Survival in Patients With Suspected Myocardial Infarction With Nonobstructive Coronary Arteries: A Comprehensive Systematic Review and Meta-Analysis From the MINOCA Global Collaboration

Abstract

Background: Suspected myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) occurs in ≈5% to 10% of patients with MI referred for coronary angiography. The prognosis of these patients may differ to those with MI and obstructive coronary artery disease (MI-CAD) and those without a MI (patients without known history of MI [No-MI]). The primary objective of this study is to evaluate the 12-month all-cause mortality of patients with MINOCA. Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the terms “MI,” “nonobstructive,” “angiography,” and “prognosis” were searched in PubMed and Embase databases from inception to December 2018, including original, English language MINOCA studies with >100 consecutive patients. Publications with a heterogeneous cohort, unreported coronary stenosis, or exclusively focusing on MINOCA-mimicking conditions, were excluded. Unpublished data were obtained from the MINOCA Global Collaboration. Data were pooled and analyzed using Paule-Mandel, Hartung, Knapp, Sidik & Jonkman, or restricted maximum-likelihood random-effects meta-analysis methodology. Heterogeneity was assessed using Cochran’s Q and I 2 statistics. The primary outcome was 12-month all-cause mortality in patients with MINOCA, with secondary comparisons to MI-CAD and No-MI. Results: The 23 eligible studies yielded 55 369 suspected MINOCA, 485 382 MI-CAD, and 33 074 No-MI. Pooled meta-analysis of 14 MINOCA studies accounting for 30 733 patients revealed an unadjusted 12-month all-cause mortality rate of 3.4% (95% CI, 2.6%–4.2%) and reinfarction (n=27 605; 10 studies) in 2.6% (95% CI, 1.7%–3.5%). MINOCA had a lower 12-month all-cause mortality than those with MI-CAD (3.3% [95% CI, 2.5%–4.1%] versus 5.6% [95% CI, 4.1%–7.0%]; odds ratio, 0.60 [95% CI, 0.52–0.70], P <0.001). In contrast, there was a statistically nonsignificant trend towards increased 12-month all-cause mortality in patients with MINOCA (2.6% [95% CI, 0%–5.9%]) compared with No-MI (0.7% [95% CI, 0.1%–1.3%]; odds ratio, 3.71 [95% CI, 0.58–23.61], P =0.09). Conclusions: In the largest contemporary MINOCA meta-analysis to date, patients with suspected MINOCA had a favorable prognosis compared with MI-CAD, but statistically nonsignificant trend toward worse outcomes compared to those with No-MI. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42020145356.

Coronary blood flow in heart failure: cause, consequence and bystander

“…[ 38 ] The impairment in coronary reserve of the non-culprit coronary arteries as measured by PET is more severe in patients with coronary artery disease and heart failure than in those without heart failure [ 253 ]. Patients with myocardial infarction in the absence of significant obstructive coronary artery disease (MINOCA) have milder impairment of coronary blood flow and coronary reserve than those with classical myocardial infarction and obstructive coronary artery disease [ 149 ] and better outcome on follow-up, including the development of heart failure; [ 173 ] however, the specific role of coronary blood flow impairment for heart failure development in MINOCA is not clear at present.…”

Myocardial infarction with non-obstructive coronary arteries (MINOCA)

“…MINOCA is considered a heterogeneous working diagnosis with an estimated prevalence of anywhere from 3 to 15% among all acute myocardial infarctions (AMI) patients ( 5 – 12 ). This heterogeneity is partly due to significant differences in what conditions are included in the term MINOCA and which definition is used.…”

“…This heterogeneity is partly due to significant differences in what conditions are included in the term MINOCA and which definition is used. In a pooled analysis of 23 studies, the prevalence of MINOCA was 8.1% among 806,851 consecutive AMI patients ( 12 ). MINOCA has been reported by large national registries worldwide, including the US, Japan, Poland, and Sweden, with the incidence of MINOCA ranging from 2.9 to 10.2% ( 6 , 9 , 13 , 14 ).…”

“…MINOCA has been reported by large national registries worldwide, including the US, Japan, Poland, and Sweden, with the incidence of MINOCA ranging from 2.9 to 10.2% ( 6 , 9 , 13 , 14 ). Compared to MI with obstructive CAD, MINOCA patients were younger, with a median age of ∼61 years ( 12 ), and MINOCA was more common in Black ( 6 , 8 , 15 ) and Hispanic ( 16 ) patients. Further, MINOCA patients were less likely to present with traditional cardiovascular risk factors, including hypertension, dyslipidemia, diabetes, and current smoking history ( 12 ).…”

Sleep Quality, Sleep Duration, and the Risk of Adverse Clinical Outcomes in Patients With Myocardial Infarction With Non-obstructive Coronary Arteries

“…Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a working diagnosis characterized by the acute presentation of myocardial infarction with no significant stenosis of the coronary arteries after angiography (stenosis <50%). MINOCA accounts for approximately 5%−10% of all patients with acute myocardial infarction (AMI) (1)(2)(3). The underlying pathophysiological mechanisms of MINOCA are varied and may include plaque rupture or ulceration, epicardial coronary spasm, coronary microvascular dysfunction, thromboembolism, spontaneous coronary artery dissection, and supply-demand mismatch.…”