Predictors of poor clinical outcomes in patients with acute myocardial infarction and non-obstructed coronary arteries (MINOCA). (15th September 2018) - Ciliberti, Giuseppe
Abstract: Objective: To assess the characteristics and prognosis of patients with myocardial infarction and non-obstructed coronary arteries (MINOCA). Methods: MINOCA was defined as acute myocardial infarction (AMI) with angiographic coronary stenosis <50%.Cardiomyopathies and myocarditis were — a priori — excluded from the study. Stenoses <30% were considered normal coronary arteries (NCA); stenoses ≥30% but <50% were considered mild coronary artery disease (MCAD). Patients were subdivided in 3 groups: I) NCA (0 vessels; stenosis <30%); II) 1–2 vessels showing MCAD and III) MCAD in 3 vessels or the left main stem (LMS). Results: From January 2006 to December 2014, 7935 consecutive AMI patients were entered into our institutional database;150 (2%) were diagnosed as having MINOCA. At a median follow-up of 7.1 years the composite end-point (cardiovascular death, AMI or acute coronary syndrome, heart failure, stroke) occurred in 23 patients (17.4%). Survival analysis showed no differences between NCA versus MCAD ( p = 0.781). When assessed by distribution of CAD, group III had a lower event-free survival compared to group I and group II, respectively 54 ± 14%, 83 ± 4% and 90 ± 5% ( p = 0.001). In a multivariate model, only 3 vessel disease or LMS involvement (HR = 23.5, 95% CI 2.59–173.49, P = 0.001) and high C-reactive protein at hospital admission (HR = 1.47, 95% CI 1.06–2.07, P = 0.005) were significant predictors of the study composite endpoint. Conclusions: In patients with MINOCA, the presence of NCA or 1–2 vessel MCAD was associated with better long-term clinical outcomes compared with patients with MCAD affecting 3 vessels or the LMS. Increased CRP concentrations on hospital admission were also a marker of worse clinical outcome during follow-up. Highlights: MINOCA is a challenging working diagnosis. A new standard definition of MINOCA has recently been proposed. MINOCA patients with MCAD affecting 3 vessels and/or the LMS have a guarded prognosis. MINOCA patients with increased CRP levels may require more aggressive treatment. Systematic assessment of both number of coronary vessels showing MCAD and CRP levels may improve prognostic scores in MINOCA patients.