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  • Review Article
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Intramyocardial haemorrhage after acute myocardial infarction

Nature Reviews Cardiology volume 12, pages 156–167 (2015)Cite this article

Subjects

Key Points

  • Intramyocardial haemorrhage arises owing to impairment of microvascular function and myocardial perfusion after reperfusion therapy, despite restoration of epicardial vessel patency

  • This major adverse event is associated with large infarct size, adverse left ventricular remodelling, major adverse cardiac events, and death

  • Although intramyocardial haemorrhage has been recognized since the early 1960s, the pathophysiology remains largely unclear

  • During thrombotic occlusion of a coronary artery, cleavage of adherence and tight-junction proteins in the ischaemic endothelium occurs, which leads to extravasation of erythrocytes into the myocardium upon reperfusion

  • Potential therapeutic strategies for the prevention or attenuation of intramyocardial haemorrhage will include protection of the microvasculature or adjustments to reperfusion

Abstract

In patients with acute myocardial infarction (AMI), the guideline-recommended treatment is mechanical revascularization by percutaneous coronary intervention (PCI), which is effective at reducing mortality. However, a substantial proportion of patients with AMI develop chronic cardiac failure owing to poor restoration of microvascular function and myocardial perfusion, despite restoration of epicardial vessel patency. This occurrence is called the 'no-reflow' phenomenon. Although pathological and clinical observations initially seemed to support the hypothesis that no-reflow was the result of microvascular obstruction, irreversible microvascular injury and subsequent intramyocardial haemorrhage are now also thought to be important factors in this process. Intramyocardial haemorrhage shares several pathophysiological features with the haemorrhagic transformation that occurs after ischaemic stroke. Understanding of the role of intramyocardial haemorrhage in the no-reflow phenomenon and myocardial injury is crucial to the development of new therapeutic strategies to treat AMI. In this Review, we provide a comprehensive overview of the pathogenesis and clinical relevance of intramyocardial haemorrhage, and discuss diagnostic options and future therapeutic strategies.

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Figure 1: Possible mechanisms underlying the development of intramyocardial haemorrhage.
Figure 2: Histopathological differences between the core and border zones in infarcted porcine myocardium.
Figure 3: Intramyocardial haemorrhage on cardiac MRI.

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Authors and Affiliations

  1. Department of Cardiology, Institute for Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands

    Ryanne P. Betgem, Guus A. de Waard, Robin Nijveldt, Aernout M. Beek & Niels van Royen

  2. Cardiovascular Institute, Hospital Clinico San Carlos/Complutense University, Calle Profesor Martín Lagos S/N, 28040, Madrid, Spain

    Javier Escaned

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R.P.B and G.A.d.W. contributed equally to this article. R.P.B. researched data for the article, made substantial contribution to discussion of the content, and wrote the manuscript. N.v.R. and G.A.d.W. made substantial contribution to discussion of the content, wrote, reviewed, and edited the manuscript before submission. R.N. and A.M.B. made substantial contribution to discussion of the content, reviewed, and edited the manuscript before submission. J.E. wrote, reviewed, and edited the manuscript before submission.

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Betgem, R., de Waard, G., Nijveldt, R. et al. Intramyocardial haemorrhage after acute myocardial infarction. Nat Rev Cardiol 12, 156–167 (2015). https://doi.org/10.1038/nrcardio.2014.188

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