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A Review of the Evidence for Treatment of Myocardial Infarction With Nonobstructive Coronary Arteries.

ABSTRACT: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is reported in 6% of patients with acute MI referred for catheterization. Because of the complex etiology and a limited amount of evidence, the treatment of MINOCA remains elusive. The etiology of MINOCA manifests from several causes including plaque disruption or erosion, epicardial coronary artery vasospasm, and coronary microvascular dysfunction. In addition, spontaneous coronary artery dissection, takotsubo, and myocarditis have been identified as contributing to the diagnosis of MINOCA. Patients with MINOCA are frequently young, non-white females with fewer traditional risk factors compared with those with an MI caused by obstructive coronary disease. Moreover, women who suffered an MI are 5 times more likely to be diagnosed with MINOCA with a trend for worse outcomes compared with men. The increased recognition/diagnosis of MINOCA has highlighted a gap in our understanding of the treatment of MINOCA. This review identified that there is a paucity of evidence on treatment strategies for patients clinically diagnosed with MINOCA, but more importantly that MINOCA should be viewed as a "syndrome" with many different pathologic causes. This suggests that a standard protocol may not be useful for patients with MINOCA. Given the ongoing debate over the complexity of MINOCA, the main focus in the management of MINOCA should be to identify the underlying mechanism for targeted therapies that may optimize outcomes.

SUBMITTER: Sluchinski SL

PROVIDER: S-EPMC7499383 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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A Review of the Evidence for Treatment of Myocardial Infarction With Nonobstructive Coronary Arteries.

Sluchinski Shelby L SL Pituskin Edith E Bainey Kevin R KR Norris Colleen M CM

CJC open 20200409 5

Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is reported in 6% of patients with acute MI referred for catheterization. Because of the complex etiology and a limited amount of evidence, the treatment of MINOCA remains elusive. The etiology of MINOCA manifests from several causes including plaque disruption or erosion, epicardial coronary artery vasospasm, and coronary microvascular dysfunction. In addition, spontaneous coronary artery dissection, takotsubo, and myoca ...[more]

PMID: 32995725

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Project description:BackgroundThe role of stress hyperglycemia in acute myocardial infarction (AMI) has long been emphasized. Recently, the stress hyperglycemia ratio (SHR), a novel index reflecting an acute glycemia rise, has shown a good predictive value in AMI. However, its prognostic power in myocardial infarction with nonobstructive coronary arteries (MINOCA) remains unclear.MethodsIn a prospective cohort of 1179 patients with MINOCA, relationships between SHR levels and outcomes were analyzed. SHR was defined as acute-to-chronic glycemic ratio using admission blood glucose (ABG) and glycated hemoglobin. The primary endpoint was defined as major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, stroke, revascularization, and hospitalization for unstable angina or heart failure. Survival analyses and receiver-operating characteristic (ROC) curve analyses were performed.ResultsOver the median follow-up of 3.5 years, the incidence of MACE markedly increased with higher SHR tertile levels (8.1%, 14.0%, 20.5%; p < 0.001). At multivariable Cox analysis, elevated SHR was independently associated with an increased risk of MACE (HR 2.30, 95% CI: 1.21-4.38, p = 0.011). Patients with rising tertiles of SHR also had a significantly higher risk of MACE (tertile 1 as reference; tertile 2: HR 1.77, 95% CI: 1.14-2.73, p = 0.010; tertile 3: HR 2.64, 95% CI: 1.75-3.98, p < 0.001). SHR remained a robust predictor of MACE in patients with and without diabetes; whereas ABG was no longer associated with the MACE risk in diabetic patients. SHR showed an area under the curve of 0.63 for MACE prediction. By incorporating SHR to TIMI risk score, the combined model further improved the discrimination for MACE.ConclusionsThe SHR independently confers the cardiovascular risk after MINOCA, and may serve as a better predictor than glycemia at admission alone, particularly in those with diabetes.KEY MESSAGESStress hyperglycemia ratio (SHR) is independently associated with the prognosis in a distinct population with myocardial infarction with nonobstructive coronary arteries (MINOCA).SHR is a better predictor of prognosis than admission glycemia alone, especially in diabetic patients with MINOCA.SHR may serve as a prognostic marker for risk stratification as well as a potential target for tailored glucose-lowering treatment in MINOCA.

Dataset Information

A Review of the Evidence for Treatment of Myocardial Infarction With Nonobstructive Coronary Arteries.

Publications

A Review of the Evidence for Treatment of Myocardial Infarction With Nonobstructive Coronary Arteries.

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