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A Noncontrast CMR Risk Score for Long-Term Risk Stratification in Reperfused ST-Segment Elevation Myocardial
Heerajnarain Bulluck1, Jaclyn Carberry2, David Carrick3
1British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland; University of East Anglia, Norwich, United Kingdom; Leeds University and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
Insights
A new noncontrast cardiovascular magnetic resonance (CMR) risk score effectively predicts major adverse cardiac events in ST-segment elevation myocardial infarction (STEMI) patients. This score stratifies patients into low, intermediate, and high-risk groups for better prognostic assessment.
Area of Science:
- Cardiovascular Imaging and Diagnostics
- Cardiac MRI
- Acute Coronary Syndromes
Background:
- A novel cardiovascular magnetic resonance (CMR) risk score was developed to assess prognosis in ST-segment elevation myocardial infarction (STEMI) patients.
- The score incorporates left ventricular ejection fraction (LVEF), myocardial infarct (MI) size, and microvascular obstruction (MVO) or intramyocardial hemorrhage (IMH).
Purpose of the Study:
- To compare the prognostic value of a noncontrast CMR risk score against established scores for predicting adverse cardiac events.
- To evaluate the ability of the CMR score to risk-stratify STEMI patients.
Main Methods:
- Three CMR-based risk scores were developed and compared, including variations with MVO and IMH, alongside the GRACE score.
- A derivation cohort (370 patients) and a validation cohort (234 patients) were utilized.
- Performance was assessed using C-statistics for 1-year composite outcomes and Kaplan-Meier curves for 5-year outcomes.
Main Results:
- The CMR risk scores demonstrated comparable or superior performance to the GRACE score in predicting 1-year composite endpoints (C-statistics ranging from 0.82 to 0.83 vs. 0.74).
- Score 3, utilizing LVEF and IMH, showed excellent discrimination (C-statistic 0.87) and calibration in the validation cohort.
- Kaplan-Meier analysis identified distinct risk groups: high-risk (LVEF ≤45%), intermediate-risk (LVEF >45% and IMH), and low-risk (LVEF >45% and no IMH) with significant differences in 5-year cumulative events.
Conclusions:
- The noncontrast CMR risk score, particularly Score 3, offers robust prognostic value for STEMI patients, comparable to existing scores.
- This CMR score effectively stratifies patients into low, intermediate, and high-risk categories based on LVEF and IMH, aiding clinical decision-making.
- The findings support the use of noncontrast CMR for risk stratification after STEMI.
Objectives:
This study compared the prognostic value of a noncontrast CMR risk score for the composite of all-cause death, nonfatal myocardial infarction, and new congestive heart failure.
Background:
A cardiovascular magnetic resonance (CMR) risk score including left ventricular ejection fraction (LVEF), myocardial infarct (MI) size, and microvascular obstruction (MVO) was recently proposed to risk-stratify patients with ST-segment elevation myocardial infarction (STEMI).
Methods:
The Eitel CMR risk score and GRACE (Global Registry of Acute Coronary Events) score were used as a reference (Score 1: acute MI size ≥19% LV, LVEF ≤47%, MVO >1.4% LV and GRACE score). MVO was replaced by intramyocardial hemorrhage (IMH) in Score 2 (acute MI size ≥19% LV, LVEF ≤47%, IMH, and GRACE score). Score 3 included only LVEF ≤45%, IMH, and GRACE score.
Results:
There were 370 patients in the derivation cohort and 234 patients in the validation cohort. In the derivation cohort, the 3 scores performed similarly and better than GRACE score to predict the 1-year composite endpoint with C-statistics of 0.83, 0.83, 0.82, and 0.74, respectively. In the validation cohort, there was good discrimination and calibration of score 3, with a C-statistic of 0.87 and P = 0.71 in a Hosmer-Lemeshow test for goodness of fit, on the 1-year composite outcome. Kaplan-Meier curves for 5-year composite outcome showed that those with LVEF ≤45% (high-risk) and LVEF >45% and IMH (intermediate-risk) had significantly higher cumulative events than those with LVEF >45% and no IMH (low-risk), log-rank tests: P = 0.02 and P = 0.03, respectively. The HR for the high-risk group was 2.3 (95% CI: 1.1-4.7) and for the intermediate-risk group was 2.0 (95% CI: 1.0-3.8), and these remained significant after adjusting for the GRACE score.
Conclusions:
This noncontrast CMR risk score has performance comparable to an established risk score, and patients with STEMI could be stratified into low risk (LVEF >45% and no IMH), intermediate risk (LVEF >45% and IMH), and high risk (LVEF ≤45%). (A Trial of Low-dose Adjunctive alTeplase During prIMary PCI [T-TIME]; NCT02257294) (Detection and Significance of Heart Injury in ST Elevation Myocardial Infarction [BHF MR-MI]; NCT02072850).
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