Delayed Enhancement Cardiac Magnetic Resonance Research Articles

Independent predictor CMR of mortality in patient with surgical aortic stenosis

Objectives: The purpose of this study was to evaluate the impact of focal fibrosis (FF) assessment by delayed-enhanced cardiac magnetic resonance (DE-CMR) on survival in patients with severe aortic stenosis (AS) treated by aortic valve replacement (AVR). Background: Prior studies have shown that DE-CMR predicts survival in severe aortic valve disease. However in context of curative surgery, FF impact is less known as well as influence of coronary status. Methods: The authors prospectively evaluated survival of 180 consecutive patients (118 males, age 72±9.5 years) with AVR undergoing DE-CMR. One hundred twenty four patients underwent isolated AVR, whereas 56 patients received associated coronary artery bypass graft (CABG). Results: Over the 3-year median follow-up, 21 patients died. Mean FF percentage was higher in patients with events versus those without (3.9±5.1 vs. 1.5±2.6, 0.001). Kaplan-Meier analyses revealed that higher degrees of FF were associated with worse long-term survival after AVR with or without associated CABG (chi-square = 3.58, p 0.05; chi-square = 4.15, p 0.04, respectively). On multivariable cox analysis, FF (hazard ratio [HR]: 1.12 (1.0-1.2), 95% confidence interval [CI]: 1.0 to 1.2, p < 0.004) and New York Heart Association functional class (HR: 2.0, 95% CI: 1.1 to 3.5, p < 0.01) were identified as strong independent determinants of poor prognosis. In patients with AS, there were 3 findings for FF distributed as follows between patients with events versus those without: no enhancement (67 vs. 42, p <0.02), infarct pattern (22 vs. 33, p =NS), and midwall enhancement (10 vs. 23, p =NS). However after exclusion of 67 patients with CAD history, prognostic value of FF was decreased (log rank=NS). Conclusions: With or without revascularization, presence of FF by DE-CMR is an independent predictor of mortality in patients AVR with AS. DE-CMR provides additional information in the evaluation of preoperative risk particularly for patients with CAD history.

Mri-guided approach to localize and ablate gaps in repeated atrial fibrillation ablation procedure

Introduction: Recurrences of atrial fibrillation (AF) after pulmonary vein (PV) isolation may be related to gaps at the ablation lines. Delayed-enhanced cardiac magnetic resonance (DE-CMR) allows the identification of radiofrequency (RF) lesions and gaps (CMR gaps). The present study aimed to test the usefulness of a new DE-CMR guided approach to ablate gaps in re-do procedures. Methods: Using DE-CMR, a 3D volume-rendered left atrial reconstruction (3D model) was created, after manually segmenting endocardium and epicardium. A pixel signal intensity map was projected on the 3D model and color-coded. The 3D model was imported into the navigation system. RF was delivered targeting the CMR gaps, with the operator blinded to electrical data. Results: Twelve patients were analyzed (58±8 years, 7 with paroxysmal AF, median [IQR] time from prior PV isolation of 16.5 [9-25.5] months). Four patients had additional roof-line ablation. In total, 68 CMR gaps were identified around the PVs and 13 at the roof-line, with a mean of 6.8 gaps/patient and median length of 5.5 mm/gap. Of 43 PVs 38 were electrically reconnected (median of 3 PV/patient). All reconnected PVs presented CMR gaps, with functional electrical-CMR concordance of 88.9%. Guided by the 3D model, isolation of 95% of PVs and conduction block through the roof-line was achieved after a mean of 3.7±3.4 RF applications/gap (22.0±20.2/patient) and 2.8±2.2 min/gap (29.3±14.0 min/patient). Conclusion: DE-CMR is a useful tool to guide the repeat PV isolation procedure by accurately identifying and locating the gaps, with the potential of reducing procedure duration and RF application time.

The relationship between cardiac enzymes after reperfusion and microvascular obstruction by delayed enhancement cardiac magnetic resonance imaging in patients with acute myocardial infarction

The relationship between cardiac enzymes after reperfusion and microvascular obstruction by delayed enhancement cardiac magnetic resonance imaging in patients with acute myocardial infarction

Predictive value of 2D and 3D deformation imaging of immediate and mid-term myocardial contractile recovery after recanalized STEMI: comparison with delayed enhancement cardiac magnetic resonance

Purpose: Demonstration of myocardial viability after STEMI is paramount to define prognosis and to address appropriate management. Accuracy of the new echocardiographic deformation techniques in comparison to delayed-enhanced cardiac magnetic resonance (de-CMR) in predicting contractile recovery in a mid-term follow-up remains to be assessed. Methods: 55 patients (58±13 years, 50 men) with STEMI (27 anterior STEMI) and treated with primary percutaneous coronary intervention, underwent a complete 2D- and 3D-echocardiogram, and de-CMR within 24 hours, at pre-discharge. Peak global 2D longitudinal strain (2D GLS) and 3D strain in its 4 components (longitudinal -3D GLS-, circumferential -3D GCS-, area strain -3D AS- and radial -3D GRS) with relative segmental data were measured and compared with extent of scar at de-CMR. A follow-up 2D and 3D echocardiogram was repeated at one year; clinical data were also collected at the same follow-up visit. Results: All but 2 (sudden deaths) patients completed the follow up (380±67 days). As expected, there was a significant correlation between peak of troponin I after STEMI and indexed 3D LV end-diastolic volumes (LVEDV) over 1 year follow-up (F value 11,7, p= 0,03); a similar correlation between the basal de-CMR infarct size index (ISI) and LVEDV was also found (F value 5,07, p=0,001) at follow-up. Predischarge peak 3DGCS showed the strongest correlation with ISI (Pearson's r= 0,63). The correlation between 3D strain measurements and amount of delayed enhancement at CMR was confirmed at segmental level but with a worse evidence in mid-ventricle and basal segments. Despite this, neither de-CMR grading, nor 2D-3D strain parameters were good predictors of contractile recovery of akinetic segments at the 1-year follow-up echocardiogram (area under the curve for segmental contractile recovery were: 0,65 and 0,57 for de-CMR and 2D-GLS, respectively). Conclusions: 2D and 3D strain parameters obtained by a pre-discharge echocardiogram show a good correlation with the global amount of scar area after a recanalized STEMI as detected by de-CMR. The accuracy of both echo- and CMR techniques to predict the contractile recovery at 1-year follow-up is limited.

Evaluation of Age-Related Interstitial Myocardial Fibrosis With Cardiac Magnetic Resonance Contrast-Enhanced T1 Mapping: MESA (Multi-Ethnic Study of Atherosclerosis)

This study sought to determine the relationship of cardiovascular magnetic resonance (CMR) measures of tissue composition to age in the Multi-Ethnic Study of Atherosclerosis (MESA).Animal and human studies have demonstrated increased collagen deposition in senescent hearts. New CMR indices of tissue composition by using T1 mapping are sensitive to the presence of myocardial fibrosis.A total of 1,231 study participants (51% women; age range 54 to 93 years) of the MESA cohort were evaluated with T1 mapping by using 1.5-T CMR scanners. None of the participants had focal scar on delayed enhancement CMR. Single-slice T1 mapping was performed at the midventricular level before and at 12- and 25-min delay after administration of gadolinium contrast by using a modified Look-Locker inversion recovery sequence. The partition coefficient was determined by the slope of the linear relationship of (1/T1myo vs. 1/T1blood). The extracellular volume fraction (ECV) was derived accounting for the hematocrit level. Multivariable regression analyses were performed, adjusting for traditional risk factors and left ventricular structure.Women had significantly greater partition coefficient, ECV, and precontrast T1 than men, as well as lower post-contrast T1 values (all p < 0.05). In general, linear regression analyses demonstrated that greater partition coefficient, pre-contrast T1 values, and ECV were associated with older age in men (multivariate regression coefficients = 0.01; 5.9 ms; and 1.04% per 10 years' change; all p < 0.05). ECV was also significantly associated with age in women after multivariable adjustments.CMR parameters that have been associated with myocardial fibrosis were related to older age in the MESA study. Women had higher ECV than men but less ECV change over time.

Myocardial Thinning in Patients With Coronary Artery Disease

To the Editor The study by Dr Shah and colleagues 1 reported that among patients with coronary artery disease (CAD), limited scar burden was present in 18% of the patients with regional wall thinning detected by cardiovascular magnetic resonance (CMR) imaging, which challenges common assumptions. We believe some other considerations should be taken into account. First, a prior study 2 revealed that most infarct healing (in terms of reduction in infarct size and wall thinning) was completed by 5 months after a myocardial infarction (MI); however, another study 3 indicated that 4 months is most likely too early to detect the full extent of regional and global left ventricular remodeling. Therefore, controversy exists regarding the time course of myocardial thinning after an ischemic event. In the study by Shah et al, 1 the time span between diagnosis of CAD and assessment by delayed-enhancement CMR imaging was not mentioned. Second, although infarct scar tissue has been considered inert, it is now recognized to be living tissue, with vascular growth 4 and connective tissue accumulation at the infarct site for years after an MI has occurred. In the study by Shah et al, 1 71% of the patients with myocardial thinning had a history of MI, and there were significantly more collateral vessels in the limited scar burden group than in the extensive scar burden group, which could lead to differences in contrast accumulation in the thinning region and cause bias in the assessment of scar burden. Third, the use of anticoagulants could influence the development of myocardial scar burden. Although there was no significant difference in aspirin use between the limited scar burden and the extensive scar burden groups, the authors should present more information about other anticoagulants (ie, clopidogrel, heparin, and glycoprotein IIb/IIIa receptor antagonists) in their study.

More Evidence for the Survival Benefit of Coronary Revascularization Versus Medical Therapy in Patients With Ischemic Cardiomyopathy and Hibernating Myocardium

For many years, it has been recognized that patients with coronary artery disease (CAD) and left ventricular (LV) dysfunction who manifest substantial myocardial viability in asynergic myocardial regions have improved LV regional and global function, exhibit reverse LV remodeling, and exhibit a reduction in ischemic mitral regurgitation and a reduction in heart failure symptoms after revascularization. Observational studies using a variety of noninvasive methodologies for assessment of myocardial viability have also shown enhanced survival with revascularization versus medical therapy in such patients. A much quoted meta-analysis of observational studies in the literature that reported outcomes in patients undergoing noninvasive viability studies with Tl-201 redistribution scintigraphy, positron emission tomography (PET) with F-18-fluorodeoxyglucose (FDG), or dobutamine echocardiography showed a ≈80% reduction in mortality (3.2% versus 16.0%) during follow-up with revascularization versus medical therapy in those patients with predominantly hibernating myocardium.1 In contrast, patients with predominantly nonviable myocardium showed no benefit from revascularization versus medical therapy. In most of these prior studies, the greater the amount of hibernating myocardium, the better the outcome with revascularization. For example, the larger the amounts of mismatch between perfusion and FDG uptake by PET, combined with revascularization, the less the probability of cardiac death, myocardial infarction, and hospitalization for cardiac causes.2 Cardiac magnetic resonance accurately quantifies the amount of transmural myocardial scar using measurements of late gadolinium enhancement. With this noninvasive technique, the greater the amount of late gadolinium enhancement, the greater the chance of functional recovery after revascularization.3 Revascularization also shows a survival benefit compared with medical therapy in the presence of dysfunctional but viable myocardium by delayed-enhanced cardiac magnetic resonance.4 Article see p 363 All the noninvasive viability imaging techniques in clinical use can adequately identify hibernating myocardium in patients with ischemic cardiomyopathy. When the relative sensitivities and specificities of these …

Usefulness of Q-Wave Area for Threshold-Based Stratification of Global Left Ventricular Myocardial Infarct Size

Left ventricular (LV) infarct size affects prognosis after acute myocardial infarction (AMI). Delayed enhancement cardiac magnetic resonance (DE-CMR) provides accurate infarct quantification but is unavailable or contraindicated in many patients. This study tested whether simple electrocardiography (ECG) parameters can stratify LV infarct size. One hundred fifty-two patients with AMI underwent DE-CMR and serial 12-lead ECG. Electrocardiograms were quantitatively analyzed for multiple aspects of Q-wave morphology, including duration, amplitude, and geometric area (QWAr) summed across all leads except aVR. Patients with pathologic Q waves had larger infarcts measured by DE-CMR or enzymes (both p <0.001), even after controlling for infarct distribution by CMR or x-ray angiography. Comparison between early (4 ± 0.4 days after AMI) and follow-up (29 ± 6 days) ECG demonstrated temporal reductions in Q-wave amplitude (1.8 ± 1.4 vs 1.6 ± 1.6 mV; p= 0.03) but not QWAr (41 ± 38 vs 39 ± 43 mV•ms; p= 0.29). At both times, QWAr augmented stepwise with DE-CMR quantified infarct size (p <0.001). QWAr increased markedly at 10% LV infarct threshold, with differences more than threefold on early ECG (59 ± 39 vs 18 ± 20 mV•ms; p <0.001) and nearly fivefold (59 ± 46 vs 13 ± 16 mV•ms; p<0.001) on follow-up. Diagnostic performance compared with a 10% infarction cutoff was good on early (area under the curve= 0.84) and follow-up (area under the curve= 0.87) ECG. Optimization of sensitivity (95% to 98%) enabled QWAr to exclude affected patients with 90% to 94% negative predictive value at each time point. In conclusion, LV infarct size is accompanied by stepwise increments in Q-wave morphology, with QWAr increased three- to fivefold at a threshold of 10% LV infarction. Stratification based on QWAr provides excellent negative predictive value for exclusion of large (≥10%) LV infarct burden.

Early assessment of sub-clinical cardiac involvement in systemic sclerosis (SSc) using delayed enhancement cardiac magnetic resonance (CE-MRI)

ObjectivesSystemic sclerosis heart involvement (SHI) is one of systemic sclerosis (SSc) most frequent complications, both in diffuse (dcSSc) and limited (lcSSc) cutaneous forms of disease. Nowadays, SHI is a major factor decreasing SSc survival rate because, when clinically evident, is associated with 70% of mortality at 5 years. SHI shows different forms, primary and/or secondary. Primary myocardial SHI is characterized by fibrosis. Aim of our study is to assess the presence and pattern of fibrosis as detected by cardiac magnetic resonance (CMR) in systemic sclerosis. MethodsIn this study, we used CE-MRI (contrast enhanced-MRI) in 58 female SSc patients. Images were evaluated to obtain functional parameters and to see presence, location and pattern (nodular, linear or diffuse) of myocardial LE, sign of fibrosis. CE-MRI findings were correlated with patients clinical setting. ResultsMyocardial fibrosis was detected in 25 of 58 patients (43%). The main finding observed in 16 of these 25 patients was a late enhancement showing a linear pattern, without coronary distribution and sparing the sub-endocardial myocardial layers. A patchy nodular enhancement pattern was observed in 9 patients (36%). Patients with linear pattern presented dcSSc, on the contrary patients with nodular LE displayed the lcSSc form. ConclusionsThis study shows that CE-MRI is a reliable technique to detect SHI earlier than other methods. SHI increase passive myocardial stiffness, proportional to collagen deposition degree, leading to cardiac remodelling with possible development of heart failure, even with normal ejection fraction. An early treatment of SHI might improve SSc patients outcome.

Left Ventricular Stroke Volume Quantification by Contrast Echocardiography – Comparison of Linear and Flow‐Based Methods to Cardiac Magnetic Resonance

Echocardiography (echo)-quantified LV stroke volume (SV) is widely used to assess systolic performance after acute myocardial infarction (AMI). This study compared 2 common echo approaches - predicated on flow (Doppler) and linear chamber dimensions (Teichholz) - to volumetric SV and global infarct parameters quantified by cardiac magnetic resonance (CMR). Multimodality imaging was performed as part of a post-AMI registry. For echo, SV was measured by Doppler and Teichholz methods. Cine-CMR was used for volumetric SV and LVEF quantification, and delayed-enhancement (DE) CMR for infarct size. Overall, 142 patients underwent same day echo and CMR. On echo, mean SV by Teichholz (78±17mL) was slightly higher than Doppler (75±16mL; Δ=3±13mL; P=0.02). Compared to SV on CMR (78±18mL), mean difference by Teichholz (Δ=-0.2±14; P=0.89) was slightly smaller than Doppler (Δ=-3±14; P=0.02), but limits of agreement were similar between CMR and echo methods (Teichholz: -28, 27mL, Doppler: -31, 24mL). For Teichholz, differences with CMR SV were greatest among patients with anteroseptal or lateral wall hypokinesis (P<0.05). For Doppler, differences were associated with aortic valve abnormalities or root dilation (P=0.01). SV by both echo methods decreased stepwise in relation to global LV injury as assessed by CMR-quantified LVEF and infarct size (P<0.01). Teichholz and Doppler calculated SV yield similar magnitude of agreement with CMR. Teichholz differences with CMR increase with septal or lateral wall contractile dysfunction, whereas Doppler yields increased offsets in patients with aortic remodeling.

MRI-GUIDED APPROACH TO LOCALIZE AND ABLATE GAPS IN REPEATED ATRIAL FIBRILLATION ABLATION PROCEDURE: A PILOT STUDY

The presence of gaps in prior pulmonary vein (PV) isolation (PVI) ablation lesions may be the cause of procedural failure. Delayed-enhanced (DE) cardiac magnetic resonance (CMR) allows the identification of radiofrequency (RF) lesions and gaps (CMR gaps). The present study aimed to test the

Circulation: Cardiovascular Imaging Editors’ Picks

<i>Circulation: Cardiovascular Imaging</i> Editors’ Picks

Mitral Apparatus Assessment by Delayed Enhancement CMR: Relative Impact of Infarct Distribution on Mitral Regurgitation

This study sought to assess patterns and functional consequences of mitral apparatus infarction after acute myocardial infarction (AMI).The mitral apparatus contains 2 myocardial components: papillary muscles and the adjacent left ventricular (LV) wall. Delayed-enhancement cardiac magnetic resonance (DE-CMR) enables in vivo study of inter-relationships and potential contributions of LV wall and papillary muscle infarction (PMI) to mitral regurgitation (MR).Multimodality imaging was performed: CMR was used to assess mitral geometry and infarct pattern, including 3D DE-CMR for PMI. Echocardiography was used to measure MR. Imaging occurred 27 ± 8 days after AMI (CMR, echocardiography within 1 day).A total of 153 patients with first AMI were studied; PMI was present in 30% (n = 46 [72% posteromedial, 39% anterolateral]). When stratified by angiographic culprit vessel, PMI occurred in 65% of patients with left circumflex, 48% with right coronary, and only 14% of patients with left anterior descending infarctions (p <0.001). Patients with PMI had more advanced remodeling as measured by LV size and mitral annular diameter (p <0.05). Increased extent of PMI was accompanied by a stepwise increase in mean infarct transmurality within regional LV segments underlying each papillary muscle (p <0.001). Prevalence of lateral wall infarction was 3-fold higher among patients with PMI compared to patients without PMI (65% vs. 22%, p <0.001). Infarct distribution also impacted MR, with greater MR among patients with lateral wall infarction (p = 0.002). Conversely, MR severity did not differ on the basis of presence (p = 0.19) or extent (p = 0.12) of PMI, or by angiographic culprit vessel. In multivariable analysis, lateral wall infarct size (odds ratio 1.20/% LV myocardium [95% confidence interval: 1.05 to 1.39], p = 0.01) was independently associated with substantial (moderate or greater) MR even after controlling for mitral annular (odds ratio 1.22/mm [1.04 to 1.43], p = 0.01), and LV end-diastolic diameter (odds ratio 1.11/mm [0.99 to 1.23], p = 0.056).Papillary muscle infarction is common after AMI, affecting nearly one-third of patients. Extent of PMI parallels adjacent LV wall injury, with lateral infarction-rather than PMI-associated with increased severity of post-AMI MR.

The dilemma of ischemic heart failure; how FDG-PET can guide therapy and improve outcomes? Case report

Abstract Patients with ischemic LV dysfunction are at increasing risk of adverse cardiac events including sudden cardiac death. Proper revascularization of viable ischemic myocardium (compared to medical treatment alone) is associated with improvement of LV systolic function, less cardiac morbidities & mortalities and better functional capacity and well-being. Many diagnostic tools are used in clinical practice for assessment of myocardial viability. Dobutamine stress Echocardiography (DSE) is the most widely used technique, while delayed enhancement cardiac magnetic resonance (DE-CMR) and Flourine-18-fluorodeoxy-glucose positron emission tomography (18F-FDG PET) are considered the standard of care for assessment of myocardial viability. Our case report illustrates how FDG PET myocardial viability assessment can guide therapy and improve outcomes in a difficult clinical and angiographic situation.

Atrial Fibrillation Through the Years

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Valentin Fuster), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. A 61-year-old man presents with 2 weeks of exertional dyspnea. Pertinent medical history includes hypertension, nephrolithiasis, and internal hemorrhoids. He takes no medications and has no known drug allergies. His father died after a myocardial infarction at 57 years of age. He formerly smoked 1 pack of cigarettes daily for 15 years but ceased tobacco use 10 years before presentation. He ingests 2 glasses of alcohol weekly and denies illicit drug use. His caffeine intake is limited. He is an architect and is married, with healthy children. On physical examination, his temperature is 98.0°F, blood pressure is 130/85 mm Hg bilaterally, pulse is irregular at 130 beats per minute, and respiratory rate is 18 breaths per minute with an oxygen saturation of 97% while breathing room air. He is a slender white man in no distress. His jugular venous pressure is elevated at 14 cm H 2 O. There is no thyromegaly, and the carotid upstrokes are brisk, without bruits. Cardiovascular examination reveals a rapid and irregular heart rhythm with variation in the intensity of the first heart sound. The point of maximal impulse is not displaced. The remainder of the chest and abdominal examination is within normal limits. The extremities are warm and show mild pitting edema. Laboratory testing is significant for normal renal function and electrolytes, but a hemogram reveals a mild thrombocytopenia of 90 000 platelets/μL. ECG demonstrates atrial fibrillation (AF) with an average ventricular rate of 123 bpm ( Figure 1 ). Figure 1. The 12-lead ECG showing atrial fibrillation with a rapid ventricular rate. Dr Valentin Fuster : This is a …

PET imaging with FDG to guide revascularization in patients with systolic heart failure

Abstract The assessment of myocardial viability is important in the management of patients with coronary artery disease and left ventricular systolic dysfunction. There are several different imaging modalities currently available for the identification of viable myocardium: dobutamine stress echocardiography, single photon emission computed tomography, delayed-enhancement cardiac magnetic resonance imaging, and F-18 fluorodeoxyglucose positron emission tomography. The goal of viability imaging is to determine the likelihood of recovery of systolic function after revascularization. Positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET) provides information about perfusion as well as myocardial metabolism, requires meticulous patient preparation, and is currently the gold standard imaging modality for the assessment of myocardial viability. Viability imaging for the purposes of predicting which patients will have improvement in left ventricular systolic function is supported under current guidelines, but the results of the recent STICH-viability substudy have created uncertainty about the incremental benefit. This review article will provide a summary of the currently available imaging modalities with an emphasis on FDG-PET and discuss the clinical relevance of viability imaging in light of the STICH-viability substudy.

Three dimensional delayed enhancement cardiovascular magnetic resonance imaging of the left atrium and pulmonary veins for atrial fibrillation ablation

Background Atrial fibrillation (AF) is the commonest sustained arrhythmia afflicting the adult population. Identifying and ablating triggers in the left atrium (LA) or more often the pulmonary veins (PV) with radiofrequency energy to restore sinus rhythm is fast becoming the mainstay of treatment. The success of the procedure often requires a combination of imaging techniques with an electroanatomical mapping system. We describe the use of three dimensional (3D) delayed enhancement cardiovascular magnetic resonance imaging (DE-MRI) to provide a road map of the anatomy as well as regions of scar tissues in the LA and PV for AF ablation. Methods

Does presence of R wave forces on surface electrocardiogram predict myocardial viability in patients with coronary disease and left ventricular dysfunction? Correlation with cardiac MRI

Background Clinicians use presence of Q waves as a sign of transmural infarction although this is an imperfect marker to predict lack of myocardial viability (MV). We hypothesized that presence of R waves as a marker of electrical activity on surface electrocardiogram (ECG) may be a sensitive marker for presence of MV as determined by delayed enhanced cardiac magnetic resonance (DECMR) imaging.

Is delayed enhancement cardiovascular magnetic resonance of some help for therapeutic strategy in hypertrophic cardiomyopathy?

Is delayed enhancement cardiovascular magnetic resonance of some help for therapeutic strategy in hypertrophic cardiomyopathy?

Relationship between obesity and unrecognized myocardial infarction: a EuroCMR multi-center study

Background Obesity is a major public health issue given its high cardiovascular morbidity and mortality. However, whether obesity predicts cardiovascular disease independent from traditional Framingham risk factors is controversial [1]. Delayed-enhancement CMR (DE-CMR) allows for sensitive and specific detection of unrecognized MI, which appears associated with adverse prognosis similar to clinically recognized MI. We examined the relationship between obesity and the prevalence of unrecognized myocardial scar (UScar) and/ or unrecognized MI (UMI) as determined by DE-CMR.