Incremental value of cardiovascular magnetic resonance over echocardiography in the detection of acute and chronic myocardial infarction

Abstract

BackgroundAlthough echocardiography is used as a first line imaging modality, its accuracy to detect acute and chronic myocardial infarction (MI) in relation to infarct characteristics as assessed with late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) is not well described.MethodsOne-hundred-forty-one echocardiograms performed in 88 first acute ST-elevation MI (STEMI) patients, 2 (IQR1-4) days (n = 61) and 102 (IQR92-112) days post-MI (n = 80), were pooled with echocardiograms of 36 healthy controls. 61 acute and 80 chronic echocardiograms were available for analysis (53 patients had both acute and chronic echocardiograms). Two experienced echocardiographers, blinded to clinical and CMR data, randomly evaluated all 177 echocardiograms for segmental wall motion abnormalities (SWMA). This was compared with LGE-CMR determined infarct characteristics, performed 104 ± 11 days post-MI. Enhancement on LGE-CMR matched the infarct-related artery territory in all patients (LAD 31%, LCx 12% and RCA 57%).ResultsThe sensitivity of echocardiography to detect acute MI was 78.7% and 61.3% for chronic MI; specificity was 80.6%. Undetected MI were smaller, less transmural, and less extensive (6% [IQR3-12] vs. 15% [IQR9-24], 50 ± 14% vs. 61 ± 15%, 7 ± 3 vs. 9 ± 3 segments, p < 0.001 for all) and associated with higher left ventricular ejection fraction (LVEF) and non-anterior location as compared to detected MI (58 ± 5% vs. 46 ± 7%, p < 0.001 and 82% vs. 63%, p = 0.03). After multivariate analysis, LVEF and infarct size were the strongest independent predictors of detecting chronic MI (OR 0.78 [95%CI 0.68-0.88], p < 0.001 and OR 1.22 [95%CI0.99-1.51], p = 0.06, respectively). Increasing infarct transmurality was associated with increasing SWMA (p < 0.001).ConclusionsIn patients presenting with STEMI, and thus a high likelihood of SWMA, the sensitivity of echocardiography to detect SWMA was higher in the acute than the chronic phase. Undetected MI were smaller, less extensive and less transmural, and associated with non-anterior localization and higher LVEF. Further work is needed to assess the diagnostic accuracy in patients with non-STEMI.

Use of transthoracic echocardiography in the evaluation of chest pain: illustrative cases and review of recent guidelines

“…Echocardiography has a high sensitivity but moderate specificity for the diagnosis of acute MI 5. Previous studies have shown that although sensitivity is high, specificity is much poorer 6 7…”

Review of Journal of Cardiovascular Magnetic Resonance 2014

“…CMR is invaluable to the study of patients with ischaemic heart disease and has made a major impact on this field and is now widely used to delineate myocardial infarction, [ 161 , 162 ] and scarring, [ 163 ] although more recently non-contrast techniques to detect infarction have been described. The use of techniques to define myocardial edema, [ 164 – 166 ] myocardium at risk, [ 167 ] myocardial hemorrhage, and microvascular obstruction, [ 168 ] has also grown greatly.…”

Review of Journal of Cardiovascular Magnetic Resonance 2013

“…Echocardiography was therefore more sensitive to detect acute versus chronic infarctions. Undetected myocardial infarctions were smaller, less extensive and less transmural, associated with non-anterior localization and higher ejection fraction as compared to detected myocardial infarctions [ 133 ].…”