Lower Serum Magnesium is Associated With MINOCA in Patients With Myocardial Bridging: A Retrospective Case‐Control Study in Nonobstructive Coronaries

Myocardial Bridging is Significantly Related to Myocardial Infarction with Non-Obstructive Coronary Artery Disease

78-Year-Old Woman With Intermittent Chest Pain and Palpitations

2389Survival after myocardial infarction with non-obstructive coronary arteries (MINOCA) - A comprehensive systematic review and meta-analysis

Introduction: Myocardial infarction with non-obstructive coronary arteries (MINOCA) has been increasingly recognized. The differences between MINOCA and obstructive coronary artery disease (OCAD) patients have not been studied in lower socioeconomic status populations. Methods: The records of all patients undergoing angiography for ACS at a large Dallas County safety-net hospital from January 2018 to January 2020 were reviewed and categorized as MINOCA or OCAD. Results: During the study period, 592 cases of acute coronary syndrome (ACS) were identified; 10.8% (n=64) were MINOCA. OCAD patients had higher peak pre-angiography troponin compared with MINOCA patients (2498 vs 335 ng/L, p<0.001). MINOCA patients were younger compared with OCAD patients (56 vs 60 y, p=0.01), while MINOCA men were younger than MINOCA women (53 vs 61 y, p=0.009). A higher proportion of MINOCA patients were Black, compared with OCAD (Figure 1). MINOCA patients had a lower prevalence of dyslipidemia and diabetes mellitus but there were no differences in the prevalence of smoking, hypertension, family history of premature CAD, current dialysis or heart failure between the groups. There were no differences in statin, aspirin, beta blocker or calcium channel blocker prescription at presentation between MINOCA and OCAD patients, regardless of sex. The majority of MINOCA patients (75%) did not have a definitive etiology of their ACS event by discharge. Conclusions: In this analysis of ACS patients presenting to a large safety-net hospital, MINOCA was common and MINOCA patients had many traditional risk factors. Men presented with MINOCA more commonly than has been seen in other studies. More Black patients presenting with ACS had MINOCA vs OCAD, likely reflecting the higher rates of left ventricular hypertrophy and diabetes in these patients. Lack of a definitive diagnosis for most MINOCA patients may reflect unfamiliarity with the diagnostic workup of MINOCA patients.

Accuracy of the GRACE Score for mortality prediction in myocardial infarction with nonobstructive coronary arteries (MINOCA)

Prognostic value of CMR-derived extracellular volume in myocardial infarction with non-obstructive coronary arteries.

Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is an important clinical problem especially in the era of extensive utilization of coronary angiography in MI patients. Its pathophysiology is poorly understood which makes diagnostics and treatment of MINOCA challenging in everyday clinical practice. The aim of the study was to assess characteristics of MINOCA patients in Poland based on data from the Polish National ORPKI Registry. In 2016, 49,893 patients with non-ST-segment elevation (NSTEMI) or ST-segment elevation (STEMI) myocardial infarction entered the ORPKI registry. MINOCA was defined as a non-obstructive coronary artery disease (CAD) and a lack of previous coronary revascularization. MINOCA was identified in 3924 (7.8%) patients and clinical presentation was more often NSTEMI than STEMI (MINOCA: 78 vs. 22%; obstructive CAD 51.1 vs. 48.9%; p < 0.0001). MINOCA patients were younger and more often females with significantly lower rates of diabetes, smoking, arterial hypertension, kidney disease, previous MI and previous stroke comparing to patients with obstructive CAD. Myocardial bridge was visualized in angiography more often in the MINOCA group (2.2 vs. 0.4%; p < 0.0001). Additional coronary assessment inducing fractional flow reserve, intravascular ultrasound, optical coherence tomography was marginally (< 1%) used in both groups. Periprocedural mortality was lower in MINOCA group (0.13% vs. 0.95%; p < 0.0001). MINOCA patients represent a significant proportion of MI patients in Poland. Due to multiple potential causes, MINOCA should be considered rather as a working diagnosis after coronary angiography and further efforts should be taken to define the cause of MI in each individual patient.

Hypothesis: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is a common cause of false positive (FP) ST-segment elevation myocardial infarction (STEMI) with associated high morbidity and mortality. Background: MINOCA is an important clinical problem found in patients presenting with acute coronary syndrome. Various clinical disorders lead to a working MINOCA diagnosis and make treatment and diagnosis a challenge for clinicians. MINOCA was recently defined by the American Heart Association (AHA) as those presenting with myocardial infarction with nonobstructive coronary arteries on angiography and no alternative diagnoses for presentation. Methods: Between 5/01/2009 -6/24/2019, all consecutive STEMI patients were prospectively examined and categorized into true positive STEMI activations or false positive STEMI activations (FP-STEMI). FP- STEMI were further categorized into groups based on the presence or absence of obstructive coronary arteries by angiography. Results: We had 472 FP-STEMI patients (42.3% female, median age of 58.9±16.9 years, 53.4% lived rurally) with 152 (31.4%) having evidence of coronary artery stenosis &gt;50%. A secondary cause was identified for an additional 162 (34.3%) patients. Of the remaining FP-STEMI, 82 (2.9%) met criteria for MINOCA and 76 (2.6%) were borderline MINOCA due to not meeting the troponin criteria. Within the MINOCA group, the three most common presentations were: unknown etiology (42.7%), supply-demand mismatch (26.8%), and spontaneous coronary artery dissection (17.1%). The MINOCA group had a higher baseline incidence of dyslipidemia (p=0.037) compared to FP-STEMI and borderline MINOCA and lower smoking compared to borderline MINOCA (p=0.029). At discharge, referral to cardiac rehabilitation was lower (p=0.015) with only 69.7% of MINOCA patients having prescriptions for aspirin, 50% angiotensin converting enzyme inhibitors or angiotensin receptor blockers, 64.5% beta blockers, and 65.8% statins. MINOCA had the highest statin prescription rate compared to borderline MINOCA and secondary (65.8% vs 51% vs 42.1%; respectively p=0.012). There was no significant difference between the mortality of MINCOA patient compared to the FP-STEMI patients. Only 10 (3.5%) had cardiac magnetic imaging studies obtained within 6 months (MINOCA 3.9%, borderline MINCOA 3.9%, and FP-STEMI 2.7% respectively). MINOCA patients had similar 30-day and 1-year mortality to FP-STEMI patients (9.0% vs 12.4% and 12.5% vs 15.2 % 30-day and 1-year respectively; p=0.064 and p=0.107). Conclusion: MINOCA represents a challenging group of patients with high mortality and low rates of medication prescription and cardiac rehabilitation referral.

Family history of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Objective: To compare the clinical features and the outcome of in-hospital mortality between patients with myocardial infarction with non-obstructive coronary arteries(MINOCA)and myocardial infarction with obstructive coronary artery disease (MI-CAD). Methods: This is a retrospective study. The clinical data of acute myocardial infarction (AMI) patients admitted to Qilu Hospital of Shandong University from January 2017 to May 2021, who underwent coronary angiography, were collected. Patients were divided into MINOCA group and MI-CAD group according to the degree of coronary stenosis (<50% or ≥50%). Baseline clinical characteristics, electrocardiograph during hospitalization, myocardial bridge, length of stay in hospital, discharge medication and the outcome of in-hospital mortality were collected and compared between the two groups. Univariate and multivariate logistic regression analysis was used to screen the related factors of MINOCA and the factors predicting the nosocomial death outcome of patients with AMI. Results: A total of 3 048 AMI patients were enrolled, age was 62 (54, 69) years, 741 (24.3%) patients were women including 165 patients (5.4%) in the MINOCA group and 2 883 patients (94.6%) in the MI-CAD group. Compared with MI-CAD patients, MINOCA patients were younger, had a higher proportion of females and a higher incidence of NSTEMI, and had a lower history of smoking, diabetes, coronary heart disease and myocardial infarction. Baseline inflammatory markers such as neutrophil count, monocyte count, neutrophil count/lymphocyte count (NLR), and monocyte count/high-density lipoprotein count (MHR) were lower, creatinine, N-terminal pro-brain B-type Natriuretic peptides (NT-proBNP), creatine kinase-MB, hypersensitive troponin I, fibrinogen, baseline blood glucose levels were lower, high-density lipoprotein cholesterol was higher, and the incidence of myocardial bridge, arrhythmia, tachycardia and atrial fibrillation was higher (P<0.05). The application rates of calcium antagonists and non-vitamin K antagonists oral anticoagulants were higher in MINOCA group (P<0.05), and there was no statistical difference in hospitalization days and in-hospital death between the two groups (P>0.05). Multiple logistic regression analysis showed that young age, female, non-smoker, no history of coronary heart disease and low MHR were risk factors of MINOCA (P<0.05). MINCOA was not associated with higher in-hospital death (P>0.05). Patients with AMI and a history of coronary heart disease, chronic renal failure, higher baseline blood glucose, higher NLR, and higher D-dimer were risk factors of in-hospital death (P<0.05). Conclusions: Compared with MI-CAD patients, MINOCA patients are younger, more likely to be female and non-smokers and on history of coronary heart disease, and have lower baseline MHR. MINOCA is often associated with myocardial bridge and atrial fibrillation. The incidence of in-hospital death in MINCOA patients is similar as in MI-CAD patients.

Reinfarction in Patients with Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Coronary Findings and Prognosis

The familial risk among patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is unknown. Previous studies of family history in myocardial infarction (MI) have not made a distinction between MINOCA and MI due to coronary artery disease (MI-CAD), based on angiographic findings. We therefore sought to investigate familial risk of MI without and with obstructive coronary arteries. Register-based cohort study with a total of 15 462 MINOCA cases, 204 424 MI-CAD cases, 38 220 control subjects without MI, and with non-obstructive coronary arteries. First-degree relatives were identified in 1995-2020. Cox proportional hazard regression models were used to compare familial risk in MINOCA and MI-CAD with control subjects. During a mean follow-up of 8.1 ± 4.2 years, MINOCA occurred in 1.0% of first-degree relatives with MINOCA whereas MI-CAD occurred in 9.7% of first-degree relatives of MINOCA. The age- and sex-adjusted hazard ratio (HR) for a MINOCA relative experiencing MINOCA and MI-CAD, compared to control subjects, was 0.99 [95% confidence interval (CI) 0.80-1.23] and 1.10 (95% CI 1.03-1.18), respectively. During a mean follow-up of 8.5 ± 4.8 years, MI-CAD occurred in 12.2% of first-degree relatives with MI-CAD with age- and sex-adjusted HR 1.43 (95% CI 1.37-1.49). No increased familial risk of MINOCA was observed for MINOCA patients whereas there was an increased familial risk for MI-CAD when compared to control subjects. These results may indicate that genetic factors and shared environmental factors within a family leading to CAD are important also for MINOCA, thus MI-CAD and MINOCA could share underlying mechanisms.

Aims Killip classification is a simple and fast clinical tool for risk stratification in patients with acute coronary syndrome (ACS). However, predictors of high Killip class at admission and its prognostic impact in the clinical contest of myocardial infarction with nonobstructive coronary artery (MINOCA) are still poorly known. To identify the clinical predictors of high Killip class and its potential prognostic role on in-hospital and follow-up outcomes in patients with MINOCA compared to patients with myocardial infarction with obstructive coronary artery (MIOCA). Methods and results We included all consecutive patients with myocardial infarction (MI) undergoing coronary angiogram between 2016 and 2019 at our hospital. According to 2016 ESC Position Paper criteria, we considered as MINOCA all patients with acute MI and with the angiographic conventional cut-off of &amp;lt; 50% coronary stenosis without clinically apparent alternative diagnosis (e.g. sepsis, stroke, pulmonary embolism, myocarditis, and Tako-tsubo). We analysed Killip class of MINOCA patients comparing with those of MIOCA (coronary stenosis ≥50%). Kaplan–Meier (KM) curves were developed for the comparison of overall-mortality among MINOCA with high Killip class (major than 1) compared to other. Multivariate logistic regression analysis was used to determine the predictors of high Killip class both in the MINOCA and MIOCA populations. Among 3165 MI, 260 patients fulfilled the 2016 ESC criteria for MINOCA. Overall, 62.3% were males and the mean age was 68.6 ± 13.2 years. The median follow-up time was 23.3 ± 14.5 months. Killip class &amp;gt;1 occurred in 24 patients in MINOCA group and 507 in MIOCA group (17.5% vs. 9.2%, P = 0.001). The KM survival distributions were significantly different across Killip class &amp;gt;1 (P &amp;lt; 0.001) in both populations with higher mortality in patients with higher Killip class. Finally, the multivariate logistic regression showed that the predictors of high Killip class at time of presentation in MIOCA population were older age [odds ratio: 1.04, 95% CI: (1.03–1.06), P &amp;lt; 0.001], diabetes [odd ratio 0.63, 95% CI (0.48–0.81), P &amp;lt; 0.001], ST elevation [odds ratio: 0.65, 95% CI (0.48–0.89), P = 0.008], left ventricle ejection fraction [odds ratio: 0.95, 95% CI (0.94–0.96), P &amp;lt; 0.001], and elevated cardiac troponin [odds ratio: 1.00, 95% CI (1.00–1.00), P = 0.01]. Older age [odds ratio: 1.08, 95% CI (1.03–1.14), P = 0.003], ST elevation [odd ratio 0.14, 95% CI (0.02–0.93), P = 0.042], and diabetes [odd ratio 3.60, 95% CI (1.08–1.96), P = 0.037] were predictors of high Killip class in MINOCA, however left ventricle ejection fraction (P = 0.3) and elevated cardiac troponin (P = 0.6) did not predict the high Killip class in MINOCA patients. Conclusions Our data suggest that Killip classification performed at the time of admission is a useful clinical marker of a high risk of early and late adverse cardiovascular events even in patients with MINOCA. The predictors of the high Killip class at time of presentation in MIOCA were older age, diabetes, ST elevation, left ventricle ejection fraction, and elevated cardiac troponin. Older age, ST elevation, and diabetes were predictors of high Killip class even in MINOCA, however left ventricle ejection fraction and elevated cardiac troponin did not predict the high Killip class in MINOCA patients. These results could reflect the different pathogenetic myocardial damage in MINOCA and MIOCA populations. Further studies are needed to evaluate these pathological mechanisms.

Myocardial infarction with non obstructive coronary arteries (MINOCA) according to definitions of 2020 ESC Guidelines: clinical profile and prognosis

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is being increasingly recognized with the frequent use of angiography following Acute Myocardial Infarction (AMI); yet there is little evaluation of these patients in the literature. The current study is a prospective, contemporary analysis of clinical features and chest pain characteristics between patients with MINOCA and Myocardial Infarction with coronary artery disease (MI-CAD). Methods: All consecutive patients undergoing coronary angiography for AMI (as per the Third Universal AMI Definition) in South Australian public hospitals from January 2012 - December 2013 were included. Data was captured by Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR ® CathPCI ® Registry. The AMI patients were classified as MI-CAD or MINOCA on the basis of the presence or absence of a significant stenosis (≥50%) on angiography. Results: From 3,431 angiography procedures undertaken for AMI, 359 (11%) were classified as MINOCA. MINOCA patients were younger (59 ± 15 vs. 64 ± 13, p &lt;0.01) and more likely to be female (60% vs. 26%, p&lt;0.01), with age adjusted analysis revealing less cardiovascular risk factors in MINOCA compared to MICAD: current smoker (21% vs. 35%, p&lt; 0.01), hypertension (56% vs. 65%, p&lt;0.01), dyslipidaemia (46% vs. 61%, p&lt;0.01), and diabetes (20% vs. 32%, p&lt;0.01). Analysis of presenting chest pain characteristics showed no significant differences between MICAD and MINOCA for the presence of retrosternal pain (81% vs. 82%, p&gt;0.05,) or shoulder pain (27% vs. 26%, p&gt;0.05) respectively, however MINOCA patients were less likely to experience arm pain (33% vs. 40%, p&lt;0.01). In regards to precipitating factors, emotional stress was more common (14% vs. 5%, p&lt;0.001) and exertion related chest pain was less common (27% vs. 40%, p&lt;0.001) in MINOCA patients. Quality of pain for MINOCA and MICAD was similar with the most frequent descriptors being burning (11% vs. 9%, p&gt;0.05), sharp 21% vs. 23%, p&gt;0.05) and tightness (41% vs. 44%, p&gt;0.05). In addition, there were no significant differences observed between groups in relieving factors and duration of chest pain Conclusions: In contemporary cardiology practice, MINOCA presentation is more common than previously appreciated, with younger women frequently implicated. Delineating a MINOCA patient from MICAD on the basis of chest pain characteristics is not feasible.