Pericardial Involvement in ST-Segment Elevation Myocardial Infarction as Detected by Cardiac MRI
Eias Massalha1, Yafim Brodov1,2, Daniel Oren1,3
1The Olga and Lev Leviev Heart Center, Sheba Medical Center, Affiliated With the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel.
Background:
Post myocardial infarction pericarditis is considered relatively rare in the current reperfusion era. The true incidence of pericardial involvement may be underestimated since the diagnosis is usually based on clinical and echocardiographic parameters.
Objectives:
This study aims to document the incidence, extent, and prognostic implication of pericardial involvement in ST-segment elevation myocardial infarction (PISTEMI) using cardiac MRI (CMR).
Methods:
One hundred and eighty-seven consecutive ST-segment elevation myocardial infarction patients underwent CMR on day 5 ± 1 following admission, including steady-state free precession (SSFP) and late Gadolinium enhancement (LGE) sequences. Late Gadolinium enhancement and microvascular obstruction (MVO) were quantified as a percentage of left ventricular (LV) mass. Late Gadolinium enhancement was graded for transmurality according to the 17 AHA left ventricle (LV) segment model (LGE score). Late pericardial enhancement (LPE), the CMR evidence of pericardial involvement, was defined as enhanced pericardium in the LGE series and was retrospectively recorded as present or absent according to the 17 AHA segments. Late pericardial enhancement was evaluated adjacent to the LV, the right ventricle, and both atria. Clinical, laboratory, angiographic, and echocardiographic data were collected. Clinical follow-up for major adverse cardiac events (MACE) was documented and correlated with CMR indices, including LGE, MVO, and LPE.
Results:
Late pericardial enhancement (LPE+) was documented in 77.5% of the study cohort. A strong association was found between LPE and the degree and extent of myocardial injury (LGE, MVO). Both LGE and MVO were significantly correlated with increased MACE on follow-up. On the contrary, LPE presence, either adjacent to the LV or the other cardiac chambers, was associated with a lower MACE rate in a median of 3 years of follow-up HR 0.39, 95% CI (0.21-0.7), p = 0.002, and HR 0.48, 95% CI (0.26-0.9), p = 0.02, respectively.
Conclusions:
Prognostic implication of pericardial involvement in ST-segment elevation myocardial infarction was documented by CMR in 77.5% of our STEMI cohort. Late pericardial enhancement presence correlated significantly with the extent and severity of the myocardial damage. Unexpectedly, it was associated with a considerably lower MACE rate in the follow-up period.
Insights
Pericardial involvement, detected by late pericardial enhancement (LPE) in 77.5% of ST-segment elevation myocardial infarction (STEMI) patients, surprisingly correlates with a lower rate of major adverse cardiac events (MACE). This finding challenges previous assumptions about pericarditis post-myocardial infarction.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Post-myocardial infarction pericarditis is often underestimated due to diagnostic limitations.
- Current diagnostic methods rely on clinical and echocardiographic parameters, potentially missing subclinical pericardial involvement.
Purpose of the Study:
- To determine the incidence, extent, and prognostic significance of pericardial involvement in ST-segment elevation myocardial infarction (STEMI) using cardiac MRI (CMR).
- To investigate the relationship between pericardial enhancement and myocardial injury, and its impact on long-term patient outcomes.
Main Methods:
- 187 STEMI patients underwent CMR, including LGE and SSFP sequences, on day 5 post-admission.
- Late pericardial enhancement (LPE) was identified on LGE sequences and correlated with myocardial injury (LGE, MVO) and clinical outcomes (MACE).
Main Results:
- Late pericardial enhancement (LPE) was observed in 77.5% of STEMI patients.
- LPE showed a strong association with the extent and severity of myocardial injury (LGE, MVO).
- Contrary to expectations, LPE presence was linked to a significantly lower rate of major adverse cardiac events (MACE) over 3 years.
Conclusions:
- Cardiac MRI effectively documents pericardial involvement (LPE) in a high percentage of STEMI patients.
- Pericardial involvement in STEMI, while associated with myocardial damage, appears to have a protective prognostic implication.
- These findings necessitate a re-evaluation of the role and prognosis of pericarditis in the context of acute myocardial infarction.
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