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Myocardial infarction with non-obstructive coronary arteries

Myocardial infarction with non-obstructive coronary arteries

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Myocardial infarction with non-obstructive coronary arteries

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  1. ANWER GHANI FIBMS IRAQ Myocardial infarction with non-obstructive coronary arteries (MINOCA)

  2. . • Acute coronary syndromes constitute a variety of myocardial injury presentations that include a subset of patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA).

  3. . • Myocardial infarction with non-obstructive coronary arteries (MINOCA) is defined by clinical evidence of myocardial infarction (MI) with normal or near-normal coronary arteries on angiography.

  4. Gross-Sternberg SyndromeBeltrame Syndrome • Acute myocardial infarction (MI) without significant coronary artery disease (CAD) was initially described almost 80 years ago by Gross and Sternberg. • Gross H, Sternberg WH. Myocardial infarction without significant lesions of coronary arteries. Arch Intern Med. 1939; 64:249–267.CrossrefGoogle Scholar • Whereas the term myocardial infarction with non-obstructive coronary arteries (MINOCA) is recent.It has been used by Beltrame to describe these patients Beltrame JF. Assessing patients with myocardial infarction and non‐obstructed coronary arteries (MINOCA). J Intern Med. 2013; 273:182–185.CrossrefMedlineGoogle Scholar

  5. . • MINOCA differs from type 1 myocardial infarction (MI) regarding patient characteristics, presentation, physiopathology, management, treatment, and prognosis.

  6. . • MINOCA patient characteristics differ from those of other Myocardial Infarction and Coronary Artery Disease (MI-CAD) patients because: • MINOCA subjects are younger, are more often female, and tend to have fewer traditional cardiovascular risk factors.

  7. . • In young patients (aged <55 years) presenting with AMI, MINOCA is relatively frequent, occurring in >10% of the population.

  8. Acute Coronary Syndrome • The diagnosis of an acute coronary syndrome should be established according to the fourth universal definition of MI, which is : • when there is evidence of acute myocardial injury accompanied by clinical data suggesting acute myocardial ischaemia such as relevant symptoms, new ischaemic electrocardiogram (ECG) changes, loss of viable myocardium present in imaging, or identification of coronary thrombus.

  9. . • Non-obstructive coronary arteries on angiography, is defined as no coronary artery stenosis ≥ 50% in any potential infarct-related artery. • Clinical criteria and biomarker behaviour of MINOCA remain similar to other acute coronary event.

  10. MINOCA is not an uncommon presentation of acute coronary syndromes • The prevalence of MINOCA is estimated to be 6-9% among patients diagnosed with MI. • With 11% in a recent prospective observational study.

  11. . • MINOCA is more common in women than men. • MINOCA patients presenting with NSTEMI than in those presenting with STEMI. • Two-thirds of MINOCA subjects present ST-segment elevation; • MINOCA patients are younger, are more often female and tend to have fewer cardiovascular risk factors.

  12. . • The risk of reinfarction was higher in the MICAD group, the risk in the MINOCA group was lower. • The mortality was higher among the MICAD pts. • Although the characteristics of patients with MINOCA and their counterparts with AMI and CAD (AMI‐CAD) were different, the mortality rates at 1 month (1.1% versus 0.6%, P=0.43) and 1 year (1.7% versus 2.3%, P=0.68) were not statistically different. (2)

  13. MINOCA is a working diagnosis, and defining the aetiologic mechanism is relevant because it affects patient care and prognosis. • Identification of underlying causes of MINOCA -optimize treatment, - improve prognosis, - promote prevention of recurrent myocardial infarction.

  14. . • The prognosis is extremely variable, depending on the cause of MINOCA.

  15. Classification of myocardial injury and infarction • Cardiac troponin is the only recommended biomarker for the detection of myocardial necrosis, and it is integral to the diagnostic criteria for myocardial infarction.

  16. Classification of myocardial injury and infarction • Myocardial injury is defined by only one criterion: the elevation of cardiac troponin. • A myocardial infarction is a myocardial injury attributed specifically to ischemia, i.e., with clinical evidence of a rise in troponin and at least one of the following: • ischemic symptoms or electrocardiographic changes, • development of pathologic Q waves, • imaging evidence of new loss of viable myocardial or regional wall motion abnormalities consistent with ischemia, and last, • identification of a coronary thrombus by angiography or autopsy.

  17. Classification of myocardial injury and infarction • The classification distinguishes between type 1 myocardial infarction due to thrombosis of an atherosclerotic plaque and • type 2 myocardial infarction due to myocardial oxygen supply-demand imbalance in the context of another acute illness. • Myocardial infarctions presenting as sudden death (type 3), • or after percutaneous coronary intervention (type 4) • and coronary artery bypass grafting (type 5) are also defined.

  18. Classification of myocardial injury • Acute nonischemic myocardial injury:Acute myocardial injury (rise and fall in biomarkers [cTn]) in the absence of a primary ischemic cause (ie, absence of MI) • Chronic myocardial injury:Chronic myocardial injury (cTn >99th percentile URL without an acute change). • Acute myocardial injury is classified where troponin concentrations are elevated with evidence of dynamic change in the absence of overt myocardial ischaemia, whereas in chronic myocardial injury troponin concentrations remain unchanged on serial testing.

  19. The most common causes of MINOCA • coronary plaque disease, • coronary dissection, • coronary artery spasm, • coronary microvascular spasm, • Takotsubo cardiomyopathy, • Myocarditis, • coronary thromboembolism, • other forms of type 2 myocardial infarction and MINOCA of uncertain aetiology.

  20. Mechanisms of myocardial injury It is now recognised that cardiac troponin may be released out with the context of myocardial ischaemia and necrosis, with several purported mechanisms. • Cardiomyocytes undergo mechanical stretch in response to pressure or volume overload, and this may trigger activation of intracellular proteases associated with intracellular degradation of troponin. • Furthermore, there is evidence that tachycardia may stimulate stress-responsive integrins within the cardiomyocyte, triggering release of intact cardiac troponin I from viable cardiomyocytes in the absence of necrosis.

  21. Due to multiple potential causes, MINOCA should be considered rather as a working diagnosis after coronary angiography and further efforts should be taken to define the cause of MI in each individual patient. • The MINOCA is a working diagnosis that requires a further diagnostic work-up by • invasive techniques, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) or • non-invasive imaging with cardiac magnetic resonance imaging (CMRI).

  22. . • When it is ascertained that obstructive coronary artery disease has not been inadvertently overlooked, other coronary disorders, such as • plaque rupture or erosion, • Thrombosis, • Dissection, • spasms • or microvascular dysfunction should be evaluated. • Furthermore, myocarditis or tako-tsubo cardiomyopathy should be excluded by CMRI as non-coronary causes.

  23. In the absence of relevant coronary artery disease, myocardial ischaemia might be triggered by an acute event in epicardial coronary arteries, coronary microcirculation, or both. • Epicardial causes of MINOCA include coronary plaque disruption, coronary dissection, and coronary spasm. • Microvascular MINOCA mechanisms involve microvascular coronary spasm, takotsubo syndrome (TTS), myocarditis, and coronary thromboembolism. • Patients with elevated cardiac markers due to presumed myocarditis or Takotsubo were not included in the VIRGO registry.

  24. . • Coronary angiography with non-significant coronary stenosis and left ventriculography are first-line tests in the differential study of MINOCA patients.

  25. MINOCA is not a benign diagnosis, and its polymorphic forms differ in prognosis. • . MINOCA care varies across centres, and future multi-centre clinical trials with standardized criteria may have a positive impact on defining optimal cardiovascular care for MINOCA patients.

  26. Epicardial causes of MINOCA • Coronary artery disease (plaque rupture) • DX: IVUS/OCT, FFR/iFR • RX: Antiplatelet therapy, statins, ACEi/ARB, beta-blockers Studies of intracoronary imaging have shown that ≈40% of patients with MINOCA have some evidence of plaque disruption. Since coronary angiography cannot evaluate the vascular lumen, intracoronary imaging modalities such as intravascular ultrasound (IVUS) might play a determinant role in evaluating the lesion. • IVUS: Intravascular ultrasound; OCT: Optical coherence tomography; FFR: Fractional flow reserve; iFR: Instantaneous wave-free ratio.. • Although intravascular ultrasound is helpful in demonstrating plaque rupture, optical coherence tomography is a better tool for identifying patients with plaque erosion and may be superior for the assessment of patients with spontaneous coronary artery dissection.(2)

  27. Epicardial causes of MINOCA • Coronary dissection • DX: IVUS/OCT • RX: Beta-blocker and simple antiplatelet therapy.

  28. Epicardial causes of MINOCA • Coronary artery spasm • DX: Intracoronary nitrates, intracoronary Ach or ergonovine test by experienced teams • RX: Calcium antagonists, nitrates.

  29. Microvascular causes of MINOCA • Microvascular coronary spasm • DX: Objective evidence of ischaemia (ECG, LV wall motion abnormalities, PET). Impaired microvascular function (CFR, intracoronary Ach test, abnormal CMR, slow coronary flow) • RX: Beta-blockers and nitrates, calcium antagonist, possibly ranolazine • CMR: Cardiac magnetic resonance; PET: Positron emission tomography.

  30. Microvascular causes of MINOCA • Takotsubo syndrome • DX: Ventriculography, echocardiography, troponin, B-natriuretic peptide, CMR • RX: Heart failure treatment, mechanical support in cardiogenic shock.

  31. Microvascular causes of MINOCA • Myocarditis • Dx: CMR, EMB, viral serologies, high c-reactive protein • Rx: Heart failure treatment if complication, autoimmune therapy in autoimmune forms. • EMB: Endomyocardial biopsies.

  32. Microvascular causes of MINOCA • Coronary embolism • Dx: History of potential thromboembolic sources, thrombophilia screen, TTE, TOE, bubble contrast echography • Rx: Antiplatelet therapy, anticoagulation, transcatheter closure or surgical repair.

  33. . • Among patients with AMI, there is a higher prevalence of nonobstructive coronary arteries among women, particularly young women. Nevertheless, the prognosis for young women with AMI is worse than that for young men.It is possible that this result is due to suboptimal (less aggressive and/or less targeted) therapeutic strategies in patients with “nonatherosclerotic” AMI. (2)

  34. . • Discharge therapies (eg, aspirin, β‐blockers, angiotensin‐converting enzyme inhibitors and angiotensin receptor II blockers, and statins) were less frequently prescribed for MINOCA patients. • Favorable outcomes when MINOCA patients were treated with β‐blockers, angiotensin‐converting enzyme inhibitors and angiotensin receptor II blockers, and statins, but no significant benefits were observed with P2Y12 inhibitors.

  35. Summary • MINOCA has comparable outcomes to MI‐CAD up to 1 year of follow‐up. Nevertheless, there is a paucity of evidence‐based data to guide our approach to the evaluation and management of MINOCA patients. • This results in variable and suboptimal practice patterns and disparities in care. The time has come to make a change!

  36. References • 1- Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions. Rafael Vidal-Perez, Charigan Abou Jokh Casas, Rosa Maria Agra-Bermejo, Belén Alvarez-Alvarez, Julia Grapsa, Ricardo Fontes-Carvalho, Pedro Rigueiro Veloso, Jose Maria Garcia Acuña, and Jose Ramon Gonzalez-Juanatey. World J Cardiol. 2019 Dec 26; 11(12): 305–315. • 2- Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): It's Time to Face Reality! Jacqueline E. Tamis‐Holland, and Hani Jneid. Originally published28 Jun 2018https://doi.org/10.1161/JAHA.118.009635Journal of the American Heart Association. 2018;7:e009635. • 3- Assessment and classification of patients with myocardial injury and infarction in clinical practice. Andrew R Chapman, Philip D Adamson, http://orcid.org/0000-0003-1926-5925Nicholas L Mills.Heart 2017;103:10-18.

  37. THANKS

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