Word count: 4478words (including figures legends and references)Running title: Prognostic role of CMR and conventional risk factors in MINOCA Abstract: Objective: Assess the prognostic impact of Cardiovascular Magnetic Resonance (CMR) and conventional risk factors in patients with Myocardial infarction with non-obstructed coronaries (MINOCA). Background: MINOCA represents a diagnostic dilemma and the prognostic markers have not been clarified. Methods: 388 consecutive MINOCA patients undergoing CMR assessment were identified retrospectively from registry database and prospectively followed up for a primary clinical endpoint of all-cause mortality. 1.5T CMR was performed using a comprehensive protocol (cines, T2-weighted, and late gadolinium enhancement sequences). Patients were grouped into 4 categories based on their CMR findings: myocardial infarction (MI) (embolic/spontaneous recanalization), myocarditis, cardiomyopathy and normal CMR. Results: CMR(performed at a median of 37days from presentation) was able to identify the cause for the troponin rise in 74% of the patients (25% myocarditis, 25% MI and 25% cardiomyopathy), whilst a normal CMR was identified in 26%. Over a median follow-up of 1262days(3.5years), 5.7% patients died. Cardiomyopathy group had the worst prognosis (mortality 15%, log rank 19.9 p<0.001), MI had 4% mortality, and 2% in both myocarditis and normal CMR. In a multivariable cox regression model (including clinical and CMR parameters), CMR diagnosis of cardiomyopathy and ST-segment elevation on presentation ECG remained the only 2 significant predictors of mortality. Using presentation with ECG ST-elevation and CMR diagnosis of cardiomyopathy as risk markers, the mortality risk rates were 2%, 11% and 21% for presence of 0, 1 and 2 factor respectively(p<0.0001). Conclusion: In a large cohort of MINOCA, CMR(median 37days from presentation) identified a final diagnosis in 74% of patients. Cardiomyopathy had the highest mortality, followed by MI. The strongest predictors of mortality were a CMR diagnosis of cardiomyopathy and ST-elevation on presentation ECG.

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Key PointsQuestionIs transcatheter aortic valve implantation (TAVI) noninferior to surgical aortic valve replacement (surgery) in patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk?FindingsIn this randomized clinical trial that included 913 patients at moderately increased operative risk due to age or comorbidity, all-cause mortality at 1 year was 4.6% with TAVI vs 6.6% with surgery, a difference that met the prespecified noninferiority margin of 5%.MeaningAmong patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, treatment with TAVI was noninferior to surgery with respect to all-cause mortality at 1 year.

To cite this article: Steg PhG, Dorman SH, Amarenco P. Atherothrombosis and the role of antiplatelet therapy. J Thromb Haemost 2011; 9 (Suppl. 1): 325-332.

ObjectiveTo define important changes in management arising from the use of cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway.DesignFormal consensus study using literature review and cardiologist expert opinion to formulate consensus statements and setting up a consensus panel to review the statements (by completing a web-based survey, attending a face-to-face meeting to discuss survey results and modify the survey to reflect group discussion and completing the modified survey to determine which statements were in consensus).ParticipantsFormulation of consensus statements: four cardiologists (two CMR and two interventional) and six non-clinical researchers. Formal consensus: seven cardiologists (two CMR and three interventional, one echocardiography and one heart failure). Forty-nine additional cardiologists completed the modified survey.ResultsThirty-seven draft statements describing changes in management following CMR were generated; these were condensed into 12 statements and reviewed through the formal consensus process. Three of 12 statements were classified in consensus in the first survey; these related to the role of CMR in identifying the cause of out-of-hospital cardiac arrest, providing a definitive diagnosis in patients found to have unobstructed arteries on angiography and identifying patients with left ventricular thrombus. Two additional statements were in consensus in the modified survey, relating to the ability of CMR to identify patients who have a poor prognosis after PPCI and assess ischaemia and viability in patients with multivessel disease.ConclusionThere was consensus that CMR leads to clinically important changes in management in five subgroups of patients who activate the PPCI pathway.