P880Cardiovascular mortality in patients with MINOCA and prognostic effect of statin treatment

Abstract

Introduction Several studies have showed a substantial risk of death in patients with MINOCA. However, little is still known about the causes of death in these patients compared to patients with MI with significant coronary lesions. On the other hand, using statins treatment in MINOCA has demonstrated to have prognosis benefit in a recent observational. In this study, we aim to describe the previous aspects in a contemporary cohort of patients with AMI. Methods We analyzed retrospective data from 4,499 consecutive patients discharged with a confirmed diagnosis of AMI from January/2010 to December/2016. Patients with coronary lesions <50% were classified as MINOCA. Patients with Tako-Tsubo syndrome were excluded. The time to death in patients with MINOCA vs MI-OCA was analyzed and the causes of death (CV death and non-CV death) were compared. When the cause of death was unknown, it was classified as unknown. The log-rank test was used to find differences in death rate between both groups. The effect of statin treatment was tested. Results 643 patients (14.3%) were diagnosed with MINOCA. The prevalence of women was higher among patients with MINOCA (42.8% vs. 22.6%, p<0.01). The MINOCA were older (69±13 years vs. 66±13 years, p<0.01) with a higher prevalence of hypertension (70.85% vs. 65.3%, p=0.007), previous stroke (10.65 vs. 7.0%; p=0.001), COPD (14.0% vs. 9.95, p=0.002) and cancer history (9.2% vs. 7.6%, p=0.16). In contrast, the MINOCA patients had a lower prevalence of active smoking (19.9% vs. 35%, p<0.01), DM (33.0 vs. 29.4%, p=0.07), dyslipidemia (65.8% vs. 66.3%, p=0.81) and peripheral arteriography (7.3% vs. 8.3%, p=0.41). STEMI was the most frequent form of hospital presentation in the MINOCA cohort (41.95% vs. 19.1%). LVEF was higher in the MINOCA cohort (55% ± 11% vs. 52% ± 10%, p=0.006). At discharge, 86.5% of MINOCAs were treated with statin vs. 86.5% in MI-OCA. The statins prescribed at discharge were of higher potency at 78.2% in MINOCA vs. 88.1% in MI-OCA, moderate potency in 16.1% vs 9.5%, and lower potency in 5.7% vs. 2.4%, respectively (p=0.001). During a median follow-up of 15 months (IQR: 12.6–26.0 months), there were 383 deaths (8.5%), of which 314 occurred in the MI-OCA cohort (8.2%) and 69 occurred in MINOCA cohort (11.1%); p=0.001. 47.8% (n=33/69) were deaths of CV origin in the MINOCA group vs. 48.1% (n=151/314) in the MI-OCA group (p=0.61). The cause of death could not be determined in 6 patients (8.7%) with MINOCA and in 46 (14.7%) with MI-OCA (p=0.19). No benefit of the statin treatment of any potency was observed in MINOCA (HR=0.8 [95% CI: 0.4–1.6]) whether there was benefit in MI-OCA group (HR=0.7 [95% CI 0.5–0.98]). Conclusions There is a considerable difference in the comorbidities between MINOCA and MI-OCA, but a similar rate of death of CV origin in the medium term. The lack of benefit of statin treatment has to be confirmed in other larger studies.

Myocardial infarction with nonobstructive coronary arteries: from pathophysiology to therapeutic strategies

“…29,41,49,50 In summary, in patients with MINOCA caused by thromboembolic mechanisms at the level of disrupted plaques, treatment should follow the same indications as are valid for the whole population of AMI patients. 36,42,46,51 Coronary embolism and hypercoagulative state Coronary artery embolism (CAE) may result in myocardial necrosis, in absence of any angiographic evidence of coronary flow-limiting lesions, by occluding a distal coronary branch or small resistance arteries of coronary microcirculation. CAE can result in MINOCA when the stenosis is < 50% of the coronary lumen.…”

“…In summary, in patients with MINOCA caused by thromboembolic mechanisms at the level of disrupted plaques, treatment should follow the same indications as are valid for the whole population of AMI patients 36,42,46,51 …”

Infarto agudo de miocardio y angina sin lesiones coronarias obstructivas minoca-anoca, implicaciones pronosticas y terapéuticas de una compleja entidad

“…Los resultados del estudio EMMACE-2 (Cenko et al, 2013) mostraron que el uso de IECA en pacientes con MINOCA se asoció significativamente con una reducción de la mortalidad a los 6 meses (HR 0,31, IC 95 % 0,03-0,78, p < 0,004). Por el contrario, algunas investigaciones han demostrado que las estatinas no reducen los MACE en pacientes MINOCA (Fernandez et al, 2019). (Ishii et al, 2016)encontraron que en pacientes con MINOCA, el uso a largo plazo de aspirina después del alta no podía reducir los eventos cardiovasculares adversos.…”

Management of myocardial infarction with Nonobstructive Coronary Arteries (MINOCA): a subset of acute coronary syndrome patients

“…Lifestyle modification including smoking cessation, regular physical activity, weight loss and meditteranean diet was recommended in all MINOCA patients [96]. The beneficial effects of renin-angiotensin converting enzyme inhibitors (ACEI) on reducing mortality and major adverse cardiac events in MINOCA have been reported by previously conducted studies [97][98][99] while conflicting results were observed with statins [65,97,98,100]. A neutral effect was linked to antiplatelet therapy which can also be harmful to some MINOCA patients [101,102].…”