Prognosis after ST-elevation myocardial infarction: a study on cardiac magnetic resonance imaging versus clinical routine

Suzanne de Waha, Ingo Eitel, Steffen Desch, Georg Fuernau, Philipp Lurz, Thomas Stiermaier, Stephan Blazek, Gerhard Schuler, Holger Thiele, Suzanne de Waha, Ingo Eitel, Steffen Desch, Georg Fuernau, Philipp Lurz, Thomas Stiermaier, Stephan Blazek, Gerhard Schuler, Holger Thiele

Abstract

Background: This study aimed to evaluate the incremental prognostic value of infarct size, microvascular obstruction (MO), myocardial salvage index (MSI), and left ventricular ejection fraction (LV-EFCMR) assessed by cardiac magnetic resonance imaging (CMR) in comparison to traditional outcome markers in patients with ST-elevation myocardial infarction (STEMI) reperfused by primary percutaneous intervention (PCI).

Methods: STEMI patients reperfused by primary PCI (n=278) within 12 hours after symptom onset underwent CMR three days after the index event (interquartile range [IQR] two to four). Infarct size and MO were measured 15 minutes after gadolinium injection. T2-weighted and contrast-enhanced CMR were used to calculate MSI. In addition, traditional outcome markers such as ST-segment resolution, pre- and post-PCI Thrombolysis In Myocardial Infarction (TIMI)-flow, maximum level of creatine kinase-MB, TIMI-risk score, and left ventricular ejection fraction assessed by echocardiography were determined in all patients. Clinical follow-up was conducted after 19 months (IQR 10 to 27). The primary endpoint was defined as a composite of death, myocardial reinfarction, and congestive heart failure (MACE).

Results: In multivariable Cox regression analysis, adjusting for all traditional outcome parameters significantly associated with the primary endpoint in univariable analysis, MSI was identified as an independent predictor for the occurrence of MACE (Hazard ratio 0.94, 95% CI 0.92 to 0.96, P<0.001). Further, C-statistics comparing a model including only traditional outcome markers to a model including CMR parameters on top of traditional outcome markers revealed an incremental prognostic value of CMR parameters (0.74 versus 0.94, P<0.001).

Conclusions: CMR parameters such as infarct size, MO, MSI, and LV-EFCMR add incremental prognostic value above traditional outcome markers alone in acute reperfused STEMI.

Trial registration: Clinicaltrials.gov NCT00463749, Clinicaltrials.gov NCT00359918.

Figures

Figure 1
Figure 1
C-statistics comparing the prognostic value for MACE prediction of model 1 (CK-MBmax, TIMI-risk score, ST-segment resolution, TIMI-flow pre-PCI, TIMI-flow post-PCI, LV-EFecho) and model 2 (model 1 + LV-EFCMR, infarct size, MO and MSI).
Figure 2
Figure 2
C-statistics comparing the prognostic value for mortality prediction of model 1 (CK-MBmax, TIMI-risk score, ST-segment resolution, TIMI-flow pre-PCI, TIMI-flow post-PCI, LV-EFecho) and model 2 (model 1 + LV-EFCMR, infarct size, MO and MSI).

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