Characterization of patients with acute chest pain using cardiac magnetic resonance imaging

Aims

The purpose of this study was to evaluate whether CMRI provides characteristic findings in patients with acute chest pain suffering from ST-elevation-myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), acute myocarditis or Tako-tsubo cardiomyopathy.

Patients and Methods

230 consecutive patients with acute chest pain underwent cardiac catheterization followed by CMRI within median 5 d. Patients were classified to suffer from STEMI (n?=?102), NSTEMI (n?=?89), acute myocarditis (n?=?27), or Tako-tsubo cardiomyopathy (n?=?12) on the synopsis of all clinical data. Wall motion abnormalities, late enhancement (LE), persistent microvascular obstruction as well ventricular volumes and functions were assessed by CMRI.

Results

Right and left ventricular volumes were significantly different between the groups and values were highest in patients with acute myocarditis. Wall motion abnormalities were observed in 100% of STEMI, 75% of NSTEMI, 67% of acute myocarditis and 100% of Tako-tsubo patients. There was a characteristic pattern of abnormal wall motion focused on midventricular-apical segments in patients with Tako-tsubo cardiomyopathy, depending on the culprit vessel in patients with STEMI/NSTEMI and with a random distribution in patients with acute myocarditis. LE was mainly subendocardial or transmural in patients with STEMI (93.2%) or NSTEMI (62.9%). LE was diffuse, intramural or subepicardial in patients with acute myocarditis. No LE was observed in patients with Tako-tsubo cardiomyopathy. Persistent microvascular obstruction was only visualized in patients STEMI (33%) or NSTEMI (6%).

Conclusions

Cardiac magnetic resonance imaging provides characteristic patterns of LE, persistent microvascular obstruction and wall motion abnormalities that allow a differentiation between patients with acute chest pain from coronary and non-coronary origin.

     

Adenosine stress cardiac magnetic resonance imaging for the assessment of ischemic heart disease

Aims  This prospective study was designed to determine the diagnostic value of adenosine stress cardiac magnetic resonance imaging (CMRI) in patients referred to elective coronary angiography. Methods and results  Myocardial perfusion measurements at rest and adenosine stress were performed in 141 patients (105 men, 36 women, mean age 63.4 years) at 1.5 T with a Turbo Flash sequence. Stress-induced perfusion deficits were correlated to angiographic stenoses ≥75%. The overall sensitivity for CMRI depicting coronary artery disease (CAD) with relevant stenoses was 90.4%, the specificity was 77.4%, the positive predictive value was 85.9%, the negative predictive value was 84.2% and the accuracy 85.2%. Subgroup analysis was performed for 3-vessel disease (n = 44, sensitivity 92.3%, specificity 75.0%), 2-vessel disease (n = 43, sensitivity 92.6%, specificity 92.9%), 1-vessel disease (n = 27, sensitivity 93.1%, specificity 71.4%) and patients without CAD (n = 27, specificity 70.4%) as well as for patients with prior myocardial infarction (n = 44, sensitivity 92.9%, specificity 86.7%), prior coronary artery bypass surgery (n = 21, sensitivity 88.2%, specificity 66.7%), prior coronary interventions (n = 88, sensitivity 91.9%, specificity 75.0%), or diabetics (n = 27, sensitivity 90.5%, specificity 83.3%). Conclusion  Our study shows that stress perfusion CMRI can accurately predict relevant CAD and contributes to the identification of hemodynamic relevant stenoses in patients scheduled for coronary angiography. C. Doesch and A. Seeger have equally contributed to this publication.     

磁共振特征追踪技术定量左心室应变评估急性STEMI患者微血管阻塞

目的 采用心脏磁共振特征追踪技术（CMR-FT）量化急性ST段抬高型心肌梗死（STEMI）患者急性期左心室心肌应变及心功能改变，探讨其检测心肌梗死伴微血管阻塞（MVO）的可行性。方法 收集78例急性STEMI患者（梗死组）和10名健康志愿者（对照组）的CMR动态电影序列图像及钆对比剂延迟强化成像（LGE）资料。采用CMR-FT分析电影序列图像左心室整体心肌应变[整体峰值径向应变（GPRS）、周向应变（GPCS）及纵向应变（GPLS）]、节段心肌应变[节段峰值径向应变（PRS）、周向应变（PCS）及纵向应变（PLS）]和左心室心功能[左心室射血分数（LVEF）、左心室舒张末期容积指数（LVEDVi）、左心室收缩末期容积指数（LVESVi）及心脏指数（CI）]。根据LGE评估是否存在MVO，将患者分为MVO组（n=50）和无MVO组（n=28），将其左心室心肌节段分为MVO节段组（n=173）和无MVO节段组（n=1 075）。根据左心室节段应变绘制ROC曲线，并计算AUC值。结果 梗死组左心室GPRS、GPCS、GPLS、PRS、PCS及PLS与对照组差异均有统计学意义（P均<0.001）；梗死组左心室LVEF、LVEDVi、LVESVi与对照组差异有统计学意义（P均<0.05）；MVO节段组左心室PRS、PCS、PLS与无MVO节段组差异均有统计学意义（P均<0.001）；PRS和PCS取24.65%和－14.05%时检测MVO的敏感性、特异性、AUC分别为89.0%、60.6%、0.816和75.7%、75.9%、0.818。结论 采用CMR-FT测量左心室心肌节段峰值应变可检测急性STEMI患者是否发生MVO，为临床对急性STEMI患者进行早期风险分层管理提供了无创、便捷的新方法。     

Clinical characteristics and role of early cardiac magnetic resonance imaging in patients with suspected ST-elevation myocardial infarction and normal coronary arteries

A variety of conditions other than acute myocardial infarction may cause ST-elevation. Our objective was to evaluate the impact of cardiac magnetic resonance (CMR) on differential diagnosis from a prospective series of patients with suspected ST-elevation myocardial infarction (STEMI) and completely normal coronary arteries. Among 1,145 patients with suspected STEMI, 49 patients had completely normal coronary arteries and entered a prospective registry. CMR was done within 24 h, if possible, and included function analyses, T2-weighted imaging (T2 ratio), T1-weighted imaging before and after gadolineum administration (global relative enhancement; gRE), and late gadolineum enhancement (LGE). All patients were asked for a follow-up CMR after approximately 3 months. The incidence of patients with suspected STEMI and normal coronary arteries was 4.3% and mean age was 45 ± 14 years (STEMI group 64 ± 13 years; P < 0.001). 55% had a recent history of infection. Cardiac biomarkers showed a moderate elevation on admission. There was a significant change from baseline to follow-up for LV end-diastolic volumes (EDV) (P < 0.001), LV mass (P < 0.05), mean T2 ratio (P < 0.05), and LGE volume (P < 0.05). Major diagnostic groups were myocarditis (29%), pericarditis (27%), and takotsubo cardiomyopathy (10%). 18% were regarded as non-diagnostic. The study showed an incidence of 4.3% of patients with suspected STEMI and completely normal coronary arteries. Early CMR was valuable in the evaluation of the differential diagnoses and to exclude myocardial abnormalities in patients with uncertain aetiology. Further studies are needed for the assessment of long-term outcome.     

Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI

BackgroundThe current ST-elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) paradigm prevents some NSTEMI patients with acute coronary occlusion from receiving emergent reperfusion, in spite of their known increased mortality compared with NSTEMI without occlusion. We have proposed a new paradigm known as occlusion MI vs. nonocclusion MI (OMI vs. NOMI).ObjectiveWe aimed to compare the two paradigms within a single population. We hypothesized that STEMI(–) OMI would have characteristics similar to STEMI(+) OMI but longer time to catheterization.MethodsWe performed a retrospective review of a prospectively collected acute coronary syndrome population. OMI was defined as an acute culprit and either TIMI 0–2 flow or TIMI 3 flow plus peak troponin T > 1.0 ng/mL. We collected electrocardiograms, demographic characteristics, laboratory results, angiographic data, and outcomes.ResultsAmong 467 patients, there were 108 OMIs, with only 60% (67 of 108) meeting STEMI criteria. Median peak troponin T for the STEMI(+) OMI, STEMI(–) OMI, and no occlusion groups were 3.78 (interquartile range [IQR] 2.18–7.63), 1.87 (IQR 1.12–5.48), and 0.00 (IQR 0.00–0.08). Median time from arrival to catheterization was 41 min (IQR 23–86 min) for STEMI(+) OMI compared with 437 min (IQR 85–1590 min) for STEMI(–) OMI (p < 0.001). STEMI(+) OMI was more likely than STEMI(–) OMI to undergo catheterization within 90 min (76% vs. 28%; p < 0.001).ConclusionsSTEMI(–) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(–) OMI.     

Comparison of magnetic resonance imaging findings in non-ST-segment elevation versus ST-segment elevation myocardial infarction patients undergoing early invasive intervention

To define causes and pathological mechanisms underlying differences in clinical outcomes, we compared the findings of contrast-enhanced magnetic resonance imaging (CE-MRI) between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). In 168 patients undergoing early invasive intervention for STEMI (n = 113) and NSTEMI (n = 55), CE-MRI was performed a median of 6 days after the index event. Infarct size was measured on delayed-enhancement imaging, and area at risk (AAR) was quantified on T2-weighted images. The median infarct size was significantly smaller in the NSTEMI group than in the STEMI group (10.7% [5.6–18.1] vs. 19.2% [10.3–30.7], P < 0.001). Although there was a trend toward a greater myocardial salvage index ([AAR ? infarct size] × 100/AAR) in the NSTEMI group compared to the STEMI group (48.2 [30.4–66.8] vs. 40.5 [24.8–53.5], P = 0.056), myocardial salvage index was similar between the groups in patients with anterior infarction (39.6 [20.0–54.9] vs. 35.5 [23.2–53.4], P = 0.96). The NSTEMI group also had a significantly lower extent of microvascular obstruction and a smaller number of segments with >75% of infarct transmurality relative to the STEMI group (0% [0–0.6] vs. 0.9% [0–2.3], P < 0.001 and 3.0 ± 2.3 vs. 4.6 ± 2.9, P = 0.001, respectively). Myocardial hemorrhage was detected less frequently in the NSTEMI group than the STEMI group (22.6% vs. 43.8%, P = 0.029). In the multivariate analysis, baseline Thrombolysis In Myocardial Infarction flow grade 3 and hemorrhagic infarction were closely associated with ST-segment elevation (OR 0.32, 95% CI 0.13–0.81, P = 0.017; OR 5.66, 95% CI 1.77–18.12, P = 0.003, respectively). In conclusion, in vivo pathophysiological differences revealed by CE-MRI assessment include more favorable infarct size, AAR, myocardial salvage and reperfusion injury in patients with NSTEMI compared to those with STEMI undergoing early invasive intervention.     

Time-dependency,predictors and clinical impact of infarct transmurality assessed by magnetic resonance imaging in patients with ST-elevation myocardial infarction reperfused by primary coronary percutaneous intervention

Previous studies analyzing the relation between time-to-reperfusion, infarct size, microvascular obstruction (MO) and infarct transmurality in patients with ST-elevation myocardial infarction (STEMI) reperfused by primary percutaneous coronary intervention (PCI) reported inconsistent results. Furthermore, it remains unclear, if transmural infarction is associated with adverse clinical outcome. The present study included STEMI patients reperfused by primary PCI (n = 322) within 720 min after symptom-onset undergoing contrast-enhanced magnetic resonance imaging (CMR) at a median of 3 days after the index event [interquartile range (IQR) 2–4]. Patients were subcategorized into tertiles according to time-to-reperfusion. Infarct size and MO were assessed approximately 15 min after gadolinium-injection. Infarct transmurality was assessed by a score with late-enhancement grading as <25, 25–50, 51–75 and >75% transmurality analyzing all 17 left ventricular segments. Clinical follow-up was performed after 20 months (IQR 13;29). The primary endpoint was defined as a composite of death and congestive heart failure. The median time-to-reperfusion was 230 min (IQR 153;390). Infarct size and MO did not increase significantly with longer time-to-reperfusion (p = 0.16 and p = 0.44, respectively). In contrast to infarct size and MO, the infarct transmurality score progressed significantly with increasing ischemic time (p < 0.001). In multivariable logistic regression analysis, time-to-reperfusion was identified as an independent predictor for transmural infarction (p = 0.03). However, transmural infarction was not predictive of the primary composite clinical endpoint (p = 0.22). In conclusion, in STEMI patients reperfused by primary PCI, time-to-reperfusion was an independent predictor for transmural infarction but not for infarct size and MO. However, transmural infarction was not predictive of death and congestive heart failure.     

Resistance to aspirin is increased by ST-elevation myocardial infarction and correlates with adenosine diphosphate levels

Background

To be fully activated platelets are dependent on two positive feedback loops; the formation of thromboxane A₂ by cyclooxygenase in the platelets and the release of ADP. We wanted to evaluate the effect of aspirin on platelet function in patients with acute coronary syndromes and we hypothesized that increased levels of ADP in patients with acute coronary syndromes could contribute to aspirin resistance.

Methods

Platelet activity in 135 patients admitted for chest pain was assessed with PFA-100. An epinephrine-collagen cartridge (EPI-COLL) was used for the detection of aspirin resistance together with an ADP-collagen cartridge (ADP-COLL). ADP was measured with hplc from antecubital vein samples. Three subgroups were compared: chest pain with no sign of cardiac disease (NCD), NonST-elevation myocardial infarction (NSTEMI) and STEMI.

Results

Platelet activation was increased for the STEMI group compared NCD. Aspirin resistance defined as <193 sec in EPI-COLL was 9.7 % in NCD, and increased to 26.0 % (n.s.) in NSTEMI and 83.3 % (p < 0.001) in STEMI. Chronic aspirin treatment significantly reduced platelet aggregation in NCD and NSTEMI, but it had no effect in STEMI. Plasma levels of ADP were markedly increased in STEMI (905 ± 721 nmol/l, p < 0.01), but not in NSTEMI (317 ± 245), compared to NCD (334 ± 271, mean ± SD). ADP levels correlated with increased platelet activity measured with ADP-COLL (r = -0.30, p < 0.05). Aspirin resistant patients (EPI-COLL < 193 sec) had higher ADP levels compared to aspirin responders (734 ± 807 vs. 282 ± 187 nmol/l, mean ± SD, p < 0.05).

Conclusion

Platelets are activated and aspirin resistance is more frequent in STEMI, probably due to a general activation of platelets. ADP levels are increased in STEMI and correlates with platelet activation. Increased levels of ADP could be one reason for increased platelet activity and aspirin resistance.     

Anxiety trait in patients with stress-induced cardiomyopathy: a case–control study

Background  

Stress-induced Tako-tsubo cardiomyopathy (TTC) is an acute cardiac syndrome, mimics ST elevation myocardial infarction (STEMI), largely confined to postmenopausal women, frequently precipitated by a stressful event. The pathogenesis of TTC is still unknown. Some authors hypothesized a possible connection between TTC and anxiety disease, but no previous study analyzed the relationship between anxiety trait and TTC. This study sought to assess the potential role of anxiety trait in the development and clinical course of TTC.     

MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain

Purpose  To retrospectively assess the performance of MR imaging in the evaluation and triage of pregnant patients presenting with acute abdominal or pelvic pain. Method and materials  MRI studies of pregnant patients who were referred for acute abdominal pain between 2001 and 2007 were included. MR images were retrospectively reviewed and compared with surgical and pathologic findings and clinical follow-up data. Analysis of imaging findings included evaluation of the visceral organs, bowel and mesentery, appendix (for presence of appendicitis), ovaries (detection and adnexal masses were evaluated), focal inflammation, presence of abscesses, and any other abnormal findings. Results  A total of 118 pregnant patients were included. MR findings were inconclusive in 2 patients and were positive for acute appendicitis in 11 patients (n = 9 confirmed by surgery, n = 2 improved without surgery). One patient with inconclusive MR had surgically confirmed appendicitis; the other patient with inconclusive MR had surgically confirmed adnexal torsion. Other surgical/interventional diagnoses suggested by MR imaging were adnexal torsion (n = 4), abscess (n = 4), acute cholecystitis (n = 1), and gastric volvulus (n = 1). Two patients with MR diagnosis of torsion improved without surgery. One patient with MR diagnosis of abscess had biliary cystadenoma at surgery. The rest of the MR diagnoses above were confirmed surgically or interventionally. MR imaging was normal in 67 patients and demonstrated medically treatable etiology in 28 patients: adnexal lesions (n = 9), urinary pathology (n = 6), cholelithiasis (n = 4), degenerating fibroid (n = 3), DVT (n = 2), hernia (n = 1), colitis (n = 1), thick terminal ileum (n = 1), rectus hematoma (n = 1). Three of these patients had negative surgical exploration and one had adnexal mass excision during pregnancy. Other patients were discharged with medical treatment. The sensitivity, specificity, accuracy, positive predictive values (ppv), and negative predictive values (npv) of MR imaging for acute appendicitis, and surgical/ interventional diagnoses were 90.0% vs. 88.9%, 98.1% vs. 95.0%, 97.5% vs. 94.1%, 81.8% vs. 76.2%, 99.1% vs. 97.9%, respectively. Conclusion  MR imaging is an excellent modality for diagnosis of acute appendicitis and exclusion of diseases requiring surgical/interventional treatment. Therefore MR imaging is useful for triage of pregnant patients with acute abdominal and pelvic pain.     

Impact of hyperglycemia at admission in patients with acute ST-segment elevation myocardial infarction as assessed by contrast-enhanced MRI

Background  

Blood glucose level at admission in ST-segment elevation myocardial infarction (STEMI) is a predictor of heart failure and mortality. This study was performed to investigate the impact of hyperglycemia at admission in non-diabetic patients on infarct size, microvascular obstruction, and long-term outcome using contrast-enhanced magnetic resonance imaging (CMR) in patients with acute STEMI.     

Change in T/QRS ratio can be a supplementary diagnostic tool in predicting coronary artery disease in patients with NSTEMI

BackgroundChanges in the electrocardiographic findings, namely the ratio T sum to QRS sum (T/QRS ratio), between the initial electrocardiogram (ECG) and the baseline ECG have rarely been investigated in patients with non-ST elevation myocardial infarction (NSTEMI). Thus, we aimed to determine whether changes in various parameters on ECG, including T/QRS ratio, can assist in distinguishing between coronary artery disease (CAD) and NSTEMI without CAD with low to moderate risk.MethodsThis retrospective study enrolled 2572 patients who presented ischemic symptoms, who were diagnosed with NSTEMI, and who underwent coronary angiography. Overall, 388 patients had prior ECG and echocardiography data available; 110 patients were included after excluding patients with other cardiac diseases except CAD. The population divided into two groups: a coronary stenosis group (n = 78); normal coronary group (n = 32) were analyzed.ResultsWe found that acute dynamic change in the most deviated T/QRS ratio in each region of leads of initial ECG from those of remote/recent ECG was an extremely strong predictor of acute CAD (odds ratio, 110; p < .001) compared to that of initial serum troponin I levels, new-onset regional wall motion abnormalities, and new-onset T inversion or ST depression. T/QRS ratio change > 1.5 or <0.5 times in injured regional leads was a significant predictor of CAD.ConclusionChange in the most deviated T/QRS ratio in the regional leads on initial ECG from the T/QRS ratio in the same lead on remote ECG can assist in predicting CAD risk between patients with CAD and patients with no CAD in NSTEMI.     

多参数心脏MRI用于急性心肌炎进展

心肌炎临床表现多样,可发展为急性心力衰竭、心源性休克和慢性扩张型心肌病,早期明确诊断对于改善预后至关重要。心脏MRI(CMRI)可显示心肌坏死、纤维化和水肿,已成为评估心肌炎的最佳影像学手段。本文就多参数CMRI用于急性心肌炎研究进展进行综述。     

Value of gadolinium-enhanced magnetic resonance imaging in patients with Tako-Tsubo-like left ventricular dysfunction.

We present gadolinium-enhanced cardiac magnetic resonance imaging (CMRI) in Tako-Tsubo-like left ventricular dysfunction showing the findings in acute phase and in follow-up. Gadolinium-enhanced CMRI allows to distinguish between myocardial infarction and other myocardial alterations, e.g., myocarditis. CMRI may thus permit to non-invasively identify patients with Tako-Tsubo syndrome by ruling out myocardial infarction or myocarditis in the setting of wall motion abnormalities (WMA).     

Is routine echocardiography useful in patients hospitalized for chest pain? Evidence of areal myocardial dysfunction detected only by echocardiography

To assess the diagnostic value of routine two-dimensional echocardiography in the coronary care unit setting, we studied 81 unselected patients admitted for acute chest pain. Using electrocardiography (ECG), clinical history and serum markers of myocardial injury, the patients were retrospectively diagnosed as having had definite acute myocardial infarction (AMI) with (n=13) or without (n=31) previous infarction, possible AMI with (n=14) or without (n=15) previous infarction, and non-coronary cardiac or other causes of chest pain (n=8). Abnormal wall motion was observed in 75/77 patients with a cardiac origin of symptoms (sensitivity 97%), and there were no false-positive wall motion findings. In the 73 patients who were finally diagnosed with coronary artery disease (CAD), echocardiography showed wall motion abnormality in at least one additional coronary territory area in which there were no diagnostic ECG changes for 56% of patients with CAD (41/73) (P<0·001). These areas were considered to be indicative of the presence of myocardium at risk for future cardiac events. We conclude that in addition to being a sensitive and accurate tool for detection of ischaemic wall motion abnormalities, two-dimensional echocardiography can give valuable information about the area of myocardium at risk. Therefore, therapeutic decisions can be affected by the findings of the routine echocardiographic examination, which is recommended even in unselected coronary care unit patients.     

Physical deterioration in an acute mental health unit: A quantitative retrospective analysis of medical emergencies

Nursing management of physical deterioration of patients within acute mental health settings is observed, recorded, and actively managed with the use of standardized Adult Deterioration Detection System (ADDS) charts. Patient deterioration may require the urgent assistance of a hospital rapid response or Medical Emergency Team. A five‐and‐a‐half‐year (2011–2016) audit of hospital‐wide Medical Emergency Team attendances was conducted in an acute mental health unit of a single large 250 bed regional hospital in Victoria, Australia. Data were extracted from the hospitals’ quality and patient safety program, RISKMan, and entered into a statistical data program for analysis. A total of 140 patient records were analysed, and the ‘Worried’ category (34%, n = 47) was the principle reason for a Medical Emergency Team call in a mental health ward, followed by hypotension (23%, n = 31) and a low Glasgow Coma Score (16%, n = 22). Upon further investigation of the ‘Worried’ category, the most common conditions recorded were an altered conscious state (22%, n = 9), low oxygen saturation (20%, n = 8), or chest pain (17%, n = 7). Activation of Medical Emergency Team calls predominantly occurred in the daylight morning hours (6am–12md). When data were compared to the general hospital patients, the context of the physiological deterioration of the mental health patients was strikingly similar. Further research is recommended to ascertain the extent and frequency with which staff working in mental health units are performing vital signs monitoring as an essential component of detection of early signs of physiological deterioration.     

Cardiac magnetic resonance visualizes acute and chronic myocardial injuries in myocarditis

Our objective was to evaluate the ability of CMR to visualize myocardial injuries over the course of myocarditis. We studied 42 patients (39 males, 3 females; age 37 ± 14 years) with myocarditis during the acute phase and after 12 ± 9 months. CMR included function analyses, T2-weighted imaging (T2 ratio), T1-weighted imaging before and after i.v. gadolinium injection (global relative enhancement; gRE), and late gadolinium enhancement (LGE). In the acute phase, the T2 ratio was elevated in 57%, gRE in 31%, and LGE was present in 64% of the patients. In 32 patients (76%) were any two (or more) out of three sequences abnormal. At follow-up, there was an increase in ejection fraction (57.4 ± 11.9% vs. 61.4 ± 7.6; P < 0.05) while both T2 ratio (2.04 ± 0.32 vs. 1.70 ± 0.28; P < 0.001) and gRE (4.07 ± 1.63 vs. 3.11 ± 1.22; P < 0.05) significantly decreased. The LGE persisted in 10 patients. Dilated cardiomyopathy was present in 3 patients and 4 patients received a defibrillator or a pacemaker. A comprehensive CMR approach is a useful tool to visualize myocardial tissue injuries over the course of myocarditis. CMR may help to differentiate acute from healed myocarditis, and add information for the differential diagnoses.     

Differences in biomarker concentrations and predictions of long-term outcome in patients with ST-elevation and non-ST-elevation myocardial infarction

BackgroundDifferences in biomarkers reflective of pathobiology and prognosis between ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) are incompletely understood and may offer insights for tailoring of treatment.MethodsThis registry-based study included 538 STEMI and 544 NSTEMI patients admitted 2008–2014. Blood samples were collected day 1–3 after admission and 175 biomarkers were analyzed using Proximity Extension Assay and Multiple Reaction Monitoring mass spectrometry. Adjusted Lasso analysis (penalized logistic regression model) was used to select biomarkers that discriminated STEMI from NSTEMI patients. Biomarkers identified by the Lasso analysis were then evaluated in adjusted Cox regressions for associations with death or major adverse cardiovascular events.ResultsBiomarkers strongly discriminated STEMI and NSTEMI when considered simultaneously in adjusted Lasso analysis (c-statistic 0.764). Eleven biomarkers independently discriminated STEMI and NSTEMI; seven showing higher concentrations in STEMI: myoglobin, N-terminal pro-B-type natriuretic peptide, serum amyloid A-1 and A-2 protein, ST2 protein, interleukin-6 and chitinase-3-like protein 1; and four showing higher concentrations in NSTEMI: fibroblast growth factor 23, membrane-bound aminopeptidase P, tumor necrosis factor-related activation-induced cytokine and apolipoprotein C-I. During up to 6.6 years of prognostic follow-up, none of these biomarkers exhibited different associations with adverse outcome between STEMI and NSTEMI.ConclusionsIn the acute setting, biomarkers indicated greater myocardial dysfunction and inflammation in STEMI, whereas they displayed a more diverse pathophysiologic pattern in NSTEMI patients. These biomarkers were similarly prognostic in STEMI and NSTEMI patients. The results do not support treating STEMI and NSTEMI patients differently based on the concentrations of these biomarkers.     

Inflammatory markers and cardiac function in acute coronary syndrome: Difference in ST-segment elevation myocardial infarction (STEMI) and in non-STEMI models

Purpose

No studies have been addressed to the differences in inflammation kinetics between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).

Patients and methods

Forty consecutive patients with acute coronary syndrome (ACS) (n = 23 STEMI, age = 61.7 ± 10.3 years; n = 17 NSTEMI, age = 65.6 ± 11.3 years) were enrolled within 12 h after symptoms. All patients received therapy according to the current Guidelines.Blood samples were collected at admission (t0), on days 7 (t1) and 30 (t2) to evaluate CD40 ligand (CD40L), transforming growth factor (TGF)-beta, interleukin (IL)-6, tumor necrosis factor (TNF)-alpha and its receptors TNFRI and TNFRII, high sensitivity C-reactive protein (hs-CRP), serum amyloid A (SAA) and white blood cells (WBC). Echocardiographic parameters were also evaluated.

Results

STEMI patients, at admission, had significantly higher median values of hs-CRP (p < 0.001), WBC (p < 0.01), ferritin (p < 0.0005) and IL-6 (p < 0.05) than NSTEMI. On the contrary, NSTEMI patients had lower median levels of every inflammatory marker except for CD40L (p < 0.05) that was significantly higher. Moreover, three out of four deceased patients presented levels of CD40L higher than the median. At admission, STEMI showed a reduced ejection fraction (EF, p < 0.01) and increased wall motion score index (WMSI, p < 0.001) and end-diastolic volume (EDV, p < 0.05) vs NSTEMI. An inverse correlation between admission values of inflammatory markers (SAA and WBC) and cardiac function was observed (p < 0.05). Moreover, the necrosis marker troponin I was positively correlated with both WMSI (p < 0.05) and hs-CRP (p < 0.05).Regarding the inflammation kinetics, a difference was observed in the two groups only for WBC (p < 0.05) and SAA (p < 0.05). SAA showed higher values in STEMI at t0 and t1. In both groups, TGF-beta had an increase at t1 and t2 with respect to admission, while IL-6 had a decreasing trend.The total incidence of major adverse clinical events (MACE) was 22.5% at t2, with a mortality rate of 10%.

Conclusion

These observations suggest a differential inflammatory pattern in STEMI and NSTEMI patients. The absence of significant correlations between inflammatory indexes and myocardial infarction in NSTEMI supports the hypothesis that a different pattern of inflammation occurs in these patients. CD40L may have an important role as a marker for risk stratification in patients with ACS.     

肥厚型心肌病患者18F-FDG PET心肌代谢显像与心脏MRI

目的 评价肥厚型心肌病（HCM）患者空腹及糖负荷状态下¹⁸F-FDG PET心肌葡萄糖代谢的变化。方法 对36例HCM患者行心脏MRI（CMRI）和空腹+糖负荷状态¹⁸F-FDG PET显像,对心肌代谢显像图像进行半定量评分。根据CMRI结果将患者分为延迟强化组（n=24）及无延迟强化组（n=12）,比较2组心肌代谢评分的差异。结果 空腹状态下延迟强化组左心室心肌代谢总评分较无延迟强化组明显减低;糖负荷状态下,2组代谢总评分差异无统计学意义。11例42个心肌节段在空腹状态下放射性摄取正常或增高,而糖负荷状态下放射性摄取稀疏或缺损,与其他25例比较,其室间隔厚度、左心室后壁厚度明显增加,延迟强化心肌节段数增多,左心室射血分数明显减低,差异均有统计学意义（P均<0.05）。结论 HCM患者空腹与糖负荷状态下¹⁸F-FDG PET心肌葡萄糖代谢显像表现出不均一性,结合CMRI,有望作为HCM患者危险度分层的指标。