Role of delayed enhancement MRI in patients with acute coronary syndrome and unobstructed coronary arteries: reply

We thank Coceani and L'Abbate for their comments on our paper.We concur that ‘pathophysiology cannot be inferred fromcoronary lumenography alone’, and this was one of thekey motivations in conducting the present study.     

Use of cardiovascular magnetic resonance for diagnosis and management in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an inherited cardiac disorder characterized by unexplained myocardial hypertrophy. The condition is associated with sudden cardiac death and is therefore often diagnosed postmortem, especially in the young and in competitive athletes. For this reason, intense research focuses on developing strategies to minimize this tragic consequence. Cardiovascular magnetic resonance (CMR) is a novel imaging modality that provides high-resolution images in an infinite number of planes with additional sequences that allows for tissue characterization and quantification of flow. The most exciting development is the application of late gadolinium-enhanced (LGE) imaging, which allows for in vivo detection of myocardial fibrosis. This review summarizes the current applications of CMR in HCM and also speculates on future applications, particularly the potential for risk stratification using LGE-CMR.     

The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries.

AIMS: Troponin measurement is used in the assessment and risk stratification of patients presenting acutely with chest pain when the main cause of elevation is coronary artery disease. However, some patients have no coronary obstruction on angiography, leading to diagnostic uncertainty. We evaluated the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in these patients. METHODS AND RESULTS: Sixty consecutive patients (mean age 44 years, 72% male) with a troponin-positive episode of chest pain and unobstructed coronary arteries were recruited within 3 months of initial presentation. All patients underwent CMR with cine imaging, T2-weighted imaging for detection of inflammation, and late gadolinium enhancement imaging for detection of infarction/fibrosis. An identifiable basis for troponin elevation was established in 65% of patients. The commonest underlying cause was myocarditis (50%), followed by myocardial infarction (11.6%) and cardiomyopathy (3.4%). In the 35% of patients where no clear diagnosis was identified by CMR, significant myocardial infarction/fibrosis was excluded. CONCLUSION: CMR is a valuable adjunct to conventional investigations in a diagnostically challenging and important group of patients with troponin-positive chest pain and unobstructed coronary arteries.     

Integrated cardiac and vascular assessment in Takayasu arteritis by cardiovascular magnetic resonance

Objective

This study was undertaken to evaluate the value of cardiovascular magnetic resonance (CMR) in the assessment of patients with Takayasu arteritis (TA).

Methods

Sixteen patients with TA and 2 populations comprising 110 normal volunteers were prospectively recruited. All patients with TA underwent a CMR protocol including measurement of carotid artery wall volume, assessment of left ventricular (LV) volumes and function, and late gadolinium enhancement for the detection of myocardial scarring.

Results

Carotid artery wall volume, total vessel volume, and the wall:outer wall ratio were elevated in TA patients compared with controls (wall volume 1,045 mm³ in TA patients versus 640 mm³ in controls, P < 0.001; total vessel volume 2,268 mm³ in TA patients versus 2,037 mm³ in controls, P < 0.05; wall:outer wall ratio 48% in TA patients versus 32% in controls, P < 0.001). The lumen volume was reduced in TA (1,224 mm³ versus 1,398 mm³ in controls, P < 0.05). In TA, LV function was more dynamic, with reduced end‐systolic volume (mean ± 95% confidence interval ejection fraction 74 ± 3% versus 67 ± 1% in controls, P < 0.001; LV end‐systolic volume 19 ± 4 ml/m² versus 25 ± 1 ml/m² in controls, P < 0.001). Myocardial late gadolinium enhancement was present in 4 (27%) of 15 patients, indicating previously unrecognized myocardial damage.

Conclusion

Our findings indicate that an integrated method of cardiovascular assessment by CMR in TA not only provides good delineation of vessel wall thickening, but has also demonstrated dynamic ventricular function, myocardial scarring, and silent myocardial infarction. CMR has benefits compared with other approaches for the assessment and followup of patients with TA, and has potential to identify patients most at risk of complications, allowing early preventative therapy.

     

Treatment for heart failure: good news and bad

Heart failure is a common disorder associated with significant morbidity, mortality and financial burden to health services. The pharmacotherapy of heart failure, including new treatments, will be discussed.     

Cardiovascular magnetic resonance assessment of myocardial infarction and post-infarct complications

The article discusses the growing role of cardiovascular magnetic resonance in both the diagnosis of myocardial infarction and its subsequent management, including the management of any resulting complications. The current roles of magnetic resonance coronary angiography and magnetic resonance perfusion are also reviewed.