Unrecognized non-Q-wave myocardial infarction: prevalence and prognostic significance in patients with suspected coronary disease

Han W Kim, Igor Klem, Dipan J Shah, Edwin Wu, Sheridan N Meyers, Michele A Parker, Anna Lisa Crowley, Robert O Bonow, Robert M Judd, Raymond J Kim, Han W Kim, Igor Klem, Dipan J Shah, Edwin Wu, Sheridan N Meyers, Michele A Parker, Anna Lisa Crowley, Robert O Bonow, Robert M Judd, Raymond J Kim

Abstract

Background: Unrecognized myocardial infarction (UMI) is known to constitute a substantial portion of potentially lethal coronary heart disease. However, the diagnosis of UMI is based on the appearance of incidental Q-waves on 12-lead electrocardiography. Thus, the syndrome of non-Q-wave UMI has not been investigated. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) can identify MI, even when small, subendocardial, or without associated Q-waves. The aim of this study was to investigate the prevalence and prognosis associated with non-Q-wave UMI identified by DE-CMR.

Methods and findings: We conducted a prospective study of 185 patients with suspected coronary disease and without history of clinical myocardial infarction who were scheduled for invasive coronary angiography. Q-wave UMI was determined by electrocardiography (Minnesota Code). Non-Q-wave UMI was identified by DE-CMR in the absence of electrocardiographic Q-waves. Patients were followed to determine the prognostic significance of non-Q-wave UMI. The primary endpoint was all-cause mortality. The prevalence of non-Q-wave UMI was 27% (50/185), compared with 8% (15/185) for Q-wave UMI. Patients with non-Q-wave UMI were older, were more likely to have diabetes, and had higher Framingham risk than those without MI, but were similar to those with Q-wave UMI. Infarct size in non-Q-wave UMI was modest (8%+/-7% of left ventricular mass), and left ventricular ejection fraction (LVEF) by cine-CMR was usually preserved (52%+/-18%). The prevalence of non-Q-wave UMI increased with the extent and severity of coronary disease on angiography (p<0.0001 for both). Over 2.2 y (interquartile range 1.8-2.7), 16 deaths occurred: 13 in non-Q-wave UMI patients (26%), one in Q-wave UMI (7%), and two in patients without MI (2%). Multivariable analysis including New York Heart Association class and LVEF demonstrated that non-Q-wave UMI was an independent predictor of all-cause mortality (hazard ratio [HR] 11.4, 95% confidence interval [CI] 2.5-51.1) and cardiac mortality (HR 17.4, 95% CI 2.2-137.4).

Conclusions: In patients with suspected coronary disease, the prevalence of non-Q-wave UMI is more than 3-fold higher than Q-wave UMI. The presence of non-Q-wave UMI predicts subsequent mortality, and is incremental to LVEF.

Trial registration: Clinicaltrials.gov NCT00493168.

Conflict of interest statement

RJK and RMJ are inventors of a US patent on Delayed Enhancement CMR, which is owned by Northwestern University. No other potential conflict of interest relevant to this article was reported.

Figures

Figure 1. Typical DE-CMR images.
Figure 1. Typical DE-CMR images.
Short and long axis views of DE-CMR images from four patients are shown. Patients A–C demonstrate hyperenhancement (red arrows) consistent with prior myocardial infarction. None had Q-waves on electrocardiography, and all three were classified as having non-Q-wave UMI. Of note, Patient C has evidence of two distinct infarcts. Patient D has hyperenhancement (blue arrows) involving the midwall of the interventricular septum, sparing the subendocardium. This pattern is not consistent with prior myocardial infarction, and this patient was categorized in the “no MI” group. See text for further details.
Figure 2. Prevalence of UMI stratified by…
Figure 2. Prevalence of UMI stratified by angiographic extent and severity of coronary artery disease.
The prevalence of non-Q-wave and Q-wave UMI increased with both the extent and severity of CAD. See text for further details. CAD = coronary artery disease; UMI = unrecognized myocardial infarction; 1V = single vessel; 2V = double vessel; 3V = triple vessel.
Figure 3. Kaplan–Meier estimates of survival (A)…
Figure 3. Kaplan–Meier estimates of survival (A) and cardiac survival (B) in patients with unrecognized non-Q-wave MI (blue line) and without MI (red line).
Overall and cardiac survival in patients with non-Q-wave UMI was significantly reduced in comparison to patients without MI (p<0.0001 for both). The annual mortality in patients with non-Q-wave MI was 15-fold higher than that in patients without MI (10.8% per year versus 0.8% per year, respectively).

References

    1. Kannel WB, Abbott RD. Incidence and prognosis of unrecognized myocardial infarction. An update on the Framingham study. N Engl J Med. 1984;311:1144–1147.
    1. Sheifer SE, Gersh BJ, Yanez ND, 3rd, Ades PA, Burke GL, et al. Prevalence, predisposing factors, and prognosis of clinically unrecognized myocardial infarction in the elderly. J Am Coll Cardiol. 2000;35:119–126.
    1. Sigurdsson E, Thorgeirsson G, Sigvaldason H, Sigfusson N. Unrecognized myocardial infarction: epidemiology, clinical characteristics, and the prognostic role of angina pectoris. The Reykjavik Study. Ann Intern Med. 1995;122:96–102.
    1. Gopinath N, Kaul U, Chadha SL, Sood AK, Bhattacharya D, et al. Asymptomatic coronary heart disease detected on epidemiological survey of urban population of Delhi. Indian Heart J. 1992;44:95–98.
    1. Medalie JH, Goldbourt U. Unrecognized myocardial infarction: five-year incidence, mortality, and risk factors. Ann Intern Med. 1976;84:526–531.
    1. Margolis JR, Kannel WS, Feinleib M, Dawber TR, McNamara PM. Clinical features of unrecognized myocardial infarction–silent and symptomatic. Eighteen year follow-up: The Framingham study. Am J Cardiol. 1973;32:1–7.
    1. Wu E, Judd RM, Vargas JD, Klocke FJ, Bonow RO, et al. Visualisation of presence, location, and transmural extent of healed Q-wave and non-Q-wave myocardial infarction. Lancet. 2001;357:21–28.
    1. Mahrholdt H, Wagner A, Holly TA, Elliott MD, Bonow RO, et al. Reproducibility of chronic infarct size measurement by contrast-enhanced magnetic resonance imaging. Circulation. 2002;106:2322–2327.
    1. Klein C, Nekolla SG, Bengel FM, Momose M, Sammer A, et al. Assessment of myocardial viability with contrast-enhanced magnetic resonance imaging: comparison with positron emission tomography. Circulation. 2002;105:162–167.
    1. Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, et al. Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet. 2003;361:374–379.
    1. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined—A consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36:959–969.
    1. Choudhury L, Mahrholdt H, Wagner A, Choi KM, Elliott MD, et al. Myocardial scarring in asymptomatic or mildly symptomatic patients with hypertrophic cardiomyopathy. J Am Coll Cardiol. 2002;40:2156–2164.
    1. Maceira AM, Joshi J, Prasad SK, Moon JC, Perugini E, et al. Cardiovascular magnetic resonance in cardiac amyloidosis. Circulation. 2005;111:186–193.
    1. Mahrholdt H, Goedecke C, Wagner A, Meinhardt G, Athanasiadis A, et al. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation. 2004;109:1250–1258.
    1. Marckmann P, Skov L, Rossen K, Dupont A, Damholt MB, et al. Nephrogenic systemic fibrosis: Suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol. 2006;17:2359–2362.
    1. Rose GA, Rose GA. Geneva: World Health Organization; WHO Publications Centre; 1982. Cardiovascular survey methods. p. 178.
    1. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, et al. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837–1847.
    1. Pitt B, Remme W, Zannad F, Neaton J, Martinez F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348:1309–1321.
    1. Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med. 2000;343:1445–1453.
    1. Sievers B, Elliott MD, Hurwitz LM, Albert TS, Klem I, et al. Rapid detection of myocardial infarction by subsecond, free-breathing delayed contrast-enhancement cardiovascular magnetic resonance. Circulation. 2007;115:236–244.
    1. Kim RJ, Fieno DS, Parrish TB, Harris K, Chen EL, et al. Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function. Circulation. 1999;100:1992–2002.
    1. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105:539–542.
    1. McCrohon JA, Moon JC, Prasad SK, McKenna WJ, Lorenz CH, et al. Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance. Circulation. 2003;108:54–59.
    1. Assomull RG, Prasad SK, Lyne J, Smith G, Burman ED, et al. Cardiovascular magnetic resonance, fibrosis, and prognosis in dilated cardiomyopathy. J Am Coll Cardiol. 2006;48:1977–1985.
    1. Mahrholdt H, Wagner A, Judd RM, Sechtem U, Kim RJ. Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies. Eur Heart J. 2005;26:1461–1474.
    1. Reimer KA, Jennings RB. The “wavefront phenomenon” of myocardial ischemic cell death. II. Transmural progression of necrosis within the framework of ischemic bed size (myocardium at risk) and collateral flow. Lab Invest. 1979;40:633–644.
    1. Heiberg E, Ugander M, Engblom H, Gotberg M, Olivecrona GK, et al. Automated quantification of myocardial infarction from MR images by accounting for partial volume effects: animal, phantom, and human study. Radiology. 2008;246:581–588.
    1. Prineas RJ, Crow RS, Blackburn HW. Boston: J. Wright; 1982. The Minnesota code manual of electrocardiographic findings: Standards and procedures for measurement and classification. p. 229.
    1. Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging—Executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). American College of Cardiology. 2003. Available: . Accessed: 10 March 2009.
    1. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, et al. Heart Disease and Stroke Statistics 2008 Update. A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;117:e25–146.
    1. Camm AJ, Lüscher TF, Serruys PW European Society of Cardiology. Oxford: Blackwell Publishing/European Society of Cardiology; 2006. The ESC textbook of cardiovascular medicine. p. 1122 p.
    1. Furman MI, Dauerman HL, Goldberg RJ, Yarzebski J, Lessard D, et al. Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: A multi-hospital, community-wide perspective. J Am Coll Cardiol. 2001;37:1571–1580.
    1. Karnegis JN, Matts J, Tuna N. Development and evolution of electrocardiographic Minnesota Q-QS codes in patients with acute myocardial infarction. Am Heart J. 1985;110:452–459.
    1. Dilsizian V, Rocco TP, Freedman NM, Leon MB, Bonow RO. Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress-redistribution imaging. N Engl J Med. 1990;323:141–146.
    1. Afridi I, Kleiman NS, Raizner AE, Zoghbi WA. Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation. 1995;91:663–670.
    1. Kim RJ, Albert TS, Wible JH, Elliott MD, Allen JC, et al. Performance of delayed-enhancement magnetic resonance imaging with gadoversetamide contrast for the detection and assessment of myocardial infarction: an international, multicenter, double-blinded, randomized trial. Circulation. 2008;117:629–637.
    1. Kwong RY, Chan AK, Brown KA, Chan CW, Reynolds HG, et al. Impact of unrecognized myocardial scar detected by cardiac magnetic resonance imaging on event-free survival in patients presenting with signs or symptoms of coronary artery disease. Circulation. 2006;113:2733–2743.
    1. Bolick DR, Hackel DB, Reimer KA, Ideker RE. Quantitative analysis of myocardial infarct structure in patients with ventricular tachycardia. Circulation. 1986;74:1266–1279.
    1. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, et al. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med. 1999;341:1882–1890.
    1. Patel MR, Anstrom KJ, Eisenstein EL, Brindis RG, Peterson ED, et al. Patients without obstructive coronary artery disease and stress test results: An analysis from the National Cardiovascular Data. Circulation. 2008;118:S_1085-b.
    1. Shaw LJ, Shaw RE, Merz CN, Brindis RG, Klein LW, et al. Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American College of Cardiology–National Cardiovascular Data Registry. Circulation. 2008;117:1787–1801.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться