Myocardial Hemorrhage After Acute Reperfused ST-Segment-Elevation Myocardial Infarction: Relation to Microvascular Obstruction and Prognostic Significance

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

Abstract

Background: The success of coronary reperfusion therapy in ST-segment-elevation myocardial infarction (MI) is commonly limited by failure to restore microvascular perfusion.

Methods and results: We performed a prospective cohort study in patients with reperfused ST-segment-elevation MI who underwent cardiac magnetic resonance 2 days (n=286) and 6 months (n=228) post MI. A serial imaging time-course study was also performed (n=30 participants; 4 cardiac magnetic resonance scans): 4 to 12 hours, 2 days, 10 days, and 7 months post reperfusion. Myocardial hemorrhage was taken to represent a hypointense infarct core with a T2* value of <20 ms. Microvascular obstruction was assessed with late gadolinium enhancement. Adverse remodeling was defined as an increase in left ventricular end-diastolic volume ≥20% at 6 months. Cardiovascular death or heart failure events post discharge were assessed during follow-up. Two hundred forty-five patients had evaluable T2* data (mean±age, 58 [11] years; 76% men). Myocardial hemorrhage 2 days post MI was associated with clinical characteristics indicative of MI severity and inflammation. Myocardial hemorrhage was a multivariable associate of adverse remodeling (odds ratio [95% confidence interval]: 2.64 [1.07-6.49]; P=0.035). Ten (4%) patients had a cardiovascular cause of death or experienced a heart failure event post discharge, and myocardial hemorrhage, but not microvascular obstruction, was associated with this composite adverse outcome (hazard ratio, 5.89; 95% confidence interval, 1.25-27.74; P=0.025), including after adjustment for baseline left ventricular end-diastolic volume. In the serial imaging time-course study, myocardial hemorrhage occurred in 7 (23%), 13 (43%), 11 (33%), and 4 (13%) patients 4 to 12 hours, 2 days, 10 days, and 7 months post reperfusion. The amount of hemorrhage (median [interquartile range], 7.0 [4.9-7.5]; % left ventricular mass) peaked on day 2 (P<0.001), whereas microvascular obstruction decreased with time post reperfusion.

Conclusions: Myocardial hemorrhage and microvascular obstruction follow distinct time courses post ST-segment-elevation MI. Myocardial hemorrhage was more closely associated with adverse outcomes than microvascular obstruction.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02072850.

Keywords: hemorrhage; magnetic resonance imaging; myocardial infarction; myocardial reperfusion; prognosis.

© 2016 The Authors.

Figures

Figure 1.
Figure 1.
Study flow diagram. CMR indicates cardiac magnetic resonance; MRI, magnetic resonance imaging, and STEMI, ST-segment–elevation myocardial infarction.
Figure 2.
Figure 2.
Three patients with acute ST-segment–elevation myocardial infarction treated by primary percutaneous coronary intervention (PCI) using the same antithrombotic strategies. Each patient had normal thrombolysis in myocardial infarction grade 3 flow at the end of PCI. Cardiac magnetic resonance imaging was performed 2 days post reperfusion. A, Patient with no evidence of myocardial hemorrhage or microvascular obstruction. B, Patient with T2-hypointense core and microvascular obstruction, in the absence of hemorrhage. C, Patient with myocardial hemorrhage (Results section in the Data Supplement).
Figure 3.
Figure 3.
Temporal evolution of the extent of microvascular obstruction (MVO; top, blue line), the hypointense core revealed by T2 mapping (middle, green line), and myocardial hemorrhage (bottom, red line) revealed by T2* mapping according to time from coronary reperfusion in 28 ST-segment–elevation myocardial infarction survivors. Data are presented as median (interquartile range) percentage of left ventricular (LV) mass. The amount of MVO and T2-hypointense core were calculated using full LV coverage, whereas the amount of myocardial hemorrhage was derived from 3 scans from the basal, mid, and apical slice acquisitions. P values were obtained from linear mixed effects model with subject as a random factor. MRI indicates magnetic resonance imaging.

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