Determining the Mechanism of Myocardial Injury and Role of Coronary Disease in Type 2 Myocardial Infarction

NCT03338504 | Completed

• 1 other identifier: FS/16/75/32533
• Study Type: observational
• Target: 100
• Locations: 1 country
• Sites: 1

Brief Summary

Myocardial injury is common in patients without acute coronary syndrome, and therefore international guidelines propose a classification of patients with myocardial infarction by aetiology. This differentiates between myocardial infarction due to plaque rupture (type 1) and myocardial oxygen supply-demand imbalance (type 2) in other acute illnesses. However, these guidelines have not been widely adopted as the diagnostic criteria for type 2 myocardial infarction are not clearly defined. Patients with type 2 myocardial infarction have poor long term outcomes, with at least twice the mortality at five years compared to those with an index type 1 myocardial infarction. Despite the majority of deaths being attributable to non-cardiovascular events, the rate of future type 1 myocardial infarction or cardiovascular death is similar regardless of index classification. If this future risk is related to the presence of underlying coronary artery disease, then there may be the potential to improve outcomes through targeted investigation and secondary prevention. The investigators will undertake a systematic evaluation of the mechanism of myocardial injury and the role of coronary artery disease in 100 patients with elevated cardiac troponin concentrations where the diagnosis is likely to be type 2 myocardial infarction. These studies will help improve the assessment of patients with myocardial injury, refine the diagnostic criteria for type 2 myocardial infarction, and aid the design of future therapeutic trials.

Conditions

Myocardial Infarction, Acute; Myocardial Ischemia; Myocardial Injury

Keywords

type 2 myocardial infarction

Outcome Measures

Primary Outcomes (1)

• Prevalence of coronary disease

  Defined as obstructive (if stenosis \>50% in the left main stem or \>70% in a major epicardial vessel) or non obstructive disease

  30 days of index presentation

Secondary Outcomes (5)

• Lesion severity

  30 days of index presentation

• Presence of intraluminal plaque rupture

  30 days of index presentation

• Pattern of myocardial injury

  30 days of index presentation

• Cardiovascular death and future myocardial infarction

  1 year

• All cause mortality

  1 year

Study Arms (1)

Suspected type 2 myocardial infarction

The investigators will identify consecutive patients with acute myocardial injury (defined as a rise and or fall in cardiac troponin concentration on serial testing, with at least one value \>99th centile) where the likely mechanism of injury is thought to be myocardial oxygen supply and demand imbalance (e.g secondary to hypoxia, hypotension, tachycardia or anaemia). Patients will be identified through screening of cardiac troponin measurements. Patients who meet both the inclusion and exclusion criteria, will be approached and those who provide consent will comprise the study population. All patients will have a Cardiac MRI scan, with invasive coronary angiography or CT coronary angiography dependent on baseline fitness. The investigators will record demographic and clinical information from the electronic patient record for patients who meet inclusion criteria but have one or more exclusion criteria.

Diagnostic Test: Invasive coronary angiography; Radiation: CT coronary angiography; Diagnostic Test: Cardiac MRI

Interventions

Invasive coronary angiography DIAGNOSTIC_TEST

Where patients are fit, coronary angiography will be performed via the femoral or radial artery with 6F arterial catheters. In patients with one or more stenoses in a major epicardial vessel, a coronary pressure guidewire (PressureWire™ Aeris™, St. Jude Medical, St. Paul, Minnesota) will be used to determine distal coronary pressure and the fractional flow reserve (FFR) calculated at maximal adenosine-induced (intravenous 140 μg/kg/min) hyperaemia. Optical coherence tomography (OCT) will be performed in all three coronary vessels using a Dragonfly® coronary imaging catheter (Abbott Diagnostics, Abbott Park, Illinois) with pullback at 20 mm/s to identify features consistent with vulnerable plaque or recent plaque rupture.(16) If there is evidence of inducible myocardial ischaemia due to coronary artery stenosis, revascularisation with percutaneous coronary intervention may be considered if in the patients best interests.

Suspected type 2 myocardial infarction

CT coronary angiography RADIATION

CT coronary angiography will be performed using a 128 multidetector row CT. Patients with a heart rate exceeding 65 beats/min will receive oral beta-blockade 1 hour before computed tomography. Additional intravenous beta blockers will be given depending on heart rate at the time of imaging. All patients will receive sublingual glyceryl trinitrate (300 μg) immediately prior to dual cardiac and respiratory-gated computed tomography imaging of the coronary arteries. The investigators will quantify total plaque burden using CT calcium scoring. A bolus of 80-100 mL of contrast will be injected intravenously at 5 mL/s. An assessment of the functional consequences of coronary artery stenosis will be made using the computed tomography fractional flow reserve (CT-FFR) technique, using the HeartFlow platform.

Suspected type 2 myocardial infarction

Cardiac MRI DIAGNOSTIC_TEST

Cardiovascular magnetic resonance (CMR) will be performed using a 3T scanner. The MRI scan will consist of localisers, axial and coronal HASTE images, standard breath-held and ECG-gated cine sequences. Short-axis cine images will be obtained for the assessment of left ventricle function and volumes. Left ventricle volumes, mass and ejection fraction will be assessed using dedicated software and values indexed to body surface area. Breath-held, ECG-gated T2 mapping sequences of the myocardium will be performed in the short-axis as a marker of myocardial inflammation. T1-weighted imaging of the coronary arteries will be performed to look for evidence of recent intraplaque thrombus or haemorrhage. The late gadolinium enhancement and T2 mapping techniques will identify regions of new or old myocardial infarction as well as other patterns of injury. Where there are no contraindications, stress MRI will be performed using intravenous Regadenoson.

Suspected type 2 myocardial infarction

Eligibility Criteria

• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Hospitalized patients with acute myocardial injury (defined as a rise and or fall in cardiac troponin concentration on serial testing, with at least one value \>99th centile) where the likely mechanism of injury is thought to be myocardial oxygen supply and demand imbalance (e.g secondary to hypoxia, hypotension, tachycardia or anaemia).

You may qualify if:

• Unscheduled hospital admission with acute myocardial injury (defined as a rise and or fall in high-sensitivity cardiac troponin I concentrations on blood testing)
• A suspected aetiology of myocardial oxygen supply and demand imbalance with symptoms or signs of myocardial ischaemia

You may not qualify if:

• Unable or unwilling to give informed consent
• Women who are pregnant, breastfeeding or of child-bearing potential (women who have experienced menarche, are pre-menopausal and have not been sterilised) will not be enrolled into the trial.
• Probable type 1 myocardial infarction
• Renal impairment (estimated glomerular filtration rate ≤30ml/min/1.73m2)
• Severe hepatic impairment
• Frailty with inability to self-transfer (determined using Katz Index)

Sponsors & Collaborators

• University of Edinburgh: lead
• British Heart Foundation: collaborator

Study Sites (1)

Centre for Cardiovascular Science

Edinburgh, EH16 4SB, United Kingdom

Location

Related Publications (4)

• Chapman AR, Adamson PD, Mills NL. Assessment and classification of patients with myocardial injury and infarction in clinical practice. Heart. 2017 Jan 1;103(1):10-18. doi: 10.1136/heartjnl-2016-309530. Epub 2016 Nov 2.

  PMID: 27806987 BACKGROUND

• Boeddinghaus J, Bularga A, Taggart C, Wereski R, McDermott M, Thurston AJF, Ferry AV, Williams MC, Baker AH, Dweck MR, Newby DE, Chapman AR, Lindahl B, Mills NL; DEMAND-MI Investigators. Implications of a new clinical classification of acute myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2025 Mar 22;14(3):131-141. doi: 10.1093/ehjacc/zuaf002.

  PMID: 39824208 DERIVED

• Meah MN, Bularga A, Tzolos E, Chapman AR, Daghem M, Hung JD, Chiong J, Taggart C, Wereski R, Gray A, Dweck MR, Roobottom C, Curzen N, Kardos A, Felmeden D, Mills NL, Slomka PJ, Newby DE, Dey D, Williams MC. Distinguishing Type 1 from Type 2 Myocardial Infarction by Using CT Coronary Angiography. Radiol Cardiothorac Imaging. 2022 Oct 27;4(5):e220081. doi: 10.1148/ryct.220081. eCollection 2022 Oct.

  PMID: 36339063 DERIVED

• Bularga A, Hung J, Daghem M, Stewart S, Taggart C, Wereski R, Singh T, Meah MN, Fujisawa T, Ferry AV, Chiong J, Jenkins WS, Strachan FE, Semple S, van Beek EJR, Williams M, Dey D, Tuck C, Baker AH, Newby DE, Dweck MR, Mills NL, Chapman AR. Coronary Artery and Cardiac Disease in Patients With Type 2 Myocardial Infarction: A Prospective Cohort Study. Circulation. 2022 Apr 19;145(16):1188-1200. doi: 10.1161/CIRCULATIONAHA.121.058542. Epub 2022 Mar 28.

  PMID: 35341327 DERIVED

Biospecimen

Retention: SAMPLES WITH DNA

Plasma samples will be stored at multiple time points during admission.

MeSH Terms

Conditions

Myocardial Infarction; Myocardial Ischemia

Condition Hierarchy (Ancestors)

Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Infarction; Ischemia; Pathologic Processes; Pathological Conditions, Signs and Symptoms; Necrosis

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: November 7, 2017
• First Posted: November 9, 2017
• Study Start: October 23, 2017
• Primary Completion: November 6, 2020
• Study Completion: November 6, 2021
• Last Updated: June 10, 2022

Record last verified: 2022-06

Locations

GB (1)