The unique value of cardiovascular magnetic resonance in patients with suspected acute coronary syndrome and culprit-free coronary angiograms

Abstract

BackgroundPatients with chest pain, elevated troponin, and unobstructed coronary disease present a clinical dilemma. The purpose of this study was to investigate the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in a cohort of patients with suspected acute coronary syndrome (ACS) and unobstructed coronary arteries.ResultsData files of patients meeting the inclusion criteria in two cardiology centres were searched and analysed. The inclusion criteria included: 1) thoracic pain suspected with ACS; 2) a significant increase in the high-sensitive Troponin T value; 3) ECG changes; 4) coronary arteries without any significant stenosis; 5) a CMR examination included in the diagnostic process; 6) an uncertain diagnosis before the CMR exam; and 7) the absence of known CMR and contrast media contraindications. Special attention was paid to the benefits of CMR in determining the final diagnosis.In total, 136 patients who underwent coronary angiography for chest pain were analysed. The most frequent underlying causes were myocarditis (38%) and perimyocarditis (18%), followed by angiographically unrecognised acute myocardial infarction (18%) and Takotsubo cardiomyopathy (15%). The final diagnosis remained unclear in 6% of the patients. The contribution of CMR in determining the final diagnosis determination was crucial in 57% of the patients. In another 35% of the patients, CMR confirmed the suspicion and, only 8% of the CMR examinations did not help at all and had no influence on diagnosis or treatment.ConclusionCMR provided a powerful incremental diagnostic value in the cohort of patients with suspected ACS and unobstructed coronary arteries. CMR is highly recommended to be incorporated as an inalienable part of the diagnostic algorithms in these patients.

Update on myocarditis – what we know so far and where we may be heading

“…Based on these findings, a novel diagnostic algorithm proposed by Patriki et al led to an average 4.9fold increase in the rate of myocarditis detection over two subsequent years. 67,[124][125][126][127][128][129][130][131]…”

Prevalence of Anxiety and Depression Symptoms in Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries

“…The results showed subendocardial infarction in 24% , myocarditis in 38%, TS in 16% and 21% patients with normal CMR 4 . There are several studies, mostly retrospective, that used CMR in MINOCA with similar results regarding myocardial infarction (16-26%) but great variation regarding myocarditis (27-54%) and normal cardiac MRI (0-30%) [74][75][76][77][78][79][80][81][82] . The time from coronary angiography to CMR is probably of importance and varied between 3-10 days in these studies ( Table 2).…”

Takotsubo cardiomyopathy in a man with no trigger and multiple cardioembolic complications—A rare constellation

“…18 Once this shows no epicardial coronary disease characterization and help differentiate it from myocarditis. 19 Usually, it is only in retrospect that the diagnosis can be made with certainty, once the wall-motion abnormalities fully resolve after a few days or weeks and the typical clinical picture becomes more evident. Studies have reported an incidence of TC of 1%-2% among patients presenting with a clinical syndrome of ACS.…”

“…Often, invasive coronary angiography is the first diagnostic test in a patient with acute chest pain and elevated cardiac biomarkers, especially if there is ST elevation or ongoing chest pain 18. LA = left atrium; LV = left ventricle; RV = right ventricle characterization and help differentiate it from myocarditis 19. Other imaging modalities such as echocardiography and CMR can be very useful in this regard because they show the typical nature of wall-motion abnormalities, and CMR can also provide tissue F I G U R E 1 Initial echo (apical 4-chamber view) with LVEF 35%, hypokinesis of mid-and apical LV, preserved basal contractility and a large, mobile apical LV clot (arrow).…”