Acute Response in the Noninfarcted Myocardium Predicts Long-Term Major Adverse Cardiac Events After STEMI

JACC Cardiovasc Imaging. 2023 Jan;16(1):46-59. doi: 10.1016/j.jcmg.2022.09.015. Epub 2022 Dec 14.


Background: Acute ST-segment elevation myocardial infarction (STEMI) has effects on the myocardium beyond the immediate infarcted territory. However, pathophysiologic changes in the noninfarcted myocardium and their prognostic implications remain unclear.

Objectives: The purpose of this study was to evaluate the long-term prognostic value of acute changes in both infarcted and noninfarcted myocardium post-STEMI.

Methods: Patients with acute STEMI undergoing primary percutaneous coronary intervention underwent evaluation with blood biomarkers and cardiac magnetic resonance (CMR) at 2 days and 6 months, with long-term follow-up for major adverse cardiac events (MACE). A comprehensive CMR protocol included cine, T2-weighted, T2∗, T1-mapping, and late gadolinium enhancement (LGE) imaging. Areas without LGE were defined as noninfarcted myocardium. MACE was a composite of cardiac death, sustained ventricular arrhythmia, and new-onset heart failure.

Results: Twenty-two of 219 patients (10%) experienced an MACE at a median of 4 years (IQR: 2.5-6.0 years); 152 patients returned for the 6-month visit. High T1 (>1250 ms) in the noninfarcted myocardium was associated with lower left ventricular ejection fraction (LVEF) (51% ± 8% vs 55% ± 9%; P = 0.002) and higher NT-pro-BNP levels (290 pg/L [IQR: 103-523 pg/L] vs 170 pg/L [IQR: 61-312 pg/L]; P = 0.008) at 6 months and a 2.5-fold (IQR: 1.03-6.20) increased risk of MACE (2.53 [IQR: 1.03-6.22]), compared with patients with normal T1 in the noninfarcted myocardium (P = 0.042). A lower T1 (<1,300 ms) in the infarcted myocardium was associated with increased MACE (3.11 [IQR: 1.19-8.13]; P = 0.020). Both noninfarct and infarct T1 were independent predictors of MACE (both P = 0.001) and significantly improved risk prediction beyond LVEF, infarct size, and microvascular obstruction (C-statistic: 0.67 ± 0.07 vs 0.76 ± 0.06, net-reclassification index: 40% [IQR: 12%-64%]; P = 0.007).

Conclusions: The acute responses post-STEMI in both infarcted and noninfarcted myocardium are independent incremental predictors of long-term MACE. These insights may provide new opportunities for treatment and risk stratification in STEMI.

Keywords: CMR, heart failure; MACE; STEMI; T1-mapping; myocardial injury; noninfarcted myocardium; prognosis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anterior Wall Myocardial Infarction* / complications
  • Contrast Media
  • Gadolinium
  • Humans
  • Magnetic Resonance Imaging, Cine / methods
  • Myocardium / pathology
  • Percutaneous Coronary Intervention* / adverse effects
  • Predictive Value of Tests
  • Prognosis
  • ST Elevation Myocardial Infarction* / complications
  • ST Elevation Myocardial Infarction* / diagnostic imaging
  • ST Elevation Myocardial Infarction* / therapy
  • Stroke Volume
  • Ventricular Function, Left


  • Contrast Media
  • Gadolinium