Advances in magnetic resonance imaging of the myocardial area at risk and salvage

No abstract available

How to mend a broken heart?

No abstract available

Advances in computational modelling for personalised medicine after myocardial infarction

Myocardial infarction (MI) is a leading cause of premature morbidity and mortality worldwide. Determining which patients will experience heart failure and sudden cardiac death after an acute MI is notoriously difficult for clinicians. The extent of heart damage after an acute MI is informed by cardiac imaging, typically using echocardiography or sometimes, cardiac magnetic resonance (CMR). These scans provide complex data sets that are only partially exploited by clinicians in daily practice, implying potential for improved risk assessment. Computational modelling of left ventricular (LV) function can bridge the gap towards personalised medicine using cardiac imaging in patients with post-MI. Several novel biomechanical parameters have theoretical prognostic value and may be useful to reflect the biomechanical effects of novel preventive therapy for adverse remodelling post-MI. These parameters include myocardial contractility (regional and global), stiffness and stress. Further, the parameters can be delineated spatially to correspond with infarct pathology and the remote zone. While these parameters hold promise, there are challenges for translating MI modelling into clinical practice, including model uncertainty, validation and verification, as well as time-efficient processing. More research is needed to (1) simplify imaging with CMR in patients with post-MI, while preserving diagnostic accuracy and patient tolerance (2) to assess and validate novel biomechanical parameters against established prognostic biomarkers, such as LV ejection fraction and infarct size. Accessible software packages with minimal user interaction are also needed. Translating benefits to patients will be achieved through a multidisciplinary approach including clinicians, mathematicians, statisticians and industry partners

Investors in People : research on the New Choices approach

"Investors in People (IIP) is a business development tool that was first launched in 1991. The IIP Standard enables organisations to assess how they are managing people, and where improvements can be made. There are 39 evidence requirements which must be met for an organisation to be recognised as meeting the IIP Standard. The New Choices approach to IIP was introduced in May 2009 to provide greater flexibility and customisation of IIP to an employer’s priorities and goals. It also allows progress beyond the IIP Standard and incorporates additional recognition in the form of Bronze, Silver and Gold award levels (for which organisations must provide evidence that they meet at least 65, 115 or 165 evidence requirements respectively). In April 2010, the UK Commission for Employment and Skills took over strategic ownership of IIP and was keen to understand the differences made by New Choices. The overall aim of this research is to identify the impact that the New Choices approach has had on perceptions and take up of IIP, with a view to informing future strategy for IIP and contributing to meeting longer-term objectives for IIP. The project methodology included: preliminary research (familiarisation with the IIP literature review, a review of management information, and discussions with key stakeholders); an e-survey of employers engaged with the New Choices approach; and 15 employer case studies to add depth to the understanding of how New Choices was working in practice. The New Choices approach was introduced across the UK in May 2009 (after being piloted in Scotland and some parts of England), so at the time of writing has been operational for less than two years. This is a relatively short period of time in which to judge the impact of the New Choices approach, as further benefits are likely to accrue over the long term. As such, this review has not identified significant direct benefits experienced by employers who have followed the extended framework and achieved a Bronze, Silver or Gold award level, though it has identified some changes that may contribute to increased business efficiency" - page i

Magnetic resonance imaging of myocardial strain after acute ST-segment-elevation myocardial infarction: a systematic review

The purpose of this systematic review is to provide a clinically relevant, disease-based perspective on myocardial strain imaging in patients with acute myocardial infarction or stable ischemic heart disease. Cardiac magnetic resonance imaging uniquely integrates myocardial function with pathology. Therefore, this review focuses on strain imaging with cardiac magnetic resonance. We have specifically considered the relationships between left ventricular (LV) strain, infarct pathologies, and their associations with prognosis. A comprehensive literature review was conducted in accordance with the PRISMA guidelines. Publications were identified that (1) described the relationship between strain and infarct pathologies, (2) assessed the relationship between strain and subsequent LV outcomes, and (3) assessed the relationship between strain and health outcomes. In patients with acute myocardial infarction, circumferential strain predicts the recovery of LV systolic function in the longer term. The prognostic value of longitudinal strain is less certain. Strain differentiates between infarcted versus noninfarcted myocardium, even in patients with stable ischemic heart disease with preserved LV ejection fraction. Strain recovery is impaired in infarcted segments with intramyocardial hemorrhage or microvascular obstruction. There are practical limitations to measuring strain with cardiac magnetic resonance in the acute setting, and knowledge gaps, including the lack of data showing incremental value in clinical practice. Critically, studies of cardiac magnetic resonance strain imaging in patients with ischemic heart disease have been limited by sample size and design. Strain imaging has potential as a tool to assess for early or subclinical changes in LV function, and strain is now being included as a surrogate measure of outcome in therapeutic trials

Pixel-tracking derived strain using the GlasgowHeart Method.

Background: Estimation of strain parameters from cine acquisitions, such as balanced steady state free precession (b-SSFP) is advantageous, as it would obviate the need for acquisition of additional strain sequences reducing scanning time and making strain more accessible to clinicians. 2D strain derived from feature-tracking is now commercially available. The GlasgowHeart cine-strain method is designed to overcome some limitations of currently available feature-tracking methods by estimating pixel-wise strain for myocardial deformation incorporating all of the myocardial tissues. The aims of this pilot study was to ensure that 2D peak circumferential strain estimated from the GlasgowHeart method is feasible in healthy volunteers (n = 20) and reproducible with minimal intra- and inter- observer variability. Methods: Healthy volunteers aged at least 18 years of age with no prior medical history were invited to participate. A subset of 20 healthy adult volunteers underwent 1.5T CMR twice, < 2 days apart. Written consent was obtained. Mid-LV cine sequences, were analysed with the GlasgowHeart software. The process involves contouring the myocardial borders at end-diastole and segmenting the myocardium by using the right ventricular insertion point according to the 16 segment AHA model. Two observers independently analysed 40 short axis slices using the cine-strain method for inter-observer variability. One observer re-analysed the 40 short axis slices 10 days later for intra-observer variability. Scans were analysed in a random order. Pearson correlation and Bland-Altman analysis were used to analyse the data. Results: 20 participants were used in the subset analysis (mean age ± SD 49.5 years (17.2) 50% male). Peak circumferential strain (Ecc) measured on the first set of MRIs by the two observers (Figure 2A,B) was highly correlated (R = 0.915, p < 0.001) and in excellent agreement (mean difference = 0.01; 95% LoA: -0.01, 0.02). The repeated image analysis (Figure 2C,D) also disclosed a high degree of association in paired measurements of Ecc that was strongly correlated(R= 0.915, p< 0.001) and in excellent agreement (mean difference = 0.00; 95% LoA: -0.02, 0.01). Ecc measured in the second set of MRIs by 2 observers was well correlated (R = 0.937, p < 0.001) and in excellent agreement (mean difference = 0.00; 95% limits of agreement were -0.016 and 0.021). The repeated image analysis at follow-up yielded Ecc that was well correlated(R= 0.942, p < 0.001) and in excellent agreement (mean = 0.00; 95% LoA: -0.009 and 0.009). There was no difference between the average global Ecc at different time points (p > 0.05)

Estimating prognosis in patients with acute myocardial infarction using personalized computational heart models

Biomechanical computational models have potential prognostic utility in patients after an acute ST-segment–elevation myocardial infarction (STEMI). In a proof-of-concept study, we defined two groups (1) an acute STEMI group (n = 6, 83% male, age 54 ± 12 years) complicated by left ventricular (LV) systolic dysfunction; (2) an age- and sex- matched hyper-control group (n = 6, 83% male, age 46 ± 14 years), no prior history of cardiovascular disease and normal systolic blood pressure (SBP < 130 mmHg). Cardiac MRI was performed in the patients (2 days & 6 months post-STEMI) and the volunteers, and biomechanical heart models were synthesized for each subject. The candidate parameters included normalized active tension (ATnorm) and active tension at the resting sarcomere length (Treq, reflecting required contractility). Myocardial contractility was inversely determined from personalized heart models by matching CMR-imaged LV dynamics. Compared with controls, patients with recent STEMI exhibited increased LV wall active tension when normalized by SBP. We observed a linear relationship between Treq 2 days post-MI and global longitudinal strain 6 months later (r = 0.86; p = 0.03). Treq may be associated with changes in LV function in the longer term in STEMI patients complicated by LV dysfunction. Further studies seem warranted

Changes and classification in myocardial contractile function in the left ventricle following acute myocardial infarction

In this research, we hypothesized that novel biomechanical parameters are discriminative in patients following acute ST-segment elevation myocardial infarction (STEMI). To identify these biomechanical biomarkers and bring computational biomechanics ‘closer to the clinic’, we applied state-of-the-art multiphysics cardiac modelling combined with advanced machine learning and multivariate statistical inference to a clinical database of myocardial infarction. We obtained data from 11 STEMI patients (ClinicalTrials.gov NCT01717573) and 27 healthy volunteers, and developed personalized mathematical models for the left ventricle (LV) using an immersed boundary method. Subject-specific constitutive parameters were achieved by matching to clinical measurements. We have shown, for the first time, that compared with healthy controls, patients with STEMI exhibited increased LV wall active tension when normalized by systolic blood pressure, which suggests an increased demand on the contractile reserve of remote functional myocardium. The statistical analysis reveals that the required patient-specific contractility, normalized active tension and the systolic myofilament kinematics have the strongest explanatory power for identifying the myocardial function changes post-MI. We further observed a strong correlation between two biomarkers and the changes in LV ejection fraction at six months from baseline (the required contractility (r = − 0.79, p < 0.01) and the systolic myofilament kinematics (r = 0.70, p = 0.02)). The clinical and prognostic significance of these biomechanical parameters merits further scrutinization

Clinical trials for the diagnosis and management of stable ischaemic heart disease: context, status and future implications

Chest pain and coronary artery disease (CAD) impose a substantial burden on public health and society. Diagnostic imaging tests are used by clinicians to identify the presence and extent of epicardial coronary disease and/or its consequences, including ischaemia, infarction, and left ventricular dysfunction. In this article, we discuss current practice guideline recommendations for the diagnosis and management of patients with suspected or known CAD, and the need for more evidence from clinical trials. We then focus on the recently published and ongoing multicentre clinical trials of imaging-based strategies for the diagnosis and management of ischaemic heart disease, and the potential future impact of these trials on clinical practice. The results of these trials have the potential to bring radical changes to the practice of cardiology in the future

Cardiovascular health technology assessment: recommendations to improve the quality of evidence

The aim of this article is to review the role of Health Technology Assessment (HTA) organisations in appraising and recommending innovative cardiovascular technologies. We consider how bias impairs the quality of evidence from clinical trials involving cardiovascular healthcare technologies. Finally, we provide recommendations to HTA organisations to take account of bias when making guideline recommendations. Clinical research studies of medical devices, diagnostics and interventions in cardiovascular healthcare are susceptible to impairment through bias. While HTA organisations, such as the National Institute of Health and Care Excellence, may require reviewers to take account of bias, there are uncertainties as to how this is achieved, especially in cardiovascular technology trials. This becomes more relevant given that large trials are few in number; therefore, the quality of evidence from an individual trial may have a large bearing on guideline recommendations and clinical practice. HTA organisations should drive improvements in the design and rigour of randomised trials. The evolving landscape of cardiovascular healthcare technologies and related trials presents a challenge for HTA organisations and healthcare providers. The rapid turnover of evidence is externally relevant because the period from the trial publication to implementation of HTA guideline recommendations by healthcare providers may be prolonged, by which time new evidence may have emerged from subsequent trials. Implementation of a cardiovascular healthcare technology including be it a medical device, diagnostic or intervention may have profound implications for healthcare providers. These technologies may have high absolute costs and access may be influenced by socioeconomic and geographic factors