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      D-Dimer Levels Predict Myocardial Injury in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study

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          Abstract

          Objectives

          Elevated D-dimer levels on admission predict prognosis in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), but the association of D-dimer levels with structural markers of myocardial injury in these patients is unknown.

          Methods

          We performed cardiac magnetic resonance (CMR) imaging in 208 patients treated with primary PCI for STEMI. CMR was performed a median of 3 days after the index procedure. Of the 208 patients studied, 75 patients had D-dimer levels above the normal range on admission (>0.5 μg/mL; high D-dimer group) while 133 had normal levels (≤0.5 μg/mL; low D-dimer group). The primary outcome was myocardial infarct size assessed by CMR. Secondary outcomes included area at risk (AAR), microvascular obstruction (MVO) area, and myocardial salvage index (MSI).

          Results

          In CMR analysis, myocardial infarct size was larger in the high D-dimer group than in the low D-dimer group (22.3% [16.2–30.5] versus 18.8% [10.7–26.7]; p = 0.02). Compared to the low D-dimer group, the high D-dimer group also had a larger AAR (38.1% [31.7–46.9] versus 35.8% [24.2–45.3]; p = 0.04) and a smaller MSI (37.7 [28.2–46.9] versus 47.1 [33.2–57.0]; p = 0.01). In multivariate analysis, high D-dimer levels were significantly associated with larger myocardial infarct (OR 2.59; 95% CI 1.37–4.87; p<0.01) and lower MSI (OR 2.62; 95% CI 1.44–4.78; p<0.01).

          Conclusions

          In STEMI patients undergoing primary PCI, high D-dimer levels on admission were associated with a larger myocardial infarct size, a greater extent of AAR, and lower MSI, as assessed by CMR data. Elevated initial D-dimer level may be a marker of advanced myocardial injury in patients treated with primary PCI for STEMI.

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          Most cited references17

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          Prognostic significance and determinants of myocardial salvage assessed by cardiovascular magnetic resonance in acute reperfused myocardial infarction.

          The aim of the study was to determine the prognostic significance and determinants of myocardial salvage assessed by cardiovascular magnetic resonance (CMR) in reperfused ST-segment elevation myocardial infarction. In acute myocardial infarction, CMR can retrospectively detect the myocardium at risk and the irreversible injury. This allows for quantifying the extent of salvaged myocardium after reperfusion as a potential strong end point for clinical trials and outcome. We analyzed 208 consecutive ST-segment elevation myocardial infarction patients undergoing primary angioplasty or= median group (2.9% vs. 22.1%, p < 0.001). The stepwise Cox proportional hazards model revealed that the MSI was the strongest predictor of major adverse cardiovascular events at 6-month follow-up (p < 0.001). All prognostic clinical (symptom onset to reperfusion), angiographic (Thrombolysis In Myocardial Infarction flow grade before angioplasty), and electrocardiographic (ST-segment resolution) parameters showed significant correlations with the MSI (p < 0.001 for all). This study for the first time demonstrates that the MSI assessed by CMR predicts the outcome in acute reperfused ST-segment elevation myocardial infarction. Therefore, MSI assessment has important implications for patient prognosis as well as for the design of future trials intended to test new reperfusion therapy efficacy. (Myocardial Salvage Assessed by Cardiovascular Magnetic Resonance-Impact on Outcome; NCT00952224).
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            The salvaged area at risk in reperfused acute myocardial infarction as visualized by cardiovascular magnetic resonance.

            We aimed to characterize the tissue changes within the perfusion bed of infarct-related vessels in patients with acutely reperfused myocardial infarction (MI) using cardiovascular magnetic resonance (CMR). Even in successful early revascularization, intermittent coronary artery occlusion affects the entire perfusion bed, also referred to as the area at risk. The extent of the salvaged area at risk contains prognostic information and may serve as a therapeutic target. Cardiovascular magnetic resonance can visualize the area at risk; yet, clinical data have been lacking. We studied 92 patients with acute MI and successful reperfusion 3 +/- 3 days after the event and 18 healthy control subjects. Breath-hold T2-weighted and contrast-enhanced ("late enhancement") CMR were used to visualize the reversible and the irreversible myocardial injury, respectively. All reperfused infarcts consistently revealed a pattern with both reversibly and irreversibly injured tissue. In contrast to the infarcted area, reversible damage was always transmural, exceeding the infarct in its maximal extent by 16 +/- 11% (absolute difference of the area of maximal infarct expansion 38 +/- 15% vs. 22 +/- 10%; p < 0.0001). None of the controls had significant T2 signal intensity abnormalities. In patients with reperfused MI, CMR visualizes both reversible and irreversible injury. This allows for quantifying the extent of the salvaged area after revascularization as an important parameter for clinical decision-making and research.
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              Impact of myocardial haemorrhage on left ventricular function and remodelling in patients with reperfused acute myocardial infarction.

              Myocardial haemorrhage is a common complication following reperfusion of ST-segment-elevation acute myocardial infarction (MI). Although its presence is clearly related to infarct size, at present it is unknown whether post-reperfusion haemorrhage affects left ventricular (LV) remodelling. Magnetic resonance imaging (MRI) can be used to identify MI, myocardial haemorrhage, and microvascular obstruction (MVO), as well as measure LV volumes, function, and mass. Ninety-eight patients (14 females, 84 males, mean age: 57.7 years) with MI reperfused with percutaneous coronary intervention (PCI) were studied within the first week (1W) and at 4 months (4M) after the event. T2-weighted MRI was used to differentiate between haemorrhagic (i.e. hypointense core) and non-haemorrhagic infarcts (i.e. hyperintense core). Microvascular obstruction and infarct size were determined on contrast-enhanced MRI, whereas cine MRI was used to quantify LV volumes, mass, and function. Twenty-four patients (25%) presented with a haemorrhagic MI. In the acute phase, the presence of myocardial haemorrhage was related to larger infarct size and infarct transmurality, lower LV ejection fraction, and lower systolic wall thickening in the infarcted myocardium (all P-values <0.001). At 4M, a significant improvement in LV ejection fraction in patients with non-haemorrhagic MI was seen (baseline: 49.3 +/- 7.9% vs. 4M: 52.9 +/- 8.1%; P < 0.01). Left ventricular ejection fraction did, however, not improve in patients with haemorrhagic MI (baseline: 42.8 +/- 6.5% vs. 4M: 41.9 +/- 8.5%; P = 0.68). Multivariate analysis showed myocardial haemorrhage to be an independent predictor of adverse LV remodelling at 4M (defined as an increase in LV end-systolic volume). This pattern was independent of the initial infarct size. Myocardial haemorrhage, the presence of which can easily be detected with T2-weighted MRI, is a frequent complication after successful myocardial reperfusion and an independent predictor of adverse LV remodelling regardless of the initial infarct size.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                11 August 2016
                2016
                : 11
                : 8
                Affiliations
                [1 ]Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
                [2 ]Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
                [3 ]Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
                [4 ]Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
                [5 ]Department of Radiology, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
                GERMANY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: SC WJJ YBS.

                • Data curation: SC WJJ YBS YHC JKH EKK JHY HCG.

                • Formal analysis: SC WJJ YBS JKH EKK.

                • Investigation: SC WJJ YBS JKH EKK JHY HCG.

                • Methodology: SC WJJ YBS.

                • Project administration: YBS HCG.

                • Resources: SC WJJ YBS JKH EKK JHY HCG.

                • Software: SC WJJ YBS JKH EKK JHY JYH SHC.

                • Supervision: YBS JAL EG HCG.

                • Validation: SC WJJ YBS SCL SHL HCG.

                • Visualization: SC WJJ YBS.

                • Writing - original draft: SC WJJ YBS JKH EKK.

                • Writing - review & editing: SC WJJ YBS JAL EG EKK.

                Article
                PONE-D-16-08632
                10.1371/journal.pone.0160955
                4981325
                27513758
                4d1858da-4e0a-481f-8e6c-1d4fdd9caaa8
                © 2016 Choi et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 4, Tables: 3, Pages: 12
                Product
                Funding
                The authors have no support or funding to report.
                Categories
                Research Article
                Medicine and Health Sciences
                Cardiology
                Myocardial Infarction
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                Diagnostic Medicine
                Diagnostic Radiology
                Magnetic Resonance Imaging
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                Imaging Techniques
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                Magnetic Resonance Imaging
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                Radiology and Imaging
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