In this retrospective, single-center study, all consecutive patients with STEMI treated with percutaneous coronary intervention who underwent CMR within 30 days of the event at the University Hospital of Cagliari, Italy, between March 3rd, 2017, and December 31st, 2023, were included.

STEMI was defined according to the ESC/ACCF/AHA/WHF consensus document criteria, which include symptoms of acute myocardial ischemia, persistent ST-segment elevation of at least 1.0 mm in two or more contiguous ECG leads or new left bundle branch block, and elevated cardiac enzyme levels.

Exclusion criteria included: subjects < 18 years, poor CMR imaging quality, previous myocardial infarction and/or cerebrovascular events, pre-existing cardiomyopathy, history of atrial fibrillation, and suspected or known prior irreversible myocardial damage.

Cardiovascular risk factors were collected from medical records. Hypertension was defined as a systolic blood pressure of ≥140 mmHg or a diastolic blood pressure of ≥ 90 mmHg at rest on more than two occasions, or the use of antihypertensive drugs. Smoking status was defined as current smokers or never smokers. Ex-smokers, defined as individuals who had quit smoking more than 6 months prior to enrollment, were included in the nonsmoker category. Hypercholesterolemia was defined as a plasma LDL cholesterol concentration ≥130 mg/dL (≥3.4 mmol/L) and/or non-HDL cholesterol ≥160 mg/dL (≥4.1 mmol/L). Cholesterol levels were measured according to the standard in-house laboratory protocol. Diabetes status was assessed using the World Health Organization criteria or an established diagnosis of type 2 diabetes. Obesity was defined as a BMI > 30, as defined by the World Health Organization criteria.

Institutional Review Board approval for this retrospective, longitudinal study was obtained from the Comitato Etico Azienda Ospedaliero Universitaria di Cagliari (NP/2023/1567), and patient consent was waived due to the retrospective nature of the study.A flowchart demonstrating the application of inclusion and exclusion criteria is provided in Figure 1 .

Flowchart of the patients enrolled.

CMR was performed at 16.2 ± 13.5 days after coronary revascularization. Scans were acquired on a Philips Achieva dStream 1.5 T scanner system ( Philips Healthcare, Best, The Netherlands ). Anterior coil arrays were used. All cine-images were acquired using a balanced steady-state free precession and retrospective gating during an expiratory breath-hold manoeuvres (TE: 1.7mssec; TR: 3.4msec/flip-angle: 45°, section thickness = 8 mm) in both long-axis (two-, three- and four-chamber view) as well as short-axis plane with whole ventricular coverage from left ventricle (LV) base to apex.

T2-short tau inversion recovery (T2-STIR) images were obtained using triple inversion recovery T2-weighted pulse sequence (TR = 2 RR, TE ≈ 70 msec; flip-angle: 45°, section thickness = 8 mm, FOV 300 × 300 mm2) in long-axis (two-, three- and four-chamber view) and short-axis plane with whole ventricular coverage from base to apex.

LGE imaging was performed in both long- and short- axis slices 10–12 min after contrast media injection (Gadovist, Bayer Healthcare) with a dose of 0.15 ml per kg body weight using phase-sensitive inversion recovery sequences (PSIR) (TE: 2.0 ms; TR: 3.4 ms; flip angle: 20°, section thickness = 8 mm) with an inversion time determined using the Look-Locker technique.

We used the commercially available software system Circle CVI42 ( CVI42, Circle Cardiovascular Imaging Inc., Calgary, Canada ) for CMR-FT data analysis. LV volumes and function were determined on short-axis cine images by manually tracing contours. LV end-diastolic volume and end-systolic volume were obtained from the cine images. The LV ejection fraction (EF) was calculated using the formula: (LV end-diastolic volume– LV end-systolic volume)/ LV end-diastolic volume * 100%.

Offline CMR feature tracking analyses were performed to evaluate peak global longitudinal strain, global radial strain, and global circumferential strain using a 16-segment, softwaregenerated 2D model. Longitudinal strain data were derived from two-, three-, and four-chamber long-axis views, while radial and circumferential strain data were obtained from apical, midventricular, and basal short-axis views in all patients. The epi‑ and endocardial borders were traced in end-diastole on all images, after which an automatic computation was initiated to outline the borders throughout the cardiac cycle. The quality of tracking and contouring was visually validated and manually corrected as needed.

CMR feature tracking analyses of atrial deformation were also conducted offline. The LA endocardial borders were manually traced on long-axis views of the cine images when the atrium was at its minimum volume. Specifically, the four-, three-, and two-chamber views were used to derive LA longitudinal strain, excluding the LA appendage and pulmonary veins. After manual segmentation, the software automatically tracked the myocardial borders throughout the entire cardiac cycle. CMR postprocessing was performed blinded to event status. The quality of tracking and contouring was visually validated and manually corrected by a radiologist with 3 years of experience in cardiac imaging. The strain curve included three peaks: reservoir, conduit, and booster strain.

All patients were followed up through clinical visits after the CMR examinations, and hospital records were reviewed for clinical events. The primary endpoint was a composite of adverse cerebrovascular events, including transient ischemic attack and ischemic stroke. Stroke was defined as an ischemic cerebral infarction resulting from embolic or thrombotic occlusion of a major intracranial artery and confirmed by imaging examinations. Transient ischemic attack was defined as sudden-onset focal neurological signs or symptoms that resolved within 24 hours. The incidence of atrial fibrillation during follow-up was ascertained through standard 12-lead electrocardiograms performed at each follow-up visit.

Continuous variables were reported as mean ± standard deviation (SD) or median and interquartile range as appropriate, while categorical variables were expressed as frequencies and percentages. Comparisons of continuous variables were performed using Welch’s t-test, and the normality of residuals was assessed using the Kolmogorov–Smirnov test. Categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate. Univariable Cox proportional hazards (PH) regression was used to identify potential predictors of cerebrovascular events. CMR variables that were statistically significant (p <0.05) in the univariable analysis were further assessed using multivariable Cox regression, adjusting for all variables that were statistically significant in the univariable models. Incident AF was treated as a time-dependent covariate. To assess differences in event-free survival from cerebrovascular events, Kaplan–Meier survival curves were generated based on LA reservoir and conduit strain values. Patients were stratified according to the cut-off values derived from ROC analysis. Subgroup comparisons were performed using the log-rank test. The optimal cut-off values for LA reservoir strain (<16%) and conduit strain (<8%) were identified through receiver operating characteristic (ROC) curve analysis using Youden’s index, as shown in Supplementary Figure 1 . All statistical tests were two-sided, and a p-value < 0.05 was considered statistically significant. Statistical analyses were performed using JASP

During the inclusion period, a total of 211 patients with STEMI (163 males [77%], mean age 64.5 ± 10.3 years) were enrolled after applying the inclusion and exclusion criteria ( Figure 1 ). Baseline characteristics of the study population are presented in Table 1 . Over a median follow-up of 25 months (interquartile range [13–36]), 23 patients (11%) experienced cerebrovascular events, including 17 acute ischemic strokes and 6 transient ischemic attacks. The remaining 188 patients completed the follow-up period without events.

The mean age of the overall population was 64.5 ± 10.33 years, with 163 males and 48 females. No significant differences in age (67.39 ± 8.37 versus 64.04 ± 10.51; p = 0.170) or sex (21 [91%] versus 142 [75%]; p = 0.090) were observed between patients who experienced cerebrovascular events and those who did not.

However, patients who experienced cerebrovascular events had a significantly higher prevalence of hypertension (18 [78%] versus 97 [52%]; p = 0.023), dyslipidemia (15 [65%] versus 69 [36%]; p = 0.012), and diabetes mellitus (11 [48%] versus 42 [22%]; p = 0.010). No other significant differences in cardiovascular risk factors were observed between the two groups. AF occurred in 26% of STEMI patients who experienced cerebrovascular events, compared to 3% of those who did not (p = 0.001).

Among the CMR findings, patients with cerebrovascular events had a significantly lower left ventricular ejection fraction (LVEF) compared to those without events (31.60 ± 9.70% versus 36.99 ± 12.45%; p = 0.047). No other significant differences were observed in left or right ventricular volumes or function, nor in left ventricular myocardial strain parameters.

Conversely, LA volume was significantly higher in patients who experienced cerebrovascular events (69.45 ± 13.27 mL versus 61.17 ± 17.65 mL; p = 0.001), while atrial strain parameters were significantly lower, including LA reservoir strain (8.52 ± 3.80% versus 20.85 ± 9.80%; p = 0.001), LA conduit strain (4.03 ± 3.51% versus 10.22 ± 6.95%; p = 0.001), and LA booster strain (6.91 ± 4.05% versus 10.73 ± 6.19%; p = 0.001). Table 2 and Figure 2 .

Box plots comparing patients with and without cerebrovascular events. Patients who experienced cerebrovascular events showed more impaired left atrial reservoir and conduit strain parameters.

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