Left ventricular outcomes following multivessel PCI vs. infarct artery-only PCI in patients with acute STEMI: the Glasgow PRAMI CMR sub-study

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Microvascular resistance predicts myocardial salvage and infarct characteristics in ST-elevation myocardial infarction

<b>Background:</b> The pathophysiology of myocardial injury and repair in patients with ST‐elevation myocardial infarction is incompletely understood. We investigated the relationships among culprit artery microvascular resistance, myocardial salvage, and ventricular function.<p></p> <b>Methods and Results:</b> The index of microvascular resistance (IMR) was measured by means of a pressure‐ and temperature‐sensitive coronary guidewire in 108 patients with ST‐elevation myocardial infarction (83% male) at the end of primary percutaneous coronary intervention. Paired cardiac MRI (cardiac magnetic resonance) scans were performed early (2 days; n=108) and late (3 months; n=96) after myocardial infarction. T2‐weighted‐ and late gadolinium–enhanced cardiac magnetic resonance delineated the ischemic area at risk and infarct size, respectively. Myocardial salvage was calculated by subtracting infarct size from area at risk. Univariable and multivariable models were constructed to determine the impact of IMR on cardiac magnetic resonance–derived surrogate outcomes. The median (interquartile range) IMR was 28 (17–42) mm Hg/s. The median (interquartile range) area at risk was 32% (24%–41%) of left ventricular mass, and the myocardial salvage index was 21% (11%–43%). IMR was a significant multivariable predictor of early myocardial salvage, with a multiplicative effect of 0.87 (95% confidence interval 0.82 to 0.92) per 20% increase in IMR; P<0.001. In patients with anterior myocardial infarction, IMR was a multivariable predictor of early and late myocardial salvage, with multiplicative effects of 0.82 (95% confidence interval 0.75 to 0.90; P<0.001) and 0.92 (95% confidence interval 0.88 to 0.96; P<0.001), respectively. IMR also predicted the presence and extent of microvascular obstruction and myocardial hemorrhage.<p></p> <b>Conclusion:</b> Microvascular resistance measured during primary percutaneous coronary intervention significantly predicts myocardial salvage, infarct characteristics, and left ventricular ejection fraction in patients with ST‐elevation myocardial infarction.<p></p&gt

Infarct size and left ventricular remodelling after preventive percutaneous coronary intervention

Objective: We hypothesised that, compared with culprit-only primary percutaneous coronary intervention (PCI), additional preventive PCI in selected patients with ST-elevation myocardial infarction with multivessel disease would not be associated with iatrogenic myocardial infarction, and would be associated with reductions in left ventricular (LV) volumes in the longer term. Methods: In the preventive angioplasty in myocardial infarction trial (PRAMI; ISRCTN73028481), cardiac magnetic resonance (CMR) was prespecified in two centres and performed (median, IQR) 3 (1, 5) and 209 (189, 957) days after primary PCI. Results: From 219 enrolled patients in two sites, 84% underwent CMR. 42 (50%) were randomised to culprit-artery-only PCI and 42 (50%) were randomised to preventive PCI. Follow-up CMR scans were available in 72 (86%) patients. There were two (4.8%) cases of procedure-related myocardial infarction in the preventive PCI group. The culprit-artery-only group had a higher proportion of anterior myocardial infarctions (MIs) (55% vs 24%). Infarct sizes (% LV mass) at baseline and follow-up were similar. At follow-up, there was no difference in LV ejection fraction (%, median (IQR), (culprit-artery-only PCI vs preventive PCI) 51.7 (42.9, 60.2) vs 54.4 (49.3, 62.8), p=0.23), LV end-diastolic volume (mL/m2, 69.3 (59.4, 79.9) vs 66.1 (54.7, 73.7), p=0.48) and LV end-systolic volume (mL/m2, 31.8 (24.4, 43.0) vs 30.7 (23.0, 36.3), p=0.20). Non-culprit angiographic lesions had low-risk Syntax scores and 47% had non-complex characteristics. Conclusions: Compared with culprit-only PCI, non-infarct-artery MI in the preventive PCI strategy was uncommon and LV volumes and ejection fraction were similar

Infarct burden following multivessel PCI vs. infarct-only PCI in patients with acute STEMI: the Glasgow PRAMI CMR sub-study

Background: In the Preventive Angioplasty in Myocardial Infarction trial (PRAMI; ISRCTN73028481), immediate multivessel PCI (MV-PCI) of non-IRA (infarct related artery) lesions in patients with acute ST elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) improved long term prognosis. We assessed infarct distribution and size in a pre-specified cardiac magnetic resonance (CMR) sub-study.<p></p> Methods: In this single centre prospective sub-study, PRAMI participants were invited to undergo 1.5 Tesla CMR 1 week and 1 year after primary PCI. The CMR scans were analysed using semi-automated software by a clinician blinded to treatment group assignment and clinical outcomes. The presence and extent of infarction were assessed quantitatively with late gadolinium enhancement (LGE) imaging (Gadovist, 0.1 mmol/kg). The infarct was delineated as an area of myocardial enhancement (cm2) using a signal intensity threshold of >5SDs above a remote region, and expressed as a % of total LV mass. The incidence of new LGE in non-infarct related artery territories at baseline and 1 year were assessed. Data were analysed by an independent statistician.<p></p> Results: Of 465 randomised trial participants in 6 UK hospitals, 138 (30%) were enrolled in Glasgow. Of these 80 patients underwent CMR 1 week post primary PCI of whom 41 (51%) were in the multi-vessel PCI group and 39 (49%) were in the IRA-only group. At 1 year, 69 (86%) patients had a follow up CMR scan. Infarct size and distribution are described in Table 1

Newsletter no. 30 for 1997

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Newsletter no. 32 for 1999

INHIGEO produces an annual publication that includes information on the commission's activities, national reports, book reviews, interviews and occasional historical articles.N