High-Risk Groups for Hemorrhagic Myocardial Infarction (MI) After Reperfusion: JACC Advances Study Finds

Hemorrhagic MI, a form of intramyocardial damage driven by reperfusion injury, carries major implications for post-infarction recovery, contributing to larger infarct size, adverse ventricular remodeling, and worse long-term outcomes. While cardiac MRI is the gold standard for detecting intramyocardial hemorrhage, it is not routinely used in U.S. STEMI pathways, making real-world, biomarker-based evaluation essential. To address the evidence gap, investigators conducted a large-scale assessment to understand how often hMI occurs in contemporary practice and which patients bear the greatest risk after PCI.

Study Overview

The researchers performed a retrospective cohort analysis of adults aged 18 to 75 years with STEMI who underwent PCI, using the Cerner Real-World Data network. Hemorrhagic MI was identified using validated post-PCI troponin kinetics, a surrogate method previously shown to correlate strongly with cardiac MRI. Electronic health record data provided demographic variables, comorbidities, and smoking history. The primary objective was to determine the incidence and predictors of hMI, and multivariable log-binomial regression models were applied to calculate adjusted risk ratios. Patients with incomplete data or prior cardiac dysrhythmias were excluded to maintain cohort integrity.

Key Findings

• Among 24,181 eligible patients, 23.8% experienced hemorrhagic MI—a substantial burden in this contemporary PCI-treated population.
• The cohort was predominantly male (71.5%), with a high prevalence of hypertension (58%) and diabetes (32%). After adjustment, several predictors emerged. Male patients had a significantly higher risk of hMI, as did African-American patients when compared with Caucasians.
• Active smoking carried an increased risk, whereas former smokers who had abstained for more than a year demonstrated lower risk, underscoring the relevance of ongoing tobacco exposure.
• Treated hypertension showed a protective effect compared with untreated hypertension, suggesting inadequate blood pressure control may exacerbate vulnerability.
• Diabetes, dyslipidemia, and several other chronic conditions did not show independent associations.

These findings indicate that both biological and modifiable risk factors influence susceptibility to hemorrhagic damage after PCI.

Although the study is limited by its reliance on administrative coding and absence of imaging confirmation, the population size and consistency of associations provide compelling evidence to refine post-STEMI surveillance and risk mitigation strategies.

Clinical Implications

From a clinical standpoint, the study highlights important implications for the management of STEMI patients following reperfusion. Because hemorrhagic MI is strongly linked with worse long-term outcomes—including impaired ventricular recovery and higher mortality—early recognition is critical. The identified risk patterns suggest that specific groups, particularly men, African-American patients, active smokers, and those with poorly controlled hypertension, may benefit from intensified rhythm and hemodynamic monitoring after PCI. The biomarker-based approach used in this analysis seems a practical framework for identifying hMI in real-world settings where advanced imaging is not routinely available.

Reference: Kalra, A, Vora, K, Bhat, V. et al. Characteristics of Hemorrhagic Myocardial Infarction After ST-Segment Elevation Myocardial Infarction in the United States. JACC Adv. 2025 Nov, 4 (11_Part_1). https://doi.org/10.1016/j.jacadv.2025.102194