Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction.
Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction.
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DOI：
10.1161/circulationaha.107.727826
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发表时间：
2008-09-02
期刊：
影响因子：
37.8
通讯作者：
Brown KA
中科院分区：
文献类型：
--
作者：
Kwong RY;Sattar H;Wu H;Vorobiof G;Gandla V;Steel K;Siu S;Brown KA
无症状性心肌梗死(MI)在糖尿病患者中普遍存在，并造成显著的发病率和死亡率。虽然心脏MRI(CMR)的晚期Gd增强(LGE)成像可以提供心肌瘢痕的敏感特征，但对于没有任何临床证据的MI的糖尿病患者，其预后意义尚不清楚。我们对187例有临床指征的糖尿病患者进行了CMR检查，这些患者按无(研究组，n=109)或有(对照组，n=78)MI临床证据(MI或心电图Q波的临床病史)分组。107例(98%)研究组和74例(95%)对照组患者CMR成像和随访成功。COX回归分析将LGE与主要不良心血管事件(MACE)相关联，包括死亡、急性心肌梗死、新的充血性心力衰竭或不稳定型心绞痛、中风和严重的室性心律失常。受试者中有30/107(28%)患者存在CMR所致的LGE。在平均17个月的随访中，38/107名患者(36%)发生了MACE，其中18例死亡。LGE的存在与MACE和死亡的危险性增加3倍相关(HR分别为3.71和3.61，P<；0.001和P=0.007)。调整后的模型结合了患者的年龄、性别、心电图ST或T改变以及左心室收缩末期容量指数，LGE的MACE风险增加了4倍(调整后HR：4.13，95%CI1.74-9.79，P=0.001)。此外，LGE对MACE和死亡提供了显著的预后价值，并调整为5年事件的糖尿病特有风险模型。在研究患者中，LGE的存在是逐步选择MACE和死亡的最强多变量预测因子。对于无心肌梗死临床证据的糖尿病患者，CMR可以表现出与心肌梗死一致的隐匿性心肌瘢痕。这一影像表现与MACE和死亡风险有很强的相关性，增加了临床、心电和左心功能。
Silent myocardial infarctions (MI) are prevalent among diabetic patients and inflict significant morbidity and mortality. While late gadolinium enhancement (LGE) imaging by cardiac MRI (CMR) can provide sensitive characterization of myocardial scar, its prognostic significance in diabetic patients without any clinical evidence of MI is unknown. We performed clinically-indicated CMR in 187 diabetic patients who were grouped by an absence (STUDY group, n=109) or presence (CONTROL group, n=78) of clinical evidence of MI (clinical history of MI or Q waves on ECG). CMR imaging and follow-up were successful in 107 (98%) STUDY and 74 (95%) CONTROL patients. Cox regression analyses were performed to associate LGE with major adverse cardiovascular events (MACE) including death, acute MI, new congestive heart failure or unstable angina, stroke, and significant ventricular arrhythmias. LGE by CMR was present in 30/107 (28%) STUDY patients. At a median follow-up of 17 months, 38/107 patients (36%) experienced MACE including 18 deaths. Presence of LGE was associated with a >3-fold hazards increase for MACE and for death (HR: 3.71 and 3.61, P<0.001 and P=0.007, respectively). Adjusted to a model that combines patient age, gender, ST or T changes on ECG, and LV end-systolic volume index, LGE maintained a >4-fold hazards increase to MACE (adjusted HR: 4.13, 95% CI 1.74-9.79, P=0.001). In addition, LGE provided significant prognostic value with MACE and with death, adjusted to a diabetic-specific risk model for 5-year events. A presence of LGE was the strongest multivariable predictor of MACE and death by stepwise selection in the STUDY patients. CMR can characterize occult myocardial scar consistent with MI in diabetics without clinical evidence of MI. This imaging finding demonstrates strong association with MACE and mortality hazards, incremental to clinical, ECG, and left ventricular function combined.