AVA-measurements between modalities were found (p = 0.278); yet, in women the particular measurements differed significantly (p < 0.001). Momentary flowrate showed sex-differences depending on momentary opening-degree (at 50 %, 75 % and 90 % of peak-AVA, all p < 0.001), with men showing higher flowrates with increasing opening-area. In women, flowrate did not differ between 75 % and 90 % of peak-AVA (p = 0.191). Conclusions In severe AS-patients, functional AVA showed marked sex-differences in all modalities, whilst geometrical AVA did not differ. Inter-methodical biases were negligible in men, but not in women. Lastly, significant sex-differences in flow-patterns fit in with the different pathogenesis of AS.
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Affiliation(s)
- Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Gudrun C Thurner
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Müllerstraße 44 6020, Innsbruck, Austria
| | - Benjamin Henninger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Gert Klug
- Department of Internal Medicine, County Hospital Bruck an der Mur, Tragoesser Strasse 1 8600, Bruck an der Mur, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
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Tiller C, Reindl M, Holzknecht M, Lechner I, Troger F, Oberhollenzer F, von der Emde S, Kremser T, Mayr A, Bauer A, Metzler B, Reinstadler SJ. Relation of plasma neuropeptide-Y with myocardial function and infarct severity in acute ST-elevation myocardial infarction. Eur J Intern Med 2024:S0953-6205(24)00137-7. [PMID: 38555253 DOI: 10.1016/j.ejim.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/01/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Acute myocardial infarction is associated with the release of the co-transmitter neuropeptide-Y (NPY). NPY acts as a potent vasoconstrictor and is associated with microvascular dysfunction after ST-elevation myocardial infarction (STEMI). This study comprehensively evaluated the association of plasma NPY with myocardial function and infarct severity, visualized by cardiac magnetic resonance (CMR) imaging, in STEMI patients revascularized by primary percutaneous coronary intervention (PCI). METHODS In this observational study, we included 260 STEMI patients enrolled in the prospective MARINA-STEMI (NCT04113356) study. Plasma NPY concentrations were measured by an immunoassay 24h after PCI from peripheral venous blood samples. Left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), infarct size (IS) and microvascular obstruction (MVO) were determined using CMR imaging. RESULTS Median plasma concentrations of NPY were 70 [interquartile range (IQR):35-115] pg/ml. NPY levels above median were significantly associated with lower LVEF (48%vs.52%, p=0.004), decreased GLS (-8.8%vs.-12.6%, p<0.001) and larger IS (17%vs.13%, p=0.041) in the acute phase after infarction as well as after 4 months (LVEF:50%vs.52%, p=0.030, GLS:-10.5vs.-12.9,p<0.001,IS:13%vs.10%,p=0.011). In addition, NPY levels were significantly related to presence of MVO (58%vs.52%, p=0.041). Moreover, in multivariable linear regression analysis, NPY remained significantly associated with all investigated CMR parameters (LVEF:p<0.001,GLS:p<0.001,IS:p=0.003,MVO:p=0.042) independent of other established clinical variables including high-sensitivity cardiac troponin T, pre-interventional TIMI flow 0 and left anterior descending artery as culprit lesion location. CONCLUSION High plasma levels of NPY, measured 24h after STEMI, were independently associated with lower LVEF, decreased GLS, larger IS as well as presence of MVO, indicating plasma NPY as a novel clinical risk marker post STEMI.
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Affiliation(s)
- Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Fritz Oberhollenzer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian von der Emde
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Thomas Kremser
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Lechner I, Reindl M, Tiller C, Holzknecht M, Oberhollenzer F, Mayr A, Bauer A, Metzler B, Reinstadler SJ. Culprit Lesion Vessel Size and Risk of Reperfusion Injury in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study. J Am Heart Assoc 2024; 13:e033102. [PMID: 38293938 PMCID: PMC11056128 DOI: 10.1161/jaha.123.033102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH) are well-established imaging biomarkers of failed myocardial tissue reperfusion in patients with ST-segment elevation-myocardial infarction treated with percutaneous coronary intervention. MVO and IMH are associated with an increased risk of adverse outcome independent of infarct size, but whether the size of the culprit lesion vessel plays a role in the occurrence and severity of reperfusion injury is currently unknown. This study aimed to evaluate the association between culprit lesion vessel size and the occurrence and severity of reperfusion injury as determined by cardiac magnetic resonance imaging. METHODS AND RESULTS Patients (n=516) with first-time ST-segment-elevation myocardial infarction underwent evaluation with cardiac magnetic resonance at 4 (3-5) days after infarction. MVO was assessed with late gadolinium enhancement imaging and IMH with T2* mapping. Vessel dimensions were determined using catheter-based reference. Median culprit lesion vessel size was 3.1 (2.7-3.6) mm. MVO and IMH were found in 299 (58%) and 182 (35%) patients. Culprit lesion vessel size was associated with body surface area, diabetes, total ischemic time, postinterventional thrombolysis in myocardial infarction flow, and infarct size. There was no association between vessel size and MVO or IMH in univariable and multivariable analysis (P>0.05). These findings were consistent across patient subgroups with left anterior descending artery and non-left anterior descending artery infarctions and those with thrombolysis in myocardial infarction 3 flow post-percutaneous coronary intervention. CONCLUSIONS Comprehensive characterization of myocardial tissue reperfusion injury by cardiac magnetic resonance revealed no association between culprit lesion vessel size and the occurrence of MVO and IMH in patients treated with primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction.
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Affiliation(s)
- Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
| | - Fritz Oberhollenzer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of InnsbruckInnsbruckAustria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
| | - Sebastian J. Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of InnsbruckInnsbruckAustria
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Lechner I, Reindl M, Oberhollenzer F, Tiller C, Holzknecht M, Fink P, Kremser T, Bonatti P, Troger F, Henninger B, Mayr A, Bauer A, Metzler B, Reinstadler SJ. Association of dysglycaemia with persistent infarct core iron in patients with acute ST-segment elevation myocardial infarction. J Cardiovasc Magn Reson 2024; 26:100996. [PMID: 38237898 DOI: 10.1016/j.jocmr.2024.100996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/11/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Dysglycaemia increases the risk of myocardial infarction and subsequent recurrent cardiovascular events. However, the role of dysglycaemia in ischemia/reperfusion injury with development of irreversible myocardial tissue alterations remains poorly understood. In this study we aimed to investigate the association of ongoing dysglycaemia with persistence of infarct core iron and their longitudinal changes over time in patients undergoing primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI). METHODS We analyzed 348 STEMI patients treated with primary PCI between 2016 and 2021 that were included in the prospective MARINA-STEMI study (NCT04113356). Peripheral venous blood samples for glucose and glycated hemoglobin (HbA1c) measurements were drawn on admission and 4 months after STEMI. Cardiac magnetic resonance (CMR) imaging including T2 * mapping for infarct core iron assessment was performed at both time points. Associations of dysglycaemia with persistent infarct core iron and iron resolution at 4 months were calculated using multivariable regression analysis. RESULTS Intramyocardial hemorrhage was observed in 147 (42%) patients at baseline. Of these, 89 (61%) had persistent infarct core iron 4 months after infarction with increasing rates across HbA1c levels (<5.7%: 33%, ≥5.7: 79%). Persistent infarct core iron was independently associated with ongoing dysglycaemia defined by HbA1c at 4 months (OR: 7.87 [95% CI: 2.60-23.78]; p < 0.001), after adjustment for patient characteristics and CMR parameters. The independent association was present even after exclusion of patients with diabetes (pre- and newly diagnosed, n = 16). CONCLUSIONS In STEMI patients treated with primary PCI, ongoing dysglycaemia defined by HbA1c is independently associated with persistent infarct core iron and a lower likelihood of iron resolution. These findings suggest a potential association between ongoing dysglycaemia and persistent infarct core iron, which warrants further investigation for therapeutic implications.
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Affiliation(s)
- Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Fritz Oberhollenzer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Thomas Kremser
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Paolo Bonatti
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Benjamin Henninger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Reindl M, Stiermaier T, Lechner I, Tiller C, Holzknecht M, Fink P, Mayr A, Klug G, Feistritzer HJ, Delewi R, Hirsch A, Carberry J, Carrick D, Bauer A, Metzler B, Nijveldt R, Thiele H, Berry C, Eitel I, Reinstadler SJ. Infarct severity and outcomes in ST-elevation myocardial infarction patients without standard modifiable risk factors - A multicenter cardiac magnetic resonance study. Eur J Intern Med 2024; 119:78-83. [PMID: 37634958 DOI: 10.1016/j.ejim.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Standard modifiable cardiovascular risk factors (SMuRFs) are well-established players in the pathogenesis of ST-elevation myocardial infarction (STEMI). However, in a significant proportion of STEMI patients, no SMuRFs can be identified, and the outcomes of this subgroup are not well described. OBJECTIVES To assess the infarct characteristics at myocardial-tissue level and subsequent clinical outcomes in SMuRF-less STEMIs. METHODS This multicenter, individual patient-data analysis included 2012 STEMI patients enrolled in four cardiac magnetic resonance (CMR) imaging studies conducted in Austria, Germany, Scotland, and the Netherlands. Unstable patients at time of CMR (e.g. cardiogenic shock/after cardiac arrest) were excluded. SMuRF-less was defined as absence of hypertension, smoking, hypercholesterolemia, and diabetes mellitus. All patients underwent CMR 3(interquartile range [IQR]:2-4) days after infarction to assess left ventricular (LV) volumes and ejection fraction, infarct size and microvascular obstruction (MVO). Clinical endpoints were defined as major adverse cardiovascular events (MACE), including all-cause mortality, re-infarction and heart failure. RESULTS No SMuRF was identified in 185 patients (9%). These SMuRF-less patients were older, more often male, had lower TIMI risk score and pre-interventional TIMI flow, and less frequently multivessel-disease. SMuRF-less patients did not show significant differences in CMR markers compared to patients with SMuRFs (all p > 0.10). During a median follow-up of 12 (IQR:12-27) months, 199 patients (10%) experienced a MACE. No significant difference in MACE rates was observed between SMuRF-less patients and patients with SMuRFs (8vs.10%, p = 0.39). CONCLUSIONS In this large individual patient-data pooled analysis of low-risk STEMI patients, infarct characteristics and clinical outcomes were not different according to SMuRF status.
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Affiliation(s)
- Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Thomas Stiermaier
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany; German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Hans-Josef Feistritzer
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Ronak Delewi
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, the Netherlands
| | - Alexander Hirsch
- Department of Cardiology and Radiology and Nuclear Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jaclyn Carberry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - David Carrick
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany; German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020, Innsbruck, Austria.
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Pogran E, Zweiker D, Gargiulo L, El‐Razek AA, Lechner I, Vosko I, Rechberger S, Bugger H, Christ G, Bonderman D, Kunschitz E, Zirlik A, Bauer A, Metzler B, Lambert T, Steinwender C, Huber K. Takotsubo syndrome before and during the COVID-19 pandemic in Austria: a retrospective cohort study (TOSCA-19). ESC Heart Fail 2023; 10:3667-3676. [PMID: 37803874 PMCID: PMC10682936 DOI: 10.1002/ehf2.14536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/05/2023] [Accepted: 09/08/2023] [Indexed: 10/08/2023] Open
Abstract
AIMS This study aims to investigate the prevalence of Takotsubo syndrome (TTS) as a percentage of the total number of acute coronary syndrome (ACS), including non-STE-elevation myocardial infarction and ST-elevation myocardial infarction, as well as the short-term outcome of TTS patients before and during the COVID-19 pandemic. METHODS AND RESULTS We compared patients from two different periods: (i) Period 1 (before the COVID-19 pandemic): 1 March to 30 December 2019, and (ii) Period 2 (during the COVID-19 pandemic): 1 March to 30 December 2020. The retrospective database was created from the archives of the participating hospitals or electronic hospital systems by trained medical personnel. The subjects' medical history, cardiovascular risk factors, laboratory values, echocardiography findings, and an in-hospital outcome were variables of interest. Furthermore, propensity score matching analysis was performed to evaluate the short-term prognosis in TTS and ACS patients. Altogether six Austrian centres-(i) 3rd Medical Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, Vienna, Austria; (ii) 5th Medical Department of Cardiology, Clinic Favoriten, Vienna, Austria; (iii) 2nd Medical Department, Hanusch Hospital, Vienna, Austria; (iv) University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria; (v) Department of Cardiology, University Hospital Graz, Graz, Austria; (vi) Department of Cardiology and Intensive Medicine, Kepler University Clinic, Linz, Austria-participated in the study. During period 1, 87 (3.5%) patients out of 2482 ACS patients had TTS in all participating centres. During period 2, 71 (2.7%) patients out of 2572 ACS patients had TTS in all participating centres. Accordingly, the prevalence of TTS remained stable irrespective of potential psychologic stress during the COVID pandemic. Furthermore, the baseline characteristics of TTS patients did not change during the COVID-19 pandemic. The prevalence of in-hospital complications [cardiogenic shock (4.6% vs. 4.3%, P = 0.925), ventricle thrombus (1.1% vs. 1.4%, P = 0.885) and in-hospital bleeding (3.4% vs. 1.4%, P = 0.417)] remained stable. The all-cause in-hospital mortality of TTS patients did not change during the COVID-19 pandemic [χ2 (2) = 0.058, P = 0.810]. Moreover, a propensity score matching analysis of all-cause in-hospital mortality between matched TTS and ACS patients showed higher in-hospital mortality in ACS patients during COVID-19 pandemic (P = 0.043). CONCLUSIONS Despite the well-known increased psychologic stress during the COVID-19 pandemic, the prevalence of TTS during the COVID-19 pandemic and the short-term clinical outcome in Austria remained unimpacted.
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Affiliation(s)
- Edita Pogran
- 3rd Medical Department of Cardiology and Intensive Care MedicineClinic Ottakring (former Wilhelminenhospital)ViennaAustria
- Doctoral Programme Meduni ViennaMedical University of ViennaViennaAustria
| | - David Zweiker
- 3rd Medical Department of Cardiology and Intensive Care MedicineClinic Ottakring (former Wilhelminenhospital)ViennaAustria
| | - Laura Gargiulo
- School of MedicineSigmund Freud Private UniversityViennaAustria
| | | | - Ivan Lechner
- University Clinic for Internal Medicine III‐Cardiology and AngiologyInnsbruckAustria
| | - Ivan Vosko
- Department of CardiologyUniversity Hospital GrazGrazAustria
| | - Stefan Rechberger
- Department of Cardiology and Intensive Care MedicineKepler University Hospital LinzLinzAustria
| | - Heiko Bugger
- Department of CardiologyUniversity Hospital GrazGrazAustria
| | - Günter Christ
- 5th Medical Department of CardiologyClinic FavoritenViennaAustria
| | - Diana Bonderman
- 5th Medical Department of CardiologyClinic FavoritenViennaAustria
| | | | - Andreas Zirlik
- Department of CardiologyUniversity Hospital GrazGrazAustria
| | - Axel Bauer
- University Clinic for Internal Medicine III‐Cardiology and AngiologyInnsbruckAustria
| | - Bernhard Metzler
- University Clinic for Internal Medicine III‐Cardiology and AngiologyInnsbruckAustria
| | - Thomas Lambert
- Department of Cardiology and Intensive Care MedicineKepler University Hospital LinzLinzAustria
| | - Clemens Steinwender
- Department of Cardiology and Intensive Care MedicineKepler University Hospital LinzLinzAustria
| | - Kurt Huber
- 3rd Medical Department of Cardiology and Intensive Care MedicineClinic Ottakring (former Wilhelminenhospital)ViennaAustria
- School of MedicineSigmund Freud Private UniversityViennaAustria
- Ludwig Boltzmann Institute for Interventional Cardiology and RhythmologyMedical University of ViennaViennaAustria
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8
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Reindl M, Lechner I, Holzknecht M, Tiller C, Fink P, Oberhollenzer F, Mayr A, Troger F, Pamminger M, Henninger B, Theurl M, Klug G, Brenner C, Bauer A, Metzler B, Reinstadler SJ. Improved detection of echocardiographically occult left ventricular thrombi following ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care 2023; 12:703-710. [PMID: 37348047 DOI: 10.1093/ehjacc/zuad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/11/2023] [Accepted: 06/21/2023] [Indexed: 06/24/2023]
Abstract
AIM The aim of this study was to investigate predictors of transthoracic echocardiography (TTE)-occult left ventricular (LV) thrombi (LVT) and to propose a clinical model for improved detection of TTE-occult LVT post-ST-elevation myocardial infarction (STEMI). Patients with acute STEMI are at significant risk for developing LVT. However, this complication often (up to 65%) remains undetected by using TTE, referred to as TTE-occult LVT. METHODS AND RESULTS In total, 870 STEMI patients underwent TTE and cardiac magnetic resonance (CMR), the reference method for LVT detection, 3 days after infarction. Clinical (body mass index, peak cardiac troponin T) and echocardiographic [ejection fraction, apical wall motion scores (AWMSs)] predictors were analysed. Primary endpoint was the presence of TTE-occult LVT identified by CMR imaging. From the overall cohort, 37 patients (4%) showed an LVT by CMR. Of these thrombi, 25 (68%) were not identified by TTE. Transthoracic echocardiography-occult thrombi did not significantly differ in volume (1.4 vs. 2.74 cm3), diameter (19.0 vs. 23.3 mm), and number of fragments or shape compared with TTE-apparent LVT (all P > 0.05). For predicting these TTE-occult LVT, the 16-segment AWMS (AWMS16Seg) showed highest validity {area under the curve: 0.91 [95% confidence interval (CI): 0.89-0.93]; P < 0.001}, with an association independent of ejection fraction and 17-segment AWMS (AWMS17Seg) [odds ratio: 1.68 (95% CI: 1.43-1.97); P < 0.001] and clinical (body mass index, peak troponin) and angiographic (culprit lesion, post-interventional thrombolysis in myocardial infarction flow) associates of TTE-occult LVT (all P < 0.05). Dichotomization at AWMS16Seg ≥ 8 (n = 260, 30%) allowed for a detection of all TTE-occult LVT (sensitivity: 100%), with a corresponding specificity of 77%. CONCLUSION After acute STEMI, AWMS16Seg served as a simple and very robust predictor of TTE-occult LVT. An AWMS16Seg-based algorithm to identify patients for additional CMR imaging offers great potential to optimize detection of TTE-occult LVT following STEMI.
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Affiliation(s)
- Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Fritz Oberhollenzer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Benjamin Henninger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Markus Theurl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christoph Brenner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
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9
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Reindl M, Lechner I, Holzknecht M, Tiller C, Fink P, Oberhollenzer F, von der Emde S, Pamminger M, Troger F, Kremser C, Laßnig E, Danninger K, Binder RK, Ulmer H, Brenner C, Klug G, Bauer A, Metzler B, Mayr A, Reinstadler SJ. Cardiac Magnetic Resonance Imaging Versus Computed Tomography to Guide Transcatheter Aortic Valve Replacement: A Randomized, Open-Label, Noninferiority Trial. Circulation 2023; 148:1220-1230. [PMID: 37634187 DOI: 10.1161/circulationaha.123.066498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Computed tomography (CT) is recommended for guiding transcatheter aortic valve replacement (TAVR). However, a sizable proportion of TAVR candidates have chronic kidney disease, in whom the use of iodinated contrast media is a limitation. Cardiac magnetic resonance imaging (CMR) is a promising alternative, but randomized data comparing the effectiveness of CMR-guided versus CT-guided TAVR are lacking. METHODS An investigator-initiated, prospective, randomized, open-label, noninferiority trial was conducted at 2 Austrian heart centers. Patients evaluated for TAVR according to the inclusion criteria (severe symptomatic aortic stenosis) and exclusion criteria (contraindication to CMR, CT, or TAVR, a life expectancy <1 year, or chronic kidney disease level 4 or 5) were randomized (1:1) to undergo CMR or CT guiding. The primary outcome was defined according to the Valve Academic Research Consortium-2 definition of implantation success at discharge, including absence of procedural mortality, correct positioning of a single prosthetic valve, and proper prosthetic valve performance. Noninferiority was assessed using a hybrid modified intention-to-treat/per-protocol approach on the basis of an absolute risk difference margin of 9%. RESULTS Between September 11, 2017, and December 16, 2022, 380 candidates for TAVR were randomized to CMR-guided (191 patients) or CT-guided (189 patients) TAVR planning. Of these, 138 patients (72.3%) in the CMR-guided group and 129 patients (68.3%) in the CT-guided group eventually underwent TAVR (modified intention-to-treat cohort). Of these 267, 19 patients had protocol deviations, resulting in a per-protocol cohort of 248 patients (121 CMR-guided, 127 CT-guided). In the modified intention-to-treat cohort, implantation success was achieved in 129 patients (93.5%) in the CMR group and in 117 patients (90.7%) in the CT group (between-group difference, 2.8% [90% CI, -2.7% to 8.2%]; P<0.01 for noninferiority). In the per-protocol cohort (n=248), the between-group difference was 2.0% (90% CI, -3.8% to 7.8%; P<0.01 for noninferiority). CONCLUSIONS CMR-guided TAVR was noninferior to CT-guided TAVR in terms of device implantation success. CMR can therefore be considered as an alternative for TAVR planning. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03831087.
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Affiliation(s)
- Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Fritz Oberhollenzer
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Sebastian von der Emde
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Elisabeth Laßnig
- Department of Cardiology and Intensive Care (E.L., K.D., R.K.B.), University Teaching Hospital Klinikum Wels-Grieskrichen, Wels, Austria
| | - Kathrin Danninger
- Department of Cardiology and Intensive Care (E.L., K.D., R.K.B.), University Teaching Hospital Klinikum Wels-Grieskrichen, Wels, Austria
| | - Ronald K Binder
- Department of Cardiology and Intensive Care (E.L., K.D., R.K.B.), University Teaching Hospital Klinikum Wels-Grieskrichen, Wels, Austria
| | - Hanno Ulmer
- Institute of Medical Statistics and Informatics (H.U.), Medical University of Innsbruck, Austria
| | - Christoph Brenner
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
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10
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Lechner I, Reindl M, Metzler B, Reinstadler SJ. Embracing nomograms: A leap in the dark for enhanced risk stratification in STEMI. Int J Cardiol 2023; 388:131106. [PMID: 37271283 DOI: 10.1016/j.ijcard.2023.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
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11
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Lechner I, Reindl M, Tiller C, Holzknecht M, Fink P, Troger F, Angerer G, Angerer S, Henninger B, Mayr A, Klug G, Bauer A, Metzler B, Reinstadler SJ. Temporal Trends in Infarct Severity Outcomes in ST-Segment-Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study. J Am Heart Assoc 2023; 12:e028932. [PMID: 37489726 PMCID: PMC10492996 DOI: 10.1161/jaha.122.028932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/10/2023] [Indexed: 07/26/2023]
Abstract
Background Severity of myocardial tissue injury is a main determinant of morbidity and death related to ST-segment-elevation myocardial infarction (STEMI). Temporal trends of infarct characteristics at the myocardial tissue level have not been described. This study sought to assess temporal trends in infarct characteristics through a comprehensive assessment by cardiac magnetic resonance imaging at a standardized time point early after STEMI. Methods and Results We analyzed patients with STEMI treated with percutaneous coronary intervention at the University Hospital of Innsbruck who underwent cardiac magnetic resonance imaging between 2005 and 2021. The study period was divided into terciles. Myocardial damage characteristics were assessed using a multiparametric cardiac magnetic resonance imaging protocol within the first week after STEMI and compared between groups. A total of 843 patients with STEMI (17% women) with a median age of 57 (interquartile range, 51-66) years were analyzed. While age, sex, and the clinical risk profile expressed as thrombolysis in myocardial infarction risk score were comparable across the study period, there were differences in guideline-recommended therapies. At the same time, there was no significant change in infarct size (P=0.25), microvascular obstruction (P=0.50), and intramyocardial hemorrhage (P=0.34). Left ventricular remodeling indices and left ventricular ejection fraction remained virtually unchanged (all P>0.05). Major adverse cardiovascular events at 4 (interquartile range, 4-5) months were similar between groups (P=0.36). Conclusions In this magnetic resonance imaging study investigating patients with STEMI treated with primary percutaneous coronary intervention over the past 15 years, no change in infarct severity at the myocardial level has been observed. Clinical research on novel therapeutic approaches to reduce myocardial tissue injury should be a priority.
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Affiliation(s)
- Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Felix Troger
- University Clinic of RadiologyMedical University of InnsbruckInnsbruckAustria
| | - Georg Angerer
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Simon Angerer
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Benjamin Henninger
- University Clinic of RadiologyMedical University of InnsbruckInnsbruckAustria
| | - Agnes Mayr
- University Clinic of RadiologyMedical University of InnsbruckInnsbruckAustria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Sebastian J. Reinstadler
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
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12
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Troger F, Tiller C, Reindl M, Lechner I, Holzknecht M, Pamminger M, Poskaite P, Kremser C, Ulmer H, Gizewski ER, Bauer A, Reinstadler S, Metzler B, Klug G, Mayr A. Slice positioning in phase-contrast MRI impacts aortic stenosis assessment. Eur J Radiol 2023; 161:110722. [PMID: 36758278 DOI: 10.1016/j.ejrad.2023.110722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023]
Abstract
AIMS To determine the phase-contrast cardiovascular magnetic resonance imaging (PC-CMR) slice-position above aortic leaflet-attachment-plane (LAP) that provides flow-velocity, -volume and aortic valve area (AVA) measurements with best agreement to invasive and echocardiographic measurements in aortic stenosis (AS). METHODS AND RESULTS Fifty-five patients with moderate/severe AS underwent cardiac catheterization, transthoracic echocardiography (TTE) and CMR. Overall, 171 image-planes parallel to LAP were measured via PC-CMR between 22 mm below and 24 mm above LAP. AVA via PC-CMR was calculated as flow-volume divided by peak-velocity during systole. Stroke volume (SV) and AVA were compared to volumetric SV and invasive AVA via the Gorlin-formula, respectively. Above LAP, SV by PC-CMR showed no significant dependence on image-plane-position and correlated strongly with volumetry (rho: 0.633, p < 0.001, marginal-mean-difference (MMD): 1 ml, 95 % confidence-interval (CI): -4 to 6). AVA assessed in image-planes 0-10 mm above LAP differed significantly from invasive measurement (MMD: -0.14 cm2, 95 %CI: 0.08-0.21). In contrast, AVA-values by PC-CMR measured 10-20 mm above LAP showed good agreement with invasive determination without significant MMD (0.003 cm2, 95 %CI: -0.09 to 0.09). Within these measurements, a plane 15 mm above LAP resulted in the lowest bias (MMD: 0.02 cm2, 95 %CI:-0.29 to 0.33). SV and AVA via TTE correlated moderately with volumetry (rho: 0.461, p < 0.001; bias: 15 ml, p < 0.001) and cardiac catheterization (rho: 0.486, p < 0.001, bias: -0.13 cm2, p < 0.001), respectively. CONCLUSION PC-CMR measurements at 0-10 mm above LAP should be avoided due to significant AVA-overestimation compared to invasive determination. AVA-assessment by PC-CMR between 10 and 20 mm above LAP did not differ from invasive measurements, with the lowest intermethodical bias measured 15 mm above LAP.
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Affiliation(s)
- Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Paulina Poskaite
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Hanno Ulmer
- Department for Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Schoepfstrasse 41/1, 6020 Innsbruck, Austria
| | - Elke Ruth Gizewski
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Sebastian Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
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13
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Lechner I, Reindl M, Tiller C, Holzknecht M, Fink P, Troger F, Mayr A, Klug G, Bauer A, Reinstadler SJ, Metzler B. Temporal trends and outcomes in ST-segment elevation myocardial infarction: a cardiac magnetic resonance imaging study over the course of 15 years. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
Development of evidence-based treatments in ST-elevation myocardial infarction (STEMI) patients during the last 30 years have been associated with improved outcome; however, there are data suggesting a plateauing since around 2008 (1). Moreover, contemporary data are very scarce regarding the temporal trends of infarct outcomes. This study sought to describe the temporal trends in infarct severity at myocardial tissue level over the course of 15 years by means of cardiac magnetic resonance imaging (MRI).
Methods
This study analyzed STEMI patients treated with percutaneous coronary intervention (PCI) in our Medical University who underwent a cardiac MRI between 2005 and 2021. The 15-year study period was divided into sequential 2-years blocks. Infarct characteristics were measured using MRI at 3 days [IQR 2–5] after PCI.
Results
A total of 844 STEMI patients (17% female) with a median age of 57 (interquartile range [IQR]: 51–66) years were included. The rate of evidence-based treatments was high for aspirin (99%), P2Y12i (99%), beta-blockers (91%), ACEi/ATi (92%) and statins (100%) and did not change significantly over the study period (p>0.05) with the exception for ACEi/ATi (p=0.03) and prasugrel (p<0.001), which increased and clopidogrel, which decreased during the study course (p<0.001). TIMI risk score did not change over the study period (p=0.43). Overall median infarct size was 16 [9–25]% and did not change (p=0.39) significantly. MVO, a marker of severe reperfusion injury, was also comparable (p=0.16). Accordingly, LV ejection fraction remained virtually unchanged (p=0.23)
Conclusion
Although further implementation of evidence-based treatments was seen also during the last 15 years, there has been no effect on infarct size, reperfusion injury and LV ejection fraction for patients who undergo primary PCI due to STEMI. Novel treatment strategies are needed to address this unmet therapeutic need.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology
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Affiliation(s)
- I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - P Fink
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - F Troger
- Medical University of Innsbruck, Department of Radiology , Innsbruck , Austria
| | - A Mayr
- Medical University of Innsbruck, Department of Radiology , Innsbruck , Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - S J Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
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14
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Tiller C, Holzknecht M, Lechner I, Reindl M, Fink P, Mayr A, Klug G, Brenner C, Bauer A, Metzler B, Reinstadler SJ. Prognostic significance of left ventricular functional parameters in relation to infarct location after ST-elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
In survivors of ST-elevation myocardial infarction (STEMI), the impact of infarct location on the prognostic significance of left ventricular functional parameters is not well established. The aim of this study was to investigate the prognostic relevance of left ventricular (LV) functional parameters in relation to infarct location in STEMI patients treated with contemporary primary percutaneous coronary intervention (PCI).
Methods
This observational study analyzed 803 patients with STEMI that underwent a cardiac magnetic resonance imaging scan in median 3 (interquartile range [IQR]: 2–5) days after primary PCI. The following LV functional parameters were evaluated: LV ejection fraction, LV global longitudinal strain, fast manual long-axis strain (LAS) and mitral annular plane systolic excursion (MAPSE). Primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as composite of death, re-infarction and congestive heart failure.
Results
Three hundred and sixty nine patients (46%) had anterior STEMI. These patients had lower LV functional parameters including LV ejection fraction (p<0.001), LV global longitudinal strain (p<0.001), LAS (p<0.001) and MAPSE (p<0.014). MACE was evaluated at a median of 13 (IQR: 12–37) months after STEMI and occurred in 78 patients (10%). In receiver operating curve analysis, the predictive value of LV ejection fraction, LV global longitudinal strain, LAS and MAPSE was 0.59 (p=0.013), 0.64 (p<0.001), 0.67 (p<0.001) and 0.66 (p<0.001), respectively. When divided according to infarct location, MACE occurred in 47 (13%) anterior STEMI patients, and in 31 (7%) non-anterior STEMI patients, respectively. Area under the curve for the prediction of MACE in anterior vs. non-anterior STEMI was 0.59 vs 0.55 for LV ejection fraction, 0.61 vs 0.63 for LV global longitudinal strain, 0.69 vs 0.62 for LAS and both 0.66 for MAPSE. In multivariable analysis, LAS was independently associated with an increased risk of MACE (hazard ratio: 1.20; 95% confidence interval: 1.10–1.30; p<0.001) in anterior STEMI, whereas in non-anterior STEMI, LV global longitudinal strain was an independent predictor of MACE (hazard ratio: 1.22; 95% confidence interval: 1.08–1.38; p=0.002).
Conclusion
Fast manual LAS emerged as independent predictor of MACE in anterior STEMI treated with contemporary primary PCI whereas LV global longitudinal strain was independently associated with MACE in non-anterior STEMI.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology
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Affiliation(s)
- C Tiller
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - M Holzknecht
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - I Lechner
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - M Reindl
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - P Fink
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - A Mayr
- Innsbruck Medical University, University Clinic of Radiology , Innsbruck , Austria
| | - G Klug
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - C Brenner
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - A Bauer
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - B Metzler
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
| | - S J Reinstadler
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology , Innsbruck , Austria
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15
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Zweiker D, Pogran E, Gargiulo L, El-Razek A, Vosko I, Rechberger S, Bugger H, Christ G, Bonderman D, Kunschitz E, Zirlik A, Bauer A, Metzler B, Steinwender C, Huber K. Neutrophile-lymphocyte ratio and outcome in takotsubo syndrome. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Takotsubo syndrome (TTS) is an important form of acute heart failure with significant risk of acute complications and death. In this analysis we sought to identify predictors for in-hospital clinical outcome in TTS patients by concentrating on routine laboratory parameters at admission.
Methods
In this analysis from the Austrian national TTS registry, univariable and multivariable analyses were performed to identify significant predictors for severe in-hospital complications requiring immediate invasive treatment or leading to irreversible damage, such as cardiogenic shock, intubation, stroke, arrhythmias and death. Furthermore, the influence of identified predictors with long-term survival was evaluated.
Results
A total of 338 patients (median age 72 years, 86.9% female) from 6 centres were included. Severe in-hospital complications occurred in 14.5% of patients, including cardiogenic shock (9.8%), death (3.3%) and intubation (1.2%), respectively. Patients with complications during the hospital stay had more prevalent chronic kidney disease (CKD), were less often previous smokers and TTS was less often preceded by an emotional trigger. C-reactive protein and neutrophile lymphocyte ratio (NLR) was higher in patients with complications, and midventricular ballooning and reduced left ventricular ejection fraction (LVEF) were more prevalent. In multivariable analysis, high NLR (OR 1.04 [95% CI 1.02–1.07], p=0.009) and low LVEF (OR 0.92 [0.90–0.95] per %, p<0.001) remained significant predictors for severe in-hospital complications. Both the highest NLR tercile and the lowest LVEF tercile were associated with significantly reduced 5-year survival.
Discussion
Low LVEF and high NLR at admission were independently associated with increased in-hospital complications and reduced long-term survival in TTS patients. NLR is a new easy-to-measure tool to predict worse short and long-term outcome after TTS.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D Zweiker
- Ottakring Clinic, 3rd Medical Department, Cardiology and Intensive Care Medicine , Vienna , Austria
| | - E Pogran
- Ottakring Clinic, 3rd Medical Department, Cardiology and Intensive Care Medicine , Vienna , Austria
| | - L Gargiulo
- Sigmund Freud University, Medical School , Vienna , Austria
| | - A El-Razek
- Medical University of Innsbruck, Clinic for Internal Medicine III - Cardiology and Angiology , Innsbruck , Austria
| | - I Vosko
- Medical University of Graz, Division of Cardiology , Graz , Austria
| | - S Rechberger
- Kepler University Hospital Linz, Department of Cardiology and Intensive Medicine , Linz , Austria
| | - H Bugger
- Medical University of Graz, Division of Cardiology , Graz , Austria
| | - G Christ
- Clinic Favoriten, 5th Medical Department for Cardiology , Vienna , Austria
| | - D Bonderman
- Clinic Favoriten, 5th Medical Department for Cardiology , Vienna , Austria
| | - E Kunschitz
- Hanusch Hospital, 2nd Medical Department , Vienna , Austria
| | - A Zirlik
- Medical University of Graz, Division of Cardiology , Graz , Austria
| | - A Bauer
- Medical University of Innsbruck, Clinic for Internal Medicine III - Cardiology and Angiology , Innsbruck , Austria
| | - B Metzler
- Medical University of Innsbruck, Clinic for Internal Medicine III - Cardiology and Angiology , Innsbruck , Austria
| | - C Steinwender
- Kepler University Hospital Linz, Department of Cardiology and Intensive Medicine , Linz , Austria
| | - K Huber
- Ottakring Clinic, 3rd Medical Department, Cardiology and Intensive Care Medicine , Vienna , Austria
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16
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Holzknecht M, Lechner I, Reindl M, Tiller C, Fink P, Mayr A, Klug G, Bauer A, Reinstadler SJ, Metzler B. Association between inflammation and left ventricular thrombus formation following ST-elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Current evidence suggests a link between the inflammatory state and left ventricular thrombus (LVT) formation following ST-elevation myocardial infarction (STEMI). However, a comprehensive study investigating the association between inflammatory biomarkers and LVT diagnosed by cardiac magnetic resonance (CMR) is lacking.
Purpose
The present study aimed to investigate the association of biochemical markers of inflammation with LVT as assessed by CMR imaging among patients with STEMI.
Methods
We studied 309 patients with acute STEMI treated with primary percutaneous coronary intervention (pPCI) from the prospective MARINA-STEMI cohort study. Concentrations of high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), white blood cell count (WBCc), fibrinogen and D-dimer were measured two days after STEMI. Infarct characteristics and presence of LVT were assessed with the use of contrast-enhanced CMR at a median of 4 (interquartile range [IQR] 3–5) days after pPCI.
Results
In total, 309 STEMI patients (18% female) with a median age of 57 (IQR 52–65) years were included. An LVT was observed in 8% (n=24) of the overall cohort and in 15% of patients with an anterior STEMI. Hs-CRP (OR: 2.16, 95% CI: 1.54–3.02, p<0.001), IL-6 (OR: 2.38, 95% CI: 1.48–3.81, p<0.001) and fibrinogen levels (OR: 2.05, 95% CI: 1.40–3.00, p<0.001) were significantly associated with presence of LVT. Among all assessed inflammatory biomarkers, only hs-CRP was independently associated with LVT after adjustment for markers of inflammation and CMR parameters (OR: 1.77, 95% CI: 1.21–2.59, p=0.004).
Conclusion
In patients with STEMI treated with pPCI, inflammatory markers (hs-CRP, IL-6 and fibrinogen) are associated with the presence of LVT. However, only hs-CRP was independently associated with the occurrence of LVT, highlighting the key role of CRP as clinical risk marker for LVT formation in STEMI patients treated with pPCI.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology
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Affiliation(s)
- M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - P Fink
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - A Mayr
- Medical University of Innsbruck, University Clinic of Radiology , Innsbruck , Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - S J Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology , Innsbruck , Austria
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17
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Klug G, Reinstadler S, Troger F, Holzknecht M, Reindl M, Tiller C, Lechner I, Fink P, Pamminger M, Kremser C, Ulmer H, Bauer A, Metzler B, Mayr A. Cardiac magnetic resonance imaging versus computed tomography to guide transcatheter aortic valve replacement: study protocol for a randomized trial (TAVR-CMR). Trials 2022; 23:726. [PMID: 36056444 PMCID: PMC9438296 DOI: 10.1186/s13063-022-06638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 08/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background The standard procedure for the planning of transcatheter aortic valve replacement (TAVR) is the combination of echocardiography, coronary angiography, and cardiovascular computed tomography (TAVR-CT) for the exact determination of the aortic valve dimensions, valve size, and implantation route. However, up to 80% of the patients undergoing TAVR suffer from chronic renal insufficiency. Alternatives to reduce the need for iodinated contrast agents are desirable. Cardiac magnetic resonance (CMR) imaging recently has emerged as such an alternative. Therefore, we aim to investigate, for the first time, the non-inferiority of TAVR-CMR to TAVR-CT regarding efficacy and safety end-points. Methods This is a prospective, randomized, open-label trial. It is planned to include 250 patients with symptomatic severe aortic stenosis scheduled for TAVR based on a local heart-team decision. Patients will be randomized in a 1:1 fashion to receive a predefined TAVR-CMR protocol or to receive a standard TAVR-CT protocol within 2 weeks after inclusion. Follow-up will be performed at hospital discharge after TAVR and after 1 and 2 years. The primary efficacy outcome is device implantation success at discharge. The secondary endpoints are a combined safety endpoint and a combined clinical efficacy endpoint at baseline and at 1 and 2 years, as well as a comparison of imaging procedure related variables. Endpoint definitions are based on the updated 2012 VARC-2 consensus document. Discussion TAVR-CMR might be an alternative to TAVR-CT for planning a TAVR procedure. If proven to be effective and safe, a broader application of TAVR-CMR might reduce the incidence of acute kidney injury after TAVR and thus improve outcomes. Trial registration The trial is registered at ClinicalTrials.gov (NCT03831087). The results will be disseminated at scientific meetings and publication in peer-reviewed journals.
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Affiliation(s)
- Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Sebastian Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Felix Troger
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.,University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Hanno Ulmer
- Department for Medical Statistics, Informatics and Health Economy, Medical University of Innsbruck, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
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18
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Zweiker D, Pogran E, Gargiulo L, Abd El-Razek A, Lechner I, Vosko I, Rechberger S, Bugger H, Christ G, Bonderman D, Kunschitz E, Czedik-Eysenberg C, Roithinger A, Weihs V, Kaufmann CC, Zirlik A, Bauer A, Metzler B, Lambert T, Steinwender C, Huber K. Neutrophile-Lymphocyte Ratio and Outcome in Takotsubo Syndrome. Biology (Basel) 2022; 11:biology11081154. [PMID: 36009781 PMCID: PMC9404721 DOI: 10.3390/biology11081154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
Background: Takotsubo syndrome (TTS) is an important type of acute heart failure with significant risk of acute complications and death. In this analysis we sought to identify predictors for in-hospital clinical outcome in TTS patients and present long-term outcomes. Methods: In this analysis from the Austrian national TTS registry, univariable and multivariable analyses were performed to identify significant predictors for severe in-hospital complications requiring immediate invasive treatment or leading to irreversible damage, such as cardiogenic shock, intubation, stroke, arrhythmias and death. Furthermore, the influence of independent predictors on long-term survival was evaluated. Results: A total of 338 patients (median age 72 years, 86.9% female) from six centers were included. Severe in-hospital complications occurred in 14.5% of patients. In multivariable analysis, high neutrophile-lymphocyte-ratio (NLR; OR 1.04 [95% CI 1.02−1.07], p = 0.009) and low LVEF (OR 0.92 [0.90−0.95] per %, p < 0.001) were significant predictors of severe in-hospital complications. Both the highest NLR tercile and the lowest LVEF tercile were significantly associated with reduced 5-year survival. Conclusions: Low LVEF and high NLR at admission were independently associated with increased in-hospital complications and reduced long-term survival in TTS patients. NLR is a new easy-to-measure tool to predict worse short- and long-term outcome after TTS.
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Affiliation(s)
- David Zweiker
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), 1160 Vienna, Austria; (E.P.); (V.W.); (C.C.K.); (K.H.)
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria; (I.V.); (H.B.); (A.Z.)
- Correspondence: ; Tel.: +43-664-8650460; Fax: +43-1-49150-2309
| | - Edita Pogran
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), 1160 Vienna, Austria; (E.P.); (V.W.); (C.C.K.); (K.H.)
- Faculty of Medicine, Sigmund Freud University, 1020 Vienna, Austria; (L.G.); (A.A.E.-R.); (A.R.)
| | - Laura Gargiulo
- Faculty of Medicine, Sigmund Freud University, 1020 Vienna, Austria; (L.G.); (A.A.E.-R.); (A.R.)
| | - Ahmed Abd El-Razek
- Faculty of Medicine, Sigmund Freud University, 1020 Vienna, Austria; (L.G.); (A.A.E.-R.); (A.R.)
| | - Ivan Lechner
- Clinic of Internal Medicine III—Cardiology and Angiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (I.L.); (A.B.); (B.M.)
| | - Ivan Vosko
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria; (I.V.); (H.B.); (A.Z.)
| | - Stefan Rechberger
- Department of Cardiology and Intensive Medicine, Kepler University Clinic, 4020 Linz, Austria; (S.R.); (T.L.); (C.S.)
| | - Heiko Bugger
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria; (I.V.); (H.B.); (A.Z.)
| | - Günter Christ
- 5th Medical Department for Cardiology, Clinic Favoriten, 1100 Vienna, Austria; (G.C.); (D.B.)
| | - Diana Bonderman
- 5th Medical Department for Cardiology, Clinic Favoriten, 1100 Vienna, Austria; (G.C.); (D.B.)
| | | | | | - Antonia Roithinger
- Faculty of Medicine, Sigmund Freud University, 1020 Vienna, Austria; (L.G.); (A.A.E.-R.); (A.R.)
| | - Valerie Weihs
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), 1160 Vienna, Austria; (E.P.); (V.W.); (C.C.K.); (K.H.)
- Core Facility, Medical University of Vienna, 1090 Vienna, Austria;
| | - Christoph C. Kaufmann
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), 1160 Vienna, Austria; (E.P.); (V.W.); (C.C.K.); (K.H.)
| | - Andreas Zirlik
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria; (I.V.); (H.B.); (A.Z.)
| | - Axel Bauer
- Clinic of Internal Medicine III—Cardiology and Angiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (I.L.); (A.B.); (B.M.)
| | - Bernhard Metzler
- Clinic of Internal Medicine III—Cardiology and Angiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (I.L.); (A.B.); (B.M.)
| | - Thomas Lambert
- Department of Cardiology and Intensive Medicine, Kepler University Clinic, 4020 Linz, Austria; (S.R.); (T.L.); (C.S.)
| | - Clemens Steinwender
- Department of Cardiology and Intensive Medicine, Kepler University Clinic, 4020 Linz, Austria; (S.R.); (T.L.); (C.S.)
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), 1160 Vienna, Austria; (E.P.); (V.W.); (C.C.K.); (K.H.)
- Faculty of Medicine, Sigmund Freud University, 1020 Vienna, Austria; (L.G.); (A.A.E.-R.); (A.R.)
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Troger F, Reindl M, Tiller C, Lechner I, Holzknecht M, Fink P, Poskaite P, Pamminger M, Metzler B, Reinstadler S, Klug G, Mayr A. Prevalence and prognostic impact of mitral annular disjunction in patients with STEMI - A cardiac magnetic resonance study. J Cardiol 2022; 80:397-401. [PMID: 35779980 DOI: 10.1016/j.jjcc.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/18/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mitral annular disjunction (MAD) represents the detachment of the mitral leaflet hinge-point from the ventricular myocardium. Its role in patients with ST-segment-elevation myocardial infarction (STEMI) is unknown. This study aims to investigate the prevalence of MAD by cardiac magnetic resonance imaging (CMR) in STEMI-patients and its association with serious adverse events. METHODS STEMI-patients (n = 621) underwent CMR 4 days [interquartile range (IQR) 2-5] after percutaneous coronary intervention. Presence and longitudinal extent of MAD were obtained in long-axis cine-images, infarct characteristics in late gadolinium enhancement-images. During a median follow-up time of 366 days (IQR 136-454), patients were observed for the occurrence of major adverse cardiac events (MACE), comprising death, myocardial reinfarction, and congestive heart failure. RESULTS Overall, 307 patients (49 %) had MAD. Longitudinal MAD-distance was 4.6 ± 1.7 mm and the P3-segment was affected most frequently (n = 262, 85 % of MAD-patients). MAD-patients had a significantly smaller infarct size, lower prevalence of microvascular obstruction, and intramyocardial hemorrhage as well as a higher ejection fraction (all p < 0.03). During follow-up period, MACE occurred in 52 patients (8 %) and did not show significant difference between patients with and without MAD (7 % vs. 9 %, p = 0.424). Cardiovascular death occurred significantly more often in patients without MAD (n = 10, 3.2 % vs. n = 2, 0.7 %, p = 0.021). CONCLUSION MAD is a rather common finding in patients presenting with STEMI. Patients with MAD had less severe infarct characteristics, however, they were not more commonly affected by MACE. Further confirmation and longer follow-up intervals are necessary to define the exact role of MAD in STEMI patients.
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Affiliation(s)
- Felix Troger
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria; University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paulina Poskaite
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
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Mayr A, Klug G, Reindl M, Lechner I, Tiller C, Holzknecht M, Pamminger M, Troger F, Schocke M, Bauer A, Reinstadler SJ, Metzler B. Evolution of Myocardial Tissue Injury: A CMR Study Over a Decade After STEMI. JACC Cardiovasc Imaging 2022; 15:1030-1042. [PMID: 35680211 DOI: 10.1016/j.jcmg.2022.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 01/11/2022] [Accepted: 02/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with a first ST-segment elevation myocardial infarction (STEMI), the multi-annual evolution of myocardial tissue injury parameters, as assessed by cardiac magnetic resonance (CMR), has not yet been described. OBJECTIVES This study examined myocardial tissue injury dynamics over a decade after STEMI. METHODS Sequential CMR examinations (within the first week after STEMI, and at 4, 12, months, and 9 years thereafter) were conducted in 74 patients with STEMI treated with primary percutaneous coronary intervention. Left ventricular function, infarct size (IS), and microvascular obstruction (MVO) were assessed at all time points. T2∗, T2, and T1 mapping (n = 59) were added at 9-year scan to evaluate the presence of iron and edema within the infarct core, respectively. RESULTS IS decreased progressively and significantly between all CMR time points (all P < 0.001), with an average reduction rate of 5.8% per year (IQR: 3.5%-8.8%) and a relative reduction of 49% (IQR: 39%-76%) over a decade. MVO was present in 61% of patients at baseline, but was not present at the follow-up examinations. At 9-year CMR, 17 of 59 (29%) patients showed iron deposition within the infarct core, whereas 82% had persistent edema. Persistent iron and edema were associated with greater IS on any occasion (all P < 0.001), as well as the presence of MVO (P < 0.001). Patients with persistent iron and edema showed a lower relative regression of IS (P = 0.005 and P = 0.032, respectively) and greater end-systolic volumes over a decade (all P < 0.012 and P > 0.023, respectively). A T1 hypointense infarct core without evidence of T2∗ iron deposition (14 of 59 [24%] patients) was attributed to lipomatous metaplasia of the infarct. CONCLUSIONS The evolution of IS is a dynamic process that extends well beyond the first few months after STEMI. Persistence of iron and edema within the infarct core occurs up to a decade after STEMI and is associated with initial infarct severity and poor infarct healing.
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Affiliation(s)
- Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Schocke
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria.
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21
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Stastny L, Krapf C, Dumfarth J, Gasser S, Bauer A, Friedrich G, Metzler B, Feuchtner G, Mayr A, Grimm M, Bonaros N. Minireview: Transaortic Transcatheter Aortic Valve Implantation: Is There Still an Indication? Front Cardiovasc Med 2022; 9:798154. [PMID: 35310977 PMCID: PMC8931192 DOI: 10.3389/fcvm.2022.798154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Transaortic (TAo) transcatheter aortic valve implantation has become a valid alternative access route in patients with unsuitable femoral arteries. The current literature does not allow to clearly favor one of the alternative access routes. Every approach has its specific advantages. Transaortic (TAo) access is of particular importance in the case of calcifications of the supra-aortic branches and the aortic arch, as under these circumstances other alternative access routes, such as transaxillary or transcarotid, are not feasible. The purpose of this minireview is to give an overview and update on TAo transcatheter aortic valve implantation focusing on indication, technical aspects, and recent clinical data.
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Affiliation(s)
- Lukas Stastny
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
- *Correspondence: Julia Dumfarth
| | - Simone Gasser
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Guy Friedrich
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Metzler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
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22
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Tiller C, Reindl M, Holzknecht M, Lechner I, Schwaiger J, Brenner C, Mayr A, Klug G, Bauer A, Metzler B, Reinstadler SJ. Association of plasma interleukin-6 with infarct size, reperfusion injury, and adverse remodelling after ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care 2022; 11:113-123. [PMID: 34849677 DOI: 10.1093/ehjacc/zuab110] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/19/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022]
Abstract
AIMS Little is known about the clinical relevance of interleukin (IL)-6 in patients with acute ST-elevation myocardial infarction (STEMI). This study examined the possible associations of plasma IL-6 concentrations with infarct size (IS), reperfusion injury and adverse left ventricular remodelling (LVR), in STEMI patients treated with primary percutaneous coronary intervention (PCI). METHODS AND RESULTS We prospectively included 170 consecutive STEMI patients (median age 57 years, 14% women) treated with primary PCI between 2017 and 2019. Blood samples for biomarker analyses including IL-6 were collected on Day 2. Left ventricular ejection fraction (LVEF), IS, and reperfusion injury [microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)] were determined using cardiac magnetic resonance (CMR) imaging on Day 4. Left ventricular remodelling was defined as ≥10% increase in left ventricular end-diastolic volume from baseline to 4 months CMR follow-up. Patients with IL-6 concentrations ≥median (17 ng/L) showed a significantly lower LVEF (43% vs. 52%, P < 0.001), larger IS (22% vs. 13%, P < 0.001), larger MVO (1.9% vs. 0.0%, P < 0.001), and more frequent IMH (52% vs. 18%, P < 0.001). Left ventricular remodelling was more common in patients with IL-6 ≥ median (24% vs. 9%, P = 0.005). In both linear and binary multivariable regression analyses, IL-6 remained independently associated with lower LVEF [odds ratio (OR): 0.10, 95% confidence interval (CI) 0.02-0.42, P = 0.002], larger IS (OR: 5.29, 95% CI 1.52-18.40, P = 0.009), larger MVO (OR: 5.20, 95% CI 1.30-20.85, P = 0.020), with presence of IMH (OR: 3.73, 95% CI 1.27-10.99, P = 0.017), and adverse LVR (OR: 2.72, 95% 1.06-6.98, P = 0.038). CONCLUSIONS High concentrations of circulating plasma IL-6 on Day 2 after STEMI were independently associated with worse myocardial function, larger infarct extent, more severe reperfusion injury, and a higher likelihood for LVR, suggesting IL-6 as a useful biomarker of more serious outcome and potential therapeutic target. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT04113356;NCT04113356.
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Affiliation(s)
- Christina Tiller
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Martin Reindl
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Magdalena Holzknecht
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Ivan Lechner
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Johannes Schwaiger
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milserstrasse 10, Hall in Tirol A-6060, Austria
| | - Christoph Brenner
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Gert Klug
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Axel Bauer
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Bernhard Metzler
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
| | - Sebastian J Reinstadler
- Departement of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck A-6020, Austria
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23
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Troger F, Lechner I, Reindl M, Tiller C, Holzknecht M, Pamminger M, Kremser C, Schwaiger J, Reinstadler SJ, Bauer A, Metzler B, Mayr A, Klug G. A novel approach to determine aortic valve area with phase-contrast cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2022; 24:7. [PMID: 34986847 PMCID: PMC8734220 DOI: 10.1186/s12968-021-00838-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/15/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is the diagnostic routine standard for assessing aortic stenosis (AS). However, its inaccuracies in determining stroke volume (SV) and aortic valve area (AVA) call for a more precise and dependable method. Phase-contrast cardiovascular magnetic resonance imaging (PC-CMR) is a promising tool to push these boundaries. Thus, the aim of this study was to validate a novel approach based on PC-CMR against the gold-standard of invasive determination of AVA in AS compared to TTE. METHODS A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR. AVA via PC-CMR was determined by plotting momentary flow across the valve against flow-velocity. SV by CMR was measured directly via PC-CMR and volumetrically using cine-images. Invasive SV and AVA were determined via Fick-principle and Gorlin-formula, respectively. TTE yielded SV and AVA using continuity equation. Gradients were calculated via the modified Bernoulli-equation. RESULTS SV by PC-CMR (85 ± 31 ml) correlated strongly (r: 0.73, p < 0.001) with cine-CMR (85 ± 19 ml) without significant bias (lower and upper limits of agreement (LLoA and ULoA): - 41 ml and 44 ml, p = 0.83). In PC-CMR, mean pressure gradient correlated significantly with invasive determination (r: 0.36, p = 0.011). Mean AVA, as determined by PC-CMR during systole (0.78 ± 0.25 cm2), correlated moderately (r: 0.54, p < 0.001) with invasive AVA (0.70 ± 0.23 cm2), resulting in a small bias of 0.08 cm2 (LLoA and ULoA: - 0.36 cm2 and 0.55 cm2, p = 0.017). Inter-methodically, AVA by TTE (0.81 ± 0.23 cm2) compared to invasive determination showed similar correlations (r: 0.58, p < 0.001 with a bias of 0.11 cm2, LLoA and ULoA: - 0.30 and 0.52, p < 0.001) to PC-CMR. Intra- and interobserver reproducibility were excellent for AVA (intraclass-correlation-coefficients of 0.939 and 0.827, respectively). CONCLUSIONS Our novel approach using continuous determination of flow-volumes and velocities with PC-CMR enables simple AVA measurement with no bias to invasive assessment. This approach highlights non-invasive AS grading through CMR, especially when TTE findings are inconclusive.
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Affiliation(s)
- Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Johannes Schwaiger
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Hall in Tirol, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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24
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Metzler B, Lechner I, Reindl M, Reinstadler SJ. Cardiac injury after COVID-19: Primary cardiac and primary non-cardiac etiology makes a difference. Int J Cardiol 2022; 350:17-18. [PMID: 34979150 PMCID: PMC8719915 DOI: 10.1016/j.ijcard.2021.12.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 12/04/2022]
Affiliation(s)
- Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
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25
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Holzknecht M, Klug G, Metzler B, Reinstadler SJ. Mechanical complications after STEMI: Another collateral damage of the COVID-19 pandemic. Int J Cardiol 2021; 348:23-25. [PMID: 34864082 PMCID: PMC8638149 DOI: 10.1016/j.ijcard.2021.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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26
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Reindl M, Stiermaier T, Lechner I, Tiller C, Holzknecht M, Mayr A, Schwaiger JP, Brenner C, Klug G, Bauer A, Thiele H, Feistritzer HJ, Metzler B, Eitel I, Reinstadler SJ. Cardiac magnetic resonance imaging improves prognostic stratification of patients with ST-elevation myocardial infarction and preserved ejection fraction. European Heart Journal Open 2021; 1:oeab033. [PMID: 35919884 PMCID: PMC9263884 DOI: 10.1093/ehjopen/oeab033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 12/03/2022]
Abstract
Aims To evaluate the prognostic validity of clinical risk factors as well as infarct characterization and myocardial deformation by cardiac magnetic resonance (CMR) in ST-elevation myocardial infarction (STEMI) patients with preserved left ventricular ejection fraction (LVEF) following primary percutaneous coronary intervention (PCI). Methods and results This multicentre, individual patient-data analysis from two large CMR trials included 1247 STEMI patients. Cardiac magnetic resonance examinations were conducted 3 [interquartile range (IQR) 2–4] days after PCI. LVEF, infarct size, microvascular obstruction (MVO), and myocardial strain values were measured. Primary endpoint was defined as composite of major adverse cardiovascular events (MACE) including death, re-infarction, and congestive heart failure. A preserved LVEF (defined as LVEF ≥50%) was observed in 724 patients (=58%). In the overall cohort, 97 patients experienced a MACE event [follow-up time 12 (IQR 12–13) months], and 34 MACE events occurred in the group with preserved LVEF (5% vs. 12% incidence rate in patients with LVEF < 50%). TIMI risk score [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.02–1.59; P = 0.03] and female gender (HR 2.24, 95% CI 1.10–4.57; P = 0.03) emerged as independent clinical determinants of MACE in the patient group with preserved LVEF. Among CMR parameters, the presence of MVO (HR 2.39, 95% CI 1.05–5.46; P = 0.04) and reduced global longitudinal strain (GLS; HR 1.12, 95% CI 1.02–1.23; P = 0.02) independently predicted MACE in the LVEF-preserved population. The addition of MVO and GLS to the clinical prognostic markers (TIMI risk score, female gender) increased (P = 0.02) the prognostic validity [AUC 0.76 (95% CI 0.73–0.79)] compared to the clinical markers alone [AUC 0.65 (0.62–0.69)]. Conclusion In contemporary treated STEMI patients showing preserved LVEF, a CMR-based risk prediction approach assessing MVO and GLS provided strong prognostic value that was incremental to clinical outcome parameters.
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Affiliation(s)
- Martin Reindl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Thomas Stiermaier
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein , Ratzeburger Allee 160, 23538 Lübeck, Germany
- German Center for Cardiovascular Research (D.Z.H.K.) , P artner Site Hamburg/Kiel/Lübeck , Lübeck, Germany
| | - Ivan Lechner
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christina Tiller
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck , Innsbruck 6020 Austria
| | - Johannes P Schwaiger
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol , Austria
| | - Christoph Brenner
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Gert Klug
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute , Leipzig, Germany
| | - Hans-Josef Feistritzer
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute , Leipzig, Germany
| | - Bernhard Metzler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein , Ratzeburger Allee 160, 23538 Lübeck, Germany
- German Center for Cardiovascular Research (D.Z.H.K.) , P artner Site Hamburg/Kiel/Lübeck , Lübeck, Germany
| | - Sebastian J Reinstadler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Anichstrasse 35, A-6020 Innsbruck, Austria
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Holzknecht M, Tiller C, Reindl M, Lechner I, Fink P, Lunger P, Mayr A, Henninger B, Brenner C, Klug G, Bauer A, Metzler B, Reinstadler SJ. Association of C-Reactive Protein Velocity with Early Left Ventricular Dysfunction in Patients with First ST-Elevation Myocardial Infarction. J Clin Med 2021; 10:5494. [PMID: 34884196 PMCID: PMC8658672 DOI: 10.3390/jcm10235494] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022] Open
Abstract
C-reactive protein velocity (CRPv) has been proposed as a very early and sensitive risk predictor in patients with ST-elevation myocardial infarction (STEMI). However, the association of CRPv with early left ventricular (LV) dysfunction after STEMI is unknown. The aim of this study was to investigate the relationship between CRPv and early LV dysfunction, either before or at hospital discharge, in patients with first STEMI. This analysis evaluated 432 STEMI patients that were included in the prospective MARINA-STEMI (Magnetic Resonance Imaging In Acute ST-elevation Myocardial Infarction. ClinicalTrials.gov Identifier: NCT04113356) cohort study. The difference of CRP 24 ± 8 h and CRP at hospital admission divided by the time (in h) that elapsed during the two examinations was defined as CRPv. Cardiac magnetic resonance (CMR) imaging was conducted at a median of 3 (IQR 2-4) days after primary percutaneous coronary intervention (PCI) for the determination of LV function and myocardial infarct characteristics. The association of CRPv with the CMR-derived LV ejection fraction (LVEF) was investigated. The median CRPv was 0.42 (IQR 0.21-0.76) mg/l/h and was correlated with LVEF (rS = -0.397, p < 0.001). In multivariable linear as well as binary logistic regression analysis (adjustment for biomarkers and clinical and angiographical parameters), CRPv was independently associated with LVEF (β: 0.161, p = 0.004) and LVEF ≤ 40% (OR: 1.71, 95% CI: 1.19-2.45; p = 0.004), respectively. The combined predictive value of peak cardiac troponin T (cTnT) and CRPv for LVEF ≤ 40% (AUC: 0.81, 95% CI 0.77-0.85, p < 0.001) was higher than it was for peak cTnT alone (AUC difference: 0.04, p = 0.009). CRPv was independently associated with early LV dysfunction, as measured by the CMR-determined LVEF, revealing an additive predictive value over cTnT after acute STEMI treated with primary PCI.
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Affiliation(s)
- Magdalena Holzknecht
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Christina Tiller
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Martin Reindl
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Ivan Lechner
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Priscilla Fink
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Patrick Lunger
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (A.M.); (B.H.)
| | - Benjamin Henninger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (A.M.); (B.H.)
| | - Christoph Brenner
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Gert Klug
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Axel Bauer
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Bernhard Metzler
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (M.H.); (C.T.); (M.R.); (I.L.); (P.F.); (P.L.); (C.B.); (G.K.); (A.B.); (B.M.)
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Schwaiger JP, Reinstadler SJ, Holzknecht M, Tiller C, Reindl M, Begle J, Lechner I, Lamina C, Mayr A, Graziadei I, Bauer A, Metzler B, Klug G. Prognostic value of depressed cardiac index after STEMI: a phase-contrast magnetic resonance study. Eur Heart J Acute Cardiovasc Care 2021; 11:53-61. [PMID: 34750623 DOI: 10.1093/ehjacc/zuab098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/14/2021] [Accepted: 10/18/2021] [Indexed: 11/15/2022]
Abstract
AIMS An invasively measured cardiac index (CI) of ≤2.2 L/min/m2 is one of the strongest prognostic indicators after ST-elevation myocardial infarction (STEMI), however, knowledge is mainly based on invasive evaluations performed in the pre-stent era. Velocity-encoded phase-contrast cardiac magnetic resonance (PC-CMR) allows non-invasive determination of CI. METHODS AND RESULTS In this prospective study, CMR was performed in 406 stable and contemporarily revascularized patients a median of 3 days after STEMI. Forward stroke volume was assessed at the level of the ascending aorta by PC-CMR. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) were determined by cine CMR. Major adverse cardiac events (MACE) were defined as the composite of death, myocardial infarction, or hospitalization for heart failure. Median CI was 2.52 L/min/m2 and 27% of patients had ≤2.2 L/min/m2. Median LVEF was 53% and median GLS was -12.2%. During a median follow-up of 14.2 [95% confidence interval (95% CI) 13.6-14.7] months, 41 patients (10.1%) experienced a MACE. A depressed CI was significantly associated with MACE after adjustment for LVEF, GLS, Thrombolysis in Myocardial Infarction (TIMI) risk score, and infarct size [hazard ratio = 3.15 (95% CI 1.53-6.47); P = 0.002] and led to significant discrimination improvement [net reclassification improvement 0.61 (95% CI 0.25-0.97); P < 0.001]. CONCLUSIONS A CI of 2.2 L/min/m2 or less as measured by PC-CMR was present in 27% of clinically stable patients after STEMI and strongly and independently predicted medium-term MACE. The prognostic value of a depressed CI was superior and incremental to LVEF, GLS, TIMI risk score, and infarct size.
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Affiliation(s)
- Johannes P Schwaiger
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milser Strasse 10, 6060 Hall in Tirol, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Jana Begle
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Claudia Lamina
- Department of Genetics and Pharmacology, Institute of Genetic Epidemiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milser Strasse 10, 6060 Hall in Tirol, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Holzknecht M, Tiller C, Reindl M, Lechner I, Troger F, Mayr A, Brenner C, Klug G, Bauer A, Metzler B, Reinstadler S. C-reactive protein velocity predicts microvascular pathology after acute ST-elevation myocardial infarction. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The role of C-reactive protein velocity (CRPv) as an early and sensitive marker of an excessive inflammatory response in the setting of acute ST-elevation myocardial infarction (STEMI) is only poorly understood.
Purpose
The aim of this study was to investigate, in patients with STEMI treated with primary percutaneous coronary intervention (PCI), the association of CRPv with microvascular infarct pathology.
Methods
This prospective cohort study included a total of 316 patients with STEMI undergoing PCI. CRPv was defined as the difference between CRP 24±8h and CRP at hospital admission, divided by the time (in h) that have passed during the two examinations. The association of biomarker levels with cardiac magnetic resonance (CMR)-determined microvascular obstruction (MVO) was evaluated. CMR was performed at a median of 3 [interquartile range 2–4] days after PCI.
Results
After adjustment for cardiac troponin T (cTnT), culprit lesion location and TIMI-flow post-PCI, CRPv (odds ratio 3.36, 95% confidence interval (CI) 1.72–6.57; p<0.001) remained significantly associated with the occurrence of MVO. CRPv (area under the curve [AUC] 0.76, 95% CI 0.71–0.81; p<0.001) was a better predictor for MVO compared to 24h CRP (AUC difference: 0.03, p=0.002). The addition of CRPv to peak cTnT resulted in a higher AUC for MVO prediction than peak cTnT alone (AUC 0.86, 95% CI 0.82–0.90; p<0.001 vs. AUC 0.84, 95% CI 0.79–0.88; p<0.001. AUC difference: 0.02, p=0.042).
Conclusions
In patients with STEMI treated with primary PCI, CRPv was associated with microvascular infarct pathology with a predictive value incremental to cTnT, suggesting CRPv as an early and sensitive biomarker for more severe infarct pathology and outcome.
Funding Acknowledgement
Type of funding sources: None. ROC analysis for the prediction of MVO.CRPv (median) and clinical outcome.
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Affiliation(s)
- M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - F Troger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - A Mayr
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - C Brenner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - S Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
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Reindl M, Lechner I, Tiller C, Holzknecht M, Rangger A, Mayr A, Theurl M, Klug G, Brenner C, Bauer A, Metzler B, Reinstadler SJ. Glycaemic status and reperfusion injury in patients with ST-segment elevation myocardial infarction. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Failed myocardial tissue reperfusion due to microvascular injury despite successful culprit lesion percutaneous coronary intervention (PCI) is associated with poor clinical outcome in patients with ST-elevation myocardial infarction (STEMI). A possible influence of dysglycaemia on myocardial reperfusion injury is unclear.
Objectives
To investigate the association between glycaemic status and microvascular injury determined by magnetic resonance imaging in STEMI patients.
Methods
This prospective observational cohort study included 260 consecutive STEMI patients undergoing primary PCI between 2016 and 2019. Peripheral venous blood samples for glucose and HbA1c measurements were drawn on admission. Primary microvascular injury endpoint was defined as presence of intramyocardial haemorrhage (IMH) assessed by cardiac magnetic resonance T2* mapping at 4 (interquartile range [IQR]:2–5) days after PCI.
Results
HbA1c (odds ratio [OR]: 1.73 [95% CI: 1.24–2.40]; p=0.001), pre-diagnosis of diabetes (OR: 2.63 [95% CI: 1.18–5.90]; p=0.02) and glucose concentration (OR: 1.01 [95% CI: 1.00–1.01]; p=0.01) significantly predicted IMH, which was present in 90 (35%) patients. Of these three parameters, only HbA1c remained significantly associated with IMH (OR: 2.12 [95% CI: 1.12–3.99]; p=0.02) after adjusting for total ischemic time, culprit lesion location, pre- and post-interventional TIMI flow and peak biomarker concentrations (troponin, N-terminal pro-B-type natriuretic peptide and C-reactive protein). The rate of IMH was 24% in patients with HbA1c <5.7%, 43% in patients with HbA1c ≥5.7 to 6.4% and 59% in patients with HbA1c ≥6.5% (p<0.001).
Conclusions
In STEMI patients undergoing primary PCI, admission HbA1c was independently associated with reperfusion injury as determined by IMH. These findings suggest that IMH could represent the underlying pathophysiological link between dysglycaemia and adverse outcomes following STEMI.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FWF - Austrian Science Fund; ÖKG - Austrian Society of Cardiology Figure 1. This figure illustrates the relation between HbA1c and IMH by two patient examples successfully treated with PCI (intervention with stent implantation schematically shown on the very left side). The first patient (upper line), representing the patient group with HbA1c <5.7% (associated IMH risk 24%), showed an anterior wall STEMI without IMH (T2* mapping on the very right, corresponding schematic picture of the infarct area without IMH next on the left). The second patient (lower line), representing the patients with HbA1c ≥5.7% (associated IMH risk 47%), showed an anterior wall STEMI with large IMH (arrows point to the hypo-intense core on the T2* mapping image and to the corresponding dark-red area in the schematic illustration). The zoomed view of one microvessel indicates the complex pathophysiology of IMH (including endothelial destruction, embolisation of thrombotic material and inflammation). (Created with BioRender)
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Affiliation(s)
- M Reindl
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - I Lechner
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - C Tiller
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - A Rangger
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - A Mayr
- Innsbruck University Hospital, Radiology, Innsbruck, Austria
| | - M Theurl
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - G Klug
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - C Brenner
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - A Bauer
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
| | - S J Reinstadler
- Innsbruck University Hospital, Cardiology and Angiology, Innsbruck, Austria
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Troger F, Reindl M, Pamminger M, Tiller C, Holzknecht M, Lechner I, Reinstadler SJ, Metzler B, Klug G, Mayr A. Cardio-pulmonary transit-time by cardiac magnetic resonance imaging: associates to infarct severity and adverse events after reperfused STEMI. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardiac magnetic resonance (CMR) data on cardiopulmonary-transit-time (cpTT) and its associates with infarct characteristics and clinical outcome after reperfused ST-elevation myocardial infarction (STEMI) are lacking so far.
Purpose
cpTT may serve as surrogate parameter for integrative cardiac performance and has been linked to heart failure.
Methods
A total of 207 patients (179 men [87%], median age 55 [interquartile range (IQR) 49–64] with acute STEMI underwent CMR on day 3 [IQR 2–4] and 4 months (m) [IQR 4–5] after primary percutaneous coronary intervention. cpTT was taken as the time between the peaks of time-intensity curves of gadolinium contrast to pass from the right ventricle (RV) to the left ventricle (LV). Infarct size, extent of microvascular obstruction (MVO), RV and LV dimensions and function were assessed at both occasions.
Results
cpTT decreased significantly between baseline and 4m CMR scan (8.6 seconds [IQR 7.5–9.6] to 7.8 sec [IQR 7–8.7], respectively, p<0.0001). Patients with presence of MVO had significantly prolonged cpTT at baseline and 4m follow-up (all p<0.022). According to Cox regression analysis (“functional model”) baseline cpTT (hazard ratio (HR) 1.5, 95% confidence interval (CI) 1.1–2.2; p=0.008) remained significantly associated to the occurrence of major adverse cardiac events (MACE) after adjustment for LV ejection fraction (EF) and cardiac index. According to Cox regression analysis (“tissue model”) baseline cpTT (HR 1.462, 95% CI 1.02–2.09, p=0.039) as well as extent of MVO (HR 1.196, 95% CI 1.081–1.324, p=0.001) remained significantly associated to MACE after adjustment for infarct size. Baseline cpTT (area under the curve [AUC]: 0.725, 95% confidence interval [CI] 0.57–0.88; p<0.009) was significantly higher for the prediction of MACE compared to LV ejection fraction (AUC: 0.686, 95% CI 0.51–0.87; p=0.031. AUC difference: 0.039, p<0.03). In Kaplan-Meier analysis, cpTT ≥9 sec was associated with clinical adverse cardiovascular events (p=0.008).
Conclusion
Following reperfused STEMI, cpTT predicts prognosis independently of infarct size and systolic function. Moreover, cpTT provides significantly higher prognostic implication in comparison with LV ejection fraction.
Funding Acknowledgement
Type of funding sources: None. cpTT over the cardiac cycle.Computation of cpTT in 2 STEMI patients.
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Affiliation(s)
- F Troger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Pamminger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - S J Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Mayr
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
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Mayr A, Klug G, Reindl M, Tiller C, Holzknecht M, Lechner I, Pamminger M, Troger F, Bauer A, Reinstadler SJ, Metzler B. Evolution of myocardial tissue injury over a decade after ST-elevation myocardial infarction: a cardiac magnetic resonance study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In patients with first ST-elevation myocardial infarction (STEMI), the evolution of myocardial tissue injury parameters over a decade as assessed by cardiac magnetic resonance (CMR) has not yet been described.
Purpose
This study examined long-term myocardial tissue injury dynamics in STEMI patients treated with primary percutaneous coronary intervention (PCI), as well as its association with patient characteristics.
Methods
A total of 104 patients with STEMI were included in this observational study. Sequential late gadolinium enhanced CMR studies (after 3 days [interquartile ranges (IQR) 2–4], 4 months [IQR 4–5] and 9 years [IQR 8–10]) were conducted to assess left ventricular (LV) dimensions and function, infarct size and microvascular obstruction (MVO). T2* mapping was added at 9 year scan to assess the presence of persistent iron within the infarct core.
Results
Infarct size decreased progressively from 13% of LV myocardial mass [IQR 7–21] to 10.2% [IQR 5.2–16.1] to 8% [IQR 2.4–12.3] (p<0.001), with an average reduction rate of 6.4% ± 3.4 per year. Relative reduction of infarct size from baseline to 9y follow-up was 43% [IQR 18–66], 21% [IQR 3–42] during the first 4m and 33% [IQR 8–54] between 4m and 9y after STEMI. Decrease of infarct size was associated with greater baseline infarct size (p<0.004) and extent of MVO (p=0.01). MVO was present in 60% (60/104) of patients at baseline, but in none of the follow-up examinations. Sixteen patients had persistent iron within the infarct core at 9 year CMR. Clinical and imaging associates of persistent iron included younger age at study inclusion (p=0.036), higher peak hs troponin T (p<0.001), higher peak creatine kinase (p<0.001) and higher peak CRP (p=0.036) as well as greater infarct size at any occasion (all p<0.001) and greater MVO (p<0.001). Patients with persistent iron showed less relative infarct size regression (51% [IQR 41–79] versus 46% [IQR 32–54], p=0.009).
Conclusion
In patients with STEMI, the evolution of infarct size is a dynamic process that extends well beyond the first few months after the acute event. MVO vanishes in the first few weeks after the index event in all patients. However, persistence of iron within the infarct core occurs up to a decade after reperfused STEMI, reflecting its irreversibility and is associated with the initial infarct severity and worse infarct healing.
Funding Acknowledgement
Type of funding sources: None. Central Illustration.Evolution of STEMI over a decade.
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Affiliation(s)
- A Mayr
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Pamminger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - F Troger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - S J Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
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Troger F, Lechner I, Reindl M, Tiller C, Holzknecht M, Pamminger M, Kremser C, Reinstadler SJ, Bauer A, Metzler B, Mayr A, Klug G. Aortic stenosis reexpanded – a novel approach to determine aortic valve area with phase contrast cardiovascular magnetic resonance imaging. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Transthoracic echocardiography (TTE) has become the diagnostic standard for evaluating aortic stenosis (AS) severity, mainly because of its advantages in comparison to the gold standard of cardiac catheterization. However, its inaccuracies in determining stroke volume (SV) and consequentially computing aortic valve area (AVA) call for a more precise and dependable method. Phase contrast cardiovascular magnetic resonance imaging (PC-CMR) is an aspiring tool to push these boundaries.
Purpose
The aim of this study was to validate a novel and simple approach based on PC-CMR against the invasive and echocardiographic determination of SV and AVA in patients with moderate and severe AS.
Methods
A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR; AVA by PC-CMR was determined via plotting momentary flow across the valve against momentary flow velocity. SV via CMR was measured directly via PC-CMR and volumetrically using cine images. Invasive SV and AVA were determined via Fick principle and Gorlin formula, respectively. TTE yielded SV and AVA using the continuity equation. Finally, gradients were calculated via the modified Bernoulli equation.
Results
SV by PC-CMR showed a strong correlation with cine-CMR with no significant bias (r: 0.730, p<0.001; SV by PC-CMR: 85±31ml; SV by cine-CMR: 85±19ml, p=0.829). Peak gradients determined by PC-CMR were 65±29mmHg and correlated inversely with AVA by PC-CMR (r: −0.371; p=0.008). Mean AVA during the whole systolic phase showed a moderate correlation (r: 0.544, p<0.001) to invasive AVA with a small bias (AVA by CMR: 0.78±0.25cm2 versus invasive AVA: 0.70±0.23cm2, bias: 0.08cm2, p=0.017). Inter-methodical correlation and bias of AVA as measured by TTE and invasive AVA (AVA by TTE: 0.81±0.23cm2, r: 0.580, p<0.001, bias 0.11cm2, p<0.001) were similar to AVA by PC-CMR and invasive AVA.
Conclusion
PC-CMR provides a great option to yield reliable and solid SV values in patients with moderate and severe AS. Furthermore, continuous determination of flow volumes and flow velocities is able to determine AVA in these patients in an easy and reproducible manner. Our novel approach shines a light on the diagnostic potential of PC-CMR for non-invasive AS grading, especially in cases where echocardiography reaches its limits and where clinical findings appear inconclusive.
Funding Acknowledgement
Type of funding sources: None. Central IllustrationCine (l,r) and PC-CMR (m) images in AS
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Affiliation(s)
- F Troger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Pamminger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - C Kremser
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - S J Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Mayr
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
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Lechner I, Reindl M, Tiller C, Holzknecht M, Mayr A, Klug G, Brenner C, Bauer A, Reinstadler SJ, Metzler B. Determinants and prognostic relevance of aortic stiffness in patients with recent ST-elevation myocardial infarction. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI.
Methods
We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (PPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regressionand logistic regression analysis were performed to explore predictors of PWV and MACCE.
Results
Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p<0.001) and hypertension (OR 2.45, 95% CI, 1.53–3.91, p<0.001) were independently associated with increased PWV. Sex, diabetes, smoking status, dyslipidemia, and obesity were not significantly associated with PWV in adjusted analysis (all p>0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p=0.014).
Conclusion
In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome post-STEMI, suggesting it as a relevant therapeutic target in this population.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology Figure 1. Biorender.com
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Affiliation(s)
- I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Mayr
- Medical University of Innsbruck, Department of Radiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - C Brenner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - S J Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
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Lechner I, Reindl M, Tiller C, Holzknecht M, Troger F, Fink P, Mayr A, Klug G, Bauer A, Metzler B, Reinstadler SJ. Impact of COVID-19 pandemic restrictions on ST-elevation myocardial infarction: a cardiac magnetic resonance imaging study. Eur Heart J 2021; 43:1141-1153. [PMID: 34632491 PMCID: PMC8524546 DOI: 10.1093/eurheartj/ehab621] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/17/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023] Open
Abstract
AIMS The severity of myocardial tissue damage following ST-elevation myocardial infarction (STEMI) strongly determines short- and long-term prognosis. This study explored the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated public health restrictions on infarct severity. METHODS AND RESULTS STEMI patients treated with primary percutaneous coronary intervention (PCI) and included in the prospective Magnetic Resonance Imaging in Acute ST-Elevation Myocardial Infarction (MARINA-STEMI) cohort study from 2015- 2020 (n = 474) were categorized according to (i) timeframes with and without major public health restrictions in 2020, and (ii) timeframes of major public health restrictions during 2020 and during the corresponding timeframes between 2015-2019. Myocardial damage was evaluated by cardiac magnetic resonance imaging. During major public health restrictions in 2020 (n = 48), there was an increase in infarct size (22 [IQR 12-29] vs. 14 [IQR 6-23]%, P < 0.01), a higher frequency (77% vs. 52%, P < 0.01) and larger extent of microvascular obstruction (1.5 [IQR 0.1-11.4] vs. 0.2 [IQR 0.0-2.6]%, P < 0.01) and a higher rate of intramyocardial haemorrhage (56% vs. 34%, P = 0.02) as compared to the phases without major restrictions in 2020 (n = 101). These findings were confirmed in adjusted analysis and were consistent when comparing patients admitted in 2020 versus patients admitted in the "pre-pandemic" era (2015-2019). Patient characteristics were comparable between groups, except for a significantly longer total ischemia time (P < 0.01) and higher frequency of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow 0 during times of major restrictions (P = 0.03). CONCLUSION This study provides novel mechanistic insights demonstrating a significant increase in myocardial damage in STEMI patients admitted during the COVID-19 pandemic with a temporal relation to major public health restrictions.
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Affiliation(s)
- Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
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Holzknecht M, Reindl M, Tiller C, Reinstadler SJ, Lechner I, Pamminger M, Schwaiger JP, Klug G, Bauer A, Metzler B, Mayr A. Global longitudinal strain improves risk assessment after ST-segment elevation myocardial infarction: a comparative prognostic evaluation of left ventricular functional parameters. Clin Res Cardiol 2021; 110:1599-1611. [PMID: 33884479 PMCID: PMC8484167 DOI: 10.1007/s00392-021-01855-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
AIM We aimed to investigate the comparative prognostic value of left ventricular ejection fraction (LVEF), mitral annular plane systolic excursion (MAPSE), fast manual long-axis strain (LAS) and global longitudinal strain (GLS) determined by cardiac magnetic resonance (CMR) in patients after ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS This observational cohort study included 445 acute STEMI patients treated with primary percutaneous coronary intervention (pPCI). Comprehensive CMR examinations were performed 3 [interquartile range (IQR): 2-4] days after pPCI for the determination of left ventricular (LV) functional parameters and infarct characteristics. Primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as composite of death, re-infarction and congestive heart failure. During a follow-up of 16 [IQR: 12-49] months, 48 (11%) patients experienced a MACE. LVEF (p = 0.023), MAPSE (p < 0.001), LAS (p < 0.001) and GLS (p < 0.001) were significantly related to MACE. According to receiver operating characteristic analyses, only the area under the curve (AUC) of GLS was significantly higher compared to LVEF (0.69, 95% confidence interval (CI) 0.64-0.73; p < 0.001 vs. 0.60, 95% CI 0.55-0.65; p = 0.031. AUC difference: 0.09, p = 0.020). After multivariable analysis, GLS emerged as independent predictor of MACE even after adjustment for LV function, infarct size and microvascular obstruction (hazard ratio (HR): 1.13, 95% CI 1.01-1.27; p = 0.030), as well as angiographical (HR: 1.13, 95% CI 1.01-1.28; p = 0.037) and clinical parameters (HR: 1.16, 95% CI 1.05-1.29; p = 0.003). CONCLUSION GLS emerged as independent predictor of MACE after adjustment for parameters of LV function and myocardial damage as well as angiographical and clinical characteristics with superior prognostic validity compared to LVEF.
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Affiliation(s)
- Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Johannes P Schwaiger
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milser Strasse 10, 6060, Hall in Tirol, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Mayr A, Klug G, Reinstadler SJ, Esterhammer R, Kremser C, Mairer K, Metzler B, Schocke MF. Cardiac exercise imaging using a 3-tesla magnetic resonance-conditional pedal ergometer: Preliminary results in healthy volunteers and patients with known or suspected coronary artery disease. Cardiol J 2021; 30:276-285. [PMID: 34490601 PMCID: PMC10129251 DOI: 10.5603/cj.a2021.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/22/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiac magnetic resonance imaging (CMR) remains underutilized as an exercise imaging modality, mostly because of the limited availability of MR-compatible exercise equipment. This study prospectively evaluates the clinical feasibility of a newly developed MR-conditional pedal ergometer for exercise CMR METHODS: Ten healthy volunteers (mean age 44 ± 16 years) and 11 patients (mean age 60 ± 9 years) with known or suspected coronary artery disease (CAD) underwent rest and post-exercise cinematic 3T CMR. Visual analysis of wall motion abnormalities (WMA) was rated by 2 experienced radiologists, and volumes and ejection fractions (EF) were determined. Image quality was assessed by a 4-point Likert scale for visibility of endocardial borders. RESULTS Median subjective image quality of real-time Cine at rest was 1 (IQR 1-2) and 2 (IQR 2-2.5) for post-exercise real-time Cine (p = 0.001). Exercise induced a significant increase in heart rate (62 [62-73] to 111 [104-143] bpm, p < 0.0001). Stroke volume and cardiac index increased from resting to post-exercise conditions (85 ± 21 to 101 ± 19 mL and 2.9 ± 0.7 to 6.6 ± 1.9 L/min/m², respectively; both p < 0.0001), driven by a reduction in end-systolic volume (55 ± 20 to 42 ± 21 mL, p < 0.0001). Patients (2/11) with inducible regional WMA at high-resolution post-exercise cine imaging revealed significant coronary artery stenosis in subsequently performed invasive coronary angiography. CONCLUSION Exercise-CMR using our newly developed 3T MR-conditional pedal ergometer is clinically feasible. Imaging of both cardiac response and myocardial ischemia, triggered by dynamic stress, is rapidly conducted while the patient is near their peak heart rate.
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Affiliation(s)
- Agnes Mayr
- Department of Radiology, Medical University Innsbruck.
| | - Gert Klug
- Clinic of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck
| | | | - Regina Esterhammer
- Rehabilitation and University Hospital Ulm, Department of Radiology and Neuroradiology, University Clinic Ulm
| | | | | | - Bernhard Metzler
- Clinic of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck
| | - Michael F Schocke
- Rehabilitation and University Hospital Ulm, Department of Radiology and Neuroradiology, University Clinic Ulm
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Lechner I, Reindl M, Tiller C, Holzknecht M, Niederreiter S, Mayr A, Klug G, Brenner C, Bauer A, Metzler B, Reinstadler SJ. Determinants and prognostic relevance of aortic stiffness in patients with recent ST-elevation myocardial infarction. Int J Cardiovasc Imaging 2021; 38:237-247. [PMID: 34476665 PMCID: PMC8818631 DOI: 10.1007/s10554-021-02383-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/16/2021] [Indexed: 12/29/2022]
Abstract
The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI. We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (PPCI). Aortic pulse wave velocity (PWV), the most widely used measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 [interquartile range (IQR) 12–31] months. Cox regression- and logistic regression analysis were performed to explore predictors of aortic stiffness and MACCE. Median aortic PWV was 6.6 m/s (IQR 5.6–8.3 m/s). In multivariable analysis, age [odds ratio (OR) 1.10, 95% confidence interval (CI), 1.08–1.14, p < 0.001] and hypertension (OR 2.45, 95% CI, 1.53–3.91, p < 0.001) were independently associated with increased PWV. Sex, diabetes, smoking status, dyslipidemia, and obesity were not significantly associated with PWV in adjusted analysis (all p > 0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis [hazard ratio (HR) 2.45, 95% CI 1.19–5.04, p = 0.014]. In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome post-STEMI, suggesting it as a relevant therapeutic target in this population. Trial (NCT04113356).
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Affiliation(s)
- Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Sarah Niederreiter
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christoph Brenner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Noc M, Laanmets P, Neskovic A, Petrović M, Stanetic B, Aradi D, Kiss R, Ungi I, Merkely B, Hudec M, Blasko P, Horvath I, Davies J, Vukcevic V, Holzer M, Metzler B, Witkowski AR, Erglis A, Fister M, Nagy G, Bulum J, Édes I, Peruga J, Średniawa B, Erlinge D, Keeble TR. A multicentre, prospective, randomised controlled trial to assess the safety and effectiveness of cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction: the COOL AMI EU Pivotal Trial. EUROINTERVENTION 2021; 17:466-473. [PMID: 34031023 PMCID: PMC9725068 DOI: 10.4244/eij-d-21-00348] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite primary PCI (PPCI), ST-elevation myocardial infarction (STEMI) can still result in large infarct size (IS). New technology with rapid intravascular cooling showed positive signals for reduction in IS in anterior STEMI. AIMS We investigated the effectiveness and safety of rapid systemic intravascular hypothermia as an adjunct to PPCI in conscious patients, with anterior STEMI, without cardiac arrest. METHODS Hypothermia was induced using the ZOLL® Proteus™ intravascular cooling system. After randomisation of 111 patients, 58 to hypothermia and 53 to control groups, the study was prematurely discontinued by the sponsor due to inconsistent patient logistics between the groups resulting in significantly longer total ischaemic delay in the hypothermia group (232 vs 188 minutes; p<0.001). RESULTS There were no differences in angiographic features and PPCI result between the groups. Intravascular temperature at wire crossing was 33.3+0.9°C. Infarct size/left ventricular (IS/LV) mass by cardiac magnetic resonance (CMR) at day 4-6 was 21.3% in the hypothermia group and 20.0% in the control group (p=0.540). Major adverse cardiac events at 30 days increased non-significantly in the hypothermia group (8.6% vs 1.9%; p=0.117) while cardiogenic shock (10.3% vs 0%; p=0.028) and paroxysmal atrial fibrillation (43.1% vs 3.8%; p<0.001) were significantly more frequent in the hypothermia group. CONCLUSIONS The ZOLL Proteus intravascular cooling system reduced temperature to 33.3°C before PPCI in patients with anterior STEMI. Due to inconsistent patient logistics between the groups, this hypothermia protocol resulted in a longer ischaemic delay, did not reduce IS/LV mass and was associated with increased adverse events.
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Affiliation(s)
- Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Peep Laanmets
- North-Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Aleksandar Neskovic
- Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milovan Petrović
- Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Faculty of Medicine, Novi Sad, Serbia
| | - Bojan Stanetic
- University Clinical Center of the Republic of Srpska, Medical Faculty of University of Banja Luka, Banja Luka, Bosnia
| | | | | | - Imre Ungi
- University of Szeged, Szeged, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Martin Hudec
- Stredoslovenski Ustav Srdcovych a Cievnych Chorob, Banska Bystrica, Slovakia
| | | | - Ivan Horvath
- Department of Cardiology, Health Faculty of Medicine, University of Pecs, Hungary
| | - John Davies
- Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital NHS Foundation Trust, Basildon, UK
| | | | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernhard Metzler
- University Hospital of Internal Medicine lll/Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Andrejs Erglis
- Pauls Stradiņš Clinical University Hospital, University of Latvia, Riga, Latvia
| | - Misa Fister
- University Medical Centre Ljubljana, Slovenia
| | - Gergely Nagy
- Borsod-Abauj-Zemplen County Central Hospital and University Teaching Hospital, 1st Department of Internal Medicine and Cardiology, Miskolc, Miskolc, Hungary
| | - Josko Bulum
- University Hospital Center Zagreb, Zagreb, Croatia
| | - István Édes
- Department of Cardiology, Faculty of Medicine, Medical and Health Science Center, University of Debrecen, Debrbrecen, Hungary
| | - Jan Peruga
- Medical University in Łódź, Bieganski Hospital, Łódź, Poland
| | - Beata Średniawa
- Silesian Center for Heart Diseases, Department of Cardiology, Medical University of Silesia, DMS in Zabrze, Zabrze, Poland
| | - David Erlinge
- Department of Cardiology, Lund University, Clinical Sciences, Skane University Hospital, Lund, Sweden
| | - Thomas R. Keeble
- Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital NHS Foundation Trust, Basildon, UK,Anglia Ruskin School of Medicine, Chelmsford, Essex, UK
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Stühlinger M, Metzler B. Do we need machine learning to predict CRT response? Int J Cardiol 2021; 342:41-42. [PMID: 34375707 DOI: 10.1016/j.ijcard.2021.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Markus Stühlinger
- University Clinic of Internal Medicine III/Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Bernhard Metzler
- University Clinic of Internal Medicine III/Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
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Reindl M, Lechner I, Reinstadler SJ, Metzler B. Transient STEMI - No STEMI at all? Int J Cardiol 2021; 339:12-13. [PMID: 34274409 DOI: 10.1016/j.ijcard.2021.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Troger F, Lechner I, Reindl M, Tiller C, Holzknecht M, Pamminger M, Reinstadler SJ, Bauer A, Gizewski ER, Metzler B, Klug G, Mayr A. Invasive validation of a novel approach to determine aortic valve area with phase-contrast cardiac magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology
Background. Echocardiography is considered the standard method for screening and diagnosing aortic valve stenosis. However, inaccuracies in the determination of stroke-volumes by the continuity equation might particularly make the evaluation of patients with low-flow states difficult. Phase-contrast cardiac magnetic resonance (PC-CMR) is a promising tool in overcoming these limitations by the simultaneous determination of flow volumes and velocities across the stenotic valve.
Purpose
The aim of this study is to validate a novel approach based on PC-CMR against the invasive determination of the aortic valve area (AVA).
Methods. PC-CMR was performed in 50 patients with moderate or severe AS (n = 52; age 72 years [interquartile range (IQR) 66 - 78], 38% of patients with low-flow states). All of them were referred to invasive evaluation of aortic stenosis by cardiac catheterization. Additionally, transthoracic echocardiography (TTE) was performed. Aortic valve area (AVA) was determined by PC-CMR (AVAPC-CMR) via plotting momentary flow across the valve against momentary flow velocity. AVAPC-CMR at different time points over the entire cardiac cycle was compared to invasively determined AVA, calculated according to the Gorlin-formula. Stroke volumes (SV) were determined by the Fick-principle, pressure gradients according to the modified Bernoulli-equation.
Results. Mean AVA during the whole systolic phase showed a good correlation (r: 0.544, p < 0.001) with invasive AVA with a small bias (AVACMR: 0.78 cm², IQR: [0.60-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87], bias: 0.08 cm², p = 0.017). Intermethodical correlation and bias of AVA as measured by TTE (AVATTE) and AVAINVASIVE were similar to AVAPC-CMR (AVATTE: 0.81 cm²; IQR: [0.64-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87] r: 0.580, p < 0.001, bias 0.11 cm², p < 0.001). SV by PC-CMR showed a good correlation with Cine-CMR with no significant bias (r: 0.730, p < 0.001; SVPC-CMR: 86 ± 31 ml; SVCine: 85 ± 19 ml). Maximum gradients determined by PC‑CMR were 65 ± 2 9mmHg and showed a good inverse correlation with AVAPC-CMR (r: ‑0.371; p = 0.008).
Conclusion. PC-CMR with continuous determination of flow volumes and flow velocities is able to determine AVA in patients with severe aortic stenosis with a tendency to overestimate AVA compared to invasively determined AVA.
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Affiliation(s)
- F Troger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Pamminger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - SJ Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - ER Gizewski
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Mayr
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
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Troger F, Reindl M, Pamminger M, Tiller C, Holzknecht M, Lechner I, Reinstadler SJ, Metzler B, Klug G, Mayr A. Cardio-pulmonary transit-time by cardiac magnetic resonance imaging: associates to infarct severity and adverse events after reperfused STEMI. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Cardiac magnetic resonance (CMR) data on cpTT and its associates with infarct characteristics and clinical outcome after reperfused ST-elevation myocardial infarction (STEMI) are lacking so far.
Purpose
To investigate cardiopulmonary-transit-time (cpTT) and its value as surrogate parameter for integrative cardiac performance and its link to heart failure.
Methods
A total of 207 patients (179 men [87%], median age 55 [interquartile range (IQR) 49-64] with acute STEMI underwent CMR on day 3 [IQR 2-4] and 4 months (m) [IQR 4-5] after primary percutaneous coronary intervention. cpTT was taken as the time between the peaks of time-intensity curves of gadolinium contrast to pass from the right ventricle (RV) to the left ventricle (LV). Infarct size, extent of microvascular obstruction (MVO), RV and LV dimensions and function were assessed at both occasions.
Results
cpTT decreased significantly between baseline and 4m CMR scan (8.6 seconds [IQR 7.5-9.6] to 7.8 sec [IQR 7-8.7], respectively, p < 0.0001). Patients with presence of MVO had significantly prolonged cpTT at baseline and 4m follow-up (all p < 0.022). According to Cox regression analysis ("functional model") baseline cpTT (hazard ratio (HR) 1.5, 95% confidence interval (CI) 1.1–2.2; p= 0.008) remained significantly associated to the occurrence of major adverse cardiac events (MACE) after adjustment for LV ejection fraction (EF) and cardiac index. According to Cox regression analysis ("tissue model") baseline cpTT (HR 1.462, 95% CI 1.02–2.09, p= 0.039) as well as extent of MVO (HR 1.196, 95% CI 1.081–1.324, p= 0.001) remained significantly associated to MACE after adjustment for infarct size. Baseline cpTT (area under the curve [AUC]: 0.725, 95% confidence interval [CI] 0.57-0.88; p < 0.009) was significantly higher for the prediction of MACE compared to LV ejection fraction (AUC: 0.686, 95% CI 0.51-0.87; p = 0.031. AUC difference: 0.039, p < 0.03). In Kaplan-Meier analysis, cpTT ≥9 sec was associated with clinical adverse cardiovascular events (p = 0.008).
Conclusion
Following reperfused STEMI, cpTT predicts prognosis independently of infarct size and systolic function. Moreover, cpTT provides significantly higher prognostic implication in comparison with LV ejection fraction.
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Affiliation(s)
- F Troger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Pamminger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - SJ Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - A Mayr
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
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Mayr A, Klug G, Reindl M, Tiller C, Holzknecht M, Lechner I, Pamminger M, Troger F, Bauer A, Reinstadler SJ, Metzler B. Evolution of myocardial tissue injury over a decade after ST-elevation myocardial infarction: a cardiac magnetic resonance study. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology
Background
In patients with first ST-elevation myocardial infarction (STEMI), the evolution of myocardial tissue injury parameters over a decade as assessed by cardiac magnetic resonance (CMR) has not yet been described.
Purpose
This study examined long-term myocardial tissue injury dynamics in STEMI patients treated with primary percutaneous coronary intervention (PCI), as well as its association with patient characteristics.
Methods
A total of 104 patients with STEMI were included in this observational study. Sequential late gadolinium enhanced CMR studies (after 3 days [interquartile ranges (IQR) 2-4], 4 months [IQR 4-5] and 9 years [IQR 8-10]) were conducted to assess left ventricular (LV) dimensions and function, infarct size and microvascular obstruction (MVO). T2* mapping was added at 9 year scan to assess the presence of persistent iron within the infarct core.
Results
Infarct size decreased progressively from 13% of LV myocardial mass [IQR 7-21] to 10.2% [IQR 5.2-16.1] to 8% [IQR 2.4-12.3] (p < 0.001), with an average reduction rate of 6.4% ± 3.4 per year. Relative reduction of infarct size from baseline to 9y follow-up was 43% [IQR 18-66], 21% [IQR 3-42] during the first 4m and 33% [IQR 8-54] between 4m and 9y after STEMI. Decrease of infarct size was associated with greater baseline infarct size (p < 0.004) and extent of MVO (p = 0.01). MVO was present in 60% (60/104) of patients at baseline, but in none of the follow-up examinations. Sixteen patients had persistent iron within the infarct core at 9 year CMR. Clinical and imaging associates of persistent iron included younger age at study inclusion (p = 0.036), higher peak hs troponin T (p < 0.001), higher peak creatine kinase (p < 0.001) and higher peak CRP (p = 0.036) as well as greater infarct size at any occasion (all p < 0.001) and greater MVO (p < 0.001). Patients with persistent iron showed less relative infarct size regression (51% [IQR 41-79] versus 46% [IQR 32-54], p = 0.009).
Conclusion
In patients with STEMI, the evolution of infarct size is a dynamic process that extends well beyond the first few months after the acute event. MVO vanishes in the first few weeks after the index event in all patients. However, persistence of iron within the infarct core occurs up to a decade after reperfused STEMI, reflecting its irreversibility and is associated with the initial infarct severity and worse infarct healing.
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Affiliation(s)
- A Mayr
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - C Tiller
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - I Lechner
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - M Pamminger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - F Troger
- Medical University of Innsbruck, University Clinic of Radiology, Innsbruck, Austria
| | - A Bauer
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - SJ Reinstadler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, University Clinic of Internal Medicine III, Cardiology and Angiology, Innsbruck, Austria
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Holzknecht M, Tiller C, Reindl M, Lechner I, Troger F, Hosp M, Mayr A, Brenner C, Klug G, Bauer A, Metzler B, Reinstadler SJ. C-reactive protein velocity predicts microvascular pathology after acute ST-elevation myocardial infarction. Int J Cardiol 2021; 338:30-36. [PMID: 34147553 DOI: 10.1016/j.ijcard.2021.06.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of C-reactive protein velocity (CRPv) as an early and sensitive marker of an excessive inflammatory response in the setting of acute ST-elevation myocardial infarction (STEMI) is only poorly understood. The aim of this study was to investigate, in patients with STEMI treated with primary percutaneous coronary intervention (PCI), the association of CRPv with microvascular infarct pathology. METHODS AND RESULTS This prospective cohort study included a total of 316 patients with STEMI undergoing PCI. CRPv was defined as the difference between CRP 24 ± 8 h and CRP at hospital admission, divided by the time (in h) that have passed during the two examinations. The association of biomarker levels with cardiac magnetic resonance (CMR)-determined microvascular obstruction (MVO) was evaluated. CMR was performed at a median of 3 [interquartile range 2-4] days after PCI. After adjustment for cardiac troponin T (cTnT), anterior infarction and TIMI flow pre and post-PCI, CRPv (odds ratio 2.70, 95% confidence interval (CI) 1.54-4.73; p = 0.001) remained significantly associated with the occurrence of MVO. CRPv (area under the curve [AUC] 0.76, 95% CI 0.71-0.81; p < 0.001) was a better predictor for MVO compared to 24 h CRP (AUC difference: 0.03, p = 0.002). The addition of CRPv to peak cTnT resulted in a higher AUC for MVO prediction than peak cTnT alone (AUC 0.86, 95% CI 0.82-0.90; p < 0.001 vs. AUC 0.84, 95% CI 0.79-0.88; p < 0.001. AUC difference: 0.02, p = 0.042). CONCLUSIONS In patients with STEMI treated with primary PCI, CRPv was associated with microvascular infarct pathology with a predictive value incremental to cTnT, suggesting CRPv as an early and sensitive biomarker for more severe infarct pathology and outcome.
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Affiliation(s)
- Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Michael Hosp
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christoph Brenner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria..
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Bauer A, Schreinlechner M, Sappler N, Dolejsi T, Tilg H, Aulinger BA, Weiss G, Bellmann-Weiler R, Adolf C, Wolf D, Pirklbauer M, Graziadei I, Gänzer H, von Bary C, May AE, Wöll E, von Scheidt W, Rassaf T, Duerschmied D, Brenner C, Kääb S, Metzler B, Joannidis M, Kain HU, Kaiser N, Schwinger R, Witzenbichler B, Alber H, Straube F, Hartmann N, Achenbach S, von Bergwelt-Baildon M, von Stülpnagel L, Schoenherr S, Forer L, Embacher-Aichhorn S, Mansmann U, Rizas KD, Massberg S. Discontinuation versus continuation of renin-angiotensin-system inhibitors in COVID-19 (ACEI-COVID): a prospective, parallel group, randomised, controlled, open-label trial. Lancet Respir Med 2021; 9:863-872. [PMID: 34126053 PMCID: PMC8195495 DOI: 10.1016/s2213-2600(21)00214-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/18/2022]
Abstract
Background SARS-CoV-2 entry in human cells depends on angiotensin-converting enzyme 2, which can be upregulated by inhibitors of the renin–angiotensin system (RAS). We aimed to test our hypothesis that discontinuation of chronic treatment with ACE-inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) mitigates the course o\f recent-onset COVID-19. Methods ACEI-COVID was a parallel group, randomised, controlled, open-label trial done at 35 centres in Austria and Germany. Patients aged 18 years and older were enrolled if they presented with recent symptomatic SARS-CoV-2 infection and were chronically treated with ACEIs or ARBs. Patients were randomly assigned 1:1 to discontinuation or continuation of RAS inhibition for 30 days. Primary outcome was the maximum sequential organ failure assessment (SOFA) score within 30 days, where death was scored with the maximum achievable SOFA score. Secondary endpoints were area under the death-adjusted SOFA score (AUCSOFA), mean SOFA score, admission to the intensive care unit, mechanical ventilation, and death. Analyses were done on a modified intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT04353596. Findings Between April 20, 2020, and Jan 20, 2021, 204 patients (median age 75 years [IQR 66–80], 37% females) were randomly assigned to discontinue (n=104) or continue (n=100) RAS inhibition. Within 30 days, eight (8%) of 104 died in the discontinuation group and 12 (12%) of 100 patients died in the continuation group (p=0·42). There was no significant difference in the primary endpoint between the discontinuation and continuation group (median [IQR] maximum SOFA score 0·00 (0·00–2·00) vs 1·00 (0·00–3·00); p=0·12). Discontinuation was associated with a significantly lower AUCSOFA (0·00 [0·00–9·25] vs 3·50 [0·00–23·50]; p=0·040), mean SOFA score (0·00 [0·00–0·31] vs 0·12 [0·00–0·78]; p=0·040), and 30-day SOFA score (0·00 [10–90th percentile, 0·00–1·20] vs 0·00 [0·00–24·00]; p=0·023). At 30 days, 11 (11%) in the discontinuation group and 23 (23%) in the continuation group had signs of organ dysfunction (SOFA score ≥1) or were dead (p=0·017). There were no significant differences for mechanical ventilation (10 (10%) vs 8 (8%), p=0·87) and admission to intensive care unit (20 [19%] vs 18 [18%], p=0·96) between the discontinuation and continuation group. Interpretation Discontinuation of RAS-inhibition in COVID-19 had no significant effect on the maximum severity of COVID-19 but may lead to a faster and better recovery. The decision to continue or discontinue should be made on an individual basis, considering the risk profile, the indication for RAS inhibition, and the availability of alternative therapies and outpatient monitoring options. Funding Austrian Science Fund and German Center for Cardiovascular Research.
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Affiliation(s)
- Axel Bauer
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Michael Schreinlechner
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolay Sappler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Dolejsi
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Benedikt A Aulinger
- Medizinische Klinik und Poliklinik II, LMU University Hospital Munich, Munich, Germany
| | - Günter Weiss
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology and Pneumology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rosa Bellmann-Weiler
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology and Pneumology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Adolf
- Medizinische Klinik und Poliklinik IV, LMU University Hospital Munich, Munich, Germany
| | - Dominik Wolf
- Department of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Pirklbauer
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University of Innsbruck, Innsbruck, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, Hospital Hall in Tirol, Hall in Tirol, Austria
| | - Hannes Gänzer
- Department of Internal Medicine, Hospital Schwaz, Schwaz, Austria
| | - Christian von Bary
- Department of Internal Medicine I, Rotkreuzklinikum Munich, Munich, Germany
| | - Andreas E May
- Department of Internal Medicine, Hospital Memmingen, Memmingen, Germany
| | - Ewald Wöll
- Department of Internal Medicine, Hospital Zams, Zams, Austria
| | - Wolfgang von Scheidt
- Department of Internal Medicine I, University Hospital Augsburg, Augsburg, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Daniel Duerschmied
- University Heart Center Freiburg, Department of Cardiology and Angiology I, University of Freiburg, Freiburg, Germany
| | - Christoph Brenner
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany; German Center for Cardiovascular Research, Munich Heart Alliance, Munich, Germany
| | - Bernhard Metzler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Hans-Ulrich Kain
- Department of Internal Medicine, Hospital Mühldorf, Mühldorf, Germany
| | - Norbert Kaiser
- Department of Internal Medicine, Hospital St Johann in Tirol, St Johann in Tirol, Austria
| | - Robert Schwinger
- Department of Internal Medicine, Hospital Weiden, Weiden, Germany
| | | | - Hannes Alber
- Department of Internal Medicine and Cardiology, Klinikum Klagenfurt am Woerthersee, Klagenfurt, Austria
| | - Florian Straube
- Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen and Schwabing, Munich, Germany
| | - Niels Hartmann
- Department of Internal Medicine I (Cardiology), University Hospital Aachen, Aachen, Germany
| | - Stephan Achenbach
- Department of Cardiology and Angiology, University Hospital Erlangen, Erlangen, Germany
| | | | - Lukas von Stülpnagel
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria; Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany; German Center for Cardiovascular Research, Munich Heart Alliance, Munich, Germany
| | - Sebastian Schoenherr
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Forer
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Germany
| | - Konstantinos D Rizas
- Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany; German Center for Cardiovascular Research, Munich Heart Alliance, Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany; German Center for Cardiovascular Research, Munich Heart Alliance, Munich, Germany.
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Reindl M, Lechner I, Tiller C, Holzknecht M, Rangger A, Mayr A, Theurl M, Klug G, Brenner C, Bauer A, Metzler B, Reinstadler SJ. Glycemic Status and Reperfusion Injury in Patients With ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Imaging 2021; 14:1875-1877. [PMID: 34023265 DOI: 10.1016/j.jcmg.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022]
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Tiller C, Holzknecht M, Reindl M, Lechner I, Kalles V, Troger F, Mayr A, Klug G, Brenner C, Bauer A, Metzler B, Reinstadler S. ESTIMATING THE EXTENT OF MYOCARDIAL DAMAGE IN STEMI PATIENTSUSING THE DETERMINE SCORE. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01421-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Poskaite P, Pamminger M, Kranewitter C, Kremser C, Reindl M, Reinstadler SJ, Reiter G, Piccini D, Tiller C, Holzknecht M, Klug G, Metzler B, Mayr A. Self-navigated 3D whole-heart MRA for non-enhanced surveillance of thoracic aortic dilation: a comparison to CTA. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
The natural history of thoracic aortic aneurysm (TAA) is one of progressive expansion. Asymptomatic patients who do not meet criteria for repair require conservative management including ongoing aneurysm surveillance, mostly carried out by contrast-enhanced computed tomography angiography (CTA).
Purpose
To prospectively compare image quality and reliability of a prototype non-contrast, self-navigated 3D whole-heart magnetic resonance angiography (MRA) with contrast-enhanced computed tomography angiography (CTA) for sizing of thoracic aortic aneurysm (TAA).
Methods
Self-navigated 3D whole-heart 1.5 T MRA was performed in 20 patients (aged 67 ± 8.6 years, 75% male) for sizing of TAA; a subgroup of 18 (90%) patients underwent additional contrast-enhanced CTA on the same day. Subjective image quality was scored according to a 4-point Likert scale and ratings between observers were compared by Cohen’s Kappa statistics. Continuous MRA and CTA measurements were analyzed with regression and Bland-Altman analysis.
Results
Overall subjective image quality as rated by two observers was 1 [interquartile range (IQR) 1-2] for self-navigated MRA and 1.5 [IQR 1-2] for CTA (p = 0.717). For MRA a perfect inter-observer agreement was found for presence of artefacts and subjective image sharpness (κ=1). Subjective signal inhomogeneity correlated highly with objectively quantified inhomogeneity of the blood pool signal (r = 0.78-0.824, all p <0.0001). Maximum diameters of TAA as measured by self-navigated MRA and CTA showed excellent correlation (r = 0.997, p < 0.0001) without significant inter-method bias (bias -0.0278, lower and upper limit of agreement -0.74 and 0.68, p = 0.749). Inter- and intraobserver correlation of aortic aneurysm as measured by MRA was excellent (r = 0.963 and 0.967, respectively) without significant bias (all p ≤ 0.05).
Conclusion
Self-navigated 3D whole-heart MRA enables reliable contrast- and radiation free aortic dilation surveillance without significant difference to standardized CTA while providing predictable acquisition time and by offering excellent image quality.
Abstract Figure.
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Affiliation(s)
- P Poskaite
- Innsbruck Medical University, Department of Radiology, Innsbruck, Austria
| | - M Pamminger
- Innsbruck Medical University, Department of Radiology, Innsbruck, Austria
| | - C Kranewitter
- Innsbruck Medical University, Department of Radiology, Innsbruck, Austria
| | - C Kremser
- Innsbruck Medical University, Department of Radiology, Innsbruck, Austria
| | - M Reindl
- Medical University of Innsbruck, Cardiology and Angiology, Innsbruck, Austria
| | - SJ Reinstadler
- Medical University of Innsbruck, Cardiology and Angiology, Innsbruck, Austria
| | - G Reiter
- Medical University of Graz, Graz, Austria
| | - D Piccini
- University of Erlangen-Nuremberg, Erlangen, Germany
| | - C Tiller
- Medical University of Innsbruck, Cardiology and Angiology, Innsbruck, Austria
| | - M Holzknecht
- Medical University of Innsbruck, Cardiology and Angiology, Innsbruck, Austria
| | - G Klug
- Medical University of Innsbruck, Cardiology and Angiology, Innsbruck, Austria
| | - B Metzler
- Medical University of Innsbruck, Cardiology and Angiology, Innsbruck, Austria
| | - A Mayr
- Medical University of Innsbruck, Innsbruck, Austria
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Tiller C, Reindl M, Holzknecht M, Lechner I, Kalles V, Rangger A, Mayr A, Klug G, Brenner C, Bauer A, Reinstadler S, Metzler B. Validation of a simple ECG score for infarct size estimation in patients with first-time ST-elevation myocardial infarction. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund
Background
The magnitude of myocardial damage after acute ST-elevation myocardial infarction (STEMI) is a crucial prognostic determinant. Cardiac magnetic resonance (CMR) imaging offers a precise infarct severity assessment after STEMI; however, limited to restricted availability in daily clinical routine. Recently, a simple ECG score (DETERMINE score) was developed for infarct size (IS) estimation in STEMI patients with prior infarction. We sought to validate this score in patients with first-time STEMI for the assessment of myocardial injury visualized by CMR.
Methods
In this validation study, 423 revascularized first-time STEMI patients (median age 56, 17% women) were included. ECG was conducted at discharge for evaluation of the DETERMINE and Selvester score. CMR imaging was performed at a median of 3 days for the assessment of infarct characteristics (IS and microvascular obstruction [MVO]).
Results
Median DETERMINE score of the overall cohort was 8 points (interquartile range: 5-11). Patients presenting with a score > 8 points had more often anterior infarct localization (64% vs. 29%, p < 0.001) and higher peak hs-TnT levels (6957 ng/l vs. 3117 ng/l, p < 0.001). In linear and binary multivariable logistic regression analysis, the DETERMINE score remained as independent associate of IS (odds ratio [OR]: 1.09, 95% confidence interval [CI] 1.00 to 1.18, p = 0.047) and MVO (OR: 1.09, 95% CI 1.02 to 1.16, p = 0.016), after adjustment for Selvester score and peak hs-cTnT.
Conclusions
In survivors of first-time STEMI, the DETERMINE score provides an easy and inexpensive tool for suitable IS estimation. Moreover, the DETERMINE score showed significant and independent association with MVO. Thus, this simple ECG score might help identify patients at high risk of large infarct burden who might benefit from more aggressive treatment strategies.
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Affiliation(s)
- C Tiller
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - M Reindl
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - M Holzknecht
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - I Lechner
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - V Kalles
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - A Rangger
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - A Mayr
- Innsbruck Medical University, University Clinic of Radiology, Innsbruck, Austria
| | - G Klug
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - C Brenner
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - A Bauer
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - S Reinstadler
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
| | - B Metzler
- Innsbruck Medical University, Internal Medicine III, Cardiology & Angiology, Innsbruck, Austria
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