Relationship between location and size of myocardial infarction and their reciprocal influences on post-infarction left ventricular remodelling

Masci, Pier Giorgio; Gáname, Javier; Francone, Marco; Desmet, Walter; Lorenzoni, Valentina; Iacucci, Ilaria; Barison, Andrea; Carbone, Iacopo; Lombardi, Massimo; Agati, Luciano; Janssens, Stefan; Bogaert, Jan

doi:10.1093/eurheartj/ehr064

Cited by 135 publications

(115 citation statements)

References 22 publications

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“…Time to revascularisation 82 and anterior MI 83,84 are strongly associated with IS and, therefore, randomisation was stratified by these variables. The clinical event rates in CMR imaging participants was inevitably lower than that in those not participating in the CMR imaging substudy, largely because of the fact that some patients died or were too ill to take part.…”

Section: Safety End Pointsmentioning

confidence: 99%

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

et al. 2016

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BackgroundComplete revascularisation in patients with multivessel disease who are treated with primary percutaneous coronary intervention (PPCI) may improve outcomes compared with an infarct-related artery (IRA)-only strategy. However, non-IRA percutaneous coronary intervention (PCI) may result in additional myocardial infarction (MI).ObjectivesTo determine whether or not in-hospital complete revascularisation was associated with increased total infarct size (IS) in patients participating in the Complete versus Lesion-only PPCI trial (CvLPRIT). Secondary objectives were to assess whether or not myocardial salvage index, myocardial ischaemia and final IS at follow-up were different with a complete revascularisation versus an IRA-only strategy.DesignMulticentre, prospective, randomised, controlled and open-label trial with blinded end-point analysis.SettingSeven PPCI centres in England, UK.ParticipantsST-segment elevation MI (STEMI) patients with multivessel disease (angiographic stenosis > 70% in one view or > 50% in orthogonal views) presenting within 12 hours of symptom onset and treated with the PPCI. Coronary artery bypass surgery, cardiogenic shock and contraindications to cardiovascular magnetic resonance (CMR; substudy only) imaging were exclusions.InterventionsPatients were randomised to either complete in-hospital revascularisation or an IRA-only strategy.Main outcome measuresThe primary outcome was IS as measured by CMR undertaken at 48–72 hours post PPCI. Secondary outcome measures included microvascular obstruction, myocardial salvage index, left ventricular volumes and ejection fraction and final IS on the acute and follow-up CMR carried out at 9 months post STEMI.ResultsPatients were recruited from May 2011 until May 2013 and followed up for 12 months. Of 296 patients randomised in the main CvLPRIT, 205 consented to participate in the CMR substudy and 203 had analysable images for the primary end point. Patients in the IRA-only group (n = 105) were well matched to those in the complete revascularisation group (n = 98) for all baseline characteristics {mean age 64.1 years [standard deviation (SD) 10.8 years] vs. 63.1 years (SD 11.3 years); male sex 89% vs. 79%, respectively}. Total IS was not significantly different in the IRA-only and complete revascularisation groups {median 13.5% [interquartile range (IQR) 6.2–21.9%] of left ventricular (LV) mass vs. median 12.6% (IQR 7.2–22.6%) LV mass, respectively; 95% confidence interval –4.09% to 31.17%;p = 0.57}. Myocardial salvage index was also not significantly different in the IRA-only and complete revascularisation groups [median 58.5% (IQR 32.8–74.9%) vs. median 60.5% (IQR 40.6–81.9%), respectively;p = 0.14]. The prevalence of non-IRA MI on acute CMR was higher in the complete revascularisation group than in the IRA-only group (22/98 vs. 11/105, respectively;p = 0.02). There was no difference in total IS, ischaemic burden or LV volumes between treatment groups at follow-up CMR.LimitationsThe CMR substudy population may not be a true representation of the overall study population. The optimal timing of CMR to measure IS post PPCI is uncertain. Myocardial salvage was assessable in only 70% of patients.ConclusionsMultivessel PCI, compared with an IRA-only revascularisation, in the setting of STEMI led to a small increase in CMR imaging-detected non-IRA MI, but total IS was not increased.Future workLarger studies are required to (1) confirm that death and MI are reduced by a complete revascularisation strategy; (2) assess whether or not functional assessment of non-IRA lesions results in similar outcomes to a pragmatic angiographic-based revascularisation strategy; and (3) assess the timing of in-hospital versus staged outpatient complete revascularisation.Trial registrationCurrent Controlled Trials ISRCTN70913605.FundingThis project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership. The main CvLPRIT was funded by the British Heart Foundation (SP/10/001) with support from the NIHR Comprehensive Local Research Networks.

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Section: Safety End Pointsmentioning

confidence: 99%

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

et al. 2016

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“…In addition, in-hospital mortality rate as well as the mortality rate in the follow-up period was not different in patients with and those without ST elevation in leads V3R/V4R. Anterior LVMI is suggested as a predictor for developing heart failure in patients with MI and larger infarct size following LAD artery occlusion is described as a causative factor (19,20). On the other hand, RV ischemia with concurrent anterior MI may only result in a small RV infarct size (13).…”

Section: Discussionmentioning

confidence: 92%

ST-Segment Elevation in the Right Precordial Leads in Patients with Acute Anterior Myocardial Infarction

Pourafkari¹,

Joudi²,

Ghaffari³

et al. 2016

Balkan Med J

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Background: Elevation of ST segment in leads V3R/ V4R, which is commonly encountered in right ventricular myocardial infarction, may also occur in patients with anterior ST elevation myocardial infarction (STEMI). However, the clinical impact of this finding in the setting of anterior myocardial infarction is not well understood. Aims: We aimed to investigate the prognostic value of ST segment elevation in leads V3R/V4R in patients with first acute anterior myocardial infarction. Study Design: Prospective cohort study. Methods: Right precordial leads V3R/V4R were recorded in 111 patients admitted with first time anterior myocardial infarction. Patients were allocated into two groups based on the presence or absence of ST elevation in leads V3R/V4R. Demographic, biochemical and echocardiographic data, as well as the angiographic information, were recorded. In-hospital and 3 month mortality, and major adverse cardiac events (MACE), death, heart failure and ventricular dysrhythmia were also compared. Results: ST elevation in lead V3R or V4R was present in 72 out of 111 patients (64.9%). Involvement of the proximal part of the left anterior descending (LAD) artery was not different in the two groups (44.4% of patients with elevation vs. 53.8% of patients without elevation, p=0.22). Post-myocardial infarction complications, mortality and major adverse cardiac events were similar in the two groups. Left ventricular ejection fraction (LVEF) was significantly lower in patients with ST elevation in V3R/V4R (35 %±8 vs. 38 %±8, p=0.02). Twenty three out of 111 patients (20.7%) developed heart failure, which was similar in the two groups [16 (22.2%) of patients with ST elevation vs. 7 (17.9%) of patients without ST elevation, p=0.39]. Conclusion: Although ST elevation in V3R/V4R can be present in patients with left anterior descending artery occlusion, it does not seem to predict the prognosis. Lower left ventricular ejection fraction in this group may play a role in the long-term prognosis; however, this issue needs further investigation.

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“…2 Moreover, patients that survive an acute myocardial infarction are at increased risk of developing congestive heart failure, with infarct size as a major predictor of post-infarct cardiac remodelling and heart failure. 3 The single most effective therapy to limit infarct size is timely and complete reperfusion. However, despite its overall benefits, reperfusion itself has been shown to result in additional cardiomyocyte death.…”

Section: In This Issue Of Actamentioning

confidence: 99%

“…3 The single most effective therapy to limit infarct size is timely and complete reperfusion. However, despite its overall benefits, reperfusion itself has been shown to result in additional cardiomyocyte death.…”

mentioning

confidence: 99%

Arginase – a novel target for cardioprotection by vagal nerve stimulation

Uitterdijk

Duncker

2017

Acta Physiologica

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. 2017. Vagal nerve stimulation reduces infarct size via a mechanism involving the alpha-7 nicotinic acetylcholine receptor and downregulation of cardiac and vascular arginase. Acta Physiol 221, 174-181.The elegant study of Kiss et al. 1 in this issue of Acta Physiologica entitled 'Vagal nerve stimulation reduces infarct size via a mechanism involving the alpha-7 nicotinic acetylcholine receptor and down-regulation of cardiac and vascular arginase' explores the role of arginase in myocardial ischaemia-reperfusion damage, and in the myocardial infarct size limitation produced by vagal nerve stimulation. Although the incidence of acute myocardial infarction has decreased over the last decades, acute myocardial infarction continues to be a major cause of morbidity and mortality, worldwide.2 Moreover, patients that survive an acute myocardial infarction are at increased risk of developing congestive heart failure, with infarct size as a major predictor of post-infarct cardiac remodelling and heart failure. 3 The single most effective therapy to limit infarct size is timely and complete reperfusion. However, despite its overall benefits, reperfusion itself has been shown to result in additional cardiomyocyte death. 4 Hence, adjunctive therapies in addition to reperfusion are still needed to further limit infarct size and improve clinical outcome. 4Myocardial necrosis and microvascular no-reflow are prominent features of ischaemia-reperfusion damage. The mechanisms underlying these events remain incompletely understood, but there is evidence that inflammation plays an important role, including regional influx of neutrophils and macrophages. 5,6 Evidence is accumulating that vagal nerve activity exerts an immunomodulatory influence, characterized by an anti-inflammatory effect that may be beneficial in a variety of cardiovascular disease states, including myocardial infarction and heart failure.6-8 Indeed, vagal nerve stimulation (VNS) has been reported to limit infarct size in a variety of experimental studies (see Table 4 of Uitterdijk et al. 6 ). The exact mechanism by which VNS exerts its cardioprotective effect is not fully understood, but includes nicotinic 8 and muscarinic 7 receptor stimulation as well as activation of nitric oxide synthase, 6 while the VNS-associated bradycardia does not appear to be mandatory for its cardioprotective effects. [6][7][8] In the present issue of Acta Physiologica, Kiss et al.1 further explore the mechanism by which VNS reduces myocardial infarct size in the setting of an in vivo rat model of 30 min of coronary artery occlusion followed by 2 h of reperfusion. Specifically, the authors set out to test the hypothesis that VNS affords cardioprotection via inhibition of arginase activity. This hypothesis was based on the established anti-inflammatory actions of VNS, 8,9 and the critical importance of activation of NO synthase in the cardioprotection by VNS, in conjunction with evidence that inflammation-mediated upregulation of arginase activity contributes to ischaemia-reperfusi...

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Relationship between location and size of myocardial infarction and their reciprocal influences on post-infarction left ventricular remodelling

Abstract: Anterior MI patients experience more pronounced post-infarction LV remodelling and dysfunction than non-anterior MI patients due to a greater magnitude of irreversible ischaemic LV damage without any independent contribution of MI location.

Cited by 135 publications

References 22 publications

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

ST-Segment Elevation in the Right Precordial Leads in Patients with Acute Anterior Myocardial Infarction

Arginase – a novel target for cardioprotection by vagal nerve stimulation

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