Multimodality Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women and Men
Abstract
BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) has several underlying causes, including mimicking conditions in some cases. Imaging is recommended to identify MINOCA etiologies, but it remains unclear which patients are most likely to have abnormal findings. We characterized MINOCA mechanisms, analyzed predictors of imaging abnormalities, and explored sex differences. METHODS: We enrolled patients with clinical diagnosis of myocardial infarction in an international, prospective, diagnostic study at 28 sites in the United States, Canada and United Kingdom. After a women-only phase, we included both sexes. Individuals with ≥50% diameter stenosis or coronary dissection on angiography, or alternate causes for the clinical presentation, were excluded. Participants had multivessel coronary optical coherence tomography (OCT) during index coronary angiography and cardiac magnetic resonance imaging (CMR) within 1 week. Independent core laboratories interpreted imaging, blinded to other results. RESULTS: Among 754 patients enrolled, 389 had MINOCA, and 336 with MINOCA underwent OCT (270 women and 66 men); CMR was completed in 284 (85%). An OCT-defined culprit lesion was identified in 45% (116 of 270 women [43%] and 35 of 66 men [53%], P =0.18). CMR demonstrated an ischemic pattern in 114 of 284 (40%), similar by sex (96 of 225 women [43%] versus 18 of 59 men [31%], P =0.12). A nonischemic pattern was observed in 23% (23% of women, 25% of men, P =0.78). We identified a cause of the clinical presentation in 79% of patients with both tests completed; 59% had an ischemic cause of MINOCA, and 20% had a non-ischemic mimicking condition. OCT alone found a MINOCA etiology in 151 of 336 (45%) and CMR alone in 180 of 284 (63%). Predictors of an OCT culprit lesion included age, abnormal angiogram, and number of vessels imaged, but 27% of normal angiograms harbored a culprit lesion. Predictors of abnormal CMR were peak troponin, shorter time to CMR, and non-Asian race, but CMR was abnormal in 40% when troponin was <4-fold above the upper reference limit. CONCLUSIONS: The combination of multivessel coronary OCT and CMR in patients with a clinical diagnosis of MINOCA confirmed myocardial infarction in 59% and identified an alternate cause (MINOCA mimic) in 20%. Clinical factors had limited usefulness to predict imaging abnormalities. No sex differences in imaging results were detected. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02905357.
Article Details
Authors (83)
Hayder D. Hashim
Section of Interventional Cardiology, Medstar Washington Hospital Center, Washington, D.C. (H.D.H.).
Kevin R. Bainey
Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada (K.R.B.).
Aun-Yeong Chong
University Of Ottawa Heart Institute, Ottawa, ON, Canada (A.-Y.C.).
Jennifer A. Tremmel
Stanford University Medical Center, Stanford, CA (J.A.T.).
Harmony Reynolds
Nathaniel Smilowitz
Sripal Bangalore
Michael Attubato
Departments of Medicine (H.R.R., N.R.S., A.S., A. Hausvater, Y.X., S.B., M.A., L.V.L., A. Holden, C.Y., J.S.H.), NYU Grossman School of Medicine, New York, NY.
Lori Vales Lay
Departments of Medicine (H.R.R., N.R.S., A.S., A. Hausvater, Y.X., S.B., M.A., L.V.L., A. Holden, C.Y., J.S.H.), NYU Grossman School of Medicine, New York, NY.
Sunil Rao
Binita Shah
Department of Cancer Biology, Dana-Farber Cancer Institute
Lindsay Elbaum
Louai Razzouk
NYU Langone Health and NYU School of Medicine, Department of Medicine, Division of Cardiology, New York
Rafael Harari
Stylianos Papadakos
Claudia Serrano Gomez
Craig Thompson
Jeffrey Trost
Jon Resar
Ehtisham Mahmud
Catalin Toma
Janet Wei
Tara Sedlak
Vancouver General Hospital, Vancouver, BC, Canada (T.S., J.S.).
Jacqueline Saw
Vancouver General Hospital, Vancouver, BC, Canada (T.S., J.S.).
Jonathon Leipsic
From Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ (P.G.); Columbia University Medical Center/New York Presbyterian Hospital (A.S., R.T.H., M.B.L.), the Cardiovascular Research Foundation (D.J.C., R.T.H., B.R., M.B.L.), and Weill Cornell Medicine (B.R.), New York, and St. Francis Hospital and Heart Center, Roslyn (D.J.C.) — all in New York; University of Colorado Health, Medical Center of the Rockies, Loveland (J.B.O.); Laval University, Quebec, QC (P.P.), St. Paul’s Hospital, University of British Columbia, Vancouver (P.B., J.L.), and McMaster University, Hamilton, ON (T.S.) — all in Canada; Vanderbilt University Medical Center, Nashville (B.R.L., K.G.); Emory University, Atlanta (V.B.); the Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University, Stanford (W.F.F.), VA Palo Alto Health Care System, Palo Alto (W.F.F.), California Pacific Medical Center, San Francisco (D.V.D.), Cedars–Sinai Medical Center, Los Angeles (R.R.M.), and Edwards ...
Anthony Fung
David Wood
Laxmi Mehta
Kevin Marzo
Juan Gaztanaga
Nisha Jhalani
Dwithiya Thomas
Luis Tejada
Marcus Averbach
Peter Puleo
Caitlin Giesler
Peter Monteleone
Ascension Texas Cardiovascular, University of Texas Austin Dell School of Medicine, Austin
Puja K. Mehta
Emory Women’s Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (P.K.M.).
Bina Ahmed
Eric Rothstein
Kevin Bainey
Bryan Har
Foothills Medical Center, University of Calgary, Calgary, AB, Canada (B.H.).
Bobak Heydari
Jennifer A Tremmel
Shuangbo Liu
Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada (S.L.).
Odayme Quesada
Hayder Hashim
Toby Rogers
Itsik Ben-Dor
Nida Syed
Aun Yeong Chong
Derek So
Thais Coutinho
Natalia Pinilla Echeverri
Department of Medicine, McMaster University, Hamilton, ON, Canada (N.P.E.).
Tej Sheth
Population Health Research Institute, McMaster University, Hamilton, ON, Canada
Matthew Sibbald
Atul Sharma
Alexander Slotwiner
George Fernaine
Boutros Karam
Yader Sandoval
Allina Health Minneapolis Heart Institute, Abbott Northwestern Hospital and Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation Minneapolis
Joao Cavalcante
Akl C. Fahed
Brian Case
Tomas Cieza
Colin Berry
Akiko Maehara
Takagi Hospital, Fukuoka, Japan (A.M.).
Mitsuaki Matsumura
Cardiovascular Research Foundation, New York, NY (A.M., M.M.).
Bobby Heydari
Departments of Medicine and Radiology, Brigham and Women’s Hospital, Boston, MA (B.H.).
Raymond Y. Kwong
Mobeen Ahmed
Department of Medical Imaging, Western University, London, ON, Canada (M.A.).
Ayako Seno
Harmony R. Reynolds
Nathaniel R. Smilowitz
Departments of Medicine (H.R.R., N.R.S., A.S., A. Hausvater, Y.X., S.B., M.A., L.V.L., A. Holden, C.Y., J.S.H.), NYU Grossman School of Medicine, New York, NY.
Anais Hausvater
Departments of Medicine (H.R.R., N.R.S., A.S., A. Hausvater, Y.X., S.B., M.A., L.V.L., A. Holden, C.Y., J.S.H.), NYU Grossman School of Medicine, New York, NY.
Judith S. Hochman
Departments of Medicine (H.R.R., N.R.S., A.S., A. Hausvater, Y.X., S.B., M.A., L.V.L., A. Holden, C.Y., J.S.H.), NYU Grossman School of Medicine, New York, NY.
Alair Holden
Departments of Medicine (H.R.R., N.R.S., A.S., A. Hausvater, Y.X., S.B., M.A., L.V.L., A. Holden, C.Y., J.S.H.), NYU Grossman School of Medicine, New York, NY.
Ellen Hada
Michelle Shum
Jessica Rodriguez
Glycobiology Research and Training Center, University of California San Diego
Yuhe Xia
Departments of Medicine (H.R.R., N.R.S., A.S., A. Hausvater, Y.X., S.B., M.A., L.V.L., A. Holden, C.Y., J.S.H.), NYU Grossman School of Medicine, New York, NY.
Chang Yu
Hua (Judy) Zhong