Microvascular obstruction and diastolic dysfunction after STEMI: An important link?

Abstract

In the context of acute ST-elevation myocardial infarction (STEMI) and treatment with primary percutaneous coronary intervention, development of infarct-related artery (IRA) microvascular obstruction (MVO) is well described and present in up to 60% of cases [ [1] Reinstadler S.J. Stiermaier T. Fuernau G. de Waha S. Desch S. Metzler B. et al. The challenges and impact of microvascular injury in ST-elevation myocardial infarction. Expert Rev. Cardiovasc Ther. 2016; 14: 431-443 Crossref PubMed Scopus (18) Google Scholar ]. Cardiovascular magnetic resonance (CMR) imaging offers comprehensive myocardial tissue characterization in patients surviving acute myocardial infarction [ [1] Reinstadler S.J. Stiermaier T. Fuernau G. de Waha S. Desch S. Metzler B. et al. The challenges and impact of microvascular injury in ST-elevation myocardial infarction. Expert Rev. Cardiovasc Ther. 2016; 14: 431-443 Crossref PubMed Scopus (18) Google Scholar , [2] Niccoli G. Montone R.A. Ibanez B. Thiele H. Crea F. Heusch G. et al. Optimized treatment of ST-elevation myocardial infarction. Circ. Res. 2019; 125: 245-258 Crossref PubMed Scopus (69) Google Scholar ] and late gadolinium enhancement techniques are considered as the reference standard for the in vivo detection and quantification of MVO [ [1] Reinstadler S.J. Stiermaier T. Fuernau G. de Waha S. Desch S. Metzler B. et al. The challenges and impact of microvascular injury in ST-elevation myocardial infarction. Expert Rev. Cardiovasc Ther. 2016; 14: 431-443 Crossref PubMed Scopus (18) Google Scholar ]. Presence of IRA MVO after revascularized STEMI entails worse prognosis and it is therefore increasingly moving into the focus of attention [ 2 Niccoli G. Montone R.A. Ibanez B. Thiele H. Crea F. Heusch G. et al. Optimized treatment of ST-elevation myocardial infarction. Circ. Res. 2019; 125: 245-258 Crossref PubMed Scopus (69) Google Scholar , 3 Montone R.A. Niccoli G. Minelli S. Fracassi F. Vetrugno V. Aurigemma C. et al. Clinical outcome and correlates of coronary microvascular obstruction in latecomers after acute myocardial infarction. Int. J. Cardiol. 2017; 236: 30-35 Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar , 4 Klug G. Mayr A. Schenk S. Esterhammer R. Schocke M. Nocker M. et al. Prognostic value at 5 years of microvascular obstruction after acute myocardial infarction assessed by cardiovascular magnetic resonance. J. Cardiovasc. Magn. Reson. 2012; 14: 46 Crossref PubMed Scopus (73) Google Scholar ]. Importantly, a recent study using individual patient data (n = 1688) from seven randomized trials that determined MVO within the first week after coronary intervention demonstrated a graded response between the extent of MVO and subsequent mortality and hospitalization for heart failure independent of infarct size [ [5] de Waha S. Patel M.R. Granger C.B. Ohman E.M. Maehara A. Eitel I. et al. Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: an individual patient data pooled analysis from seven randomized trials. Eur. Heart J. 2017; 38: 3502-3510 Crossref PubMed Scopus (156) Google Scholar ]. Despite this, there have been few large clinical trials specifically designed to prevent or ameliorate MVO [ [2] Niccoli G. Montone R.A. Ibanez B. Thiele H. Crea F. Heusch G. et al. Optimized treatment of ST-elevation myocardial infarction. Circ. Res. 2019; 125: 245-258 Crossref PubMed Scopus (69) Google Scholar ]. In addition to IRA MVO, it was recently suggested that the presence of MVO at non-IRA areas, as visualized by CMR, might represent another imaging biomarker for adverse cardiovascular events [ [6] Khorramirouz R. Corban M.T. Yang S.W. Lewis B.R. Bois J. Foley T. et al. Microvascular obstruction in non-infarct related coronary arteries is an independent predictor of major adverse cardiovascular events in patients with ST segment-elevation myocardial infarction. Int. J. Cardiol. 2018; 273: 22-28 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ].