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. 2021 Nov 9;1(3):oeab033.
doi: 10.1093/ehjopen/oeab033. eCollection 2021 Nov.

Cardiac magnetic resonance imaging improves prognostic stratification of patients with ST-elevation myocardial infarction and preserved ejection fraction

Martin Reindl  1 , Thomas Stiermaier  2 , Ivan Lechner  1 , Christina Tiller  1 , Magdalena Holzknecht  1 , Agnes Mayr  3 , Johannes P Schwaiger  4 , Christoph Brenner  1 , Gert Klug  1 , Axel Bauer  1 , Holger Thiele  5 , Hans-Josef Feistritzer  5 , Bernhard Metzler  1 , Ingo Eitel  2 , Sebastian J Reinstadler  1
Affiliations

Cardiac magnetic resonance imaging improves prognostic stratification of patients with ST-elevation myocardial infarction and preserved ejection fraction

Martin Reindl et al. Eur Heart J Open. .

Abstract

Aims: To evaluate the prognostic validity of clinical risk factors as well as infarct characterization and myocardial deformation by cardiac magnetic resonance (CMR) in ST-elevation myocardial infarction (STEMI) patients with preserved left ventricular ejection fraction (LVEF) following primary percutaneous coronary intervention (PCI).

Methods and results: This multicentre, individual patient-data analysis from two large CMR trials included 1247 STEMI patients. Cardiac magnetic resonance examinations were conducted 3 [interquartile range (IQR) 2-4] days after PCI. LVEF, infarct size, microvascular obstruction (MVO), and myocardial strain values were measured. Primary endpoint was defined as composite of major adverse cardiovascular events (MACE) including death, re-infarction, and congestive heart failure. A preserved LVEF (defined as LVEF ≥50%) was observed in 724 patients (=58%). In the overall cohort, 97 patients experienced a MACE event [follow-up time 12 (IQR 12-13) months], and 34 MACE events occurred in the group with preserved LVEF (5% vs. 12% incidence rate in patients with LVEF < 50%). TIMI risk score [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.02-1.59; P = 0.03] and female gender (HR 2.24, 95% CI 1.10-4.57; P = 0.03) emerged as independent clinical determinants of MACE in the patient group with preserved LVEF. Among CMR parameters, the presence of MVO (HR 2.39, 95% CI 1.05-5.46; P = 0.04) and reduced global longitudinal strain (GLS; HR 1.12, 95% CI 1.02-1.23; P = 0.02) independently predicted MACE in the LVEF-preserved population. The addition of MVO and GLS to the clinical prognostic markers (TIMI risk score, female gender) increased (P = 0.02) the prognostic validity [AUC 0.76 (95% CI 0.73-0.79)] compared to the clinical markers alone [AUC 0.65 (0.62-0.69)].

Conclusion: In contemporary treated STEMI patients showing preserved LVEF, a CMR-based risk prediction approach assessing MVO and GLS provided strong prognostic value that was incremental to clinical outcome parameters.

Keywords: Cardiac magnetic resonance; Preserved ejection fraction; ST-elevation myocardial infarction.

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Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Flow diagram of the present study. AIDA, Abciximab Intracoronary versus intravenously Drug Application in ST-Elevation Myocardial Infarction; CMR, cardiac magnetic resonance; LGE, late gadolinium enhancement; LVEF, left ventricular ejection fraction; MACE, major adverse cardiovascular events; MARINA, Magnetic Resonance Imaging In Acute ST-Elevation Myocardial Infarction; STEMI, ST-elevation myocardial infarction.
Figure 2
Figure 2
Prognostic stratification in STEMI patients showing a preserved LVEF. The stepwise increase of MACE rates with higher risk classes is illustrated by the bar graph. The MACE-free survival according to the different risk classes is illustrated by the Kaplan–Meier curve. CI, confidence interval; MACE, major adverse cardiovascular events.
Figure 3
Figure 3
Discriminative power of prognosis markers in STEMI with preserved LVEF. Receiver operating characteristic analysis which compares the prognostic value of clinical prognostic markers (TIMI risk score and female gender, blue dotted line) with the combined variable incorporating the clinical markers plus CMR markers (GLS and MVO, red line). CMR, cardiac magnetic resonance; GLS, left ventricular global longitudinal strain; LVEF, left ventricular ejection fraction; MVO, microvascular obstruction; STEMI, ST-elevation myocardial infarction; TIMI, thrombolysis in myocardial infarction.
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