Elsevier

Atherosclerosis

Volume 366, February 2023, Pages 8-13
Atherosclerosis

Nonobstructive coronary atherosclerosis is associated with adverse prognosis among patients diagnosed with myocardial infarction without obstructive coronary arteries

https://doi.org/10.1016/j.atherosclerosis.2023.01.005Get rights and content

Highlights

  • Myocardial infarction with no obstructive coronary arteries (MINOCA) carries a considerable long-term risk for death and recurrent acute coronary syndrome (re-ACS).

  • In MINOCA, the presence of nonobstructive CAD carries higher risk for death or re-ACS.

  • Reduced LVEF and older age are associated with increased risk for death and re-ACS.

  • Sinus rhythm and female sex are associated with lower risk for death and re-ACS.

Abstract

Background and aims

The prognostic impact of nonobstructive coronary artery disease (CAD), as opposed to normal coronary arteries, on long-term outcomes of patients with myocardial infarction with no obstructive coronary arteries (MINOCA) is unclear. We aimed to address the association between nonobstructive-CAD and major adverse events (MAE) following MINOCA.

Methods

We conducted a retrospective cohort study of consecutive MINOCA patients admitted to a large referral medical center between 2005 and 2018. Patients were classified according to coronary angiography as having either normal-coronaries or nonobstructive-CAD. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS).

Results

Of the 1544 MINOCA patients, 651 (42%) had normal coronaries, and 893 (58%) had CAD. The mean age was 61.2 ± 12.6 years, and 710 (46%) were females. Nonobstructive-CAD patients were older and less likely to be females, with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal-failure (p < 0.05). At a median follow-up of 7 years, MAE occurred in 203 (23%) patients and 67 (10%) patients in the nonobstructive-CAD and normal-coronaries groups, respectively (p < 0.01). In multivariable models, nonobstructive -CAD was significantly associated with long-term MAE [adjusted-hazard-ratio (aHR):1.67, 95% confidence-interval (95%CI):1.25–2.23; p < 0.001]. Other factors associated with a higher MAE-risk were older-age (aHR:1.05,95%CI:1.03–1.06; p < 0.001) and left ventricular ejection-fraction<40% (aHR:3.04,95%CI:2.03–4.57; p < 0.001), while female-sex (aHR:0.72, 95%CI: 0.56–0.94; p=0.014) and sinus rhythm at presentation (aHR:0.66, 95%CI: 0.44–0.98; p=0.041) were associated with lower MAE-risk.

Conclusions

In MINOCA, nonobstructive-CAD is independently associated with a higher MAE-risk than normal-coronaries. This finding may promote risk-stratification of patients with nonobstructive-CAD-MINOCA who require tighter medical follow-up and treatment optimization.

Introduction

Myocardial infarction with no obstructive coronary arteries (MINOCA) represents approximately 5% of all MI cases [[1], [2], [3]]. Typically, MINOCA patients are relatively young, more often females, and have fewer traditional cardiovascular risk factors [[4], [5], [6]]. MINOCA may occur in the presence of normal coronary arteries or nonobstructive coronary artery disease.

MINOCA may be caused by multiple pathologies, including microvascular disease, epicardial coronary artery spasm, Takotsubo cardiomyopathy, and coronary dissection. Thus, different etiologies of MINOCA require substantially different and sometimes opposite treatment strategies. Consequently, there is great importance in diagnosing the underlying pathology of MINOCA [7]. To achieve maximal diagnostic potential, the recommended workup of MINOCA has recently expanded to include intracoronary imaging and functional testing, along with cardiac magnetic resonance (CMR) [8,9].

Although MINOCA is associated with a better prognosis than MI with obstructive coronary artery disease (CAD), this condition is far from benign. MINOCA is associated with an in-hospital mortality rate of ∼1% and a 12-month mortality rate of ∼5%, along with a significant risk of recurrence [3,4]. Recent works with follow-up lengths of 2–4.5 years suggested that adverse prognostic factors among MINOCA patients were similar to those of patients with obstructive CAD, such as older age, increased creatinine, diabetes, and reduced left ventricular ejection fraction (LVEF) [[10], [11], [12], [13]]. However, the prognostic consequences of nonobstructive-CAD, indicating subclinical coronary atherosclerosis, as opposed to normal coronary arteries among MINOCA patients, remain debatable and poorly explored.

Section snippets

Study settings and population

This is a retrospective, population-based cohort study among all comers admitted to Soroka University Medical Center (SUMC), a 1000-bed single referral center in Southern Israel, between January 1st, 2005, and December 31st, 2018. SUMC represents a unique case of a single and only referral center in Israel's Southern region. Thus, the great majority of readmissions are at that center [14,15]. For this analysis, based on a cohort of all coronary angiographies performed in SUMC, we included

Results

The study flowchart is depicted in Fig. 1. Of 36,462 patients in the entire cohort, 16,651 (45.6%) had MI. Of these patients, 1544 patients (9.3%) had MINOCA, met the inclusion criteria, and were included in the final analysis. Baseline characteristics of the study population are presented across angiographic coronary diagnosis groups in Table 1. The mean age was 61 ± 13 years, and 46% were females. The normal coronaries group was younger and included more women compared with the

Discussion

In this study, based on long-term follow-up of 1544 consecutive patients with MINOCA, we found that nonobstructive-CAD presence in MINOCA poses a significant and independent risk factor for long-term MAE. Other factors associated with increased risk for MAE were older-age and LVEF <40%, while female sex and sinus rhythm at presentation were associated with lower MAE risk. To our knowledge, this report is the most comprehensive, with the most extended follow-up to date regarding the long-term

CRediT authorship contribution statement

Gal Tsaban: Conceptualization, Investigation, Methodology, Project administration, results interpretation, Writing – original draft, report drafting. Orit Barrett: Conceptualization, critical review of the report. Ido Peles: Data curation, Formal analysis, Methodology. Yigal Abramowitz: Conceptualization, critical review of the report. Hezzy Shmueli: Conceptualization, critical review of the report. Hilmi Alnsasra: Conceptualization, critical review of the report. Carlos Cafri:

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (28)

  • G. Niccoli et al.

    Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management

    Eur. Heart J.

    (2015)
  • P. Paolisso et al.

    Impact of admission hyperglycemia on short and long-term prognosis in acute myocardial infarction: MINOCA versus MIOCA

    Cardiovasc. Diabetol.

    (2021)
  • E.H. Choo et al.

    Prognosis and predictors of mortality in patients suffering myocardial infarction with non-obstructive coronary arteries

    J. Am. Heart Assoc.

    (2019)
  • B. Safdar et al.

    Presentation, clinical profile, and prognosis of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): results from the VIRGO study

    J. Am. Heart Assoc.

    (2018)
  • Cited by (1)

    View full text