Unrecognized Myocardial Infarction Research Articles

Predictors and Prognostic value of Coronary Computed Tomography Angiography for Unrecognized Myocardial Infarction in Patients with Chronic Coronary Syndrome

BackgroundUnrecognized myocardial infarction (UMI) on delayed-enhancement cardiac magnetic resonance imaging (DE-CMR) and coronary computed tomography angiography (CCTA) derived high-risk features provide prognostic information in patients with chronic coronary syndrome (CCS). The study aimed to assess the prognostic value of UMI and predictors of UMI using CCTA in patients with CCS undergoing elective percutaneous coronary intervention (PCI). MethodsThis study enrolled 181 CCS patients underwent both DE-CMR and CCTA before elective PCI. The CCTA-derived predictors of UMI and the association of baseline clinical characteristics, CCTA findings, and CMR-derived factors including UMI with MACE, defined as death, nonfatal myocardial infarction, unplanned late revascularization, hospitalization for congestive heart failure, and stroke were investigated. ResultsUMI was detected in 57 patients (31.5%). ROC analysis revealed the optimal cut-off values of Agatston score and mean pericoronary fat attenuation index (FAI) for predicting the presence of UMI were 397 and -69.8, respectively. Multivariable logistic regression analysis revealed that left ventricular mass, Agatston score >397, mean FAI >-69.8, positive remodeling of the target lesion, and CCTA-derived stenosis severity were independent predictors of UMI. Kaplan-Meier analysis revealed that patients with UMI were associated with increased risk of MACE. Cox’s proportional hazards analysis showed post-PCI minimum lumen diameter and the presence of UMI were independent predictors of MACE. The risk of MACE significantly increased according to the number of 4 preprocedural CCTA relevant features of UMI. ConclusionPreprocedural comprehensive CCTA analysis may help predict the presence of UMI and provide prognostic information in patients with CCS undergoing PCI.

Evaluation of deep learning-based reconstruction late gadolinium enhancement images for identifying patients with clinically unrecognized myocardial infarction

BackgroundThe presence of infarction in patients with unrecognized myocardial infarction (UMI) is a critical feature in predicting adverse cardiac events. This study aimed to compare the detection rate of UMI using conventional and deep learning reconstruction (DLR)-based late gadolinium enhancement (LGEO and LGEDL, respectively) and evaluate optimal quantification parameters to enhance diagnosis and management of suspected patients with UMI.MethodsThis prospective study included 98 patients (68 men; mean age: 55.8 ± 8.1 years) with suspected UMI treated at our hospital from April 2022 to August 2023. LGEO and LGEDL images were obtained using conventional and commercially available inline DLR algorithms. The myocardial signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and percentage of enhanced area (Parea) employing the signal threshold versus reference mean (STRM) approach, which correlates the signal intensity (SI) within areas of interest with the average SI of normal regions, were analyzed. Analysis was performed using the standard deviation (SD) threshold approach (2SD–5SD) and full width at half maximum (FWHM) method. The diagnostic efficacies based on LGEDL and LGEO images were calculated.ResultsThe SNRDL and CNRDL were two times better than the SNRO and CNRO, respectively (P < 0.05). Parea−DL was elevated compared to Parea−O using the threshold methods (P < 0.05); however, no intergroup difference was found based on the FWHM method (P > 0.05). The Parea−DL and Parea−O also differed except between the 2SD and 3SD and the 4SD/5SD and FWHM methods (P < 0.05). The receiver operating characteristic curve analysis revealed that each SD method exhibited good diagnostic efficacy for detecting UMI, with the Parea−DL having the best diagnostic efficacy based on the 5SD method (P < 0.05). Overall, the LGEDL images had better image quality. Strong diagnostic efficacy for UMI identification was achieved when the STRM was ≥ 4SD and ≥ 3SD for the LGEDL and LGEO, respectively.ConclusionsSTRM selection for LGEDL magnetic resonance images helps improve clinical decision-making in patients with UMI. This study underscored the importance of STRM selection for analyzing LGEDL images to enhance diagnostic accuracy and clinical decision-making for patients with UMI, further providing better cardiovascular care.

IS IT REALLY A CASE OF TAKOTSUBO? SOMETIMES APPEARENCES CAN BE DECEPTIVE

Abstract We report the case of a 22–year–old female with a history of David procedure and mechanical valve replacement (ATS 22 mm) due to bicuspid aortic valve and severe AR with ascending aorta aneurysm in 2015. Regular annual clinical follow–up (EKG and ultrasound) was always normal. Since 2022 the patient suffered from episodes of dyspnea, chest pain and sadness diagnosed as Panic Disorder. Home–therapy: Warfarin, estroprogestinic pill. At the latest outpatient visit she was asymptomatic and in good overall condition, but her EKG showed novel alterations (T wave inversion in antero–lateral leads and QT prolongation). She was then sent to the ED. LAB: troponin levels were normal (6.8 ng/ml) with an elevated Nt–proBNP (425 ng/ml) and a low INR (1.53). Questioned about recent events she reported a road trauma which occurred two weeks prior. She was then admitted to Cardiology clinic. Ultrasound: apical akinesia with reduced wall thickness, EF 48%, E/E‘ 10, and normal right ventricular function. The aortic valve prosthesis was functional without pathological regurgitation, and other echocardiographic parameters were within normal limits. EKG and ultrasound abnormalities along with a recent history of trauma supported Takotsubo Syndrome diagnosis (InterTAK score = 79.8% – 67pt), even though troponin levels were normal. Throughout hospitalization there were no changes in the EKG or pathological increases in troponin, and the patient remained asymptomatic. The patient was treated with LMWH to achieve adequate INR levels and initiated on B–blocker, ACEi, and SGLT2i for HFmrEF. Cardiac MRI revealed apical segment akinesia with dilation and reduced wall thickness (EDV 97 ml/m²), EF 41%, transmural ischemic LGE in the apical region and a ventricular thrombus (16x4 mm). The patient underwent coronary angiography which showed normal epicardial coronary arteries. Upon careful history–taking, the patient admitted irregular intake of VKA in the previous months. Given this information, the MRI and angiographic findings the diagnosis of unrecognized prior acute coronary syndrome, likely due to coronary thromboembolism in a patient with PHV and suboptimal compliance with VKA, was established. The patient was discharged home upon achieving a persistently therapeutic INR, with instructions to discontinue contraceptive therapy. Conclusion: coronary thromboembolism is a rare complication of PHV with inadequate anticoagulation leading, in this case, to an unrecognized MI.

Diagnostic and prognostic value of cardiac troponins in emergency department patients presenting after a fall: A prospective, multicenter study.

Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF. This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient. In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the goldstandard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both). A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.

Clinical research progress in detecting unrecognized myocardial infarction using cardiac magnetic resonance imaging

Clinical research progress in detecting unrecognized myocardial infarction using cardiac magnetic resonance imaging

Association between subclinical atherosclerosis burden and unrecognized myocardial infarction detected by cardiac magnetic resonance in middle-aged low-risk adults.

Evidence on the association between subclinical atherosclerosis (SA) and cardiovascular (CV) events in low-risk populations is scant. To study the association between SA burden and an ischaemic scar (IS), identified by cardiac magnetic resonance (CMR), as a surrogate of CV endpoint, in a low-risk population. A cohort of 712 asymptomatic middle-aged individuals from the Progression of Early SA (PESA-CNIC-Santander) study (median age 51 years, 84% male, median SCORE2 3.37) were evaluated on enrolment and at 3-year follow-up with 2D/3D vascular ultrasound (VUS) and coronary artery calcification scoring (CACS). A cardiac magnetic study (CMR) was subsequently performed and IS defined as the presence of subendocardial or transmural late gadolinium enhancement (LGE). On CMR, 132 (19.1%) participants had positive LGE, and IS was identified in 20 (2.9%) participants. Individuals with IS had significantly higher SCORE2 at baseline and higher CACS and peripheral SA burden (number of plaques by 2DVUS and plaque volume by 3DVUS) at both SA evaluations. High CACS and peripheral SA (number of plaques) burden were independently associated with the presence of IS, after adjusting for SCORE2 [OR for 3rd tertile, 8.31; 95% confidence interval (CI) 2.85-24.2; P < 0.001; and 2.77; 95% CI, 1.02-7.51; P = 0.045, respectively] and provided significant incremental diagnostic value over SCORE2. In a low-risk middle-aged population, SA burden (CAC and peripheral plaques) was independently associated with a higher prevalence of IS identified by CMR. These findings reinforce the value of SA evaluation to early implement preventive measures. Progression of Early Subclinical Atherosclerosis (PESA) Study Identifier: NCT01410318.

Abstract TMP99: Risk of Stroke Recurrence and Silent Myocardial Infarction

Background: Prior data suggest that unrecognized or silent myocardial infarction (MI) detected on routine ECG is associated with first-ever stroke, but the impact on stroke recurrence is unknown. We aimed to determine the association of silent MI with stroke recurrence in patients with recent ischemic stroke. Methods: We included all subjects with an index stroke and available baseline ECG enrolled in the Insulin Resistance in Ischemic Stroke (IRIS) trial. Clinical MI was defined as a prior hospitalization for MI. Silent MI was defined as ECG evidence of MI (Q wave or equivalent patterns) without prior hospitalization for MI. The primary outcome was recurrent stroke. Ischemic stroke and ischemic stroke subtype were assessed as secondary outcomes. Multivariate cox regression adjusted for age, sex, race, pioglitazone, and vascular risk factors was performed for analysis. Results: Of 2285 participants analyzed, prior clinical and silent MI were identified in 164 (7.2%) and 94 (4.1%) patients respectively. Over an average of 4.5 years, 209 recurrent strokes occurred with 191 classified as ischemic. In the fully adjusted model, silent MI was associated with stroke (HR 2.27, CI 1.33-3.88) and ischemic stroke (HR 2.08, CI 1.17-3.68) recurrence. Clinical MI was associated with stroke and ischemic stroke recurrence in the unadjusted analysis; however, the association was no longer significant after adjustment (all stroke: HR 1.31, CI 0.81-2.11; ischemic stroke: HR 1.42, CI 0.87-2.32). No association between silent MI and stroke subtype was significant. Discussion: Among patients with a recent ischemic stroke, silent MI is associated with stroke recurrence. Tailored secondary stroke prevention strategies in this population require future investigation.

Sex and ethnic differences in unrecognized myocardial infarctions: Observations on recognition and preventive therapies from the multiethnic population-based HELIUS cohort

BackgroundEpidemiological studies suggest sex differences in the prevalence and characteristics of unrecognized and recognized myocardial infarction (uMI, rMI). Despite increasingly diverse populations, observations are limited in multiethnic contexts. Gaining better understanding may inform policy makers and healthcare professionals on populations at risk of uMI who could benefit from preventive measures. MethodsWe used baseline data from the multiethnic population-based HELIUS cohort (2011–2015; Amsterdam, the Netherlands). Using logistic regressions, we studied sex differences in the prevalence and proportion of uMIs across ethnic groups. Next, we studied whether symptoms, clinical parameters, and sociocultural factors were associated with uMIs. Finally, we compared secondary preventive therapies in women and men with a uMI or rMI. We relied on pathological Q-waves on a resting electrocardiogram as the electrocardiographic signature for (past) MI. ResultsOverall, and in Turkish and Moroccan subgroups, the prevalence of uMIs was higher in men than women. The proportion of uMIs was similar in women (21.0%) and men (18.4%), yet varied by ethnicity. In women and men, symptoms (chest pain, dyspnea) and clinical parameters (hypertension, hypercholesterolemia), and in women also lower educational level and diabetes were associated with lower odds of uMIs. Women (0.0%) and men (3.6%) with uMI were unlikely to receive secondary preventive therapies compared to those with rMI (28.1–40.9%). ConclusionsThe prevalence of uMIs was higher in men than women, and sex differences in the proportion of uMIs varied somewhat across ethnic groups. People with uMIs did not receive adequate preventative medications, posing a risk for recurrent events.

Detection of unrecognized myocardial infarction by preprocedural transthoracic echocardiography in patients undergoing elective percutaneous coronary intervention.

Previous studies showed that unrecognized myocardial infarction (UMI) identified on cardiac magnetic resonance (CMR) was related to worse prognosis. We aimed to investigate the efficacy of preprocedural transthoracic echocardiography (TTE) to detect the presence of UMI in patients undergoing percutaneous coronary intervention (PCI). A total of 138 patients with chronic coronary syndrome (CCS) and preserved left ventricular ejection fraction (LVEF) without history of myocardial infarction or revascularization were retrospectively studied. UMI was evaluated with pre-PCI late gadolinium enhancement (LGE)-CMR. TTE and two-dimensional speckle-tracking echocardiography (2D-STE) were performed before PCI. All patients were divided into two groups according to the presence or absence of UMI, and clinical and echocardiographic findings were compared between these two groups. UMI was detected in 43 patients (31.2%). Multivariable logistic regression analysis revealed that higher SYNTAX score, the presence of wall motion abnormalities (WMAs) and lower global longitudinal strain (GLS) were independent predictors of the presence of UMI. Furthermore, GLS provided incremental efficacy for the detection of UMI over abnormal Q waves, SYNTAX score and WMAs. Preprocedural TTE in combination with 2D-STE could help identify patients with UMI regardless of the presence or absence of ECG findings and WMAs.

Prevalence of traditional cardiovascular risk factors in subjects with unrecognized myocardial infarction: a systematic review and meta-analysis

Abstract Background Unrecognized myocardial infarction (UMI) is defined as myocardial ischemia (MI) that was not recognized as such during the acute phase, but later identified by pathological Q waves on an electrocardiogram (ECG), myocardial imaging evidence, or pathological findings on autopsy. Previous studies found that UMI accounts for up to 50% of all MIs, especially in women and the elderly. UMI is associated with increased risk of adverse cardiovascular outcomes and mortality, similar to subjects with recognized myocardial infarction (RMI). However, associated risk factors of UMI remain understudied. Purpose We aimed to summarize and combine the evidence on the associations between traditional cardiovascular risk factors and UMI in the general population. We also sought to assess sex differences in these risk factors. Methods A systematic search of general population-based cohort studies investigating UMI and reporting traditional cardiovascular risk factors of subjects with UMI and subjects without MI was performed through Embase, Medline, and Google Scholar up to 7 February 2023. Study selection, data extraction and risk of bias were assessed independently by 2 authors. Pooled standardized mean differences (SMD) or odds ratios (ORs) with 95% confidence intervals (CI) of traditional cardiovascular risk factors were determined, comparing UMI to subjects without MI. Random-effects meta-analyses were performed. If data allowed, analyses were repeated stratified by sex. Results A total of 17 studies were included involving 216,858 individuals, among which 4,717 experienced UMI (mean age 66.1±8.3 year, 49% women). UMI was diagnosed through ECG in 14 studies and MRI in 3 studies. All studies established diagnosis of UMI and risk factors in a cross-sectional manner. Compared to subjects without MI, individuals with UMI demonstrated significantly larger values of BMI (SMD 0.05, 95% CI 0.03-0.08) and SBP (SMD 0.25, 95% CI 0.12-0.39), and higher prevalence of hypertension (OR 1.71, 95% CI 1.07-2.72) and diabetes mellitus (DM) (OR 1.81, 95% CI 1.40-2.34). Risk factors were reported stratified by sex in 3 studies. The relation between hypertension and UMI was stronger in women than in men. In contrast, the association of DM with UMI was weaker in women. However, these differences were statistically non-significant. Conclusion BMI, SBP, hypertension and diabetes mellitus are associated with an increased risk of UMI, similar to RMI. Limited evidence from studies stratified for sex indicate a differential impact of traditional risk factors on UMI in women and men.

Effect of symptoms recognition in patients with recurrent acute myocardial infarction: from KRAMI-RCC

Abstract Background Clinical significance of self-recognition for myocardial infarction symptom in the general population has been well-known. However, evidence of self-recognition for ischemic symptoms in patients with recurrent myocardial infarction is limited. The study is aimed to verify the association between self-recognition and clinical characteristics, and clinical outcomes in patients with recurrent myocardial infarction. Method From 2016 to 2019, the Korean Registry of Acute Myocardial Infarction for Regional Cardiocerebrovascular Centers (KRAMI-RCC), a web-based registry for myocardial infarction in South Korea, was used. We divided into two groups based on self-recognition in questionnaire. Patient characteristics and clinical outcomes were analyzed. Result Among 11,894 MI patients, the rate of recurrent MI was 9.7%. The rate of self-recognition in subjects with first MI and recurrent MI was 14.4% and 52.0%, respectively (p&amp;lt;0.001). Patients without responses to the self-recognition questionnaire were excluded (n=86). Finally, enrolled subjects were 1,050. Males had a higher rate of self-recognition (79.3% vs. 69.0%). Younger patients, higher graduation levels, and living with a spouse were associated with the well-recognized symptoms. Chest pain, cold sweating, and radiating pain were related to being noticed as a symptom of MI. However, no difference of respiratory difficulties and stomachache in both groups was observed. The unrecognized group had more frequently occurred with cardiogenic shock and heart failure. A history of stroke and malignancy was associated with a low incidence of recognition. Patients with dyslipidemia had a high recognition rate. There was no difference of symptom recognition between ST elevation MI and non-ST elevation MI. Interestingly, previously registered patients in KRAMI-RCC were significantly associated with higher recognition. The symptom recognition was related to prompt visit in regional cardiovascular centers (57% vs. 47%, p=0.002). The in-hospital mortality rate in the unrecognized group was higher at 6.7% compared to the recognized group (1.5%, p&amp;lt;0.000). Unrecognized MI symptoms and a presentation with cardiogenic shock were independent predictors in multivariate analysis to predict a model for in-hospital mortality. Conclusion The MI symptom recognition rate was still low in patients with recurrent MI. Self-recognition of MI symptoms was an independent predictor for in-hospital mortality. In this study, it is thought that rapid symptom recognition might help patients with myocardial infarction visit the hospital as soon as possible, thereby reducing cardiogenic shock and death.Multivariable analysisSelf-recognition and Outcomes

Safety and outcomes analysis: transcatheter implantation of autologous angiogenic cell precursors for the treatment of cardiomyopathy

BackgroundStem cell transplantation is an emerging therapy for severe cardiomyopathy, proffering stem cell recruitment, anti-apoptosis, and proangiogenic capabilities. Angiogenic cell precursors (ACP-01) are autologous, lineage-specific, cells derived from a multipotent progenitor cell population, with strong potential to effectively engraft, form blood vessels, and support tissue survival and regeneration.MethodsThis IRB approved outcome analysis reports upon 74 consecutive patients who failed medical management for severe cardiomyopathy, and were selected to undergo transcatheter intramyocardial or intracoronary implantation of ACP-01. Serious adverse events (SAEs) were reported. Cell analysis was conducted for each treatment. The left ventricular ejection fraction (LVEF) was measured by multi-gated acquisition scan (MUGA) or echocardiogram at 4 months ± 1.9 months and 12 months ± 5.5 months. Patients reported quality of life statements at 6 months (± 5.6 months).ResultsFifty-four of 74 patients met requirements for inclusion (48 males and five females; age 68.1 ± 11.3 years). The mean treatment cell number of 57 × 106 ACP-01 included 7.7 × 106 CD34 + and 21 × 106 CD31 + cells with 97.6% viability. SAEs included one death (previously unrecognized silent MI), ventricular tachycardia (n = 2) requiring cardioversion, and respiratory infection (n = 2). LVEF in the ischemic subgroup (n = 41) improved by 4.7% ± 9.7 from pre-procedure to the first follow-up (4 months ± 1.9 months) (p < 0.004) and by 7.2% ± 10.9 at final follow-up (n = 25) at average 12 months (p < 0.004). The non-ischemic dilated cardiomyopathy subgroup (n = 8) improved by 7.5% ± 6.0 at the first follow-up (p < 0.017) and by 12.2% ± 6.4 at final follow-up (p < 0.003, n = 6). Overall improvement in LVEF from pre-procedure to post-procedure was significant (Fisher’s exact test p < 0.004). LVEF improvement was most marked in the patients with the most severe cardiomyopathy (LVEF < 20%) improving from a mean 14.6% ± 3.4% pre-procedurally to 28.4% ± 8% at final follow-up. Quality of life statements reflected improvement in 33/50 (66%), no change in 14/50 (28%), and worse in 3/50 (6%).ConclusionTranscatheter implantation of ACP-01 for cardiomyopathy is safe and improves LVEF in the setting of ischemic and non-ischemic cardiomyopathy. The results warrant further investigation in a prospective, blinded, and controlled clinical study.Trial Registration: IRB from Genetic Alliance #APC01-001, approval date July 25, 2022.Condensed Cardiomyopathy is common and associated with high mortality. Stem cell transplantation is an emerging therapy. Angiogenic cell precursors (ACP-01) are lineage-specific endothelial progenitors, with strong potential for migration, engraftment, angiogenesis, and support of tissue survival and regeneration. A retrospective outcomes analysis of 53 patients with ischemic and non-ischemic dilated cardiomyopathy undergoing transcatheter implantation of ACP-01 demonstrated improvements in the left ventricular ejection fraction of 7.2% ± 10.9 (p < 0.004) and 12.2% ± 6.4, respectively, at 12 months (± 5) follow-up. Quality of life statements reflected improvement in 33/50 (66%) patients.

Reassessing the clinical significance of electrocardiographically unrecognized myocardial infarctions: Radionuclide infarct size and its impact on long-term prognosis.

Silent or unrecognized myocardial infarction (UMI) diagnosed by surveillance electrocardiography (ECG) carries similarly poor prognosis as recognized MI (RMI) for poorly understood reasons. This study included 5430 consecutive patients who presented to the nuclear laboratory and underwent 2-day stress and rest Tc-99m sestamibi and ECG studies between March 1991 and June 1999. UMI was diagnosed if ECG showed Q-wave MI in the absence of a history of RMI. We measured infarct size (% defect size as compared with the entire left ventricular sestamibi uptake), ejection fraction (EF, %), and summed difference score (SDS, sestamibi uptake by myocardium in stress minus sestamibi uptake in rest images as a marker of ischemia). Survival was determined by follow-up survey (median 6 years). We identified 346 UMIs, 628 RMIs, and 4456 subjects without MI (No MI). As compared with RMI, UMI patients had lesser abnormalities on nuclear scans (p < .0001 for all), including smaller infarct size (5.7% vs. 12.2%), higher EF (58% vs. 53%), and lesser ischemia (SDS; 3.9% vs. 2.7%). UMI prognosis was as poor as that of RMI (annual mortality rate 4.7% vs. 4.8% with No MI rate of 2.9%; p < .001 for all comparisons), and this persisted after multivariate analysis. Infarct size quantification successfully risk-stratified ECG-UMI patients, but UMI patients continued to predict mortality even if the infarct size was 0%. Although UMI patients have lesser abnormalities on nuclear scans, ECG-based UMI continues to independently predict mortality, indicating the continuing relevance of ECG in clinical practice.

Prognostic implications of unrecognized myocardial infarction and periprocedural myocardial injury on cardiac magnetic resonance imaging in patients with chronic coronary syndrome

This study sought to evaluate the prognostic implications of the presence of preprocedural unrecognized myocardial infarction (UMI) and periprocedural myocardial injury (PMI) evaluated by delayed gadolinium enhancement cardiac magnetic resonance (DE-CMR) in patients with chronic coronary syndrome (CCS) undergoing elective percutaneous coronary intervention (PCI). We enrolled 250 CCS patients scheduled for elective PCI. UMI was defined as the presence of late gadolinium enhancement (LGE) detected by pre-PCI CMR in the region without medical history of revascularization and/or MI. Periprocedural new occurrence or increased volume of LGE in the target territory detected by post-PCI CMR (PPL) were used to assess PMI. In the final analysis of 235 patients, UMI and PPL were detected in 43 patients (18.3%) and 45 patients (19.1%), respectively. During follow-up for a median of 2.2 years, major adverse cardiac events (MACE) occurred in 31 (13.2%) patients. On multivariable analysis, UMI and PPL remained as significant predictors of MACE after adjusting confounding factors (HR 4.62, 95% CI 2.24–9.54, P < 0.001, HR 2.33, 95% CI 1.11–4.91, P = 0.026). In patients with CCS who underwent elective PCI, UMI and PPL were independent predictors of worse outcomes. UMI and PPL on DE-CMR might provide additional potential insight for the risk stratification of patients undergoing elective PCI.

Multimodality coronary imaging to predict non-culprit territory unrecognized myocardial infarction in Non-ST-Elevation acute coronary syndrome.

Unrecognized myocardial infarction (UMI) detected by cardiac magnetic resonance (CMR) imaging is associated with adverse outcomes in patients with acute and chronic coronary syndrome. This study aimed to assess the predictors of optical coherence tomography (OCT) and coronary computed tomography angiography (CCTA) findings for non-infarct-related (non-IR) territory UMI in patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS). We investigated 69 patients with a first clinical episode of NSTE-ACS who underwent pre-percutaneous coronary intervention (PCI) 320-slice CCTA, uncomplicated urgent PCI with OCT assessment within 24h of admission, and post-PCI CMR. UMI was assessed using late gadolinium enhancement to identify regions of hyperenhancement with an ischemic distribution pattern in non-IR territories. Non-IR UMI was detected in 11 patients (15.9%). Lower ejection fraction, higher Gensini score, higher Agatston score, high pericoronary adipose tissue attenuation (PCATA), OCT-defined culprit lesion plaque rupture, and OCT-defined culprit lesion cholesterol crystal were significantly associated with the presence of non-IR UMI. On dividing the total cohort was divided into five groups according to the numbers of two OCT-derived risk factors and two CCTA-derived risk factors, the frequency of non-IR UMI frequency significantly increased according to the number of these relevant risk features (p < 0.001). Patients with all of the non-IR UMI risk factors showed 50% prevalence of non-IR UMI, compared with 2.2% of patients with low risk factors (≤ 2). Integrated CCTA and culprit lesion OCT assessment may help identify the presence of non-IR UMI, potentially providing prognostic information in patients with first NSTE-ACS episode.

Prognostic implications of non-infarct-related territory unrecognized myocardial infarction in patients with non-ST-segment-elevation acute coronary syndrome

BackgroundPrognostic value of non-infarct-related territory (non-IR) unrecognized myocardial infarction (UMI) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) remains to be elucidated. We sought to evaluate the prognostic impact of non-IR UMI in patients with first NSTE-ACS presentation. MethodsThis retrospective single-center analysis was conducted in patients with NSTE-ACS without prior history of coronary artery disease, who underwent uncomplicated urgent percutaneous coronary intervention (PCI) within 48 h of admission between August 2014 and January 2018. All patients underwent postprocedural cardiac magnetic resonance imaging (CMR) within 30 days after PCI. Non-IR UMI was defined as the presence of non-IR delayed gadolinium enhancement with an ischemic distribution pattern. We investigated the association of non-IR UMI, other CMR findings and baseline clinical characteristics with major adverse cardiac events (MACE), defined as death, non-fatal myocardial infarction, stroke, late revascularization, and hospitalization for congestive heart failure. ResultsA total of 168 NSTE-ACS patients were included [124 men (73.8 %); 66 ± 11 years]. Non-IR UMI was detected in 28 patients (16.7 %). During a median follow-up of 32 (15–58) months, MACE occurred in 10 (35.7 %) patients with non-IR UMI, and 20 (14.3 %) patients without (p = 0.013). Cox's proportional hazards analysis showed that the presence of non-IR UMI was an independent predictor of MACE (hazard ratio [HR], 2.37, 95 % confidence interval [CI], 1.09–5.18, p = 0.030). In patients with NSTE-ACS undergoing urgent PCI, the prevalence of non-IR UMI was 16.7 %. ConclusionsNon-IR UMI provided prognostic information independent of conventional risk factors and the extent of myocardial injury caused by NSTE-ACS.

P371 CONFOUNDING CARDIAC MARKERS IN A CASE OF COVID–19 MYOCARDITIS

Abstract Background–Aim A man of 81 years, with previous coronary artery disease, unrecognized myocardial infarction, carrier of implanted pacemaker, presented to the cardiology department for a scheduled hospitalization to treat shortness of breath and symptoms of heart failure. There was no chest pain, ECG poorly assessable for pacemaker–induced rhythm, cardiac troponin I of 35,879 ng/L (cut–off 20). Suspecting an acute coronary syndrome (ACS), the patient undergoes immediate coronary angiography that does not showed any change compared to a previous examination. Meanwhile SARS–CoV–2 research in nasopharyngeal swab by RT–PCR was positive and after a few hours fever appears. Methods The authors discussed the case and extensive monitoring of cardiac markers and intensive evaluation of clinical parameters were activated. Troponin I HS, CK–MB, Myoglobin (Beckman Coulter DxI), CK, AST, LDH are determined by routine methods (Beckman Coulter AU700), Troponin T (cTnT–hs Roche Diagnostics) on (Roche Cobas 8000). Results All markers (except Troponin T) had the typical pattern of an ACS, in accordance with their characteristic half–life of an acute insult with development of a peak and subsequent decrease in a few days. The peaks recorded were cTnI 35,789 ng/L, CK–MB 72.6 ug/L, CK 800 U/L, AST 1,51U/L, Myoglobin 244 ng/ml, LDH 600 U/L, all at time 0. Troponin T was moderately increased at presentation (3700 ng/L, cut–off 10) followed by a peak of 3,872 after 2 hours stabilizing around 2,800 ng/L for the next days and decreasing after day 7. The final diagnosis was acute COVID–19–related myocarditis. Conclusions It has been described that the presentation of a SARS–CoV–2 infection can sometimes simulate a condition of ACS when there is an inflammatory involvement of the heart. In this case all the clinical data pointed towards an ischemic pathology which, however, was excluded in diagnostic imaging. A conclusive assessment with cardiac MRI was not possible due to the presence of the pacemaker, so the diagnosis was made as probable. Among the different markers, Troponin I was found to express a more intense signal and an earlier positive evolution than that of Troponin T. Our report highlights the different evolution of cardiac troponins in this disease.

Myocardial Infarction Signs and Symptoms: Females vs. Males.

Cardiovascular disease is the number one killer of females in the United States today, and myocardial infarction (MI) plays a role in many of these deaths. Females also present with more "atypical" symptoms than males and appear to have differences in pathophysiology underlying their MIs. Despite both differences in symptomology and pathophysiology being present in females versus males, a possible link between the two has not been studied extensively. In this systematic review, we analyzed studies examining differences in symptoms and pathophysiology of MI in females and males and evaluated possible links between the two. A search was performed for sex differences in MI in the databases PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Biomedical Reference Collection: Comprehensive, Jisc Library Hub Discover, and Web of Science. Seventy-four articles were ultimately included in this systematic review. Typical symptoms for both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) such as chest, arm, or jaw pain were more common in both sexes, but females presented on average with more atypical symptoms such as nausea, vomiting, and shortness of breath. Females with MI also presented with more prodromal symptoms such as fatigue in days leading up to MI, had longer delays in presentation to the hospital after symptom onset, and were older with more comorbidities than males. Males on the other hand were more likely to have a silent or unrecognized MI, which concurs with their overall higher rate of MI. As they age, females have a decrease in antioxidative metabolites and worsened cardiac autonomic function than male. In addition, at all ages, females have less atherosclerotic burden than mles, have higher rates of MI not related to plaque rupture or erosion, and have increased microvasculature resistance when they have an MI. It has been proposed that this physiological difference is etiologic for the male-female difference in symptoms, but this has not been studied directly and is a promising area of future research. It is also possible that differences in pain tolerance between males and females may play a role in differing symptom recognition, but this has only been studied one time where females with higher pain thresholds were more likely to have unrecognized MI. Again, this is a promising area for future study for the early detection of MI. Finally, differences in symptoms for patients with different atherosclerotic burden and for patients with MI due to a cause other than plaque rupture or erosion has not been studied and are both promising avenues to improve detection and patient care in the future.

Prognostic value of unrecognized myocardial infarction and silent ischemia detected by stress CMR in asymptomatic patients with prior cryptogenic ischemic stroke

Prognostic value of unrecognized myocardial infarction and silent ischemia detected by stress CMR in asymptomatic patients with prior cryptogenic ischemic stroke

Prognostic implications of unrecognized myocardial infarction before elective percutaneous coronary intervention

Unrecognized myocardial infarction (UMI) is associated with adverse outcomes. This prospective, single-center study elucidated the prevalence and prognostic significance of UMI before elective percutaneous coronary intervention (PCI) using delayed-enhancement cardiac magnetic resonance (DE-CMR). We enrolled 236 patients with stable coronary artery disease who underwent DE-CMR before elective PCI. The prevalence of UMI and the association of clinical and CMR-derived variables with major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal MI, hospitalization for congestive heart failure, and unplanned late revascularization, were assessed. Final analysis revealed that 63/213 (29.6%) patients had UMI. Target territory UMI was observed in 38 patients (17.8% of the total cohort, 60.3% of patients with UMI). UMI was significantly associated with sex, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and fractional flow reserve in the target vessels. During follow-up (median, 23 months), MACE occurred in 17 (27.0%) patients with UMI and 17 (11.3%) without UMI (P = 0.001). Multivariable modeling revealed that UMI (hazard ratio: 2.18, 95%CI, 1.10–4.33, P = 0.001) was an independent predictor of MACE. Kaplan–Meier analysis indicated that the presence of UMI was significantly associated with a higher incidence of MACE. UMI was independently associated with a greater risk of MACE after successful PCI.