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      The Relationship between Transmural Extent of Infarction on Contrast Enhanced Magnetic Resonance Imaging and Recovery of Contractile Function in Patients with First Myocardial Infarction Treated with Thrombolysis

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          Background: The aim of the current study was to assess the utility of transmurality of delayed enhancement on cardiac magnetic resonance imaging (MRI) in predicting functional recovery in patients with first ST-elevation myocardial infarction (MI) who had received thrombolysis. Methods: Nineteen patients underwent cine and contrast-enhanced MRI 3 days and 8 weeks after MI. The transmural extent of infarction (TEI) was determined from the late enhancement component of the first scan. Segmental wall thickening was scored from the cine components of both the initial and follow-up scans. Results: The TEI was inversely related to the likelihood of improvement in wall thickening; χ<sup>2</sup> test for trend = 53.9, p < 0.0001. Delayed enhancement with >50% transmurality predicted a lack of recovery with 82% sensitivity and 54% specificity. The equivalent values for >75% transmurality were 57 and 77%, respectively. The proportion of the left ventricular segments exhibiting functional recovery was related to the percentage of the left ventricle that was severely dysfunctional but had ≤50% TEI (r = 0.49, p = 0.03). In a backward conditional regression model this was the only independent predictor. Conclusion: These data suggest that TEI, determined by contrast-enhanced cardiac MRI, is a useful predictor of the likelihood, or otherwise, of functional recovery following acute MI treated with thrombolysis.

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          Most cited references 7

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          A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS).

          To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to examine adherence to current guidelines. We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42.3%, non-ST elevation ACS in 51.2%, and undetermined electrocardiogram ACS in 6.5%. The discharge diagnosis was Q wave myocardial infarction in 32.8%, non-Q wave myocardial infarction in 25.3%, and unstable angina in 41.9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93.0%, 77.8%, 62.1%, and 86.8%, respectively, with corresponding rates of 88.5%, 76.6%, 55.8%, and 83.9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56.3%, 40.4%, and 3.4% of ST elevation ACS patients, respectively, with corresponding rates of 52.0%, 25.4%, and 5.4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55.8% received reperfusion treatment; 35.1% fibrinolytic therapy and 20.7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7.0%, for non-ST elevation ACS 2.4%, and for undetermined electrocardiogram ACS 11.8%. At 30 days, mortality was 8.4%, 3.5%, and 13.3%, respectively. This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region.
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            Accuracy of contrast-enhanced magnetic resonance imaging in predicting improvement of regional myocardial function in patients after acute myocardial infarction.

            Contrast-enhanced (CE) MRI demonstrates a pattern of hypoenhancement early after contrast injection in acute myocardial infarction (MI) and a pattern of hyperenhancement late after contrast injection. Because the significance of these CE patterns for myocardial viability remains debated, we evaluated their diagnostic accuracy to quantitatively predict late functional improvement of regional contractility. Twenty patients underwent CE and tagged MRI at 4 days and again at 7 months after acute MI. Resting circumferential shortening strain (Ecc) was analyzed in 24 segments per patient, and its improvement was correlated with the presence or absence of the CE patterns. Immediately after MI, 389 segments were considered dysfunctional because of having less than mean+/-2 SD Ecc of the remote region (-18+/-4%). At follow-up, significant improvement of Ecc occurred in 170 dysfunctional segments with normal CE (from -4+/-7% to -12+/-7%, P<0.001) but not in 60 segments with early hypoenhancement (from -2+/-6% to -6+/-9% Ecc, P=NS). In 240 dysfunctional segments with delayed hyperenhancement, the improvement of Ecc (from -2+/-6% to -5+/-8%, P<0.001) decreased with increasing transmural extent of hyperenhancement. Receiver operating characteristic analysis demonstrated that absence of delayed hyperenhancement, compared with absence of early hypoenhancement, had better sensitivity (82% versus 19%, respectively; P<0.001) and accuracy (74% versus 49%, respectively; P<0.001) in predicting recovery of Ecc to any given level. Compared with lack of early hypoenhancement, lack of delayed hyperenhancement has better diagnostic accuracy in predicting functional improvement in dysfunctional segments. The early hypoenhanced regions, which represent only the fraction of infarcted tissue with concomitant microvascular obstruction, greatly underestimate the amount of irreversibly injured myocardium present after acute MI.
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              Delayed contrast-enhanced magnetic resonance imaging for the prediction of regional functional improvement after acute myocardial infarction.

              We evaluated whether delayed contrast-enhanced magnetic resonance imaging (DCE-MRI) using an extracellular contrast agent could predict improvement of dysfunctional but viable myocardium after acute reperfused myocardial infarction (MI). The transmural extent of hyperenhancement at DCE-MRI has been related to improvement of function in reperfused MI. However, evidence is still limited, and earlier reports have produced conflicting results regarding the significance of contrast patterns after infarction. Thirty patients (mean age 59 +/- 11 years, 27 males) underwent cine MRI and DCE-MRI 7 +/- 3 days after a first reperfused acute MI and follow-up cine MRI at 13 +/- 3 weeks. Segmental wall thickening and segmental extent of hyperenhancement were scored in 1,689 segments. Of 500 dysfunctional segments, 273 (55%) improved at follow-up. There was no difference in likelihood of improvement or complete functional recovery between segments with 0% and 1% to 25% hyperenhancement. The likelihood of improvement of segments without hyperenhancement was 2.9, 14.3, and 20 times higher than that of segments with 26% to 50%, 51% to 75%, and >75% hyperenhancement, respectively (p 75% hyperenhancement, respectively (p < 0.001). In patients with recent reperfused MI, functional improvement of stunned myocardium is predicted by DCE-MRI.

                Author and article information

                S. Karger AG
                November 2007
                07 November 2006
                : 108
                : 4
                : 217-222
                Departments of aCardiology and bMedical Physics, Aberdeen Royal Infirmary, Aberdeen, UK
                96781 Cardiology 2007;108:217–222
                © 2007 S. Karger AG, Basel

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                Page count
                Figures: 1, Tables: 4, References: 12, Pages: 6
                Original Research


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