The importance of evaluating patients with MINOCA (myocardial infarction with non-obstructive coronary arteries)

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.

Revisiting the use of the provocative acetylcholine test in patients with chest pain and nonobstructive coronary arteries: A five-year follow-up of the AChPOL registry, with special focus on patients with MINOCA

This study aimed to assess the angiographic characteristics, feasibility and safety of the provocative test with acetylcholine (AChT), and the influence on further treatment and prognosis of Middle European patients in 5-year follow-up, especially focusing on those with a history of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA). The AChPOL Registry was an ongoing prospective single-center registry that included patients undergoing AChT from December 2010 to March 2013 for further diagnostic evaluation of a suspicious variant angina or coronary microvascular spasm, based on the COVADIS criteria. AChT was injected in incremental doses of 25, 50, and 75µg into the right coronary artery and 25, 50, and 100 µg into the left coronary artery, and the patients were followed up for 5 years. We enrolled 211 patients in the AChPOL Registry. Their mean age was 60.5 ± 7.8 years, with women accounting for 67.8%. The median follow-up was 56 months. AChT revealed variant angina in 99 patients (46.9%) and coronary microvascular spasm in the remaining 72 patients (34.1%). In patients with variant angina, spasm was most frequently observed in the left anterior descending artery (89.9%) and was most frequently diffuse (61.6%). In the microvascular spasm subgroup, there was a significantly higher rate of recurrent chest pain requiring hospitalization in the follow-up than in AChT negative patients. Interestingly, patients with a history of MINOCA had higher rates of MI and recurrent chest pain requiring hospitalization in the follow-up. We showed that AChT was safe in Middle European patients. In the follow-up patients with microvascular spasm and a history of MINOCA had the highest risk of MI and recurrent chest pain requiring hospitalization.

Clinical and electrocardiographic features of patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA)

AIMS

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is often an underdiagnosed and undertreated condition. This study aimed to evaluate clinical and ECG characteristics of MINOCA in a large cohort of patients admitted for acute coronary syndrome.

METHODS

All coronary angiograms performed at the University Heart Center in Zurich (Switzerland) between 2012 and 2016 were investigated. MINOCA was defined according to European Society of Cardiology guidelines and patients were divided into two groups, based on the presence or absence of coronary sclerosis at angiogram[nonobstructive coronary artery disease (noCAD) and normal coronary arteries (NCA)]), after exclusion of myocarditis and Takotsubo syndrome.

RESULTS

Out of 13 669 angiographic studies, 3695 were diagnosed with acute coronary syndrome; of these, 244 patients presented MINOCA (6.6%). Patients with noCAD were more likely to be older (67.9 vs. 59.2 years, P < 0.001) with higher prevalence of traditional cardiovascular risk factors (hypertension 64.1 vs. 41.2%, P = 0.002; diabetes 19.7 vs. 10.8%, P = 0.036; hypercholesterolemia 36.6 vs. 23.5%, P = 0.037). On surface ECG, anterior ST- segment elevation was more frequent in NCA patients (13.7 vs. 5.0%, P = 0.016). Secondary prevention therapy was significantly more prescribed in noCAD compared with NCA patients (acetylsalicylic acid 68.3 vs. 21.6%, P less than 0.001; statins 76.1 vs. 22.5%, P less than 0.001; angiotensin-converting enzyme inhibitor-AT1 blockers 51.4 vs. 31.3%, P = 0.006). One-year mortality was very low (0.4% for noCAD patients).

CONCLUSION

noCAD patients were older, with higher prevalence of cardiovascular risk factors and more frequently discharged with secondary prevention therapy. NCA patients presented more frequently anterior ST- segment elevation. Further diagnostic tests should be highly recommended to determine the underlying mechanism of MINOCA.

Prognostic Value of the Neutrophil-to-Lymphocyte Ratio in Patients With Myocardial Infarction With Non-obstructive Coronary Arteries

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous entity with an inflammatory etiopathogenesis. This study investigated the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in patients with MINOCA. Coronary angiographies performed between June 2015 and August 2018 were analyzed retrospectively and included 72 patients with MINOCA and 248 controls with normal coronary angiograms. The predictors of mortality were determined by univariate Cox regression analysis. The mean age of the subjects was 46 ± 9 years, and 176 (55%) were female. Median follow-up was 21 (max: 42) months. Neutrophil-to-lymphocyte ratio was significantly higher in the MINOCA group than in the controls (P < .01). During long-term follow-up, the number of deaths was 6 in the MINOCA group and none in the control patients (P < .01). Univariate Cox regression analysis revealed that the NLR (hazard ratio: 1.24, 95% confidence interval: 1.09-1.41, P = .001) was a predictor of mortality in patients with MINOCA. Kaplan-Meier analysis also showed that patients with MINOCA had relatively higher mortality rate (long-rank test; P < .01). In conclusion, the NLR is significantly higher in patients with MINOCA compared with controls, and it is a predictor of long-term mortality.

The Myocardial Bridge: Potential Influences on the Coronary Artery Vasculature

A myocardial bridge (MB) is an anatomical abnormality of the coronary artery and is characterized by the systolic narrowing of the epicardial coronary artery caused by myocardial compression during systole. An MB is frequently observed on cardiac computed tomography or coronary angiography and generally appears to be harmless in the majority of patients. However, the presence of MB is reportedly associated with abnormalities of the cardiovascular system, including coronary artery diseases, arrhythmia, certain types of cardiomyopathy, and cardiac death, indicating that MB serves a pivotal role in the occurrence and/or development of such cardiovascular events. Recently, there has been an increasing interest in the coexistence of MB and coronary spasm in research due to opposing aspects regarding their treatments. For example, monotherapy using β-blockers, which are effective in patients with MB, may worsen symptoms in patients with coronary spasm. By contrast, nitroglycerin, which is an effective treatment option for coronary spasm, may worsen symptoms in patients with MB. This review focuses on the pathophysiology and diagnosis of MB and MB-related cardiovascular diseases, including coronary spasm, and on the treatment strategies for MB.

Modern Management of ST-Segment Elevation Myocardial Infarction

Disruption of intracoronary plaque with thrombus formation resulting in severe or total occlusion of the culprit coronary artery provides the pathophysiologic foundation for ST-segment elevation myocardial infarction (STEMI). Management of STEMI focuses on timely restoration of coronary blood flow along with antithrombotic therapies and secondary prevention strategies. The purpose of this review is to discuss the epidemiology, pathophysiology, and diagnosis of STEMI. In addition, the review will focus on guideline-directed therapy for these patients and review potential associated complications.

Presentation, Clinical Profile, and Prognosis of Young Patients With Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): Results From the VIRGO Study

BACKGROUND

We compared the clinical characteristics and outcomes of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) versus obstructive disease (myocardial infarction due to coronary artery disease [MI-CAD]) and among patients with MINOCA by sex and subtype.

METHODS AND RESULTS

Between 2008 and 2012, VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) prospectively enrolled acute myocardial infarction patients aged 18 to 55 years in 103 hospitals at a 2:1 ratio of women to men. Using an angiographically driven taxonomy, we defined patients as having MI-CAD if there was revascularization or plaque ≥50% and as having MINOCA if there was <50% obstruction or a nonplaque mechanism. Patients who did not have an angiogram or who received thrombolytics before an angiogram were excluded. Outcomes included 1- and 12-month mortality and functional (Seattle Angina Questionnaire [SAQ]) and psychosocial status. Of 2690 patients undergoing angiography, 2374 (88.4%) had MI-CAD, 299 (11.1%) had MINOCA, and 17 (0.6%) remained unclassified. Women had 5 times higher odds of having MINOCA than men (14.9% versus 3.5%; odds ratio: 4.84; 95% confidence interval, 3.29-7.13). MINOCA patients were more likely to be without traditional cardiac risk factors (8.7% versus 1.3%; P<0.001) but more predisposed to hypercoaguable states than MI-CAD patients (3.0% versus 1.3%; P=0.036). Women with MI-CAD were more likely than those with MINOCA to be menopausal (55.2% versus 41.2%; P<0.001) or to have a history of gestational diabetes mellitus (16.8% versus 11.0%; P=0.028). The MINOCA mechanisms varied: a nonplaque mechanism was identified for 75 patients (25.1%), and their clinical profiles and management also varied. One- and 12-month mortality with MINOCA and MI-CAD was similar (1-month: 1.1% and 1.7% [P=0.43]; 12-month: 0.6% and 2.3% [P=0.68], respectively), as was adjusted 12-month SAQ quality of life (76.5 versus 73.5, respectively; P=0.06).

CONCLUSIONS

Young patients with MINOCA were more likely women, had a heterogeneous mechanistic profile, and had clinical outcomes that were comparable to those of MI-CAD patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.