Imaging of Clinically Unrecognized Myocardial Fibrosis in Patients With Suspected Coronary Artery Disease

Antiochos, Panagiotis; Ge, Yin; Steel, Kevin; Bingham, Scott E.; Abdullah, Shuaib; Mikolich, J. Ronald; Arai, Andrew E; Bandettini, W. Patricia; Patel, Amit R.; Farzaneh‐Far, Afshin; Heitner, John F.; Shenoy, Chetan; Leung, Steve W.; González, Jorge A.; Shah, Dipan J.; Raman, Subha V.; Ferrari, Victor A.; Schulz‐Menger, Jeanette; Stuber, Matthias; Simonetti, Orlando P.; Kwong, Raymond Y.

doi:10.1016/j.jacc.2020.06.063

Cited by 48 publications

(35 citation statements)

References 23 publications

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“…The prevalence of inducible ischemia (15%) and LGE (11%) were consistent with previous large studies in patients referred to stress CMR for suspected or known CAD ( 8 , 9 ). This prevalence might appear relatively low in patients with obstructive CAD on CCTA, but it could be explained by the frequent overestimation of the severity of coronary stenosis by CCTA ( 33 ).…”

Section: Discussionsupporting

confidence: 90%

“…Stress cardiovascular magnetic resonance (CMR) can assess the presence of both inducible ischemia and myocardial scar. In patients with known or suspected CAD, numerous large studies have shown the incremental prognostic value of inducible ischemia or unrecognized myocardial infarction (MI) by stress CMR, above traditional risk factors (8)(9)(10)(11). Notably, perfusion stress CMR may improve diagnostic yield in patients with high coronary artery calcium (CAC) score (12), emphasizing the complementary roles of anatomical and functional data.…”

Section: Introductionmentioning

confidence: 99%

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Phenotypic Clustering of Patients With Newly Diagnosed Coronary Artery Disease Using Cardiovascular Magnetic Resonance and Coronary Computed Tomography Angiography

Pezel

Unterseeh

Hovasse

et al. 2021

Front. Cardiovasc. Med.

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Background: Epidemiological characteristics and prognostic profiles of patients with newly diagnosed coronary artery disease (CAD) are heterogeneous. Therefore, providing individualized cardiovascular (CV) risk stratification and tailored prevention is crucial.Objective: Phenotypic unsupervised clustering integrating clinical, coronary computed tomography angiography (CCTA), and cardiac magnetic resonance (CMR) data were used to unveil pathophysiological differences between subgroups of patients with newly diagnosed CAD.Materials and Methods: Between 2008 and 2020, consecutive patients with newly diagnosed obstructive CAD on CCTA and further referred for vasodilator stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or non-fatal myocardial infarction. For this exploratory work, a cluster analysis was performed on clinical, CCTA, and CMR variables, and associations between phenogroups and outcomes were assessed.Results: Among 2,210 patients who underwent both CCTA and CMR, 2,015 (46% men, mean 70 ± 12 years) completed follow-up [median 6.8 (IQR 5.9–9.2) years], in which 277 experienced a MACE (13.7%). Three mutually exclusive and clinically distinct phenogroups (PG) were identified based upon unsupervised hierarchical clustering of principal components: (PG1) CAD in elderly patients with few traditional risk factors; (PG2) women with metabolic syndrome, calcified plaques on CCTA, and preserved left ventricular ejection fraction (LVEF); (PG3) younger men smokers with proximal non-calcified plaques on CCTA, myocardial scar, and reduced LVEF. Using survival analysis, the occurrence of MACE, cardiovascular mortality, and all-cause mortality (all p < 0.001) differed among the three PG, in which PG3 had the worse prognosis. In each PG, inducible ischemia was associated with MACE [PG1, Hazards Ratio (HR) = 3.09, 95% CI, 1.70–5.62; PG2, HR = 3.62, 95% CI, 2.31–5.7; PG3, HR = 3.55, 95% CI, 2.3–5.49; all p < 0.001]. The study presented some key limitations that may impact generalizability.Conclusions: Cluster analysis of clinical, CCTA, and CMR variables identified three phenogroups of patients with newly diagnosed CAD that were associated with distinct clinical and prognostic profiles. Inducible ischemia assessed by stress CMR remained associated with the occurrence of MACE within each phenogroup. Whether automated unsupervised phenogrouping of CAD patients may improve clinical decision-making should be further explored in prospective studies.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Phenotypic Clustering of Patients With Newly Diagnosed Coronary Artery Disease Using Cardiovascular Magnetic Resonance and Coronary Computed Tomography Angiography

Pezel

Unterseeh

Hovasse

et al. 2021

Front. Cardiovasc. Med.

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“…Recent studies had shown promising new therapies targeting inflammation and coagulation to improve outcomes (31,32). The prevalence of inducible ischemia (15%) and LGE (11%) were consistent with previous large studies in patients referred to stress CMR for suspected or known CAD (8,9). This prevalence might appear relatively low in patients with obstructive CAD on CCTA, but it could be explained by the frequent overestimation of the severity of coronary stenosis by CCTA (33).…”

Section: Discussionsupporting

confidence: 84%

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“…Although the current study lacks prognostic information, our findings suggest that CCTA in the setting of NSTE-ACS could provide the information of the previous occurrence of non-IR UMI and the status of vascular inflammation, potentially resulting in the risk stratification in these patients showing a wide heterogeneity in its symptoms and prognosis reported in patients with NSTE-ACS (30,31). A recent study by Antiochos et al reported, in a multicenter cohort study of patients with suspected coronary artery disease, that presence of UMI or clinically recognized MI portended an equally significant risk for death and MI, independently of the presence of ischemia (2). Further studies are required to test the clinical significance of CCTA in the setting of NSTE-ACS, particularly with respect to the inflammatory status by FAI and the predictability of non-IR UMI and its prognostication.…”

Section: Discussionmentioning

confidence: 99%

“…A large proportion of acute myocardial infarction (MI) is asymptomatic or atypically presented without clinical recognition (1)(2)(3). Unrecognized myocardial infarction (UMI) has been reported to constitute up to more than 50% of all MI in the general population and in the cohort older than 60 years or in patients with chronic coronary syndrome, depending on the cardiovascular risk and modalities to detect UMI (4,5).…”

Section: Introductionmentioning

confidence: 99%

Coronary Computed Tomography Angiographic Predictors of Non-culprit Territory Unrecognized Myocardial Infarction Assessed by Cardiac Magnetic Resonance in Non-ST-elevation Acute Coronary Syndrome

Matsuda

Hoshino

Kanaji

et al. 2022

Front. Cardiovasc. Med.

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ObjectivesThis study sought to assess the predictors of coronary computed tomography angiographic findings for non-infarct-related (non-IR) territory unrecognized myocardial infarction (UMI) in patients with a first episode of non-ST-elevation acute coronary syndrome (NSTE-ACS).BackgroundUMI detected by cardiac magnetic resonance imaging (CMR) is associated with adverse outcomes in patients with both acute coronary syndrome and chronic coronary syndrome. However, the association between the presence of UMI and coronary computed tomography angiographic (CCTA) findings remains unknown.MethodsWe investigated 158 patients with a first clinical episode of NSTE-ACS, who underwent pre-PCI 320-slice CCTA and uncomplicated urgent percutaneous coronary intervention (PCI) within 48 h of admission. In these patients, post-PCI CMR was performed within 30 days from urgent PCI and before non-IR lesion staged PCI. UMI was assessed using late gadolinium enhancement (LGE)-CMR by identifying regions of hyperenhancement with an ischemic distribution pattern in non-IR territories (non-IR UMI). CCTA analysis included qualitative and quantitative assessments of the culprit segment, Agatston score, mean peri-coronary fat attenuation index (FAI), epicardial fat volume (EFV) and epicardial fat attenuation (EFA).ResultsNon-IR UMI was detected in 30 vessel territories (9.7%, 30/308 vessels) of 28 patients (17.7%, 28/158 patients). The presence of low-attenuation plaque, spotty calcification, napkin ring sign, and positive remodeling was not significantly different between vessels with and without subtended non-IR UMI. Agatston score >30.0 (OR: 8.39, 95% confidence interval (CI): 2.17 to 32.45, p = 0.002), mean FAI >-64.3 (OR: 3.23, 95% CI: 1.34 to 7.81, p = 0.009), and stenosis severity (OR: 1.04, 95% CI: 1.02 to 1.06, p < 0.001) were independently associated with non-IR UMI. Neither EFV (p = 0.340) nor EFA (p = 0.700) was associated with non-IR UMI.ConclusionThe prevalence of non-IR UMI was 17.7 % in patients with first NSTE-ACS presentation. Agatston score, mean FAI, and coronary stenosis severity were independent CCTA predictors of the presence of non-IR UMI. The integrated CCTA assessment may help identify the presence of non-IR UMI before urgent PCI.

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Imaging of Clinically Unrecognized Myocardial Fibrosis in Patients With Suspected Coronary Artery Disease

Cited by 48 publications

References 23 publications

Phenotypic Clustering of Patients With Newly Diagnosed Coronary Artery Disease Using Cardiovascular Magnetic Resonance and Coronary Computed Tomography Angiography

Phenotypic Clustering of Patients With Newly Diagnosed Coronary Artery Disease Using Cardiovascular Magnetic Resonance and Coronary Computed Tomography Angiography

Data_Sheet_1.docx

Coronary Computed Tomography Angiographic Predictors of Non-culprit Territory Unrecognized Myocardial Infarction Assessed by Cardiac Magnetic Resonance in Non-ST-elevation Acute Coronary Syndrome

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