Imaging of Clinically Unrecognized Myocardial Fibrosis in Patients With Suspected Coronary Artery Disease.

Antiochos P; Ge Y; Steel K; Bingham S; Abdullah S; Mikolich JR; Arai AE; Bandettini WP; Patel AR; Farzaneh-Far A; Heitner JF; Shenoy C; Leung SW; Gonzalez JA; Shah DJ; Raman SV; Ferrari VA; Schulz-Menger J; Stuber M; Simonetti OP; Kwong RY

doi:10.1016/j.jacc.2020.06.063

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Journal article

Imaging of Clinically Unrecognized Myocardial Fibrosis in Patients With Suspected Coronary Artery Disease.

Antiochos P Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Cardiovascular Division, University Hospital of Lausanne, Lausanne, Switzerland.
Ge Y Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
Steel K Cardiology Division, San Antonio Military Medical Center, San Antonio, Texas.
Bingham S Revere Health, Provo, Utah.
Abdullah S Veteran Administration North Texas Healthcare System, University of Texas Southwestern Medical Center, Dallas, Texas.
Mikolich JR Department of Cardiovascular Medicine, Sharon Regional Health System, Sharon, Pennsylvania.
Arai AE National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
Bandettini WP National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
Patel AR Cardiology Division, Department of Medicine, University of Chicago, Chicago, Illinois.
Farzaneh-Far A Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois.
Heitner JF Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York.
Shenoy C Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.
Leung SW Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
Gonzalez JA Division of Cardiology and Radiology, Scripps Clinic, La Jolla, California.
Shah DJ Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
Raman SV Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio.
Ferrari VA Cardiovascular Division, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Schulz-Menger J Charité, Medical Faculty of the Humboldt University Berlin, Experimental and Clinical Research Center and Helios Clinics, German Center for Cardiovascular Research Partner site, Berlin, Germany.
Stuber M Department of Radiology, University Hospital and University of Lausanne, Lausanne, Switzerland.
Simonetti OP Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio.
Kwong RY Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts. Electronic address: rykwong@bwh.harvard.edu.

2020-08-22

Published in:

Journal of the American College of Cardiology. - 2020

stress cardiac magnetic resonance

unrecognized myocardial infarction

English BACKGROUND
Stress cardiac magnetic resonance (CMR) provides accurate assessment of both myocardial infarction (MI) and ischemia.

OBJECTIVES
This study aimed to evaluate the incremental prognostic value of unrecognized myocardial infarction (UMI), detected during assessment of coronary artery disease (CAD) by stress CMR, beyond cardiac function and ischemia.

METHODS
In the multicenter SPINS (Stress CMR Perfusion Imaging in the United States) study, 2,349 consecutive patients (63 ± 11 years of age, 53% were male) with suspected CAD were assessed by stress CMR and followed over a median of 5.4 years. UMI was defined as the presence of late gadolinium enhancement consistent with MI in the absence of medical history of MI. This study investigated the association of UMI with all-cause mortality and nonfatal MI (death and/or MI), and major adverse cardiac events (MACE).

RESULTS
UMI was detected in 347 patients (14.8%) and clinically recognized myocardial infarction (RMI) in 358 patients (15.2%). Compared with patients with RMI, patients with UMI had a similar burden of cardiovascular risk factors, but significantly lower left ventricular ejection fraction (p < 0.001) and lower rates of guideline-directed medical therapies, including aspirin (p < 0.001), statin (p < 0.001), and beta-blockers (p = 0.002). During follow-up, 328 deaths and/or MIs and 528 MACE occurred. In univariate analysis, UMI and RMI were strongly associated with death and/or MI (UMI: hazard ratio [HR]: 2.15; 95% confidence interval [CI]: 1.63 to 2.83; p < 0.001; RMI: HR: 2.45; 95% CI: 1.89 to 3.18) and MACE. Compared with patients with RMI, patients with UMI presented an increased risk for heart failure hospitalization (UMI vs. RMI: HR: 2.60; 95% CI: 1.48 to 4.58; p < 0.001). In a multivariate model including ischemia and left ventricular ejection fraction, UMI and RMI maintained robust prognostic association with death and/or MI (UMI: HR: 1.82; 95% CI: 1.37 to 2.42; p < 0.001; RMI: HR: 1.54; 95% CI: 1.14 to 2.09) and MACE.

CONCLUSIONS
In a multicenter cohort of patients with suspected CAD, presence of UMI or RMI portended an equally significant risk for death and/or MI, independently of the presence of ischemia. Compared with RMI patients, those with UMI were less likely to receive guideline-directed medical therapies and presented an increased risk for heart failure hospitalization that warrants further study. (Stress CMR Perfusion Imaging in the United States [SPINS]; NCT03192891).

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