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