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Gavara J, Merenciano-Gonzalez H, Llopis-Lorente J, Molina-Garcia T, Perez-Solé N, de Dios E, Marcos-Garces V, Monmeneu JV, Lopez-Lereu MP, Canoves J, Bonanad C, Moratal D, Núñez J, Bayés-Genis A, Sanchis J, Chorro FJ, Rios-Navarro C, Bodí V. Impact of Epicardial Adipose Tissue on Infarct Size and Left Ventricular Systolic Function in Patients with Anterior ST-Segment Elevation Myocardial Infarction. Diagnostics (Basel) 2024; 14:368. [PMID: 38396407 PMCID: PMC10888463 DOI: 10.3390/diagnostics14040368] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
We aimed to assess the correlation of cardiovascular magnetic resonance (CMR)-derived epicardial adipose tissue (EAT) with infarct size (IS) and residual systolic function in ST-segment elevation myocardial infarction (STEMI). We enrolled patients discharged for a first anterior reperfused STEMI submitted to undergo CMR. EAT, left ventricular (LV) ejection fraction (LVEF), and IS were quantified at the 1-week (n = 221) and at 6-month CMR (n = 167). At 1-week CMR, mean EAT was 31 ± 13 mL/m2. Patients with high EAT volume (n = 72) showed larger 1-week IS. After adjustment, EAT extent was independently related to 1-week IS. In patients with large IS at 1 week (>30% of LV mass, n = 88), those with high EAT showed more preserved 6-month LVEF. This association persisted after adjustment and in a 1:1 propensity score-matched patient subset. Overall, EAT decreased at 6 months. In patients with large IS, a greater reduction of EAT was associated with more preserved 6-month LVEF. In STEMI, a higher presence of EAT was associated with a larger IS. Nevertheless, in patients with large infarctions, high EAT and greater subsequent EAT reduction were linked to more preserved LVEF in the chronic phase. This dual and paradoxical effect of EAT fuels the need for further research in this field.
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Affiliation(s)
- Jose Gavara
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, 46022 Valencia, Spain; (J.G.); (D.M.)
| | - Hector Merenciano-Gonzalez
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
| | - Jordi Llopis-Lorente
- Centro de Investigación e Innovación en Bioingeniería (Ci2B), Universitat Politècnica de València, 46010 Valencia, Spain;
| | - Tamara Molina-Garcia
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
| | - Nerea Perez-Solé
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
| | - Elena de Dios
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28022 Madrid, Spain; (E.d.D.); (A.B.-G.)
| | - Víctor Marcos-Garces
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
| | - Jose V. Monmeneu
- Cardiovascular Magnetic Resonance Unit, ASCIRES Biomedical Group, 46004 Valencia, Spain; (J.V.M.); (M.P.L.-L.)
| | - Maria P. Lopez-Lereu
- Cardiovascular Magnetic Resonance Unit, ASCIRES Biomedical Group, 46004 Valencia, Spain; (J.V.M.); (M.P.L.-L.)
| | - Joaquim Canoves
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
| | - Clara Bonanad
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
| | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, 46022 Valencia, Spain; (J.G.); (D.M.)
| | - Julio Núñez
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28022 Madrid, Spain; (E.d.D.); (A.B.-G.)
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Antoni Bayés-Genis
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28022 Madrid, Spain; (E.d.D.); (A.B.-G.)
- Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, 08193 Badalona, Spain
- Department of Medicine, Universitat Autonoma de Barcelona, 08193 Barcelona, Spain
| | - Juan Sanchis
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28022 Madrid, Spain; (E.d.D.); (A.B.-G.)
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Francisco J. Chorro
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28022 Madrid, Spain; (E.d.D.); (A.B.-G.)
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Cesar Rios-Navarro
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Department of Pathology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Vicente Bodí
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (H.M.-G.); (T.M.-G.); (N.P.-S.); (V.M.-G.); (J.C.); (C.B.); (J.N.); (J.S.); (F.J.C.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28022 Madrid, Spain; (E.d.D.); (A.B.-G.)
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
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Bodi V, Gavara J, Lopez-Lereu MP, Monmeneu JV, de Dios E, Perez-Sole N, Bonanad C, Marcos-Garces V, Canoves J, Minana G, Nunez J, Moratal D, Chorro FJ, Rodríguez-Palomares JF, Freixa A, Borrás R, Ortiz-Pérez JT, Rios-Navarro C. Impact of Persistent Microvascular Obstruction Late After STEMI on Adverse LV Remodeling: A CMR Study. JACC Cardiovasc Imaging 2023:S1936-878X(23)00094-3. [PMID: 37052556 DOI: 10.1016/j.jcmg.2023.01.021] [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: 05/12/2022] [Revised: 12/23/2022] [Accepted: 01/26/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Little is known about the occurrence and implications of persistent microvascular obstruction (MVO) after reperfused ST-segment elevation myocardial infarction (STEMI). OBJECTIVES The authors used cardiac magnetic resonance (CMR) to characterize the impact of persistent MVO on adverse left ventricular remodeling (ALVR). METHODS A prospective registry of 471 STEMI patients underwent CMR 7 (IQR: 5-10) days and 198 (IQR: 167-231) days after infarction. MVO (≥1 segment) and ALVR (relative increase >15% at follow-up CMR) of left ventricular end-diastolic index (LVEDVI) and left ventricular end-systolic volume index (LVESVI) were determined. RESULTS One-week MVO occurred in 209 patients (44%) and persisted in 30 (6%). Extent of MVO (P = 0.026) and intramyocardial hemorrhage (P = 0.001) at 1 week were independently associated with the magnitude of MVO at follow-up CMR. Compared with patients without MVO (n = 262, 56%) or with MVO only at 1 week (n = 179, 38%), those with persistent MVO at follow-up (n = 30, 6%) showed higher rates of ALVR-LVEDVI (22%, 27%, 50%; P = 0.003) and ALVR-LVESVI (20%, 21%, 53%; P < 0.001). After adjustment, persistent MVO at follow-up (≥1 segment) was independently associated with ΔLVEDVI (relative increase, %) (P < 0.001) and ΔLVESVI (P < 0.001). Compared with a 1:1 propensity score-matched population on CMR variables made up of 30 patients with MVO only at 1 week, patients with persistent MVO more frequently displayed ALVR-LVEDVI (12% vs 50%; P = 0.003) and ALVR-LVESVI (12% vs 53%; P = 0.001). CONCLUSIONS MVO persists in a small percentage of patients in chronic phase after STEMI and exerts deleterious effects in terms of LV remodeling. These findings fuel the need for further research on microvascular injury repair.
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Affiliation(s)
- Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain.
| | - Jose Gavara
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | | | - Jose V Monmeneu
- Cardiovascular Magnetic Resonance Unit, Grupo ASCIRES, Valencia, Spain
| | - Elena de Dios
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Nerea Perez-Sole
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Clara Bonanad
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Victor Marcos-Garces
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Joaquim Canoves
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Gema Minana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Julio Nunez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Francisco J Chorro
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Jose F Rodríguez-Palomares
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain; Department of Cardiology, Hospital Universitario Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrea Freixa
- Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Roger Borrás
- Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Jose T Ortiz-Pérez
- Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Cesar Rios-Navarro
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Valencia, Spain
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3
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Marcos-Garcés V, Perez N, Gavara J, Lopez-Lereu MP, Monmeneu JV, Rios-Navarro C, de Dios E, Merenciano-González H, Gabaldon-Pérez A, Ferrero-De-Loma-Osorio Á, Martínez-Brotons Á, Bondanza L, Sánchez-Gómez JM, Albiach C, Nunez J, Bayés-Genís A, Chorro FJ, Ruiz-Granell R, Bodi V. Cardiac magnetic resonance outperforms echocardiography to predict subsequent implantable cardioverter defibrillator therapies in ST-segment elevation myocardial infarction patients. Front Cardiovasc Med 2023; 10:991307. [PMID: 36818338 PMCID: PMC9937054 DOI: 10.3389/fcvm.2023.991307] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Background Implantable cardioverter defibrillators (ICD) are effective as a primary prevention measure of ventricular tachyarrhythmias in patients with ST-segment elevation myocardial infarction (STEMI) and depressed left ventricular ejection fraction (LVEF). The implications of using cardiac magnetic resonance (CMR) instead of echocardiography (Echo) to assess LVEF prior to the indication of ICD in this setting are unknown. Materials and methods We evaluated 52 STEMI patients (56.6 ± 11 years, 88.5% male) treated with ICD in primary prevention who underwent echocardiography and CMR prior to ICD implantation. ICD implantation was indicated based on the presence of heart failure and depressed LVEF (≤ 35%) by echocardiography, CMR, or both. Prediction of ICD therapies (ICD-T) during follow-up by echocardiography and CMR before ICD implantation was assessed. Results Compared to echocardiography, LVEF was lower by cardiac CMR (30.2 ± 9% vs. 37.4 ± 7.6%, p < 0.001). LVEF ≤ 35% was detected in 24 patients (46.2%) by Echo and in 42 (80.7%) by CMR. During a mean follow-up of 6.1 ± 4.2 years, 10 patients received appropriate ICD-T (3.16 ICD-T per 100 person-years): 5 direct shocks to treat very fast ventricular tachycardia or ventricular fibrillation, 3 effective antitachycardia pacing (ATP) for treatment of ventricular tachycardia, and 2 ineffective ATP followed by shock to treat ventricular tachycardia. Echo-LVEF ≤ 35% correctly predicted ICD-T in 4/10 (40%) patients and CMR-LVEF ≤ 35% in 10/10 (100%) patients. CMR-LVEF improved on Echo-LVEF for predicting ICD-T (area under the curve: 0.76 vs. 0.48, p = 0.04). Conclusion In STEMI patients treated with ICD, assessment of LVEF by CMR outperforms Echo-LVEF to predict the subsequent use of appropriate ICD therapies.
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Affiliation(s)
- Víctor Marcos-Garcés
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain,INCLIVA Health Research Institute, Valencia, Spain
| | - Nerea Perez
- INCLIVA Health Research Institute, Valencia, Spain
| | - Jose Gavara
- INCLIVA Health Research Institute, Valencia, Spain,Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Maria P. Lopez-Lereu
- Cardiovascular Magnetic Resonance Unit, ASCIRES Biomedical Group, Valencia, Spain
| | - Jose V. Monmeneu
- Cardiovascular Magnetic Resonance Unit, ASCIRES Biomedical Group, Valencia, Spain
| | | | - Elena de Dios
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Hector Merenciano-González
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain,INCLIVA Health Research Institute, Valencia, Spain
| | - Ana Gabaldon-Pérez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain,INCLIVA Health Research Institute, Valencia, Spain
| | | | | | - Lourdes Bondanza
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Cristina Albiach
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Julio Nunez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain,INCLIVA Health Research Institute, Valencia, Spain,Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain,Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francisco J. Chorro
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain,INCLIVA Health Research Institute, Valencia, Spain,Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ricardo Ruiz-Granell
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain,INCLIVA Health Research Institute, Valencia, Spain,Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain,*Correspondence: Vicente Bodi,
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4
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Palau P, Núñez J, Monmeneu JV, Lopez-Lereu MP, Gavara J, Rios-Navarro C, de Dios E, Perez-Sole N, Marcos-Garces V, Domínguez E, Moratal D, Canoves J, Miñana G, Chorro FJ, Bodi V. Sex Effect in the Decision to Perform Invasive Coronary Angiography in Patients With Chronic Coronary Syndrome After Undergoing Vasodilator Stress MRI. J Magn Reson Imaging 2022; 56:1680-1690. [PMID: 35344231 DOI: 10.1002/jmri.28163] [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: 12/20/2021] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stress cardiac MRI permits comprehensive evaluation of patients with known or suspected chronic coronary syndromes (CCS). The impact of sex on the use of invasive cardiac angiography (ICA) after vasodilator stress cardiac MRI is unclear. PURPOSE To evaluate the impact of sex on ICA use after vasodilator stress cardiac MRI. STUDY TYPE Retrospective. POPULATION A total of 6229 consecutive patients (age [mean ± standard deviation] 65.2 ± 11.5 years, 38.1% women). FIELD STRENGTH/SEQUENCE A 5-T; a steady-state free-precession cine sequence; stress first-pass perfusion imaging; late enhancement imaging. ASSESSMENT Patients underwent vasodilator stress cardiac MRI for known or suspected CCS. The ischemic burden (at stress first-pass perfusion imaging) was computed (17-segment model). STATISTICAL TESTS Multivariate logistic regression was used to evaluate the potential differential association between ischemic burden and use of cardiac MRI-related ICA across sex. RESULTS A total of 1109 (17.8%) patients were referred to ICA, among which there were significantly more men (762, 19.7%) than women (347, 14.6%). Overall, after multivariate adjustment, female sex was not associated with lower use of ICA (odds ratio [OR] = 0.99; confidence interval [CI] 95%: 0.84-1.18, P = 0.934). However, significant sex differences were detected across ischemic burden. Whereas women with nonischemic vasodilator stress cardiac MRI (0 ischemic segments) were less commonly submitted to ICA (OR = 0.49; CI 95%: 0.35-0.69) in patients with ischemia (>1 ischemic segment), adjusted use of ICA was more frequent in women than men (OR = 1.27; CI 95%: 1.1-1.5). DATA CONCLUSIONS In patients with known or suspected CCS submitted to undergo vasodilator stress cardiac MRI, cardiac MRI-related ICA may be overused in men without ischemia. Furthermore, ICA referral in patients with negative ischemia resulted in greater odds of revascularization in men. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- Patricia Palau
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jose V Monmeneu
- Cardiovascular Unit, ASCIRES Biomedical Group, Valencia, Spain
| | | | - Jose Gavara
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Cesar Rios-Navarro
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Elena de Dios
- Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Nerea Perez-Sole
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Victor Marcos-Garces
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | | | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Joaquim Canoves
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Gema Miñana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Francisco Javier Chorro
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.,Faculty of Medicine, Universitat de València, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
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5
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Marcos Garces V, Gabaldon-Perez A, Gavara J, Lopez-Lereu MP, Monmeneu JV, Perez N, Rios-Navarro C, De Dios E, Merenciano-Gonzalez H, Chorro FJ, Valente F, Lorenzatti D, Ortiz-Perez JT, Rodriguez-Palomares JF, Bodi V. Prognostic value of cardiac magnetic resonance in elderly patients soon after ST-segment elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2552] [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
Elderly patients with ST-segment elevation myocardial infarction (STEMI) represent a very high-risk population. Data on the prognostic value of cardiac magnetic resonance (CMR) in this scenario are scarce.
Purpose
We aim to study the prognostic value of an early (1-week) CMR in elderly patients after STEMI and to create a simple risk score including clinical and CMR variables.
Methods
The registry comprised 247 patients over 70 years of age discharged for a first STEMI treated with percutaneous intervention and included in a multicenter registry. Baseline characteristics, echocardiographic parameters and CMR-derived left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were prospectively collected. The additional prognostic power of CMR was assessed using adjusted C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).
Results
During a 4.8-year mean follow-up, 66 (26.7%) first major adverse cardiac events (MACE) occurred (27 all-cause deaths and 39 re-admissions for acute heart failure). Higher GRACE score (HR 1.03 [1.02–1.04], p<0.001), more depressed CMR-LVEF (HR 0.97 [0.95–0.99] per increased %, p=0.006) and more extensive MVO (HR 1.24 [1.09–1.4] per segment, p=0.001) predicted MACE occurrence. The addition of CMR data significantly improved MACE prediction compared to the model with baseline and echocardiographic characteristics (C-statistic 0.759 [0.694–0.824] vs. 0.685 [0.613–0.756], NRI=0.6, IDI=0.08, p<0.001). The best cut-offs for independent variables were GRACE score >155, LVEF <40%, and MVO ≥2 segments. A simple score (0, 1, 2, and 3) based on the number of altered factors accurately predicted the MACE per 100 person-years: 0.78, 5.53, 11.51 and 78.79, respectively (p<0.001).
Conclusions
CMR data contribute valuable prognostic information in elderly patients submitted to undergo CMR soon after STEMI.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.
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Affiliation(s)
- V Marcos Garces
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - A Gabaldon-Perez
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - M P Lopez-Lereu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - J V Monmeneu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - N Perez
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - E De Dios
- Center for Networked Biomedical Research – Cardiovascular (CIBER-CV) , Madrid , Spain
| | | | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - F Valente
- University Hospital Vall d'Hebron, Department of Cardiology , Barcelona , Spain
| | - D Lorenzatti
- Institute of Biomedical Research August Pi Sunyer (IDIBAPS) , Barcelona , Spain
| | - J T Ortiz-Perez
- Barcelona Hospital Clinic, Department of Cardiology , Barcelona , Spain
| | | | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
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6
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Bertolin-Boronat C, Marcos Garces V, Perez N, Gavara J, Lopez-Lereu MP, Monmeneu JV, Rios-Navarro C, De Dios E, Merenciano-Gonzalez H, Gabaldon-Perez A, Iraola Viana D, Bonanad C, Moratal D, Chorro FJ, Bodi V. Cardiac magnetic resonance characterization and prediction of left ventricular thrombus after ST-segment elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.291] [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
Left ventricular thrombus (LVTh) is an uncommon yet serious complication after ST-segment elevation myocardial infarction (STEMI). Late gadolinium enhancement (LGE) sequences in cardiac magnetic resonance (CMR) imaging allows for accurate detection of LVTh. However, the implications of CMR to predict and characterize LVTh occurrence is this population is unclear.
Purpose
We aim to characterize the incidence, outcomes, and predictors of LVTh after STEMI by CMR imaging.
Methods
Our registry comprised 455 patients admitted for a first reperfused STEMI in our university hospital. Baseline characteristics were recorded. All patients underwent early (1-week) and late (6-month) CMR. Left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were measured. LGE sequences were used to analyze the presence of LVTh. Patients with LVTh at 6-month CMR underwent an additional CMR 1 year after admission. Univariate and multivariate comparisons were performed to study the ocurrence of LVTh in the first 6 months after STEMI.
Results
Mean age was 58.24±11.69 years, most patients were male (82.6%) and anterior infarction occurred in more than half of the cohort (52.7%). LVTh was detected in 36 (7.9%) patients in the first 6 months after STEMI. Anticoagulation was initiated in all cases. Of these, 27 patients had LVTh at early (1-week) CMR, but 9 had LVTh at late (6-month) CMR with no prior evidence of LVTh at early CMR. A total of 6 patients had persisting LVTh at 1-year CMR (37.5% of patients with 6-month LVTh). In multivariable analysis, anterior infarction (HR 6.6 [1.91–22.83], p<0.001) and 1-week CMR-LVEF (HR 0.97 [0.93–0.99], p=0.04) and MVO (HR 1.19 [1.02–1.39], p=0.03) independently predicted the occurrence of LVTh in the first 6 months after STEMI. We computed a risk score of LVTh assigning 1 point to each of these variables (anterior infarction, CMR-LVEF <50% and MVO >3.5 segments), which allowed us to stratify the risk of LVTh in the first 6 months after STEMI (0.6% if 0 points, 3.8% if 1 point, 14.4% if 2 points, and 31.2% if 3 points).
Conclusions
CMR imaging soon after STEMI can contribute relevant prognostic value regarding LVTh occurrence after the acute event. Patients with anterior infarction, LVEF <50% and MVO in >3.5 segments at early (1-week) CMR have the highest risk of LVTh in the first 6 months after STEMI.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.
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Affiliation(s)
- C Bertolin-Boronat
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - V Marcos Garces
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - N Perez
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - M P Lopez-Lereu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - J V Monmeneu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - E De Dios
- Center for Networked Biomedical Research – Cardiovascular (CIBER-CV) , Madrid , Spain
| | | | - A Gabaldon-Perez
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - D Iraola Viana
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - C Bonanad
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - D Moratal
- Polytechnic University of Valencia, Center for Biomaterials and Tissue Engineering , Valencia , Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
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7
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Silva C, Marcos-Carrion A, Garcia-Lopez MP, Lopez-Lereu MP, Monmeneu JV, Higueras L, Ferreira AM, Maceira AM. Myocardial deformation in athletes measured with feature tracking cardiovascular magnetic resonance. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.271] [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
Morphological changes of the heart associated with exercise are well studied. However, changes in myocardial mechanics of athlete's heart are less understood. The aim of this study was to analyze myocardial deformation parameters in athletes and controls, using feature tracking cardiac magnetic resonance (FT-CMR).
Methods
In a cohort of 73 athletes who had been submitted to CMR at 1.5T and 3 T (mean age 31±12 years, 69% males), we used CMR-FT to measure longitudinal, circumferential and radial strain and strain rates of both ventricles. Left ventricle (LV) longitudinal, circumferential and radial dyssynchrony index (L-SDI, C-SDI and R-CDI, respectively) was calculated as the standard deviation of the calculated time to peak strain percentages of the cardiac cycle with segmental strain analysis. We also measured these parameters in 73 age-matched healthy subjects.
Results
In comparison to the control subjects, athletes revealed lower left and right ventricle global longitudinal strain (−14.24% vs. −13.31%, p=0.03, and −18.12% vs. −15.95% p=0.01, respectively) and right ventricular (RV) global radial strain (19.28 vs 15.74, p<0.05) – Figure 1. There were no significant differences in LV global radial and circumferential strain. LV longitudinal, radial and circumferential systolic strain rate were also lower in athletes compared to controls (−0.69 s–1 vs. −0.78 s–1, p=0.04; 1.35 s–1 vs. 1.50 s–1, p=0.03: −0.92 s–1 vs −0.98 s–1, p=0.05, respectively). Regarding LV dyssynchrony index, we found no significant difference for L-SDI (10.76% vs. 10.72%, p=0.956), but athletes group showed lower C-SDI and R-SDI values (5.99% vs 4.84%, p=0.006, and 5.53% vs 4.47%, p=0.002).
Conclusion
Our study revealed attenuation of biventricular strain values and lower circumferential and radial LV dyssynchrony indexes in athletes, compared with healthy controls. We hypothesize that these differences may be related with exercise physiologic cardiac adaptations.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- C Silva
- Hospital de Santa Cruz , Lisbon , Portugal
| | | | | | | | | | - L Higueras
- Ascires Biomedical Group , Valencia , Spain
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8
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Aimo A, Gavara J, Lopez-Lereu MP, Monmeneu JV, De Dios E, Perez-Sole N, Marcos-Garces V, Rios-Navarro C, Emdin M, Lupon J, Bayes-Genis A, Bodi V. Epicardial adipose tissue, infarct size, microvascular obstruction and ventricular remodelling after ST-segment elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1296] [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
Epicardial adipose tissue (EAT) is a biologically active fat deposit contained beneath the pericardium promoting coronary atherosclerosis. EAT can be accurately measured through cardiac magnetic resonance (CMR), which also enables an accurate quantification of infarct size, microvascular obstruction (MVO), left ventricular (LV) ejection fraction (EF) and volumes in patients with ST-elevation myocardial infarction (STEMI).
Purpose
We performed a systematic assessment of the correlates of EAT volume at baseline and after 6 months in a homogeneous cohort of patients with STEMI.
Methods
We prospectively enrolled patients with a first anterior STEMI reperfused within 12 hours from symptom onset. These patients underwent a first CMR exam after 1 week from the MI and after 6 months.
Results
Patients (n=138) were more often men (81%), with a median age of 58 years (interquartile range 48–66). EAT volume was 30 mL/m2 (23–41). Patients with EAT >30 mL/m2 (n=69) were older (60±12 vs. 55±11 years, p=0.02), more often diabetic (26% vs. 12%, p=0.03), and showed a worse baseline risk profile (Thrombolysis in Myocardial Infarction risk score 3 [2–5] vs. 2 [1–4], p=0.05). Patients with EAT >30 mL/m2 also displayed a larger IS (33±15 vs. 23±16% of LV mass, p=0.001) and MVO (1.5 [0–6.8] vs. 0% [0–2.2], p=0.008). Again in patients with EAT >30 mL/m2, EAT volume independently predicted infarct size (standardized beta coefficient=0.30, p<0.001) and MVO area (standardized beta coefficient=0.36, p<0.001) after adjusting for age, sex and infarct characteristics at 1 week (Figure 1). Despite these correlations with infarct size and MVO, patients with EAT >30 mL/m2 did not display more depressed LVEF or larger LV volumes than those with EAT ≤30 mL/m2, either at 1 week or at 6-month CMR (p>0.1 for all comparisons).
Conclusions
In a cohort of patients with first anterior STEMI undergoing timely reperfusion, those with a greater EAT volume have a larger infarct size and a larger area of MVO. Despite these correlates of EAT volume size, patients with larger EAT do not have a higher risk of adverse LV remodelling.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A Aimo
- Sant'Anna School of Advanced Studies , Pisa , Italy
| | - J Gavara
- Valencia University Clinical Hospital , Valencia , Spain
| | | | - J V Monmeneu
- Valencia University Clinical Hospital , Valencia , Spain
| | - E De Dios
- Valencia University Clinical Hospital , Valencia , Spain
| | - N Perez-Sole
- Valencia University Clinical Hospital , Valencia , Spain
| | | | - C Rios-Navarro
- Valencia University Clinical Hospital , Valencia , Spain
| | - M Emdin
- Sant'Anna School of Advanced Studies , Pisa , Italy
| | - J Lupon
- Germans Trias i Pujol Hospital , Badalona , Spain
| | | | - V Bodi
- Valencia University Clinical Hospital , Valencia , Spain
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9
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Marcos Garces V, Perez N, Gavara J, Lopez-Lereu MP, Monmeneu JV, Rios-Navarro C, De Dios E, Merenciano-Gonzalez H, Gabaldon-Perez A, Chorro FJ, Valente F, Lorenzatti D, Ortiz-Perez JT, Rodriguez-Palomares JF, Bodi V. A novel clinical and cardiac magnetic resonance risk score for early risk prediction after ST-segment elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.347] [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) performed early after ST-segment elevation myocardial infarction (STEMI) can improve major adverse cardiac event (MACE) risk prediction. However, predictive models including clinical and CMR variables are scarce and not routinely implemented in clinical practice.
Purpose
We aimed to create a simple clinical-CMR risk score for early MACE risk stratification in STEMI patients.
Methods
We performed a multicenter prospective registry in three Spanish university hospitals of reperfused STEMI patients (n=1118) in whom early (1-week) CMR-derived left ventricular ejection fraction (LVEF), infarct size and microvascular obstruction (MVO) were quantified. MACE was defined as a combined clinical endpoint of cardiovascular (CV) death, non-fatal myocardial infarction (NF-MI) or re-admission for acute decompensated heart failure (HF), whichever occurred first. Univariate and multivariate analyses were performed and a risk score was computed using the variables which independently predicted the risk of MACE.
Results
During a median follow-up of 5.52 [2.63–7.44] years, 216 first MACE (58 CV deaths, 71 NF-MI and 87 HF) were registered. Mean age was 59.3±12.3 years and most patients (82.8%) were male. Based on the four variables independently associated with MACE, we computed an 8-point risk score: time to reperfusion >4.15h (1 point), GRACE risk score >155 (3 points), CMR-LVEF <40% (3 points), and MVO >1.5 segments (1 point). This score permitted MACE risk stratification: MACE per 100 person-years was 1.96 in the low-risk category (0–2 points), 5.44 in the intermediate-risk category (3–5 points), and 19.7 in the high-risk category (6–8 points): p<0.001 in multivariable Cox survival analysis.
Conclusions
A novel risk score including clinical (time to reperfusion >4.15h and GRACE risk score >155) and CMR (LVEF <40% and MVO >1.5 segments) variables allows for simple and straightforward MACE risk stratification early after STEMI. External validation should confirm the applicability of the risk score.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional (FEDER) and Sociedad Española de Cardiología.
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Affiliation(s)
- V Marcos Garces
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - N Perez
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - M P Lopez-Lereu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - J V Monmeneu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - E De Dios
- Center for Networked Biomedical Research – Cardiovascular (CIBER-CV) , Madrid , Spain
| | | | - A Gabaldon-Perez
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - F Valente
- University Hospital Vall d'Hebron, Department of Cardiology , Barcelona , Spain
| | - D Lorenzatti
- Institute of Biomedical Research August Pi Sunyer (IDIBAPS) , Barcelona , Spain
| | - J T Ortiz-Perez
- Barcelona Hospital Clinic, Department of Cardiology , Barcelona , Spain
| | | | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
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10
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Gavara J, Rios Navarro C, Lopez-Lereu MP, Monmeneu JV, De Dios E, Perez-Sole N, Marcos-Garces V, Canoves J, Nunez J, Chorro FJ, Rodriguez-Palomares JF, Freixa A, Borras R, Ortiz-Perez JT, Bodi V. Impact of persistent MVO late after STEMI on adverse left ventricular remodelling: a CMR study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.150] [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
Despite successful revascularization at the epicardial level, microvascular obstruction (MVO) appears soon after reperfusion in up to 50% of cases. Early MVO has been solidly associated with adverse resulting cardiac structure and heightened risk of future cardiovascular events. Although clinical and experimental studies demostrated the spontaneous repair of MVO, little is known about the occurrence and implications of persistent MVO late after infarction.
Purpose
We used cardiovascular magnetic resonance (CMR) to characterize the impact of persistent MVO late after reperfused ST-segment elevation myocardial infarction (STEMI) on adverse left ventricular (LV) remodelling (ALVR).
Methods
A prospective registry of 471 STEMI patients underwent CMR 7 [5–10] and 198 [167–231] days post infarction, and MVO (>1 segment) and ALVR (relative increase >15% at follow-up CMR) of LV end-diastolic (LVEDVI) and end-systolic volume indices (LVESVI) were determined.
Results
One-week MVO occurred in 209 patients (44%) and persisted in 30 of these (6%). Most patients with persistent MVO (22/30, 73%) displayed extensive (>2.5% of LV mass) MVO at 1 week. Compared with patients without MVO (n=262, 56%) or with MVO only at 1 week (n=179, 38%), those with persistent MVO at follow-up (n=30, 6%) showed higher rates of ALVR-LVEDVI (22%, 27%, 50% p=0.003) and ALVR-LVESVI (20%, 21%, 53% p<0.001). After adjustment, the extent (% of LV mass) of MVO at follow-up was independently associated with ΔLVEDVI (relative increase, %) (p=0.01) and ΔLVESVI (p=0.03). Compared to a 1:1 matched population of 30 patients with MVO only at 1 week, patients with persistent MVO more frequently displayed ALVR-LVEDVI (12% vs. 50%, p=0.003) and ALVR-LVESVI (12% vs. 53%, p=0.001).
Conclusion
MVO persists in a small percentage of patients in chronic phase after STEMI and exerts deleterious effects in terms of LV remodelling. These findings fuel the need for further research on microvascular injury repair.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” [grant numbers PI20/00637, PI15/00531, FI18/00320, and CIBERCV16/11/00486] and by Conselleria de Educaciόn – Generalitat Valenciana (PROMETEO/2021/008).
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Affiliation(s)
- J Gavara
- Polytechnic University of Valencia , Valencia , Spain
| | - C Rios Navarro
- Research Foundation Hospital of Valencia (INCLIVA) , Valencia , Spain
| | | | | | - E De Dios
- University of Valencia , Valencia , Spain
| | - N Perez-Sole
- Research Foundation Hospital of Valencia (INCLIVA) , Valencia , Spain
| | - V Marcos-Garces
- Research Foundation Hospital of Valencia (INCLIVA) , Valencia , Spain
| | - J Canoves
- Hospital Clínico Universitario de Valencia , Valencia , Spain
| | - J Nunez
- Hospital Clínico Universitario de Valencia , Valencia , Spain
| | - F J Chorro
- Hospital Clínico Universitario de Valencia , Valencia , Spain
| | | | - A Freixa
- Barcelona Hospital Clinic , Barcelona , Spain
| | - R Borras
- Barcelona Hospital Clinic , Barcelona , Spain
| | | | - V Bodi
- Hospital Clínico Universitario de Valencia , Valencia , Spain
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11
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Merenciano-Gonzalez H, Marcos Garces V, Gabaldon-Perez A, Gavara J, Lopez-Lereu MP, Monmeneu JV, Perez N, Rios-Navarro C, De Dios E, Chorro FJ, Valente F, Lorenzatti D, Ortiz-Perez JT, Rodriguez-Palomares JF, Bodi V. Cardiac magnetic resonance predictors of readmission for heart failure in elderly vs not elderly patients after ST-segment elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.931] [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
Patients with ST-segment elevation acute myocardial infarction (STEMI) have an increased risk of re-admission for acute heart failure (AHF). However, identification of patients at higher risk of AHF is challenging, especially in elderly individuals. The implications of cardiac magnetic resonance (CMR) imaging soon after the acute event for this specific purpose are unknown.
Purpose
We aim to study the clinical and CMR predictors of AHF in elderly and not elderly patients after STEMI.
Methods
STEMI patients treated with percutaneous coronary intervention and discharged from three university hospitals were included in a multicenter registry. We registered baseline clinical characteristics, echocardiographic parameters and early (1-week) CMR parameters - left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments). Univariate and multivariate comparisons were performed in elderly (>70 years) and not elderly (≤70 years) patients to predict AHF during follow-up.
Results
The cohort was comprised of 759 patients, of which 177 (23.3%) were elderly (>70 years). During a mean follow-up of 5.23±3.54 years, 79 (10.4%) patients presented AHF. In not elderly patients, Killip class at admission (HR 2.05 [1.32–3.17], p=0.001), anterior infarction (HR 3.43 [1.13–10.36], p=0.03) and CMR-LVEF (HR 0.94 [0.91–0.98] per increased %, p=0.001) independently predicted AHF. However, a combined risk score comprising these variables was not superior to CMR-LVEF alone to predict AHF during follow-up (AUC 0.81 [0.74–0.88] vs. 0.81 [0.73–0.88], p=NS). In elderly patients, CMR-LVEF was the only predictor of AHF in the final multivariable model (HR 0.94 [0.91–0.97], p<0.001), although its predictive power was moderate (AUC 0.68 [0.56–0.80], p=0.001). Most AHF events in the not elderly subgroup occurred in patients with reduced (≤40%) CMR-LVEF (71%), while in the elderly subgroup AHF occurred more frequently in patients with preserved (≥50%, 30%) or mildly reduced (40–49%, 32%) CMR-LVEF than reduced (≤40%) CMR-LVEF (38%).
Conclusions
LVEF quantified by CMR soon after STEMI can accurately predict the risk of AHF in not elderly (≤70 years) patients and identify those individuals at higher risk (i.e. CMR-LVEF ≤40%). However, in elderly (>70 years) patients most AHF occur in patients with CMR-LVEF >40%, emphasizing the need for better predictive strategies in this population.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.
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Affiliation(s)
| | - V Marcos Garces
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - A Gabaldon-Perez
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - M P Lopez-Lereu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - J V Monmeneu
- ERESA Medical Group, Cardiovascular Magnetic Resonance Unit , Valencia , Spain
| | - N Perez
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA , Valencia , Spain
| | - E De Dios
- Center for Networked Biomedical Research – Cardiovascular (CIBER-CV) , Madrid , Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
| | - F Valente
- University Hospital Vall d'Hebron, Department of Cardiology , Barcelona , Spain
| | - D Lorenzatti
- Institute of Biomedical Research August Pi Sunyer (IDIBAPS) , Barcelona , Spain
| | - J T Ortiz-Perez
- Barcelona Hospital Clinic, Department of Cardiology , Barcelona , Spain
| | | | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology , Valencia , Spain
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12
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Marcos-Garcés V, Perez N, Gavara J, Lopez-Lereu MP, Monmeneu JV, Rios-Navarro C, de Dios E, Merenciano-González H, Gabaldon-Pérez A, Cànoves J, Racugno P, Bonanad C, Minana G, Nunez J, Moratal D, Chorro FJ, Valente F, Lorenzatti D, Ortiz-Pérez JT, Rodríguez-Palomares JF, Bodi V. Risk score for early risk prediction by cardiac magnetic resonance after acute myocardial infarction. Int J Cardiol 2021; 349:150-154. [PMID: 34826497 DOI: 10.1016/j.ijcard.2021.11.050] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/15/2021] [Accepted: 11/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) performed early after ST-segment elevation myocardial infarction (STEMI) can improve major adverse cardiac event (MACE) risk prediction. We aimed to create a simple clinical-CMR risk score for early MACE risk stratification in STEMI patients. METHODS We performed a multicenter prospective registry of reperfused STEMI patients (n = 1118) in whom early (1-week) CMR-derived left ventricular ejection fraction (LVEF), infarct size and microvascular obstruction (MVO) were quantified. MACE was defined as a combined clinical endpoint of cardiovascular (CV) death, non-fatal myocardial infarction (NF-MI) or re-admission for acute decompensated heart failure (HF). RESULTS During a median follow-up of 5.52 [2.63-7.44] years, 216 first MACE (58 CV deaths, 71 NF-MI and 87 HF) were registered. Mean age was 59.3 ± 12.3 years and most patients (82.8%) were male. Based on the four variables independently associated with MACE, we computed an 8-point risk score: time to reperfusion >4.15 h (1 point), GRACE risk score > 155 (3 points), CMR-LVEF <40% (3 points), and MVO >1.5 segments (1 point). This score permitted MACE risk stratification: MACE per 100 person-years was 1.96 in the low-risk category (0-2 points), 5.44 in the intermediate-risk category (3-5 points), and 19.7 in the high-risk category (6-8 points): p < 0.001 in multivariable Cox survival analysis. CONCLUSIONS A novel risk score including clinical (time to reperfusion >4.15 h and GRACE risk score > 155) and CMR (LVEF <40% and MVO >1.5 segments) variables allows for simple and straightforward MACE risk stratification early after STEMI. External validation should confirm the applicability of the risk score.
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Affiliation(s)
- Víctor Marcos-Garcés
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Health Research Institute - INCLIVA, Valencia, Spain
| | - Nerea Perez
- Health Research Institute - INCLIVA, Valencia, Spain
| | - Jose Gavara
- Health Research Institute - INCLIVA, Valencia, Spain; Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | | | - Jose V Monmeneu
- Cardiovascular Magnetic Resonance Unit, ERESA, Valencia, Spain
| | | | - Elena de Dios
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | | | - Ana Gabaldon-Pérez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Joaquim Cànoves
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Paolo Racugno
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Clara Bonanad
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Health Research Institute - INCLIVA, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Gema Minana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Health Research Institute - INCLIVA, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Julio Nunez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Health Research Institute - INCLIVA, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Francisco J Chorro
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Health Research Institute - INCLIVA, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Filipa Valente
- Hospital Universitari Vall d'Hebron, Department of Cardiology, Barcelona, Spain
| | - Daniel Lorenzatti
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Jose T Ortiz-Pérez
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain; Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Jose F Rodríguez-Palomares
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain; Hospital Universitari Vall d'Hebron, Department of Cardiology, Barcelona, Spain; Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain; Health Research Institute - INCLIVA, Valencia, Spain; Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain.
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13
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Valente FX, Gavara J, Gutierrez L, Rios-Navarro C, Rello P, Maymi M, Fernandez-Galera R, Monmeneu JV, Sao-Aviles A, Lopez-Lereu MP, Gonzalez-Alujas MT, Moratal D, Cuellar H, Barrabés J, Otaegui I, Evangelista A, Ferreira I, Bodi V, Rodriguez-Palomares J. Predictive Value of Cardiac Magnetic Resonance Feature Tracking after Acute Myocardial Infarction: A Comparison with Dobutamine Stress Echocardiography. J Clin Med 2021; 10:jcm10225261. [PMID: 34830543 PMCID: PMC8624532 DOI: 10.3390/jcm10225261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
In acute ST-segment elevation myocardial infarction (STEMI) late gadolinium enhancement (LGE) may underestimate segmental functional recovery. We evaluated the predictive value of cardiac magnetic resonance (CMR) feature-tracking (FT) for functional recovery and whether it incremented the value of LGE compared to low-dose dobutamine stress echocardiography (LDDSE) and speckle-tracking echocardiography (STE). Eighty patients underwent LDDSE and CMR within 5–7 days after STEMI and segmental functional recovery was defined as improvement in wall-motion at 6-months CMR. Optimal conventional and FT parameters were analyzed and then also applied to an external validation cohort of 222 STEMI patients. Circumferential strain (CS) was the strongest CMR-FT predictor and addition to LGE increased the overall accuracy to 74% and was especially relevant in segments with 50–74% LGE (AUC 0.60 vs. 0.75, p = 0.001). LDDSE increased the overall accuracy to 71%, and in the 50–74% LGE subgroup improved the AUC from 0.60 to 0.69 (p = 0.039). LGE + CS showed similar value as LGE + LDDSE. In the validation cohort, CS was also the strongest CMR-FT predictor of recovery and addition of CS to LGE improved overall accuracy to 73% although this difference was not significant (AUC 0.69, p = 0.44). Conclusion: CS is the strongest CMR-FT predictor of segmental functional recovery after STEMI. Its incremental value to LGE is comparable to that of LDDSE whilst avoiding an inotropic stress agent. CS is especially relevant in segments with 50–74% LGE where accuracy is lower and further testing is frequently required to clarify the potential for recovery.
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Affiliation(s)
- Filipa X. Valente
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
- Correspondence:
| | - José Gavara
- Centro de Biomateriales y Ingeniería de Tejidos, Universitat Politècnica de Valencia, 46022 Valencia, Spain; (J.G.); (D.M.)
| | - Laura Gutierrez
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Cesar Rios-Navarro
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (C.R.-N.); (V.B.)
| | - Pau Rello
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Manel Maymi
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Ruben Fernandez-Galera
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - José V. Monmeneu
- Unidad de Resonancia Magnética Cardiovascular, Exploraciones Radiológicas Especiales (ERESA), 46015 Valencia, Spain; (J.V.M.); (M.P.L.-L.)
| | - Augusto Sao-Aviles
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Maria P. Lopez-Lereu
- Unidad de Resonancia Magnética Cardiovascular, Exploraciones Radiológicas Especiales (ERESA), 46015 Valencia, Spain; (J.V.M.); (M.P.L.-L.)
| | - M. Teresa Gonzalez-Alujas
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - David Moratal
- Centro de Biomateriales y Ingeniería de Tejidos, Universitat Politècnica de Valencia, 46022 Valencia, Spain; (J.G.); (D.M.)
| | - Hug Cuellar
- Radiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain;
| | - José Barrabés
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Imanol Otaegui
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Artur Evangelista
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Ignacio Ferreira
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
| | - Vicente Bodi
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain; (C.R.-N.); (V.B.)
- Cardiology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
- Centrode Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28029 Madrid, Spain
- Medicine Department, Facultad de Medicina y Odontología, Universidad de Valencia, 46010 Valencia, Spain
| | - José Rodriguez-Palomares
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (L.G.); (P.R.); (M.M.); (R.F.-G.); (A.S.-A.); (M.T.G.-A.); (J.B.); (I.O.); (A.E.); (I.F.); (J.R.-P.)
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14
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Gavara J, Perez N, Marcos-Garces V, Monmeneu JV, Lopez-Lereu MP, Rios-Navarro C, De Dios E, Bonanad C, Cánoves J, Moratal D, Palau P, Miñana G, Nunez J, Chorro FJ, Bodi V. Combined assessment of stress cardiovascular magnetic resonance and angiography to predict the effect of revascularization in chronic coronary syndrome patients. Eur J Prev Cardiol 2021; 29:407-416. [PMID: 34686874 DOI: 10.1093/eurjpc/zwab170] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/02/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022]
Abstract
AIMS The role of revascularization in chronic coronary syndrome (CCS) and the value of ischaemia vs. anatomy to guide decision-making are in constant debate. We explored the potential of a combined assessment of ischaemic burden by vasodilator stress cardiovascular magnetic resonance (CMR) and presence of multivessel disease by angiography to predict the effect of revascularization on all-cause mortality in CCS. METHODS AND RESULTS The study group comprised 1066 CCS patients submitted to vasodilator stress CMR pre-cardiac catheterization (mean age 66 ± 11 years, 69% male). Stress CMR-derived ischaemic burden (extensive if >5 ischaemic segments) and presence of multivessel disease in angiography (two- or three-vessel or left main stem disease) were computed. The influence of revascularization on all-cause mortality was explored and adjusted hazard ratios (HRs) with the corresponding 95% confidence intervals were obtained. During a median 7.51-year follow-up, 557 (52%) CMR-related revascularizations and 308 (29%) deaths were documented. Revascularization exerted a neutral effect on all-cause mortality in the whole study group [HR 0.94 (0.74-1.19), P = 0.6], in patients without multivessel disease [n = 598, 56%, HR 1.12 (0.77-1.62), P = 0.6], and in those with multivessel disease without extensive ischaemic burden [n = 181, 17%, HR 1.66 (0.91-3.04), P = 0.1]. However, compared to non-revascularized patients, revascularization significantly reduced all-cause mortality in patients with simultaneous multivessel disease and extensive ischaemic burden (n = 287, 27%): 3.77 vs. 7.37 deaths per 100 person-years, HR 0.60 (0.40-0.90), P = 0.01. CONCLUSIONS In patients with CCS submitted to catheterization, evidence of simultaneous extensive CMR-related ischaemic burden and multivessel disease identifies the subset in whom revascularization can reduce all-cause mortality.
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Affiliation(s)
- Jose Gavara
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Camí de Vera s/n, 46022 Valencia, Spain
| | - Nerea Perez
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain
| | - Victor Marcos-Garces
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
| | - Jose V Monmeneu
- Cardiovascular Magnetic Resonance Unit, Exploraciones Radiologicas Especiales (ERESA), Calle del Marqués de San Juan 6, 46015 Valencia, Spain
| | - Maria P Lopez-Lereu
- Cardiovascular Magnetic Resonance Unit, Exploraciones Radiologicas Especiales (ERESA), Calle del Marqués de San Juan 6, 46015 Valencia, Spain
| | - Cesar Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain
| | - Elena De Dios
- Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Avenida Monforte de Lemos 3-5, 28029 Madrid, Spain
| | - Clara Bonanad
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain.,Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain.,Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
| | - Joaquim Cánoves
- Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
| | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Camí de Vera s/n, 46022 Valencia, Spain
| | - Patricia Palau
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain.,Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain.,Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
| | - Gema Miñana
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain.,Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain.,Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
| | - Julio Nunez
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain.,Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain.,Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Avenida Monforte de Lemos 3-5, 28029 Madrid, Spain.,Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
| | - Francisco Javier Chorro
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain.,Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain.,Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Avenida Monforte de Lemos 3-5, 28029 Madrid, Spain.,Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
| | - Vicente Bodi
- Instituto de Investigacion Sanitaria INCLIVA, Calle de Menéndez y Pelayo 4, 46010 Valencia, Spain.,Department of Cardiology, Hospital Clinico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain.,Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Avenida Monforte de Lemos 3-5, 28029 Madrid, Spain.,Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain
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15
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Marcos Garces V, Minana G, Nunez J, Monmeneu JV, Lopez-Lereu MP, Gavara J, Rios-Navarro C, Perez N, De Dios E, Fernandez-Cisnal A, Nunez E, Chorro FJ, Sanchis J, Bodi V. Sex differences in mortality in stable patients undergoing vasodilator stress cardiovascular magnetic resonance. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2781] [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
Introduction
The prognostic value and therapeutic implications of ischemia as derived from vasodilator stress cardiovascular magnetic resonance (CMR) could differ in men and women, but it has not been stablished.
Purpose
We assessed the influence of the ischemic burden as derived from CMR on the risk of death and the effect of revascularization across sex.
Methods
We evaluated 6,237 consecutive patients with known or suspected chronic coronary syndrome (CCS). Extensive ischemia was defined as >5 segments with perfusion deficit. Multivariate Cox proportional hazard regression models were used.
Results
A total of 2,371 (38.0%) patients were women and 583 (9.3%) underwent CMR-related revascularization. During a median follow-up of 5.13 years, 687 (11.0%) deaths were reported. We found an adjusted differential effect of CMR-derived ischemic burden across sex (p-value for interaction=0.039). Women exhibited an adjusted lower risk of death along most of the continuous ischemic burden but equalled men's risk when extensive ischemia was present. Likewise, CMR-related revascularization was shown to be differentially associated with the risk of mortality across sex (p-value for interaction=0.025). In patients with non-extensive ischemia, revascularization was related to a higher risk of death, with a greater extent in women. At higher ischemic burden, revascularization was associated with a lower risk in men, with more uncertain results in women.
Conclusions
CMR-derived ischemic burden allows predicting the risk of death and gives insight into the potential effect of revascularization in men and women with CCS. Compared to men, women with nonextensive ischemia displayed a lower risk and a similar risk with a higher ischemic burden. The impact of CMR-related revascularization on mortality risk was also significantly different according to ischemic burden and sex.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the Instituto de Salud Carlos III and cofunded by the European Regional Development Fund (ERDF).
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Affiliation(s)
- V Marcos Garces
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - G Minana
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Nunez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J V Monmeneu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - M P Lopez-Lereu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - N Perez
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - E De Dios
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - A Fernandez-Cisnal
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - E Nunez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Sanchis
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
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16
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Gabaldon-Perez A, Marcos-Garces V, Merenciano-Gonzalez H, Nunez-Marin G, Lorenzo-Hernandez M, Gavara J, Perez-Sole N, De Dios E, Bonanad C, Racugno P, Lopez-Lereu MP, Monmeneu JV, Chorro FJ, Bodi V. Downstream testing after exercise ECG stress test – can we predict ischemia on subsequent vasodilator stress cardiac magnetic resonance? Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1179] [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
Exercise ECG stress test (ExECG) is useful in the diagnostic work-up of patients with chest pain and known or suspected stable ischemic heart disease (SIHD). However, current guidelines recommend a stress imaging, ischemia-detecting technique such as vasodilator stress cardiac magnetic resonance (vs-CMR) if available. Whether clinical and ExECG variables can predict ischemia on subsequent vs-CMR testing is unknown.
Material and methods
We retrospectively included 289 patients who underwent an ExECG and a subsequent vs-CMR in the year after this test and who didn't undergo a revascularization procedure in this time frame. Clinical, ExECG and vs-CMR variables were included in the registry. vs-CMR was considered positive if ischemia was evident in at least one myocardial segment on stress first-pass perfusion without concomitant necrosis on late gadolinium enhancement imaging. We performed univariate and multivariate analysis to check for the association of variables with the risk of ischemia on vs-CMR.
Results
Mean time from ExECG to vs-CMR was 97,27±88,31 days and 91 vs-CMR were positive for ischemia. Age, male sex, diabetes mellitus, hypertension, dyslipidaemia and personal history of ischemic heart disease, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were predictors of ischemia on vs-CMR in the univariate analysis. On ExECG, time of exercise, exercise capacity, chest pain during ExECG, maximum heart rate (HR) and systolic blood pressure (SBP), % of predicted HR, chronotropic reserve index, maximum and reserve of double product and Duke Treadmill Score were also associated with ischemia on vs-CMR. However, the only independent predictors on multivariate binary logistic regression stepwise analysis were history of PCI (HR 3.79 [2.03–7.09], p<0.001) or CABG (HR 5.57 [1.80–17.26], p=0.003), maximum double product (HR 0.94 [0.90–0.99] per 1000 increase, p=0.02) and Duke Treadmill Score (HR 0.95 [0.91–0.99], p=0.019). Subgroup analysis showed that male sex (HR 1.95 [1.16–3.28], p=0.012), history of ischemic heart disease (HR 4.73 [2.88–7.76], p<0.001) and maximum double product (HR 0.94 [0.90–0.98] per 1000 increase, p=0.006) were predictors of ischemia on vs-CMR in non-revascularized patients (n=212). In revascularized patients (n=77) the only independent predictor was the Duke Treadmill Score on ExECG (HR 0.93 [0.86–0.99], p=0.048).
Conclusions
Several ExECG variables, namely Duke Treadmill Score and parameters of myocardial oxygen consumption such as maximum doble product, can predict the risk of ischemia on subsequent vs-CMR in revascularized and non-revascularized patients with chest pain. This can help select patients who should undergo vs-CMR afeter ExECG for ischemia detection.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A Gabaldon-Perez
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - V Marcos-Garces
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | | | - G Nunez-Marin
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - M Lorenzo-Hernandez
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - N Perez-Sole
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - E De Dios
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - C Bonanad
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - P Racugno
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | | | | | - F J Chorro
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - V Bodi
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
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17
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Merenciano Gonzalez H, Marcos-Garces V, Gabaldon-Perez A, Lorenzo-Hernandez M, Nunez-Marin G, Gavara J, Perez N, Rios-Navarro C, De Dios E, Bonanad C, Racugno P, Lopez-Lereu MP, Monmeneu JV, Chorro FJ, Bodi V. Exercise ECG testing in patients without known ischemic heart disease: predictors of ischemia of downstream vasodilator stress cardiac magnetic resonance. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2671] [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 routine clinical practice, patients with chest pain and suspected stable ischemic heart disease (SIHD) usually undergo an exercise ECG stress test (ExECG) for ischemia detection. However, since the sensitivity of this technique is relatively low, concerns exist that many patients could remain underdiagnosed. We intend to assess the clinical and ExECG predictors of ischemia on subsequent vasodilator stress cardiac magnetic resonance (vs-CMR) to help select which patients should undergo downstream testing after an initial ExECG.
Material and methods
We retrospectively included 197 patients without previous history of ischemic heart disease who underwent an ExECG and a subsequent vs-CMR in the year after this test and who didn't undergo a revascularization procedure in this time frame. Clinical, ExECG and vs-CMR variables were included in the registry. vs-CMR was considered positive if ischemia was evident in at least one myocardial segment on stress first-pass perfusion without concomitant necrosis on late gadolinium enhancement imaging. We performed univariate and multivariate analysis to check for the association of variables with the risk of ischemia on vs-CMR.
Results
Mean time from ExECG to vs-CMR was 88.69±84.32 days and 37 vs-CMR were positive for ischemia. Male sex, less exercise time, less % of maximum predicted exercise capacity, less maximum double product (heart rate x systolic blood pressure) and less double product reserve (DPR = maximum double product - basal double product) were associated with ischemia on vs-CMR on univariate analyses. However, the only independent predictors of ischemia on vs-CMR on multivariate binary logistic regression were male sex (HR 2.62 [CI 95%: 1.13–5.76], p=0.016) and less DPR (HR 0.90 [CI 95%: 0.84–0.97] per 1000 increase, p=0.006). The risk score derived from these two variables had a moderate predictive power (ROC curves, AUC 0.657, p=0.003). The best cut-off point for the DPR was 12400, as derived from the Youden index. It allowed stratification of the risk of ischemia on vs-CMR, which ranged from 9% in women with >12400 DPR, 18.8% in men with >12400 DPR, 24.1% in women with ≤12400 DPR to 42.9% in men with ≤12400 DPR (p=0.005, Figure 1).
Conclusions
Male sex and less double product reserve on ExECG can moderately predict the risk of ischemia on subsequent vs-CMR in patients presenting with chest pain and without previous SIHD. This can help select patients who benefit most from vs-CMR for diagnostic purposes.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
| | - V Marcos-Garces
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - A Gabaldon-Perez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - M Lorenzo-Hernandez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - G Nunez-Marin
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - N Perez
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - E De Dios
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - C Bonanad
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - P Racugno
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - M P Lopez-Lereu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - J V Monmeneu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
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18
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Merenciano Gonzalez H, Gavara J, Marcos-Garces V, Pedro-Tudela A, Gabaldon-Perez A, Perez N, Rios-Navarro C, De Dios E, Monmeneu JV, Lopez-Lereu MP, Racugno P, Bonanad C, Chorro FJ, Bodi V. Residual ST-segment elevation at pre-discharge ECG after STEMI: association with long-term prognosis and structural consequences at 6-month CMR. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1469] [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
Introduction
Residual ST-segment elevation after ST-segment elevation myocardial infarction (STEMI) has been traditionally interpreted as a predictor of left ventricular dysfunction and ventricular aneurism. More recently, it has also been associated with more severe structural consequences in cardiac magnetic resonance (CMR) performed soon after STEMI. However, the implications in terms of long-term prognosis of patients and structural consequences in CMR performed late after STEMI are unclear.
Methods
Data was obtained from a prospective registry of reperfused STEMI patients. At pre-discharge ECG, sum and maximum ST-segment elevation (mm), ST-segment resolution (%) and the number of Q-leads with residual ST-segment elevation >1 mm (Q-STE) were assessed. 6-month CMR parameters were quantified: left ventricular ejection fraction (LVEF, %), left ventricular end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI, mL/m2), infarct size (IS, % left ventricular mass) and microvascular obstruction (MVO, % left ventricular mass). The primary end-point was major adverse cardiac events (MACE), defined as all-cause death and/or re-admission for acute heart failure, whichever occurred first.
Results
488 patients were included. Mean age was 58±12 years, 80.3% were males and smoking was the most prevalent cardiovascular risk factor. During a 7-year mean and median follow-up, 92 MACE were registered (19%), 39 all-cause deaths and 53 re-admission for acute heart failure. Q-STE >1 lead was detected in 172 patients (35%) and it was the most potent ECG predictor of MACE (26% vs 15%, p=0.002). Q-STE was also associated with structural changes at 6-month CMR: larger LVEDVI (87,39±27,47 mL/m2 vs 74,31±24,13 mL/m2) and LVESVI (45,45±25,24 mL/m2 vs 32,53±20,85 mL/m2), less LVEF (50,48±13,95% vs 58,75±12,3%) and larger infarct size (24,91±11,6% vs 14,38±11,41%) (p<0.001 for all comparisons, Figure 1). After adjustment for baseline and ECG characteristics, Q-STE (per lead with >1 mm) was independently associated with a higher risk of long-term MACE (HR 1.24 [CI 95%: 1.09–1.40], p=0.001), depressed (<40%) LVEF (HR 1.26 [CI 95%: 1.02–1.56], p=0.03) and large (>30% left ventricular mass) infarct size (HR 1.34 [CI 95%: 1.08–1.67], p=0.008) at 6-month CMR. Survival free from MACE was lower in patients with >1 lead Q-STE (log-rank=9.07, p=0.003) (Figure 2).
Conclusions
Residual ST-segment elevation after STEMI represents a widely available predictor of adverse long-term prognosis and late CMR-derived left ventricular remodelling. It could contribute to select patients who would benefit of close monitoring.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Fondos Europeos de Desarrollo Regional FEDERInstituto de Salud Carlos III Figure 1. Structural changes at 6-month CMRFigure 2. Survival free from MACE
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Affiliation(s)
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - V Marcos-Garces
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - A Pedro-Tudela
- University of Valencia, Faculty of Medicine, Valencia, Spain
| | - A Gabaldon-Perez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - N Perez
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - E De Dios
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - J V Monmeneu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - M P Lopez-Lereu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - P Racugno
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - C Bonanad
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
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19
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Monmeneu Menadas JV, García Gonzalez MP, Lopez-Lereu MP, Higueras Ortega L, Maceira Gonzalez AM. Safety and tolerability of regadenoson in comparison with adenosine stress cardiovascular magnetic resonance: Data from a multicentre prospective registry. Int J Cardiovasc Imaging 2021; 38:195-209. [PMID: 34331614 DOI: 10.1007/s10554-021-02363-4] [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: 03/03/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Abstract
To assess the feasibility and incidence of immediate complications of stress cardiovascular magnetic resonance (CMR) with regadenoson in comparison with adenosine in a large referral population. This is a large, multicenter, prospective registry of vasodilator stress-CMR in a referral population. We recorded the clinical and demographic data, quality of test, CMR findings, hemodynamic data, and complications. Between January 2016 and July 2019, 2908 patients underwent stress-CMR, 2253 with regadenoson and 655 with adenosine. 25.1% of patients had previously known coronary artery disease (CAD). In 305 patients regadenoson was used due to presence of chronic obstructive pulmonary disease (COPD) or asthma, while in 1948 subjects regadenoson was used as first-line vasodilator. Quality was optimal in 90.0%, suboptimal in 9.5%, and poor in 0.5%. Images were diagnostic in 98.9%. After stress with regadenoson, aminophylline 200 mg was administered intravenously in all patients. No patient died or had severe immediate complications with regadenoson as opposed to 2 severe bronchospasm with adenosine (p = 0.05). 11 patients (0.5%) had non-severe complications with regadenoson and five patients (0.8%) with adenosine (p = n.s.). Only two patients (0.088%) had non-severe bronchospasm after regadenoson administration. All complications were solved in the CMR unit, with no need for further specific care. Factors significantly associated with presence of complications were history of COPD or asthma and detection of inducible ischaemia. Patients had significantly more minor symptoms when adenosine was used (66.0% vs. 18.4%, p < 0.0001). Stress-CMR with regadenoson is feasible, providing diagnostic information in a referral population. Regadenoson had an excellent safety profile and better tolerability than adenosine, with no serious immediate complications and low incidence of non-severe complications. Only inducible ischaemia and previous history of COPD or asthma were associated with complications after regadenoson-CMR. The incidence of minor symptoms was low.
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Affiliation(s)
- Jose V Monmeneu Menadas
- Cardiovascular Unit, ASCIRES Biomedical Group, C/Marqués de San Juan, 6, 46015, Valencia, Spain.
| | - Maria P García Gonzalez
- Cardiovascular Unit, ASCIRES Biomedical Group, C/Marqués de San Juan, 6, 46015, Valencia, Spain
| | - Maria P Lopez-Lereu
- Cardiovascular Unit, ASCIRES Biomedical Group, C/Marqués de San Juan, 6, 46015, Valencia, Spain
| | - Laura Higueras Ortega
- Cardiovascular Unit, ASCIRES Biomedical Group, C/Marqués de San Juan, 6, 46015, Valencia, Spain
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20
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Bonanad Lozano C, Gabaldon-Perez A, Garcia-Blas S, Gavara J, Rios-Navarro C, Perez-Sole N, De Dios E, Marcos-Garces V, Merenciano-Gonzalez H, Monmeneu-Menadas JV, Lopez-Lereu MP, Nunez J, Chorro FJ, Bodi V. Stress cardiovascular magnetic resonance and mortality in a registry of 2496 elderly patients with chronic coronary syndrome. Prognosis and decision-making. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.128] [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): Instituto de Salud Carlos III, Fondo Europeo de Desarrollo Regional (FEDER)
Introduction and objectives. Management of the elderly with chronic coronary syndrome (CCS) is challenging. We explore the prognostic value and the usefulness for decision-making of the ischemic burden determined by vasodilator stress cardiac magnetic resonance (CMR) imaging in elderly patients with known or suspected CCS.
Methods. The study group was made up of 2496 patients older than 70 years submitted to vasodilator stress CMR for known or suspected CCS. The ischemic burden (number of segments with stress-induced perfusion deficit) was calculated following the 17-segment model. Its association with all-cause mortality and the effect of CMR-guided revascularization were analyzed retrospectively.
Results. During a median follow-up of 4.58 years, 430 deaths (17.2%) were recorded. A larger ischemic burden was an independent predictor of mortality: hazard ratio [95% confidence intervals]: 1.04 [1.01-1.07] for each additional ischemic segment, p = 0.006). This association also occurred in patients over 80 years of age and in women (p < 0.001). Compared to non-revascularized patients, revascularization associated with worse outcomes at low ischemic burden and exerted protective prognostic effect in patients with extensive ischemia both in the whole group (p for interaction = 0.003) and in 496 patients matched 1:1 by a propensity score (p = 0.06).
Conclusions. Vasodilator stress CMR represents a valuable tool to stratify risk in elderly patients with CCS and might be helpful to guide decision-making in this scenario.
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Affiliation(s)
- C Bonanad Lozano
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - A Gabaldon-Perez
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - S Garcia-Blas
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - J Gavara
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - C Rios-Navarro
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - N Perez-Sole
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - E De Dios
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - V Marcos-Garces
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | | | | | - MP Lopez-Lereu
- University Hospital Clinic, Imaging Unit-ERESA, Valencia, Spain
| | - J Nunez
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - FJ Chorro
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - V Bodi
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
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21
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Gavara J, Marcos-Garces V, Rios-Navarro C, Lopez-Lereu MP, Monmeneu JV, Bonanad Lozano C, Moratal D, Chorro FJ, Valente F, Lorenzatti D, Rodriguez-Palomares JF, Ortiz-Perez JT, Bodi V. Sequential cardiovascular magnetic resonance assessment of left ventricular ejection fraction for prediction of subsequent events in a large multicenter STEMI registry. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.042] [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: Public grant(s) – EU funding. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER”
Background. Cardiovascular magnetic resonance (CMR) is the best tool for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of sequential LVEF assessment for major adverse cardiac event (MACE) prediction after ST-segment elevation myocardial infarction (STEMI) is uncertain.
Purpose. We explored the prognostic impact of sequential assessment of CMR-derived LVEF after STEMI to predict subsequent MACE.
Methods. We recruited 1036 STEMI patients in a large multicenter registry. LVEF (reduced [r]: <40%; mid-range [mr]: 40-49%; preserved [p]: ≥50%) was sequentially quantified by CMR at 1 week and after >3 months of follow-up. MACE was regarded as cardiovascular death or re-admission for acute heart failure after follow-up CMR.
Results. During a 5.7-year mean follow-up, 82 MACE (8%) were registered. The MACE rate was higher only in patients with LVEF < 40% at follow-up CMR (r-LVEF 22%, mr-LVEF 7%, p-LVEF 6%; p-value < 0.001). Based on LVEF dynamics from 1-week to follow-up CMR, incidence of MACE was 5% for sustained LVEF³40% (n = 783), 13% for improved LVEF (from <40 to ³40%, n = 96), 21% for worsened LVEF (from ³40% to <40%, n = 34) and 22% for sustained LVEF <40% (n = 100), p-value < 0.001. Using a Markov approach that considered all studies performed, transitions towards improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to higher incidence of subsequent MACE.
Conclusions. LVEF constitutes a pivotal CMR index for simple and dynamic post-STEMI risk stratification. Detection of reduced LVEF (<40%) by CMR at any time during follow-up identifies a small subset of patients at high risk of subsequent events.
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Affiliation(s)
- J Gavara
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - V Marcos-Garces
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - C Rios-Navarro
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - MP Lopez-Lereu
- University Hospital Clinic, Imaging Unit-ERESA, Valencia, Spain
| | - JV Monmeneu
- University Hospital Clinic, Imaging Unit-ERESA, Valencia, Spain
| | - C Bonanad Lozano
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - D Moratal
- Polytechnic University of Valencia, Center for Biomaterials and Tissue Engineering, Valencia, Spain
| | - FJ Chorro
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - F Valente
- University Hospital Vall d"Hebron, Department of Cardiology, Barcelona, Spain
| | - D Lorenzatti
- Barcelona Hospital Clinic, Cardiovascular Institute, Barcelona, Spain
| | | | - JT Ortiz-Perez
- Barcelona Hospital Clinic, Cardiovascular Institute, Barcelona, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
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22
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Rios-Navarro C, Gavara J, Nunez J, Bonanad Lozano C, Revuelta-Lopez E, Monmeneu JV, Lopez-Lereu MP, De Dios E, Perez-Sole N, Vila JM, Oltra R, Chorro FJ, Bayes-Genis A, Bodi V. EpCAM and microvascular obstruction in patients with STEMI: a cardiac magnetic resonance study. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.052] [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) – EU funding. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER”
Bachground. Microvascular obstruction (MVO) is negatively associated with cardiac structure and worse prognosis after ST-segment elevation myocardial infarction (STEMI). Epithelial cell adhesion molecule (EpCAM), involved in endothelium adhesion, is an understudied area in the MVO setting.
Purpose. We aimed to evaluate whether EpCAM is associated with the appearance of cardiac magnetic resonance (CMR)-derived MVO and long-term systolic function in reperfused STEMI.
Methods. We prospectively included 106 patients with a first STEMI treated with primary percutaneous coronary intervention, quantifying serum levels of EpCAM 24 hours post-reperfusion. All patients underwent CMR imaging 1 week and 6 months post-STEMI. The independent correlation of EpCAM with MVO, systolic volume indices, and left ventricular ejection fraction (LVEF) was evaluated.
Results. The mean age of the sample was 59 ± 13 years and 76% were male. Patients were dichotomized according to EpCAM median (4.48 pg/mL). At 1-week CMR, lower EpCAM was related to extensive MVO (p-value = 0.02) and greater infarct size (p-value = 0.02). At presentation, only EpCAM values were significantly associated with the presence of MVO in univariate (Odds Ratio [95% confidence interval] (OR [95% CI]): 0.58 [0.38-0.88], p-value = 0.01) and multivariate logistic regression models (OR [95% CI]: 0.54 [0.34-0.85], p-value = 0.007). Although MVO tends to resolve at chronic phases, decreased EpCAM was associated with worse systolic function: depressed LVEF (p-value = 0.009) and higher left ventricular end-systolic volume (p-value = 0.04).
Conclusions. EpCAM is associated with occurrence of CMR-derived MVO at acute phases and long-term adverse ventricular remodeling post-STEMI. Future studies are needed to confirm EpCAM as biomarker, and eventually biotarget in STEMI pathophysiology.
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Affiliation(s)
- C Rios-Navarro
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - J Gavara
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - J Nunez
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - C Bonanad Lozano
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - E Revuelta-Lopez
- Germans Trias i Pujol Hospital, Instituto del Corazón, Badalona, Spain
| | - JV Monmeneu
- University Hospital Clinic, Imaging Unit-ERESA, Valencia, Spain
| | - MP Lopez-Lereu
- University Hospital Clinic, Imaging Unit-ERESA, Valencia, Spain
| | - E De Dios
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - N Perez-Sole
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - JM Vila
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
| | - R Oltra
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - FJ Chorro
- University Hospital Clinic, Department of Cardiology, Valencia, Spain
| | - A Bayes-Genis
- Germans Trias i Pujol Hospital, Instituto del Corazón, Badalona, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Cardiology. INCLIVA. University of Valencia., Valencia, Spain
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23
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Gavara J, Marcos-Garces V, Lopez-Lereu MP, Monmeneu JV, Rios-Navarro C, de Dios E, Perez N, Merenciano H, Gabaldon A, Cànoves J, Racugno P, Bonanad C, Minana G, Nunez J, Nunez E, Moratal D, Chorro FJ, Valente F, Lorenzatti D, Rodríguez-Palomares JF, Ortiz-Pérez JT, Bodi V. Magnetic Resonance Assessment of Left Ventricular Ejection Fraction at Any Time Post-Infarction for Prediction of Subsequent Events in a Large Multicenter STEMI Registry. J Magn Reson Imaging 2021; 56:476-487. [PMID: 34137478 DOI: 10.1002/jmri.27789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/26/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is the most accurate imaging technique for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of LVEF assessment at any time after ST-segment elevation myocardial infarction (STEMI) for subsequent major adverse cardiac event (MACE) prediction is uncertain. PURPOSE To explore the prognostic impact of MRI-derived LVEF at any time post-STEMI to predict subsequent MACE (cardiovascular death or re-admission for acute heart failure). STUDY TYPE Prospective. POPULATION One thousand thirteen STEMI patients were included in a multicenter registry. FIELD STRENGTH/SEQUENCE 1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences. ASSESSMENT Post-infarction MRI-derived LVEF (reduced [r]: <40%; mid-range [mr]: 40%-49%; preserved [p]: ≥50%) was sequentially quantified at 1 week and after >3 months of follow-up. STATISTICAL TESTS Multi-state Markov model to determine the prognostic value of each LVEF state (r-, mr- or p-) at any time point assessed to predict subsequent MACE. A P-value <0.05 was considered to be statistically significant. RESULTS During a 6.2-year median follow-up, 105 MACE (10%) were registered. Transitions toward improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to a higher incidence of subsequent MACE. The observed transitions from r-LVEF, mr-LVEF, and p-LVEF states to MACE were: 15.3%, 6%, and 6.7%, respectively. Regarding the adjusted transition intensity ratios, patients in r-LVEF state were 4.52-fold more likely than those in mr-LVEF state and 5.01-fold more likely than those in p-LVEF state to move to MACE state. Nevertheless, no significant differences were found in transitions from mr-LVEF and p-LVEF states to MACE state (P-value = 0.6). DATA CONCLUSION LVEF is an important MRI index for simple and dynamic post-STEMI risk stratification. Detection of r-LVEF by MRI at any time during follow-up identifies a subset of patients at high risk of subsequent events. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Jose Gavara
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Victor Marcos-Garces
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Jose V Monmeneu
- Cardiovascular Magnetic Resonance Unit, ERESA, Valencia, Spain
| | - Cesar Rios-Navarro
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Elena de Dios
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Nerea Perez
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Hector Merenciano
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Ana Gabaldon
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Joaquim Cànoves
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Paolo Racugno
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Clara Bonanad
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Gema Minana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Julio Nunez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Eduardo Nunez
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Francisco J Chorro
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Filipa Valente
- Department of Cardiology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Daniel Lorenzatti
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Jose T Ortiz-Pérez
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
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Gabaldon-Perez A, Garcia-Blas S, Gavara J, Rios-Navarro C, Perez-Sole N, De Dios E, Marcos-Garces V, Merenciano-Gonzalez H, Monmeneu JV, Lopez-Lereu MP, Nunez J, Chorro FJ, Bonanad C, Bodi V. Stress cardiovascular magnetic resonance and mortality in a registry of 2496 elderly patients with chronic coronary syndrome. Prognosis and decision-making. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.397] [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]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background. In recent guidelines, non-invasive imaging techniques play a pivotal role in the management of chronic coronary syndrome (CCS). The elderly represent a large percentage of our routine CCS population and risk stratification in this scenario is challenging. The potential of vasodilator stress cardiovascular magnetic resonance (CMR) for this purpose is unknown.
Purpose. We explore the prognostic value and the usefulness for decision-making of the ischemic burden determined by vasodilator stress CMR imaging in a large cohort of elderly patients with known or suspected CCS.
Methods. The study group was made up of 2496 patients older than 70 years submitted to vasodilator stress CMR for known or suspected CCS in our health department from 2001 to 2016 (mean age 76 ± 4 years, 52% male). Clinical and vasodilator stress CMR characteristics were prospectively recorded. The ischemic burden (number of segments with stress-induced perfusion deficit) was calculated following the 17-segment model. Its association with all-cause mortality and the effect of vasodilator stress CMR-guided revascularization (within the following 3 months) were analyzed retrospectively.
Results. During a median follow-up of 4.58 years, 430 deaths (17.2%) were recorded. A larger ischemic burden was an independent predictor of mortality: hazard ratio [95% confidence intervals]: 1.04 [1.01-1.07] for each additional ischemic segment, p = 0.006). This association also occurred in patients over 80 years of age and in women (p < 0.001). Compared to non-revascularized patients, revascularization associated with worse outcomes at low ischemic burden and exerted protective prognostic effect in patients with extensive ischemia both in the whole group (p for interaction = 0.003) and in 496 patients matched 1:1 by a propensity score (p = 0.06).
Conclusions. Vasodilator stress CMR represents a valuable tool to stratify risk in elderly patients with known or suspected CCS and might be helpful to guide decision-making in this scenario.
Abstract Figure 1
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Affiliation(s)
- A Gabaldon-Perez
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - S Garcia-Blas
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - J Gavara
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - C Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - N Perez-Sole
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - E De Dios
- Instituto de Investigacion Sanitaria INCLIVA, Valencia, Spain
| | - V Marcos-Garces
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | | | | | | | - J Nunez
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - FJ Chorro
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - C Bonanad
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
| | - V Bodi
- University Clinical Hospital of Valencia, Cardiology Department, Valencia, Spain
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25
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Marcos-Garces V, Gavara J, Lopez-Lereu MP, Monmeneu JV, Rios-Navarro C, de Dios E, Perez N, Cànoves J, Gonzalez J, Minana G, Nunez J, de la Espriella R, Santas E, Moratal D, Chorro FJ, Valente F, Lorenzatti D, Rodríguez-Palomares JF, Ortiz-Pérez JT, Bodi V. Ejection Fraction by Echocardiography for a Selective Use of Magnetic Resonance After Infarction. Circ Cardiovasc Imaging 2020; 13:e011491. [PMID: 33297764 DOI: 10.1161/circimaging.120.011491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Indexed: 11/16/2022]
Abstract
Background Cardiac magnetic resonance (CMR) permits robust risk stratification of discharged ST-segment-elevation myocardial infarction patients, but its indiscriminate use in all cases is not feasible. We evaluated the utility of left ventricular ejection fraction (LVEF) by echocardiography for a selective use of CMR after ST-segment-elevation myocardial infarction. Methods Echocardiography and CMR were performed in 1119 patients discharged for ST-segment-elevation myocardial infarction included in a multicenter registry. The prognostic power of CMR beyond echocardiography-LVEF was assessed using adjusted C statistic, net reclassification improvement index, and integrated discrimination improvement index. Results During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 readmissions for acute heart failure). In the entire group, CMR-LVEF (but not echocardiography-LVEF) independently predicted MACE occurrence. The MACE rate significantly increased only in patients with CMR-LVEF<40% (≥50%: 7%, 40%-49%: 9%, <40%: 27%, P<0.001). Most patients displayed echocardiography-LVEF≥50% (629, 56%), and they had a low MACE rate (57/629, 9%). In patients with echocardiography-LVEF<50% (n=490, 44%), the MACE rate was also low in those with CMR-LVEF≥40% (24/278, 9%) but significantly increased in patients with CMR-LVEF<40% (55/212, 26%; P<0.001). Compared with echocardiography-LVEF, CMR-LVEF significantly improved MACE prediction in the group of patients with echocardiography-LVEF<50% (C statistic, 0.80 versus 0.72; net reclassification improvement index, 0.73; integrated discrimination improvement index, 0.10) but not in those with echocardiography-LVEF≥50% (C statistic 0.66 versus 0.66; net reclassification improvement index, 0.17; integrated discrimination improvement index, 0.01). Conclusions A straightforward strategy based on a selective use of CMR for risk prediction in ST-segment-elevation myocardial infarction patients with echocardiography-LVEF<50% can provide insights into patient care. The cost-effectiveness of this approach, as well as the direct implications in clinical management, should be further explored.
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Affiliation(s)
- Victor Marcos-Garces
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - Jose Gavara
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - Maria P Lopez-Lereu
- Cardiovascular Magnetic Resonance Unit, ERESA, Valencia, Spain (M.P.L.-L., J.V.M.)
| | - Jose V Monmeneu
- Cardiovascular Magnetic Resonance Unit, ERESA, Valencia, Spain (M.P.L.-L., J.V.M.)
| | - Cesar Rios-Navarro
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - Elena de Dios
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - Nerea Perez
- Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - Joaquim Cànoves
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Faculty of Medicine and Odontology, University of Valencia, Spain (J.C., G.M., J.N., F.J.C., V.B.)
| | - Jessika Gonzalez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - Gema Minana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Faculty of Medicine and Odontology, University of Valencia, Spain (J.C., G.M., J.N., F.J.C., V.B.)
| | - Julio Nunez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Faculty of Medicine and Odontology, University of Valencia, Spain (J.C., G.M., J.N., F.J.C., V.B.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain (G.M., J.N., F.J.C., V.B.)
| | - Rafael de la Espriella
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - Enrique Santas
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.)
| | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, Spain (D.M.)
| | - Francisco J Chorro
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Faculty of Medicine and Odontology, University of Valencia, Spain (J.C., G.M., J.N., F.J.C., V.B.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain (G.M., J.N., F.J.C., V.B.)
| | - Filipa Valente
- Department of Cardiology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (F.V., J.F.R.-P.)
| | - Daniel Lorenzatti
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (D.L., J.T.O.-P.)
| | | | - Jose T Ortiz-Pérez
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (D.L., J.T.O.-P.).,Cardiovascular Institute, Hospital Clínic, Barcelona, Spain (J.T.O.-P.)
| | - Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Spain (V.M.G., J.C., J. Gonzalez, G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain (J. Gavara, C.R.-N., E.d.D., N.P., G.M., J.N., R.d.l.E., E.S., F.J.C., V.B.).,Faculty of Medicine and Odontology, University of Valencia, Spain (J.C., G.M., J.N., F.J.C., V.B.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain (G.M., J.N., F.J.C., V.B.)
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26
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Marcos-Garces V, Gavara J, Monmeneu JV, Lopez-Lereu MP, Bosch MJ, Merlos P, Perez N, Rios-Navarro C, De Dios E, Bonanad C, Racugno P, Bellver Navarro A, Ventura Perez B, Aguilar Botella J, Ventura S, Mainar L, Canoves J, Pellicer M, Moratal D, Miñana G, Nuñez J, Chorro FJ, Bodi V. Vasodilator Stress CMR and All-Cause Mortality in Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2020; 13:1674-1686. [DOI: 10.1016/j.jcmg.2020.02.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 12/31/2019] [Accepted: 02/07/2020] [Indexed: 01/14/2023]
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27
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Marcos-Garces V, Gavara J, Monmeneu JV, Lopez-Lereu MP, Perez N, Rios-Navarro C, De Dios E, Moratal D, Miñana G, Nuñez J, Chorro FJ, Bodi V. A Novel Clinical and Stress Cardiac Magnetic Resonance (C-CMR-10) Score to Predict Long-Term All-Cause Mortality in Patients with Known or Suspected Chronic Coronary Syndrome. J Clin Med 2020; 9:E1957. [PMID: 32585832 PMCID: PMC7356983 DOI: 10.3390/jcm9061957] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/12/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 01/19/2023] Open
Abstract
Vasodilator stress cardiac magnetic resonance (stressCMR) has shown robust diagnostic and prognostic value in patients with known or suspected chronic coronary syndrome (CCS). However, it is unknown whether integration of stressCMR with clinical variables in a simple clinical-imaging score can straightforwardly predict all-cause mortality in this population. We included 6187 patients in a large registry that underwent stressCMR for known or suspected CCS. Several clinical and stressCMR variables were collected, such as left ventricular ejection fraction (LVEF) and ischemic burden (number of segments with stress-induced perfusion defects (PD)). During a median follow-up of 5.56 years, we registered 682 (11%) all-cause deaths. The only independent predictors of all-cause mortality in multivariable analysis were age, male sex, diabetes mellitus (DM), LVEF and ischemic burden. Based on the weight of the chi-square increase at each step of the multivariable analysis, we created a simple clinical-stressCMR (C-CMR-10) score that included these variables (age ≥ 65 years = 3 points, LVEF ≤ 50% = 3 points, DM = 2 points, male sex = 1 point, and ischemic burden > 5 segments = 1 point). This 0 to 10 points C-CMR-10 score showed good performance to predict all-cause annualized mortality rate ranging from 0.29%/year (score = 0) to >4.6%/year (score ≥ 7). The goodness of the model and of the C-CMR-10 score was separately confirmed in 2 internal cohorts (n > 3000 each). We conclude that a novel and simple clinical-stressCMR score, which includes clinical and stressCMR variables, can provide robust prediction of the risk of long-term all-cause mortality in a population of patients with known or suspected CCS.
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Affiliation(s)
- Victor Marcos-Garces
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (V.M.-G.); (G.M.); (J.N.); (F.JC.)
| | - Jose Gavara
- Instituto de Investigacion Sanitaria INCLIVA, 46010 Valencia, Spain; (J.G.); (N.P.); (C.R.-N.)
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, 46022 Valencia, Spain;
| | - Jose V Monmeneu
- Cardiovascular Magnetic Resonance Unit, Exploraciones Radiologicas Especiales (ERESA), 46015 Valencia, Spain; (J.VM.); (M.PL.-L.)
| | - Maria P Lopez-Lereu
- Cardiovascular Magnetic Resonance Unit, Exploraciones Radiologicas Especiales (ERESA), 46015 Valencia, Spain; (J.VM.); (M.PL.-L.)
| | - Nerea Perez
- Instituto de Investigacion Sanitaria INCLIVA, 46010 Valencia, Spain; (J.G.); (N.P.); (C.R.-N.)
| | - Cesar Rios-Navarro
- Instituto de Investigacion Sanitaria INCLIVA, 46010 Valencia, Spain; (J.G.); (N.P.); (C.R.-N.)
| | - Elena De Dios
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28029 Madrid, Spain;
| | - David Moratal
- Center for Biomaterials and Tissue Engineering, Universitat Politècnica de València, 46022 Valencia, Spain;
| | - Gema Miñana
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (V.M.-G.); (G.M.); (J.N.); (F.JC.)
- Instituto de Investigacion Sanitaria INCLIVA, 46010 Valencia, Spain; (J.G.); (N.P.); (C.R.-N.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28029 Madrid, Spain;
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Julio Nuñez
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (V.M.-G.); (G.M.); (J.N.); (F.JC.)
- Instituto de Investigacion Sanitaria INCLIVA, 46010 Valencia, Spain; (J.G.); (N.P.); (C.R.-N.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28029 Madrid, Spain;
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Francisco J Chorro
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (V.M.-G.); (G.M.); (J.N.); (F.JC.)
- Instituto de Investigacion Sanitaria INCLIVA, 46010 Valencia, Spain; (J.G.); (N.P.); (C.R.-N.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28029 Madrid, Spain;
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
| | - Vicente Bodi
- Department of Cardiology, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (V.M.-G.); (G.M.); (J.N.); (F.JC.)
- Instituto de Investigacion Sanitaria INCLIVA, 46010 Valencia, Spain; (J.G.); (N.P.); (C.R.-N.)
- Centro de Investigación Biomédica en Red—Cardiovascular (CIBER-CV), 28029 Madrid, Spain;
- Department of Medicine, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain
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28
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Monmeneu JV, Dominguez Mafe E, Andres Soler J, Ventura Perez B, Solsona Caravaca J, Broseta Torres R, García-Gonzalez P, Higueras Ortega L, Lopez-Lereu MP, Maceira AM. Subacute perimyocarditis in a young patient with COVID-19 infection. Eur Heart J Case Rep 2020; 4:1-3. [PMID: 33089043 PMCID: PMC7314082 DOI: 10.1093/ehjcr/ytaa157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 04/22/2020] [Accepted: 05/12/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Jose V Monmeneu
- Cardiovascular Unit, ASCIRES Biomedical Group, Valencia, Spain
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29
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Perez-Terol I, Rios-Navarro C, de Dios E, Morales JM, Gavara J, Perez-Sole N, Diaz A, Minana G, Segura-Sabater R, Bonanad C, Bayés-Genis A, Husser O, Monmeneu JV, Lopez-Lereu MP, Nunez J, Chorro FJ, Ruiz-Sauri A, Bodi V, Monleon D. Magnetic resonance microscopy and correlative histopathology of the infarcted heart. Sci Rep 2019; 9:20017. [PMID: 31882712 PMCID: PMC6934559 DOI: 10.1038/s41598-019-56436-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 04/30/2018] [Accepted: 12/10/2019] [Indexed: 02/08/2023] Open
Abstract
Delayed enhancement cardiovascular magnetic resonance (MR) is the gold-standard for non-invasive assessment after myocardial infarction (MI). MR microscopy (MRM) provides a level of detail comparable to the macro objective of light microscopy. We used MRM and correlative histopathology to identify infarct and remote tissue in contrast agent-free multi-sequence MRM in swine MI hearts. One control group (n = 3 swine) and two experimental MI groups were formed: 90 min of ischemia followed by 1 week (acute MI = 6 swine) or 1 month (chronic MI = 5 swine) reperfusion. Representative samples of each heart were analysed by contrast agent-free multi-sequence (T1-weighting, T2-weighting, T2*-weighting, T2-mapping, and T2*-mapping). MRM was performed in a 14-Tesla vertical axis imager (Bruker-AVANCE 600 system). Images from MRM and the corresponding histopathological stained samples revealed differences in signal intensities between infarct and remote areas in both MI groups (p-value < 0.001). The multivariable models allowed us to precisely classify regions of interest (acute MI: specificity 92% and sensitivity 80%; chronic MI: specificity 100% and sensitivity 98%). Probabilistic maps based on MRM images clearly delineated the infarcted regions. As a proof of concept, these results illustrate the potential of MRM with correlative histopathology as a platform for exploring novel contrast agent-free MR biomarkers after MI.
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Affiliation(s)
- Itziar Perez-Terol
- Laboratory of Metabolomics, Institute of Health Research-INCLIVA, Valencia, Spain
| | - Cesar Rios-Navarro
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain
| | - Elena de Dios
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain
| | - Jose M Morales
- Laboratory of Metabolomics, Institute of Health Research-INCLIVA, Valencia, Spain.,Unidad Central de Investigación Biomédica, University of Valencia, Valencia, Spain.,Pathology Department, School of Medicine, University of Valencia, Valencia, Spain
| | - Jose Gavara
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain
| | - Nerea Perez-Sole
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain
| | - Ana Diaz
- Unidad Central de Investigación Biomédica, University of Valencia, Valencia, Spain
| | - Gema Minana
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain.,Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain.,Medicine Department, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Clara Bonanad
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain.,Medicine Department, School of Medicine, University of Valencia, Valencia, Spain
| | - Antoni Bayés-Genis
- Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain.,Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol. Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oliver Husser
- Department of Cardiology, St.-Johannes-Hospital, Dortmund, Germany
| | - Jose V Monmeneu
- Cardiovascular Magnetic Resonance Unit, ERESA, Valencia, Spain
| | | | - Julio Nunez
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain.,Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain.,Medicine Department, School of Medicine, University of Valencia, Valencia, Spain
| | - Francisco J Chorro
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain.,Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain.,Medicine Department, School of Medicine, University of Valencia, Valencia, Spain
| | - Amparo Ruiz-Sauri
- Pathology Department, School of Medicine, University of Valencia, Valencia, Spain
| | - Vicente Bodi
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Valencia, Spain. .,Centro de Investigación Biomédica en Red - Cardiovascular (CIBER-CV), Madrid, Spain. .,Medicine Department, School of Medicine, University of Valencia, Valencia, Spain.
| | - Daniel Monleon
- Laboratory of Metabolomics, Institute of Health Research-INCLIVA, Valencia, Spain. .,Pathology Department, School of Medicine, University of Valencia, Valencia, Spain. .,Centro de Investigación Biomédica en Red - Fragilidad y Envejecimiento Saludable (CIBER-FES), Madrid, Spain.
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30
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Marcos Garces V, Gonzalez J, Gavara J, Rios-Navarro C, Bonanad C, Chorro FJ, Ortiz JT, Rodriguez J, Mendieta G, Rodriguez-Palomares JF, Valente F, Garcia-Dorado D, Lopez-Lereu MP, Monmeneu JV, Bodi V. P1475Risk stratification after STEMI. Ejection fraction by echocardiography as the gatekeeper for a selective use of cardiac magnetic resonance. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0240] [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
Introduction
Cardiac magnetic resonance (CMR) has emerged as the most potent non-invasive imaging technique for risk stratification after ST-segment elevation myocardial infarction (STEMI) but an indiscriminate use in all patients is unfeasible. Echocardiography (Echo) has been universally used for prognostication in this scenario. We hypothesized that left ventricular ejection fraction (LVEF) by Echo can represent the gatekeeper for selecting those patients who benefit most from CMR for prognostic purposes.
Methods
Data were obtained from a large prospective registry of reperfused STEMI patients (n=516) in whom Echo (2D and Doppler variables) and CMR (cine images, microvascular obstruction and infarct size) were simultaneously recorded at pre-discharge (7±2 days). Major adverse cardiac events (MACE) were defined as a combined clinical end-point: death or re-admission for acute heart failure (whichever occurred first). Patients were categorized in reduced LVEF (r-LVEF, <40%), mid-range LVEF (mr-LVEF, 40–49%) and preserved LVEF (p-LVEF, ≥50%). Hierarchical multivariate Cox regression analyses including first clinical+Echo variables and then CMR variables where carried out. C-statistics, “net reclassification” (NRI) and “integrated discrimination” (IDI) indexes were obtained.
Results
During a mean and median follow-up of 4 years, 86 first MACE (17%) were registered (39 deaths and 47 re-admissions for acute heart failure). In the whole study group (n=516), the independent predictors of MACE were time to revascularization (min), GRACE score, CMR-LVEF (%) and CMR-microvascular obstruction (% of LV mass); C-statistic 0.82 (p<0.001). The MACE rate in patients with r-LVEF, mr-LVEF and p-LVEF was 47%, 23% and 11% by Echo-LVEF and 45%, 17% and 8% by CMR-LVEF. LVEF was lower by CMR than by Echo (51±13 vs. 54±10, p<0.001) and r-LVEF was more frequently detected by CMR (n=94, 18%) than by Echo (n=48, 9%), p<0.001. CMR significantly improved clinical+Echo stratification in those 112 patients (22%) with mr-Echo-LVEF (C-statistitics 0.74 vs 0.82; NRI and IDI: p<0.05) but it did not in those 355 patients (69%) with p-Echo-LVEF (C-statistitics 0.75 vs 0.76; NRI and IDI: non-significant) and in those 49 patients (9%) with r-Echo-LVEF (C-statistitics 0.77 vs 0.77; NRI and IDI: non-significant).
Figure 1. Risk stratification after STEMI
Conclusions
Applied in an individualized manner, Echo-LVEF appears as a useful gatekeeper for a selective use of CMR soon after STEMI for prognostic purposes. The event rate is high in patients with reduced Echo-LVEF and low in those with preserved Echo-LVEF; CMR does not seem to significantly improve risk stratification in these scenarios. Nevertheless, the occurrence of mid-range Echo-LVEF permits discriminating the specific subset of STEMI patients (less than a quarter) who really benefit from pre-discharge CMR in terms of risk assessment.
Acknowledgement/Funding
Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).
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Affiliation(s)
- V Marcos Garces
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Gonzalez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Gavara
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | | | - C Bonanad
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J T Ortiz
- Hospital Clinic de Barcelona, Department of Cardiology, Barcelona, Spain
| | - J Rodriguez
- Hospital Clinic de Barcelona, Department of Cardiology, Barcelona, Spain
| | - G Mendieta
- Hospital Clinic de Barcelona, Department of Cardiology, Barcelona, Spain
| | | | - F Valente
- Vall d'Hebron University Hospital, Department of Cardiology, Barcelona, Spain
| | - D Garcia-Dorado
- Vall d'Hebron University Hospital, Department of Cardiology, Barcelona, Spain
| | - M P Lopez-Lereu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - J V Monmeneu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
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31
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Marcos Garces V, Gavara J, Rios-Navarro C, Racugno P, Bellver Navarro A, Ventura Perez B, Aguilar Botella J, Ventura S, Mainar L, Bosch MJ, Merlos P, Lopez-Lereu MP, Monmeneu JV, Chorro FJ, Bodi V. 393Ischemic burden by vasodilator stress CMR predicts long-term all-cause death and the effect of revascularization in patients with known or suspected stable ischemic heart disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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 stable ischemic heart disease (SIHD) the effect of revascularization on all-cause death (the most verifiable clinical event) is unknown.
Objectives
We explored the potential of the ischemic burden as derived from vasodilator stress cardiovascular magnetic resonance (CMR) to guide decision-making in this scenario.
Methods
In a large prospective multicenter registry, we recruited 6389 patients (mean age 65±11 years, 38% female) submitted to undergo vasodilator stress CMR for known or suspected SIHD. Baseline and CMR characteristics were prospectively recorded. The ischemic burden (at vasodilator stress first-pass perfusion imaging) and necrosis extent (at late enhancement imaging) were computed (17-segment model). The effect of CMR-related revascularization (within the following three months) on all-cause death (revised using the unified regional electronic health system registry) was explored.
Results
During a 5.75-year median follow-up, 717 (11.2%) all-cause deaths were documented. In multivariable analyses, more extensive ischemic burden (per 1-segment increase) independently related to all-cause death (1.05 [1.03–1.07], p<0.001). In 1034 patients (517 revascularized, 517 non-revascularized) strictly 1:1 matched for the independent predictors of outcome and of undergoing CMR-related revascularization (age, diabetes mellitus, male sex, LVEF, ischemic burden and necrosis extent), CMR-related revascularization did not significantly alter all-cause death rate (13.3% vs. 13.3%, p=0.54). Nevertheless, a potent interaction existed with the ischemic burden (p<0.001). CMR-related revascularization independently reduced the risk of all-cause death in 430 patients with ischemic burden >5 segments (9.3% vs. 16.3%, HR 0.56 [0.32–0.98], p=0.02) but it independently increased risk in 604 patients with ischemic burden ≤5 segments (16.2% vs. 11.3%, HR 1.59 [1.03–2.45], p=0.037).
Figure 1. CMR-related revascularization
Conclusions
In patients with known or suspected stable ischemic heart disease the ischemic burden as derived from vasodilator stress CMR can be helpful to predict the effect of revascularization on long-term all-cause death.
Acknowledgement/Funding
Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).
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Affiliation(s)
- V Marcos Garces
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Gavara
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | | | - P Racugno
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - A Bellver Navarro
- University General Hospital, Department of Cardiology, Castellon de la Plana, Spain
| | - B Ventura Perez
- University General Hospital, Department of Cardiology, Castellon de la Plana, Spain
| | | | - S Ventura
- Hospital La Plana, Department of Cardiology, Vila-Real, Spain
| | - L Mainar
- Hospital of Manises, Department of Cardiology, Manises, Spain
| | - M J Bosch
- Francesc de Borja Hospital, Department of Cardiology, Gandia, Spain
| | - P Merlos
- Francesc de Borja Hospital, Department of Cardiology, Gandia, Spain
| | - M P Lopez-Lereu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - J V Monmeneu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - F J Chorro
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
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Merenciano Gonzalez HM, Marcos-Garces V, Gavara J, Rios-Navarro C, Ortiz JT, Rodriguez J, Mendieta G, Rodriguez-Palomares JF, Valente F, Garcia-Dorado D, Lopez-Lereu MP, Monmeneu JV, Nunez E, Nunez J, Bodi V. P6397Ejection fraction by cardiac magnetic resonance 6 months after STEMI: impact on risk stratification in chronic phase. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0993] [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
Left ventricular ejection fraction (LVEF) has traditionally been used as the cornerstone for risk stratification after STEMI and it can be accurately quantified by cine cardiovascular magnetic resonance (CMR). In recent years, the additional prognostic value of contrast CMR-derived infarct size (IS) and microvascular obstruction (MVO) soon after infarction has been demonstrated. The usefulness of CMR-derived LVEF in chronic phase for risk stratification late after STEMI is unclear.
Purpose
We hypothesized that 6-month CMR-derived LVEF can contribute in the prediction of clinical events late after STEMI beyond pre-discharge LVEF, IS and MVO.
Methods
Data were obtained from a prospective registry of reperfused STEMI patients (n=456) who were stable 6 months after infarction and in whom 1-week and 6-month CMR-derived LVEF, IS and MVO were sequentially quantified. Major adverse cardiac events (MACE) were defined as a combined clinical end-point that included death or re-admission for acute decompensated heart failure (r-ADHF), whichever occurred first, occurring after the 6-month CMR.
Results
During a mean and median follow-up of 6 years, 56 late MACE (12%, 32 deaths and 24 r-ADHF) were registered. From 1-week to 6-month, CMR parameters exhibited significant dynamic changes (p<0.001): LVEF improved (52±12 vs. 56±13%), IS decreased (21±14 vs. 18±12% of LV mass) and MVO vanished (2±4 vs. 0±1% of LV mass). At 6-month CMR, 60 patients (13%) displayed reduced LVEF (<40%), 69 (15%) mid-range LVEF (40–50%) and 327 (72%) preserved LVEF (≥50%). Late MACE rates were 28% in patients with reduced LVEF, 14% in those with mid-range LVEF and 9% in those with preserved LVEF at 6-month CMR (p<0.001 for the trend). After adjustment for baseline characteristics and for 1-week and 6-month CMR parameters, more preserved LVEF at 6 months independently associated with a lower risk of MACE late after STEMI (hazard ratio 0.96 [0.94–0.98] per 1% increase).
Conclusions
Dramatic dynamic changes occur in CMR parameters within the first months after STEMI. Reassessment of CMR-derived LVEF in chronic phase in those patients who remain stable provides relevant prognostic information for long-term risk stratification.
Acknowledgement/Funding
Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).
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Affiliation(s)
| | - V Marcos-Garces
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Gavara
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | | | - J T Ortiz
- Hospital Clinic de Barcelona, Department of Cardiology, Barcelona, Spain
| | - J Rodriguez
- Hospital Clinic de Barcelona, Department of Cardiology, Barcelona, Spain
| | - G Mendieta
- Hospital Clinic de Barcelona, Department of Cardiology, Barcelona, Spain
| | | | - F Valente
- University Hospital Vall d'Hebron, Department of Cardiology, Barcelona, Spain
| | - D Garcia-Dorado
- University Hospital Vall d'Hebron, Department of Cardiology, Barcelona, Spain
| | - M P Lopez-Lereu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - J V Monmeneu
- ERESA, Cardiovascular Magnetic Resonance Unit, Valencia, Spain
| | - E Nunez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - J Nunez
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Department of Cardiology, Valencia, Spain
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Marcos V, Gavara J, Perez N, Rios-Navarro C, Bonanad C, Racugno P, Lopez-Lereu MP, Monmeneu JV, Chorro FJ, Bodi V. P266Vasodilator stress cardiovascular magnetic resonance imaging predicts long-term cardiac death and all-cause death in patients with known or suspected coronary artery disease. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.p266] [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] [Indexed: 11/12/2022] Open
Affiliation(s)
- V Marcos
- University Hospital Clinic of Valencia, Dept. of Cardiology, Valencia, Spain
| | - J Gavara
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - N Perez
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | | | - C Bonanad
- University Hospital Clinic of Valencia, Dept. of Cardiology, Valencia, Spain
| | - P Racugno
- University Hospital Clinic of Valencia, Dept. of Cardiology, Valencia, Spain
| | | | | | - F J Chorro
- University Hospital Clinic of Valencia, Dept. of Cardiology, Valencia, Spain
| | - V Bodi
- University Hospital Clinic of Valencia, Dept. of Cardiology, Valencia, Spain
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Colunga Blanco S, Gonzalez Matos C, Angelis A, Dinis PG, Chinali M, Toth A, Andreassi MG, Rodriguez Munoz D, Reid AB, Park JH, Shetye A, Novo G, De Marchi SF, Cikes M, Smarz K, Illatopa V, Peluso D, Wellnhofer E, De La Rosa Riestra A, Sattarzadeh Badkoubeh R, Mandour Ali M, Azoz A, Pontone G, Krljanac G, Acar R, Nucifora G, Sirtautas A, Roos ST, Qasem MS, Marini C, Fabiani I, Gillis K, Bandera F, Borowiec A, Lim YJ, Chalbia TE, Santos M, Gao SA, Zilberszac R, Farrag AAM, Palmiero G, Aruta P, De Diego Soler O, Fasano D, Tamborini G, Ancona F, Raafat DM, Marchel M, De Gregorio C, Gommans DHF, Godinho AR, Mielczarek M, Bandera F, Kubik M, Cho JY, Tarando F, Lourenco Marmelo BF, Reis L, Domingues K, Krestjyaninov MV, Mesquita J, Ikonomidis I, Ferferieva V, Peluso D, Peluso D, King GJ, D'ascenzi F, Ferrera Duran C, Sormani P, Gonzalez Fernandez O, Tereshina O, Cambronero Cortinas E, Kupczynska K, Carvalho JF, Shivalkar B, Aghamohammadzadeh R, Cifra B, Cifra B, Bandera F, Kuznetsov VA, Van Zalen JJ, Kochanowski J, Goebel B, Ladeiras-Lopes R, Goebel B, Karvandi M, Karvandi M, Alonso Salinas G, Unkun T, Ranjbar S, Hubert A, Enescu OA, Liccardo M, Cameli M, Ako E, Lembo M, Goffredo C, Enache R, Novo G, Wdowiak-Okrojek K, Nemes A, Nemes A, Di Salvo G, Capotosto L, Caravaca P, Maceira Gonzalez AM, Iriart X, Jug B, Garcia Campos A, Capin Sampedro E, Corros Vicente C, Martin Fernandez M, Leon Arguero V, Fidalgo Arguelles A, Velasco Alonso E, Lopez Iglesias F, De La Hera Galarza JM, Chaparro-Munoz M, Recio-Mayoral A, Vlachopoulos C, Ioakeimidis N, Felekos I, Abdelrasoul M, Aznaouridis K, Chrysohoou C, Rousakis G, Aggeli K, Tousoulis D, Faustino AC, Paiva L, Fernandes A, Costa M, Cachulo MC, Goncalves L, Emma F, Rinelli G, Esposito C, Franceschini A, Doyon A, Raimondi F, Schaefer F, Pongiglione G, Mateucci MC, Vago H, Juhasz C, Janosa C, Oprea V, Balint OH, Temesvari A, Simor T, Kadar K, Merkely B, Bruno RM, Borghini A, Stea F, Gargani L, Mercuri A, Sicari R, Picano E, Lozano Granero C, Carbonell San Roman A, Moya Mur JL, Fernandez-Golfin C, Moreno Planas J, Fernandez Santos S, Casas Rojo E, Hernandez-Madrid A, Zamorano Gomez JL, Pearce K, Gamlin W, Miller C, Schmitt M, Seong IW, Kim KH, Kim MJ, Jung HO, Sohn IS, Park SM, Cho GY, Choi JO, Park SW, Nazir SA, Khan JN, Singh A, Kanagala P, Squire I, Mccann GP, Di Lisi D, Meschisi MC, Brunco V, Badalamenti G, Bronte E, Russo A, Novo S, Von Tscharner M, Urheim S, Aakhus S, Seiler C, Schmalholz S, Biering-Sorensen T, Cheng S, Oparil S, Izzo J, Pitt B, Solomon SD, Zaborska B, Jaxa-Chamiec T, Tysarowski M, Budaj A, Cordova F, Aguirre O, Sanabria S, Ortega J, Romeo G, Perazzolo Marra M, Tona F, Famoso G, Pigatto E, Cozzi F, Iliceto S, Badano LP, Kriatselis C, Gerds-Li JH, Kropf M, Pieske B, Graefe M, Martinez Santos P, Batlle Lopez E, Vilacosta I, Sanchez Sauce B, Espana Barrio E, Jimenez Valtierra J, Campuzano Ruiz R, Alonso Bello J, Martin Rios MD, Farrashi M, Abtahi H, Sadeghi H, Sadeghipour P, Tavoosi A, Abdel Rahman TA, Mohamed LA, Maghraby HM, Kora IM, Abdel Hameed FR, Ali MN, Al Shehri A, Youssef A, Gad A, Alsharqi M, Alsaikhan L, Andreini D, Rota C, Guglielmo M, Mushtaq S, Baggiano A, Beltrama V, Solbiati A, Guaricci AI, Pepi M, Trifunovic D, Sobic Saranovic D, Savic L, Grozdic Milojevic I, Asanin M, Srdic M, Petrovic M, Zlaic N, Mrdovic I, Dogan C, Izci S, Gecmen C, Unkun T, Cap M, Erdogan E, Onal C, Yilmaz F, Ozdemir N, Muser D, Tioni C, Zanuttini D, Morocutti G, Spedicato L, Bernardi G, Proclemer A, Pranevicius R, Zapustas N, Briedis K, Valuckiene Z, Jurkevicius R, Juffermans LJM, Enait V, Van Royen N, Van Rossum AC, Kamp O, Khalaf HASSEN, Hitham SAKER, Osama AS, Abazid RAMI, Guall RAHIM, Durdan SHAFAT, Mohammed ZYAD, Stella S, Rosa I, Ancona F, Spartera M, Italia L, Latib A, Colombo A, Margonato A, Agricola E, Scatena C, Mazzanti C, Conte L, Pugliese N, Barletta V, Bortolotti U, Naccarato AG, Di Bello V, Bala G, Roosens B, Hernot S, Remory I, Droogmans S, Cosyns B, Generati G, Labate V, Donghi V, Pellegrino M, Carbone F, Alfonzetti E, Guazzi M, Dabrowski R, Kowalik I, Firek B, Chwyczko T, Szwed H, Kawamura A, Kawano S, Zaroui A, Ben Said R, Ben Halima M, Kheder N, Farhati A, Mourali S, Mechmech R, Leite L, Martins R, Baptista R, Barbosa A, Ribeiro N, Oliveira A, Castro G, Pego M, Polte CL, Lagerstrand K, Johnsson ÅA, Janulewicz M, Bech-Hanssen O, Gabriel H, Wisser W, Maurer G, Rosenhek R, El Aroussy W, Abdel Ghany M, Al Adeeb K, Ascione L, Carlomagno G, Sordelli C, Ferro A, Ascione R, Severino S, Caso P, Muraru D, Janei C, Haertel Miglioranza M, Cavalli G, Romeo G, Peluso D, Cucchini U, Iliceto S, Badano L, Armario Bel X, Garcia-Garcia C, Ferrer Sistach E, Rueda Sobella F, Oliveras Vila T, Labata Salvador C, Serra Flores J, Lopez-Ayerbe J, Bayes-Genis A, Conte E, Gonella A, Morena L, Civelli D, Losardo L, Margaria F, Riva L, Tanga M, Carminati C, Muratori M, Gripari P, Ghulam Ali S, Fusini L, Vignati C, Bartorelli AL, Alamanni F, Pepi M, Rosa I, Stella S, Marini C, Spartera M, Latib A, Montorfano M, Colombo A, Margonato A, Agricola E, Ismaiel A, Ali N, Amry S, Serafin A, Kochanowski J, Filipiak KJ, Opolski G, Speranza G, Ando' G, Magaudda L, Cramer GE, Bakker J, Michels M, Dieker HJ, Fouraux MA, Marcelis CLM, Timmermans J, Brouwer MA, Kofflard MJM, Vasconcelos M, Araujo V, Almeida P, Sousa C, Macedo F, Cardoso JS, Maciel MJ, Voilliot D, Huttin O, Venner C, Olivier A, Villemin T, Deballon R, Manenti V, Juilliere Y, Selton-Suty C, Generati G, Pellegrino M, Labate V, Carbone F, Alfonzetti E, Guazzi M, Dabrowska-Kugacka A, Dorniak K, Lewicka E, Szalewska D, Kutniewska-Kubik M, Raczak G, Kim KH, Yoon HJ, Park HJ, Ahn Y, Jeong MH, Cho JG, Park JC, Kim JH, Galli E, Habib G, Schnell F, Lederlin M, Daubert JC, Mabo P, Donal E, Faria R, Magalhaes P, Marques N, Domingues K, Lourenco C, Almeida AR, Teles L, Picarra B, Azevedo O, Lourenco C, Oliveira M, Magalhaes P, Domingues K, Marmelo B, Almeida A, Picarra B, Faria R, Marques N, Bento D, Lourenco C, Magalhaes P, Cruz I, Marmelo B, Reis L, Picarra B, Faria R, Azevedo O, Gimaev RH, Melnikova MA, Olezov NV, Ruzov VI, Goncalves P, Almeida MS, Branco P, Carvalho MS, Dores H, Gaspar MA, Sousa H, Andrade MJ, Mendes M, Makavos G, Varoudi M, Papadavid E, Andreadou I, Gravanis K, Liarakos N, Pavlidis G, Rigopoulos D, Lekakis J, Deluyker D, Bito V, Pigatto E, Romeo G, Muraru D, Cozzi F, Punzi L, Iliceto S, Badano LP, Pigatto E, Romeo G, Muraru D, Cozzi F, Iliceto S, Badano LP, Neilan T, Coen K, Gannon S, Bennet K, Clarke JG, Solari M, Cameli M, Focardi M, Corrado D, Bonifazi M, Henein M, Mondillo S, Gomez-Escalonilla C, De Agustin A, Egido J, Islas F, Simal P, Gomez De Diego JJ, Luaces M, Macaya C, Perez De Isla L, Zancanella M, Rusconi C, Musca F, Santambrogio G, De Chiara B, Vallerio P, Cairoli R, Giannattasio G, Moreo A, Alvarez Ortega C, Mori Junco R, Caro Codon J, Meras Colunga P, Ponz De Antonio I, Lopez Fernandez T, Valbuena Lopez S, Moreno Yanguela M, Lopez-Sendon JL, Surkova E, Bonanad-Lozano C, Lopez-Lereu MP, Monmeneu-Menadas JV, Gavara J, De Dios E, Paya-Chaume A, Escribano-Alarcon D, Chorro-Gasco FJ, Bodi-Peris V, Michalski BW, Miskowiec D, Kasprzak JD, Lipiec P, Morgado G, Caldeira D, Cruz I, Joao I, Almeida AR, Lopes L, Fazendas P, Cotrim C, Pereira H, De Block C, Buys D, Salgado R, Vrints C, Van Gaal L, Mctear C, Irwin RB, Dragulescu A, Friedberg M, Mertens L, Dragulescu A, Friedberg M, Mertens L, Carbone F, Generati G, Pellegrino M, Labate V, Alfonzetti E, Guazzi M, Krinochkin DV, Yaroslavskaya EI, Zaharova EH, Pushkarev GS, Sugihara C, Patel NR, Sulke AN, Lloyd GW, Piatkowski R, Scislo P, Grabowski M, Marchel M, Opolski G, Roland H, Hamadanchi A, Otto S, Jung C, Lauten A, Figulla HC, Poerner TC, Sampaio F, Fonseca P, Fontes-Carvalho R, Pinho M, Campos AS, Castro P, Fonseca C, Ribeiro J, Gama V, Heck R, Hamdanchi A, Otto S, Jung C, Lauten A, Figulla HR, Poerner TC, Ranjbar S, Ghaffaripour Jahromi M, Ranjbar S, Hinojar R, Fernandez Golfin C, Esteban A, Pascual-Izco M, Garcia-Martin A, Casas Rojo E, Jimenez-Nacher JJ, Zamorano JL, Gecmen C, Cap M, Izci S, Erdogan E, Onal C, Acar R, Bakal RB, Kaymaz C, Ozdemir N, Karvandi M, Ghaffaripour Jahromi M, Galand V, Schnell F, Matelot D, Martins R, Leclercq C, Carre F, Suran BC, Margulescu AD, Rimbas RC, Siliste C, Vinereanu D, Nocerino P, Urso AC, Borrino A, Carbone C, Follero P, Ciardiello C, Prato L, Salzano G, Marino F, Ruspetti A, Sparla S, Di Tommaso C, Loiacono F, Focardi M, D'ascenzi F, Henein M, Mondillo S, Porter J, Walker M, Lo Iudice F, Esposito R, Santoro C, Cocozza S, Izzo R, De Luca N, De Simone G, Trimarco B, Galderisi M, Gervasi F, Patti G, Mega S, Bono M, Di Sciascio G, Buture A, Badea R, Platon P, Ghiorghiu I, Jurcut R, Coman IM, Popescu BA, Ginghina C, Lunetta M, Spoto MS, Lo Vi AM, Pensabene G, Meschisi MC, Carita P, Coppola G, Novo S, Assennato P, Shim A, Wejner-Mik P, Kasprzak JD, Lipiec P, Havasi K, Domsik P, Kalapos A, Forster T, Piros GA, Domsik P, Kalapos A, Lengyel C, Orosz A, Forster T, Bulbul Z, Issa Z, Al Sehly A, Pergola V, Oufi S, Conde Y, Cimino E, Rinaldi E, Ashurov R, Ricci S, Pergolini M, Vitarelli A, Lujan Valencia JE, Chaparro M, Garcia-Guerrero A, Cristo Ropero MJ, Izquierdo Bajo A, Madrona L, Recio-Mayoral A, Monmeneu JV, Igual B, Lopez Lereu P, Garcia MP, Selmi W, Jalal Z, Thambo JB, Kosuta D, Fras Z. Poster session 5The imaging examinationP1097Correlation between visual and quantitative assessment of left ventricle: intra- and inter-observer agreementP1099Incremental prognostic value of late gadolinium-enhanced by cardiac magnetic resonance in patients with heart failureAnatomy and physiology of the heart and great vesselsP1100Left ventricular geometry and diastolic performance in erectile dysfunction patients; a topic of differential arterial stiffness influenceAssessment of diameters, volumes and massP1101Impact of the percutaneous closure of atrial septal defect on the right heart "remodeling"P1102Left Ventricular Mass Indexation in Infants, Children and Adolescents: a Simplified Approach for the Identification of Left Ventricular Hypertrophy in Clinical PracticeP1103Impact of trabecules while quantifying cardiac magnetic resonance exams in patients with systemic right ventricleP1104Detection of subclinical atherosclerosis by carotid intima-media thickness: correlation with leukocytes telomere shorteningAssessments of haemodynamicsP1105Flow redirection towards the left ventricular outflow tract: vortex formation is not affected by variations in atrio-ventricular delayAssessment of systolic functionP1106Reproducibility and feasibility of cardiac MRI feature tracking in Fabry diseaseP1107Normal left ventricular strain values by two-dimensional strain echocardiography; result of normal (normal echocardiographic dimensions and functions in korean people) studyP1108Test-retest repeatability of global strain following st-elevation myocardial infarction - a comparison of tagging and feature trackingP1109Cardiotoxicity induced by tyrosine kinase inhibitors in patients with gastrointestinal stromal tumors (GIST)P1110Finite strain ellipses for the analysis of left ventricular principal strain directions using 3d speckle tracking echocardiographyP1111Antihypertensive therapy reduces time to peak longitudinal strainP1112Right ventricular systolic function as a marker of prognosis after inferior myocardial infarction - 5-year follow-upP1113Is artery pulmonary dilatation related with right but also early left ventricle dysfunction in pulmonary artery hypertension?P1114Right ventricular mechanics changes according to pressure overload increasing, a 2D-speckle tracking echocardiographic evaluationAssessment of diastolic functionP1115Paired comparison of left atrial strain from P-wave to P-wave and R-wave to R-waveP1116Diagnostic role of Tissue Doppler Imaging echocardiographic criteria in obese heart failure with preserved ejection fraction patientsP1117Evaluation of diastolic function of right ventricle in idiopathic pulmonary arterial hypertensionP1118Severity and predictors of diastolic dysfunction in a non-hypertensive non-ischemic cohort of Egyptian patients with documented systemic autoimmune disease; pilot reportP1119correlation between ST segment shift and cardiac diastolic function in patients with acute myocardial infarctionIschemic heart diseaseP1120Computed tomography coronary angiography verSus sTRess cArdiac magneTic rEsonance for the manaGement of sYmptomatic revascularized patients: a cost effectiveness study (STRATEGY study)P1121Utility of transmural myocardial mechanic for early infarct size prediction after primary percutaneous coronary intervention in STEMI patientsP1122Progressive Improvements of the echocardiographic deformation parameters in ST Elevation Myocardial Infarction after five years follow-upP1123Long-term prognostic value of left ventricular dyssynchrony as assessed by cardiac magnetic resonance feature-tracking imaging after a first st-segment elevation myocardial infarctionP1124Differences in mitral annulus remodeling in acute anterior ST elevation and acute inferior ST elevation myocardial infarctionP1125Reduction of microvascular injury using a novel theragnostic ultrasound strategy: a first in men feasibility and safety studyP1126Impact of focused echocardiography in clinical decision of patient presented with st elevation myocardial infarction underwent primary angioplastyHeart valve DiseasesP1127Aortic valve area calculation in aortic stenosis: a comparison among conventional and 3D-transesophageal echocardiography and computed tomographyP1128Myocardial fibrosis and microRNA-21 expression in patients with severe aortic valve stenosis and preserved ejection fraction: a 2D speckle tracking echocardiography, tissutal and plasmatic studyP1129Quantification of calcium amount in a new experimental model: a comparison between calibrated integrated backscatter of ultrasound and computed tomographyP1130Altered diffusion capacity in aortic stenosis: role of the right heartP1131Osteoprotegerin predicts all-cause mortality in calcific aortic stenosis patients with preserved left ventricle ejection fraction in long term observationP1132Mitral regurgitation as a risk factor for pulmonary hypertension in patients with aortic stenosisP1133The relationship between the level of plasma B-type natriuretic peptide and mitral stenosisP1134Aortic regurgitation, left ventricle mechanics and vascular load: a single centre 2d derived-speckle tracking studyP1135Feasibility and reproducibility issues limit the usefulness of quantitative colour Doppler parameters in the assessment of chronic aortic and mitral regurgitation severityP1136Predictors of postoperative outcome in degenerative mitral regurgitationP1137Left ventricular mechanical dyssynchrony in patients with severe mitral regurgitation of rheumatic etiology; three dimensional echocardiography studyP1138Functional mitral regurgitation and left atrial dysfunction concur in determining pulmonary hypertension and functional status in subjects with left ventricular systolic dysfunctionP11393D echocardiography allows more effective quantitative assessment of the severity of functional tricuspid regurgitation than conventional 2D/Doppler echocardiographyP1140Prosthetic valve thrombosis: still a severe disease? 10-years experience in a university hospitalP1141Validity of echocardiography in the hospital course of patients with feverP1142Do baseline 3DTEE characteristics of mitral valve apparatus predict long term result in patients undergoing percutaneous valve repair for degenerative regurgitation?P1143Influence of baseline aortic regurgitation on mitral regurgitation change after transcatheter aortic valve replacement for aortic stenosisP1144Prevalence of echocardiography detected significant valvular regurge in subclinical rheumatic carditis in assiut childrenCardiomyopathiesP1145Can we early detect left ventricular systolic dysfunction in patients with Duchenne muscular dystrophy using global longitudinal strain assessment?P1146Prevalence of isolated papillary muscle hypertrophy in young competitive athletesP1147Troponin release after exercise in patients with hypertrophic cardiomyopathy: associations with clinical and mr imaging characteristicsP1148Atrial fibrillation in hypertrophic cardiomyopathy: can we score the risk?P1149Impact of hypertrophy on multiple layer longitudinal deformation in hypertrophy cardiomyopathy and cardiac amyloidosis compared to controlsP1150Functional evaluation in hypertrophic cardiomyopathy combining cardiopulmonary exercise testing combined with exercise-echocardiographyP1151Refinement of the old diagnostic criteria of left ventricular noncompaction cardiomyopathy (LVNC) based on cardiac magnetic resonance (CMR)P1152Differences of clinical characteristics and outcomes between acute myocarditis with preserved and reduced left ventricular systolic functionP1153Value of longitudinal strain for distinguishing left ventricular non-compaction from idiopathic dilated cardiomyopathyP1154Speed of recovery of left ventricular function is not related to the prognosis of Takotsubo cardiomyopathy. A Portuguese multicentre studyP1155Predictors of in-hospital left ventricular systolic function recovery after admission with takotsubo cardiomyopathy. Portuguese multicentre studyP1156Mid-ventricular takotsubo detected by initial echocardiogram associates with recurrence of takotsubo cardiomyopathy - a portuguese multicentre studySystemic diseases and other conditionsP1157Relations between left ventricle remodelling and expression of angiotensin 2 AT2R1 geneP1158Impact of renal denervation on long-term blood pressure variability and surrogate markers of target organ damage in individuals with drug-resistant arterial hypertensionP1159Greater improvement of coronary artery function, left ventricular deformation and twisting by IL12/23 compared to TNF-a inhibition in psoriasisP1160Advanced glycation end products play a role in adverse LV remodeling following MIP1161Incidence of subclinical myocardial dysfunction in patients with systemic sclerosis and normal left ventricular systolic and diastolic functionP1162Left atrial remodeling and dysfunction occur early in patients with systemic sclerosis and normal left ventricular functionP1163Intrinsic vortex formation : a unique performance indicatorP1164P-wave morphology is unaffected by training-induced biatrial dilatation: a prospective, longitudinal study in healthy athletesP1165Usefulness of transthoracic echocardiography in diagnosis of young patients with ischemic strokeP1166Primary cardiac lymphoma: role of echocardiography in the clinical managementP1167Abnormal echocardiographic findings in cancer patients before chemotherapyMasses, tumors and sources of embolismP1168Three-dimensional transesophageal echocardiography of the left atrial appendage reduces rate of postpone electrical cardioversionP1169Detection of ventricular thrombus by cmr after reperfused st-segment elevation myocardial infarction correlated with echocardiographyP1170Clinical and transthoracic echocardiographic predictors of left atrial appendage thrombus in patients with atrial fibrillationStress echocardiographyP1171Pharmacological stress echocardiography complications: a 4-year single center experienceP1172Myocardial functional and perfusion reserve in type I diabetesP1173Feasibility of incorporating 3D Dobutamine stress echocardiography into routine clinical practiceP1174Right ventricular isovolumic acceleration at rest and during exercise in children after heart transplantP1175Right ventricular systolic and diastolic response to exercise in children after heart transplant -a bicycle exercise studyP1176Determinants of functional capacity in heart failure patients with reduced ejection fractionP1177Handgrip stress echocardiography with emotional component compared to conventional isometric exercise in coronary artery disease diagnosisP1178The relationship between resting transthoracic echocardiography and exercise capacity in patients with paroxysmal atrial fibrillationP1179Correlation between NT-proBNP and selected echocardiography parameters at rest and after exercise in patients with functional ischemic mitral regurgitation qualified for cardiosurgical treatmentReal-time three-dimensional TEEP1180Vena contracta area for severity grading in functional and degenerative mitral regurgitation: A study based on transesophageal 3D colour Doppler in 419 patientsP1181Proximal flow convergence by 3D echocardiography in the evaluation of mitral valve area in rheumatic mitral stenosisP1182Quantification of valve dimensions by transesophageal 3D echocardiography in patients with functional and degenerative mitral regurgitationTissue Doppler and speckle trackingP1183Automatic calculation of left ventricular volume changes over a cardiac cycle from echocardiography images by nonlinear dimensionality reductionP1184Effect of the mitral valve repairs on the left ventricular blood flow formationP1185Quantification of left atrial strain using cardiovascular magnetic resonance. a comparison between hypertrophic cardiomyopathy and healthy controlsP1186The role of early systolic lengthening in patients with non-ST elevation acute coronary syndrome and its relation to syntax scoreP1187Different standard two dimensional strain methods to quantity left ventricular mechanicsP1188Atrial function and electrocardiography caracteristics in sportsmen with or without paroxysmal atrial fibrillationP1189Right ventricular outflow premature contractions induce regional left ventricular dysfunctionP1190Ultrasound guided venous access for pacemaker and defibrillators. Randomized TrialP1191Atrial function analysis correlates with symptoms and quality of life of heart failure patientsP1192The use of tissue doppler echocardiography in myocardial iron overload in patients with thalassaemia majorP1193Independent association between pulse pressure and left ventricular global longitudinal strainP1194Global and regional longitudinal strain identifies the presence of coronary artery disease in patients with suspected reduction of coronary flow reserve and absence of wall motion abnormalitiesP1195Prognostic value of invasive and noninvasive parameters of right ventricular function in patients with pulmonary arterial hypertension receiving specific vasodilator therapyP1196Myocardial deformation analysis to improve arrhythmic risk stratificationP1197Quantitative assessment of regional systolic and diastolic function parameters for detecting prior transient ischemia in normokinetic segmentsP1198Left atrial function in patients with corrected tetralogy of Fallot - a three-dimensional speckle-tracking echocardiographic studyP1199Left atrial ejection force correlates with left atrial strain and volume-based functional properties as assessed by three-dimensional speckle tracking echocardiographyP1200Acute angulation of the aortic arch late after the arterial switch operation for transposition of the great arteries: impact on cardiac mechanicsP1201Circumferential deformation of the ascending thoracic aorta in hypertensive patients by three-dimensional speckle tracking echocardiographyCardiac Magnetic ResonanceP1202The incremental value of cardiac magnetic resonance on diagnosis myocardial infarction and non-obstructed coronary arteriesP1204Reference ranges of global and regional myocardial T1 values derived from MOLLI and shMOLLI at 3TComputed Tomography & Nuclear CardiologyP1205Deformation of the left atrial appendage after percutaneous closure with the Amplatzer cardiac plugP1206Prognostic impact of non-obstructive coronary artery disease on coronary computed tomographic angiography: A single-center study. Eur Heart J Cardiovasc Imaging 2015. [DOI: 10.1093/ehjci/jev275] [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: 11/13/2022] Open
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Bodi V, Monmeneu JV, Ortiz-Perez JT, Lopez-Lereu MP, Bonanad C, Husser O, Minana G, Gomez C, Nunez J, Forteza MJ, Hervas A, de Dios E, Moratal D, Bosch X, Chorro FJ. Prediction of Reverse Remodeling at Cardiac MR Imaging Soon after First ST-Segment-Elevation Myocardial Infarction: Results of a Large Prospective Registry. Radiology 2015; 278:54-63. [PMID: 26348232 DOI: 10.1148/radiol.2015142674] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To assess predictors of reverse remodeling by using cardiac magnetic resonance (MR) imaging soon after ST-segment-elevation myocardial infarction (STEMI). MATERIALS AND METHODS Written informed consent was obtained from all patients, and the study protocol was approved by the institutional committee on human research, ensuring that it conformed to the ethical guidelines of the 1975 Declaration of Helsinki. Five hundred seven patients (mean age, 58 years; age range, 24-89 years) with a first STEMI were prospectively studied. Infarct size and microvascular obstruction (MVO) were quantified at late gadolinium-enhanced imaging. Reverse remodeling was defined as a decrease in left ventricular (LV) end-systolic volume index (LVESVI) of more than 10% from 1 week to 6 months after STEMI. For statistical analysis, a simple (from a clinical perspective) multiple regression model preanalyzing infarct size and MVO were applied via univariate receiver operating characteristic techniques. RESULTS Patients with reverse remodeling (n = 211, 42%) had a lesser extent (percentage of LV mass) of 1-week infarct size (mean ± standard deviation: 18% ± 13 vs 23% ± 14) and MVO (median, 0% vs 0%; interquartile range, 0%-1% vs 0%-4%) than those without reverse remodeling (n = 296, 58%) (P < .001 in pairwise comparisons). The independent predictors of reverse remodeling were infarct size (odds ratio, 0.98; 95% confidence interval [CI]: 0.97, 0.99; P = .04) and MVO (odds ratio, 0.92; 95% CI: 0.86, 0.99; P = .03). Once infarct size and MVO were dichotomized by using univariate receiver operating characteristic techniques, the only independent predictor of reverse remodeling was the presence of simultaneous nonextensive infarct-size MVO (infarct size < 30% of LV mass and MVO < 2.5% of LV mass) (odds ratio, 3.2; 95% CI: 1.8, 5.7; P < .001). CONCLUSION Assessment of infarct size and MVO with cardiac MR imaging soon after STEMI enables one to make a decision in the prediction of reverse remodeling.
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Affiliation(s)
- Vicente Bodi
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Jose V Monmeneu
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Jose T Ortiz-Perez
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Maria P Lopez-Lereu
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Clara Bonanad
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Oliver Husser
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Gemma Minana
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Cristina Gomez
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Julio Nunez
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Maria J Forteza
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Arantxa Hervas
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Elena de Dios
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - David Moratal
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Xavier Bosch
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
| | - Francisco J Chorro
- From the Department of Cardiology, Hospital Clínico Universitario, Universidad de Valencia, INCLIVA, Avenida Blasco Ibañez 17, 46010 Valencia, Spain (V.B., C.B., G.M., C.G., J.N., M.J.F., A.H., E.d.D., F.J.C.); ERESA, Valencia, Spain (J.V.M., M.P.L.L.); Department of Cardiology, Hospital Clínic de Barcelona, Barcelona, Spain (J.T.O.P., X.B.); Klinik für Herz-und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany (O.H.); and Center for Biomaterials and Tissue Engineering, Universidad Politécnica de Valencia, Valencia, Spain (D.M.)
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Monmeneu Menadas JV, Lopez-Lereu MP, Estornell Erill J, Garcia Gonzalez P, Igual Muñoz B, Maceira Gonzalez A. Pharmacological stress cardiovascular magnetic resonance: feasibility and safety in a large multicentre prospective registry. Eur Heart J Cardiovasc Imaging 2015; 17:308-15. [PMID: 26108417 DOI: 10.1093/ehjci/jev153] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 01/08/2015] [Accepted: 05/23/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS To assess the feasibility and incidence of immediate complications of stress cardiovascular magnetic resonance (CMR) and to determine associated factors. METHODS AND RESULTS This was a large multicentre, prospective registry of pharmacologic stress CMR in a referral population. We used dipyridamole when no contraindication was present and dobutamine in the remaining patients. Stress CMR was performed at 1.5 T. We recorded the clinical and demographic data, quality of test, CMR findings, haemodynamic data, and complications. Stress CMR was performed in 11 984 patients (98.2% of requested), using dipyridamole in 95.4% and dobutamine in 4.6%. The study could not be performed due to claustrophobia in 0.2%. Quality was optimal in 93.4%, suboptimal in 6.2%, and poor in 0.4% of studies. Images were diagnostic in 97.6% of patients (98.7% with dipyridamole and 75.1% with dobutamine, P < 0.0001). No patient died or had acute myocardial infarction during the test. Ten patients (0.08%) had severe immediate complications, seven after dipyridamole and two after dobutamine (P = 0.062), and one anaphylactic shock post-gadolinium. The only factor significantly associated with higher incidence of serious complications was the detection of inducible ischaemia. Incidence of non-severe complications was low (1.5%), severe controlled chest pain being the most frequent. Minor symptoms occurred frequently (24.8%). Both were significantly more frequent when dobutamine was used. CONCLUSION Performance of stress CMR is safe in a referral population. Inducible ischaemia was the only factor identified which was associated with serious complications. The incidence of non-severe complications and minor symptoms was greater with dobutamine.
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Husser O, Monmeneu JV, Bonanad C, Lopez-Lereu MP, Nuñez J, Bosch MJ, Garcia C, Sanchis J, Chorro FJ, Bodi V. Valor pronóstico de la isquemia miocárdica y la necrosis en pacientes con la función ventricular izquierda deprimida: un registro multicéntrico con resonancia magnética cardiaca de estrés. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Husser O, Monmeneu JV, Bonanad C, Lopez-Lereu MP, Nuñez J, Bosch MJ, Garcia C, Sanchis J, Chorro FJ, Bodi V. Prognostic value of myocardial ischemia and necrosis in depressed left ventricular function: a multicenter stress cardiac magnetic resonance registry. ACTA ACUST UNITED AC 2014; 67:693-700. [PMID: 25172064 DOI: 10.1016/j.rec.2014.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 10/16/2013] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVES The incremental prognostic value of inducible myocardial ischemia over necrosis derived by stress cardiac magnetic resonance in depressed left ventricular function is unknown. We determined the prognostic value of necrosis and ischemia in patients with depressed left ventricular function referred for dipyridamole stress perfusion magnetic resonance. METHODS In a multicenter registry using stress magnetic resonance, the presence (≥ 2 segments) of late enhancement and perfusion defects and their association with major events (cardiac death and nonfatal infarction) was determined. RESULTS In 391 patients, perfusion defect or late enhancement were present in 224 (57%) and 237 (61%). During follow-up (median, 96 weeks), 47 major events (12%) occurred: 25 cardiac deaths and 22 myocardial infarctions. Patients with major events displayed a larger extent of perfusion defects (6 segments vs 3 segments; P <.001) but not late enhancement (5 segments vs 3 segments; P =.1). Major event rate was significantly higher in the presence of perfusion defects (17% vs 5%; P =.0005) but not of late enhancement (14% vs 9%; P =.1). Patients were categorized into 4 groups: absence of perfusion defect and absence of late enhancement (n = 124), presence of late enhancement and absence of perfusion defect (n = 43), presence of perfusion defect and presence of late enhancement (n = 195), absence of late enhancement and presence of perfusion defect (n = 29). Event rate was 5%, 7%, 16%, and 24%, respectively (P for trend = .003). In a multivariate regression model, only perfusion defect (hazard ratio = 2.86; 95% confidence interval, 1.37-5.95]; P = .002) but not late enhancement (hazard ratio = 1.70; 95% confidence interval, 0.90-3.22; P =.105) predicted events. CONCLUSIONS In depressed left ventricular function, the presence of inducible ischemia is the strongest predictor of major events.
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Affiliation(s)
- Oliver Husser
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Munich, Germany
| | | | - Clara Bonanad
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | | | - Julio Nuñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Maria J Bosch
- Servicio de Cardiología, Hospital La Plana, Vila-real, Spain
| | - Carlos Garcia
- Servicio de Cardiología, Hospital General de Castellón, Castellon, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Francisco J Chorro
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Vicente Bodi
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain.
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Bodi V, Sanchis J, Mainar L, Chorro FJ, Nunez J, Monmeneu JV, Chaustre F, Forteza MJ, Ruiz-Sauri A, Lopez-Lereu MP, Gomez C, Noguera I, Diaz A, Giner F, Llacer A. Right ventricular involvement in anterior myocardial infarction: a translational approach. Cardiovasc Res 2010; 87:601-8. [PMID: 20304784 DOI: 10.1093/cvr/cvq091] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [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
AIMS The aim of the present study was to evaluate the involvement of the right ventricle (RV) in reperfused anterior ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS Left anterior descending (LAD)-perfused area (using thioflavin-S staining after selective infusion in proximal LAD artery, %), infarct size (using triphenyltetrazolium chloride staining, %), and salvaged myocardium (% of LAD-perfused area) in the right and left ventricle (LV) were quantified in a 90-min LAD occlusion 3-day reperfusion model in swine (n = 8). Additionally, we studied, using cardiovascular magnetic resonance, 20 patients with a first STEMI due to proximal LAD occlusion treated with primary angioplasty. Area at risk (T2-weighted sequence, %), infarct size (late enhancement imaging, %), and salvaged myocardium (% of area at risk) in the right and LV were quantified. In swine, a large LAD-perfused area was detected both in the right and LV (30 +/- 5 vs. 62 +/- 15%, P< 0.001) but more salvaged myocardium (94 +/- 6 vs. 73 +/- 11%, P< 0.001) resulted in a smaller right ventricular infarct size (2 +/- 1 vs. 16 +/- 5%, P< 0.001). Similarly, in patients a large area at risk was detected both in the right and LV (34 +/- 13 vs. 43 +/- 12%, P = 0.02). More salvaged myocardium (94 +/- 10 vs. 33 +/- 26%, P < 0.001) resulted in a smaller infarct size (2 +/- 3 vs. 30 +/- 16%, P< 0.001) in the RV. CONCLUSION In reperfused extensive anterior STEMI, a large area of the RV is at risk but the resultant infarct size is small.
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Affiliation(s)
- Vicente Bodi
- Department of Cardiology, Hospital Clinico Universitario, INCLIVA, University of Valencia, Blasco Ibanez 17, Valencia 46010, Spain.
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Bodi V, Sanchis J, Lopez-Lereu MP, Nunez J, Mainar L, Monmeneu JV, Ruiz V, Rumiz E, Husser O, Moratal D, Millet J, Chorro FJ, Llacer A. Prognostic and therapeutic implications of dipyridamole stress cardiovascular magnetic resonance on the basis of the ischaemic cascade. Heart 2008; 95:49-55. [PMID: 18381373 DOI: 10.1136/hrt.2007.139683] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [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: 11/04/2022] Open
Abstract
OBJECTIVE To determine the prognostic and therapeutic implications of stress perfusion cardiovascular magnetic resonance (CMR) on the basis of the ischaemic cascade. SETTING Single centre study in a teaching hospital in Spain. PATIENTS Dipyridamole stress CMR was performed on 601 patients with ischaemic chest pain and known or suspected coronary artery disease. On the basis of the ischaemic cascade, patients were categorised in C1 (no evidence of ischaemia, n = 354), C2 (isolated perfusion deficit at stress first-pass perfusion imaging, n = 181) and C3 (simultaneous perfusion deficit and inducible wall motion abnormalities, n = 66). CMR-related revascularisation (n = 102, 17%) was defined as the procedure prompted by the CMR results and carried out within the next three months. RESULTS During a median follow-up of 553 days, 69 major adverse cardiac events (MACE), including 21 cardiac deaths, 14 non-fatal myocardial infarctions and 34 admissions for unstable angina with documented abnormal angiography were detected. In non-revascularised patients (n = 499), the MACE rate was 4% (14/340) in C1, 20% (26/128) in C2 and 39% (12/31) in C3 (adjusted p value = 0.004 vs C2 and <0.001 vs C1). CMR-related revascularisation had neutral effects in C2 (20% vs 19%, 1.1 (0.5 to 2.4), p = 0.7) but independently reduced the risk of MACE in C3 (39% vs 11%, 0.2 (0.1 to 0.7), p = 0.01). CONCLUSIONS Dypiridamole stress CMR is able to stratify risk on the basis of the ischaemic cascade. A small group of patients with severe ischaemia-simultaneous perfusion deficit and inducible wall motion abnormalities-are at the highest risk and benefit most from MACE reduction due to revascularisation.
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Affiliation(s)
- V Bodi
- Cardiology Department, Hospital Clinico Universitario, Universidad de Valencia, Valencia, Spain.
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Bodi V, Sanchis J, Lopez-Lereu MP, Nunez J, Mainar L, Monmeneu JV, Husser O, Dominguez E, Chorro FJ, Llacer A. Prognostic Value of Dipyridamole Stress Cardiovascular Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease. J Am Coll Cardiol 2007; 50:1174-9. [PMID: 17868810 DOI: 10.1016/j.jacc.2007.06.016] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Revised: 06/05/2007] [Accepted: 06/19/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We evaluated the prognostic value of dipyridamole stress cardiovascular magnetic resonance imaging (CMR) in patients with chest pain and known or suspected coronary artery disease. BACKGROUND Stress perfusion CMR has been incorporated in daily practice. Data on its prognostic value are preliminary. METHODS Dipyridamole stress CMR was performed in 420 patients with chest pain and known or suspected coronary artery disease. The extent (number of segments according to the 17-segment model) of abnormal wall motion at rest (AWM-rest), abnormal wall motion with dipyridamole (AWM-D), perfusion deficit (at stress first-pass perfusion imaging), and delayed enhancement (at late enhancement imaging) were analyzed. RESULTS During a median follow-up of 420 days, 41 major adverse cardiac events (MACE), including 9 cardiac deaths, 14 nonfatal myocardial infarctions, and 18 readmissions for unstable angina with documented abnormal angiography, were documented. The MACE were more frequent in patients with significant (>1 segment) AWM-rest (22% vs. 5%), AWM-D (21% vs. 4%), perfusion deficit (17% vs. 5%), and delayed enhancement (20% vs. 6%; p <0.0001 in all cases). In a multivariate analysis adjusted for baseline characteristics, the extent of AWM-D was independently related to MACE (hazard ratio [HR] 1.15 [95% confidence interval (CI) 1.06 to 1.24] per segment; p = 0.0006) and to major events (cardiac death or nonfatal myocardial infarction; HR 1.15 [95% CI 1.05 to 1.26] per segment; p = 0.002). CONCLUSIONS Dipyridamole stress CMR is useful for predicting the outcome of patients with known or suspected coronary artery disease.
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Affiliation(s)
- Vicente Bodi
- Cardiology Department, University Clinic Hospital, University of Valencia, Valencia, Spain.
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Bodí V, Sanchis J, Lopez-Lereu MP, Nunez J, Mainar L, Pellicer M, Sanz R, Gomez C, Bosch MJ, Husser O, Chorro FJ, Llacer A. Evolution of 5 cardiovascular magnetic resonance-derived viability indexes after reperfused myocardial infarction. Am Heart J 2007; 153:649-55. [PMID: 17383307 DOI: 10.1016/j.ahj.2006.12.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 12/17/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the simultaneous evolution of 5 cardiovascular magnetic resonance-derived myocardial viability indexes. METHODS We studied 72 patients with a first ST-elevation myocardial infarction and sustained TIMI 3 flow. In the first week and in the sixth month of the study, using cardiovascular magnetic resonance imaging, we determined wall thickening (WT) and the following viability indexes: wall thickness, WT with low-dose dobutamine, microvascular perfusion in first-pass imaging, microvascular obstruction in late-enhancement imaging, and transmural extent of necrosis. RESULTS In 250 dysfunctional segments, the evolution outcomes for the viability indexes were as follows: (1) wall thickness thinned (8.6 +/- 2.9 versus 7.7 +/- 3 mm, P < .001), (2) WT with low-dose dobutamine improved (1.5 +/- 1.9 versus 2.6 +/- 3 mm, P < .001), (3) the number of segments showing abnormal microvascular perfusion in first-pass imaging decreased (22% versus 7%, P < .001), (4) the number of segments showing microvascular obstruction in late-enhancement imaging decreased (14% versus 2%, P < .001), and (5) the transmural extent of necrosis remained stable throughout follow-up (56% +/- 40% versus 54% +/- 39%, P = .3). CONCLUSIONS After reperfused myocardial infarction, dynamic changes in wall thickness, contractile reserve, microvascular perfusion, and microvascular obstruction take place. These changes may affect their accuracy as viability indexes early after myocardial infarction. The transmural extent of necrosis does not vary, however.
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Affiliation(s)
- Vicente Bodí
- Cardiology Department, Hospital Clínico y Universitario de Valencia, Universidad de Valencia, Valencia, Spain.
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