Key result
Anterior STEMI is linked to ~4.6-fold higher risk of post-infarction LV thrombus.
Why the study?
Left ventricular thrombus is a serious complication after STEMI that can be accurately detected by LGE sequences on CMR, but criteria for selecting which patients should undergo CMR for thrombus detection are not yet defined.
Cohort (n=377)
Hazard Ratio: 4.57 (95% CI 1.28–16.29)
Absolute Event Rate: 26.5% vs 1.6%
p-value: p=0.02
Readily available pre-discharge variables—anterior infarction, echocardiographic LVEF ≤48%, and >3 leads with Q wave and ST-segment elevation >1mm—identify a high-risk STEMI subgroup with a 26.5% incidence of left ventricular thrombus, helping guide selective use of cardiac magnetic resonance imaging.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This approach would enable earlier identification of more cases, reducing associated complications and optimising available resources. In particular, we propose prioritising cardiac MRI for patients at higher risk, striking a balance between diagnostic efficacy and economic sustainability”
“Left ventricular thrombus is a serious complication that significantly increases the risk of stroke and mortality, even years after a myocardial infarction. Although echocardiography is a commonly used tool, it has limitations, as up to half of the thrombi can go undetected using this technique”
Anterior infarction independently predicts post-STEMI LV thrombus on CMR; supports refined screening selection but leaves open prospective validation.
Background Left ventricular thrombus (LVTh) is an uncommon yet serious complication after ST-segment elevation myocardial infarction (STEMI). LVTh can be accurately detected in late gadolinium enhancement (LGE) sequences in cardiac magnetic resonance (CMR). However, selection of patients who should undergo this imaging technique for LVTh detection is not defined yet. Purpose We aim to stratify the risk of LVTh occurrence after STEMI by clinical, echocardiographic and ECG variables during admission and help select patients who should undergo CMR for LVTh detection. Methods Our registry comprised reperfused STEMI patients who underwent early (1-week) and late (6-month) CMR for clinical indication. LGE sequences were used to analyze the presence of LVTh. Baseline clinical characteristics were recorded. Echocardiography (Echo) was performed before discharge and left ventricular (LV) ejection fraction (LVEF, in %), LV end-diastolic and end-systolic diameters (in mm), tricuspid annular plane systolic excursion (TAPSE, in mm), E and A waves velocities (in m/s) and left auricular antero-posterior diameter (in mm) were measured. ECG during admission were analyzed and maximum and minimum ST-segment elevation, resolution of ST-segment (in %) and the number of leads with Q wave and ST-segment elevation >1mm (Q-STE) were recorded. Univariate and multivariate comparisons were performed to check for an association with LVTh in the first 6 months after STEMI (by CMR). A p<0.05 was considered statistically significant. Results The final cohort comprised 377 STEMI patients (mean age 58.51±11.64 years, 82% male). LVTh was detected in 29 (7.7%) patients by CMR during the first 6 months after STEMI. Predictors of LVTh on multivariate analysis were anterior infarction (HR 4.57 [1.28-16.29], p=0.02), Echo-LVEF (HR 0.97 [0.93-0.99] per %, p=0.04) and Q-STE (HR 1.33 [1.06-1.67] per lead, p=0.01). Echo-LVEF (best cut-off: ≤48%) and Q-STE (best cut-off: >3 leads) were dichotomized and several risk categories for LVTh were defined. In patients with zero or one risk factor the prevalence of LVTh ranged from 1.6% to 5.2% (if anterior infarction and no other risk factors). Patients with anterior infarction and any other risk factor had a 14.3% prevalence of LVTh. However, the highest prevalence was found in patients with concomitantly anterior infarction, Echo-LVEF ≤48% and Q-STE in >3 leads - in this subgroup (n=34, 9% of the cohort) LVTh was found in 26.5% of patients. Conclusions Left ventricular thrombus occurrence in the first 6 months after STEMI can be predicted by readily available clinical (anterior infarction), echocardiographic (LVEF) and ECG (Q-STE) variables before discharge. More than a quarter of patients with anterior infarction, Echo-LVEF≤48% and Q-STE in >3 leads depict LVTh. This could help select patients who should undergo CMR after infarction for LVTh detection.Central Figure.
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Garcés et al. (2023) conducted a cohort in ST-segment elevation myocardial infarction (STEMI) (n=377). Anterior infarction, Echo-LVEF <=48%, and Q-STE in >3 leads vs. Zero or one risk factor was evaluated on Left ventricular thrombus (LVTh) in the first 6 months after STEMI (by CMR) (HR 4.57, 95% CI 1.28-16.29, p=0.02). Anterior infarction (HR 4.57, p=0.02), LVEF <=48%, and Q-STE >3 leads predicted post-STEMI LV thrombus, with a 26.5% prevalence when all three were present.
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