Temporal Evolution of Myocardial Hemorrhage and Edema in Patients After Acute ST-Segment Elevation Myocardial Infarction: Pathophysiological Insights and Clinical Implications

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

Abstract

Background: The time course and relationships of myocardial hemorrhage and edema in patients after acute ST-segment elevation myocardial infarction (STEMI) are uncertain.

Methods and results: Patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention underwent cardiac magnetic resonance imaging on 4 occasions: at 4 to 12 hours, 3 days, 10 days, and 7 months after reperfusion. Myocardial edema (native T2) and hemorrhage (T2*) were measured in regions of interest in remote and injured myocardium. Myocardial hemorrhage was taken to represent a hypointense infarct core with a T2* value <20 ms. Thirty patients with ST-segment elevation myocardial infarction (mean age 54 years; 25 [83%] male) gave informed consent. Myocardial hemorrhage occurred in 7 (23%), 13 (43%), 11 (33%), and 4 (13%) patients at 4 to 12 hours, 3 days, 10 days, and 7 months, respectively, consistent with a unimodal pattern. The corresponding median amounts of myocardial hemorrhage (percentage of left ventricular mass) during the first 10 days after myocardial infarction were 2.7% (interquartile range [IQR] 0.0-5.6%), 7.0% (IQR 4.9-7.5%), and 4.1% (IQR 2.6-5.5%; P<0.001). Similar unimodal temporal patterns were observed for myocardial edema (percentage of left ventricular mass) in all patients (P=0.001) and for infarct zone edema (T2, in ms: 62.1 [SD 2.9], 64.4 [SD 4.9], 65.9 [SD 5.3]; P<0.001) in patients without myocardial hemorrhage. Alternatively, in patients with myocardial hemorrhage, infarct zone edema was reduced at day 3 (T2, in ms: 51.8 [SD 4.6]; P<0.001), depicting a bimodal pattern. Left ventricular end-diastolic volume increased from baseline to 7 months in patients with myocardial hemorrhage (P=0.001) but not in patients without hemorrhage (P=0.377).

Conclusions: The temporal evolutions of myocardial hemorrhage and edema are unimodal, whereas infarct zone edema (T2 value) has a bimodal pattern. Myocardial hemorrhage is prognostically important and represents a target for therapeutic interventions that are designed to preserve vascular integrity following coronary reperfusion.

Clinical trial registration: URL: https://ichgcp.net/clinical-trials-registry/NCT02072850" title="See in ClinicalTrials.gov">NCT02072850.

Keywords: magnetic resonance imaging; myocardial edema; myocardial hemorrhage; myocardial infarction; pathophysiology; reperfusion injury.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
Study flow diagram. CMR indicates cardiac magnetic resonance; STEMI, ST‐segment elevation myocardial infarction.
Figure 2
Figure 2
Cardiac magnetic resonance T2 mapping, T2* mapping, and contrast‐enhanced images at 4 time points after reperfusion from patients without (A) and with (B) myocardial hemorrhage, following emergency percutaneous coronary intervention (Data S2). MRI indicates magnetic resonance imaging.
Figure 3
Figure 3
A, Time course of myocardial edema, reflected by T2 relaxation times (in ms) in patients with ST‐segment elevation myocardial infarction with or without myocardial hemorrhage during the first 10 days after ischemia–reperfusion (Data S2). Edema (T2 values) evolved with a bimodal time course in patients with myocardial hemorrhage but with a unimodal time course in patients without hemorrhage. The red continuous red line links edema T2 relaxation times in the infarct core. The interrupted blue line links edema T2 relaxation times in the infarct zone. Because cardiac magnetic resonance scans were not obtained before reperfusion, the baseline mean T2 values are imputed T2 values at the midventricular level obtained from age‐matched healthy volunteers. B, The amount of myocardial edema (% LV mass) evolved with a unimodal time course to a maximum on day 3. C, Amount of myocardial hemorrhage in the subgroup of patients with hemorrhage. In a linear mixed‐effects model, the amount of myocardial hemorrhage across the time points of assessment was not associated with infarct size (P=1.0). %LV mass indicates percentage of left ventricular mass.

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