Abstract
Background
Premature myocardial infarction (MI) is an increasingly prevalent cause of morbidity
and mortality worldwide. A subset of patients, predominantly young women, present
with MI with no obstructive coronary artery disease (MINOCA), a nomenclature gaining
recognition. However, few data exist on presentation and prognosis according to the
severity of coronary artery disease (CAD).
Methods
We studied patients with premature (younger than 55 years of age) acute MI enrolled
in a large cohort in 24 centres across Canada. Baseline clinical, psychosocial, and
coronary anatomy characteristics as well as 12-month outcomes were compared between
patients with MINOCA (< 50% stenosis) and patients with MI with obstructive CAD (≥
50% stenosis; MICAD).
Results
From a cohort of 1210 patients with acute coronary syndrome, we examined 998 MI patients
with available angiography core lab readings: 82 (8.2%) had a MINOCA and 916 (91.8%)
had a MICAD. Forty percent of patients with MINOCA were women compared with one-third
with MICAD. The prevalence of traditional risk factors and chest pain at presentation
was lower in MINOCA patients, yet 37% had a ST-elevation MI and 10% presented with
a cardiac arrest. No evident etiology was detected in > 70% of MINOCA, but 10% presented
with either spontaneous coronary dissection or Takotsubo cardiomyopathy. Although
combined major adverse cardiovascular events and all-cause readmission rate was lower
in the MINOCA group (14% vs 25%; adjusted hazard ratio, 0.51; 95% confidence interval,
0.28-0.93), it was not negligible.
Conclusions
Patients with MINOCA present with high-risk features despite the absence of obstructive
CAD. A search for etiology and eventual treatment provides a rich avenue for improving
prognosis in young women with premature MI.
Résumé
Contexte
L’infarctus du myocarde (IM) prématuré est une cause de morbidité et de mortalité
de plus en plus fréquente dans le monde. Un sous-groupe de patients, composé majoritairement
de jeunes femmes, est touché par l’IM à coronaires saines, une entité clinique de
plus en plus reconnue. Cependant, il existe peu de données sur le tableau clinique
et le pronostic en fonction de la gravité de la coronaropathie.
Méthodologie
Nous avons mené une étude auprès de patients ayant subi un IM aigu prématuré (survenu
avant l’âge de 55 ans) formant une vaste cohorte répartie dans 24 centres à l’échelle
du Canada. Dans le cadre de cette étude, nous avons comparé les caractéristiques cliniques,
psychosociales et anatomocoronariennes initiales des patients ayant subi un IM à coronaires
saines (sténose < 50 %) à celles des patients ayant subi un IM dans un contexte d’obstruction
coronaire (sténose ≥ 50 %). Nous avons aussi comparé les résultats obtenus à 12 mois
dans ces deux groupes de patients.
Résultats
Au sein d’une cohorte de 1210 patients atteints d’un syndrome coronarien aigu, nous
avons examiné 998 cas d’IM pour lesquels on disposait de données angiographiques de
base; 82 (8,2 %) cas d’IM à coronaires saines et 916 (91,8 %) cas d’IM dans un contexte
d’obstruction coronaire ont été recensés. Les femmes représentaient 40 % des patients
ayant subi un IM à coronaires saines; à titre de comparaison, le tiers des patients
ayant subi un IM dans un contexte d’obstruction coronaire étaient des femmes. La prévalence
des facteurs de risque classiques et de la douleur thoracique dans le tableau clinique
était plus faible chez les patients ayant subi un IM à coronaires saines; néanmoins,
37 % avaient subi un IM avec sus-décalage du segment ST, et 10 % un arrêt cardiaque.
Aucune étiologie manifeste n’a été mise en lumière dans > 70 % des cas d’IM à coronaires
saines; toutefois, une dissection spontanée de l’artère coronaire ou une myocardiopathie
de Takotsubo faisait partie du tableau clinique dans 10 % des cas. Le taux combiné
d’événements cardiovasculaires indésirables majeurs et de réadmissions toutes causes
confondues était plus faible dans le groupe des patients ayant subi un IM à coronaires
saines (14 % vs 25 %; rapport des risques instantanés ajusté : 0,51; intervalle de
confiance à 95 % : 0,28-0,93), mais il n’était pas négligeable.
Conclusions
Dans les cas d’IM à coronaires saines, les patients présentent des caractéristiques
à haut risque malgré l’absence de coronaropathie obstructive. La recherche des causes
et d’un traitement éventuel représente une avenue prometteuse pour l’amélioration
du pronostic dans les cas d’IM prématuré chez les jeunes femmes.
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References
- Heart disease and stroke statistics-2017 update: a report from the American Heart Association.Circulation. 2017; 135: e146-603
- Sex, death, and the diagnosis gap.Circulation. 2014; 130: 740-742
- Knowledge, attitudes, and beliefs regarding cardiovascular disease in women: the Women's Heart Alliance.J Am Coll Card. 2017; 70: 123-132
- Stable coronary syndromes: the case for consolidating the nomenclature of stable ischemic heart disease.Circulation. 2017; 136: 437-439
- Ischemia and no obstructive coronary artery disease (INOCA): developing evidence-based therapies and research agenda for the next decade.Circulation. 2017; 135: 1075-1092
- ESC working group position paper on myocardial infarction with non-obstructive coronary arteries.Eur Heart J. 2017; 38: 143-153
- 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2018; 39: 119-177
- Acute coronary syndromes: the way forward from mechanisms to precision treatment.Circulation. 2017; 136: 1155-1166
- Basis for sex-specific expression of Takotsubo cardiomyopathy, cardiac syndrome X, and spontaneous coronary artery dissection.Can J Cardiol. 2014; 30: 738-746
- Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease.Circulation. 2011; 124: 1414-1425
- Spontaneous reperfusion in ST-elevation myocardial infarction: comparison of angiographic and electrocardiographic assessments.Am Heart J. 2008; 156: 248-255
- Coronary microvascular dysfunction.N Engl J Med. 2007; 356: 830-840
- Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events.Eur Heart J. 2012; 33: 734-744
- Adverse cardiovascularoutcomes in women with nonobstructive coronary artery disease: a report from the Women's Ischemia Syndrome Evaluation Study and the St James Women Take Heart Project.Arch Intern Med. 2009; 169: 843-850
- Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease: results from the National Institutes of Health-National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE).Circulation. 2004; 109: 2993-2999
- Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women's Ischaemia Syndrome Evaluation (WISE) study.Eur Heart J. 2006; 27: 1408-1415
- Nonobstructive coronary artery disease and risk of myocardial infarction.JAMA. 2014; 312: 1754-1763
- Excess cardiovascular risk in women relative to men referred for coronary angiography is associated with severely impaired coronary flow reserve, not obstructive disease.Circulation. 2017; 135: 566-577
- Cardiac syndrome X: mystery continues.Can J Cardiol. 2012; 28: S3-6
- Cardiac syndrome X: update 2014.Cardiol Clin. 2014; 32: 463-478
- Women, cardiac syndrome X, and microvascular heart disease.Can J Cardiol. 2012; 28: S42-S49
- Sex differences in clinical outcomes in patients with stable angina and no obstructive coronary artery disease.Am Heart J. 2013; 166: 38-44
- Predictors of coronary artery disease in the Lebanese population.Thromb Res. 2006; 117: 631-637
- Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management.Eur Heart J. 2015; 36: 475-481
- Angina with “normal” coronary arteries: sex differences in outcomes.Am Heart J. 2008; 155: 375-381
- Adverse outcomes among women presenting with signs and symptoms of ischemia and no obstructive coronary artery disease: findings from the NationalHeart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) angiographic core laboratory.Am Heart J. 2013; 166: 134-141
- Long-term survival and causes of death in patients with ST-elevation acute coronary syndrome without obstructive coronary artery disease.Eur Heart J. 2018; 39: 102-110
- GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond-Premature Acute Coronary SYndrome).Am Heart J. 2012; 163: 741-746
- A validated prediction model for all forms of acute coronarysyndrome: estimating the risk of 6-month postdischarge death in an international registry.JAMA. 2004; 291: 2727-2733
- The hospital anxiety and depression scale.Acta Psychiatr Scand. 1983; 67: 361-370
- Development of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey.J Cardiovasc Nurs. 2004; 19: 58-67
- A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity.Med Care. 1996; 34: 220-233
- SF-36 Physical and Mental Health Summary Scales: A User's Manual.2nd Ed. The Health Institute, New England Medical Center, Boston, MA1994
- Systematic review of patients presenting with suspected myocardial infarction and non-obstructive coronary arteries.Circulation. 2015; 131: 861-870
- Sex-specific factors in microvascular angina.Can J Cardiol. 2014; 30: 747-755
- Coronary angiogram classification of spontaneous coronary artery dissection.Catheter Cardiovasc Interv. 2014; 84: 1115-1122
- Cardiac MR enables diagnosis in 90% of patients with acute chest pain, elevated biomarkers and unobstructed coronary arteries.Br J Radiol. 2015; 88: 20150025
- Troponin-positive chest pain with unobstructed coronary arteries: incremental diagnostic value of cardiovascular magnetic resonance imaging.Eur Heart J Cardiovasc Imaging. 2016; 17: 1146-1152
- Myocardial Infarction with nonobstructed coronary arteries: impact of CMR early after presentation.JACC Cardiovasc Imaging. 2017; 10: 1204-1206
- The value of a new cardiac magnetic resonance imaging protocol in Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) - a case-control study using historical controls from a previous study with similar inclusion criteria.BMC Cardiovasc Disord. 2017; 17: 199
- Oxygenation-sensitive cardiovascular magnetic resonance.J Cardiovasc Magn Reson. 2013; 15: 43
- Young women with acute myocardial infarction: current perspectives.Circ Cardiovasc Qual Outcomes. 2017; 10: e003480
- Quality and equitable health care gaps for women: attributions to sex differences in cardiovascular medicine.J Am Coll Cardiol. 2017; 70: 373-388
- Acute myocardial infarction in women: a scientific statement from the American Heart Association.Circulation. 2016; 133: 916-947
Article info
Publication history
Published online: January 15, 2018
Accepted:
January 1,
2018
Received:
October 12,
2017
Footnotes
See page 475 for disclosure information.
Identification
Copyright
© 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
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