Persistent Iron Within the Infarct Core After ST-Segment Elevation Myocardial Infarction: Implications for Left Ventricular Remodeling and Health Outcomes

Jaclyn Carberry, David Carrick, Caroline Haig, Nadeem Ahmed, Ify Mordi, Margaret McEntegart, Mark C Petrie, Hany Eteiba, Stuart Hood, Stuart Watkins, Mitchell Lindsay, Andrew Davie, Ahmed Mahrous, Ian Ford, Naveed Sattar, Paul Welsh, Aleksandra Radjenovic, Keith G Oldroyd, Colin Berry, Jaclyn Carberry, David Carrick, Caroline Haig, Nadeem Ahmed, Ify Mordi, Margaret McEntegart, Mark C Petrie, Hany Eteiba, Stuart Hood, Stuart Watkins, Mitchell Lindsay, Andrew Davie, Ahmed Mahrous, Ian Ford, Naveed Sattar, Paul Welsh, Aleksandra Radjenovic, Keith G Oldroyd, Colin Berry

Abstract

Objectives: This study sought to determine the incidence and prognostic significance of persistent iron in patients post-ST-segment elevation myocardial infarction (STEMI).

Background: The clinical significance of persistent iron within the infarct core after STEMI complicated by acute myocardial hemorrhage is poorly understood.

Methods: Patients who sustained an acute STEMI were enrolled in a cohort study (BHF MR-MI [Detection and Significance of Heart Injury in ST Elevation Myocardial Infarction]). Cardiac magnetic resonance imaging including T2* (observed time constant for the decay of transverse magnetization seen with gradient-echo sequences) mapping was performed at 2 days and 6 months post-STEMI. Myocardial hemorrhage or iron was defined as a hypointense infarct core with T2* signal <20 ms.

Results: A total of 203 patients (age 57 ± 11 years, n = 158 [78%] male) had evaluable T2* maps at 2 days and 6 months post-STEMI; 74 (36%) patients had myocardial hemorrhage at baseline, and 44 (59%) of these patients had persistent iron at 6 months. Clinical associates of persistent iron included heart rate (p = 0.009), the absence of a history of hypertension (p = 0.017), and infarct size (p = 0.028). The presence of persistent iron was associated with worsening left ventricular (LV) end-diastolic volume (regression coefficient: 21.10; 95% confidence interval [CI]: 10.92 to 31.27; p < 0.001) and worsening LV ejection fraction (regression coefficient: -6.47; 95% CI: -9.22 to -3.72; p < 0.001). Persistent iron was associated with the subsequent occurrence of all-cause death or heart failure (hazard ratio: 3.91; 95% CI: 1.37 to 11.14; p = 0.011) and major adverse cardiac events (hazard ratio: 3.24; 95% CI: 1.09 to 9.64; p = 0.035) (median follow-up duration 1,457 days [range 233 to 1,734 days]).

Conclusions: Persistent iron at 6 months post-STEMI is associated with worse LV and longer-term health outcomes. (Detection and Significance of Heart Injury in ST Elevation Myocardial Infarction [BHF MR-MI]; NCT02072850).

Keywords: magnetic resonance imaging; myocardial infarction; remodeling.

Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Two Patients With a Similar Presentation of Acute STEMI The full details are outlined in the Online Appendix. Contrast-enhanced cardiac magnetic resonance 2 days post-STEMI showed anteroseptal infarct in both patients (left, yellow arrows). (A) Patient with resolved myocardial hemorrhage: T2* mapping at 2 days showed myocardial hemorrhage (middle left, black arrow) with resolution at 6 months (middle right). The T2 value in the surrounding infarct region was 53 ms (right). Left ventricular end-diastolic volume was unchanged from 126 to 127 ml in 6 months. This patient had an uncomplicated clinical course. (B) Patient with persisting iron: T2* mapping at 2 days showed myocardial hemorrhage (middle left, black arrow) that persisted at 6 months (middle right, black arrow). The T2 value in the surrounding infarct region was 55 ms (right). Left ventricular end-diastolic volume increased from 191 to 228 ml in 6 months. This patient was rehospitalized with new-onset heart failure. STEMI = ST-segment elevation myocardial infarction.
Figure 2
Figure 2
Persistent Iron and Adverse Outcomes After STEMI Kaplan-Meier survival curve for the relationship between infarct core iron status at 6 months and (A) all-cause death or heart failure and (B) major adverse cardiac events (censor time 1,457 days [range 233 to 1,734 days]). Persisting iron at 6 months post-ST-segment elevation myocardial infarction (STEMI) was associated with all-cause death or heart failure and major adverse cardiac events.

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