Management of patients with myocardial infarction and nonobstructive coronary arteries: literature review and own data

Abstract

Over the past few years, much attention has been paid to the diagnosis and treatment of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA). Its prevalence achieves 5 — 15 %, and impact of risk factors of cardiovascular disease development on the MINOCA onset has some specific features. The following criteria are required to diagnose MINOCA: compliance with the MI criteria, absence of obstructive coronary artery disease (≥ 50 %) and exclusion of an alternative diagnosis. Myocardial ischemia is the underlying cause of cardiomyocyte damage during MINOCA. It can be caused by coronary artery thrombosis due to the rupture of atherosclerotic plaque (type 1 MI), spasm or spontaneous coronary artery dissection (type 2 MI). The aim of our study was to analyse risk factors and the incidence of MINOCA in patients with acute myocardial infarction. A retrospective analysis has been performed on 1358 histories of patients with MI who were hospitalized in Dnipropetrovsk Regional Clinical Center of Cardiology and Cardiac Surgery during the period of 2019 — 2020 years. From them, 60 (4.4 %) patients were selected based on MINOCA diagnostic criteria according to the European Society of Cardiology (2018). The mean age of patients was 58.6 ± 14 years. ST‑segment elevation MI (STEMI) was diagnosed in 87.2 %. Cardiac and non‑cardiac comorbidity has been investigated with the following results: atrial fibrillation (AF) was revealed in 13.3 % of patients, hypertension (AH) — in 85 %, history of coronary heart disease (CHD) — in 31.7 %, recurrent MI — in 11.7 %, chronic heart failure (CHF) — in 75 %, atherosclerosis of peripheral arteries — in 33.3 %, type 2 diabetes mellitus (DM 2) — in 20 %, obesity — in 40.7 %. The proportion of smokers was 43.8 %. According to the results of laboratory studies, dyslipidemia was diagnosed in 44.7 % of patients. According to coronary angiography, 55 % of patients had no coronary artery stenosis, 21.7 % had stenosis of one artery, and stenosis of two or more arteries was defined in 23.3 % of cases. The following distribution by lesions’ types was established: irregularities in the contours of arteries or stenosis up to 30 % in 35 % of cases; stenosis ≥ 30 < 50 % in 18.3 %, and slow evacuation of the contrast agent in 16.7 % of cases. Men prevailed in our research, which is inconsistent with the data of large observational studies, probably due to a small quantity of patients. Hypertension, chronic heart failure, tobacco smoking, obesity and dyslipidemia prevailed among the basic risk factors. Patients with MINOCA require careful evaluation to determine the causative agent and appropriate treatment choices. Conduction of large‑scale studies, in particular, randomized controlled observations, is reasonable and necessary to determine the optimal tactics for management patients with MINOCA.