Noninvasive Imaging Post–ST-Segment–Elevation Myocardial Infarction
Towards Targeted Therapy or Targeted End Points?
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Recent decades have witnessed a remarkable decline in the incidence and mortality of ST-segment–elevation myocardial infarction (STEMI).1 In Western countries, improvements in acute care have seen in-hospital mortality from STEMI decrease dramatically from ≈20% in the 1980s to ≈5% in the present day.1,2 However, declining mortality engenders an increasing number of survivors with residual cardiac damage and its associated sequelae. Infarct-related left ventricular (LV) remodeling predisposes to systolic dysfunction and the development of heart failure. Consequently, there is an increasing global incidence of ischemic heart failure, a condition whose mortality rate, in contrast to that of STEMI, has barely changed in the last 2 decades (53% survival at 5 years).3 Identifying those at risk of adverse remodeling and heart failure early may allow individualized, targeted treatment to ameliorate heart failure and thereby improve survival.
See Article by Stiermaier et al
Noninvasive imaging plays a key role in risk stratification post-STEMI. LV ejection fraction (EF) is an independent predictor of survival and forms the basis of treatment stratification (eg, device therapy, aldosterone antagonists).4 The prognostic impact of LV dilatation (as measured by end-diastolic and end-systolic volumes) in historical echocardiographic studies is also well established.5 A relatively recent addition to the diagnostic armamentarium is cardiovascular magnetic resonance (CMR). As well as providing a highly accurate and reproducible depiction of myocardial injury and function, CMR also affords additional prognostic markers. Infarct size (IS) as determined by gadolinium imaging is a stronger predictor of adverse remodeling than EF or volumetric indices and serves as a useful surrogate end point in clinical trials.6,7 Risk prediction is further enhanced by CMR assessment of microvascular obstruction (MVO). Arising …