The Value of Cardiac Magnetic Resonance in Patients With Acute Coronary Syndrome and Normal Coronary Arteries

Zaldumbide, E. Laraudogoitia; Pérez-David, Esther; Larena, J. A.; Castillo, Sonia Velasco del; Cuevas, José Ramón Rumoroso; Onaindia, José Juan; Goya, Iñaki Lekuona; Garcı́a-Fernández, Miguel Ángel

doi:10.1016/s1885-5857(09)73263-3

Cited by 31 publications

(10 citation statements)

References 26 publications

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“…31-35 The distribution of patterns was different than in prior studies, 32, 33 likely related to demographic and clinical characteristics. For example, studies reporting a higher frequency of non-ischemic LGE (e.g., myocarditis) included younger, predominantly male cohorts, 31, 33, 34 often with a requirement for completely normal angiography, as opposed to the present series of women with a clinical diagnosis of MI. Some prior reports specifically excluded patients with a clinical diagnosis of MI.…”

Section: Discussioncontrasting

confidence: 57%

Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease

et al. 2011

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Background There is no angiographically demonstrable obstructive coronary artery disease (CAD) in a significant minority of patients with myocardial infarction (MI), particularly women. We sought to determine mechanism(s) of MI in this setting using multiple imaging techniques. Methods and Results Women with MI were enrolled prospectively, prior to angiography if possible. Women with ≥50% angiographic stenosis or use of vasospastic agents were excluded. Intravascular ultrasound (IVUS) was performed during angiography and cardiac magnetic resonance imaging (CMR) within one week. Fifty women (age 57±13 years) had median peak troponin 1.60 ng/ml; 11 had ST elevation. Median diameter stenosis of the worst lesion was 20% by angiography; 15 patients (30%) had normal angiograms. Plaque disruption was observed in 16/42 patients (38%) undergoing IVUS. There were abnormal myocardial CMR findings in 26/44 patients (59%) undergoing CMR: late gadolinium enhancement (LGE) in 17 and T2 signal hyperintensity indicating edema in 9 additional patients. The most common LGE pattern was ischemic (transmural/subendocardial). Non-ischemic LGE patterns (midmyocardial/subepicardial) were also observed. LGE was infrequent with plaque disruption but T2 signal hyperintensity was common with plaque disruption. Conclusions Plaque rupture and ulceration are common in women with MI without angiographically demonstrable obstructive CAD. LGE is also 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. IVUS and CMR provide complementary mechanistic insights in female MI patients without obstructive CAD and may be useful in identifying potential etiologies and therapies.

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Section: Discussioncontrasting

confidence: 57%

Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease

et al. 2011

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“…[5][6][7][8] All patients enrolled in this study had a clinical diagnosis of myocardial infarction and were referred for angiography on the basis of this diagnosis, which may explain our lower observed prevalence of LGE suggestive of myocarditis compared with prior publications. We did not think it appropriate to exclude these patients from the study retrospectively.…”

mentioning

confidence: 89%

Response to Letters Regarding Article, “Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease”

et al. 2012

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Dr Ward suggests that plaque ruptures identified by the core laboratory in our study 1 were not responsible for troponin elevation and instead had a nonischemic cause, and that these plaque ruptures may have been caused by intravascular ultrasound. We respectfully disagree. We believe that the observed ruptured plaques were responsible for troponin elevation in patients in this study for several reasons. First, all patients presented with acute onset of ischemic symptoms, and we find it very unlikely that plaque rupture is incidental in this setting. We acknowledge that it is impossible to exclude plaque rupture caused by the intravascular ultrasound procedure in this or any study using intravascular ultrasound. Though we did not include stable control patients, we reference in the manuscript 2 previous publications that reported no plaque rupture in a total of 155 stable patients without myocardial infarction, most of whom had atherosclerotic disease on intravascular ultrasound. 2,3 Furthermore, 75% of participants in our study who were found to have plaque disruption had T2 signal hyperintensity, which indicates acute myocardial edema. As shown in the representative image in the published article (Figures 4Aiv and 4Av), T2 hyperintensity in those patients with plaque disruption generally involved a large territory. We believe, therefore, that the culprit artery may have been transiently occluded, causing early myocardial injury. This hypothesized occlusion was relieved by the time of angiography, and the duration of decreased flow must have been sufficiently short to avoid the development of myocardial changes consistent with late gadolinium enhancement (LGE). Moreover, the presence of LGE does not equate with "definite MI": Note that only 10 of 17 participants who manifested LGE on the cardiac magnetic resonance had an ischemic pattern of LGE on the cardiac magnetic resonance, whereas others suggested a nonischemic cause or had a mixed pattern. Further studies are needed to definitively link cause and effect in this patient population.We agree with Drs Chen and Zhang that some patients with a nonischemic cause of chest pain, as evidenced by a nonischemic pattern of myocardial injury, do meet the universal criteria for diagnosis of myocardial infarction, as in our study, the referenced study by Assomull et al, 4 and several other prior publications. [5][6][7][8] All patients enrolled in this study had a clinical diagnosis of myocardial infarction and were referred for angiography on the basis of this diagnosis, which may explain our lower observed prevalence of LGE suggestive of myocarditis compared with prior publications. We did not think it appropriate to exclude these patients from the study retrospectively. In our study, as in prior reports, not all participants had T2 signal hyperintensity and/or LGE on cardiac magnetic resonance. This finding highlights the somewhat insensitive nature of cardiac magnetic resonance for localization of myocardial injury in patients who have been proven to have myocardial ...

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“…Furthermore, C-MRI is the recommended imaging modality of choice to confirm myocardial involvement according to the ESC (European Society of Cardiology) guidelines and it was favourably compared to the gold standard endomyocardial biopsy [48,52,[69][70][71][72]. It is worthy to mention that C-MRI is normal in a large proportion of MINOCA patients (8-67%), thereby raising the reconsideration for alternative non-cardiac disorders or undetectable small infarct or little widely distributed necrotic myocytes [4,[73][74][75][76][77][78][79]. Performing C-MRI within 7 days from clinical presentation is the optimal time to increase the diagnostic yield [73,75,76].…”

Section: Management Of Patients Suspected Of Minocamentioning

confidence: 99%

Management of myocardial infarction with Nonobstructive Coronary Arteries (MINOCA): a subset of acute coronary syndrome patients

Matta¹,

Nader²,

Roncalli³

2021

Reviews in Cardiovascular Medicine

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Myocardial infarction with non-obstructive coronary artery disease (MINOCA) represents a significant proportion (up to 15%) of acute myocardial infarction (AMI) population. MINOCA is diagnosed in patients who fullfilled the fourth universal definition of AMI in the absence of significant obstructive coronary artery disease on coronary angiography. MINOCA is a group of heterogeneous diseases with different pathophysiological mechanisms requiring multimodality imaging. Left ventriculography, cardiac magnetic resonance imaging and intra-coronary imaging (IVUS, OCT) are useful tools playing a pivotal role in the diagnostic work-up. There are no standard guidelines on the management of MINOCA patients and the therapeutic approach is personalized, thereby detecting the underlying aetiology is fundamental to initiate an early appropriate cause-targeted therapy.

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The Value of Cardiac Magnetic Resonance in Patients With Acute Coronary Syndrome and Normal Coronary Arteries

Cited by 31 publications

References 26 publications

Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease

Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease

Response to Letters Regarding Article, “Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease”

Management of myocardial infarction with Nonobstructive Coronary Arteries (MINOCA): a subset of acute coronary syndrome patients

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