Many patients who undergo stress cardiac magnetic resonance (CMR) imaging snort proof of a earlier myocardial infarction (MI) that has long previous unrecognized, and their future cardiovascular (CV) threat, including mortality, resembles that of linked patients with identified prior MI, a cohort glimpse suggests.
The occurrence of both unrecognized and identified ragged MI used to be about 15%, and both predicted slack future MI or demise as successfully, despite any ischemia evident at stress attempting out, within the evaluation of extra than 2300 patients from the Stress CMR Perfusion Imaging within the US (SPINS) Gaze.
CMR imaging “would possibly presumably well maybe if truth be told absorb a feature as both a baseline screening utility as smartly as a noninvasive apply-up formula in learn of unrecognized MI prevention in excessive CV threat populations,” the authors propose in a document printed August 17 within the Journal of the American College of Cardiology.
Unrecognized MI used to be associated with a different of modifiable CV threat factors, including hypertension and diabetes. Therefore, intense preventive therapies would possibly presumably well maybe also lower its occurrence at CMR and lend a hand outcomes, enact the authors, led by Panagiotis Antiochos, MD, Brigham and Ladies folk’s Effectively being facility, Boston, Massachusetts.
The adjusted threat for demise or MI over about 5.4 years used to be 69% elevated for patients with a earlier MI when put next with these with out an MI historical previous eventually of the entire population as smartly as among patients with out stress-inducible ischemia.
The corresponding dangers for predominant negative cardiac occasions (MACE) went up 78% and 89%, respectively.
However the dangers for patients with unrecognized prior MI were linked to these with identified prior MI, also despite inducible ischemia.
On the opposite hand, patients with unrecognized MI were extra than twice as doubtless as these with known ragged MI to be hospitalized for heart failure (HF). The charges were 11.8% and 5.0% (P < .001), respectively. The adaptation remained valuable in adjusted evaluation, the group writes.
Unrecognized MI used to be outlined by CMR as a presence of slack gadolinium enhancement (LGE, a marker of fibrosis) in a coronary-artery-served space of endocardium within the absence of a identified MI historical previous.
“These compelling recordsdata snort undertreatment of patients with unrecognized MI and highlight a probability to lend a hand outcomes with extra aggressive clinical therapies,” agree Erik B. Schelbert, MD, University of Pittsburgh College of Treatment, Pennsylvania, and colleagues in an accompanying editorial.
“Whether the diagnosis of unrecognized MI outcomes in intensified clinical therapy and improves affected person care requires extra glimpse, but looks doubtless,” they recount.
The excessive price of unrecognized MI by CMR within the glimpse “illustrates the constraints of contemporary principal prevention suggestions that ignore unrecognized MI” and “illustrates the challenges of its detection with out CMR,” the editorialists recount.
Of the patients with out previously documented CAD at the time of CMR, for whom there used to be therefore no indication for secondary-prevention therapy, glorious 55% of these with unrecognized MI had been taking aspirin, and 52% had been taking statins, the editorialists relate.
CMR “is surely helpful for identifying an ragged infarct, and I focus on it is attention-grabbing that they found as many unrecognized MIs as known MIs. It be obviously an unlimited field for patients,” Matthew J. Budoff, MD, Harbor-UCLA Scientific Heart Lundquist Institute, Torrance, California, told theheart.org | Medscape Cardiology.
For a test to be helpful in screening a excessive-threat population for occult MI, the yield would must be excessive, observed Budoff, who is never always associated with the contemporary glimpse. And its 15% yield for unrecognized MI used to be “reasonably excessive.”
Identification of ragged MI qualifies the affected person for a broader fluctuate of secondary prevention drug therapies, he famed. “We can then be extra aggressive with our statins, ACE inhibitors, and beta blockers, and with reasonably of luck they’ll enact better over time.”
The contemporary evaluation highlights CMR as one in all the ways of threat-stratifying patients with suspected myocardial ischemia and reinforces the belief that LDE-essentially based entirely stress CMR would possibly presumably well maybe even absorb “a doable feature in some of our patients,” Budoff mentioned.
It factors to “a probability, if their screening takes them down the CMR pathway, to absorb a further revenue in shopping for LDE to spy if they’ve had an unrecognized MI within the previous.”
The glimpse’s 2349 patients ranged in age from 35 to 85 years (mean, 63 years), and 47% were females. They’d finally two valuable CV threat factors, corresponding to diabetes or hypercholesterolemia, but no historical previous of bypass surgical operation, contemporary MI, excessive valvular illness, or lowered ejection.
All had been referred for stress CMR overview of “chest agonize, dyspnea, contemporary ECG, or diverse scientific presentation that raised a suspicion of myocardial ischemia as particular by the treating clinician.”
Beforehand unrecognized MI by LDE-CMR used to be viewed in 14.8% of the group. Prior clinically known MI used to be viewed in 15.2%.
The presence of ragged MI, whether or now now not unrecognized or identified, seriously and independently predicted both composite endpoints (demise or MI and MACE) total and within the subgroup with out inducible ischemia.
| Desk. Hazard Ratio(HR) for Later CV Outcomes by CMR Outcomes | ||
| Subgroup and comparability | All patients, HR (95% CI) | Stress CMR noninducible, HR (95% CI) P |
| Loss of life/MI threat by subgroup | ||
| MI vs no MI | 1.69 (1.32 – 2.15), P < .001 | 1.69 (1.28 – 2.22), P < .001 |
| Unrecognized vs identified MI | 0.84 (0.61 – 1.17), P = .307 | 0.83 (0.53 –1 .29), P = .409 |
| MACE threat by subgroup | ||
| MI vs no MI | 1.78 (1.46 – 2.16), P < .001 | 1.89 (1.51 – 2.36), P < .001 |
| Unrecognized vs identified MI | 0.86 (0.67 – 1.11), P = .255 | 0.94 (0.67 – 1.33), P = .738 |
| *Adjusted for age, smoking, diabetes, LVEF, ischemia, and known vs unrecognized MI | ||
It stays unanswered whether or now now not CMR is extra healthy than nuclear imaging and even stress echocardiography for highlighting unrecognized MI, he mentioned. But CMR would possibly presumably well maybe be of extra pronounce when the findings of diverse imaging modalities disagree or are indeterminant.
“I focus on MR would possibly presumably well maybe also additionally be mature as a clarifier and moreover as an adjudicator of hibernating myocardium vs infarct, since the slack gadolinium enhancement would glorious happen in a atmosphere of an infarct,” Budoff mentioned. At centers that pronounce LDE-CMR, “I focus on that’s the blueprint it is mature this present day,” he mentioned.
The glimpse used to be supported by Siemens Healthineers and Bayer AG. Antiochos has got learn funding from the Novartis Foundation for Scientific-Biological Overview. Schelbert has favorite distinction topic materials from Bracco Diagnostics for learn functions and serving on advisory boards for Merck, Bayer, and Haya Therapeutics. Disclosures for the various authors and editorialists are within the respective publications. Budhoff discloses talking or serving on a audio system bureau for Amarin Pharma and receiving learn grants from Common Electric and Amarin Pharma.
J Am Coll Cardiol. Revealed online August 17, 2020. Abstract, Editorial
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