Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease – insights from a nationwide registry

Abstract Background Approximately 10% of patients presenting with myocardial infarction (MI) do not have obstructive coronary artery disease (MINOCA). The role of antiplatelet therapy and outcomes in this group remain unclear. We assessed prognosis and the effect of an intensified clopidogrel regimen in MINOCA patients. Methods We analyzed data from the CURRENT-OASIS 7 trial, which randomized 25,086 patients with acute coronary syndromes (ACS) referred for early intervention to receive either double-dose (600mg day 1; 150mg days 2–7; then 75mg daily) or standard-dose (300mg day 1; then 75mg daily) clopidogrel. We evaluated clinical outcomes at 30-days in patients with versus without obstructive CAD and in relation to standard versus double-dose clopidogrel. Results Overall, 23,783 MI patients were included, of which 1,599 (6.7%) had MINOCA. MINOCA patients were younger, more frequently presented with non-ST-segment elevation MI and had fewer comorbidities. Rates of all-cause mortality (0.7% versus 2.4%, p=0.0046), cardiovascular mortality (0.6 versus 2.2%, p=0.0056), repeat MI (0.5% versus 2.3%, p=0.0009) and major bleedings (0.7% versus 2.5%, p=0.0001) were significantly lower among patients with MINOCA versus those with obstructive CAD. Compared with the standard-dose clopidogrel regimen, the double-dose regimen appeared to increase the risk of cardiovascular death, MI or stroke in MINOCA patients (0.8% versus 2.1%, hazard ratio (HR) 2.74, P=0.033). There was no difference in those with obstructive CAD (4.7% versus 4.4%, HR 0.93, P=0.226; P-for-interaction=0.023) (see Figure 1A). Major bleeding did not occur more frequently in MINOCA patients with double- versus standard-dose clopidogrel regimen (0.7% versus 0.6%, (HR 1.16 (95% CI 0.35–3.80), p=0.805), but their rate was higher In MI patients with obstructive CAD (2.7% versus 2.2% (HR 1.26 (95% CI 1.06–1.49), p=0.008) (Figure 1B). Figure 1A & B Conclusions Compared to MI patients with obstructive CAD, patients presenting with MINOCA represent a distinct cohort, which is generally younger, has a higher NSTEMI prevalence and fewer comorbidities. Their risk for adverse events, especially repeat MI, stroke, death, and bleeding, is low (<1%) at 30 days. Applying an intensified clopidogrel regimen in MINOCA patients appears to be related to a higher risk for CV death, MI and stroke. Accordingly, more potent antiplatelet regimens might be harmful among MINOCA patients and should not be administered routinely. Nevertheless, there is a need for more prospective studies evaluating the role of dual antiplatelet therapies in MINOCA patients. Acknowledgement/Funding The CURRENT-OASIS 7 trial was sponsored by Sanofi-Aventis and Bristol-Myers Squibb.

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Antiplatelet therapy in patients with myocardial infarction without obstructive coronary artery disease

Heart ◽

10.1136/heartjnl-2020-318045 ◽

2021 ◽

pp. heartjnl-2020-318045

Author(s):

Matthias Bossard ◽

Peggy Gao ◽

William Boden ◽

Gabriel Steg ◽

Jean-Francois Tanguay ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Antiplatelet Therapy ◽

Recurrent Events ◽

Primary Outcome ◽

Standard Dose ◽

Obstructive Coronary Artery Disease ◽

Double Dose ◽

Artery Disease

ObjectiveApproximately 10% of patients with myocardial infarction (MI) have no obstructive coronary artery disease. The prognosis and role of intensified antiplatelet therapy in those patients were evaluated.MethodsWe analysed data from the Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events–Seventh Organisation to Assess Strategies in Ischaemic Symptoms trial randomising patients with ACS referred for early intervention to receive either double-dose (600 mg, day 1; 150 mg, days 2–7; then 75 mg/day) or standard-dose (300 mg, day 1; then 75 mg/day) clopidogrel. Outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) versus those with obstructive coronary artery disease (CAD) and their relation to standard-dose versus double-dose clopidogrel were evaluated. The primary outcome was cardiovascular (CV) death, MI or stroke at 30 days.ResultsWe included 23 783 patients with MI and 1599 (6.7%) with MINOCA. Patients with MINOCA were younger, presented more frequently with non-ST-segment elevation MI and had fewer comorbidities. All-cause mortality (0.6% vs 2.3%, p=0.005), CV mortality (0.6% vs 2.2%, p=0.006), repeat MI (0.5% vs 2.3%, p=0.001) and major bleeding (0.6% vs 2.4%, p<0.0001) were lower among patients with MINOCA than among those with obstructive CAD. Among patients with MINOCA, 2.1% of patients in the double-dose clopidogrel group and 0.6% in the standard-dose group experienced a primary outcome (HR 3.57, 95% CI 1.31 to 9.76), whereas in those with obstructive CAD, rates were 4.3% and 4.7%, respectively (HR 0.91, 95% CI 0.80 to 1.03; p value for interaction=0.011).ConclusionsPatients with MINOCA are at lower risk of recurrent CV events compared with patients with MI with obstructive CAD. Compared with a standard clopidogrel-based dual antiplatelet therapy (DAPT) regimen, an intensified dosing strategy appears to offer no additional benefit with a signal of possible harm. Further randomised trials evaluating the effects of potent DAPT in patients with MINOCA are warranted.Trial registration numberNCT00335452.

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Dual Antiplatelet Therapy Can Be Discontinued at Three Months after Implantation of Zotarolimus-Eluting Stent in Patients with Coronary Artery Disease

ISRN Cardiology ◽

10.1155/2013/518968 ◽

2013 ◽

Vol 2013 ◽

pp. 1-7 ◽

Cited By ~ 4

Author(s):

Tadashi Wada ◽

Makoto Nakahama ◽

Hironobu Toda ◽

Atsuyuki Watanabe ◽

Katsushi Hashimoto ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Bleeding Risk ◽

Coronary Intervention ◽

Cardiac Events ◽

Bleeding Events ◽

Artery Disease

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention increases the risk of bleeding. We studied the safety and clinical outcomes of switching from DAPT to aspirin monotherapy at 3 months after ZES implantation. We retrospectively evaluated 168 consecutive patients with coronary artery disease who had been implanted with a ZES from June 2009 through March 2010. After excluding 40 patients according to exclusion criteria such as myocardial infarction, 128 patients were divided into a 3-month DAPT group (67 patients, 88 lesions) and a 12-month conventional DAPT group (61 patients, 81 lesions). Coronary angiographic followup and clinical followup were conducted at more than 8 months and at 12 months after ZES implantation, respectively. Minor and major bleeding events, stent thrombosis (ST), and major adverse cardiac events (MACE) (death, myocardial infarction, cerebrovascular accident, target lesion revascularization, and target vessel revascularization) were evaluated. There were no statistically significant differences in the incidences of ST and MACE between the two groups. The incidence of bleeding events was significantly lower in the 3-month group than in the 12-month group (1.5% versus 11.5%, ). DAPT can be safely discontinued at 3 months after ZES implantation, which reduces bleeding risk.

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OCT Findings in MINOCA

Journal of Clinical Medicine ◽

10.3390/jcm10132759 ◽

2021 ◽

Vol 10 (13) ◽

pp. 2759

Author(s):

Krzysztof Bryniarski ◽

Pawel Gasior ◽

Jacek Legutko ◽

Dawid Makowicz ◽

Anna Kedziora ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Imaging Modality ◽

Obstructive Coronary Artery Disease ◽

Coronary Artery Spasm ◽

Morphological Characteristics ◽

Artery Dissection ◽

Plaque Disruption ◽

Artery Disease

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is a working diagnosis for patients presenting with acute myocardial infarction without obstructive coronary artery disease on coronary angiography. It is a heterogenous entity with a number of possible etiologies that can be determined through the use of appropriate diagnostic algorithms. Common causes of a MINOCA may include plaque disruption, spontaneous coronary artery dissection, coronary artery spasm, and coronary thromboembolism. Optical coherence tomography (OCT) is an intravascular imaging modality which allows the differentiation of coronary tissue morphological characteristics including the identification of thin cap fibroatheroma and the differentiation between plaque rupture or erosion, due to its high resolution. In this narrative review we will discuss the role of OCT in patients presenting with MINOCA. In this group of patients OCT has been shown to reveal abnormal findings in almost half of the cases. Moreover, combining OCT with cardiac magnetic resonance (CMR) was shown to allow the identification of most of the underlying mechanisms of MINOCA. Hence, it is recommended that both OCT and CMR can be used in patients with a working diagnosis of MINOCA. Well-designed prospective studies are needed in order to gain a better understanding of this condition and to provide optimal management while reducing morbidity and mortality in that subset patients.

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Association of plasma miR-223 and platelet reactivity in patients with coronary artery disease on dual antiplatelet therapy: A preliminary report

Platelets ◽

10.3109/09537104.2014.974527 ◽

2014 ◽

Vol 26 (6) ◽

pp. 593-597 ◽

Cited By ~ 26

Author(s):

Bernadeta Chyrchel ◽

Justyna Totoń-Żurańska ◽

Olga Kruszelnicka ◽

Michał Chyrchel ◽

Waldemar Mielecki ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Antiplatelet Therapy ◽

Preliminary Report ◽

Dual Antiplatelet Therapy ◽

Platelet Reactivity ◽

Artery Disease

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RISE AND/OR FALL IN THE SERIAL TROPONIN VALUES LACK CORRELATION WITH THE INCIDENCE OF OBSTRUCTIVE CORONARY ARTERY DISEASE IN PATIENTS WITH NON-ST ELEVATION MYOCARDIAL INFARCTION

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(15)60141-3 ◽

2015 ◽

Vol 65 (10) ◽

pp. A141

Author(s):

Naoki Misumida ◽

Akihiro Kobayashi ◽

Yumiko Kanei

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Obstructive Coronary Artery Disease ◽

St Elevation Myocardial Infarction ◽

St Elevation ◽

Artery Disease

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Abstract 13804: Clinical Profile and Outcomes of Myocardial Infarction With Non-obstructive Coronary Arteries in Older Adults

Circulation ◽

10.1161/circ.142.suppl_3.13804 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Ara H Rostomian ◽

Derek Q Phan ◽

Mingsum Lee ◽

Ray X Zadegan

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Los Angeles ◽

Coronary Arteries ◽

Medical Center ◽

Invasive Coronary Angiography ◽

Obstructive Coronary Artery Disease ◽

Kaiser Permanente ◽

Artery Disease

Introduction: Myocardial Infarction with non-obstructive coronary artery disease (MINOCA) is found in 5%-6% of patients with acute myocardial infarction (AMI). As such, the diagnosis and management of AMI patients with non-obstructive coronary artery disease (NOCAD) poses a challenge as compared to patients with MI with coronary artery disease (MICAD). Hypothesis: To evaluate the characteristics and outcomes of MINOCA in older patients as compared with MICAD patients, with and without revascularization. Methods: This was a retrospective observational study of patients ≥80 years old who underwent invasive coronary angiography (ICA) for AMI between 2009-2019 at Kaiser Permanente Los Angeles Medical Center. MINOCA was defied as <50% stenosis of coronary arteries on angiography with a troponin level ≥0.05 ng/ml. Patients with MINOCA vs MICAD were compared. Multivariate logistic regression was used to identify independent predictors of MINOCA and Kaplan-Meier survival analysis was used to analyze all-cause mortality between cohorts. Results: A total of 259 patients with MINOCA (mean ± SD age 83.8±2.7 years, 68% female) and 687 patients with MICAD (84.7±3.4 years, 40% female) were analyzed. Younger age (odds ratio [OR]=1.11; 95% confidence interval [CI]=1.05-1.18), female sex (OR=3.14; CI=2.20-4.48), black race (OR=2.53; CI=1.61-3.98), no history of prior stroke (OR=1.56; CI=1.06-2.33), atrial fibrillation or flutter (OR=2.04; CI:1.38-3.02), lower troponin levels (OR=1.08; CI:1.03-1.11), and lower triglyceride levels per 10 mg/dl increments (OR=1.06; CI:1.03-1.11) increased the odds of having MINCOA as compared to MICAD. At median follow-up of 2.4 years, MINOCA was associated with a lower rate of death (44.8% vs 55.2%, p<0.01) compared to un-revascularized MICAD, but no difference (31.3% vs 40.4%, p=0.68) when compared to re-vascularized MICAD. Conclusions: Patients age ≥80 years with MINOCA have fewer traditional risk factors compared to their counterparts with MICAD and fewer deaths compared to un-revascularized MICAD, but similar mortality compared to revascularized MICAD

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