doi:10.1016/j.jcmg.2009.03.011 2009 2 835-842 J. Am. Coll. Cardiol. Img. Forteza, Francisco J. Chorro, and Angel Llacer J. V. Monmeneu, Eva Rumiz, Fabian Chaustre, Isabel Trapero, Oliver Husser, Maria Vicente Bodi, Juan Sanchis, Julio Nunez, Luis Mainar, Maria P. Lopez-Lereu, Jose Soon After a First ST-Segment Elevation Myocardial Infarction Prognostic Value of a Comprehensive Cardiac Magnetic Resonance Assessment This information is current as of December 24, 2011 http://imaging.onlinejacc.org/cgi/content/full/2/7/835 located on the World Wide Web at: The online version of this article, along with updated information and services, is by on December 24, 2011 imaging.onlinejacc.org Downloaded from

I n patients with ST-segment elevation myocardial infarction (STEMI) discharged from hospital, risk stratification is a challenge (1). Noninvasive tech- niques are necessary not only to establish the probability of systolic recovery (2) but also to predict risk (3). See page 843 Soon after STEMI, cardiac magnetic resonance (CMR) allows for a simultaneous state-of-the-art analysis of the extent of wall motion abnormalities (WMA) at baseline, WMA with low-dose dobut- amine (WMA-dobutamine), microvascular ob- struction and transmural necrosis (2,4). Separately, some of these CMR indexes have been proven to be useful for stratifying risk (5–8), but their rela- tive prognostic weight once adjusted for well-established predictors is unknown. Taking into account that this is a time- consuming approach and that CMR is not widely available yet, this issue needs to be addressed. The management and risk stratification of patients with STEMI has to be based on a complete clinical evaluation and on an estimation of systolic function (1). We hypothesized that a comprehensive assessment of CMR soon after STEMI can provide independent prognostic in- formation beyond this traditional and well-established approach. The relative value of CMR indexes for predicting out- come soon after a first STEMI was also analyzed. M E T H O D S Study group. From January 2004 to December 2006, we prospectively included 250 consecutive patients admitted to a tertiary university hospital with a first STEMI treated with thrombolytic therapy or primary angioplasty. The exclusion criteria were as follows: contraindications to CMR (n 3), death (n 14), reinfarction (n 5), severe clinical instability (n 11), and need for cardiac surgery during admission (n 3). Accordingly, the study group comprised 214 patients without serious complications during admis- sion, discharged from hospital, and in whom CMR studies were successfully performed. The local ethics committee approved the research protocol. Informed consent was obtained from all subjects. Reperfusion therapy. Reperfusion strategy and medical treatment were left to the discretion of the attending cardiologists. Thrombolytic agents were administered in 125 patients (58%), and 89 (42%) were directly submitted to percutaneous revascularization. Overall, 198 patients (92%) were treated with a stent: 89 during primary angioplasty, 23 during rescue angioplasty, and 86 during routine cardiac catheterization performed after thrombolysis (me- dian 2 days). Thrombolysis In Myocardial Infarction (TIMI) flow grade and myocardial blush grade were deter- mined offline by an experienced observer unaware of CMR results with the software Integris HM3000 (Philips, Best, the Netherlands). A TIMI flow grade 3 and myocardial blush grade 2 to 3 were regarded as normal (9). Baseline characteristics, electrocardiogram, and blood samples. Baseline characteristics and clinical data were recorded in all cases. The TIMI risk score for STEMI was calculated in all patients as a surrogate of baseline clinical risk (10). The percentage of sum ST-segment resolution 90 min after reperfusion therapy was determined. Peak troponin I was assessed. CMR. CMR (1.5-T scanner, Sonata Magnetom, Siemens, Erlangen, Germany) was performed 7 1 day (at least 48 h after cardiac catheterization) after STEMI in accordance with our laboratory protocol (2,8,11). All images were acquired by a phased- array body surface coil during breath-holds and were electrocardiogram (ECG)-triggered. Cine images were acquired at rest and during intravenous infusion of low-dose (10 g/kg/min) dobutamine in 2-, 3-, and 4-chamber views and every 1 cm in short-axis views with steady-state free precession imaging sequences (repetition time/echo time: 3.2/1.6 ms flip angle: 61° matrix: 256 128 slice thickness: 6 mm temporal resolution: 26 ms). Delayed enhancement imaging was performed in the same projections used for cine images at least 10 min after administering 0.1 mmol/kg of gadolinium- diethylenetriaminepentaacetic acid (Magnograf, Juste S.A.Q.F., Madrid, Spain). A segmented inversion recovery steady-state free precession imaging sequence was used (repetition time/echo time: 2.5/1.1 ms slice thickness: 6 mm flip angle: 50° matrix: 195 192) nullifying myocardial signal. CMR data analysis. The CMR studies were analyzed offline by an experienced observer blinded to all patient data with customized software (QMASS A B B R E V I A T I O N S A N D A C R O N Y M S CI confidence interval CMR cardiac magnetic resonance ECG electrocardiogram HR hazard ratio MACE major adverse cardiac events STEMI ST-segment elevation myocardial infarction TIMI Thrombolysis In Myocardial Infarction WMA wall motion abnormalities WMA-dobutamine WMA with low-dose dobutamine J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 2 , N O . 7 , 2 0 0 9 J U L Y 2 0 0 9 : 8 3 5 – 4 2 Bodi et al. CMR and Prognosis After Infarction 836 by on December 24, 2011 imaging.onlinejacc.org Downloaded from