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. 2024 Sep;17(9):1044-1058.
doi: 10.1016/j.jcmg.2024.05.007. Epub 2024 Jun 4.

Cardiovascular Magnetic Resonance Before Invasive Coronary Angiography in Suspected Non-ST-Segment Elevation Myocardial Infarction

Mayooran Shanmuganathan  1 , Chrysovalantou Nikolaidou  2 , Matthew K Burrage  3 , Alessandra Borlotti  4 , Rafail Kotronias  1 , Roberto Scarsini  5 , Abhirup Banerjee  6 , Dimitrios Terentes-Printzios  5 , Alex Pitcher  5 , Edit Gara  7 , Jeremy Langrish  5 , Andrew Lucking  5 , Robin Choudhury  8 , Giovanni Luigi De Maria  8 , Adrian Banning  8 ; Oxford Acute Myocardial Infarction (OxAMI) Study Investigators  4 ; Stefan K Piechnik  7 , Keith M Channon  1 , Vanessa M Ferreira  9
Affiliations

Cardiovascular Magnetic Resonance Before Invasive Coronary Angiography in Suspected Non-ST-Segment Elevation Myocardial Infarction

Mayooran Shanmuganathan et al. JACC Cardiovasc Imaging. 2024 Sep.

Abstract

Background: In suspected non-ST-segment elevation myocardial infarction (NSTEMI), this presumed diagnosis may not hold true in all cases, particularly in patients with nonobstructive coronary arteries (NOCA). Additionally, in multivessel coronary artery disease, the presumed infarct-related artery may be incorrect.

Objectives: This study sought to assess the diagnostic utility of cardiac magnetic resonance (CMR) before invasive coronary angiogram (ICA) in suspected NSTEMI.

Methods: A total of 100 consecutive stable patients with suspected acute NSTEMI (70% male, age 62 ± 11 years) prospectively underwent CMR pre-ICA to assess cardiac function (cine), edema (T2-weighted imaging, T1 mapping), and necrosis/scar (late gadolinium enhancement). CMR images were interpreted blinded to ICA findings. The clinical care and ICA teams were blinded to CMR findings until post-ICA.

Results: Early CMR (median 33 hours postadmission and 4 hours pre-ICA) confirmed only 52% (52 of 100) of patients had subendocardial infarction, 15% transmural infarction, 18% nonischemic pathologies (myocarditis, takotsubo, and other forms of cardiomyopathies), and 11% normal CMR; 4% were nondiagnostic. Subanalyses according to ICA findings showed that, in patients with obstructive coronary artery disease (73 of 100), CMR confirmed only 84% (61 of 73) had MI, 10% (7 of 73) nonischemic pathologies, and 5% (4 of 73) normal. In patients with NOCA (27 of 100), CMR found MI in only 22% (6 of 27 true MI with NOCA), and reclassified the presumed diagnosis of NSTEMI in 67% (18 of 27: 11 nonischemic pathologies, 7 normal). In patients with CMR-MI and obstructive coronary artery disease (61 of 100), CMR identified a different infarct-related artery in 11% (7 of 61).

Conclusions: In patients presenting with suspected NSTEMI, a CMR-first strategy identified MI in 67%, nonischemic pathologies in 18%, and normal findings in 11%. Accordingly, CMR has the potential to affect at least 50% of all patients by reclassifying their diagnosis or altering their potential management.

Keywords: CMR; MINOCA; NSTEMI; acute coronary syndrome; early cardiac magnetic resonance; myocarditis.

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Conflict of interest statement

Funding Support and Author Disclosures The OxAMI study is supported by a British Heart Foundation (BHF) Centre of Research Excellence (CRE) Oxford (RE/13/1/30181), and the National Institute for Health Research Oxford Biomedical Research Centre. Dr Shanmuganathan has received funding from the Alison Brading Memorial Graduate Scholarship in Medical Science, Lady Margaret Hall, University of Oxford. Dr Burrage has received support from a British Heart Foundation Clinical Research Training Fellowship (FS/19/65/34692). Dr Gara has received a European Society of Cardiology, EACVI Research grant. Dr Piechnik has received support from the BHF CRE Oxford (RE/18/3/34214); and has patent authorship rights for U.S. patent 9285446 B2 (systems and methods for Shortened Look Locker Inversion Recovery [Sh-MOLLI] cardiac gated mapping of T1), granted March 15, 2016; intellectual properties are owned and managed by Oxford University Innovations. Dr Channon has received funding from a BHF Chair award (CH/16/1/32013). Dr Ferreira has received funding from the BHF, BHF CRE Oxford, and National Institute for Health Research Oxford Biomedical Research Center. The funders were not involved in the design and conduct of the study, in the collection, analysis, and interpretation of the data, and in the preparation, review, or approval of the manuscript. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Study Flowchart Patients admitted to hospital with suspected NSTEMI and listed for ICA were prospectively recruited to undergo CMR before ICA, as part of the OxAMI (Oxford Acute Myocardial Infarction) study. The clinicians performing ICA were blinded to CMR findings. CMR experts were also blinded to the ICA findings. ACS = acute coronary syndrome; CMR = cardiac magnetic resonance; ICA = invasive coronary angiogram; MINOCA = myocardial infarction with nonobstructive coronary arteries; NSTEMI = non-ST-segment elevation myocardial infarction.
Figure 2
Figure 2
Diagnoses Made Using CMR Prior to ICA Break down (dot-plot) of diagnoses made using CMR performed prior to ICA. DCM = dilated cardiomyopathy; HCM = hypertrophic cardiomyopathy; other abbreviations as in Figure 1.
Figure 3
Figure 3
Multiparametric CMR of Acute MI (Top) T2-weighted images show hyperenhancement (white arrows) indicating areas of myocardial edema in the anterior and anterolateral walls of the left ventricle. (Middle, first) The overlay masks used to highlight the areas of myocardium with pixels of abnormally high T1 values on the shortened modified Look-Locker inversion recovery T1 maps (middle, second) (>1,244 milliseconds). (Bottom) Late gadolinium enhancement (LGE) images show hyperenhancement (yellow arrows) indicating areas of myocardial infarction (MI). CMR = cardiac magnetic resonance.
Figure 4
Figure 4
Multiparametric CMR of Takotsubo Syndrome (Top) T2-weighted images show global hyperenhancement in midapical left ventricle indicative of intense myocardial edema (the tile in the top-right corresponds to the midventricular slice of the left ventricle with myocardial-skeletal muscle T2 signal intensity ratio of >2). (Middle, first) The overlay masks used to highlight the areas of myocardium with pixels of abnormally high T1 values on the shortened modified Look-Locker inversion recovery T1 maps (middle, second) (>1,244 milliseconds). The edematous segments were hypokinetic on cine imaging. (Bottom) Late gadolinium enhancement (LGE) images show no evidence of significant myocardial fibrosis or infarction. shortened modified Look-Locker inversion recovery
Figure 5
Figure 5
Findings on Multiparametric CMR in Patients With Suspected NSTEMI Multiparametric CMR using T2-weighted (T2W) imaging, T1 maps, LGE demonstrate normal findings, MI with and without microvascular injury, takotsubo syndrome, and myocarditis. Representative short-axis slices provided for illustration purposes. White block arrows point to areas of focal pathology. IMH = intramyocardial hemorrhage; LV = left ventricle; MVO = microvascular obstruction; other abbreviations as in Figures 1 and 3.
Central Illustration
Central Illustration
Clinical Utility of Cardiac Magnetic Resonance Prior to Invasive Coronary Angiography in Suspected Acute Non-ST-Segment Elevation Myocardial Infarction Cardiac magnetic resonance (CMR) prior to invasive coronary angiography (ICA) produced a diagnosis in 85% and has the potential to change diagnosis and/or clinical management in at least 50% of the patients. Note: CMR was not interpretable in 4% of patients due to incomplete scan or poor image quality. CAD = coronary artery disease; IRA = infarct related artery; MINOCA = myocardial infarction with nonobstructive coronary arteries; NSTEMI = non–ST-segment elevation myocardial infarction.
Figure 6
Figure 6
Reclassification of ICA Diagnoses by CMR Reclassification of diagnoses by CMR in patients treated for MI on ICA (n = 73) and nonobstructed coronary arteries (NOCA) on ICA (n = 27). Nonischemic causes include myocarditis, dilated cardiomyopathy, hypertrophic cardiomyopathy, takotsubo cardiomyopathy, and right ventricular failure. NAD = no significant abnormality detected; other abbreviations as in Figures 1 and 3.
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References

    1. Amsterdam E.A., Wenger N.K., Brindis R.G., et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139–e228. - PubMed
    1. Bueno H. In: The ESC Textbook of Cardiovascular Medicine. James S., Camm A.J., Lüscher T.F., Maurer G., Serruys P.W., editors. Oxford University ress; 2018. Epidemiology of acute coronary syndromes. - DOI
    1. NICOR Myocardial Ischaemia/MINAP (Heart Attack audit) https://www.nicor.org.uk/national-cardiac-audit-programme/heart-attack-a...
    1. Tamis-Holland J.E., Jneid H. Myocardial infarction with nonobstructive coronary arteries (MINOCA): it’s time to face reality. J Am Heart Assoc. 2018;7(13) doi: 10.1161/JAHA.118.009635. - DOI - PMC - PubMed
    1. Dastidar A.G., Baritussio A., De Garate E., et al. Prognostic role of CMR and conventional risk factors in myocardial infarction with nonobstructed coronary arteries. JACC Cardiovasc Imaging. 2019;12(10):1973–1982. doi: 10.1016/j.jcmg.2018.12.023. - DOI - PubMed

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