ST 段抬高型心肌梗死中的右心室损伤：通过心肌磁共振电影、水肿和延迟强化显像进行危险分层。
Right ventricular injury in ST-elevation myocardial infarction: risk stratification by visualization of wall motion, edema, and delayed-enhancement cardiac magnetic resonance.
机构信息
Department of Radiology, University of Leipzig-Heart Center, Leipzig, Germany.
出版信息
Circ Cardiovasc Imaging. 2012 Jan;5(1):60-8. doi: 10.1161/CIRCIMAGING.111.967810. Epub 2011 Nov 11.
BACKGROUND
Patients with right ventricular injury (RVI) complicating ST-elevation myocardial infarction (STEMI) have impaired prognosis, but it is unclear which patients are at risk of developing RVI. Cardiac magnetic resonance can identify these patients and might add important information on risk stratification, prognosis, and treatment. Aims were to determine the predictors and the prognostic significance of RVI assessed by wall motion abnormalities, edema, myocardial salvage index, and delayed enhancement in acute reperfused STEMI.
METHODS AND RESULTS
We studied 450 patients 1-4 days after primary angioplasty in STEMI. T2-weighted and delayed-enhancement cardiac magnetic resonance was used for visualizing edema and scar to calculate myocardial salvage index. Cine-imaging was performed to assess wall motion abnormalities, which, in combination with edema, were considered diagnostic for RVI. Patients with RVI were compared with matched patients with isolated left ventricular infarction. The primary end point was the occurrence of a major adverse cardiac event: a composite of death, reinfarction, and congestive heart failure after a median follow-up period of 20.9 months. RVI was present in 69 patients, and 41 of 69 showed myocardial necrosis. In a multivariable stepwise forward logistic regression analysis, a high RV myocardial mass (odds ratio, 2.06; 95% confidence interval, 1.18-3.58; P=0.012) and a low Thrombolysis In Myocardial Infarction flow before angioplasty (odds ratio, 0.50; 95% confidence interval, 0.32-0.76; P=0.011) were associated with RVI. Cox regression analysis revealed RVI as the most statistically significant predictor of time to major adverse cardiac events (hazard-ratio, 3.36; 95% confidence interval, 1.99-5.66; P<0.001).
CONCLUSIONS
RVI detected by cardiac magnetic resonance is a strong and independent predictor of clinical outcome after acute reperfused STEMI.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01359306.
背景
右心室损伤（RVI）合并 ST 段抬高型心肌梗死（STEMI）的患者预后较差，但尚不清楚哪些患者有发生 RVI 的风险。心脏磁共振可以识别这些患者，并可能提供关于风险分层、预后和治疗的重要信息。本研究旨在确定经壁运动异常、水肿、心肌挽救指数和延迟强化评估的急性再灌注 STEMI 患者中 RVI 的预测因素及其预后意义。
方法和结果
我们对 450 例首次经皮冠状动脉介入治疗后 1-4 天的 STEMI 患者进行了研究。采用 T2 加权和延迟强化心脏磁共振来显示水肿和瘢痕，以计算心肌挽救指数。电影成像用于评估壁运动异常，将其与水肿结合起来用于诊断 RVI。将 RVI 患者与单纯左心室梗死的匹配患者进行比较。主要终点是主要不良心脏事件的发生：中位随访 20.9 个月后死亡、再梗死和充血性心力衰竭的复合终点。69 例患者存在 RVI，其中 41 例存在心肌坏死。多变量逐步向前逻辑回归分析显示，右心室心肌质量高（优势比，2.06；95%置信区间，1.18-3.58；P=0.012）和经皮冠状动脉介入治疗前 Thrombolysis In Myocardial Infarction 血流低（优势比，0.50；95%置信区间，0.32-0.76；P=0.011）与 RVI 相关。Cox 回归分析显示，RVI 是急性再灌注 STEMI 后时间至主要不良心脏事件的最具统计学意义的预测因素（风险比，3.36；95%置信区间，1.99-5.66；P<0.001）。
结论
心脏磁共振检测到的 RVI 是急性再灌注 STEMI 后临床结局的一个强有力且独立的预测因素。
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