Late microvascular obstruction after acute myocardial infarction: Relation with cardiac and inflammatory markers

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Abstract

Objectives

We sought to assess the relation of late microvascular obstruction (l-MVO) size as quantified by cardiac magnetic resonance (CMR) imaging with cardiac and inflammatory marker concentrations after acute myocardial infarction (AMI).

Methods

CMR was performed in 118 consecutive patients within 8 days after successful interventional reperfused first acute ST-elevation AMI. Infarct volumes and l-MVO sizes were calculated from late enhancement (LE) sequences and functional parameters were determined from short-axis cine MR sequences. Creatine kinase (CK) and cardiac troponin T (cTnT), high-sensitivity C-reactive protein (hs-CRP) as well as lactate dehydrogenase (LD) concentrations were determined serially from day 1 to day 4 after symptom onset.

Results

L-MVO was detected in 66/118 patients (55.9%) and comprised 18.2 ± 10% of infarct size and 4.7 ± 3% of left ventricle myocardial mass. Each single-point, peak and cumulative release concentration of cTnT (r = 0.44 to 0.73, p < 0.0001), CK (r = 0.21 to 0.76, p < 0.0001), LD (r = 0.36 to 0.82, all p < 0.0001) as well as hs-CRP single-point values as assessed from day 1 to day 4 and its peak and cumulative release concentrations (r = 0.24 to 0.49, p < 0.003) significantly correlated with l-MVO size. Receiver operating curve (ROC) analysis indicated a cut-off value of 4.7 μg/l cTnT to best identify the presence of l-MVO (area under the curve (AUC) 0.904; 95% CI: 0.85–0.95; p < 0.0001).

Conclusion

L-MVO sizes significantly correlate with cardiac and inflammatory marker concentrations as determined early after AMI. cTnT concentration of > 4.7 μg/l could help to identify patients in whom l-MVO is present.

Introduction

Despite rapid achievement of patency in the infarct-related artery with primary percutaneous coronary intervention (p-PCI) after acute myocardial infarction (AMI), inadequate tissue perfusion may occur [1]. Microvascular obstruction (MVO) is known to be a significant and independent prognostic factor affecting outcome [2], [3]. The concomitant presence of MVO in the necrotic myocardium is generated by an interaction of multiple factors, including embolization of thrombus and plaque, endothelial dysfunction, inflammation, myocardial edema and microvascular dysfunction after AMI [4], [5], [6], [7].

Among accurate assessment of functional and morphological cardiac details, CMR with its sequences of first-pass perfusion (FFP) and late-enhancement (LE) imaging allows the detection of MVO in clinical settings [8], [9], [10], [11]. Prevalence of hypoenhancement of MVO assessed either by FPP or LE was found to be inconsistent [12], [13], [14], [15], which can be explained by the dynamic of the phenomenon with a slow rise of signal intensity in the first 5–10 min and a decrease of the visible MVO area on LE images [16]. Nevertheless, late MVO (l-MVO) correspond to anatomically defined areas of microvascular injury [17], [18], and recently it was shown to be the better prognostic marker of left ventricular (LV) remodeling than early MVO as assessed on FPP images [12]. Its correlation with more frequent post-MI complications such as cardiovascular death, recurrent MI, congestive heart failure and stroke emphasize the clinical importance of an early identification of patients with MVO.

Cardiac magnetic resonance (CMR) data strongly support the role of cardiac marker testing for diagnostic evaluation, therapeutic decision-making and estimation of prognosis after AMI [19], [20], [21]. In contrast to cardiac imaging, measuring simple biochemical markers is a cost-effective, easy-to-implement and widely available tool. Nevertheless, clinical studies quantifying l-MVO size by LE-CMR in a large, homogeneous study population of uniformly treated ST-elevation myocardial infarction (STEMI) patients and its correlation with cardiac as well as with inflammatory markers are lacking. The aim of the present study was to assess the relation between biochemical markers measured early after admission, on the one hand, and l-MVO size evaluated a few days after successful interventional treatment of AMI by contrast-enhanced magnetic resonance imaging, (CE-MRI) on the other. Furthermore, we analysed which marker would be most sensitive and specific for the prediction of l-MVO presence.

Section snippets

Patient population

Hundred and eighteen (n = 118) consecutive patients admitted to the coronary care unit of the Innsbruck University Hospital with the diagnosis of first AMI were investigated with CMR. Imaging scans were performed within 8 days (3.1 ± 1.5 days) after AMI.

Inclusion criteria were a) diagnosis of ST-elevation myocardial infarction (STEMI) according to the redefined ESC/ACC committee criteria [22] as first cardiac event b) pre-procedural Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 2 and a

Patient population data

The mean age of the study cohort was 55.7 ± 11.7 years (range 31 to 84 years); 99 patients (83.9%) were male and 19 (16.1%) were female.

Infarct-related arteries were the right coronary artery (RCA) in 49 patients (41.5%), the left anterior descending artery (LAD) in 46 patients (39.0%) and the left circumflex artery (LCX) in 23 patients (19.5%). All patients underwent successful PCI of the culprit lesion with a median delay of 270.61 ± 264.97 (range 30 to 1440 min) minutes, 12 of them have additional

Discussion

The main findings of the present study are the significant correlations of l-MVO size as assessed by LE-CMR with single-point, cumulative release and peak concentrations of cTnT, CK, hs-CRP as well as of LD, measured in the first four days after AMI. In comparison to patients without l-MVO, those showing l-MVO within the hyperenhanced myocardium on LE images presented significantly higher concentrations of inflammatory and cardiac markers on the first days after the acute event. Furthermore,

Conflict of Interest

None.

Acknowledgements

This work was supported by grants from the Austrian Society of Cardiology (Vienna, Austria), the Medizinische Forschungsfond Tirol, and the Österreichischer Herzfonds (all to B.M.).

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [44].

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