Cardiovascular Magnetic Resonance of Myocardial Fibrosis, Edema, and Infiltrates in Heart Failure.

Cardiac magnetic resonance (CMR) imaging is a unique imaging modality, which provides accurate noninvasive tissue characterization. Various CMR sequences can be utilized to identify and quantify patterns of myocardial edema, fibrosis, and infiltrates, which are important determinants for diagnosis and prognostication of heart failure. This article describes available methods of tissue characterization imaging applied in CMR. The presence and patterns of abnormal tissue characterization are related to common etiologies of heart failure and the techniques employed to demonstrate this. CMR provides the opportunity to identify the etiology of heart failure based on the recognition of different patterns of myocardial abnormalities.

Long-term outcome of paediatric-onset multiple sclerosis: a population-based study.

BACKGROUND: Age of onset of multiple sclerosis (MS) peaks in the 3rd and 4th decades and is rarely less than 18. Robust longitudinal studies in paediatric-onset MS (POMS) are limited, and a clearer understanding of outcome could optimise management strategies. METHODS: Patients with disease onset <18 years were identified from a prospective population-based register. Clinical features including presenting symptoms, time to Expanded Disability Status Scale (EDSS) 4.0, 6.0 and 8.0 and onset of secondary progression were compared with patients with adult-onset MS (AOMS). RESULTS: 111 POMS patients were identified from a cohort of 2068. No significant differences in sex ratio, familial recurrence, relapse rate, ethnicity or clinical symptoms at presentation were identified between POMS and AOMS. However, interval to second relapse was longer (5 vs 2.6 years, p=0.04) and primary progressive disease was less common (0.9% vs 8.5%, p=0.003) in POMS than in AOMS. POMS patients also took longer to develop secondary progressive disease (32 vs 18 years, p=0.0001) and to reach disability milestones (EDSS 4.0, 23.8 vs 15.5 years, p<0.0001; EDSS 6.0, 30.8 vs 20.4 years, p<0.0001; EDSS 8.0, 44.7 vs 39 years, p=0.02), but did so between 7.0 and 12 years younger than in AOMS. CONCLUSIONS: 5.4% of patients with MS have POMS (2.7% <16 years; 0.3% <10 years) and have distinct phenotypic characteristics in early disease. Furthermore, while patients with POMS take longer to reach disability milestones, they do so at a younger age than their adult counterparts and could be considered to have a poorer prognosis. Management strategies for these patients should take account of these data.

CMR reclassifies the majority of patients with suspected MINOCA and non MINOCA.

AIMS: In ∼5-15% of all cases of acute coronary syndromes (ACS) have unobstructed coronaries on angiography. Cardiac magnetic resonance (CMR) has proven useful to identify in most patients the underlying diagnosis associated with this presentation. However, the role of CMR to reclassify patients from the initial suspected condition has not been clarified. The aim of this study was to assess the proportion of patients with suspected MINOCA, or non-MINOCA, that CMR reclassifies with an alternative diagnosis from the original clinical suspicion. METHODS AND RESULTS: A retrospective cohort of patients in a tertiary cardiology centre was identified from a registry database. Patients who were referred for CMR for investigation of suspected MINOCA, and a diagnosis pre- and post-CMR was recorded to determine the proportion of diagnoses reclassified. A total of 888 patients were identified in the registry. CMR reclassified diagnosis in 78% of patients. Diagnosis of MINOCA was confirmed in only 243 patients (27%), whilst most patients had an alternative diagnosis (73%): myocarditis n = 217 (24%), Takotsubo syndrome n = 115 (13%), cardiomyopathies n = 97 (11%), and normal CMR/non-specific n = 216 (24%). CONCLUSION: In a large single-centre cohort of patients presenting with ACS and unobstructed coronary arteries, most patients had a non-MINOCA diagnosis (73%) (myocarditis, Takotsubo, cardiomyopathies, or normal CMR/non-specific findings), whilst only a minority had confirmed MINOCA (27%). Performing CMR led to reclassifying patients' diagnosis in 78% of cases, thus confirming its important clinical role and underscoring the clinical challenge in diagnosing MINOCA and non MINOCA conditions.

Sex differences in patients with acute coronary syndromes and non-obstructive coronary arteries: Presentation and outcome.

BACKGROUND: A substantial number of patients present with a suspected ACS and non-obstructive coronary arteries; sex differences in these patients are not well understood. This study aims to evaluate the impact of sex on clinical presentation and outcome in patients with suspected acute coronary syndrome (ACS) and non-obstructive coronary arteries with a final diagnosis confirmed by cardiovascular magnetic resonance imaging (CMR). METHODS: Consecutive patients with ACS and non-obstructive coronary arteries (n = 719) with an unclear cause from a single tertiary centre who were referred for CMR were included. The primary endpoint was all-cause mortality. RESULTS: CMR was performed at a median time of 30 days after presentation and identified a diagnosis in 74% of patients. All-cause mortality was 9.5% over a median follow up of 4.9 years, with no significant difference between sexes (8.8% versus 10.1%; p = 0.456). Men were more likely to have non-ischaemic aetiology on CMR than women (55% v 41%, p < 0.001), but were equally likely to have an ischaemic cause (25% v 27%, p = 0.462). Age group (HR 1.58, p < 0.001) and LV ejection fraction (HR 0.98, p = 0.023) were independent predictors of mortality. CONCLUSIONS: There is no difference in all-cause mortality between sexes in patients presenting with suspected ACS and non-obstructive coronary arteries.

Cardiac magnetic resonance imaging unmasks presumed embolic myocardial infarction due to patent foramen ovale case report.

BACKGROUND: Occurrence of paradoxical coronary embolism is reported in up to 10-15% of all myocardial infarctions but embolic infarctions presumed to be as a result of a patent foramen ovale (PFO) are rare. Although rare, it is important to identify these patients as they need appropriate investigations to confirm their diagnosis and guide further treatment. CASE SUMMARY: We present the case of a gentleman with troponin positive chest pain with non-obstructed coronaries on invasive coronary angiogram. Subsequent cardiac magnetic resonance imaging (MRI) demonstrated multi-focal myocardial infarctions in several coronary artery territories. Further investigations including echocardiogram were performed in order to identify a cause and source of the embolic infarctions and led to the diagnosis of patent foramen ovale. The patient was treated as myocardial infarction with non-obstructed coronary arteries most likely due to embolic phenomena in the presence of a PFO. CONCLUSION: Multiple focal infarctions in multiple coronary artery territories should raise the suspicion of an intra-cardiac shunt. Multi-modality imaging with cardiac MRI and echocardiogram is important in correctly identifying any source of emboli and the diagnosis of any intra-cardiac shunt. Whilst PFO closure is a possible treatment for patients, considerations regarding risk stratification and local provisions needs to be taken into account. Patients should be referred to the appropriate subspecialist to ensure suitable long-term follow-up.

Imaging Findings of COVID-19-Related Cardiovascular Complications.

Other than respiratory disease, patients with coronavirus disease 2019 (COVID-19) commonly have cardiovascular manifestations, which are recognized as significant risk factors for increased mortality. COVID-19 patients may present with a wide spectrum of clinical presentations ranging from asymptomatic heart disease detected incidentally by cardiac investigations (troponin, BNP, and imaging) to cardiogenic shock and sudden cardiac death. In this broad clinical course, advanced imaging plays an important role in the diagnosis of different patterns of myocardial injury, risk stratification of COVID-19 patients, and in detecting potential cardiac side effects of the current treatments and vaccines against the severe acute respiratory syndrome.

Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries.

BACKGROUND: Patients presenting with acute coronary syndrome (ACS) and nonobstructive coronary arteries are a diagnostic dilemma. Cardiac magnetic resonance (CMR) has an overall diagnostic yield of ∼75%; however, in ∼25% of patients, CMR does not identify any myocardial injury. Identifying the underlying diagnosis has important clinical implications for patients' management and outcome. OBJECTIVES: The authors sought to assess whether the combination of CMR and peak troponin levels in patients with ACS and nonobstructive coronary arteries would lead to increased diagnostic yield. METHODS: Consecutive patients with ACS and nonobstructive coronary arteries without an obvious cause underwent CMR. The primary endpoint of the study was the diagnostic yield of CMR. The Youden index was used to find the optimal diagnostic cut point for peak troponin T to combine with CMR to improve diagnostic yield. Logistic or Cox regression models were used to estimate predictors of a diagnosis by CMR. RESULTS: A total of 719 patients met the inclusion criteria. The peak troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Overall, CMR has a diagnostic yield of 74%. CMR performed <14 days from presentation and with a peak troponin of ≥211 ng/L (n = 198) leads to an improved diagnostic yield (94% vs 72%) compared with CMR performed ≥14 days (n = 245). When CMR was performed <14 days and with a peak troponin of <211 ng/L, the diagnostic yield was 76% (n = 86) compared with 53% (n = 190) when performed ≥14 days. An increase in 1 peak troponin decile increases the odds of the CMR identifying a diagnosis by 20% (OR: 1.20; P = 0.008, 95% CI: 1.05-1.36). CONCLUSIONS: The combination of CMR performed <14 days from presentation and peak troponin T ≥211 ng/L leads to a very high diagnostic yield (94%) on CMR. The diagnostic yield remains high (72%) even when CMR is performed ≥14 days from presentation, but reduces to 53% when peak troponin T was <211 ng/L.

Prospective multiparametric CMR characterization and MicroRNA profiling of anthracycline cardiotoxicity: A pilot translational study.

Background: Anthracycline cardiotoxicity is a significant clinical challenge. Biomarkers to improve risk stratification and identify early cardiac injury are required. Objectives: The purpose of this pilot study was to prospectively characterize anthracycline cardiotoxicity using cardiovascular magnetic resonance (CMR), echocardiography and MicroRNAs (MiRNAs), and identify baseline predictors of LVEF recovery. Methods: Twenty-four patients (age 56 range 18-75 years; 42 % female) with haematological malignancy scheduled to receive anthracycline chemotherapy (median dose 272 mg/m2 doxorubicin equivalent) were recruited and evaluated at three timepoints (baseline, completion of chemotherapy, and 6 months after completion of chemotherapy) with multiparametric 1.5 T CMR, echocardiography and circulating miRNAs sequencing. Results: Seventeen complete datasets were obtained. CMR left ventricular ejection fraction (LVEF) fell significantly between baseline and completion of chemotherapy (61 ± 3 vs 53 ± 3 %, p < 0.001), before recovering significantly at 6-month follow-up (55 ± 3 %, p = 0.018). Similar results were observed for 3D echocardiography-derived LVEF and CMR-derived longitudinal, circumferential and radial feature-tracking strain. Patients were divided into tertiles according to LVEF recovery (poor recovery, partial recovery, good recovery). CMR-derived mitral annular plane systolic excursion (MAPSE) was significantly different at baseline in patients exhibiting poor LVEF recovery (11.7 ± 1.5 mm) in comparison to partial recovery (13.7 ± 2.7 mm), and good recovery (15.7 ± 3.1 mm; p = 0.028). Furthermore, baseline miRNA-181-5p and miRNA-221-3p expression were significantly higher in this group. T2 mapping increased significantly on completion of chemotherapy compared to baseline (54.0 ± 4.6 to 57.8 ± 4.9 ms, p = 0.001), but was not predictive of LVEF recovery. No changes to LV mass, extracellular volume fraction, T1 mapping or late gadolinium enhancement were observed. Conclusions: Baseline CMR-derived MAPSE, circulating miRNA-181-5p, and miRNA-221-3p were associated with poor recovery of LVEF 6 months after completion of anthracycline chemotherapy, suggesting their potential predictive role in this context. T2 mapping increased significantly on completion of chemotherapy but was not predictive of LVEF recovery.

The Role of Cardiac Magnetic Resonance in Myocardial Infarction and Non-obstructive Coronary Arteries.

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) accounts for 5-15% of all presentations of acute myocardial infarction. The absence of obstructive coronary disease may present a diagnostic dilemma and identifying the underlying etiology ensures appropriate management improving clinical outcomes. Cardiac magnetic resonance (CMR) imaging is a valuable, non-invasive diagnostic tool that can aide clinicians to build a differential diagnosis in patients with MINOCA, as well as identifying non-ischemic etiologies of myocardial injury (acute myocarditis, Takotsubo Syndrome, and other conditions). The role of CMR in suspected MINOCA is increasingly recognized as emphasized in both European and American clinical guidelines. In this paper we review the indications for CMR, the clinical value in the differential diagnosis of patients with suspected MINOCA, as well as its current limitations and future perspectives.

Cardiovascular magnetic resonance characterisation of anthracycline cardiotoxicity in adults with normal left ventricular ejection fraction.

BACKGROUND: Anthracycline therapy may lead to changes in cardiac structure and function not detectable by solely evaluating left ventricular ejection fraction (LVEF). OBJECTIVES: We hypothesized that cardiovascular magnetic resonance (CMR) would identify structural and functional myocardial abnormalities in anthracycline-treated cancer survivors with normal LVEF, compared to a matched control population. METHODS: Forty-five cancer survivors (56 ± 16 yrs., 60% female) with normal LVEF (59.5 ± 4.1%) were studied a median of 11 months (range 3-36) following administration of 237 ± 83 mg/m2 anthracycline, and compared with forty-five healthy control subjects of similar age and sex (53 ± 16 yrs., 60% female) with normal LVEF (60.8 ± 2.4%) using 1.5 T CMR. RESULTS: Significantly smaller indexed left ventricular mass (45.6 ± 8.7 vs 50.3 ± 10.1 g/m2, p = 0.02) and indexed myocardial cell volume (30.5 ± 5.7 vs 34.8 ± 7.2 ml/m2, p = 0.002) were evident in cancer survivors and the latter was inversely associated with cumulative anthracycline dose (r = -0.31, p = 0.02). Surrogate CMR markers of myocardial fibrosis were significantly increased in cancer survivors (native myocardial T1: 1021 ± 40 vs 996 ± 35 ms, p = 0.002; extracellular volume: 29.5 ± 4.5 vs 27.4 ± 2.3%, p = 0.006). CMR-derived feature-tracking global longitudinal strain (GLS) was significantly impaired in cancer survivors (2D GLS -18.3 ± 2.6 vs -20.0 ± 2.0%, p < 0.001; 3D GLS -14.5 ± 2.3 vs -16.4 ± 2.6%, p < 0.001). Parameters exhibited good to excellent (ICC = 0.86-0.98) inter- and intra-observer reproducibility. CONCLUSIONS: Anthracycline-treated cancer survivors with normal LVEF have significant perturbations of LV mass, myocardial cell volume, native myocardial T1, ECV, CMR-derived 2D and 3D GLS, compared to controls, with good to excellent levels of inter- and intra-observer reproducibility.

Magnetic Resonance Imaging to Detect Cardiovascular Effects of Cancer Therapy: JACC CardioOncology State-of-the-Art Review.

This paper aims to empower and inform cardio-oncologists by providing a practical guide to the clinical application of cardiac magnetic resonance (CMR) in the rapidly evolving field of cardio-oncology. Specifically, we describe how CMR can be used to assess the cardiovascular effects of cancer therapy. The CMR literature, relevant societal guidelines, indication-specific imaging protocols, and methods to overcome some of the challenges encountered in performing and accessing CMR are reviewed.

Afternoon ward rounds: bad for patients, bad for doctors?

Hospital medicine in the UK is under unprecedented pressure, with increasing demand on physicians as well as challenges in recruiting new doctors into the physicianly specialties. We sought to assess the prevalence of the afternoon ward round and its effect on those undertaking them. We sampled each hospital within our postgraduate region, surveying junior doctors working on inpatient medical wards. We surveyed roughly two-thirds of eligible doctors, -finding that 30% of juniors had some commitment, of varying frequency, to ward rounds beginning after 1.00pm. Of the -doctors involved in afternoon ward rounds, the majority felt they contributed to late finishes, delayed discharge of -patients, reduced team efficiency and reduced job -satisfaction. Just under 80% felt they were less likely to consider a career in hospital medicine as a result The afternoon ward round lives on, and we should not -underestimate its effect. Low junior doctor morale coupled with high work intensity can lead to burnout as well as -impairing the effectiveness of the clinical service. Clinical -leaders should consider leaving this practice in the past so we can cope with the challenges of the future.