Myocardial area at risk

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The myocardial area at risk (AAR) is defined by the ischaemic proportion of the myocardium after coronary occlusion and reflects the potential size of the myocardial infarction ^1-9.

Usage

The assessment of the myocardial area at risk is an important measure in the evaluation of the potentially salvageable myocardium for therapeutic approaches like coronary reperfusion ¹.

Measurement

The myocardial area at risk can be assessed by different means in cardiac magnetic resonance, including T2W/STIR imaging, T2 mapping, T1 mapping, early gadolinium enhancement, contrast-enhanced steady-state free precession and extracellular volume (ECV) imaging ⁹ as well with SPECT ^10,11 and angiographic scores ^12,13.

Interpretation

MRI

The more traditional approach for assessing myocardial area at risk with T2/STIR and more recently with T2 and T1 mapping techniques are founded on the assumption that post-infarct myocardial oedema also reflects reversibly injured myocardium respectively the area at risk ⁹.

However, limitations of this approach are that the affected myocardial region is highly dynamic within the postinfarct period and myocardial oedema is not quite as stable as previously thought and influenced by cardioprotective measures, which has risen doubts about the above-mentioned concept ⁹.

Early gadolinium enhancement, extracellular volume (ECV) imaging and contrast-enhanced steady-state free precession are contrast based quantification methods, which have been proposed as a different approach of assessing myocardial area at risk, in which the process model seems not quite clear as yet ⁹.

Angiography (DSA)

The modified APPROACH score, which takes the site of coronary occlusion, coronary dominance, and the size of major branches into account is one means to determine the area at risk, another one is the BARI score ¹².

-<p>The <strong>myocardial area at risk (AAR)</strong> is defined by the ischaemic proportion of the <a href="/articles/myocardium">myocardium</a> after coronary occlusion and reflects the potential size of the <a href="/articles/myocardial-infarction">myocardial infarction</a> <sup>1-9</sup>.</p><h4>Usage</h4><p>The assessment of the myocardial area at risk is an important measure in the evaluation of the potentially <a href="/articles/myocardial-salvage">salvageable myocardium</a> for therapeutic approaches like coronary reperfusion <sup>1</sup>.</p><h4>Measurement</h4><p>The myocardial area at risk can be assessed by different means in cardiac magnetic resonance, including <a href="/articles/t2-weighted-image">T2W</a>/<a href="/articles/short-tau-inversion-recovery">STIR</a> imaging, <a href="/articles/t2-mapping-myocardium">T2 mapping</a>, <a href="/articles/t1-mapping-myocardium">T1 mapping</a>, early gadolinium enhancement, contrast-enhanced <a href="/articles/steady-state-free-precession-mri-2">steady-state free precession</a> and <a href="/articles/extracellular-volume-ecv-myocardium">extracellular volume (ECV)</a> imaging <sup>9</sup> as well with SPECT <sup>10,11</sup> and angiographic scores <sup>12,13</sup>.</p><h4>Interpretation</h4><h5>MRI</h5><p>The more traditional approach for assessing myocardial area at risk with T2/STIR and more recently with <a href="/articles/t2-mapping-myocardium">T2</a> and <a href="/articles/t1-mapping-myocardium">T1 mapping</a> techniques are founded on the assumption that post-infarct <a href="/articles/myocardial-oedema">myocardial oedema</a> also reflects reversibly injured myocardium respectively the area at risk <sup>9</sup>.</p><p>However, limitations of this approach are that the affected myocardial region is highly dynamic within the postinfarct period and <a href="/articles/myocardial-oedema">myocardial oedema</a> is not quite as stable as previously thought and influenced by cardioprotective measures, which has risen doubts about the above-mentioned concept <sup>9</sup>.</p><p>Early gadolinium enhancement, <a href="/articles/extracellular-volume-ecv-myocardium">extracellular volume (ECV)</a> imaging and contrast-enhanced <a href="/articles/steady-state-free-precession-mri-2">steady-state free precession</a> are contrast based quantification methods, which have been proposed as a different approach of assessing myocardial area at risk, in which the process model seems not quite clear as yet <sup>9</sup>.</p><h5>Angiography (DSA)</h5><p>The modified APPROACH score, which takes the site of coronary occlusion, <a href="/articles/coronary-arterial-dominance">coronary dominance</a>, and the size of major branches into account is one means to determine the area at risk, another one is the BARI score <sup>12</sup>.</p><h4>See also</h4><ul>
+<p>The <strong>myocardial area at risk (AAR)</strong> is defined by the ischaemic proportion of the <a href="/articles/myocardium">myocardium</a> after coronary occlusion and reflects the potential size of the <a href="/articles/myocardial-infarction">myocardial infarction</a> <sup>1-9</sup>.</p><h4>Usage</h4><p>The assessment of the myocardial area at risk is an important measure in the evaluation of the potentially <a href="/articles/myocardial-salvage">salvageable myocardium</a> for therapeutic approaches like coronary reperfusion <sup>1</sup>.</p><h4>Measurement</h4><p>The myocardial area at risk can be assessed by different means in cardiac magnetic resonance, including <a href="/articles/t2-weighted-image">T2W</a>/<a href="/articles/short-tau-inversion-recovery">STIR</a> imaging, <a href="/articles/t2-mapping-myocardium">T2 mapping</a>, <a href="/articles/t1-mapping-myocardium">T1 mapping</a>, early gadolinium enhancement, contrast-enhanced <a href="/articles/steady-state-free-precession-mri-2">steady-state free precession</a> and <a href="/articles/extracellular-volume-myocardium">extracellular volume (ECV)</a> imaging <sup>9</sup> as well with SPECT <sup>10,11</sup> and angiographic scores <sup>12,13</sup>.</p><h4>Interpretation</h4><h5>MRI</h5><p>The more traditional approach for assessing myocardial area at risk with T2/STIR and more recently with T2 and T1 mapping techniques are founded on the assumption that post-infarct <a href="/articles/myocardial-oedema">myocardial oedema</a> also reflects reversibly injured myocardium respectively the area at risk <sup>9</sup>.</p><p>However, limitations of this approach are that the affected myocardial region is highly dynamic within the postinfarct period and myocardial oedema is not quite as stable as previously thought and influenced by cardioprotective measures, which has risen doubts about the above-mentioned concept <sup>9</sup>.</p><p>Early gadolinium enhancement, extracellular volume (ECV) imaging and contrast-enhanced steady-state free precession are contrast based quantification methods, which have been proposed as a different approach of assessing myocardial area at risk, in which the process model seems not quite clear as yet <sup>9</sup>.</p><h5>Angiography (DSA)</h5><p>The modified APPROACH score, which takes the site of coronary occlusion, <a href="/articles/coronary-arterial-dominance">coronary dominance</a>, and the size of major branches into account is one means to determine the area at risk, another one is the BARI score <sup>12</sup>.</p><h4>See also</h4><ul>

References changed:

1. Aletras A, Tilak G, Natanzon A et al. Retrospective Determination of the Area at Risk for Reperfused Acute Myocardial Infarction with T2-Weighted Cardiac Magnetic Resonance Imaging: Histopathological and Displacement Encoding with Stimulated Echoes (DENSE) Functional Validations. Circulation. 2006;113(15):1865-70. <a href="https://doi.org/10.1161/CIRCULATIONAHA.105.576025">doi:10.1161/CIRCULATIONAHA.105.576025</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16606793">Pubmed</a>
2. Friedrich M, Kim H, Kim R. T2-Weighted Imaging to Assess Post-Infarct Myocardium at Risk. JACC Cardiovasc Imaging. 2011;4(9):1014-21. <a href="https://doi.org/10.1016/j.jcmg.2011.07.005">doi:10.1016/j.jcmg.2011.07.005</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21920341">Pubmed</a>
3. Eitel I & Friedrich M. T2-Weighted Cardiovascular Magnetic Resonance in Acute Cardiac Disease. J Cardiovasc Magn Reson. 2011;13(1):13. <a href="https://doi.org/10.1186/1532-429X-13-13">doi:10.1186/1532-429X-13-13</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21332972">Pubmed</a>
4. Ubachs J, Sörensson P, Engblom H et al. Myocardium at Risk by Magnetic Resonance Imaging: Head-To-Head Comparison of T2-Weighted Imaging and Contrast-Enhanced Steady-State Free Precession. European Heart Journal - Cardiovascular Imaging. 2012;13(12):1008-15. <a href="https://doi.org/10.1093/ehjci/jes091">doi:10.1093/ehjci/jes091</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22645203">Pubmed</a>
5. Ugander M, Bagi P, Oki A et al. Myocardial Edema as Detected by Pre-Contrast T1 and T2 CMR Delineates Area at Risk Associated With Acute Myocardial Infarction. JACC Cardiovasc Imaging. 2012;5(6):596-603. <a href="https://doi.org/10.1016/j.jcmg.2012.01.016">doi:10.1016/j.jcmg.2012.01.016</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22698528">Pubmed</a>
6. Bulluck H, Hammond-Haley M, Fontana M et al. Quantification of Both the Area-At-Risk and Acute Myocardial Infarct Size in ST-Segment Elevation Myocardial Infarction Using T1-Mapping. J Cardiovasc Magn Reson. 2017;19(1):57. <a href="https://doi.org/10.1186/s12968-017-0370-6">doi:10.1186/s12968-017-0370-6</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28764773">Pubmed</a>
7. Garg P, Broadbent D, Swoboda P et al. Acute Infarct Extracellular Volume Mapping to Quantify Myocardial Area at Risk and Chronic Infarct Size on Cardiovascular Magnetic Resonance Imaging. Circ Cardiovasc Imaging. 2017;10(7). <a href="https://doi.org/10.1161/CIRCIMAGING.117.006182">doi:10.1161/CIRCIMAGING.117.006182</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28674085">Pubmed</a>
8. Hammer-Hansen S, Leung S, Hsu L et al. Early Gadolinium Enhancement for Determination of Area at Risk. JACC Cardiovasc Imaging. 2017;10(2):130-9. <a href="https://doi.org/10.1016/j.jcmg.2016.04.009">doi:10.1016/j.jcmg.2016.04.009</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27665165">Pubmed</a>
9. Ibanez B, Aletras A, Arai A et al. Cardiac MRI Endpoints in Myocardial Infarction Experimental And Clinical Trials. J Am Coll Cardiol. 2019;74(2):238-56. <a href="https://doi.org/10.1016/j.jacc.2019.05.024">doi:10.1016/j.jacc.2019.05.024</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31296297">Pubmed</a>
10. Botker H, Kaltoft A, Pedersen S, Kim W. Measuring Myocardial Salvage. Cardiovasc Res. 2012;94(2):266-75. <a href="https://doi.org/10.1093/cvr/cvs081">doi:10.1093/cvr/cvs081</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22311720">Pubmed</a>
11. Vauchot F, Ben Bouallègue F, Hedon C, Piot C, Roubille F, Mariano-Goulart D. Assessment of the Area at Risk After Acute Myocardial Infarction Using 123I-MIBG SPECT: Comparison with the Angiographic APPROACH-Score. J Nucl Cardiol. 2016;25(2):572-80. <a href="https://doi.org/10.1007/s12350-016-0644-7">doi:10.1007/s12350-016-0644-7</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27549427">Pubmed</a>
12. Ortiz-Perez J, Meyers S, Lee D et al. Angiographic Estimates of Myocardium at Risk During Acute Myocardial Infarction: Validation Study Using Cardiac Magnetic Resonance Imaging. Eur Heart J. 2007;28(14):1750-8. <a href="https://doi.org/10.1093/eurheartj/ehm212">doi:10.1093/eurheartj/ehm212</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/17586811">Pubmed</a>
13. Berry C, Kellman P, Mancini C et al. Magnetic Resonance Imaging Delineates the Ischemic Area at Risk and Myocardial Salvage in Patients with Acute Myocardial Infarction. Circ Cardiovasc Imaging. 2010;3(5):527-35. <a href="https://doi.org/10.1161/CIRCIMAGING.109.900761">doi:10.1161/CIRCIMAGING.109.900761</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20631034">Pubmed</a>
1. Aletras A, Tilak G, Natanzon A et al. Retrospective Determination of the Area at Risk for Reperfused Acute Myocardial Infarction With T2-Weighted Cardiac Magnetic Resonance Imaging. Circulation. 2006;113(15):1865-70. <a href="https://doi.org/10.1161/circulationaha.105.576025">doi:10.1161/circulationaha.105.576025</a>
2. Friedrich M, Kim H, Kim R. T2-Weighted Imaging to Assess Post-Infarct Myocardium at Risk. JACC Cardiovasc Imaging. 2011;4(9):1014-21. <a href="https://doi.org/10.1016/j.jcmg.2011.07.005">doi:10.1016/j.jcmg.2011.07.005</a>
3. Eitel I & Friedrich M. T2-Weighted Cardiovascular Magnetic Resonance in Acute Cardiac Disease. J Cardiovasc Magn Reson. 2011;13(1):1-11. <a href="https://doi.org/10.1186/1532-429x-13-13">doi:10.1186/1532-429x-13-13</a>
4. Ubachs J, Sörensson P, Engblom H et al. Myocardium at Risk by Magnetic Resonance Imaging: Head-To-Head Comparison of T2-Weighted Imaging and Contrast-Enhanced Steady-State Free Precession. European Heart Journal - Cardiovascular Imaging. 2012;13(12):1008-15. <a href="https://doi.org/10.1093/ehjci/jes091">doi:10.1093/ehjci/jes091</a>
5. Ugander M, Bagi P, Oki A et al. Myocardial Edema as Detected by Pre-Contrast T1 and T2 CMR Delineates Area at Risk Associated With Acute Myocardial Infarction. JACC Cardiovasc Imaging. 2012;5(6):596-603. <a href="https://doi.org/10.1016/j.jcmg.2012.01.016">doi:10.1016/j.jcmg.2012.01.016</a>
6. Bulluck H, Hammond-Haley M, Fontana M et al. Quantification of Both the Area-At-Risk and Acute Myocardial Infarct Size in ST-Segment Elevation Myocardial Infarction Using T1-Mapping. J Cardiovasc Magn Reson. 2017;19(1):1-11. <a href="https://doi.org/10.1186/s12968-017-0370-6">doi:10.1186/s12968-017-0370-6</a>
7. Garg P, Broadbent D, Swoboda P et al. Acute Infarct Extracellular Volume Mapping to Quantify Myocardial Area at Risk and Chronic Infarct Size on Cardiovascular Magnetic Resonance Imaging. Circ: Cardiovascular Imaging. 2017;10(7). <a href="https://doi.org/10.1161/circimaging.117.006182">doi:10.1161/circimaging.117.006182</a>
8. Hammer-Hansen S, Leung S, Hsu L et al. Early Gadolinium Enhancement for Determination of Area at Risk. JACC Cardiovasc Imaging. 2017;10(2):130-9. <a href="https://doi.org/10.1016/j.jcmg.2016.04.009">doi:10.1016/j.jcmg.2016.04.009</a>
9. Ibanez B, Aletras A, Arai A et al. Cardiac MRI Endpoints in Myocardial Infarction Experimental And Clinical Trials. J Am Coll Cardiol. 2019;74(2):238-56. <a href="https://doi.org/10.1016/j.jacc.2019.05.024">doi:10.1016/j.jacc.2019.05.024</a>
10. Botker H, Kaltoft A, Pedersen S, Kim W. Measuring Myocardial Salvage. Cardiovasc Res. 2012;94(2):266-75. <a href="https://doi.org/10.1093/cvr/cvs081">doi:10.1093/cvr/cvs081</a>
11. Vauchot F, Ben Bouallègue F, Hedon C, Piot C, Roubille F, Mariano-Goulart D. Assessment of the Area at Risk After Acute Myocardial Infarction Using 123I-MIBG SPECT: Comparison with the Angiographic APPROACH-Score. J Nucl Cardiol. 2016;25(2):572-80. <a href="https://doi.org/10.1007/s12350-016-0644-7">doi:10.1007/s12350-016-0644-7</a>
12. Ortiz-Perez J, Meyers S, Lee D et al. Angiographic Estimates of Myocardium at Risk During Acute Myocardial Infarction: Validation Study Using Cardiac Magnetic Resonance Imaging. Eur Heart J. 2007;28(14):1750-8. <a href="https://doi.org/10.1093/eurheartj/ehm212">doi:10.1093/eurheartj/ehm212</a>
13. Berry C, Kellman P, Mancini C et al. Magnetic Resonance Imaging Delineates the Ischemic Area at Risk and Myocardial Salvage in Patients With Acute Myocardial Infarction. Circ Cardiovasc Imaging. 2010;3(5):527-35. <a href="https://doi.org/10.1161/circimaging.109.900761">doi:10.1161/circimaging.109.900761</a>

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myocardial infarction
myocardial ischaemia

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