Association of Adverse Clinical Outcomes With Peri-Infarct Ischemia Detected by Stress Cardiac Magnetic Imaging
Benedikt Bernhard1, Yin Ge1, Panagiotis Antiochos2
1Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
Background:
Early invasive revascularization guided by moderate to severe ischemia did not improve outcomes over medical therapy alone, underlying the need to identify high-risk patients for a more effective invasive referral. CMR could determine the myocardial extent and matching locations of ischemia and infarction.
Objectives:
This study sought to investigate if CMR peri-infarct ischemia is associated with adverse events incremental to known risk markers.
Methods:
Consecutive patients were included in an expanded cohort of the multicenter SPINS (Stress CMR Perfusion Imaging in the United States) study. Peri-infarct ischemia was defined by the presence of any ischemic segment neighboring an infarcted segment by late gadolinium enhancement imaging. Primary outcome events included acute myocardial infarction and cardiovascular death, whereas secondary events included any primary events, hospitalization for unstable angina, heart failure hospitalization, and late coronary artery bypass surgery.
Results:
Among 3,915 patients (age: 61.0 ± 12.9 years; 54.7% male), ischemia, infarct, and peri-infarct ischemia were present in 752 (19.2%), 1,123 (28.8%), and 382 (9.8%) patients, respectively. At 5.3 years (Q1-Q3: 3.9-7.2 years) of median follow-up, primary and secondary events occurred in 406 (10.4%) and 745 (19.0%) patients, respectively. Peri-infarct ischemia was the strongest multivariable predictor for primary and secondary events (HRadjusted: 1.72 [95% CI: 1.23-2.41] and 1.71 [95% CI: 1.32-2.20], respectively; both P < 0.001), adjusted for clinical risk factors, left ventricular function, ischemia extent, and infarct size. The presence of peri-infarct ischemia portended to a >6-fold increased annualized primary event rate compared to those with no infarct and ischemia (6.5% vs 0.9%).
Conclusions:
Peri-infarct ischemia is a novel and robust prognostic marker of adverse cardiovascular events.
Insights
Peri-infarct ischemia, identified by cardiac MRI, is a strong predictor of adverse cardiovascular events. This finding helps identify high-risk patients needing invasive referral for better outcomes.
Area of Science:
- Cardiovascular imaging and diagnostics
- Myocardial infarction and ischemia research
- Prognostic marker development in cardiology
Background:
- Current strategies for invasive revascularization guided by ischemia severity do not consistently improve patient outcomes.
- There is a critical need to identify high-risk patients who would benefit most from invasive procedures.
- Cardiac Magnetic Resonance (CMR) imaging offers detailed assessment of myocardial ischemia and infarction extent and location.
Purpose of the Study:
- To determine if peri-infarct ischemia, visualized by CMR, predicts adverse cardiovascular events.
- To assess the incremental prognostic value of peri-infarct ischemia beyond established risk markers.
- To investigate the association between peri-infarct ischemia and major adverse cardiac events.
Main Methods:
- Analysis of a large, multicenter cohort from the Stress CMR Perfusion Imaging in the United States (SPINS) study.
- Definition of peri-infarct ischemia as ischemic segments adjacent to infarcted segments identified by late gadolinium enhancement.
- Evaluation of primary outcomes (acute myocardial infarction, cardiovascular death) and secondary outcomes (including hospitalizations and late revascularization).
Main Results:
- Among 3,915 patients, peri-infarct ischemia was identified in 9.8% of the cohort.
- Peri-infarct ischemia emerged as the strongest independent predictor of both primary and secondary adverse events (aHR 1.72 and 1.71, respectively).
- Patients with peri-infarct ischemia exhibited a significantly higher annualized primary event rate (6.5%) compared to those without (0.9%).
Conclusions:
- Peri-infarct ischemia is a novel and powerful prognostic indicator for adverse cardiovascular events.
- This finding underscores the importance of assessing peri-infarct ischemia in risk stratification for cardiovascular disease.
- CMR imaging can effectively identify peri-infarct ischemia, aiding in the selection of patients for targeted interventions.
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