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      Cardiac magnetic resonance in patients with acute cardiac injury and unobstructed coronary arteries

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          Abstract

          AIM

          To define the role of cardiac magnetic resonance (CMR) by analyzing a particular group of patients with suspected acute coronary syndrome (ACS) and normal coronary angiogram.

          METHODS

          From January 2009 to December 2015, we examined 220 patients with clinical suspicion of ACS, Troponin elevation [the threshold used to define a positive Troponin T test (TnT) was 0.1 ng/mL] and no significant coronary disease at angiography (the patients were considered to have significant angiographic disease only a 50% stenosis was detected in any of their coronary arteries). The role of CMR with the late gadolinium enhancement was evaluated.

          RESULTS

          CMR was performed to 190 patients (86%) of this group which reveals: Myocarditis in 90 patients (47%); apical ballooning (Tako-Tsubo syndrome) in 32 patients (17%); myocardial infarction (MI) in 40 patients (21%) and no clear diagnosis identified by CMR in 28 patients (15%). A comparison with previous studies was also made. Clinical and echocardiographic follow-ups were performed at 12 ± 2 mo and no major adverse cardiac events were revealed.

          CONCLUSION

          There is a group of patients with clinical suspicion of ACS displaying normal coronary angiograms. CMR was demonstrated to be a valuable tool in the differential diagnosis evaluation of myocarditis, apical ballooning and MI.

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          Most cited references15

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          Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology.

          Myocarditis can occasionally lead to sudden death and may progress to dilated cardiomyopathy in up to 10% of patients. Because the initial onset is difficult to recognize clinically and the diagnostic tools available are unsatisfactory, new strategies to diagnose myocarditis are needed. Cardiovascular MR imaging (CMR) was performed in 32 patients who were diagnosed with myocarditis by clinical criteria. To determine whether CMR visualizes areas of active myocarditis, endomyocardial biopsy was taken from the region of contrast enhancement and submitted to histopathologic analysis. Follow-up was performed 3 month later. Contrast enhancement was present in 28 patients (88%) and was usually seen with one or several foci in the myocardium. Foci were most frequently located in the lateral free wall. In the 21 patients in whom biopsy was obtained from the region of contrast enhancement, histopathologic analysis revealed active myocarditis in 19 patients (parvovirus B19, n=12; human herpes virus type 6 [HHV 6], n=5). Conversely, in the remaining 11 patients, in whom biopsy could not be taken from the region of contrast enhancement, active myocarditis was found in one case only (HHV6). At follow-up, the area of contrast enhancement decreased from 9+/-11% to 3+/-4% of left ventricular mass as the left ventricular ejection fraction improved from 47+/-19% to 60+/-10%. Contrast enhancement is a frequent finding in the clinical setting of suspected myocarditis and is associated with active inflammation defined by histopathology. Myocarditis occurs predominantly in the lateral free wall. Contrast CMR is a valuable tool for the evaluation and monitoring of inflammatory heart disease.
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            The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries.

            Troponin measurement is used in the assessment and risk stratification of patients presenting acutely with chest pain when the main cause of elevation is coronary artery disease. However, some patients have no coronary obstruction on angiography, leading to diagnostic uncertainty. We evaluated the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in these patients. Sixty consecutive patients (mean age 44 years, 72% male) with a troponin-positive episode of chest pain and unobstructed coronary arteries were recruited within 3 months of initial presentation. All patients underwent CMR with cine imaging, T2-weighted imaging for detection of inflammation, and late gadolinium enhancement imaging for detection of infarction/fibrosis. An identifiable basis for troponin elevation was established in 65% of patients. The commonest underlying cause was myocarditis (50%), followed by myocardial infarction (11.6%) and cardiomyopathy (3.4%). In the 35% of patients where no clear diagnosis was identified by CMR, significant myocardial infarction/fibrosis was excluded. CMR is a valuable adjunct to conventional investigations in a diagnostically challenging and important group of patients with troponin-positive chest pain and unobstructed coronary arteries.
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              Contrast media-enhanced magnetic resonance imaging visualizes myocardial changes in the course of viral myocarditis.

              The course of tissue changes in acute myocarditis in humans is not well understood. Diagnostic tools currently available are unsatisfactory. We tested the hypothesis that inflammation is reflected by signal changes in contrast-enhanced magnetic resonance imaging (MRI). We assessed 44 consecutive patients with symptoms of acute myocarditis. Nineteen patients met the inclusion criteria revealing ECG changes, reduced myocardial function, elevated creatine kinase, positive troponin T, serological evidence for acute viral infection, exclusion of coronary heart disease, and positive antimyosin scintigraphy. We studied these patients on days 2, 7, 14, 28, and 84 after the onset of symptoms. We obtained ECG-triggered, T1-weighted images before and after application of 0.1 mmol/kg gadolinium. We measured the global relative signal enhancement of the left ventricular myocardium related to skeletal muscle and compared it with measurements in 18 volunteers. The global relative enhancement was higher in patients on days 2 (4.8+/-0.3 [mean+/-SE] versus 2.5+/-0.2; P<.0001); 7 (4.7+/-0.5, P<.0001); 14 (4.6+/-0.5, P<.0002); and 28 (3.9+/-0.4, P=.009) but not on day 84 (3.1+/-0.3; P=NS). On day 2, the enhancement was focal, whereas at later time points, the enhancement was diffuse. In patients with evidence of ongoing disease, the values remained elevated. Acute myocarditis evolves from a focal to a disseminated process during the first 2 weeks after onset of symptoms. Contrast media-enhanced MRI visualizes the localization, activity, and extent of inflammation and may serve as a powerful noninvasive diagnostic tool in acute myocarditis.
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                Author and article information

                Journal
                World J Radiol
                WJR
                World Journal of Radiology
                Baishideng Publishing Group Co., Limited
                1949-8470
                28 June 2017
                28 June 2017
                : 9
                : 6
                : 280-286
                Affiliations
                Giovanni Salvatore Camastra, Stefano Sbarbati, Massimiliano Danti, Luca Cacciotti, Raffaella Semeraro, Sabino Walter Della Sala, Gerardo Ansalone, Department of Cardiology and of Radiology M.G.Vannini Hospital, 00177 Roma, Italy
                Author notes

                Author contributions: Camastra GS, Sbarbati S and Danti M performed the research and wrote the paper; Cacciotti L, Semeraro R, Della Sala SW and Ansalone G contributed to the analisys and supervised the report.

                Correspondence to: Giovanni Salvatore Camastra, MD, Department of Cardiology and of Radiology M.G.Vannini Hospital, via di acqua Bullicante 4, 00177 Roma, Italy. gcamastra@ 123456virgilio.it

                Telephone: +39-062-4291386 Fax: +39-062-4291418

                Article
                jWJR.v9.i6.pg280
                10.4329/wjr.v9.i6.280
                5491655
                25d06313-4e76-4615-8556-98855c575182
                ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.

                Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 4 January 2017
                : 9 May 2017
                : 18 May 2017
                Categories
                Retrospective Study

                magnetic resonance,acute coronary syndrome,troponin,myocarditis,coronary angiography

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