Division of Cardiology, Yokohama City University Medical Center, Japan.
Circ Cardiovasc Imaging. 2022 Nov;15(11):e014497. doi: 10.1161/CIRCIMAGING.122.014497. Epub 2022 Nov 15.
Rapidly progressive, extensive myocardial injury/infarction (RPEMI) beyond the concept of wave-front phenomenon can be observed even when achieving timely reperfusion; however, the pathogenesis of RPEMI remains unknown. This retrospective study investigated clinical and lesion characteristics of RPEMI, focusing on culprit-lesion morphology (CLM).
Among patients with extensive anterior-wall ST-segment elevation myocardial infarction due to proximal left anterior descending artery lesions who had reperfusion within 3 hours of symptom onset, 60 patients undergoing both intravascular ultrasound and cardiac magnetic resonance imaging were enrolled. Myocardial injury/infarction before reperfusion therapy was assessed by QRS scores at hospitalization electrocardiogram, and the extent of myocardial injury/infarction was evaluated by cardiac magnetic resonance imaging, which measured area at risk, infarct size, myocardial salvage index, microvascular obstruction, and left ventricular ejection fraction. RPEMI was defined as lower left ventricular ejection fraction (less median value) with microvascular obstruction.
Despite comparable onset-to-door and onset-to-reperfusion times and area at risk, patients with RPEMI showed higher QRS scores at hospitalization (5 [4.3-6] versus 3 [2-4], <0.001) and infarct size (26.5±9.1 versus 20.4±10.5%, =0.04), and a tendency toward lower myocardial salvage index (0.27±0.14 versus 0.36±0.20, =0.10) compared with those without. Patients with versus without RPEMI more frequently observed specific CLM on intravascular ultrasound, characterized by the combination of vulnerable plaques, plaque ruptures, and/or large thrombi. When stratified by CLM-score composed of these 3 criteria, higher CLM-scores were or tended to be associated with higher QRS scores and incidence of RPEMI. In multivariate analyses including no-reflow phenomenon and final coronary-flow deterioration, increased CLM-score (≥2) was independently associated with high QRS scores and RPEMI (odd ratio 11.25 [95% CI, 2.43-52.00]; =0.002).
Vulnerable CLM was a consistent determinant of advanced myocardial injury/infarction both before and after reperfusion therapy and may play a pivotal role in the development of RPEMI.
即使实现了及时再灌注，也能观察到超出波前现象概念的快速进展、广泛的心肌损伤/梗死（RPEMI）；然而，RPEMI 的发病机制仍不清楚。本回顾性研究调查了 RPEMI 的临床和病变特征，重点是罪犯病变形态（CLM）。
入选了 60 例因左前降支近端病变导致广泛前壁 ST 段抬高型心肌梗死且于症状发作后 3 小时内接受再灌注治疗的患者，这些患者均同时接受了血管内超声和心脏磁共振成像检查。入院心电图 QRS 评分评估再灌注治疗前的心肌损伤/梗死程度，心脏磁共振成像评估心肌损伤/梗死程度，测量危险区面积、梗死面积、心肌挽救指数、微血管阻塞和左心室射血分数。RPEMI 定义为较低的左心室射血分数（低于中位数）伴微血管阻塞。
尽管发病至门和发病至再灌注时间以及危险区面积相似，但 RPEMI 患者的入院时 QRS 评分更高（5[4.3-6]比 3[2-4]，<0.001）和梗死面积更大（26.5±9.1 比 20.4±10.5%，=0.04），且心肌挽救指数呈下降趋势（0.27±0.14 比 0.36±0.20，=0.10）。与无 RPEMI 患者相比，RPEMI 患者更频繁地在血管内超声上观察到特定的 CLM，表现为易损斑块、斑块破裂和/或大血栓的组合。根据这 3 个标准组成的 CLM 评分进行分层时，较高的 CLM 评分与更高的 QRS 评分和 RPEMI 发生率相关或呈相关趋势。在包括无复流现象和最终冠状动脉血流恶化的多变量分析中，较高的 CLM 评分（≥2）与高 QRS 评分和 RPEMI 独立相关（比值比 11.25[95%CI，2.43-52.00]；=0.002）。
易损的 CLM 是再灌注治疗前后进展性心肌损伤/梗死的一致决定因素，可能在 RPEMI 的发展中起关键作用。
