Comparing pharmacotherapy in MINOCA versus medically managed obstructive acute coronary syndrome

Prognostic factors of MINOCA and their possible mechanisms

Objective

Despite not showing substantial stenosis of coronary arteries, Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) presents with myocardial ischemia injury, thus having a grave prognosis and a high risk of long-term complications. This necessitates increased clinical attention and exploration of its root causes to prevent a similar crisis.

Methods

Research on MINOCA is limited, especially in terms of its clinical attributes, long-term outlook, risk stratification, and prognosis-linked cardiometabolic risk factors. This review aims to fill these gaps, providing an extensive overview of clinical trials and studies on MINOCA to separate the issue from the presence of non-obstructive coronary arteries in cardiac patients.

Results

It has been found that MINOCA patients still face a high risk of long-term adverse events. Due to social and physiological factors, the hospital mortality rate is higher among women, and they are also more susceptible to MINOCA. Cardiac metabolic risk factors, including disorder of glucose and lipid metabolism, as well as changes in serum CysC levels, have significant impacts on the occurrence and prognosis of MINOCA.

Conclusions

Further research is still needed to fully understand the complex biological mechanisms underlying the prognostic factors of MINOCA. A profound understanding of these factors could reveal potential targets for improving prognosis, thereby indicating new strategies for managing this cardiovascular condition.

Outcomes and Medical Therapy in Myocardial Infarction With Nonobstructive Coronary Arteries: A Systematic Review and Meta-Analysis

Myocardial infarction with nonobstructive coronary arteries (MINOCAs) is a disease that has been poorly characterized with unclear clinical and therapeutic outcomes. The association of medical therapy with cardiovascular outcomes in patients with MINOCA has been inadequately assessed. The purpose of this meta-analysis is to evaluate the association of MINOCA at risk of adverse cardiovascular outcomes as compared with myocardial infarction with coronary artery disease (MICAD) and the efficacy of medical therapy in reducing the risk of adverse outcomes. A literature search was conducted for studies reporting on the association of MINOCA at risk of adverse outcomes as compared with MICAD. A literature search was also conducted for studies reporting on the association of medical therapy at risk of adverse outcomes in patients with MINOCA. A total of 29 studies with 893,134 participants met inclusion criteria comparing MINOCA to MICAD. Patients with MINOCA had a significantly lower risk of adverse outcomes as compared with MICAD. Nine studies with 27,731 MINOCA patients met inclusion criteria for evaluating the utility of medical therapy. Medical therapy did not significantly reduce risk of MACE; however, there was a trend toward lower risk in patients treated with β blockers. In conclusion, our results suggest that MINOCA is associated with a lower risk of in-hospital and long-term adverse outcomes compared with MICAD. Standard medical therapy is not associated with a lower risk of adverse cardiovascular outcomes in patients with MINOCA. Additional high-quality studies are required to evaluate the utility of specific medication classes for the treatment of specific etiologies of MINOCA.

Sex differences in treatment and outcomes amongst myocardial infarction patients presenting with and without obstructive coronary arteries: a prospective multicentre study

Aims

Women have an increased prevalence of myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA). Whether sex differences exist in the outcomes of patients with MI and obstructive coronary arteries (MIOCA) vs. MINOCA remains unclear. We describe sex-based differences in diagnosis, treatment, and clinical outcomes of patients with MINOCA vs. MIOCA.

Methods and results

A large-scale cohort study of patients with ST/non-ST elevation MI undergoing coronary angiography (01/2015-12/2019). Patient demographics, diagnosis, prescribed discharge medications, in-hospital complications, and follow-up data were prospectively collected. A total of 13 202 participants were included (males 68.2% and females 31.8%). 10.9% were diagnosed with MINOCA. Median follow-up was 4.62 years. Females (44.8%) were as commonly diagnosed with MINOCA as males (55.2%), unlike the male preponderance in MIOCA (male, 69.8%; female, 30.2%). Less secondary prevention medications were prescribed at discharge for MINOCA than MIOCA. There was no difference in mortality risk between MINOCA and MIOCA [in-hospital: adjusted odds ratio (OR) 1.32, 95% confidence interval (CI) 0.74-2.35, P = 0.350; long term: adjusted hazard ratio (HR) 1.03, 95% CI 0.81-1.31, P = 0.813]. MINOCA patients had reduced mortality at long-term follow-up if prescribed secondary prevention medications (aHR 0.64, 95% CI 0.47-0.87, P = 0.004). Females diagnosed with MIOCA had greater odds of in-hospital and 1-year mortality than males (aOR 1.50, 95% CI 1.09-2.07, P = 0.014; aHR 1.18, 95% CI 1.01-1.38, P = 0.048).

Conclusion

MINOCA patients have similar mortality rates as MIOCA patients. MINOCA patients were less likely than those with MIOCA to be discharged with guideline-recommended secondary prevention therapy; however, those with MINOCA who received secondary prevention survived longer. Females with MIOCA experienced higher mortality rates vs. males.

MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.

Do Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries Have Similar Prognosis Compared to Ones with MI-CAD?

Acute myocardial infarction (AMI) is a leading cause of morbidity and mortality worldwide and it is primarily caused by acute plaque disruption and coronary occlusion. Recent studies suggest that myocardial infarction with non-obstructive coronary arteries (MINOCA) also occurs but the underlying mechanisms have not been fully understood until recently. The evidence also suggests that the clinical outcomes of patients presenting with MINOCA are similar to AMI patients with obstructive coronary artery disease (MI-CAD), including all-cause mortality and major adverse cardiovascular events. The present narrative review considers the risk factors, pathological changes, and outcomes associated with MINOCA and compares them with MI-CAD.