{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T06:58:31Z","timestamp":1780901911586,"version":"3.54.1"},"reference-count":53,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,6,7]],"date-time":"2026-06-07T00:00:00Z","timestamp":1780790400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Intramyocardial hemorrhage (IMH) is a severe form of post-ischemic microvascular injury that may occur after myocardial infarction, particularly in the setting of extensive ischemia and reperfusion. IMH is closely related to microvascular obstruction (MVO), larger infarct size, impaired left-ventricular (LV) function, and adverse clinical outcomes. Cardiovascular magnetic resonance (CMR), especially susceptibility-sensitive techniques such as T2* or R2* mapping, enables in vivo detection of hemorrhagic microvascular injury and may refine post-MI risk stratification. Mechanistic and translational studies suggest that erythrocyte degradation and infarct-core iron deposition may contribute to persistent inflammation, maladaptive healing, adverse remodeling, and possibly arrhythmogenic substrate formation. However, most clinical evidence remains observational, and IMH-guided management has not yet been prospectively validated. This narrative review summarizes current evidence on the pathophysiology, imaging diagnosis, prognostic significance, and emerging therapeutic implications of IMH, while highlighting unresolved questions regarding standardized imaging, clinical implementation, and future phenotype-directed therapies.<\/jats:p>","DOI":"10.3390\/medsci14020296","type":"journal-article","created":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T05:43:46Z","timestamp":1780897426000},"page":"296","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Hemorrhagic Myocardial Infarction and Intramyocardial Hemorrhage: From Microvascular Damage to Emerging Therapeutic Targets"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0630-8033","authenticated-orcid":false,"given":"Valentin","family":"Chioncel","sequence":"first","affiliation":[{"name":"Department of Cardiology, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania"},{"name":"Emergency Clinical Hospital Bagdasar-Arseni, 041915 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1742-3128","authenticated-orcid":false,"given":"Anamaria-Georgiana","family":"Avram","sequence":"additional","affiliation":[{"name":"Emergency Clinical Hospital Bagdasar-Arseni, 041915 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raluca","family":"Ciomag","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania"},{"name":"Emergency Clinical Hospital Bagdasar-Arseni, 041915 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,7]]},"reference":[{"key":"ref_1","first-page":"100444","article-title":"Impact of intramyocardial hemorrhage on clinical outcomes in ST-elevation myocardial infarction: A systematic review and meta-analysis","volume":"1","author":"Vyas","year":"2022","journal-title":"J. Soc. Cardiovasc. Angiogr. Interv."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2052","DOI":"10.1016\/j.jacc.2024.03.408","article-title":"Clinical outcomes associated with various microvascular injury patterns identified by cardiovascular magnetic resonance after ST-segment elevation myocardial infarction","volume":"83","author":"Lechner","year":"2024","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2063","DOI":"10.1016\/j.jacc.2024.03.413","article-title":"Hemorrhagic myocardial infarction: Light after 50 years in the tunnel","volume":"83","author":"Dharmakumar","year":"2024","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_4","first-page":"930","article-title":"Prognostic value of microvascular obstruction and infarct size, as measured by CMR in ST-segment elevation myocardial infarction patients","volume":"7","author":"Magro","year":"2014","journal-title":"J. Am. Coll. Cardiol. Cardiovasc. Imaging"},{"key":"ref_5","first-page":"940","article-title":"Effect of microvascular obstruction and intramyocardial hemorrhage by CMR on left ventricular remodeling and outcomes after myocardial infarction: A systematic review and meta-analysis","volume":"7","author":"Hamirani","year":"2014","journal-title":"J. Am. Coll. Cardiol. Cardiovasc. Imaging"},{"key":"ref_6","first-page":"795","article-title":"Microvascular obstruction and intramyocardial hemorrhage in reperfused myocardial infarctions: Pathophysiology and clinical insights from imaging","volume":"17","author":"Vora","year":"2024","journal-title":"J. Am. Coll. Cardiol. Cardiovasc. Imaging"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1016\/0002-9149(74)90742-5","article-title":"Deleterious effects due to hemorrhage after myocardial reperfusion","volume":"33","author":"Bresnahan","year":"1974","journal-title":"Am. J. Cardiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1274","DOI":"10.1161\/01.CIR.62.6.1274","article-title":"The relationship of vascular injury and myocardial hemorrhage to necrosis after reperfusion","volume":"62","author":"Fishbein","year":"1980","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1161\/01.CIR.65.1.62","article-title":"Determinants of myocardial hemorrhage after coronary reperfusion in the anesthetized dog","volume":"65","author":"Higginson","year":"1982","journal-title":"Circulation"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"610","DOI":"10.1016\/0002-9149(83)90036-X","article-title":"Effect of coronary reperfusion on myocardial hemorrhage and infarct healing","volume":"52","author":"Roberts","year":"1983","journal-title":"Am. J. Cardiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"916","DOI":"10.1148\/radiol.2503081154","article-title":"Reperfusion hemorrhage following acute myocardial infarction: Assessment with T2* mapping and effect on measuring the area at risk","volume":"250","author":"Ahmed","year":"2009","journal-title":"Radiology"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1186\/s12968-021-00787-4","article-title":"Assessment of intramyocardial hemorrhage with dark-blood T2*-weighted cardiovascular magnetic resonance","volume":"23","author":"Guan","year":"2021","journal-title":"J. Cardiovasc. Magn. Reson."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/s12968-020-00607-1","article-title":"Standardized cardiovascular magnetic resonance imaging (CMR) protocols: 2020 update","volume":"22","author":"Kramer","year":"2020","journal-title":"J. Cardiovasc. Magn. Reson."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"7","DOI":"10.15698\/cst2023.02.276","article-title":"Chronic heart failure following hemorrhagic myocardial infarction: Mechanism, treatment and outlook","volume":"7","author":"Chan","year":"2023","journal-title":"Cell Stress"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e005651","DOI":"10.1161\/JAHA.117.005651","article-title":"Predictors of intramyocardial hemorrhage after reperfused ST-segment elevation myocardial infarction","volume":"6","author":"Amier","year":"2017","journal-title":"J. Am. Heart Assoc."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e11617","DOI":"10.1097\/MD.0000000000011617","article-title":"Clinical associations of microvascular obstruction and intramyocardial hemorrhage on cardiovascular magnetic resonance in patients with acute ST-segment elevation myocardial infarction: An observational cohort study","volume":"97","author":"Ma","year":"2018","journal-title":"Medicine"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1393","DOI":"10.2147\/IJGM.S501504","article-title":"Intramyocardial hemorrhage in patients with acute myocardial infarction without reperfusion therapy: A prospective study","volume":"18","author":"Li","year":"2025","journal-title":"Int. J. Gen. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"295","DOI":"10.15386\/mpr-1261","article-title":"Microvascular obstruction in acute myocardial infarction: An old and unsolved mystery","volume":"92","author":"Marc","year":"2019","journal-title":"Med. Pharm. Rep."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1496","DOI":"10.1172\/JCI107898","article-title":"The \u201cno-reflow\u201d phenomenon after temporary coronary occlusion in the dog","volume":"54","author":"Kloner","year":"1974","journal-title":"J. Clin. Investig."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1136\/heart.87.2.162","article-title":"The \u201cno-reflow\u201d phenomenon: Basic science and clinical correlates","volume":"87","author":"Reffelmann","year":"2002","journal-title":"Heart"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"661","DOI":"10.1016\/j.acvd.2015.09.006","article-title":"The no-reflow phenomenon: State of the art","volume":"108","author":"Bouleti","year":"2015","journal-title":"Arch. Cardiovasc. Dis."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Ghobrial, M., Bawamia, B., Cartlidge, T., Spyridopoulos, I., Kunadian, V., Zaman, A., Egred, M., McDiarmid, A., Williams, M., and Farag, M. (2023). Microvascular obstruction in acute myocardial infarction, a potential therapeutic target. J. Clin. Med., 12.","DOI":"10.3390\/jcm12185934"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"919","DOI":"10.1016\/j.recesp.2015.06.023","article-title":"Microvascular obstruction: The bane of myocardial reperfusion","volume":"68","author":"Bulluck","year":"2015","journal-title":"Rev. Esp. Cardiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1006","DOI":"10.1161\/01.CIR.98.10.1006","article-title":"Magnitude and time course of microvascular obstruction and tissue injury after acute myocardial infarction","volume":"98","author":"Rochitte","year":"1998","journal-title":"Circulation"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1016\/j.jacc.2019.05.024","article-title":"Cardiac MRI endpoints in myocardial infarction experimental and clinical trials: JACC Scientific Expert Panel","volume":"74","author":"Ibanez","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1038\/nrcardio.2014.188","article-title":"Intramyocardial haemorrhage after acute myocardial infarction","volume":"12","author":"Betgem","year":"2015","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1016\/0002-9149(78)90164-9","article-title":"Myocardial hemorrhage after coronary reperfusion in pigs","volume":"41","author":"Capone","year":"1978","journal-title":"Am. J. Cardiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"6394","DOI":"10.1038\/s41467-022-33776-x","article-title":"Intramyocardial hemorrhage drives fatty degeneration of infarcted myocardium","volume":"13","author":"Cokic","year":"2022","journal-title":"Nat. Commun."},{"key":"ref_30","first-page":"1248","article-title":"Persistent iron within the infarct core after ST-segment elevation myocardial infarction: Implications for left ventricular remodeling and clinical outcomes","volume":"11","author":"Carberry","year":"2018","journal-title":"J. Am. Coll. Cardiol. Cardiovasc. Imaging"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e004940","DOI":"10.1161\/CIRCIMAGING.116.004940","article-title":"Residual myocardial iron following intramyocardial hemorrhage during the convalescent phase after reperfused myocardial infarction and association with adverse left ventricular remodeling","volume":"9","author":"Bulluck","year":"2016","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1007\/s00395-020-0782-6","article-title":"Action of an iron chelator on intramyocardial hemorrhage and cardiac remodeling following acute myocardial infarction","volume":"115","author":"Behrouzi","year":"2020","journal-title":"Basic Res. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e004996","DOI":"10.1161\/CIRCIMAGING.115.004996","article-title":"Persistent microvascular obstruction after myocardial infarction culminates in the confluence of ferric iron oxide crystals, proinflammatory burden, and adverse remodeling","volume":"9","author":"Kali","year":"2016","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1016\/j.jacc.2015.02.032","article-title":"Evolving therapies for myocardial ischemia\/reperfusion injury","volume":"65","author":"Ibanez","year":"2015","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/j.jacc.2021.10.034","article-title":"Intramyocardial Hemorrhage and the \"Wave Front\" of Reperfusion Injury Compromising Myocardial Salvage","volume":"79","author":"Liu","year":"2022","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1016\/0735-1097(93)90700-B","article-title":"Does reperfusion injury exist in humans?","volume":"21","author":"Kloner","year":"1993","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1018","DOI":"10.1161\/01.CIR.86.3.1018","article-title":"Assessment of postreperfusion myocardial injury using proton NMR imaging at 1.5 T","volume":"86","author":"Lotan","year":"1992","journal-title":"Circulation"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"247","DOI":"10.3109\/10976649909088337","article-title":"Hemorrhagic myocardial infarction after coronary reperfusion detected in vivo by magnetic resonance imaging in humans: Prevalence and clinical implications","volume":"1","author":"Ochiai","year":"1999","journal-title":"J. Cardiovasc. Magn. Reson."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1002\/jmri.25638","article-title":"Diagnostic performance of T1 and T2 mapping to detect intramyocardial hemorrhage in reperfused ST-segment elevation myocardial infarction","volume":"45","author":"Bulluck","year":"2017","journal-title":"J. Magn. Reson. Imaging"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1161\/CIRCIMAGING.110.960500","article-title":"Prognostic value and determinants of a hypointense infarct core in T2-weighted cardiac magnetic resonance in acute reperfused ST-segment elevation myocardial infarction","volume":"4","author":"Eitel","year":"2011","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1186\/1532-429X-14-59","article-title":"Assessment of intramyocardial hemorrhage by T1-weighted cardiovascular magnetic resonance in reperfused acute myocardial infarction","volume":"14","author":"Pedersen","year":"2012","journal-title":"J. Cardiovasc. Magn. Reson."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Goldfarb, J.W., and Hasan, U. (2015). Imaging of reperfused intramyocardial hemorrhage with cardiovascular magnetic resonance susceptibility weighted imaging (SWI). PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0123560"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Pogosyan, A., Colbert, C.M., Mahmoudi, M., Keushkerian, M.J., Llanes, A.C., Sim, M.S., Fishbein, G.A., Zhu, C., Finn, J.P., and Currier, J.W. (2026). Ferumoxytol-Enhanced Cardiac Magnetic Resonance for Delineation of Hyperacute Intramyocardial Hemorrhage with Ex Vivo Validation. Investig. Radiol., Online ahead of print.","DOI":"10.1097\/RLI.0000000000001281"},{"key":"ref_44","first-page":"102194","article-title":"Characteristics of Hemorrhagic Myocardial Infarction After ST-Segment Elevation Myocardial Infarction in the United States","volume":"4","author":"Kalra","year":"2025","journal-title":"J. Am. Coll. Cardiol. Adv."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1093\/eurheartj\/ehy462","article-title":"Fourth universal definition of myocardial infarction (2018)","volume":"40","author":"Thygesen","year":"2019","journal-title":"Eur. Heart J."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Talle, M.A., Ngarande, E., Doubell, A.F., and Herbst, P.G. (2023). Prevalence of myocardial injury and myocardial infarction in patients with a hypertensive emergency: A systematic review. Diagnostics, 13.","DOI":"10.3390\/diagnostics13010060"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"ehad655.1422","DOI":"10.1093\/eurheartj\/ehad655.1422","article-title":"Prevalence and prognostic impact of myocardial injury following hypertensive crisis","volume":"44","author":"Soerensen","year":"2023","journal-title":"Eur. Heart J."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"e000346","DOI":"10.1136\/openhrt-2015-000346","article-title":"Myocardial hemorrhage: A predictor of adverse left ventricular remodeling and clinical outcome in patients with reperfused ST-elevation myocardial infarction","volume":"3","author":"Hansen","year":"2016","journal-title":"Open Heart"},{"key":"ref_49","first-page":"1101","article-title":"Incidence, predictors, and prognostic value of intramyocardial hemorrhage lesions in ST-elevation myocardial infarction","volume":"79","author":"Amabile","year":"2012","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1093\/eurheartj\/ehx393","article-title":"2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation","volume":"39","author":"Ibanez","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1440","DOI":"10.1093\/eurheartj\/ehp093","article-title":"Impact of myocardial haemorrhage on left ventricular function and remodelling in patients with reperfused acute myocardial infarction","volume":"30","author":"Ganame","year":"2009","journal-title":"Eur. Heart J."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1161\/CIRCULATIONAHA.125.074645","article-title":"Intramyocardial Hemorrhage After Myocardial Infarction: A Prognostic Outcome for Clinical Practice and Trials","volume":"152","author":"Berry","year":"2025","journal-title":"Circulation"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Murphy, T., Jones, D.A., Friebel, R., Uchegbu, I., Mohiddin, S.A., and Petersen, S.E. (2021). A Cost Analysis of Cardiac Magnetic Resonance Imaging in the Diagnostic Pathway of Patients Presenting with Unexplained Acute Myocardial Injury and Culprit-Free Coronary Angiography. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.749668"}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/2\/296\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T06:12:48Z","timestamp":1780899168000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/2\/296"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,7]]},"references-count":53,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["medsci14020296"],"URL":"https:\/\/doi.org\/10.3390\/medsci14020296","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,7]]}}}