Long-Term Prognostic Implications of Previous Silent Myocardial Infarction in Patients Presenting With Acute Myocardial Infarction

JACC Cardiovasc Imaging. 2018 Dec;11(12):1773-1781. doi: 10.1016/j.jcmg.2018.02.009. Epub 2018 Apr 18.


Objectives: This study investigated the prevalence of silent myocardial infarction (MI) in patients presenting with first acute myocardial infarction (AMI), and its relation with mortality and major adverse cardiovascular events (MACE) at long-term follow-up.

Background: Up to 54% of MI occurs without apparent symptoms. The prevalence and long-term prognostic implications of previous silent MI in patients presenting with seemingly first AMI are unclear.

Methods: A 2-center observational longitudinal study was performed in 392 patients presenting with first AMI between 2003 and 2013, who underwent late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) examination within 14 days post-AMI. Silent MI was assessed on LGE-CMR images by identifying regions of hyperenhancement with an ischemic distribution pattern in other territories than the AMI. Mortality and MACE (all-cause death, reinfarction, coronary artery bypass grafting, and ischemic stroke) were assessed at 6.8 ± 2.9 years follow-up.

Results: Thirty-two patients (8.2%) showed silent MI on LGE-CMR. Compared with patients without silent MI, mortality risk was higher in patients with silent MI (hazard ratio: 3.87; 95% confidence interval: 1.21 to 12.38; p = 0.023), as was risk of MACE (hazard ratio: 3.10; 95% confidence interval: 1.22 to 7.86; p = 0.017), both independent from clinical and infarction-related characteristics.

Conclusions: Silent MI occurred in 8.2% of patients presenting with first AMI and was independently related to poorer long-term clinical outcome, with a more than 3-fold risk of mortality and MACE. Silent MI holds prognostic value over important traditional prognosticators in the setting of AMI, indicating that these patients represent a high-risk subgroup warranting clinical awareness.

Keywords: acute myocardial infarction; cardiovascular magnetic resonance; late gadolinium enhancement; prognosis; unrecognized myocardial infarction.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • Aged
  • Asymptomatic Diseases
  • Brain Ischemia / epidemiology
  • Coronary Artery Bypass
  • Female
  • Humans
  • Longitudinal Studies
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Myocardial Infarction / diagnostic imaging
  • Myocardial Infarction / epidemiology*
  • Myocardial Infarction / mortality
  • Myocardial Infarction / therapy
  • Prevalence
  • Prognosis
  • Recurrence
  • Risk Assessment
  • Risk Factors
  • Stroke / epidemiology
  • Time Factors