Cardiovascular magnetic resonance accurately detects obstructive coronary artery disease in suspected non-ST elevation myocardial infarction: a sub-analysis of the CARMENTA Trial

Abstract

Background Invasive coronary angiography (ICA) is still the reference test in suspected non-ST elevation myocardial infarction (NSTEMI), although a substantial number of patients do not have obstructive coronary artery disease (CAD). Early cardiovascular magnetic resonance (CMR) may be a useful gatekeeper for ICA in this setting. The main objective was to investigate the accuracy of CMR to detect obstructive CAD in NSTEMI. Methods This study is a sub-analysis of a randomized controlled trial investigating whether a non-invasive imaging-first strategy safely reduced the number of ICA compared to routine clinical care in suspected NSTEMI (acute chest pain, non-diagnostic electrocardiogram, high sensitivity troponin T > 14 ng/L), and included 51 patients who underwent CMR prior to ICA. A stepwise approach was used to assess the diagnostic accuracy of CMR to detect (1) obstructive CAD (diameter stenosis ≥ 70% by ICA) and (2) an adjudicated final diagnosis of acute coronary syndrome (ACS). First, in all patients the combination of cine, T2-weighted and late gadolinium enhancement (LGE) imaging was evaluated for the presence of abnormalities consistent with a coronary etiology in any sequence. Hereafter and only when the scan was normal or equivocal, adenosine stress-perfusion CMR was added. Results Of 51 patients included (63 ± 10 years, 51% male), 34 (67%) had obstructive CAD by ICA. The sensitivity, specificity and overall accuracy of the first step to diagnose obstructive CAD were 79%, 71% and 77%, respectively. Additional vasodilator stress-perfusion CMR was performed in 19 patients and combined with step one resulted in an overall sensitivity of 97%, specificity of 65% and accuracy of 86%. Of the remaining 17 patients with non-obstructive CAD, 4 (24%) had evidence for a myocardial infarction on LGE, explaining the modest specificity. The sensitivity, specificity and overall accuracy to diagnose ACS (n = 43) were 88%, 88% and 88%, respectively. Conclusion CMR accurately detects obstructive CAD and ACS in suspected NSTEMI. Non-obstructive CAD is common with CMR still identifying an infarction in almost one-quarter of patients. CMR should be considered as an early diagnostic approach in suspected NSTEMI. Trial registration. The CARMENTA trial has been registered at ClinicalTrials.gov with identifier NCT01559467.

Early diagnosis and prognosis of MINOCA by CMR

“…In patients with suspected non-ST-segment elevation myocardial infarction, CMR can accurately distinguish obstructive CAD and MINOCA, and then be used to confirm the early diagnosis of MINOCA for patient. T2 mapping, cine CMR and late gadolinium enhancement (LGE) imaging are all combined in a study of NSTEMI to diagnose potential obstructive CAD and ACS, and to propose their coronary etiology simultaneously [5]. The findings in this study demonstrate that CMR has 70% higher sensitivity, specificity and overall accuracy for detecting obstructive CAD than others.…”

Determination of the infarct‐related artery in patients with myocardial infarction without ST segment elevation

“…Преимуществом СМР является его способность оценивать региональную и глобальную функцию миокарда, наличие и характер рубцов, ишемию миокарда и дифференцировать коронарную и некоронарную этиологию в рамках одного исследования [1,18]. Вазодилататорная стрессперфузионная СМР точно выявляет обструктивную ИБС в популяции со стабильной болью в груди, а стратегия под контролем СМР снижает вероятность неадекватной инвазивной коронарографии [19].…”

“…CMР точно обнаруживает обструктивную ИБС и острый коронарный синдром при подозрении на ИМбпST. Необструктивная ИБС является распространённым заболеванием, при этом CMР всё ещё выявляет инфаркт почти у четверти пациентов [1]. Раннее включение CMР в диагностическую стратегию может безопасно избежать инвазивную коронарную ангиографию у значительного числа пациентов с ИМбпST [1].…”

“…2024;14 (1):62-67. https://doi.org/10.20340/vmi-rvz.2024.1.CLIN. 4 Введение Инфаркт миокарда без подъёма сегмента ST (ИМбпST) является частью спектра острого коронарного синдрома и представляет собой тип частичной закупорки одной из коронарных артерий, вызывающий снижение притока богатой кислородом крови к сердечной мышце, а также является важным острым проявлением ишемической болезни сердца (ИБС) и основной причиной смерти [1]. Доля пациентов с ИМбпST в госпитализации составляет 60-70% [2].…”

Early invasive versus non-invasive assessment in patients with suspected non-ST-elevation acute coronary syndrome

“…In a further subanalysis, diagnostic accuracy of CMR was reported to be 77% in detecting obstructive CAD using T2-weighted and late gadolinium enhancement imaging in the setting of suspected NSTE-ACS. 46 More recently, the RAPID CTCA trial evaluated whether early CCTA improved clinical outcomes among intermediate to high-risk patients with suspected NSTE-ACS. 47 Enrolling 1,748 symptomatic patients with at least one of: prior CAD , elevated hs-Tn and abnormal ECG, the primary outcome of all-cause mortality, Type 1 or Type 4b MI (stent thrombosis) was reported to be no different between the two strategies.…”