Residual ischemia by stress CMR in stable post-STEMI patients. Association with clinical events and implications of guided revascularization
Bibliographic record
Abstract
Abstract Introduction Stress cardiac magnetic resonance (sCMR) represents a gold standard approach to identify and localize myocardial ischemia. However, in the setting of stable STEMI patients, data on the prognostic implications of residual ischemia as derived from sCMR are scarce. Moreover, the association of sCMR-guided revascularization with angina class improvement and patients’ outcomes is unknown. Objectives To evaluate the implications of residual ischemia and sCMR related revascularization with prognosis and anginal symptoms of STEMI patients after the index event. Material and methods Reperfused, stable STEMI patients submitted to undergo sCMR within the first year after STEMI were included in the registry. We analyzed the association of residual ischemia and sCMR related revascularization with the occurrence of major adverse cardiac events (MACE), comprised of all-cause death, non-fatal myocardial infarction, re-admission for heart failure, or unplanned revascularization. Additionally, we explored the effect of sCMR related revascularization on angina class as derived from the Canadian Cardiovascular Society (CCS) Angina Score. A p-value <0.05 was considered statistically significant. Results The study group was made up of 234 patients who underwent sCMR for evaluation of non-revascularized lesions in the non-culprit arteries (n=139, 59.4%) or assessment of new onset chest pain (n=95, 40.6%). Residual ischemia was noted in a minority of patients (n=63, 26.9%), and most of them presented with mild or moderate ischemic burden (n=56, 88.9% with residual ischemia in ≤5 myocardial segments). During a median follow up of 7.49 [3.03-10.02] years, 78 (33.3%) patients presented MACE. In multivariate analysis, the extent (number of segments) of residual ischemia did not associate with MACE (HR 0.97 [0.83-1.12] per segment, p=0.65). Patients were categorized in 3 groups: Group 1 (G1, no ischemia-no revascularization, n=166), Group 2 (G2, ischemia-no revascularization, n=29), and Group 3 (G3, ischemia-revascularization, n=34). No differences in survival free from MACE were noted between these groups. Most patients (n=192, 84.6%) were in CCS Angina Score Class I before sCMR. Patients in G1 remained asymptomatic or paucisymptomatic during follow-up (CCS II-IV between 4.8 and 9%, p>0.05). In G3, patients were predominantly in CCS II-IV (52.9%) before sCMR, and a significant reduction in anginal symptoms was noted after revascularization (CCS II-IV between 6.5 and 12.1%, p≤0.001). Patients with ischemia on sCMR but no revascularization (G2) depicted higher proportion of patients with CCS II-IV before (24.1%) and after sCMR (13 to 19.2%, p>0.05). Conclusions In STEMI patients evaluated post-discharge in stable phase, residual ischemia as derived from sCMR is usually mild and does not associate with the occurrence of MACE. sCMR-guided revascularization relates to a significant and sustained improvement of anginal symptoms but not to the event rate.Survival free from MACE.Changes in CCS Angina Score.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".