Ejection Fraction by Echocardiography for a Selective Use of Magnetic Resonance After Infarction

Abstract

Background Cardiac magnetic resonance (CMR) permits robust risk stratification of discharged ST-segment–elevation myocardial infarction patients, but its indiscriminate use in all cases is not feasible. We evaluated the utility of left ventricular ejection fraction (LVEF) by echocardiography for a selective use of CMR after ST-segment–elevation myocardial infarction. Methods Echocardiography and CMR were performed in 1119 patients discharged for ST-segment–elevation myocardial infarction included in a multicenter registry. The prognostic power of CMR beyond echocardiography-LVEF was assessed using adjusted C statistic, net reclassification improvement index, and integrated discrimination improvement index. Results During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 readmissions for acute heart failure). In the entire group, CMR-LVEF (but not echocardiography-LVEF) independently predicted MACE occurrence. The MACE rate significantly increased only in patients with CMR-LVEF<40% (≥50%: 7%, 40%–49%: 9%, <40%: 27%, P <0.001). Most patients displayed echocardiography-LVEF≥50% (629, 56%), and they had a low MACE rate (57/629, 9%). In patients with echocardiography-LVEF<50% (n=490, 44%), the MACE rate was also low in those with CMR-LVEF≥40% (24/278, 9%) but significantly increased in patients with CMR-LVEF<40% (55/212, 26%; P <0.001). Compared with echocardiography-LVEF, CMR-LVEF significantly improved MACE prediction in the group of patients with echocardiography-LVEF<50% (C statistic, 0.80 versus 0.72; net reclassification improvement index, 0.73; integrated discrimination improvement index, 0.10) but not in those with echocardiography-LVEF≥50% (C statistic 0.66 versus 0.66; net reclassification improvement index, 0.17; integrated discrimination improvement index, 0.01). Conclusions A straightforward strategy based on a selective use of CMR for risk prediction in ST-segment–elevation myocardial infarction patients with echocardiography-LVEF<50% can provide insights into patient care. The cost-effectiveness of this approach, as well as the direct implications in clinical management, should be further explored.

Risk score for early risk prediction by cardiac magnetic resonance after acute myocardial infarction

“…Leading on from previous research to determine which patients could benefit most from CMR for prognostic purposes, e.g. those with echocardiography-LVEF<50% [7], the present study focuses on simple risk prediction in patients who undergo CMR. This technique is recommended when echocardiography is suboptimal or inconclusive, and brings the added benefit of additional assessment of residual ischemia and myocardial viability [4].…”

“…Use of cardiac magnetic resonance (CMR) in this setting has increased exponentially this century. CMR performed early after the acute event permits comprehensive evaluation of the structural consequences of myocardial infarction and can improve risk prediction by means of accurate LVEF, microvascular obstruction (MVO) and infarct size (IS) measurement [5][6][7]. Exploring the prognostic value of novel predictive scores including CMR parameters is therefore an essential undertaking.…”

Magnetic Resonance Assessment of Left Ventricular Ejection Fraction at Any Time Post‐Infarction for Prediction of Subsequent Events in a Large Multicenter STEMI Registry

“…3,7 We recently showed that significant crossovers can occur between LVEF categories when pre- discharge values from echocardiography and MRI are compared. 12 Risk reconsideration in chronic phase has shown an impact on decision-making. Patients with less closely monitored LVEF are less likely to be treated with specific evidence-based medications and implantable cardioverter-defibrillators.…”

“…Furthermore, based on the high MACE rate detected in patients with LVEF < 40% (vs. those with ≥40%) both at 1 week and after follow‐up MRI in this registry and previous analysis by our group, 12 additional analyses were performed using this cut‐off value to study the prognostic impact of LVEF dynamics (i.e., LVEF change from initial to follow up). Consequently, patients were classified into Group 1—sustained LVEF < 40% (“r‐ to r‐LVEF”), Group 2—worsened LVEF (“p‐ or mr‐ to r‐LVEF”), Group 3—improved LVEF (“r‐ to mr‐ or p‐LVEF”), and Group 4—sustained LVEF ≥ 40% (“mr‐ or p‐ to mr‐ or p‐LVEF”).…”

Rationale and design of a multi‐center, prospective randomized controlled trial on the effects of sacubitril–valsartan versus enalapril on left ventricular remodeling in ST‐elevation myocardial infarction: The PERI‐STEMI study

“…A recent study suggested use of CMR for further risk stratification on STEMI patients with lower LVEF on echocardiography. 36 Thus, with a multiple‐sequence design in our CMR protocol for this trial, we proposed that PERI‐STEMI could better demonstrate the advanced functional benefits ARNI could bring, as well as pave understanding of its cardiovascular mechanism.…”