Myocardial Infarction With Non-obstructive Coronary Arteries Patients Research Articles

Role of Lipoprotein Ratios and Remnant Cholesterol in Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA).

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a clinical situation characterized by evidence of acute myocardial infarction (AMI)-according to the Fourth Universal Definition of Myocardial Infarction-with normal or near-normal coronary arteries on angiographic study (stenosis < 50%). This condition is extremely variable in etiology, pathogenic mechanisms, clinical manifestations, prognosis and consequently therapeutic approach. The objective of the study was the evaluation of remnant cholesterol (RC), monocyte/high-density lipoprotein cholesterol ratio (MHR), platelet/lymphocyte ratio (PLR) and various lipoprotein ratios in patients with MINOCA in order to establish their validity as predictors of this event. We included 114 patients hospitalized in the Intensive Coronary Care Unit (ICCU) and Hospital Wards of our Hospital Center from 2015 to 2019 who received a diagnosis of MINOCA compared to a control group of 110 patients without previous cardiovascular events. RC was calculated with the following formula: RC = total cholesterol (TC) - HDL-C - LDL-C. MHR was calculated by dividing the monocyte count in peripheral blood by high-density lipoprotein cholesterol (HDL-C) levels; PLR was obtained by dividing platelet count by lymphocyte count. We also calculated various lipoprotein ratios, like total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C), low-density lipoprotein cholesterol/high-density lipoprotein cholesterol (LDL-C/HDL-C), triglycerides/high-density lipoprotein cholesterol (TG/HDL-C), and non-high-density lipoprotein cholesterol/high-density lipoprotein cholesterol (non-HDL-C/HDL-C) ratios. The MINOCA group had higher mean levels of RC (21.3 ± 10.6 vs. 13.2 ± 7.7 mg/dL), MHR (23 ± 0.009 vs. 18.5± 8.3) and PLR (179.8 ± 246.1 vs. 135 ± 64.7) than the control group. Only the mean values of all calculated lipoprotein ratios were lower in MINOCA patients. Statistical significance was achieved only in the RC evaluation. Higher levels of RC and MHR were found in patients with MINOCA. We also observed higher levels of PLR than in the control group. Only various lipoprotein ratios were lower, but this could reflect the extreme heterogeneity underlying the pathogenic mechanisms of MINOCA. In patients who receive a diagnosis of MINOCA with a baseline alteration of the lipid profile and higher levels of cholesterol at admission as well, the evaluation of these parameters could play an important role, providing more detailed information about their cardiometabolic risk.

The correlation of atherogenic index of plasma with non-obstructive CAD and unfavorable prognosis among patients diagnosed with MINOCA

BackgroundThe atherogenic index of plasma (AIP) is linked to lipid metabolism and has shown considerable prognostic value in cardiovascular disorders. However, its role in myocardial infarction with non-obstructive coronary arteries (MINOCA) has not been investigated. We assessed the relationship between AIP, the severity of coronary stenosis, and prognosis in MINOCA. MethodsWe included consecutive patients who were diagnosed with MINOCA. AIP was calculated using the base 10 logarithm of the ratio between the levels of TG and HDL-C. The patients were divided into four groups based on their AIP quartiles: Q1 (AIP<-0.145), Q2 (AIP≥-0.145and≤0.049), Q3 (AIP>0.049and≤0.253), and Q4 (AIP>0.253). All patients underwent follow-up for MACE. ResultsThe final analysis included 421 patients, with 188 having normal coronaries (0 stenosis) and 233 exhibiting non-obstructive coronary artery disease (CAD) (<50 % stenosis). In the multivariate logistic analysis, highest AIP (Q4) group was significantly associated with increased risk of non-obstructive CAD in MINOCA (OR,1.994;95 % CI:1.075–3.698; P = 0.029). During the follow-up period, MACE occurred in 22.8 % of MINOCA patients. Q4 group exhibited a significantly higher rate of MACE (P = 0.021). Furthermore, when both AIP and coronary stenosis status were considered, the results revealed individuals in the Q4 group with non-obstructive CAD had the highest risk of MACE (log-rank P = 0.027). The adjusted Cox analysis indicated that the Q4 group was associated with a 2.052-fold increase in the HR of MACE. ConclusionAIP exhibits a notable association with the incidence of MACE in MINOCA patients and serves as a substantial marker for non-obstructive CAD in this patient group.

Association of Depression With Myocardial Infarction With Non-obstructive Coronary Arteries: A Systematic Review.

This systematic review examined the association between depression and myocardial infarction with non-obstructive coronary arteries (MINOCA). A comprehensive literature search was conducted using electronic databases, resulting in the inclusion of six small case-control and cohort studies reported from Spain, Australia, China, and Pakistan. The studies included various study designs, such as cohort studies, case-control studies, and prospective cohort studies. The results of the systematic review indicate a significant association between depression and MINOCA. Several studies reported a higher prevalence of depression among MINOCA patients compared to those with obstructive coronary artery disease. Additionally, depression was found to be associated with worse outcomes in MINOCA patients, including increased cardiovascular events, all-cause mortality, and reduced quality of life. Some studies suggest that psychological factors, such as chronic stress, inflammation, and altered sympathetic nervous system activity, may play a role in the development and progression of MINOCA in individuals with depression. The findings highlight the importance of considering depression as a potential risk factor and prognostic marker in MINOCA patients. Early identification and management of depression in these individuals may improve outcomes and quality of life. A multi-center randomized controlled trial is needed to better understand the underlying mechanisms and to develop targeted interventions for individuals with depression and MINOCA.

Reduced stress perfusion in myocardial infarction with nonobstructive coronary arteries

Myocardial infarction with nonobstructive coronary arteries (MINOCA) has several possible underlying causes, including coronary microvascular dysfunction (CMD). Early cardiovascular magnetic resonance imaging (CMR) is recommended, however cannot provide a diagnosis in 25% of cases. Quantitative stress CMR perfusion mapping can identify CMD, however it is unknown if CMD is present during long-term follow-up of MINOCA patients. Therefore, this study aimed to evaluate presence of CMD during long-term follow-up in MINOCA patients with an initial normal CMR scan. MINOCA patients from the second Stockholm myocardial infarction with normal coronaries study (SMINC-2), with a normal CMR scan at median 3 days after hospitalization were investigated with comprehensive CMR including stress perfusion mapping a median of 5 years after the index event, together with age- and sex-matched volunteers without symptomatic ischemic heart disease. Cardiovascular risk factors, medication and symptoms of myocardial ischemia measured by the Seattle Angina Questionnaire 7 (SAQ-7), were registered. In total, 15 patients with MINOCA and an initial normal CMR scan (59 ± 7 years old, 60% female), and 15 age- and sex-matched volunteers, underwent CMR. Patients with MINOCA and an initial normal CMR scan had lower global stress perfusion compared to volunteers (2.83 ± 1.8 vs 3.53 ± 0.7 ml/min/g, p = 0.02). There were no differences in other CMR parameters, hemodynamic parameters, or cardiovascular risk factors, except for more frequent use of statins in the MINOCA patient group compared to volunteers. In conclusion, global stress perfusion is lower in MINOCA patients during follow-up, compared to age- and sex-matched volunteers, suggesting that CMD may be a possible pathophysiological mechanism in MINOCA.Clinical Trial Registration: Clinicaltrials.gov identifier NCT02318498. Registered 2014-12-17.

A STUDY OF CLINICAL AND ETIOLOGICAL PROFILE OF PATIENTS OF MINOCA (MYOCARDIAL INFARCTION WITH ANGIOGRAPHICALLY NON OBSTRUCTIVE CORONARY ARTERIES) AMONG THE PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION

Objective: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is a relatively new term that is characterized by clinical evidence of MI with normal or near-normal coronary arteries on coronary angiography. The aim of this was to document the prevalence and demographics of MINOCA in an Indian population. Methods: It is a single center study. All consecutive patients who were ≥18 years old, diagnosed with MI according to the Third Universal Definition of Myocardial Infarction, and had undergone coronary angiography were included in the study. Patients with stable coronary artery disease, unstable angina pectoris, a history of revascularization, and type 4/5 MI were excluded. Results: A total of 548 patients who were diagnosed with MI and had undergone coronary angiography were enrolled. The prevalence of MINOCA was 6.2% in the overall study population. Compared with non-MINOCA patients, those with MINOCA were younger, had a higher prevalence of the female gender, and had a history of COVID 19 infection. Also, the median left ventricular ejection fraction as seen on echocardiography and the ratio of Killip Class I status at presentation was significantly higher in MINOCA patients than in non-MINOCA patients (p&lt;0.001).

MINOCA: A Working Diagnosis.

Cases of patients presenting with myocardial infarction (MI) without angiographic obstructive CAD are not trivial and have significant prevalence. "The Fourth Universal Definition of MI" (4UDMI) published in 2018 introduced MI with non-obstructive coronary arteries (MINOCA).The new section was of great importance as it validated the diagnosis by defining its criteria and recognizing its presence in the community and the need for further investigation. Given the nature of the diagnosis of MINOCA, coronary angiography provides limited information about prognosis and risk stratification for future major adverse cardiovascular events (MACE). Thus, additional imaging to understand the underlying etiology of MINOCA in conjunction with a better understanding of prognostic factors is necessary to expand on the current guidelines and aid in screening for possible complications, risk of MACE, and all-cause mortality. Discerning the etiology of the presentation is crucial, and physiologic studies, as well as additional imaging, are an important part of this evaluation. These modalities includeintravascular studies such as optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), and imaging in the form of cardiac CT (CCT) and cardiac MRI (CMR). This step is essential to target treatment regimens more efficiently. The purpose of promoting multiple imaging modalities beyond traditional angiography is to address the working MINOCA diagnosis, with the finality of identifying the specific ischemic pathophysiology. MINOCA has multiple causative mechanisms, making it a heterogeneous collection of etiologies, resulting in acute MI: atherosclerotic, and non-atherosclerotic. This literature revision demonstrates that MINOCA prevalence and mortality are not trivial, and the diagnosis affects quality of life. MINOCA presents a definitive risk of MACE without proper stratification and targeted medical therapy. Several prognostic factors of morbidity and mortality in MI-CAD patients have been identified to correlate with MINOCA patients, especially inflammatory markers. MINOCA is not an exclusion diagnosis but a working diagnosis for which further imaging studies should be performed.

Effect of statin therapy on long-term mortality among patients with myocardial infarction with non-obstructive coronary arteries (MINOCA)

Abstract Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) is associated with the lack of visible atherosclerosis in coronary arteries. Current 2020 ESC Guidelines on the management of acute coronary syndromes state that statins may be beneficial to reducing all-cause mortality and major adverse cardiac events (MACE) among MINOCA patients. Although, the existing literature data remains conflicting, recent meta-analysis based on observational studies showed that statin therapy resulted in a reduction of MACE and mortality. Purpose We aimed to assess the effect of statin therapy on long-term mortality among MINOCA patients. Methods 1011 patients were hospitalized between 2012 and 2017 with the diagnosis of MI based on clinical symptoms, electrocardiographic findings, and the evolution of myocardial necrotic biomarkers according to the universal criteria of MI. On admission, coronary angiography was performed in all patients to assess the existence of obstructive lesions in coronary arteries. 72 patients had lesions narrowing a coronary artery by less than 50% and were classified as MINOCA. Results Statins were used by 54 (75.0%) of MINOCA patients. Those treated with statins had a higher prevalence of hypertension (P=0.001), dyslipidemia (P&amp;lt;0.001), lower Killip class on admission (P=0.005) and a higher LVEF (P=0.019) than MINOCA not treated with a statin. At the time of the decision about statin therapy, LDL cholesterol level was higher in the MINOCA population with subsequently prescribed statins (P=0.008). Long-term mortality was significantly higher in MINOCA patients not treated with statins (17.7%/year versus 6.6%/year, P=0.009) compared with those treated with statins. Conclusions According to our results, statins should be routinely prescribed in the heterogeneous group of MINOCA patients. However, more research regarding that issue is needed.The long-term outcomes.

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

Abstract Introduction Myocardial infarction with nonobstructive coronary arteries (MINOCA) patients account for 3.5 to 15% of all myocardial infarctions. The GRACE risk score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome, but the accuracy of the risk score for prognostic stratification in patients with MINOCA remains uncertain. Purpose We aimed to investigate whether the GRACE risk score can predict mortality in a real-world cohort of patients presenting with MINOCA. Methods We retrospectively analyzed patients admitted with MINOCA in a single center. Patients who were diagnosed with myocarditis and Takotsubo syndrome were excluded from the analysis. The GRACE risk score on admission was calculated. Patients were divided into a low-intermediate risk group (≤ 140 points, 71.5%) and a high-risk group (&amp;gt;140 points, 28.5%) according to their GRACE risk scores. Receiver operating characteristic (ROC) analysis was used to quantify the accuracy of the GRACE risk score to estimate both in-hospital and one-year mortality in MINOCA patients. Results Of a total of 3721 myocardial infarction patients, MINOCA was identified in 11.6% (n=430). 313 patients had complete data for the calculation of the GRACE on admission and were included in the analysis. Mean age was 65±12 years, and 49% (n=154) of patients were male. Mean GRACE score was 125±31 points. Patients in the high-risk group were older (74±9 vs. 61±11 years, p&amp;lt;0.001), had a higher incidence of in-hospital mortality (0.4% vs. 5.6%, p=0.008), and had a higher rate of one-year mortality (2.7% vs. 19.5%, p&amp;lt;0.001), compared with the low-intermediate risk group. There were no differences regarding sex and cardiovascular risk factors between the groups. In-hospital mortality was 1.9% and one-year mortality was 7.3%. ROC curve analysis showed that the GRACE risk score has a high value in predicting in-hospital mortality (AUC ROC 0.892; 95% CI 0.798–0.986; p=0.001), and one-year mortality (AUC ROC 0.826; 95% CI 0.739–0.0.914; p&amp;lt;0.001) in MINOCA patients. (Figure 1). The overall c-statistics were similar compared with estimates obtained from patients with myocardial infarction and significant coronary artery disease: in-hospital mortality (AUC ROC 0.0.849; 95% CI, 0.807–0.891; p&amp;lt;0.001); and one-year mortality (AUC ROC 0.776; 95% CI, 0.747–0.806; p&amp;lt;0.001). Conclusions In conclusion, the GRACE risk score provides potentially valuable prognostic information on in-hospital and one-year mortality when applied to MINOCA patients.Figure 1

Biological profiling in the spectrum of acute coronary syndrome: characterizing patients from MINOCA to NSTEMI with different features of the culprit plaque

Abstract Background In the last two decades, the development of procedures and tools such as coronary angiography and optical coherence tomography (OCT) have made it possible to highlight several aspects of acute coronary syndromes (ACS), identifying multiple subgroups such as patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) and ruptured fibrous cap (RFC) or intact fibrous cap (IFC) culprit lesions. The aim of the study is to better characterize the ACS spectrum by evaluating the biological profile of non-characterized NTSEMI, RFC-NSTEMI, IFC-NSTEMI, and MINOCA patients. Methods We enrolled 56 consecutive patients presenting with ACS, specifically 16 patients with non-characterized NSTEMI, 12 patients with RFC-NSTEMI, 8 patients with IFC-NSTEMI, and 20 patients with MINOCA. Biological samples were collected and stored. We performed gene expression analysis through qRT-PCR technique for 21 genes. Results Our data displayed several differences in gene expression levels involved in inflammation, cellular adhesion, extracellular matrix turnover, and oxidative stress between the groups under examination. We observed no significant difference between non-characterized NSTEMI and MINOCA for all the studied genes. Alongside, MINOCA displayed significantly lower levels of the following genes than RFC and IFC patients: CD44, GPX1, ICAM1, PLA2G7, SOD1, and VEGFA. Furthermore, when compared with IFC patients, MINOCA showed lower levels of EDN1, LGALS8, MMP1, and TNF, and non-characterized NSTEMI showed a lower gene expression of CD31, ICAM1, and PI16. Finally, CD44, EDN1, GPX1, LGALS8, NOS3, SOD1, TFRC, and VEGFA were more expressed in RFC and IFC compared to non-characterized NSTEMI patients. Conclusions Our preliminary data, besides exploring new pathways in MINOCA patients, reflects the need for characterization and patients’ stratifications in the clinical management of ACS, since no differences were observed between non-characterized NSTEMI and MINOCA. This result may indicate that a one size fits all approach is not the most suitable since a plaque could be an innocent bystander and should be treated accordingly. A precision medicine approach that recognizes the presence of obstructive plaque and defines the type of culprit plaque (i.e., RFC or IFC) could identify better treatment, for a tailored therapy, allowing better prognosis and quality of life.Figure

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

Abstract Introduction Genetic factors play an important role in the development of myocardial infarction (MI), and a positive family history is a risk factor for MI. The significance of family history among patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is not known, and previous studies of family history in MI have not made a distinction between MINOCA and MI due to coronary artery disease (MI-CAD) based on angiographic findings. Purpose To investigate family history of MI with and without obstructive coronary arteries in patients with a working diagnosis of MINOCA. Methods A nationwide register-based case-control study of 15 462 MINOCA cases and 38 220 controls without MI with a non-obstructive coronary angiography due to chest pain, together with 204 424 MI-CAD cases, defined as MI with obstructive coronary arteries with a degree of stenosis &amp;gt;50%, between the years 1995-2020. Data from the Swedish coronary angiography and angioplasty register with information about angiographic findings was merged with information on first-degree relatives from the Swedish multi-generation register. Odds ratio (OR) was calculated with a 95% confidence interval (CI), to analyze the probability of MINOCA patients having first-degree relatives with 1) MINOCA, 2) MI-CAD, and 3) MI-CAD patients having first-degree relatives with MI-CAD. Logistic regression models adjusted for age, sex, hypertension, diabetes, hyperlipidemia and smoking status. Results A total of 161 MINOCA patients (1%) had ≥1 first-degree relative with MINOCA and the probability of having a positive family history of MINOCA did not differ compared to controls, with age and sex adjusted OR 1.08 (95% CI 0.89-1.31) and when adjusting for all covariates 1.08 (95% CI 0.87-1.34). Conversely, 1436 MINOCA patients (9%) had ≥1 first-degree relative with MI-CAD and the probability of having a positive family history of MI-CAD was higher compared to controls with age and sex adjusted OR 1.12 (95% CI 1.05-1.20) and when adjusting for all covariates OR 1.16 (95% CI 1.04-1.20). The sensitivity analysis showed that 24 972 MI-CAD (9%) patients had a positive family history of MI-CAD compared to controls, OR adjusted for age and sex 1.68 (95% CI 1.61-1.75), and OR adjusted for all covariates 1.68 (95% CI 1.60-1.75). Conclusions In this first study that examines family history of MINOCA, including data from over 250 000 coronary angiograms, a positive family history of MI-CAD was more common among patients with a working diagnosis of MINOCA compared to controls without MI and with non-obstructive coronary arteries. A family history of MINOCA was uncommon and was not associated with MINOCA. These results indicate that genetic factors and shared environmental factors within a family leading to CAD are important also for MINOCA, thus MI-CAD and MINOCA share underlying mechanisms.

Prognostic impact of inflammation in myocardial infarction with non-obstructive coronary arteries

Abstract Background The prognosis of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is worse than that of the general population. Nevertheless, the predictors for a worse outcome in patients with MINOCA are not fully determined. Purpose The aim of this study was to evaluate the prognostic value of C-Reactive Protein (CRP) in MINOCA patients. Methods Retrospective analysis of 706 consecutively admitted patients due to acute myocardial infarction (AMI), in whom coronary angiography revealed absence of obstructive coronary artery disease (≥50% stenosis). CRP levels were measured at admission. Demographic characteristics, symptoms at presentation, past medical history, laboratory characteristics and medication at discharge were examined. The primary endpoint analysed was all-cause mortality at 5 years. Possible predictors of the endpoint were assessed by Cox regression models. When statistically significant values were found in univariable analysis, multivariate analysis was used to determine whether CRP was an independent predictor of the outcome. Results In the studied sample, 55% of the patients were male. Median age was 64 [interquartile range (IQR) 55–72] and median body mass index was 27.3 kg/m2 (IQR 24.6-30.1). Regarding past medical history, 76.5% were hypertensive, 77.8% were dyslipidemic, 12.6% were smokers, 37.4% were diabetic and 59.3% had a previous history of angina. At presentation, 94.8% were in Killip 1, 3.8% were in Killip 2, 1% were in Killip 3 and 0.4% were in Killip 4. At admission, median CRP was 0.38 mg/dL (IQR 0.14-0.81), median Troponin I was 0.09 ng/ml (IQR 0.04-1.65), median creatinine was 0.85 mg/dL (IQR 0.73-1), median low density lipoprotein cholesterol (LDL-C) was 121.5 mg/dL (IQR 97.5-146), median haemoglobin was 13.6 g/dL (IQR 12.5-14.6) and median left ventricular ejection fraction (LVEF) was 58% (IQR 50-60). At discharge, 74.2% had a beta-blocker prescribed, 88.4% had a renin-angiotensin system inhibitor (RASi) prescribed, 98.2% had a statin prescribed and 76.5% had aspirin prescribed. All-cause mortality at 5 years was 8.5%. In univariable analysis, CRP was significantly associated with the endpoint [hazard ratio (HR) 1.138 per 1 mg/dL increase, 95% CI 1.090–1.188, p&amp;lt;0.001], as was age, diabetes, Killip class, troponin I, creatinine, LDL-C, haemoglobin, LVEF and absence of prescription of RASi. In multivariate analysis, CRP remained significantly associated with the endpoint (HR 1.141, 95% CI 1.087–1.199, p&amp;lt;0.001), as did age, creatinine and absence of prescription of RASi. Conclusions CRP at admission seems to be an independent predictor of all-cause mortality at the 5-year mark. This could indicate that inflammation has an important role in the pathophysiology and prognosis of MINOCA patients. It would be interesting to investigate if targeting inflammation would improve the long-term prognosis of these patients.

Myocardial infarction with non obstructive coronary arteries (MINOCA): clinical profile and prognosis

Abstract Background MINOCA is a clinical condition that has grown interest in the last few years. The aim of this study is to compare the clinical profile, treatment and prognosis of MINOCA patients and those with myocardial infarction (MI) with obstructive coronary artery disease (MICAD). Methods We analyzed all consecutive patients with MI who underwent coronary angiography admitted in our Hospital. The database and all the patient's angiographies were revised by a group of experts in order to adequate MINOCA definition to 2020 ESC Guidelines definition and American Heart Association consensus statement. Results We included 915 patients, of whom 108 (12%) were MINOCA, with a median follow-up of 45 [21-65] months (see table 1). The underlying mechanism in MINOCA was coronary spasm (15%), plaque rupture (9.3%), coronary embolism (4.7%), coronary dissection (5.6%), type II infarction (17.8%) or unknown (43.8%). A total of 58.3% had angiographically smooth coronary arteries and 38.9% had plaques &amp;lt;50%. MINOCA patients in our study were younger and mostly female, with higher prevalence of connective tissue diseases, migraine or patient-reported stress and less smoking, diabetes and chronic kidney disease compared to patients with obstructive coronary artery disease. Symptoms at admission did not differ between both groups, although MINOCA had EKG with fewer alterations, most had a diagnosis of non-ST-elevation MI (NSTEMI) and significantly lower myocardial injury biomarkers’ levels (Troponine T hs peak 176 [37.25-430] vs 860 [187.50- 2640.50] ng/L, p&amp;lt;0.001 and CK 179 [86.75-342.75] vs 435 [159.50-1090] U/L, p&amp;lt;0.001). They had fewer cardiovascular complications during hospitalization such as inotropic requirements (0% vs 8%, P=0.003), cardiogenic shock (0% vs 6.4%, P=0.007) or left ventricular dysfunction (11.1% vs 29.6%, P&amp;lt;0.001). There were no significant differences in MACE (25.3% vs 34.7%, p=0,086): death (10.7% vs 15.5%, p=0.25), readmission (19% vs 28.7%, p=0.06), AMI (8.3 % vs 7.3%, p=0.74) and stroke (2.4% vs 3.4%, p=0.61) in both groups at follow-up. Conclusions 1) MINOCA is frequent (12% of MI), 2) the clinical profile of MINOCA patients is different than MICAD (lower cardiovascular risk factors burden, younger and more females), 3) the severity of myocardial infarction is lower (more diagnosis of NSTEMI, lower myocardial injury biomarkers’ levels, fewer complications during hospitalization and less left ventricular dysfunction), 4) we found no differences in prognosis in both groups.Table 1

Predictors for and the role of abnormal mapping values at cardiac magnetic resonance in myocardial infarction with non-obstructive coronary arteries

Abstract Background Cardiovascular magnetic resonance (CMR) plays a crucial role in the diagnostic approach of Myocardial infarction with non-obstructive coronary arteries (MINOCA), as a result of its ability to perform myocardial tissue characterization using mapping sequences. Purpose To analyze clinical and prognostic differences in MINOCA patients with and without abnormal mapping values when early CMR is performed. Methods We assessed all MINOCA cases from January 2017 to October 2021 in our Center. MINOCA was defined according to current European guidelines criteria. Acute myocarditis, Tako-tsubo syndromes and cardiomyopathies were excluded. CMR protocol included cine images, T1 and T2 mapping and late gadolinium enhancement (LGE). Abnormal mapping was considered as the presence of prolonged native T1 and T2 mapping with a specific pattern suggestive of ischemic myocardial injury. The receiver operating characteristics curve (ROC) for the detection of abnormal mapping was derivate. Multivariate logistic regression analysis was used to determine predictors of abnormal mapping. The primary outcome of major adverse cardiovascular events (MACE) in patients with and without abnormal mapping was evaluated. Results The final cohort included 198 MINOCA, 161 (81.3%) of which constituted the abnormal mapping group (M+) while the remaining 37 consisted of MINOCA without either abnormal mapping values or presence of late gadolinium enhancement (normal CMR findings, m-). The mean time delay between acute clinical presentation and CMR was 4.8 ± 1.5 days. Among the M+ group, patients were older and presented familiarity for cardiovascular disease and hypercholesterolemia more frequently compared to the m- group. At admission, the M+ group more frequently presented ST segment alterations, wall motion abnormalities (WMA) and greater left ventricular (LV) volumes, compared to the m- ones. Furthermore, the M+ group exhibit greater peak high sensitivity-Troponin I (hs-TnI) values. The ROC curve for the detection of abnormal mapping showed that peak Tn values had an excellent area under the curve (AUC) of 0.935 (95%CI 0.902-0.968), p&amp;lt;0.001. At multivariable analyses, adjusted for confounding factors, the strongest predictor of abnormal mapping was the peak hs-TnI values (OR 1.02, 95% CI 1.01-1.03, p&amp;lt;0.001). Finally, MINOCA M+ had more MACE compared to MINOCA m- (16.8% vs 2.7%, p&amp;lt;0.001) at a mean follow up time of 33.7 ± 12.0 months. Conclusion Among selected MINOCA, abnormal mapping values when early CMR is performed identify a subgroup of patients with worse clinical presentation and outcome. Some baseline characteristics (such as ST alterations, WMA and LV volumes) may support the detection of abnormal mapping. Overall, peak hs-TnI values have an excellent diagnostic performance to predict abnormal mapping values and could be useful in identifying high-risk MINOCA and the consequent need for a CMR evaluation.

Management of hospital resources for patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) - an approach to deescalate ?

Abstract Background Patients with myocardial infarction with non - obstructive coronary arteries (MINOCA) present as a main feature a non-relevant (≤ 50%) obstructive coronary artery upon angiography despite clinical symptoms related to acute coronary syndrome. Being mostly a benign syndrome with favorable clinical outcome and almost exclusively conservative treatment, it still utilizes relevant financial and capacity resources including high care monitoring and in - hospital treatment of relevant length. Regarding scarcity of resources, this entity should be put under particular consideration. Objective Our investigation focuses on the procedural and economic impact of MINOCA patients vs. "true myocardial" infarction patients and related clinical outcomes in a single - center patient collective of a large university heart center in Germany. Methods We analyzed all patients admitted to our hospital with suspected acute coronary syndrome within a 12-month period (2017 – 2018) who had a troponin elevation and received invasive coronary angiography. We collected data on in-hospital costs, procedures, clinical parameters, work-flow timelines, and other relevant parameters. Results Of a total 3021 screened patients, we included 660 patients with acute coronary syndrome. Of those, 103 patients were attributed to the MINOCA – group. 542 patients presented with a "classical" myocardial infarction, and thus formed the MIOCA (myocardial infarction with obstructive coronary arteries) group (Table 1). In - hospital mortality (MIOCA vs. MINOCA: 59 (11.1%) vs. 0 (0%) patients; p &amp;lt; 0.01), and 30 – day mortality (MIOCA vs. MINOCA: 94 (17.3%) vs. 5 (4.2%) patients; p &amp;lt; 0.01) after the clinical index event were significantly higher in the "classical" myocardial infarction group (MIOCA). Overall length of hospital stay (mean: 9.5 ± 8.7 days vs. 12.5 ± 12.7 days; p= 0.016; median: 8.0 (5 - 14) vs. 7.0 (4 - 11); p = 0.023) as well as duration of high care monitoring (mean: 2.4 ± 4.6 days vs. 4.7 ± 7.7 days; p= 0.004; median: 1.9 (1.1 – 4.4) vs. 1.5 (0.4 – 2.7);p = 0.01)) were shorter in the MINOCA group compared to MIOCAs. However, in a 12-months period, a total sum of 298.4 days was attributed to high care monitoring for MINOCA patients (Figure 1). With average and median costs of 6871.5 ± 5670.8 and 3585.2 (3461.4 – 10167.2) EUR per index, MINOCA treatment costs were lower compared to the MIOCA group (mean: 13045.9 ± 7896.9 EUR; p = 0.02; median: 5958.9 (4682.7 – 16654.9) EUR; p &amp;lt; 0.01). MINOCA treatment was not associated with a relevant profit for these expanses (mean: 198.1 ± 4329.2 EUR; // median: 0 (-1702.6 – 1405.1) EUR; p = 0.042) and a relevant share of 36.2% of the total cost was generated due to high care monitoring in these patients (Figure 1). Conclusion In light of growing scarcity of staff, financial and capacity resources MINOCA should be put under particular consideration for refining care concepts and resource allocation.Table 1Figure 1

Sex differences in patients with MINOCA: baseline characteristics and prognosis

Abstract Background The difference between men and women regarding the diagnosis and treatment of cardiovascular diseases has been an object of study during the last few years, with an underrepresentation of female patients in old studies. The epidemiology, diagnosis, and treatment of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) has not yet been wholly elucidated up to this day. The aim of this study is to compare the characteristics and prognosis of MINOCA patients based on sex. Methods We analyzed all consecutive patients with MINOCA diagnosed at a University Hospital between 2016 and 2022. MINOCA diagnostic criteria compelled at the ESC Clinical Guidelines and the AHA Scientific Statement have been followed. Results Our sample comprises 107 patients with MINOCA, 61 male (57%) and 46 female (43%), but once the age of 80 years old was reached, MINOCA was more prevalent in women. We found the female population to have a higher prevalence of stress (usually chronic stress) and transient ischaemic attacks. On the contrary, men usually have more night shifts, psychiatric disorders, and a higher prevalence of smoking. We found no significant differences in cardiovascular risk factors (hypertension, dyslipidemia, or DM), clinical presentation, or other symptoms at admission. (Table 1). High-sensitivity troponin peak concentration was higher in women. As for the main MINOCA physiological mechanisms, we found a significantly higher prevalence of vasospasm in men and coronary artery dissection in women. There were no significant differences regarding coronary embolism, type II acute myocardial infarction (AMI), plaque rupture, or unknown mechanisms. Regarding prognosis, with a median follow-up of 45 [20-65] months, no significant differences were found between both groups for the development of in-hospital complications or mortality, nor cardiovascular readmissions, reinfarction or death from any cause (Table 2). Conclusion Unlike the previous popular perception of this disease, there are more MINOCA male patients than females in our sample, and psychiatric disorders are more prevalent in men. In octogenary people, MINOCA was more prevalent in women. At admission, symptoms and electrocardiographic parameters were very similar between both groups, while cardiac biomarkers reached higher levels in women, unrelated to coronary artery extension or the severity of left ventricular dysfunction.

Incidence and predictors of heart failure in a cohort of MINOCA patients

Abstract Background/Introduction A higher risk of death and major cardiovascular events, including Heart Failure (HF), after a Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) has been described. In particular, HF has a negative impact not only on survival but also on quality of life. In this context, strategies to identify subjects with a greater risk of developing HF are needed. Purpose. Assess incidence and predictors of HF developing subsequently a MINOCA. Methods 461 subjects with suspected MINOCA from 2016 to 2021 were assessed. Acute myocarditis, Takotsubo syndromes, cardiomyopathies and patients with incomplete data were excluded. The final cohort consisted of 188 patients with a confirmed MINOCA diagnosis. After a mean follow-up of 36±14.8 months, 20 patients (10.6%) had hospital readmission for HF. Demographic, clinical, laboratory, and instrumental data were collected and analyzed. Results None among demographic characteristics, cardiovascular risk factors or comorbidities showed correlation with HF occurrences. Paroxysmal or permanent atrial fibrillation was more frequent among patients who developed HF (p .005), such as ST-elevation at onset (p .001). Higher glycemia at admission correlated with HF (p .012). In this regard, hyperglycemia could act as a direct toxic agent or as an indirect marker of a greater stress response. Cardiac troponin I (cTnI) at peak, but not first cTnI measurement, was significantly higher in patients who developed HF (p&amp;lt;.001), confirming the prognostic value of troponin, even in this context. Concerning echocardiography, HF incidence was higher in patients with any wall motion abnormalities (p .037), lower ejection fraction (EF; p .046), especially if EF≤40% (p&amp;lt;.001), higher atrial maximum diameter (p .005), end-diastolic diameter (p. 001) or normalized end-diastolic volume (p&amp;lt;.001). HF occurred more often (p&amp;lt;.001) in patients with a transmural pattern of late gadolinium enhancement (LGE), which resulted as an independent risk factor for HF developing in multivariate analysis (HR 15.32, 95% CI 5.13-45.75, p&amp;lt;.001). 32 patients (17%) were affected by non-obstructive coronary arteries stenosis (i.e., &amp;lt;50%). This finding, but not re-infarction, was also associated with HF development (p .004). Only 2 out of the 68 patients dismissed with DAPT developed HF (p .010). In our study beta-blockers, RAS inhibitors and statins at dismission had not reduced the risk of HF. Nevertheless, the low sample size forbids inferring conclusions about the therapy. Conclusion In our cohort of patients with MINOCA, several clinical, laboratory and echocardiographic characteristics correlated with a higher frequency of HF occurrences. Moreover, a broader extent of cardiac damage, as testified by cTnI, wall motion abnormalities, reduced EF and transmural LGE, could predict HF development. Further studies to establish adequate follow-up programs and therapy to prevent HF progression in these patients are needed.Figure 1

Abstract 13510: Clinical Characteristics and In-Hospital Outcomes of Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries in Japan -Lessons From the Real-World Database of JAMIR-

Background: A certain percentage of patients with acute myocardial infarction (AMI) do not have significant stenosis and they are termed as "myocardial infarction with nonobstructive coronary arteries (MINOCA)”. However, there were few studies representing MINOCA patients in the era of coronary intervention, in Asia in particular. Aims: We aimed to elucidate the clinical characteristics and in-hospital outcomes of patients with MINOCA in Japan by using a real-world database. Methods: The Japan Acute Myocardial Infarction Registry (JAMIR) is a nationwide, real-world multi-center registry study. We retrospectively analyzed 22,236 AMI patients (68±13 years, female 23.4%) enrolled in the JAMIR between 2011 and 2016. Results: Of those, 286 patients (1.3%) were diagnosed as MINOCA following coronary angiography and the remaining 21,950 patients (98.7%) were inevitably as myocardial infarction with obstructive coronary artery disease (MI-CAD). MINOCA patients were characterized by younger age, higher prevalence of women, fewer coronary risk factors, lower rate of ST-elevation AMI, lower Killip classes, and lower peak creatinine phosphokinase levels as compared to those with MI-CAD. In-hospital all-cause mortality was not different between MINOCA and MI-CAD groups (5.2% vs. 5.7%, P=0.82, OR adjusted by age and sex 1.06; 95%CI [0.63-1.80]), meanwhile non-cardiac mortality was significantly higher in the MINOCA group (4.2% vs. 1.6%, P&lt;0.01, adjusted OR 3.14; 95%CI [1.74-5.68]) ( Figure A ). Importantly, non-cardiac mortality increased with age in the MI-CAD group, whereas this did not apply in the MINOCA group ( Figure B ). Conclusions: The large-scale real-world database JAMIR demonstrated high prevalence of non-cardiac death in MINOCA, which indicate a clinical significance of comprehensive evaluations concerning underlying pathophysiological mechanisms of myocardial injury, especially in the younger patient group.

Outcomes and Medical Therapy in Myocardial Infarction With Nonobstructive Coronary Arteries: A Systematic Review and Meta-Analysis

Myocardial infarction with nonobstructive coronary arteries (MINOCAs) is a disease that has been poorly characterized with unclear clinical and therapeutic outcomes. The association of medical therapy with cardiovascular outcomes in patients with MINOCA has been inadequately assessed. The purpose of this meta-analysis is to evaluate the association of MINOCA at risk of adverse cardiovascular outcomes as compared with myocardial infarction with coronary artery disease (MICAD) and the efficacy of medical therapy in reducing the risk of adverse outcomes. A literature search was conducted for studies reporting on the association of MINOCA at risk of adverse outcomes as compared with MICAD. A literature search was also conducted for studies reporting on the association of medical therapy at risk of adverse outcomes in patients with MINOCA. A total of 29 studies with 893,134 participants met inclusion criteria comparing MINOCA to MICAD. Patients with MINOCA had a significantly lower risk of adverse outcomes as compared with MICAD. Nine studies with 27,731 MINOCA patients met inclusion criteria for evaluating the utility of medical therapy. Medical therapy did not significantly reduce risk of MACE; however, there was a trend toward lower risk in patients treated with β blockers. In conclusion, our results suggest that MINOCA is associated with a lower risk of in-hospital and long-term adverse outcomes compared with MICAD. Standard medical therapy is not associated with a lower risk of adverse cardiovascular outcomes in patients with MINOCA. Additional high-quality studies are required to evaluate the utility of specific medication classes for the treatment of specific etiologies of MINOCA.

Psychosocial Factors of Women Presenting With Myocardial Infarction With or Without Obstructive Coronary Arteries

BackgroundWomen with myocardial infarction (MI) are more likely to have elevated stress levels and depression than men with MI. ObjectivesWe investigated psychosocial factors in women with myocardial infarction with nonobstructive coronary arteries (MINOCA) and those with MI and obstructive coronary artery disease (CAD). MethodsWomen with MI enrolled in a multicenter study and completed measures of perceived stress (Perceived Stress Scale-4) and depressive symptoms (Patient Health Questionnaire-2) at the time of MI (baseline) and 2 months later. Stress, depression, and changes over time were compared between MI subtypes. ResultsWe included 172 MINOCA and 314 MI-CAD patients. Women with MINOCA were younger (age 59.4 years vs 64.2 years; P < 0.001) and more diverse than those with MI-CAD. Women with MINOCA were less likely to have high stress (Perceived Stress Scale-4 ≥6) at the time of MI (51.0% vs 63.0%; P = 0.021) and at 2 months post-MI (32.5% vs 46.3%; P = 0.019) than women with MI-CAD. There was no difference in elevated depressive symptoms (Patient Health Questionnaire-2 ≥2) at the time of MI (36% vs 43%; P = 0.229) or at 2 months post-MI (39% vs 40%; P = 0.999). No differences in the rate of 2-month decline in stress and depression scores were observed between groups. ConclusionsStress and depression are common among women at the time of and 2 months after MI. MINOCA patients were less likely to report high stress compared with MI-CAD patients, but the frequency of elevated depressive symptoms did not differ between the 2 groups. Stress and depressive symptoms decreased in both MI-CAD and MINOCA patients over time.

Performance of Prognostic Scoring Systems in MINOCA: A Comparison among GRACE, TIMI, HEART, and ACEF Scores.

Background: the prognosis of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is not benign; thus, prompting the need to validate prognostic scoring systems for this population. Aim: to evaluate and compare the prognostic performance of GRACE, TIMI, HEART, and ACEF scores in MINOCA patients. Methods: A total of 250 MINOCA patients from January 2017 to September 2021 were included. For each patient, the four scores at admission were retrospectively calculated. The primary outcome was a composite of all-cause death and acute myocardial infarction (AMI) at 1-year follow-up. The ability to predict 1-year all-cause death was also tested. Results: Overall, the tested scores presented a sub-optimal performance in predicting the composite major adverse event in MINOCA patients, showing an AUC ranging between 0.7 and 0.8. Among them, the GRACE score appeared to be the best in predicting all-cause death, reaching high specificity with low sensitivity. The best cut-off identified for the GRACE score was 171, higher compared to the cut-off of 140 generally applied to identify high-risk patients with obstructive AMI. When the scores were tested for prediction of 1-year all-cause death, the GRACE and the ACEF score showed very good accuracy (AUC = 0.932 and 0.828, respectively). Conclusion: the prognostic scoring tools, validated in AMI cohorts, could be useful even in MINOCA patients, although their performance appeared sub-optimal, prompting the need for risk assessment tools specific to MINOCA patients.