Unraveling the Multitude of Etiologies in Myocardial Infarction With Nonobstructive Coronary Arteries

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Although recent studies revealed suboptimal outcomes in patients with myocardial infarction with nonobstructive coronary arteries (MINOCAs), the underlying etiology remains unknown in most patients. Therefore, adequate treatment modalities have not yet been established. We aimed to assess demographics, treatment strategies, and long-term clinical outcome in MINOCA subgroups. We retrospectively analyzed data from a large, prospective observational study of patients with acute coronary syndrome admitted to the Isala hospital in Zwolle, The Netherlands between 2006 and 2014. Patients with MINOCA were divided into subgroups based on the underlying cause of the event. From 7,693 patients, 402 patients (5%) concerned MINOCA. After the exclusion of missing cases (n = 47), 5 subgroups were distinguished: “true” acute myocardial infarction (10%), perimyocarditis (13%), cardiomyopathy (including Takotsubo cardiomyopathy) (19%), miscellaneous causes (21%), and an indeterminate group (38%). Patients with cardiomyopathy were predominantly women (78%) and showed the highest incidence of major adverse cardiovascular events at 30 days follow-up (7%; p = 0.012), 1 year (19%; p = 0.004), and mortality at long-term follow-up (27%; p = 0.010) compared with any other MINOCA subgroup. The cardiomyopathy group was followed by the indeterminate group, with major adverse cardiovascular events rates of 1% and 5%, respectively, and 17% long-term all-cause mortality. In conclusion, long-term prognosis in MINOCA depends on the underlying etiology. Prognosis is worst in the cardiomyopathy group followed by the indeterminate group. This underlines the importance of revealing the diagnosis to ultimately optimize treatment.

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Methods

We performed a retrospective analysis of data from a large, prospective observational study in patients with acute coronary syndrome (ACS). All consecutive adult patients admitted with ACS to the Isala hospital (Zwolle, The Netherlands) between January 2006 and December 2014 were included. The design of this study has been published previously.2 Patients were subdivided into either single-vessel obstructive ACS (SV-ACS), multivessel obstructive ACS (MV-ACS), or MINOCA. Patients with MINOCA were

Results

The database consisted of 9,198 patients with ACS. After exclusion of cases with missing data on crucial parameters (as described previously2), 7,693 patients remained eligible. Of these, 3,266 had SV-ACS (43%) and 4,025 MV-ACS (52%), whereas 402 patients (5%) were diagnosed with MINOCA. Finally, 355 patients with MINOCA remained for further analysis because no working or differential diagnosis could be retrieved in 47 cases (12%) which were excluded from further analysis. Five MINOCA subgroups

Discussion

The current analysis focused on long-term prognosis of the different subgroups of MINOCA based on the underlying diagnosis. The cardiomyopathy group showed poorest survival rates (73%), even worse compared with SV-ACS and MV-ACS. Secondly, the “indeterminate” subgroup also showed a relatively poor prognosis, with a more pronounced decrease in survival after approximately 5 years following index hospitalization. This is in line with previous research which also found the cardiomyopathy subgroup

Disclosures

The authors have no conflicts of interest to declare.

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1

Drs. Pustjens and Dr. Vranken contributed equally to this work.

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