Combined assessment of stress cardiovascular magnetic resonance and angiography to predict the effect of revascularization in chronic coronary syndrome patients

[EN] 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.This work was supported by the Instituto de Salud Carlos III and co-funded by Fondo Europeo de Desarrollo Regional (FEDER) (PI20/00637 and CIBERCV16/11/00486) and by Sociedad Espanola de Cardiologia (SEC/FEC-INV-CLI 21/024). J.G. acknowledges financial support from the Agencia Estatal de Investigacion (FJC2020-043981-I/AEI/10.13039/501100011033). D.M. acknowledges financial support from the Conselleria d'Educacio, Investigacio, Cultura i Esport, Generalitat Valenciana (AEST/2019/037 and AEST/2020/029).Gavara-Doñate, J.; Pérez, N.; Marcos-Garces, V.; Monmeneu, JV.; Lopez-Lereu, MP.; Rios-Navarro, C.; De Dios, E.... (2022). Combined assessment of stress cardiovascular magnetic resonance and angiography to predict the effect of revascularization in chronic coronary syndrome patients. European Journal of Preventive Cardiology. 29(2):407-416. https://doi.org/10.1093/eurjpc/zwab17040741629

Sex Effect in the Decision to Perform Invasive Coronary Angiography in Patients With Chronic Coronary Syndrome After Undergoing Vasodilator Stress MRI

[EN] 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.This work was supported by "Instituto de Salud Carlos III" and "Fondos Europeos de Desarrollo Regional FEDER" (grant numbers PI20/00637 and CIBERCV16/11/00486), by Conselleria de Educacio - Generalitat Valenciana (grant number PROMETEO/2021/008), and by the Spanish Society of Cardiology (grant number SEC/FECINV-CLI 21/024).Palau, P.; Núñez, J.; Monmeneu, JV.; Lopez-Lereu, MP.; Gavara-Doñate, J.; Rios-Navarro, C.; De Dios, E.... (2022). Sex Effect in the Decision to Perform Invasive Coronary Angiography in Patients With Chronic Coronary Syndrome After Undergoing Vasodilator Stress MRI. Journal of Magnetic Resonance Imaging. 56(6):1680-1690. https://doi.org/10.1002/jmri.281631680169056

Longitudinal strain in remote non-infarcted myocardium by tissue tracking CMR: characterization, dynamics, structural and prognostic implications

[EN] Purpose In ST-segment elevation myocardial infarction (STEMI) patients, longitudinal strain (LS) in remote non-infarcted myocardium (RNM) has not yet been characterized by tissue tracking (TT) cardiovascular magnetic resonance (CMR). In STEMI patients, we aimed to characterize RNM-LS by TT-CMR and to assess both its dynamics and its structural and prognostic implications. Methods We recruited 271 patients with a first STEMI studied with TT-CMR 1 week after infarction. Of these patients, 145 underwent 1-week and 6-month TT-CMR and were used to characterize both the dynamics and the short-term and long-term structural implications of RNM-LS. Based on previously validated data, RNM areas were defined depending on the culprit coronary artery. Results Reduced RNM-LS at 1 week (n = 70, 48%) was associated with larger infarct size and more depressed left ventricular ejection fraction (LVEF) at both the 1-week and 6-month TT-CMR (p value < 0.001). Late normalization of RNM-LS was frequent (28/70, 40%) and independently related to late recovery of LVEF (p value = 0.002). Patients with reduced RNM-LS at 1-week TT-CMR had more major adverse cardiac events (death, heart failure or re-infarction) in both the 271 patients included in the study group (26% vs. 11%, p value = 0.002) and in an external validation cohort made up of 177 STEMI patients (57% vs. 13%, p value < 0.001). Conclusion After STEMI, reduced RNM-LS by TT-CMR is common and is associated with more severe short- and long-term structural damage. There is a beneficial tendency towards recovery of RNM-LS that parallels late recovery of LVEF. More events occur in patients with reduced RNM-LS.This work was supported by the Instituto de Salud Carlos III and co-funded by Fondo Europeo de Desarrollo Regional (FEDER) [Grant Numbers PI17/01836, PIE15/00013, CIBERCV16/11/00486, CIBERCV16/11/00479 and a postgraduate contract FI18/00320 to C. R.-N.] and by the Generalitat Valenciana [Grant Number GV/2018/116]. JG and DM acknowledge financial support from the Agencia Valenciana de la Innovacio, Generalitat Valenciana (Grant INNCAD00/18/026).Gavara-Doñate, J.; Rodríguez-Palomares, JF.; Rios-Navarro, C.; Valente, F.; Monmeneu, JV.; Lopez-Lereu, MP.; Ferreira-González, I.... (2021). Longitudinal strain in remote non-infarcted myocardium by tissue tracking CMR: characterization, dynamics, structural and prognostic implications. International Journal of Cardiovascular Imaging. 37(1):241-253. https://doi.org/10.1007/s10554-020-01890-wS24125337

Residual ST-segment elevation to predict long-term clinical and CMR-derived outcomes in STEMI

[EN] Residual ST-segment elevation after ST-segment elevation myocardial infarction (STEMI) has traditionally been considered a predictor of left ventricular (LV) dysfunction and ventricular aneurism. However, the implications in terms of long-term prognosis and cardiac magnetic resonance (CMR)-derived structural consequences are unclear. A total of 488 reperfused STEMI patients were prospectively included. The number of Q wave leads with residual ST-segment elevation> 1 mm (Q-STE) at pre-discharge ECG was assessed. LV ejection fraction (LVEF, %) and infarct size (IS, % of LV mass) were quantifed in 319 patients at 6-month CMR. Major adverse cardiac events (MACE) were defned as all-cause death and/or re-admission for acute heart failure (HF), whichever occurred frst. During a mean follow-up of 6.1 years, 92 MACE (18.9%), 39 deaths and 53 HF were recorded. After adjustment for baseline characteristics, Q-STE (per lead with> 1 mm) was independently associated with a higher risk of long-term MACE (HR 1.24 [1.07¿1.44] per lead, p = 0.004), reduced (< 40%) LVEF (HR 1.36 [1.02¿1.82] per lead, p = 0.04) and large (> 30% of LV mass) IS (HR 1.43 [1.11¿1.85] per lead, p = 0.006) at 6-month CMR. Patients with Q-STE¿ 2 leads (n= 172, 35.2%) displayed lower MACE-free survival, more depressed LVEF, and larger IS at 6-month CMR (p< 0.001 for all comparisons). Residual ST-segment elevation after STEMI represents a universally available tool that predicts worse longterm clinical and CMR-derived structural outcomes.This work was supported by the Instituto de Salud Carlos III and co-funded by Fondo Europeo de Desarrollo Regional (FEDER) (Grants PI20/00637 and CIBERCV16/11/00486, postgraduate contract FI18/00320 to C.R.-N. and CM21/00175 to V.M.-G.), Generalitat Valenciana (Grant PROMETEO/2021/008), and by Sociedad Espanola de Cardiologia (Grant SEC/FECINV-CLI 21/024). J. G. acknowledges financial support from the Agencia Estatal de Investigacion (Grant FJC2020-043981-I/AEI/).Merenciano-Gonzalez, H.; Marcos-Garces, V.; Gavara-Doñate, J.; Pedro-Tudela, A.; Lopez-Lereu, MP.; Monmeneu, JV.; Pérez, N.... (2022). Residual ST-segment elevation to predict long-term clinical and CMR-derived outcomes in STEMI. Scientific Reports. 12(1):1-12. https://doi.org/10.1038/s41598-022-26082-511212

Impact of Epicardial Adipose Tissue on Infarct Size and Left Ventricular Systolic Function in Patients with Anterior ST-Segment Elevation Myocardial Infarction

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