Myocardial Infarction With Non-obstructive Coronary Arteries Research Articles

Critical role of the coronary microvasculature in heart disease: From pathologic driving force to “innocent” bystander

The coronary microvasculature is responsible for providing oxygen and nutrients to myocardial tissue. A healthy microvasculature with an intact and properly functioning endothelium accomplishes this by seemless changes in vascular tone to match supply and demand. Perturbations in the normal physiology of the microvasculature, including endothelial and/or vascular smooth muscle dysfunction, result in impaired function (vasoconstriction, antithrombotic, etc.) and structural (hypertrophic, fibrotic) abnormalities that lead to microvascular ischemia and potential organ damage. While coronary microvascular dysfunction (CMD) is the primary pathologic driving force in ischemia with non-obstructive coronary artery disease (INOCA), angina with no obstructive coronary arteries (ANOCA), and myocardial infarction with non-obstructed coronary arteries (MINOCA), it may be a bystander in many cardiac disorders which later become pathologically associated with signs and/or symptoms of myocardial ischemia. Importantly, regardless of the primary or secondary basis of CMD in the heart, it is associated with important increases in morbidity and mortality. In this review we discuss salient features pertaining to known pathophysiologic mechanisms driving CMD, the spectrum of heart diseases where it places a critical role, invasive and non-invasive diagnostic testing, management strategies, and the gaps in knowledge where future research efforts are needed.

Myocardial Infarction with Nonobstructive Coronary Arteries.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an important subtype of myocardial infarction (MI) that occurs in approximately 6-8% of patients with spontaneous MI who are referred for coronary angiography. MINOCA disproportionately affects women, but men are also affected. Pathogenesis is more variable than in MI with obstructive coronary artery disease (MI-CAD). Dominant mechanisms include atherosclerosis, thrombosis, and coronary artery spasm. Management of MINOCA varies based on the underlying mechanism of infarction. Therefore, systematic approaches to diagnosis are recommended. The combination of invasive coronary angiography, multivessel intracoronary imaging, provocative testing for coronary spasm, and cardiac magnetic resonance imaging provides the greatest diagnostic yield. Current clinical practice guidelines for the secondary prevention of MI are based largely on data from patients with MI-CAD. Thus, optimal medications after MINOCA are uncertain. Clinical trials focused on the treatment of patients with MINOCA are urgently needed to define optimal care.

Clinical characteristics and prognosis of myocardial infarction with non-obstructive coronary arteries: A prospective single-center study.

BackgroundA definition of myocardial infarction with non-obstructive coronary arteries (MINOCA) was published by European Society of Cardiology in 2016. The aim of this study is to analyze the clinical profile and prognosis of these patients in a prospective single-center study and compare it with the literature data.MethodsDuring a 3-year period, information from every consecutive MINOCA patient was gathered (n = 109). It was then compared with 412 contemporaneous patients with myocardial infarction and obstructive coronary arteries (MIOCA). Univariate and multivariate analyses were performed. Prognosis analysis was adjusted by age and cardiovascular risk factors (CVRF).ResultsMINOCA represented 16.9% of the total of patients admitted for myocardial infarction (MI). Compared with MIOCA, they had more psychosocial disorders (22.9% vs. 10.7%; p < 0.01) and more pro-inflammatory conditions (34.9% vs. 14.0%; p < 0.01). Atrial fibrillation was twice as frequent in MINOCA (14.7% vs. 7.3%; p = 0.016). Predictors of MINOCA were as follows: female gender, absence of diabetes, absence of tobacco use, tachycardia, troponin above 10 times the 99th percentile, and proinflammatory conditions. Median follow-up was 17.3 ± 9.3 months. Major adverse cardiovascular events (MACE; a composite of a recurrence of acute MI, transient ischemic attack/stroke, or death from cardiovascular cause and death from any cause) occurred in 10.8% of the MINOCA group as compared with 10.7% in the MIOCA group (hazard ratio [HR] 1.19, 95% confidence interval [CI] 0.58–2.45; p = 0.645). Cardiovascular re-admission rates were higher in the MINOCA group: 19.8% vs. 13.9% (HR 1.85; CI 1.06–3.21; p = 0.030).ConclusionsThe frequency of MINOCA is high, with fewer CVRF, and it is linked to atrial fibrillation, psychosocial disorders, and pro-inflammatory conditions. Mid-term prognosis is worse than previously thought, with a similar proportion of MACE as compared to MIOCA, and even a higher rate of cardiovascular re-admissions.

Analysis of clinical features and the outcome of in-hospital mortality of myocardial infarction with non-obstructive coronary arteries

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.

MINOCA: One Size Fits All? Probably Not-A Review of Etiology, Investigation, and Treatment.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.

Myocardial infarction with nonobstructive coronary arteries: the need for precision medicine.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) represents about 6-8% of all patients with myocardial infarction (MI), and several pathophysiological mechanisms showed to be involved in this heterogeneous clinical condition. Of note, MINOCA proved to be associated with a significant risk of mortality, angina burden and socioeconomic costs. Results from randomized clinical trials evaluating the clinical effectiveness of a comprehensive diagnostic algorithm, along with the acute and long-term management of patients with MINOCA, are pending. In this review article, we aim at providing an overview of the clinical features, diagnostic work-up and the therapeutic management of patients presenting with MINOCA, highlighting the recent acquisition along with the remaining important knowledge gaps in this field.

Coronary morphological features in women with non-ST-segment elevation MINOCA and MI-CAD as assessed by optical coherence tomography.

AimsWe aimed to use optical coherence tomography (OCT) to identify differences in atherosclerotic culprit lesion morphology in women with myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) compared with MI with obstructive coronary artery disease (MI-CAD).Methods and resultsWomen with an OCT-determined atherosclerotic aetiology of non-ST segment elevation (NSTE)-MINOCA (angiographic diameter stenosis <50%) who were enrolled in the multicentre Women’s Heart Attack Research Program (HARP) study were compared with a consecutive series of women with NSTE-MI-CAD who underwent OCT prior to coronary intervention at a single institution. Atherosclerotic pathologies identified by OCT included plaque rupture, plaque erosion, intraplaque haemorrhage (IPH, a region of low signal intensity with minimum attenuation adjacent to a lipidic plaque without fibrous cap disruption), layered plaque (superficial layer with clear demarcation from the underlying plaque indicating early thrombus healing), or eruptive calcified nodule.We analysed 58 women with NSTE-MINOCA and 52 women with NSTE-MI-CAD. Optical coherence tomography features of underlying vulnerable plaque (thin-cap fibroatheroma) were less common in MINOCA (3 vs. 35%) than in MI-CAD. Intraplaque haemorrhage (47 vs. 2%) and layered plaque (31 vs. 12%) were more common in MINOCA than MI-CAD, whereas plaque rupture (14 vs. 67%), plaque erosion (8 vs. 14%), and calcified nodule (0 vs. 6%) were less common in MINOCA. The angle of ruptured cavity was smaller and thrombus burden was lower in MINOCA.ConclusionThe prevalence of atherothrombotic culprit lesion subtype varied substantially between MINOCA and MI-CAD. A majority of culprit lesions in MINOCA had the appearance of IPH or layered plaque.Clinical Trial Registration Information Clinical Trial Name: Heart Attack Research Program- Imaging Study (HARP); ClinicalTrial.gov Identifier: NCT02905357; URL: https://clinicaltrials.gov/ct2/show/NCT02905357

Współwystępowanie zapalenia pęcherzyka żółciowego i zawału serca bez istotnych zwężeń w tętnicach wieńcowych u 65-letniej chorej

Myocardial infarction with nonobstructive coronary arteries (MINOCA), is increasingly recognized as an important and separate cause of myocardial infarction among patients with the acute coronary syndrome (ACS). The dominant pathophysiological mechanisms of MINOCA include coronary pathologies (epicardial spasm, coronary microcirculation disorder, spontaneous coronary dissection, coronary thrombosis/embolism) with the absence of disease with significant angiographic artery stenosis. This study presents a clinical course of myocardial infarction (MI) without significant stenosis in the coronary arteries and cholecystitis, in 65 years old woman, with some risk factors of atherosclerosis (smoking, obesity, atherogenic dyslipidemia, high levels of C-reactive protein, old age and physical inactivity). In the first days, myocardial infarction was complicated by an atrioventricular block. Coronarography revealed no significant stenosis confirming the occurrence of MINOCA.

Air Pollution and Coronary Vasomotor Disorders in Patients With Myocardial Ischemia and Unobstructed Coronary Arteries

BackgroundCoronary vasomotor abnormalities are important causes of myocardial ischemia in patients with nonobstructive coronary artery disease (NOCAD). However, the role of air pollution in determining coronary vasomotor disorders has never been investigated. ObjectivesWe aimed to evaluate the association between long-term exposure to particulate matter 2.5 (PM2.5) and 10 (PM10), and coronary vasomotor disorders in NOCAD patients. MethodsPatients with myocardial ischemia and NOCAD undergoing coronary angiography and intracoronary provocation test with acetylcholine were prospectively studied. Both patients with chronic myocardial ischemia and nonobstructive coronary arteries and myocardial infarction with nonobstructive coronary arteries (MINOCA) were enrolled. Based on each case’s home address, exposure to PM2.5 and PM10 was assessed. ResultsWe included 287 patients (median age, 62.0 years [IQR: 52.0-70.0 years], 149 [51.9%] males); there were 161 (56.1%) myocardial ischemia and nonobstructive coronary arteries and 126 (43.9%) MINOCA cases. One hundred seventy-six patients (61.3%) had positive provocation test. Exposure to PM2.5 and PM10 was higher in patients with a positive provocation test (P < 0.001). At multivariate logistic regression analysis, PM2.5 and PM10 were independent predictors of a positive provocation test (P = 0.001 and P = 0.029, respectively). Interestingly, among these patients, PM2.5 and PM10 were both independent predictors of MINOCA (P < 0.001 and P = 0.001, respectively) as clinical presentation, whereas PM2.5 was independently associated with the occurrence of epicardial spasm as opposed to microvascular spasm (P = 0.001). ConclusionsHigher exposure to PM2.5 and PM10 in patients with myocardial ischemia and NOCAD is associated with coronary vasomotor abnormalities. In particular, PM2.5 is an independent risk factor for the occurrence of epicardial spasm and MINOCA as clinical presentation.

Coronary functional assessment in non-obstructive coronary artery disease: Present situation and future direction.

Non-obstructive coronary artery disease (CAD), which is defined as coronary stenosis <50%, has been increasingly recognized as an emerging entity in clinical practice. Vasomotion abnormality and coronary microvascular dysfunction are two major mechanisms contributing to the occur of angina with non-obstructive CAD. Although routine coronary functional assessment is limited due to several disadvantages, functional evaluation can help to understand the pathophysiological mechanism and/or to exclude specific etiologies. In this review, we summarized the potential mechanisms involved in ischemia with non-obstructive coronary arteries (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA), the two major form of non-obstructive CAD. Additionally, we reviewed currently available functional assessment indices and their use in non-obstructive CAD. Furthermore, we speculated that novel technique combined anatomic and physiologic parameters might provide more individualized therapeutic choice for patients with non-obstructive CAD.

Do Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries Have Similar Prognosis Compared to Ones with MI-CAD?

Acute myocardial infarction (AMI) is a leading cause of morbidity and mortality worldwide and it is primarily caused by acute plaque disruption and coronary occlusion. Recent studies suggest that myocardial infarction with non-obstructive coronary arteries (MINOCA) also occurs but the underlying mechanisms have not been fully understood until recently. The evidence also suggests that the clinical outcomes of patients presenting with MINOCA are similar to AMI patients with obstructive coronary artery disease (MI-CAD), including all-cause mortality and major adverse cardiovascular events. The present narrative review considers the risk factors, pathological changes, and outcomes associated with MINOCA and compares them with MI-CAD.

Combination of White Blood Cell Count to Mean Platelet Volume Ratio and Neutrophil-to-Platelet Ratio Predicts Long-Term Adverse Events in Patients with MINOCA.

Background White blood cell count to mean platelet volume ratio (WMR) and neutrophil-to-platelet ratio (NPR) have been demonstrated as prognostic inflammatory biomarkers of the acute coronary syndrome. We aimed to evaluate the prognostic value of WMR and NPR among myocardial infarction with nonobstructive coronary arteries (MINOCA) patients. Method A total of 274 MINOCA patients were enrolled. Baseline clinical data, blood cell panel, and biochemical parameters were evaluated. The patients were classified according to the medians of WMR and NPR. The primary endpoint of the present study was major adverse cardiovascular events (MACE). Multivariable Cox regression analysis was used to assess the effect of independent variables of WMR and NPR on the dependent variable (MACE). Result The median values of WMR and NPR were 701 and 0.03, respectively. During the median follow-up of 28 months, a total of 58 incidences of MACE occurred. The MACE rate was more frequent in high WMR and high NPR patients. In Kaplan-Meier analysis, the incidence of MACE was higher in WMR>701 and NPR>0.03 (long-rank P = 0.004 and P = 0.002, respectively). The combined high WMR and high NPR showed a significantly higher rate of MACE (long-rank P = 0.001). Cox regression analysis showed that the combined high WMR and high NPR were independent predictors of long-term MACE with the highest hazard ratio (HR, 2.511; 95% CI, 1.271 to 4.960; P = 0.008). Conclusion High WMR and NPR separately or in combination were correlated with increased risk of MACE among MINOCA patients, suggesting WMR and NPR may assist as a reliable inflammatory marker in risk prediction of MINOCA patients.

MINOCA: under recognized and affecting predominantly female patients-an Australian experience.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is now being recognized as an important clinical entity with prognostic implications. There are limited data in relation to MINOCA in our local Australian settings. We investigated the prevalence, clinical characteristics, major adverse cardiovascular events (MACE), and 1-year mortality of patients with MINOCA at Peninsula Health. A single-center retrospective study of all adult patients aged ≥ 18years who underwent invasive angiography from January 2018 to June 2020 was identified from medical records. We included patients who met the definition of MINOCA as per the 2019 AHA Statement. A simple descriptive statistical analysis was performed. The prevalence of MINOCA at Peninsula Health was 10.9% (131/1199) with a median age of 62 (IQR 53-74). Female patients were predominant, comprising 64% (84/131) of these patients. Chest pain was the most common symptom in 92.3% (121/131) and 58.8% (77/131) had ECG changes. A total of 81% (106/131) had a normal left ventricular systolic function and 47% of patients (66/139) had no luminal disease on invasive angiography. A total of 15.9% (23/144) of patients with an initial working diagnosis of MINOCA were referred for CMR on discharge. MACE was 5.2% (6/115) over a median follow-up of 23months. The all-cause mortality rate at 1year was 0.7% (1/131). The clinical prevalence rate of MINOCA at Peninsula Health is 10.9% with a MACE of 5.2%. MINOCA is recognized and the low rate of additional testing could be improved given the female predominance and prognostic implications.

Myocardial infarction with non-obstructive coronary arteries in hypertrophic cardiomyopathy vs Fabry disease

BackgroundLittle is known about prevalence and predictors of myocardial infarction with non-obstructive coronary arteries (MINOCA) in Fabry disease (FD) and hypertrophic cardiomyopathy (HCM). We assessed and compared the prevalence and predictors of MINOCA in a large cohort of HCM and FD patients. MethodsIn this multicenter, retrospective study we enrolled 2870 adult patients with HCM and 267 with FD. The only exclusion criterion was documented obstructive coronary artery disease. MINOCA was defined according to guidelines. For each patient we collected clinical, ECG and echocardiographic data recorded at initial evaluation. ResultsOverall, 36 patients had MINOCA during a follow-up period of 4.5 ± 11.2 years. MINOCA occurred in 16 patients with HCM (0.5%) and 20 patients with FD (7.5%; p < 0.001). The difference between the 2 groups was highly significant, also after adjustment for the main clinical, ECG and echocardiographic variables (OR 6.12; 95%CI 2.80–13.3; p < 0.001). In the FD population MINOCA occurred in 17 out of 96 patients with left ventricle hypertrophy (LVH, 17.7%) and in 3 out of 171 patients without LVH (1.7%; OR 12.0; 95%CI 3.43–42.3; p < 0.001). At multivariable analysis, voltage criteria for LVH at ECG (OR 7.3; 95%CI 1.93–27.7; p = 0.003) and maximal LV wall thickness at echocardiography (OR 1.15; 95%CI 1.05–1.27; p = 0.002) maintained an independent association with MINOCA. No major significant differences were found in clinical, ECG and echocardiographic findings between HCM patients with or without MINOCA. ConclusionsMINOCA was rare in HCM patients, and 6-fold more frequent in FD patients. MINOCA may be considered a red flag for FD and aid in the differential diagnosis from HCM.

Clinical Features and Long-Term Outcomes in Very Young Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries.

Background The main cause of acute coronary syndrome (ACS) is coronary artery obstruction due to atherosclerotic plaque growth or thrombus formation secondary to plaque rupture or erosion. However, there is a subgroup of patients with signs and symptoms suggestive of ACS but without relevant coronary artery obstruction on coronary angiography. This population is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA). The present study analyzes the clinical features and outcomes of very young patients with a diagnosis of MINOCA. Method Nested case-control study of ≤40-year-old patients referred for coronary angiography due to clinical suspicion of ACS. Patients were divided into three groups: patients with obstructive coronary artery disease (CAD), patients diagnosed with MINOCA, and controls with non-coronary artery disease. Results Of 19,321 coronary angiographies performed in our center in a period of 10 years, 408 (2.1%) were in patients ≤40 years old, and MINOCA was identified in 32 (21%) patients. The cardiovascular risk factors for obstructive CAD and MINOCA were very similar. The incidence of major adverse cardiovascular events (MACE) at follow-up was significantly higher in the MINOCA (HR 4.13 (95%CI 1.22–13.89) and obstructive CAD (HR 4.59 (95%CI 1.90–10.99) patients compared to controls. Cocaine use HR 14.58 (95%CI 3.08–69.02), family history of CAD HR 6.20 (95%CI 1.40–27.43), and depression HR 5.16 (95%CI 1.06–25.24) were associated with a poor outcome in the MINOCA population. Conclusion Very young patients with MINOCA had a poor prognosis at long-term follow-up, similar to patients with obstructive CAD. Focusing efforts on secondary prevention is essential in this population.

The e-mental health treatment in Stockholm myocardial infarction with non-obstructive coronaries or Takotsubo syndrome study (E-SMINC): a study protocol for a randomised controlled trial

BackgroundIn the aftermath of a myocardial infarction with non-obstructive coronary arteries (MINOCA) or Takotsubo syndrome (TS), patients commonly express high levels of stress and anxiety. Current treatment alternatives rarely address these issues.MethodsThe study is a randomised controlled trial, where 90 patients with a discharge diagnosis of MINOCA or TS who also report symptoms of stress or anxiety will be randomised 2–6 weeks after their cardiac event. The treatment consists of 10 weeks of Internet-based cognitive behaviour therapy (CBT) and starts immediately after randomisation for the treatment group. The control group receives usual care. Main outcomes are symptoms of anxiety measured with the Hospital Anxiety and Depression scale, anxiety subscale, and perceived stress measured with the Perceived Stress Scale, 14-item version, 10 weeks after randomisation. Secondary measures include cardiac specific anxiety, symptoms of post-traumatic stress, quality of life, cortisol measured in hair and physiological stress responses (heart rate variability, blood pressure and saliva cortisol) during a stress procedure. Ten weeks after randomisation, the control group will also receive treatment. Long-term follow-up in the self-report measures mentioned above will be conducted 20 and 50 weeks after randomisation where the total group’s development over time is followed, and the groups receiving intervention early versus late compared.DiscussionAt present, there are no randomised studies evaluating psychological treatment for patients with MINOCA or TS. There is an urgent need for treatment alternatives aiming at relieving stress and anxiety considering the high mental stress and anxiety levels observed in MINOCA and TS, leading to decreased quality of life. CBT aiming at reducing mental stress has been shown to be effective regarding prognosis in patients with coronary artery disease. The current protocol describes a randomised open-label controlled trial evaluating an Internet-based CBT program for reduction of stress and anxiety in patients with increased mental stress and/or anxiety with a discharge diagnosis of either MINOCA or TS.Trial registrationClinicalTrials.govNCT04178434. Registered on 26 November 2019

Clinical and instrumental indicators of acute myocardial infarction without coronary artery obstruction

The frequency of myocardial infarction with non-obstructive coronary arteries (MINOCA) ranges from 5 to 11.1% in the structure of all myocardial infarctions. Left ventricular myocardial performance index (LV MPI) is the only echocardiographic independent predictor of unfavourable prognosis in patients with acute coronary syndrome. Purpose: to study risk factors for coronary heart disease, laboratory and echocardiographic indicators with the calculation of LV MPI in patients within the acute period of myocardial infarction. Material and methods. The study included 72 patients diagnosed with myocardial infarction. 40 patients had single-vessel coronary artery disease, 32 patients did not have stenosis &gt; 50% according to coronary angiography. All patients underwent clinical examination, electrocardiography, clinical blood analysis and body chemistries. Echocardiography was performed on the first day of the disease. Results. A statistically significant difference among risk factors is hereditary load; in patients with MINOCA, it is the level of low-density lipoproteins and triglycerides. The glomerular filtration rate by CKD-Epi is lower by 17.6 ml/min (p = 0.0007). The LV ejection fraction, MPI is higher in patients with MINOCA (p = 0.001), in 3 patients (7.5%) who underwent percutaneous coronary intervention, LV MPI was 22.6%. Findings. 1. According to clinical signs, patients with MINOCA had a more severe course of the acute period. 2. Indicators of intracardiac hemodynamics are better in the group of patients with myocardial infarction, including the left ventricular myocardial performance index

Reducing stress and anxiety in patients with myocardial infarction with non-obstructive coronary arteries or Takotsubo syndrome: A non-randomized feasibility study

Background and aimIn the aftermath of a myocardial infarction with non-obstructive coronary arteries (MINOCA) or Takotsubo syndrome (TS), patients commonly express high levels of stress and anxiety. Current treatment alternatives rarely address these issues. The planned E-health Treatment of Stress and Anxiety in Stockholm Myocardial Infarction With Non-obstructive Coronaries Study (e-SMINC) aims to evaluate the effects of an internet-based intervention, building on cognitive behavioral therapy (CBT) by comparison with treatment as usual using an RCT approach. This was a small-scale single arm study designed to test the feasibility of the RCT, addressing uncertainties regarding recruitment, data collection, and intervention delivery. MethodsParticipant recruitment and screening took place before discharge from the coronary care unit at a large Swedish hospital. Eligible patients were invited to a nine-step psychologist guided, internet-based CBT intervention. The sample size was set in advance to 10 participants completing the intervention. The recruitment and flow of participants were documented and evaluated in relation to seven pre-defined progression criteria. Self-reports of anxiety (HADS-A), stress (PSS-14), cardiac anxiety (CAQ), posttraumatic stress (IES-6) and quality of life (Rand-36), collected at screening, pre-intervention and post-intervention, were analysed descriptively and by effect sizes (Cohen's d). Individual interviews targeting participant experiences were conducted. ResultsSix out of seven progression criteria yielded no concerns. Out of 49 patients with a working diagnosis of MINOCA or TS, 31 were eligible for screening, 26 consented to participate, and 14 were eligible with regard to symptoms of stress and/or anxiety. Eleven completed the pre-assessment and were given access the intervention, and 9 completed the intervention. Only the number of patients screened prior to eligibility assessment was slightly lower than expected, indicating possible concerns. Self-reports of anxiety, stress, cardiac anxiety, posttraumatic stress, and quality of life all indicated symptom reduction from pre- to post-intervention, generally showing large effect sizes (d = 0.6–2.6). The general consensus among participants was that the programme was helpful and relevant, and that the personal contact with the psychologist was highly valued. Setting aside time to complete assignments was found critical. ConclusionConducting a full scale RCT was found feasible. Inclusion of more study sites and minor amendments to the protocol and intervention were decided to improve feasibility further. Trial registrationClinicaltrials.govNCT04178434

Incidence and Clinical Characteristics of Patients Presenting With Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA)

Incidence and Clinical Characteristics of Patients Presenting With Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA)

Myocardial Infarction With Nonobstructive Coronary Arteries in New-onset Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) is a systemic pro-inflamma­tory condition with rare cardiovascular extraintestinal manifestations. Increasing evidence links gut inflammation and cardiovascular pathology, with myopericarditis encompassing approximately 70% of cases.1–3 Myocardial infarction with nonobstructive coronary arteries (MINOCA) has not been described in this population.4 A 36-year-old man with a history of gastroesophageal reflux disease and hypertension presented with a 10-day history of fever, hematochezia, and abdominal pain. Negative history included no travel, suspect foods, or drug use. Family history was negative for IBD or cardiac disease. Exam was unremarkable except for mild abdominal tenderness in bilateral lower quadrants. Labs revealed elevated white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. Admission troponin and electrocardiogram (ECG) were normal. Computed tomography (CT) abdomen and pelvis revealed diffuse bowel wall thickening and associated mesenteric inflammation of the entire colon. A stool infectious panel was negative. Sigmoidoscopy demonstrated diffuse continuous ulceration, friability, and granularity up to the splenic flexure (Figure 1A). Colon biopsies demonstrated diffuse, markedly active colitis. Although pathology had no evidence of chronicity, given a negative workup for infection or ischemia, no offending medications, no response to antibiotics, a characteristic endoscopic appearance, and a worsening clinical course that ultimately responded only to steroids, it was determined to be a diagnosis of early and new-onset ulcerative colitis.