Coronary artery disease
Effect of Left Ventricular Scar Size, Location, and Transmurality on Left Ventricular Remodeling With Healed Myocardial Infarction

https://doi.org/10.1016/j.amjcard.2006.11.059Get rights and content

Studies of patients with acute myocardial infarction (MI) suggest that anterior transmural infarcts are associated with greater left ventricular (LV) remodeling compared with nontransmural nonanterior infarctions. It is unclear whether this relation also exists in long-term survivors of MI. Cardiac magnetic resonance imaging was used to explore the relation between myocardial scar size, localization, transmurality, and degree of long-term LV remodeling in patients with healed MI. Subjects were recruited from a registry of patients with healed MI who participated in the OPTIMAAL trial. Cardiac magnetic resonance imaging was performed to assess LV mass, volumes, LV ejection fraction, and myocardial scarring, adjusting for myocardial ischemia. Fifty-seven patients (mean age 69 ± 10 years mean ejection fraction 49 ± 13%) were studied 4.4 ± 0.4 years after MI. Anterior scar was found in 19 patients and nonanterior scar in 33, whereas 5 patients did not show myocardial scar. Transmural scar was evident in 36 patients. In the 52 patients with scar, average total scar size was 13 ± 8% of total LV mass. There was a strong linear relation between scar size and LV end-diastolic volume index (r = 0.81, p <0.0001), end-systolic volume index (r = 0.86, p <0.0001), and LV ejection fraction (r = −0.74, p <0.0001). In multivariate analysis, scar size was the strongest independent predictor of ejection fraction and LV volumes independently of scar localization and transmurality. In conclusion, in the studied cohort, there was a linear relation between scar size and ejection fraction and LV volumes. This relation was independent of scar location and transmurality.

Section snippets

Methods

To increase the likelihood of LV remodeling in long-term survivors of MI, only patients with high-risk complicated MI were included in the present study.

Patients were drawn from a registry of long-term survivors originally included in the Comparison of the Effects of Losartan and Captopril on Mortality and Morbidity in Patients Following Acute Myocardial Infarction (OPTIMAAL) trial at a single center (Stavanger, Norway). The OPTIMAAL trial14 compared losartan (50 mg) with captopril (150 mg) in

Results

Fifty-seven patients (age 68.7 ± 10 years) were included in the study 4.4 ± 0.4 years after their last MI. Baseline characteristics are listed in Table 1. In the acute phase, 33 patients received thrombolytic treatment, 5 patients underwent percutaneous coronary intervention, and 4 patients underwent coronary artery bypass grafting. During follow-up (in the OPTIMAAL trial), 15 patients underwent percutaneous coronary intervention and an additional 5 patients underwent coronary artery bypass

Discussion

The present study is the first to show that scar size, rather than location and transmurality, is the primary determinant of LV remodeling in long-term survivors of MI. These results are in apparent contrast to the conventional perception that scar location and transmurality are the important determinants of LV remodeling. Our findings imply that minimizing or reducing scar size appears to be critical to preventing long-term adverse remodeling irrespective of the location of the initial injury.

Acknowledgment

We acknowledge Fredrikke Wick, RT, and Bent Erdal, RT (CMR technicians) for important contributions and Jorunn Nielsen, RN, and Torbjørn Aarsland, RN (Stavanger Health Research) for patient follow-up and conduct of the study.

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The OPTIMAAL trial was sponsored mainly by Merck, Sharp, & Dohme Research Laboratories, West Point, Pennsylvania, and supported by Helse Vest Grant No. 911017 supplied by government authorities. Amersham Health, a division of GE Healthcare Ltd., Little Chalfont, United Kingdom, supplied the contrast needed to perform the study.

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