SlideShare a Scribd company logo
1 of 5
Case
80 yo F with PMH of HTN, HLD, DM, CVA
with a history of continuous chest pain x 2
weeks. Patient was found to have a LBBB on
unknown duration. Cardiac enzymes were
negative. The patient was transferred to
WHC for further management.
Dobutamine CMR
•   Contractile reserve can be assessed using low dose dobutamine stress test
    •   Allows for superior endocardial border definition facilitating more
        accurate wall motion and wall thickening
•   Dobutamine CMR vs PET
    •   35 patients with mild LV dysfunction
    •   Sensitivity of 88% and Specificity of 87% for detecting regions of viable
        myocardium
•   Reduced predictive ability with more severe dysfunction is present at rest
    with specificity in the 80% range, but sensitivity limited to 50%
    •   If contractile function improves with dobutamine the there is likely
        viability
    •   Lack of improvement, however, does may not rule out viability as
        ischemia may develop at even low levels of dobutamine administration

                                                     Mahrholdt, et al. Heart 2007
Contrast Enhancement
                CMR
•   Regions of myocardial infarct exhibit signal intensity (contrast
    enhancement) on T1-weighted images after administration
    gadolinium
    •   Gadolinium passively diffuses into the intracellular space due to
        rupture of myocyte membranes leading to increased contrast
        concentration in interstitial space between collagen fibers
•   Contrast images are acquired mid-diastole
•   The inversion time must be manually selected to null signal from
    normal myocardial regions
    •   This varies btw patients as a function of dose and and time
        after administration of contrast due to varying
        pharmacokinetics.
                                                 Mahrholdt, et al. Heart 2007
tivity ofwas LAD or not (AUC: 0.95 for LAD infarct ratio of for (AUC: 0.71; 95% be greatest. We have demo
                                                          89%, specificity of 74%, positive likelihood vs. 0.89         benefits might CI: 0.60 to 0.82, p         0.00
                                                         non-LAD infarct, p ratio of 0.1. This cutoff waswere with LGE STEMI, LGE percentage is(AUC: 0
                                                3.6, and negative likelihood      0.3) and whether Q waves             during percentage), CK-MB rise the stron
                                                selectedpresent or not at STEMI presentation (AUC 0.93 for 0.69 to 0.89, p failure and adverse events, openin
                                                                                                                       of late heart 0.01), and LVEF during ST
    Predicting Late Myocardial Recovery and Outcomes in Early hours
                                                           to screen for patients at risk for developing LV
                                                         Q waves present vs. 0.88 for Q waves absent, p 0.3).
                                                dysfunction late after STEMI, correctly classifying 80% of         0.84; 95% CI: 0.76 to 0.93,early risk stratific
                                                                                                                       improved strategies for very
                                                                                                                                                      p     0.03) (F
                                                            We additionally explored clinical outcomes: over 2.3       LVEF measurement after STEMI. Consi
                                                the population. The 23% LGE cutoff seemed useful in                diagnostic accuracy of LGE percentage for pr
                                of STEMI
                                                         0.4 year follow-up, MACE occurred in 23 (22%) subjects (1     has gone toward earlier risk stratification and
                                                dichotomizing 2 groups with widely diverging recoveries in 4 LV dysfunction did not differ, whether the inf
                                                         death, 2 MIs, 5 malignant arrhythmias requiring AICD,                       mentation of prognosis-altering intervention
                                                       severe LV dysfunction 35%, 11 hospital stays for heart                        STEMI (5,26). Treatment strategies based
                                                       failure). The previously defined Associations of Variables <50%
                                                                     Measured During Acute STEMI With
                                                                     Multivariable Associations of Variables
                                                                                       Multivariable        cutoff of 6-Month LVEF
                                                                                                                       LGE 23%       LVEF after STEMI have shown important su
                                                                        Table 4
                                                       measured during hyperacute STEMI incurred a significant
•
                                                                                       Measured During Acute STEMI With 6-Month LVEF <50%
                                                                                                                                     (2– 4,27). However, LVEF measured very ear
      Methods                                          risk of adverse events by univariable Cox proportional                        an imperfect predictor of later LVEF reco
                                                                                                                                          OR             95% CI            p Value
                                                       hazards regression (hazard ratio: 10.1; 95% CI: 3.7 to 27.3,                  global EF at the time of STEMI might beg
     •                                                         0.0001) (Fig. 4). In addition, LGE Table 3 selection
                                                                        Best overall multivariable model by stepwise forward
                                                       p                                                              percentage re-
          104 prospectively enrolled patients with                            including all significant variables from
                                                       mained independently ECG Q waves atwith MACE in multiva-
                                                                                          associated presentation
                                                                                                                                     later months—as observed in this study and
                                                                                                                                     as a6.27 of the 0.81–74.9 disappearance of the
                                                                                                                                          result        gradual
          successfully reperfused STEMI
                                                                           Presence of                                                                                      0.08
                                                       riable Cox regression that included CK-MB rise and LVEF
                                                                           LGE during STEMI*                                         increased contractility of healthy segments an
                                                                                                                                         1.33           1.09–1.78           0.002
                                                       during STEMI (hazard ratio: 1.72; 95% CI: 1.43 to 2.01,                       (6,26). In addition, low EF at the time of S
     •
                                                                           Pain-to-balloon time, min                                     1.15           1.01–1.32           0.09
          Exclusion criteria were recent MI            p 0.007).Adjusted for LVEF during STEMI, LGE %, and CK-MB                     beget normal EF after infarct healing, as sys
                                                         JACC Vol. 55, No. LVEF2010 STEMI*
                                                                            22, during
                                                                                                                                                               after During 0.20 Larose e
                                                                                                                                     tion0.95 Predicting0.88–1.03
                                                                                                                                            observed early Recovery STEMI mightST
          (<6months), shock requiring IABP,              June 1, 2010:2459–69
                                                       Discussion LGE during STEMI*                                                                      Late               Hyperacute
                                                                                                                                     combination of reversible myocardial stunning
                                                                                                                                         1.36           1.11–1.66           0.004

          respiratory failure, contraindications for                       Maximum CK-MB rise after STEMI, mmol/l
                                                       The major finding of this study is that LGE quantification                      ible1.00
                                                                                                                                          necrosis (28,29). The failure of recent tre
                                                                                                                                                        0.99–1.01           0.40

                                                                                                                                     egies such as AICD implantation based on
          MRI                                          very early *Values givenSTEMI predicts late heart failure and
                                                                       during as percentages.
                                                       adverse events beyond traditional risk factors such as infarct
                                                                        Abbreviations as in Tables 1 and 3.                          LVEF very early after STEMI, contrary t
                                                                                                                                     observed when LVEF was measured 40 d
     •    Subjects were followed prospectively at 33
                                                       territory, maximum CK-MB rise, pain-to-balloon time,
                                                       presence of Q waves, and LVEF during STEMI. A second                          might be due to the observed variability in L
                                                                                                                                     during early infarct healing (3,30).
          months and MRI was repeated at 6 months      major finding is that, during the hyperacute phase of
                                                       STEMI, LGE volume incurred the strongest association to                       Predictors of residual systolic function after i

     •                                                 LV function change, beyond infarct transmurality, MVO,                        and remodeling. Systolic function after STE
          Primary endpts were change in LVEF and LV    and SM. Significant variability in preload and afterload                       a function of the infarct territory (31), the
          dysfunction at 6 months.                     conditions and difficulty in discriminating stunned from                       segment elevation on ECG (32,33), microvas
                                                                                                                                     tion (34,35), time to reperfusion (36), and tim
                                                       nonviable myocardium at the time of STEMI have rendered

         •      Secondary endpt was MACE
                                                       most early variables imperfect predictors of late systolic
                                                       function and adverse events. However, strategies for the
                                                                                                                                     (37). Although LVEF at the time of STE
                                                                                                                                     correlated to late systolic function in early stu
                                                                                                                                     has since been called into question by m
•
                                                       earliest possible risk assessment after STEMI have become
      Results                                          essential not only to better target therapies but also to                     radionuclide (38) and volumetric techniques (9
                                                       introduce these therapies in the timeliest manner while                       remodeling is a particularly heterogeneous pr

     •    LGE was the best predictor of late LV
          dysfunction                                     Figure 2      Relative Change in LVEF From STEMI to 6-Month Follow-Up, Assessed According to Quartiles of LVEF During ST


     •    LGE > 23% of volume accurately predicted        The LGE 23% during STEMI identifies a subgroup of patients with significantly worse functional recovery
                                                          compared with those with less LGE, across the entire range of LVEF quartiles during STEMI. Abbreviations as in Figure 1.

          late dysfunction (sensitivity 89%, specificity
          74%)
     •    LGE > 23 % carried a hazard ration of 6.1
          percent for adverse events (p<0.0001)
             Larose et al JACC, 2010

More Related Content

Viewers also liked

Seconda media storia
Seconda media storiaSeconda media storia
Seconda media storiaIstitutoorte
 
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...Pino Ciampolillo
 
Comunicazione prassi intervento v
Comunicazione prassi intervento vComunicazione prassi intervento v
Comunicazione prassi intervento vimartini
 
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...Pino Ciampolillo
 
Ghivizzano 6 marzo 2012 ok
Ghivizzano 6 marzo 2012  okGhivizzano 6 marzo 2012  ok
Ghivizzano 6 marzo 2012 okMaria Concetta
 
Crescita e sviluppo, ripartendo dall’uomo
Crescita e sviluppo, ripartendo dall’uomoCrescita e sviluppo, ripartendo dall’uomo
Crescita e sviluppo, ripartendo dall’uomoRaffaele Nappi
 
Scuola primaria orte
Scuola  primaria orteScuola  primaria orte
Scuola primaria orteIstitutoorte
 
Vedutismo E Secolo Dei Lumi
Vedutismo E Secolo Dei LumiVedutismo E Secolo Dei Lumi
Vedutismo E Secolo Dei LumiValentina Meli
 
Icare - Una piattaforma per l'integrazione
Icare - Una piattaforma per l'integrazioneIcare - Una piattaforma per l'integrazione
Icare - Una piattaforma per l'integrazionectseuropa
 
Vespasiano
VespasianoVespasiano
Vespasianomisalvo
 
Il «Rapporto sullo stato del paesaggio alimentare italiano» non è confortante
Il «Rapporto sullo stato del paesaggio alimentare italiano» non è confortanteIl «Rapporto sullo stato del paesaggio alimentare italiano» non è confortante
Il «Rapporto sullo stato del paesaggio alimentare italiano» non è confortanteVita in Campagna
 
Metodologia franco bellezza
Metodologia franco bellezzaMetodologia franco bellezza
Metodologia franco bellezzaFranco bellezza
 
Fitopatologia in ambito bonsai
Fitopatologia in ambito bonsaiFitopatologia in ambito bonsai
Fitopatologia in ambito bonsaibonsai italia
 
Equamagliana: presente, passato e futuro
Equamagliana: presente, passato e futuroEquamagliana: presente, passato e futuro
Equamagliana: presente, passato e futuroequamagliana
 
Csi pavia notizie_n_01_del_08.01.13
Csi pavia notizie_n_01_del_08.01.13Csi pavia notizie_n_01_del_08.01.13
Csi pavia notizie_n_01_del_08.01.13CSI PAVIA
 

Viewers also liked (20)

Dalton John
Dalton JohnDalton John
Dalton John
 
Halloween poem
Halloween poemHalloween poem
Halloween poem
 
Seconda media storia
Seconda media storiaSeconda media storia
Seconda media storia
 
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
 
3lezioni
3lezioni3lezioni
3lezioni
 
Percorso dei giusti
Percorso dei giustiPercorso dei giusti
Percorso dei giusti
 
Comunicazione prassi intervento v
Comunicazione prassi intervento vComunicazione prassi intervento v
Comunicazione prassi intervento v
 
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
Piano aria regione sicilia anza' salvatore giuseppe ciampolillo procedimento ...
 
Ghivizzano 6 marzo 2012 ok
Ghivizzano 6 marzo 2012  okGhivizzano 6 marzo 2012  ok
Ghivizzano 6 marzo 2012 ok
 
Crescita e sviluppo, ripartendo dall’uomo
Crescita e sviluppo, ripartendo dall’uomoCrescita e sviluppo, ripartendo dall’uomo
Crescita e sviluppo, ripartendo dall’uomo
 
Scuola primaria orte
Scuola  primaria orteScuola  primaria orte
Scuola primaria orte
 
Vedutismo E Secolo Dei Lumi
Vedutismo E Secolo Dei LumiVedutismo E Secolo Dei Lumi
Vedutismo E Secolo Dei Lumi
 
Icare - Una piattaforma per l'integrazione
Icare - Una piattaforma per l'integrazioneIcare - Una piattaforma per l'integrazione
Icare - Una piattaforma per l'integrazione
 
Les flors i les abelles
Les flors i les abellesLes flors i les abelles
Les flors i les abelles
 
Vespasiano
VespasianoVespasiano
Vespasiano
 
Il «Rapporto sullo stato del paesaggio alimentare italiano» non è confortante
Il «Rapporto sullo stato del paesaggio alimentare italiano» non è confortanteIl «Rapporto sullo stato del paesaggio alimentare italiano» non è confortante
Il «Rapporto sullo stato del paesaggio alimentare italiano» non è confortante
 
Metodologia franco bellezza
Metodologia franco bellezzaMetodologia franco bellezza
Metodologia franco bellezza
 
Fitopatologia in ambito bonsai
Fitopatologia in ambito bonsaiFitopatologia in ambito bonsai
Fitopatologia in ambito bonsai
 
Equamagliana: presente, passato e futuro
Equamagliana: presente, passato e futuroEquamagliana: presente, passato e futuro
Equamagliana: presente, passato e futuro
 
Csi pavia notizie_n_01_del_08.01.13
Csi pavia notizie_n_01_del_08.01.13Csi pavia notizie_n_01_del_08.01.13
Csi pavia notizie_n_01_del_08.01.13
 

Similar to new

Kshivets O. Esophageal Cancer Surgery
Kshivets O.  Esophageal Cancer SurgeryKshivets O.  Esophageal Cancer Surgery
Kshivets O. Esophageal Cancer SurgeryOleg Kshivets
 
Frédérique Penault Llorca : Oncotype DX® Breast Cancer Assay: Results and Im...
Frédérique Penault Llorca :  Oncotype DX® Breast Cancer Assay: Results and Im...Frédérique Penault Llorca :  Oncotype DX® Breast Cancer Assay: Results and Im...
Frédérique Penault Llorca : Oncotype DX® Breast Cancer Assay: Results and Im...breastcancerupdatecongress
 
Poster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery
Poster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer SurgeryPoster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery
Poster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer SurgeryRamzi Amri
 
Management of early breast cancer
Management of early breast cancerManagement of early breast cancer
Management of early breast cancermostafa hegazy
 
Renal cell carcinoma ( RCC )ADJUVANT TRIALS.pptx
Renal cell carcinoma ( RCC )ADJUVANT TRIALS.pptxRenal cell carcinoma ( RCC )ADJUVANT TRIALS.pptx
Renal cell carcinoma ( RCC )ADJUVANT TRIALS.pptxAnandHosalli
 
Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...
Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...
Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...Γιώργος Ζωγράφος
 
Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...
Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...
Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...carlofino
 
Common statistical pitfalls & errors in biomedical research (a top-5 list)
Common statistical pitfalls & errors in biomedical research (a top-5 list)Common statistical pitfalls & errors in biomedical research (a top-5 list)
Common statistical pitfalls & errors in biomedical research (a top-5 list)Evangelos Kritsotakis
 
Cardiac MR and viability
Cardiac MR and viabilityCardiac MR and viability
Cardiac MR and viabilitycallroom
 
Risk score to preoperatively predict tnm in gastric cancer
Risk score to preoperatively predict tnm  in gastric cancerRisk score to preoperatively predict tnm  in gastric cancer
Risk score to preoperatively predict tnm in gastric cancerprecirujanos
 
Virologic monitoring during ART
Virologic monitoring during ARTVirologic monitoring during ART
Virologic monitoring during ARTKimberly Schafer
 
Post mastectomy Radiotherapy with trails
Post mastectomy Radiotherapy with trailsPost mastectomy Radiotherapy with trails
Post mastectomy Radiotherapy with trailsAnban Bala
 
Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...
Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...
Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...i3 Health
 
Adjuvant treatment in high risk endometrial carcinoma.pptx
Adjuvant treatment in high risk endometrial carcinoma.pptxAdjuvant treatment in high risk endometrial carcinoma.pptx
Adjuvant treatment in high risk endometrial carcinoma.pptxKomalMittal55
 
Closed loop muscle relaxant infusion
Closed loop muscle relaxant infusionClosed loop muscle relaxant infusion
Closed loop muscle relaxant infusionClaudio Melloni
 
Part ii management of testicular carcinoma - dr vandana
Part ii   management of testicular carcinoma - dr vandanaPart ii   management of testicular carcinoma - dr vandana
Part ii management of testicular carcinoma - dr vandanaDr Vandana Singh Kushwaha
 
Melanoma Nancy Shum And Anne Marcy Intro To Clinical Data Management
Melanoma   Nancy Shum And Anne Marcy Intro To Clinical Data ManagementMelanoma   Nancy Shum And Anne Marcy Intro To Clinical Data Management
Melanoma Nancy Shum And Anne Marcy Intro To Clinical Data Managementcunniffe6
 

Similar to new (20)

Kshivets O. Esophageal Cancer Surgery
Kshivets O.  Esophageal Cancer SurgeryKshivets O.  Esophageal Cancer Surgery
Kshivets O. Esophageal Cancer Surgery
 
Frédérique Penault Llorca : Oncotype DX® Breast Cancer Assay: Results and Im...
Frédérique Penault Llorca :  Oncotype DX® Breast Cancer Assay: Results and Im...Frédérique Penault Llorca :  Oncotype DX® Breast Cancer Assay: Results and Im...
Frédérique Penault Llorca : Oncotype DX® Breast Cancer Assay: Results and Im...
 
QC test
QC testQC test
QC test
 
Poster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery
Poster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer SurgeryPoster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery
Poster: The impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery
 
Management of early breast cancer
Management of early breast cancerManagement of early breast cancer
Management of early breast cancer
 
sentinel lymph node post neoadjuvant
sentinel lymph node post neoadjuvant sentinel lymph node post neoadjuvant
sentinel lymph node post neoadjuvant
 
Renal cell carcinoma ( RCC )ADJUVANT TRIALS.pptx
Renal cell carcinoma ( RCC )ADJUVANT TRIALS.pptxRenal cell carcinoma ( RCC )ADJUVANT TRIALS.pptx
Renal cell carcinoma ( RCC )ADJUVANT TRIALS.pptx
 
Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...
Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...
Prognostic parameters in adrenocortical carcinoma | Γιώργος Ζωγράφος - Γιατ...
 
Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...
Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...
Prognostic Value of Right Ventricular Parameters in Patients with Left Ventri...
 
造影剤腎症
造影剤腎症造影剤腎症
造影剤腎症
 
Common statistical pitfalls & errors in biomedical research (a top-5 list)
Common statistical pitfalls & errors in biomedical research (a top-5 list)Common statistical pitfalls & errors in biomedical research (a top-5 list)
Common statistical pitfalls & errors in biomedical research (a top-5 list)
 
Cardiac MR and viability
Cardiac MR and viabilityCardiac MR and viability
Cardiac MR and viability
 
Risk score to preoperatively predict tnm in gastric cancer
Risk score to preoperatively predict tnm  in gastric cancerRisk score to preoperatively predict tnm  in gastric cancer
Risk score to preoperatively predict tnm in gastric cancer
 
Virologic monitoring during ART
Virologic monitoring during ARTVirologic monitoring during ART
Virologic monitoring during ART
 
Post mastectomy Radiotherapy with trails
Post mastectomy Radiotherapy with trailsPost mastectomy Radiotherapy with trails
Post mastectomy Radiotherapy with trails
 
Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...
Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...
Enhancing MRD Testing in Hematologic Malignancies: When Negativity is a Posit...
 
Adjuvant treatment in high risk endometrial carcinoma.pptx
Adjuvant treatment in high risk endometrial carcinoma.pptxAdjuvant treatment in high risk endometrial carcinoma.pptx
Adjuvant treatment in high risk endometrial carcinoma.pptx
 
Closed loop muscle relaxant infusion
Closed loop muscle relaxant infusionClosed loop muscle relaxant infusion
Closed loop muscle relaxant infusion
 
Part ii management of testicular carcinoma - dr vandana
Part ii   management of testicular carcinoma - dr vandanaPart ii   management of testicular carcinoma - dr vandana
Part ii management of testicular carcinoma - dr vandana
 
Melanoma Nancy Shum And Anne Marcy Intro To Clinical Data Management
Melanoma   Nancy Shum And Anne Marcy Intro To Clinical Data ManagementMelanoma   Nancy Shum And Anne Marcy Intro To Clinical Data Management
Melanoma Nancy Shum And Anne Marcy Intro To Clinical Data Management
 

More from callroom

Test Presentation
Test PresentationTest Presentation
Test Presentationcallroom
 
Thyroid and the Heart
Thyroid and the HeartThyroid and the Heart
Thyroid and the Heartcallroom
 
Myocardial Viability - the STICH Trial NEJM May 2011
Myocardial Viability - the STICH Trial NEJM May 2011Myocardial Viability - the STICH Trial NEJM May 2011
Myocardial Viability - the STICH Trial NEJM May 2011callroom
 
Flail Leaflet
Flail LeafletFlail Leaflet
Flail Leafletcallroom
 
Fat versus Fit
Fat versus FitFat versus Fit
Fat versus Fitcallroom
 
Cardiac MR and viability
Cardiac MR and viabilityCardiac MR and viability
Cardiac MR and viabilitycallroom
 
LFT Review
LFT ReviewLFT Review
LFT Reviewcallroom
 
testing123
testing123testing123
testing123callroom
 
Hypertrophic Cardiomyopathy
Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
Hypertrophic Cardiomyopathycallroom
 
C. diff presentation
C. diff presentationC. diff presentation
C. diff presentationcallroom
 
Hemostasis and Thrombosis
Hemostasis and ThrombosisHemostasis and Thrombosis
Hemostasis and Thrombosiscallroom
 

More from callroom (20)

ppt6
ppt6ppt6
ppt6
 
PPT5
PPT5PPT5
PPT5
 
PPT2
PPT2PPT2
PPT2
 
PPT1
PPT1PPT1
PPT1
 
Test Presentation
Test PresentationTest Presentation
Test Presentation
 
Thyroid and the Heart
Thyroid and the HeartThyroid and the Heart
Thyroid and the Heart
 
Myocardial Viability - the STICH Trial NEJM May 2011
Myocardial Viability - the STICH Trial NEJM May 2011Myocardial Viability - the STICH Trial NEJM May 2011
Myocardial Viability - the STICH Trial NEJM May 2011
 
Flail Leaflet
Flail LeafletFlail Leaflet
Flail Leaflet
 
Fat versus Fit
Fat versus FitFat versus Fit
Fat versus Fit
 
Cardiac MR and viability
Cardiac MR and viabilityCardiac MR and viability
Cardiac MR and viability
 
LFT Review
LFT ReviewLFT Review
LFT Review
 
testing123
testing123testing123
testing123
 
Hypertrophic Cardiomyopathy
Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
Hypertrophic Cardiomyopathy
 
C. diff presentation
C. diff presentationC. diff presentation
C. diff presentation
 
test
testtest
test
 
Hemostasis and Thrombosis
Hemostasis and ThrombosisHemostasis and Thrombosis
Hemostasis and Thrombosis
 
 
 
qwqsqw
qwqsqwqwqsqw
qwqsqw
 
asaswwww
asaswwwwasaswwww
asaswwww
 

new

  • 2. 80 yo F with PMH of HTN, HLD, DM, CVA with a history of continuous chest pain x 2 weeks. Patient was found to have a LBBB on unknown duration. Cardiac enzymes were negative. The patient was transferred to WHC for further management.
  • 3. Dobutamine CMR • Contractile reserve can be assessed using low dose dobutamine stress test • Allows for superior endocardial border definition facilitating more accurate wall motion and wall thickening • Dobutamine CMR vs PET • 35 patients with mild LV dysfunction • Sensitivity of 88% and Specificity of 87% for detecting regions of viable myocardium • Reduced predictive ability with more severe dysfunction is present at rest with specificity in the 80% range, but sensitivity limited to 50% • If contractile function improves with dobutamine the there is likely viability • Lack of improvement, however, does may not rule out viability as ischemia may develop at even low levels of dobutamine administration Mahrholdt, et al. Heart 2007
  • 4. Contrast Enhancement CMR • Regions of myocardial infarct exhibit signal intensity (contrast enhancement) on T1-weighted images after administration gadolinium • Gadolinium passively diffuses into the intracellular space due to rupture of myocyte membranes leading to increased contrast concentration in interstitial space between collagen fibers • Contrast images are acquired mid-diastole • The inversion time must be manually selected to null signal from normal myocardial regions • This varies btw patients as a function of dose and and time after administration of contrast due to varying pharmacokinetics. Mahrholdt, et al. Heart 2007
  • 5. tivity ofwas LAD or not (AUC: 0.95 for LAD infarct ratio of for (AUC: 0.71; 95% be greatest. We have demo 89%, specificity of 74%, positive likelihood vs. 0.89 benefits might CI: 0.60 to 0.82, p 0.00 non-LAD infarct, p ratio of 0.1. This cutoff waswere with LGE STEMI, LGE percentage is(AUC: 0 3.6, and negative likelihood 0.3) and whether Q waves during percentage), CK-MB rise the stron selectedpresent or not at STEMI presentation (AUC 0.93 for 0.69 to 0.89, p failure and adverse events, openin of late heart 0.01), and LVEF during ST Predicting Late Myocardial Recovery and Outcomes in Early hours to screen for patients at risk for developing LV Q waves present vs. 0.88 for Q waves absent, p 0.3). dysfunction late after STEMI, correctly classifying 80% of 0.84; 95% CI: 0.76 to 0.93,early risk stratific improved strategies for very p 0.03) (F We additionally explored clinical outcomes: over 2.3 LVEF measurement after STEMI. Consi the population. The 23% LGE cutoff seemed useful in diagnostic accuracy of LGE percentage for pr of STEMI 0.4 year follow-up, MACE occurred in 23 (22%) subjects (1 has gone toward earlier risk stratification and dichotomizing 2 groups with widely diverging recoveries in 4 LV dysfunction did not differ, whether the inf death, 2 MIs, 5 malignant arrhythmias requiring AICD, mentation of prognosis-altering intervention severe LV dysfunction 35%, 11 hospital stays for heart STEMI (5,26). Treatment strategies based failure). The previously defined Associations of Variables <50% Measured During Acute STEMI With Multivariable Associations of Variables Multivariable cutoff of 6-Month LVEF LGE 23% LVEF after STEMI have shown important su Table 4 measured during hyperacute STEMI incurred a significant • Measured During Acute STEMI With 6-Month LVEF <50% (2– 4,27). However, LVEF measured very ear Methods risk of adverse events by univariable Cox proportional an imperfect predictor of later LVEF reco OR 95% CI p Value hazards regression (hazard ratio: 10.1; 95% CI: 3.7 to 27.3, global EF at the time of STEMI might beg • 0.0001) (Fig. 4). In addition, LGE Table 3 selection Best overall multivariable model by stepwise forward p percentage re- 104 prospectively enrolled patients with including all significant variables from mained independently ECG Q waves atwith MACE in multiva- associated presentation later months—as observed in this study and as a6.27 of the 0.81–74.9 disappearance of the result gradual successfully reperfused STEMI Presence of 0.08 riable Cox regression that included CK-MB rise and LVEF LGE during STEMI* increased contractility of healthy segments an 1.33 1.09–1.78 0.002 during STEMI (hazard ratio: 1.72; 95% CI: 1.43 to 2.01, (6,26). In addition, low EF at the time of S • Pain-to-balloon time, min 1.15 1.01–1.32 0.09 Exclusion criteria were recent MI p 0.007).Adjusted for LVEF during STEMI, LGE %, and CK-MB beget normal EF after infarct healing, as sys JACC Vol. 55, No. LVEF2010 STEMI* 22, during after During 0.20 Larose e tion0.95 Predicting0.88–1.03 observed early Recovery STEMI mightST (<6months), shock requiring IABP, June 1, 2010:2459–69 Discussion LGE during STEMI* Late Hyperacute combination of reversible myocardial stunning 1.36 1.11–1.66 0.004 respiratory failure, contraindications for Maximum CK-MB rise after STEMI, mmol/l The major finding of this study is that LGE quantification ible1.00 necrosis (28,29). The failure of recent tre 0.99–1.01 0.40 egies such as AICD implantation based on MRI very early *Values givenSTEMI predicts late heart failure and during as percentages. adverse events beyond traditional risk factors such as infarct Abbreviations as in Tables 1 and 3. LVEF very early after STEMI, contrary t observed when LVEF was measured 40 d • Subjects were followed prospectively at 33 territory, maximum CK-MB rise, pain-to-balloon time, presence of Q waves, and LVEF during STEMI. A second might be due to the observed variability in L during early infarct healing (3,30). months and MRI was repeated at 6 months major finding is that, during the hyperacute phase of STEMI, LGE volume incurred the strongest association to Predictors of residual systolic function after i • LV function change, beyond infarct transmurality, MVO, and remodeling. Systolic function after STE Primary endpts were change in LVEF and LV and SM. Significant variability in preload and afterload a function of the infarct territory (31), the dysfunction at 6 months. conditions and difficulty in discriminating stunned from segment elevation on ECG (32,33), microvas tion (34,35), time to reperfusion (36), and tim nonviable myocardium at the time of STEMI have rendered • Secondary endpt was MACE most early variables imperfect predictors of late systolic function and adverse events. However, strategies for the (37). Although LVEF at the time of STE correlated to late systolic function in early stu has since been called into question by m • earliest possible risk assessment after STEMI have become Results essential not only to better target therapies but also to radionuclide (38) and volumetric techniques (9 introduce these therapies in the timeliest manner while remodeling is a particularly heterogeneous pr • LGE was the best predictor of late LV dysfunction Figure 2 Relative Change in LVEF From STEMI to 6-Month Follow-Up, Assessed According to Quartiles of LVEF During ST • LGE > 23% of volume accurately predicted The LGE 23% during STEMI identifies a subgroup of patients with significantly worse functional recovery compared with those with less LGE, across the entire range of LVEF quartiles during STEMI. Abbreviations as in Figure 1. late dysfunction (sensitivity 89%, specificity 74%) • LGE > 23 % carried a hazard ration of 6.1 percent for adverse events (p<0.0001) Larose et al JACC, 2010

Editor's Notes

  1. \n
  2. \n
  3. \n
  4. \n
  5. \n