Prevalence and Causes of Myocardial Infarction with Non-Obstructive Coronary Arteries in a Contemporary Cohort of Patients with Suspected Myocardial Infarction

Background: A significant proportion of patients presenting with acute myocardial infarction (MI) has no coronary obstruction at coronary angiography and no other obvious non-coronary pathophysiology causing MI. These patients are classified as MI with non-obstructive coronary arteries (MINOCA). Data on incidence and predictors of MINOCA are still limited. Methods: This study enrolled patients presenting symptoms suggestive of MI and undergoing a comprehensive cardiac work-up including an early invasive strategy. Patients with non-obstructive coronary arteries and without other obvious reasons for MI were scheduled for further work-up including magnetic resonance or intraluminal imaging. MINOCA was diagnosed according to the current European Society of Cardiology guidelines. Results: From the 1532 patients enrolled, 730 had available coronary imaging and 546 were diagnosed with MI. No significant coronary obstructions were found in 117 patients with MI. After the exclusion of 6 patients with acute myocarditis or takotsubo-syndrome as well as 88 with type II MI, 23 patients were diagnosed with MINOCA (4% of all MIs). Among these 23 patients, the most common etiology of MINOCA was thromboembolic events followed by coronary spasm. Female sex, the absence of hypercholesterolemia, and a normal left-ventricular ejection fraction were independently predictive for MINOCA compared to patients with other causes of MI. Conclusion: More than 20% of patients presenting with acute MI showed no significant coronary obstruction. About 4% of these patients were diagnosed with MINOCA. Female sex, a lower cardiovascular risk profile, and normal left-ventricular function were predictive for MINOCA.

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The outcome of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and impaired kidney function: a 3-year observational study

International Urology and Nephrology ◽

10.1007/s11255-021-02794-x ◽

2021 ◽

Author(s):

Malgorzata Zalewska-Adamiec ◽

Jolanta Malyszko ◽

Ewelina Grodzka ◽

Lukasz Kuzma ◽

Slawomir Dobrzycki ◽

...

Keyword(s):

Myocardial Infarction ◽

Incidence Rate ◽

Kidney Function ◽

Coronary Arteries ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Risk Of Death ◽

Group 2 ◽

Group 1

Abstract Background Myocardial infarction with nonobstructive coronary arteries (MINOCA) constitutes about 10% of the cases of acute coronary syndromes (ACS). It is a working diagnosis and requires further diagnostics to determine the cause of ACS. Methods In this study, 178 patients were initially diagnosed with MINOCA over a period of 3 years at the Department of Invasive Cardiology of the University Clinical Hospital in Białystok. The value of estimated glomerular filtration rate (eGFR) was calculated for all patients. The patients were divided into 2 groups depending on the value of eGFR: group 1—53 patients with impaired kidney function (eGFR < 60 mL/min/1.73 m2; 29.8%) and group 2—125 patients with normal kidney function (eGFR ≥ 60 mL/min/1.73 m2; 70.2%). Results In group 1, the mean age of patients was significantly higher than that of group 2 patients (77.40 vs 59.27; p < 0.0001). Group had more women than group 2 (73.58% vs 49.60%; p = 0.003). Group 1 patients had higher incidence rate of arterial hypertension (92.45% vs 60.80%; p < 0.0001) and diabetes (32.08% vs 9.60%; p = 0.0002) and smoked cigarettes (22.64% vs 40.80%; p = 0.020). Group 1 patients had higher incidence rate of pulmonary edema, cardiogenic shock, sudden cardiac arrest (13.21% vs 4.00%; p = 0.025), and pneumonia (22.64% vs 6.40%; p = 0.001). After the 37-month observation, the mortality rate of the patients with MINOCA was 16.85%. Among group two patients, more of them became deceased during hospitalization (7.55% vs 0.80%; p = 0.012), followed by after 1 year (26.42% vs 7.20%; p = 0.0004) and after 3 years (33.96% vs 9.6%; p < 0.0001). Multivariate analysis revealed that the factors increasing the risk of death in MINOCA are as follows: older age, low eGFR, higher creatinine concentration, low left ventricular ejection fraction, and ST elevation in ECG. Conclusion Impaired kidney function is diagnosed in every third patient with MINOCA. Early and late prognosis of patents with MINOCA and renal dysfunction is poor, and their 3-year mortality is comparable to patients with myocardial infarction with significant stenosis of the coronary arteries and impaired kidney function.

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Prevalence of Myocardial Infarction with Non-Obstructive Coronary Arteries in Western Nepal

Nepalese Heart Journal ◽

10.3126/njh.v17i2.32677 ◽

2020 ◽

Vol 17 (2) ◽

pp. 39-42

Author(s):

Ram Chandra Kafle ◽

Girija Shankar Jha ◽

Dibya Sharma ◽

Vijay Madhav Alurkar

Keyword(s):

Myocardial Infarction ◽

Coronary Artery ◽

Coronary Angiography ◽

Coronary Arteries ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Systemic Hypertension ◽

Ventricular Ejection Fraction ◽

St Segment Elevation ◽

Prior Use

Background and Aims: It is well known that ST segment elevation myocardial infarction results from complete occlusion of a coronary artery supplying that area. However, in up to 15% of patients with clinical diagnosis of myocardial infarction, early angiography reveal either non-obstructive or normal coronary artery. This subgroup of disease, myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA), represent a diagnostic and therapeutic challenge to clinicians. We aimed to determine prevalence and clinical profile of patients with MINOCA in current study. Methods: This is a retrospective, observational study conducted in cardiology department of Manipal Teaching Hospital, Pokhara, Nepal from 6th April 2014 to 5th April 2019. Patients with age ≥18 years and clinically diagnosed acute myocardial infarction who underwent coronary angiography without prior use of thrombolytic agents were selected. Data were analyzed using the software SPSS for windows version 18. Results: A total of 177 patients’ underwent early coronary angiography without prior use of thrombolytic agent. The prevalence of MINOCA was 13.5% (n=24) in our study population. MINOCA patients were younger (p<0.001) compared to non-MINOCA. Smoking, systemic hypertension, access through femoral route and depressed left ventricular ejection fraction were significantly lower in MINOCA patients (p<0.05, for all). Conclusion: The prevalence of MINOCA was high (13.5%) in our study. Prospective studies are needed to conclude its high prevalence and to look for other associated factors and etiology.

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Variability of discharge medical therapy for secondary prevention among patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) in the United States

PLoS ONE ◽

10.1371/journal.pone.0255462 ◽

2021 ◽

Vol 16 (8) ◽

pp. e0255462

Author(s):

Nathaniel R. Smilowitz ◽

Rachel Dubner ◽

Anne S. Hellkamp ◽

Robert J. Widmer ◽

Harmony R. Reynolds

Keyword(s):

Myocardial Infarction ◽

Secondary Prevention ◽

Medical Therapy ◽

Coronary Arteries ◽

Clinical Data ◽

High Volume ◽

The United States ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction

Background Optimal medical therapy after myocardial infarction with nonobstructive coronary arteries (MINOCA; <50% stenosis) is uncertain. We evaluated variability in discharge prescription of angiotensin-converting enzyme inhibitors / angiotensin receptor blockers (ACEI/ARB) and beta-blockers (BB) to MINOCA patients between hospitals to assess physician equipoise about secondary prevention. Methods Patients with MINOCA between 2007–2014 were identified in the NCDR Chest Pain–MI Registry. Those with prior revascularization or missing demographic, angiographic, or medication data were excluded. Analysis was limited to high-volume hospitals with ≥20 MINOCA total discharges. Discharge prescriptions for ACEI/ARB and BB after MINOCA were analyzed for each hospital. Clinical data on left ventricular ejection fraction (LVEF), glomerular filtration rate (GFR), and diabetes mellitus status were extracted to identify other indications for ACEI/ARB or BB. Results Clinical data were available for 17,849 MINOCA patients, of whom 8,752 (49%) had LVEF <40%, GFR ≤60 mL/min, and/or diabetes. 5,913 patients without one of these indications for ACEI/ARB or BB were discharged from 156 high-volume hospitals. At discharge, ACEI/ARB was prescribed to between 16.0% and 88.8% of MINOCA patients (median 45.6%, IQR 38.0%-56.5%) and BB to between 28.0% and 97.5% (median 74.1%, IQR 64.7%-80.0%). Conclusion There is marked variability between hospitals in the proportions of patients receiving ACEI/ARB and BB after hospitalization for MINOCA, suggesting clinical equipoise about the routine use of these agents. Randomized clinical trials are necessary to establish the benefit of ACEI/ARB and BB to improve outcomes after MINOCA.

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Importance of confirming the underlying diagnosis in patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): a single-centre retrospective cohort study

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-02176-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

T. F. S. Pustjens ◽

A. Meerman ◽

N. P. A. Vranken ◽

A. W. Ruiters ◽

B. Gho ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Arteries ◽

Cardiovascular Events ◽

Troponin T ◽

Multivariable Analysis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Cardiac Events ◽

Ventricular Ejection Fraction ◽

Conclusive Diagnosis

Abstract Background Many patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) are discharged without a known aetiology for their clinical presentation. This study sought to assess the effect of this ‘indeterminate MINOCA’ diagnosis on the prevalence of recurrent cardiovascular events and presentations to the Cardiac Emergency Department (CED). Methods We retrospectively analysed all patients meeting the diagnostic MINOCA criteria presenting at a large secondary hospital between January 2017 and April 2019. Participants Patients were divided into the (1) ‘indeterminate MINOCA’, or (2) ‘MINOCA with diagnosis’ group. The primary outcome was the occurrence of major adverse cardiac events (MACE) defined as the composite of all-cause mortality, non-fatal myocardial infarction, stroke and any revascularisation procedure. Secondary outcomes were all recurrent visits at the CED, and MACE including unplanned cardiac hospitalisation. Results In 62/198 (31.3%) MINOCA patients, a conclusive diagnosis was found (myocardial infarction, (peri)myocarditis, cardiomyopathy, or miscellaneous). MINOCA patients with a confirmed diagnosis were younger compared to those with an indeterminate diagnosis (56.7 vs. 62.3 years, p = 0.007), had higher maximum troponin-T [238 ng/L vs. 69 ng/L, p < 0.001] and creatine kinase (CK) levels [212U/L vs. 152U/L, p = 0.007], and presented more frequently with electrocardiographic signs of ischaemia (71.0% vs. 47.1%, p = 0.002). Indeterminate MINOCA patients more often showed recurrent CED presentations (36.8% vs. 22.6%, p = 0.048), however the occurrence of cardiovascular events was equal (8.8 vs. 8.1%, p = 0.86). Multivariable analysis showed that elevated levels of troponin-T and CK, ST-segment deviation on electrocardiography, reduced left ventricular ejection fraction, regional wall motion abnormalities, and performance of additional examination methods were independent predictors for finding the underlying MINOCA cause. Conclusions Only in one-third of MINOCA patients a conclusive diagnosis for the acute presentation was identified. Recurrent CED visits were more often observed in the indeterminate MINOCA group, while the occurrence of cardiovascular events was similar across groups. Trial registration Retrospectively registered

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