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      Imaging Beyond the Angiogram in Women with Suspected Myocardial Infarction and No Obstructive Coronary Artery Disease

      , MD, FACC, FSCAI , 1

      Cardiovascular Innovations and Applications

      Compuscript

      women, myocardial infarction, imaging, angiogram, intracoronary imaging, cardiac MRI

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          Abstract

          A subset of women referred to the cardiac catheterization lab for suspected myocardial infarction thought to be due to a culprit artery are found to have no obstructive coronary artery disease by angiography. The mechanism by which these women have myocardial injury varies and is not usually clear by history and angiography alone. Additional imaging, including modalities such as cardiac MRI, intravascular imaging, and computed tomography may be helpful to clarify diagnoses and direct treatment.

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          Most cited references 14

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          Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries.

          Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a puzzling clinical entity with no previous evaluation of the literature. This systematic review aims to (1) quantify the prevalence, risk factors, and 12-month prognosis in patients with MINOCA, and (2) evaluate potential pathophysiological mechanisms underlying this disorder.
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            Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease.

            There is no angiographically demonstrable obstructive coronary artery disease (CAD) in a significant minority of patients with myocardial infarction, particularly women. We sought to determine the mechanism(s) of myocardial infarction in this setting using multiple imaging techniques. Women with myocardial infarction were enrolled prospectively, before angiography, if possible. Women with ≥50% angiographic stenosis or use of vasospastic agents were excluded. Intravascular ultrasound was performed during angiography; cardiac magnetic resonance imaging was performed within 1 week. Fifty women (age, 57±13 years) had median peak troponin of 1.60 ng/mL; 11 had ST-segment elevation. Median diameter stenosis of the worst lesion was 20% by angiography; 15 patients (30%) had normal angiograms. Plaque disruption was observed in 16 of 42 patients (38%) undergoing intravascular ultrasound. There were abnormal myocardial cardiac magnetic resonance imaging findings in 26 of 44 patients (59%) undergoing cardiac magnetic resonance imaging, late gadolinium enhancement (LGE) in 17 patients, and T2 signal hyperintensity indicating edema in 9 additional patients. The most common LGE pattern was ischemic (transmural/subendocardial). Nonischemic LGE patterns (midmyocardial/subepicardial) were also observed. Although LGE was infrequent with plaque disruption, T2 signal hyperintensity was common with plaque disruption. Plaque rupture and ulceration are common in women with myocardial infarction without angiographically demonstrable obstructive coronary artery disease. In addition, LGE is common in this cohort of women, with an ischemic pattern of injury most evident. Vasospasm and embolism are possible mechanisms of ischemic LGE without plaque disruption. Intravascular ultrasound and cardiac magnetic resonance imaging provide complementary mechanistic insights into female myocardial infarction patients without obstructive coronary artery disease and may be useful in identifying potential causes and therapies. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00798122.
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              T2-weighted cardiovascular magnetic resonance in acute cardiac disease

              Cardiovascular magnetic resonance (CMR) using T2-weighted sequences can visualize myocardial edema. When compared to previous protocols, newer pulse sequences with substantially improved image quality have increased its clinical utility. The assessment of myocardial edema provides useful incremental diagnostic and prognostic information in a variety of clinical settings associated with acute myocardial injury. In patients with acute chest pain, T2-weighted CMR is able to identify acute or recent myocardial ischemic injury and has been employed to distinguish acute coronary syndrome (ACS) from non-ACS as well as acute from chronic myocardial infarction. T2-weighted CMR can also be used to determine the area at risk in reperfused and non-reperfused infarction. When combined with contrast-enhanced imaging, the salvaged area and thus the success of early coronary revascularization can be quantified. Strong evidence for the prognostic value of myocardial salvage has enabled its use as a primary endpoint in clinical trials. The present article reviews the current evidence and clinical applications for T2-weighted CMR in acute cardiac disease and gives an outlook on future developments. "The principle of all things is water" Thales of Miletus (624 BC - 546 BC)
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                Author and article information

                Journal
                CVIA
                Cardiovascular Innovations and Applications
                CVIA
                Compuscript (Ireland )
                2009-8782
                2009-8618
                April 2019
                April 2019
                : 4
                : 1
                : 25-30
                Affiliations
                1NYU Langone Medical Center, New York, NY, USA
                Author notes
                Correspondence: Sohah N. Iqbal, MD, FACC, FSCAI, NYU Langone Medical Center, 550 1st Ave HHC 14, New York, NY 10019, USA, E-mail: sohah.iqbal@ 123456nyumc.org
                Article
                cvia20190008
                10.15212/CVIA.2019.0008
                Copyright © 2019 Cardiovascular Innovations and Applications

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

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