Population-level incidence and outcomes of myocardial infarction with non-obstructive coronary arteries (MINOCA): Insights from the Alberta contemporary acute coronary syndrome patients invasive treatment strategies (COAPT) study

Bainey, Kevin R.; Welsh, Robert C.; Alemayehu, Wendimagegn; Westerhout, Cynthia M.; Traboulsi, Dean; Anderson, Todd J.; Brass, Neil; Armstrong, Paul W.; Kaul, Padma

doi:10.1016/j.ijcard.2018.04.004

Cited by 112 publications

(94 citation statements)

References 29 publications

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“…Several previous investigations have demonstrated that MINOCA is associated with adverse outcome . A recent meta‐analysis based on 1924 MINOCA patients from four studies demonstrated a 1‐year all‐cause mortality rate of 4.7% which is close to the all‐cause mortality observed in our cohort.…”

Section: Discussionsupporting

confidence: 84%

“…COPD also exhibited a stronger prognostic value in MINOCA compared to MI‐CAD, and MINOCA patients had an increased risk of dying from pulmonary causes. Increased rates of non‐cardiovascular mortality have been reported in other studies on MINOCA although the causes of death had not been differentiated . Thirdly, MINOCA patients may represent a vulnerable phenotype per se; hence, MINOCA could be regarded as a first indicator of processes affecting cardiac integrity and posing the patient to an increased risk.…”

Section: Discussionmentioning

confidence: 95%

“…A recent meta‐analysis based on 1924 MINOCA patients from four studies demonstrated a 1‐year all‐cause mortality rate of 4.7% which is close to the all‐cause mortality observed in our cohort. Most studies on the prognostic importance of MINOCA, however, are limited due to short follow‐up periods , ambiguous criteria to define MI and the investigation of smaller cohorts . Additionally, most studies lack a control group which is essential to place the prognostic importance of MINOCA into perspective.…”

Section: Discussionmentioning

confidence: 99%

“…Data from observational studies and systematic reviews indicate that MINOCA patients are at increased risk of adverse outcome . However, there are limited amount of data closer investigating cardiovascular morbidity in MINOCA , and cause‐specific mortality has never been studied to the best of our knowledge. Such information is necessary for a closer understanding of potential disease mechanisms that distinguish MINOCA from MI with significant coronary artery disease (MI‐CAD), and that might require differentiated patient management.…”

Section: Introductionmentioning

confidence: 99%

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Morbidity and cause‐specific mortality in first‐time myocardial infarction with nonobstructive coronary arteries

et al. 2018

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Eggers KM, Hjort M, Baron T, Jernberg T, Nordenskj€ old AM, Tornvall P, Lindahl B (). Morbidity and cause-specific mortality in first-time myocardial infarction with nonobstructive coronary arteries. J Intern Med 2019; 285: 419-428.Background. Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is receiving increasing interest as a prognostically adverse entity distinct from myocardial infarction with significant coronary artery disease (MI-CAD). However, data are still limited regarding long-term cardiovascular morbidity and cause-specific mortality in MINOCA.Methods. This is a registry-based cohort study using data from patients admitted to Swedish coronary care units. We investigated various nonfatal outcomes (recurrent MI, hospitalization for heart failure or stroke) and fatal outcomes (cardiovascular, respiratory or cancer-related mortality) in 4069 patients without apparent acute cardiovascular disease, used as non-MI controls, 7266 patients with first-time MINOCA and 69 267 patients with first-time MI-CAD.Results. Almost all event rates (median follow-up 3.8 years) increased in a stepwise fashion across the three cohorts [rates of major adverse events (MAE; composite of all-cause mortality, recurrent MI, hospitalization for heart failure or stroke): n = 268 (6.6%), n = 1563 (21.5%), n = 17 777 (25.7%), respectively]. Compared to non-MI controls, MINOCA patients had an adjusted hazard ratio (HR) of 2.12 (95% confidence interval 1.84-2.43) regarding MAE. MINOCA patients had a substantial risk of cardiovascular mortality and the highest numerical risks of respiratory and cancer-related mortality. Male sex, previous heart failure and chronic obstructive pulmonary disease had a stronger prognostic impact in MINOCA than in MI-CAD. Female MINOCA patients with atrial fibrillation were at particular risk.Conclusions. Patients with first-time MINOCA have a considerable risk of adverse events. This stresses the need for a comprehensive search of the cause of MINOCA, thorough treatment of underlying disease triggers and close follow-up.

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Section: Discussionsupporting

confidence: 84%

Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Morbidity and cause‐specific mortality in first‐time myocardial infarction with nonobstructive coronary arteries

et al. 2018

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“…Whereas patients with STEMI typically have complete occlusion of a large epicardial coronary artery, patients with NSTEMI are often affected by multiple variable factors; including varying degrees of reduction of coronary flow, atherosclerotic changes in the vessel wall, calcification, plaque rupture, and subsequent nonocclusive intracoronary thrombus formation . Indeed, in a study of patients hospitalized with MI who underwent coronary angiography in Alberta, Canada, of the 2092 patients with MI with nonobstructive coronary arteries, 1542 (73.7%) received a diagnosis of NSTEMI, and 550 (26.3%) a diagnosis of STEMI …”

Section: Challenges For the Treatment Of Patients With Nstemimentioning

confidence: 99%

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Ahrens

Zúñiga

et al. 2019

Clinical Cardiology

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Clinical guidelines for the treatment of patients with non‐ST‐segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long‐term mortality risk than patients with ST‐segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the “treatment‐risk paradox”). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four “P” factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long‐term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.

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Mortality in ST-Segment Elevation Myocardial Infarction With Nonobstructive Coronary Arteries and Mimickers

Quesada,

Yildiz,

Henry

et al. 2023

JAMA Netw Open

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ImportanceThe clinical characteristics and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) with nonobstructive coronaries (MINOCA) are largely unknown.ObjectiveTo assess differences in 5-year mortality in patients presenting with STEMI due to MINOCA and MINOCA mimickers as compared with obstructive disease.Design, Setting, and ParticipantsA retrospective analysis of a prospective registry-based cohort study of consecutive STEMI activations at 3 regional Midwest STEMI programs. STEMI without a culprit artery and elevated troponin levels were categorized as MINOCA (absence of coronary artery stenosis &gt;50% and confirmed or suspected coronary artery plaque disruption, epicardial coronary spasm, or coronary embolism/thrombosis) or MINOCA mimickers (takotsubo cardiomyopathy, myocarditis, or nonischemic cardiomyopathy). Data were analyzed from March 2003 to December 2020.Main Outcomes and MeasuresAdjusted Cox regression analysis was used to assess 5-year mortality risk in STEMI presenting with MINOCA and MINOCA mimickers in comparison with obstructive disease.ResultsAmong 8560 consecutive patients with STEMI, mean (SD) age was 62 (14) years, 30% were female (2609 participants), and 94% were non-Hispanic White (4358 participants). The cohort included 8151 patients with STEMI due to obstructive disease (95.2%), 120 patients with MINOCA (1.4%), and 289 patients with MINOCA mimickers (3.8%). Patients were followed up for a median (IQR) of 7.1 (3.6-10.7) years. Patients with MINOCA and MINOCA mimickers were less likely to be discharged with cardiac medications compared with obstructive disease. At 5-year follow-up, mortality in STEMI presenting with obstructive disease (1228 participants [16%]) was similar to MINOCA (20 participants [18%]; χ21 = 1.1; log-rank P = .29) and MINOCA mimickers (52 participants [18%]; χ21 = 2.3; log-rank P = .13). In adjusted Cox regression analysis compared with obstructive disease, the 5-year mortality hazard risk was 1.93 times higher in MINOCA (95% CI, 1.06-3.53) and similar in MINOCA mimickers (HR, 1.08; 95% CI, 0.79-1.49).Conclusions and RelevanceIn this large multicenter cohort study of consecutive clinical patients with STEMI, presenting with MINOCA was associated with a higher risk of mortality than obstructive disease; the risk of mortality was similar in patients with MINOCA mimickers and obstructive disease. Further investigation is necessary to understand the pathophysiologic mechanisms involved in this high-risk STEMI population.

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Population-level incidence and outcomes of myocardial infarction with non-obstructive coronary arteries (MINOCA): Insights from the Alberta contemporary acute coronary syndrome patients invasive treatment strategies (COAPT) study

Cited by 112 publications

References 29 publications

Morbidity and cause‐specific mortality in first‐time myocardial infarction with nonobstructive coronary arteries

Morbidity and cause‐specific mortality in first‐time myocardial infarction with nonobstructive coronary arteries

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Mortality in ST-Segment Elevation Myocardial Infarction With Nonobstructive Coronary Arteries and Mimickers

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