Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction : Looking Back to Move Forward. Focus on CMR

After a myocardial infarction (MI), despite the resolution of the coronary occlusion, the deterioration of myocardial perfusion persists in a considerable number of patients. This phenomenon is known as microvascular obstruction (MVO). Initially, the focus was placed on re-establishing blood flow in the epicardial artery. Then, the observation that MVO has profound negative structural and prognostic repercussions revived interest in microcirculation. In the near future, the availability of co-adjuvant therapies (beyond timely coronary reperfusion) aimed at preventing, minimizing, and repairing MVOs and finding convincing answers to questions regarding what, when, how, and where to administer these therapies will be of utmost importance. The objective of this work is to review the state-of-the-art concepts on pathophysiology, diagnostic methods, and structural and clinical implications of MVOs in patients with ST-segment elevation MIs. Based on this knowledge we discuss previously-tested and future opportunities for the prevention and repair of MVO

A Novel Clinical and Stress Cardiac Magnetic Resonance (C-CMR-10) Score to Predict Long-Term All-Cause Mortality in Patients with Known or Suspected Chronic Coronary Syndrome

[EN] Vasodilator stress cardiac magnetic resonance (stressCMR) has shown robust diagnostic and prognostic value in patients with known or suspected chronic coronary syndrome (CCS). However, it is unknown whether integration of stressCMR with clinical variables in a simple clinical-imaging score can straightforwardly predict all-cause mortality in this population. We included 6187 patients in a large registry that underwent stressCMR for known or suspected CCS. Several clinical and stressCMR variables were collected, such as left ventricular ejection fraction (LVEF) and ischemic burden (number of segments with stress-induced perfusion defects (PD)). During a median follow-up of 5.56 years, we registered 682 (11%) all-cause deaths. The only independent predictors of all-cause mortality in multivariable analysis were age, male sex, diabetes mellitus (DM), LVEF and ischemic burden. Based on the weight of the chi-square increase at each step of the multivariable analysis, we created a simple clinical-stressCMR (C-CMR-10) score that included these variables (age >= 65 years = 3 points, LVEF 5 segments = 1 point). This 0 to 10 points C-CMR-10 score showed good performance to predict all-cause annualized mortality rate ranging from 0.29%/year (score = 0) to >4.6%/year (score >= 7). The goodness of the model and of the C-CMR-10 score was separately confirmed in 2 internal cohorts (n> 3000 each). We conclude that a novel and simple clinical-stressCMR score, which includes clinical and stressCMR variables, can provide robust prediction of the risk of long-term all-cause mortality in a population of patients with known or suspected CCS.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 and CIBERCV16/11/00486).Marcos-Garces, V.; Gavara-Doñate, J.; Monmeneu-Menadas, JV.; Lopez-Lereu, MP.; Pérez, N.; Rios-Navarro, C.; De Dios, E.... (2020). A Novel Clinical and Stress Cardiac Magnetic Resonance (C-CMR-10) Score to Predict Long-Term All-Cause Mortality in Patients with Known or Suspected Chronic Coronary Syndrome. Journal of Clinical Medicine. 9(6):1-13. https://doi.org/10.3390/jcm9061957S11396Hendel, R. C., Friedrich, M. G., Schulz-Menger, J., Zemmrich, C., Bengel, F., Berman, D. S., … Nagel, E. (2016). CMR First-Pass Perfusion for Suspected Inducible Myocardial Ischemia. JACC: Cardiovascular Imaging, 9(11), 1338-1348. doi:10.1016/j.jcmg.2016.09.010Chang, S.-A., & Kim, R. J. (2016). The Use of Cardiac Magnetic Resonance in Patients with Suspected Coronary Artery Disease: A Clinical Practice Perspective. Journal of Cardiovascular Ultrasound, 24(2), 96. doi:10.4250/jcu.2016.24.2.96Kiaos, A., Tziatzios, I., Hadjimiltiades, S., Karvounis, C., & Karamitsos, T. D. (2018). Diagnostic performance of stress perfusion cardiac magnetic resonance for the detection of coronary artery disease. International Journal of Cardiology, 252, 229-233. doi:10.1016/j.ijcard.2017.11.066Li, M., Zhou, T., Yang, L., Peng, Z., Ding, J., & Sun, G. (2014). Diagnostic Accuracy of Myocardial Magnetic Resonance Perfusion to Diagnose Ischemic Stenosis With Fractional Flow Reserve as Reference. JACC: Cardiovascular Imaging, 7(11), 1098-1105. doi:10.1016/j.jcmg.2014.07.011Siontis, G. C., Mavridis, D., Greenwood, J. P., Coles, B., Nikolakopoulou, A., Jüni, P., … Windecker, S. (2018). Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials. BMJ, k504. doi:10.1136/bmj.k504Nagel, E., Greenwood, J. P., McCann, G. P., Bettencourt, N., Shah, A. M., Hussain, S. T., … Berry, C. (2019). Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease. New England Journal of Medicine, 380(25), 2418-2428. doi:10.1056/nejmoa1716734Siontis, G. C., Branca, M., Serruys, P., Silber, S., Räber, L., Pilgrim, T., … Hunziker, L. (2019). Impact of left ventricular function on clinical outcomes among patients with coronary artery disease. European Journal of Preventive Cardiology, 26(12), 1273-1284. doi:10.1177/2047487319841939Buckert, D., Kelle, S., Buss, S., Korosoglou, G., Gebker, R., Birkemeyer, R., … Bernhardt, P. (2016). Left ventricular ejection fraction and presence of myocardial necrosis assessed by cardiac magnetic resonance imaging correctly risk stratify patients with stable coronary artery disease: a multi-center all-comers trial. Clinical Research in Cardiology, 106(3), 219-229. doi:10.1007/s00392-016-1042-5Catalano, O., Moro, G., Perotti, M., Frascaroli, M., Ceresa, M., Antonaci, S., … Priori, S. G. (2012). Late gadolinium enhancement by cardiovascular magnetic resonance is complementary to left ventricle ejection fraction in predicting prognosis of patients with stable coronary artery disease. Journal of Cardiovascular Magnetic Resonance, 14(1). doi:10.1186/1532-429x-14-29Lipinski, M. J., McVey, C. M., Berger, J. S., Kramer, C. M., & Salerno, M. (2013). Prognostic Value of Stress Cardiac Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease. Journal of the American College of Cardiology, 62(9), 826-838. doi:10.1016/j.jacc.2013.03.080Gargiulo, P., Dellegrottaglie, S., Bruzzese, D., Savarese, G., Scala, O., Ruggiero, D., … Filardi, P. P. (2013). The Prognostic Value of Normal Stress Cardiac Magnetic Resonance in Patients With Known or Suspected Coronary Artery Disease. Circulation: Cardiovascular Imaging, 6(4), 574-582. doi:10.1161/circimaging.113.000035Kwong, R. Y., Ge, Y., Steel, K., Bingham, S., Abdullah, S., Fujikura, K., … Simonetti, O. P. (2019). Cardiac Magnetic Resonance Stress Perfusion Imaging for Evaluation of Patients With Chest Pain. Journal of the American College of Cardiology, 74(14), 1741-1755. doi:10.1016/j.jacc.2019.07.074Marcos-Garces, V., Gavara, J., Monmeneu, J. V., Lopez-Lereu, M. P., Bosch, M. J., Merlos, P., … Bodi, V. (2020). Vasodilator Stress CMR and All-Cause Mortality in Stable Ischemic Heart Disease. JACC: Cardiovascular Imaging, 13(8), 1674-1686. doi:10.1016/j.jcmg.2020.02.027Heitner, J. F., Kim, R. J., Kim, H. W., Klem, I., Shah, D. J., Debs, D., … Judd, R. M. (2019). Prognostic Value of Vasodilator Stress Cardiac Magnetic Resonance Imaging. JAMA Cardiology, 4(3), 256. doi:10.1001/jamacardio.2019.0035Bodi, V., Sanchis, J., Lopez-Lereu, M. P., Nunez, J., Mainar, L., Monmeneu, J. V., … Llacer, A. (2007). Prognostic Value of Dipyridamole Stress Cardiovascular Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease. Journal of the American College of Cardiology, 50(12), 1174-1179. doi:10.1016/j.jacc.2007.06.016Bodi, V., Husser, O., Sanchis, J., Núñez, J., Monmeneu, J. V., López-Lereu, M. P., … Llacer, Á. (2012). Prognostic Implications of Dipyridamole Cardiac MR Imaging: A Prospective Multicenter Registry. Radiology, 262(1), 91-100. doi:10.1148/radiol.11110134Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G. F., Coats, A. J. S., … van der Meer, P. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 37(27), 2129-2200. doi:10.1093/eurheartj/ehw128Marschner, I. C., Colquhoun, D., Simes, R. J., Glasziou, P., Harris, P., Singh, B. B., … Tonkin, A. (2001). Long-term risk stratification for survivors of acute coronary syndromes. Journal of the American College of Cardiology, 38(1), 56-63. doi:10.1016/s0735-1097(01)01360-2Knuuti, J., Wijns, W., Saraste, A., Capodanno, D., Barbato, E., Funck-Brentano, C., … Cuisset, T. (2019). 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. European Heart Journal, 41(3), 407-477. doi:10.1093/eurheartj/ehz425Klem, I., Shah, D. J., White, R. D., Pennell, D. J., van Rossum, A. C., Regenfus, M., … Kim, R. J. (2011). Prognostic Value of Routine Cardiac Magnetic Resonance Assessment of Left Ventricular Ejection Fraction and Myocardial Damage. Circulation: Cardiovascular Imaging, 4(6), 610-619. doi:10.1161/circimaging.111.964965Grothues, F., Smith, G. C., Moon, J. C. ., Bellenger, N. G., Collins, P., Klein, H. U., & Pennell, D. J. (2002). Comparison of interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects and in patients with heart failure or left ventricular hypertrophy. The American Journal of Cardiology, 90(1), 29-34. doi:10.1016/s0002-9149(02)02381-0Timmis, A., Raharja, A., Archbold, R. A., & Mathur, A. (2018). Validity of inducible ischaemia as a surrogate for adverse outcomes in stable coronary artery disease. Heart, 104(21), 1733-1738. doi:10.1136/heartjnl-2018-313230Pontone, G., Andreini, D., Bertella, E., Loguercio, M., Guglielmo, M., Baggiano, A., … Masci, P. G. (2015). Prognostic value of dipyridamole stress cardiac magnetic resonance in patients with known or suspected coronary artery disease: a mid-term follow-up study. European Radiology, 26(7), 2155-2165. doi:10.1007/s00330-015-4064-xHeydari, B., Juan, Y.-H., Liu, H., Abbasi, S., Shah, R., Blankstein, R., … Kwong, R. Y. (2016). Stress Perfusion Cardiac Magnetic Resonance Imaging Effectively Risk Stratifies Diabetic Patients With Suspected Myocardial Ischemia. Circulation: Cardiovascular Imaging, 9(4). doi:10.1161/circimaging.115.004136Vincenti, G., Masci, P. G., Monney, P., Rutz, T., Hugelshofer, S., Gaxherri, M., … Schwitter, J. (2017). Stress Perfusion CMR in Patients With Known and Suspected CAD. JACC: Cardiovascular Imaging, 10(5), 526-537. doi:10.1016/j.jcmg.2017.02.006Buckert, D., Cieslik, M., Tibi, R., Radermacher, M., Rottbauer, W., & Bernhardt, P. (2017). Cardiac magnetic resonance imaging derived quantification of myocardial ischemia and scar improves risk stratification and patient management in stable coronary artery disease. Cardiology Journal, 24(3), 293-304. doi:10.5603/cj.a2017.0036Zemrak, F., & Petersen, S. E. (2011). Late Gadolinium Enhancement CMR Predicts Adverse Cardiovascular Outcomes and Mortality in Patients With Coronary Artery Disease: Systematic Review and Meta-Analysis. Progress in Cardiovascular Diseases, 54(3), 215-229. doi:10.1016/j.pcad.2011.07.003El Aidi, H., Adams, A., Moons, K. G. M., Den Ruijter, H. M., Mali, W. P. T. M., Doevendans, P. A., … Leiner, T. (2014). Cardiac Magnetic Resonance Imaging Findings and the Risk of Cardiovascular Events in Patients With Recent Myocardial Infarction or Suspected or Known Coronary Artery Disease. Journal of the American College of Cardiology, 63(11), 1031-1045. doi:10.1016/j.jacc.2013.11.048Fox, K. A. A., Metra, M., Morais, J., & Atar, D. (2019). The myth of ‘stable’ coronary artery disease. Nature Reviews Cardiology, 17(1), 9-21. doi:10.1038/s41569-019-0233-ySchiele, F., Ecarnot, F., & Chopard, R. (2017). Coronary artery disease: Risk stratification and patient selection for more aggressive secondary prevention. European Journal of Preventive Cardiology, 24(3_suppl), 88-100. doi:10.1177/2047487317706586Fordyce, C. B., Douglas, P. S., Roberts, R. S., Hoffmann, U., Al-Khalidi, H. R., … Patel, M. R. (2017). Identification of Patients With Stable Chest Pain Deriving Minimal Value From Noninvasive Testing. JAMA Cardiology, 2(4), 400. doi:10.1001/jamacardio.2016.5501Papireddy, M. R., Lavie, C. J., Deoker, A., Mamudu, H., & Paul, T. K. (2018). New Algorithm for the Prediction of Cardiovascular Risk in Symptomatic Adults with Stable Chest Pain. Current Cardiology Reports, 20(5). doi:10.1007/s11886-018-0973-

Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome

Ischemic heart disease (IHD) persists as the leading cause of death in the Western world. In recent decades, great headway has been made in reducing mortality due to IHD, based around secondary prevention. The advent of coronary revascularization techniques, first coronary artery bypass grafting (CABG) surgery in the 1960s and then percutaneous coronary intervention (PCI) in the 1970s, has represented one of the major breakthroughs in medicine during the last century. The benefit provided by these techniques, especially PCI, has been crucial in lowering mortality rates in acute coronary syndrome (ACS). However, in the setting where IHD is most prevalent, namely chronic coronary syndrome (CCS), the increase in life expectancy provided by coronary revascularization is controversial. Over more than 40 years, several clinical trials have been carried out comparing optimal medical treatment (OMT) alone with a strategy of routine coronary revascularization on top of OMT. Beyond a certain degree of symptomatic improvement and lower incidence of minor events, routine invasive management has not demonstrated a convincing effect in terms of reducing mortality in CCS. Based on the accumulated evidence more than half a century after the first revascularization procedures were used, invasive management should be considered in those patients with uncontrolled symptoms despite OMT or high-risk features related to left ventricular function, coronary anatomy, or functional assessment, taking into account the patient expectations and preferences

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

A Novel Clinical and Stress Cardiac Magnetic Resonance (C-CMR-10) Score to Predict Long-Term All-Cause Mortality in Patients with Known or Suspected Chronic Coronary Syndrome

Vasodilator stress cardiac magnetic resonance (stressCMR) has shown robust diagnostic and prognostic value in patients with known or suspected chronic coronary syndrome (CCS). However, it is unknown whether integration of stressCMR with clinical variables in a simple clinical-imaging score can straightforwardly predict all-cause mortality in this population. We included 6187 patients in a large registry that underwent stressCMR for known or suspected CCS. Several clinical and stressCMR variables were collected, such as left ventricular ejection fraction (LVEF) and ischemic burden (number of segments with stress-induced perfusion defects (PD)). During a median follow-up of 5.56 years, we registered 682 (11%) all-cause deaths. The only independent predictors of all-cause mortality in multivariable analysis were age, male sex, diabetes mellitus (DM), LVEF and ischemic burden. Based on the weight of the chi-square increase at each step of the multivariable analysis, we created a simple clinical-stressCMR (C-CMR-10) score that included these variables (age ≥ 65 years = 3 points, LVEF ≤ 50% = 3 points, DM = 2 points, male sex = 1 point, and ischemic burden > 5 segments = 1 point). This 0 to 10 points C-CMR-10 score showed good performance to predict all-cause annualized mortality rate ranging from 0.29%/year (score = 0) to >4.6%/year (score ≥ 7). The goodness of the model and of the C-CMR-10 score was separately confirmed in 2 internal cohorts (n > 3000 each). We conclude that a novel and simple clinical-stressCMR score, which includes clinical and stressCMR variables, can provide robust prediction of the risk of long-term all-cause mortality in a population of patients with known or suspected CCS

Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction: Looking Back to Move Forward. Focus on CMR

After a myocardial infarction (MI), despite the resolution of the coronary occlusion, the deterioration of myocardial perfusion persists in a considerable number of patients. This phenomenon is known as microvascular obstruction (MVO). Initially, the focus was placed on re-establishing blood flow in the epicardial artery. Then, the observation that MVO has profound negative structural and prognostic repercussions revived interest in microcirculation. In the near future, the availability of co-adjuvant therapies (beyond timely coronary reperfusion) aimed at preventing, minimizing, and repairing MVOs and finding convincing answers to questions regarding what, when, how, and where to administer these therapies will be of utmost importance. The objective of this work is to review the state-of-the-art concepts on pathophysiology, diagnostic methods, and structural and clinical implications of MVOs in patients with ST-segment elevation MIs. Based on this knowledge we discuss previously-tested and future opportunities for the prevention and repair of MVO

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

Magnetic Resonance Assessment of Left Ventricular Ejection Fraction at Any Time Post-Infarction for Prediction of Subsequent Events in a Large Multicenter STEMI Registry

[EN] Background Magnetic resonance imaging (MRI) is the most accurate imaging technique for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of LVEF assessment at any time after ST-segment elevation myocardial infarction (STEMI) for subsequent major adverse cardiac event (MACE) prediction is uncertain. Purpose To explore the prognostic impact of MRI-derived LVEF at any time post-STEMI to predict subsequent MACE (cardiovascular death or re-admission for acute heart failure). Study Type Prospective. Population One thousand thirteen STEMI patients were included in a multicenter registry. Field Strength/Sequence 1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences. Assessment Post-infarction MRI-derived LVEF (reduced [r]: = 50%) was sequentially quantified at 1 week and after >3 months of follow-up. Statistical Tests Multi-state Markov model to determine the prognostic value of each LVEF state (r-, mr- or p-) at any time point assessed to predict subsequent MACE. A P-value During a 6.2-year median follow-up, 105 MACE (10%) were registered. Transitions toward improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to a higher incidence of subsequent MACE. The observed transitions from r-LVEF, mr-LVEF, and p-LVEF states to MACE were: 15.3%, 6%, and 6.7%, respectively. Regarding the adjusted transition intensity ratios, patients in r-LVEF state were 4.52-fold more likely than those in mr-LVEF state and 5.01-fold more likely than those in p-LVEF state to move to MACE state. Nevertheless, no significant differences were found in transitions from mr-LVEF and p-LVEF states to MACE state (P-value = 0.6). Data Conclusion LVEF is an important MRI index for simple and dynamic post-STEMI risk stratification. Detection of r-LVEF by MRI at any time during follow-up identifies a subset of patients at high risk of subsequent events. Level of Evidence 2 Technical Efficacy Stage 2This work was supported by "Instituto de Salud Carlos III," "Fondos Europeos de Desarrollo Regional FEDER" (grants PI15/00531, PI17/01836, PI20/00637, and CIBERCV16/11/00486), and "Marato TV3" (grant 20153030-31-32), a grant from the Catalonian Society of Cardiology 2015 and a grant from La Caixa Foundation (HR17-00527). David Moratal and Jose Gavara acknowledge financial support from the "Conselleria d'Educacio, Investigacio, Cultura i Esport, Generalitat Valenciana" (grants AEST/2019/037 and AEST/2020/029), "Agencia Valenciana de la Innovacion, Generalitat Valenciana" (ref. INNCAD00/19/085 and INNCAD/2020/84), and "Centro para el Desarrollo Tecnologico Industrial" (Programa Eurostars-2, actuacion Interempresas Internacional), Spanish "Ministerio de Ciencia, Innovacion y Universidades" (ref. CIIP-20192020).Gavara-Doñate, J.; Marcos-Garces, V.; Lopez-Lereu, MP.; Monmeneu, JV.; Rios-Navarro, C.; De Dios, E.; Pérez, N.... (2022). Magnetic Resonance Assessment of Left Ventricular Ejection Fraction at Any Time Post-Infarction for Prediction of Subsequent Events in a Large Multicenter STEMI Registry. Journal of Magnetic Resonance Imaging. 56(2):476-487. https://doi.org/10.1002/jmri.2778947648756

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

Ejection Fraction by Echocardiography for a Selective Use of Magnetic Resonance After Infarction

[EN] Background Cardiac magnetic resonance (CMR) permits robust risk stratification of discharged ST-segment-elevation myocardial infarction patients, but its indiscriminate use in all cases is not feasible. We evaluated the utility of left ventricular ejection fraction (LVEF) by echocardiography for a selective use of CMR after ST-segment-elevation myocardial infarction. Methods Echocardiography and CMR were performed in 1119 patients discharged for ST-segment-elevation myocardial infarction included in a multicenter registry. The prognostic power of CMR beyond echocardiography-LVEF was assessed using adjusted C statistic, net reclassification improvement index, and integrated discrimination improvement index. Results During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 readmissions for acute heart failure). In the entire group, CMR-LVEF (but not echocardiography-LVEF) independently predicted MACE occurrence. The MACE rate significantly increased only in patients with CMR-LVEF= 50%: 7%, 40%-49%: 9%, = 50% (629, 56%), and they had a low MACE rate (57/629, 9%). In patients with echocardiography-LVEF= 40% (24/278, 9%) but significantly increased in patients with CMR-LVEF= 50% (C statistic 0.66 versus 0.66; net reclassification improvement index, 0.17; integrated discrimination improvement index, 0.01). Conclusions A straightforward strategy based on a selective use of CMR for risk prediction in ST-segment-elevation myocardial infarction patients with echocardiography-LVEF<50% can provide insights into patient care. The cost-effectiveness of this approach, as well as the direct implications in clinical management, should be further explored.This work was supported by Instituto de Salud Carlos III and Fondos Europeos de Desarrollo Regional FEDER (grant numbers PI15/00531, PI17/01836, PI20/00637 and, CIBERCV16/11/00486), Marato TV3 (grant number 20153030-31-32), a grant from the Catalonian Society of Cardiology 2015, and Generalitat Valenciana (grant number GV/2018/116). The study was partially funded by Siemens Healthcare, which provided financial support to conduct CMR studies in 94 subjects of this series. D.M. acknowledges financial support from the Agencia Valenciana de la Innovacion, Generalitat Valenciana (grant number INNCAD00/19/085), and from the Conselleria d'Educacio, Investigacio, Cultura i Esport, Generalitat Valenciana (grant number AEST/2019/037).Marcos-Garces, V.; Gavara, J.; Lopez-Lereu, MP.; Monmeneu, JV.; Rios-Navarro, C.; De Dios, E.; Pérez, N.... (2020). 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