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Acute coronary syndromes
Unrecognised myocardial infarction in subjects at high vascular risk: prevalence and determinants
  1. M F L Meijs1,2,
  2. M L Bots3,
  3. M J M Cramer1,
  4. E-J A Vonken2,
  5. B K Velthuis2,
  6. Y van der Graaf3,
  7. F L Visseren4,
  8. W P Th M Mali2,
  9. P A Doevendans1,
  10. on behalf of the SMART Study group
  1. 1
    Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
  2. 2
    Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
  3. 3
    Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
  4. 4
    Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
  1. Professor P A Doevendans, University Medical Center Utrecht, Department of Cardiology, Heidelberglaan 100, 3584 CX Utrecht, HP E03.406, The Netherlands; p.doevendans{at}


Objective: To investigate the prevalence and determinants of unrecognised myocardial infarction (UMI).

Design, setting, patients: In this cross-sectional study in a tertiary centre, a delayed enhancement cardiac MRI (DE-CMR), which identifies both Q-wave and non-Q wave MIs, was performed in 502 subjects with manifest extracardiac atherosclerotic disease or marked risk factors for atherosclerosis without symptomatic coronary artery disease.

Main outcome measures: UMI was defined as the presence of delayed enhancement without corresponding clinical history.

Results: DE-CMR was of sufficient image quality in 480 (95.6%) subjects. A UMI was present in 45 (9.4%) of all subjects; in 13.1% of men and in 3.7% of women. The risk of UMI increased from 6.0% (95% CI 2.2 to 9.8%) in those with two vascular risk factors up to 26.2% (95% CI 15.2 to 37.3%) in those with four or five risk factors. In a multivariable analysis, the risk of UMI was related to male gender (OR 2.3 (95% CI 1.0 to 5.6)), age (OR 1.04 (95% CI 1.00 to 1.07) per year), ever smoking (OR 3.1 (95% CI 1.0 to 9.1), history of stroke (OR 1.9 (95% CI 0.8 to 4.3)) and history of aneurysm of the abdominal aorta (OR 2.6 (95% CI 1.0 to 6.9)).

Conclusions: In cardiac asymptomatic subjects at high vascular risk, UMI is common. The risk of UMI increases with increasing presence of risk factors.

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  • Funding: The SMART study was financially supported by a grant of the University Medical Center Utrecht. MFLM was financially supported by EUGene.

  • Competing interests: None.

  • Ethics approval: Ethics approval was provided by the medical ethics committee of the UMCU.

  • Patient consent: Obtained.

  • SMART Study Group: A Algra, Julius Center for Health Sciences and Primary Care and Rudolph Magnus Institute of Neuroscience, Department of Neurology; Y van der Graaf, GEHM Rutten, DE Grobbee, Julius Center for Health Sciences and Primary Care; FLJ Visseren, Department of Internal Medicine; PA Doevendans, Department of Cardiology; FL Moll, Department of Vascular Surgery; LJ Kappelle, Department of Neurology; WPThM Mali, Department of Radiology.