Diagnostic and prognostic implications of CMR-modelled postcapillary wedge pressure in patients following acute myocardial infarction

Presenting Author(s)

• TL

  Torben Lange, MD

  Resident
  University Medical Center Göttingen, Germany, Germany

Primary Author(s)

• TL

  Torben Lange, MD

  Resident
  University Medical Center Göttingen, Germany, Germany

Co-Author(s)

• 

  Alexander Schulz, MD

  Dr.
  Harvard Medical School / BIDMC, Germany
• SB

  Sören Backhaus, MD

  Consultant Cardiologist
  Department of Cardiology, Heart Centre, Kerckhoff-Clinic Bad Nauheim, Germany
• JG

  Judith Gronwald, MD

  Cardiology resident
  Department of Cardiology and Pneumology, University Medical Center Göttingen, Germany
• 

  Thomas Stiermaier, MD

  Cardiologist
  University Heart Center Lübeck, Germany
• RE

  Ruben Evertz, MD

  Dr.
  University Medical Center Göttingen, Germany, Germany
• JK

  Johannes Kowallick, MD

  Prof.
  University Medical Center Göttingen, Germany, Germany
• GH

  Gerd Hasenfuß, MD

  Prof
  University Medical Center Göttingen, Germany, Germany
• HT

  Holger Thiele, MD

  Director
  Heart Center Leipzig, Germany
• 

  Ingo Eitel, MD

  Director
  University Heart Center Lübeck, Germany
• 

  Andreas Schuster, MD, PhD

  Cardiologist
  University Medical Center Göttingen, Germany

Background: Elevated cardiac filling pressures are a key feature of adverse outcome after acute myocardial infarction (AMI). Recently, a cardiovascular magnetic resonance (CMR)-modelled postcapillary wedge pressure (PCWP) estimation has been introduced, but data on its diagnostic and prognostic implications are scare. We hypothesized, that CMR PCWP would enable risk stratification beyond conventional CMR parameters and cardiovascular risk factors.

Methods: A total of 1046 AMI patients were included in this study. CMR imaging was performed after primary percutaneous coronary intervention. Comprehensive image analyses included assessment of myocardial function and infarct characteristics. CMR-modelled PCWP was calculated based on a previously published equation including left ventricular (LV) mass and left atrial volume (Figure1). Primary clinical endpoint of the study was the occurrence of major adverse cardiac events (MACE) including death, reinfarction or congestive heart failure within 12 months after infarction.

Results: Youden Index identified an optimal PCWP cut-off at 16.3mmHg to classify patients at high-risk (p=0.004 on log-rank testing)(Figure2). Dichotomizing the cohort into patients with high and low PCWP (≥/ < 16.3mmHg), there were no differences in age (p=0.12) or sex (p=0.053) but higher presence of risk factors (diabetes: p=0.02, hypertension: p=0.003), impaired myocardial function (LV ejection fraction and strain) and larger infarct size (IS)(p< 0.001 for all) in patients with higher PCWP (Table1). Higher PCWP was associated with MACE on univariate regression modeling (HR 1.12 95% CI 1.03 – 1.23, p=0.008). In patients with smaller IS according to the median (13.3%LVmass), CMR PCWP remained significantly associated with MACE on multivariate modeling independently from all strain values (HR 1.15 95% CI 1.0-1.31, p=0.03) or risk factors (Table 2).

Conclusion: CMR-modelled PCWP is associated with adverse outcome in patients following AMI. Especially in patients with smaller myocardial damage, CMR PCWP detects patients at higher risk for the occurrence of MACE and enables independent risk prediction.

Figure 1: Equation for CMR-modelled PCWP estimation according to Garg et al. (2022). Left atrial volume (LAV) and left ventricular mass (LVM) are included in the formula. Exemplary 4 chamber views show marked LAV and LVM in a patient with and without a major adverse event (MACE) during follow up.

Figure 2: Kaplan-Meier curves for risk assessment in patients after acute myocardial infarction. Incidence of major adverse events (MACE) according to high (red) and low (green) CMR-modelled postcapillary wedge pressure (PCWP) values according to cut-off value 16.3 mmHg identified by Youden´s Index.