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Canadian Journal of Cardiology

Myocardial Infarction With No Obstructive Coronary Artery Disease: Angiographic and Clinical Insights in Patients With Premature Presentation

  • Valeria Raparelli
    Affiliations
    Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy

    Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
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  • Malik Elharram
    Affiliations
    Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada

    Department of Experimental Medicine, McGill University, Montreal, Quebec, Canada
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  • Avi Shimony
    Affiliations
    Department of Cardiology, Soroka University Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
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  • Mark J. Eisenberg
    Affiliations
    Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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  • Asim N. Cheema
    Affiliations
    St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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  • Louise Pilote
    Correspondence
    Corresponding author: Dr Louise Pilote, Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, 5252 De Maisonneuve Blvd, Suite B2.39, Montreal, Quebec H4A 3S5, Canada. Tel.: +1-514 934-1934 ×44722; fax: +1-514 843-1676.
    Affiliations
    Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada

    Department of Experimental Medicine, McGill University, Montreal, Quebec, Canada

    Divisions of General Internal Medicine and Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada
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Published:January 15, 2018DOI:https://doi.org/10.1016/j.cjca.2018.01.004

      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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