TY - JOUR
T1 - Nonobstructive coronary atherosclerosis is associated with adverse prognosis among patients diagnosed with myocardial infarction without obstructive coronary arteries
AU - Tsaban, Gal
AU - Peles, Ido
AU - Barrett, Orit
AU - Abramowitz, Yigal
AU - Shmueli, Hezzy
AU - Alnsasra, Hilmi
AU - Cafri, Carlos
AU - Zahger, Doron
AU - Koifman, Edward
N1 - Funding Information:
Some limitations of our study should be considered. First, this is a retrospective analysis that relies on data recorded by the attending physicians. A core laboratory did not validate these reports; therefore, some errors in the coronary angiography diagnosis and classifications are possible. Nevertheless, we performed cross-validation of the coronary diagnosis and compared the EMR-based diagnosis with the detailed coronary angiography report; thus, if misclassification of patients exists, its proportion should be negligible. The low 30-day recurrent ACS and mortality event rates observed in our study, which were similar across study groups, also support the assumption that if diagnostic misclassifications were made, they were small in numbers and similar between the study groups. Second, the low rate of MINOCA-related workups, such as CMR or functional tests to elucidate the underlying condition, bundles the entire MINOCA patient population into a single stack, which may include various conditions leading to MINOCA. However, this reflects the current real-world practice characterized by low rates of intracoronary or non-invasive imaging workup and highlights the need to increase the implementation of such tools in routine clinical practice [18]. Third, confounders that were not recorded and thus not included in the analyses might impact prognosis, a potential bias relevant to all historical population-based studies. Nevertheless, we captured all traditional risk factors and conventional prognostic markers and conducted a rigorous multivariable analysis accounting for potential confounders and clinically relevant variables. It is essential, however, to address the findings of this study in the context of possible residual-confounding, and further confirmatory studies to complement and support our findings on the prognostic importance of nonobstructive-CAD in patients with MINOCA are warranted. Fourth, our study is comprised of patient data collected over a considerable period and, thus, is prone to the effects of temporal trends in medicinal and pharmaceutical developments. Despite the inclusive models performed with adjustment to multiple possible confounders, studies involving a more contemporary patient population may add further information on the prognostic importance of nonobstructive-CAD in MINOCA. Fifth, medical diagnoses on which this study was based were derived from EMRs based on ICD-9 codes, thus in cases of nonspecific diagnoses, such as dyslipidemia that can be accounted for hypertriglyceridemia or hypercholesterolemia, we could not be sure of the specific, accurate diagnosis. This is a known limitation of most, if not all, historical registry-based studies; however, dyslipidemia is a complex diagnosis with many definitions that are patient- and era-sensitive and most commonly related to hypercholesterolemia. Also, we did not account for long-term compliance with medical therapy, which may attenuate the association of nonobstructive-CAD with long-term MAE due to possible improved secondary prevention.
Publisher Copyright:
© 2023 Elsevier B.V.
PY - 2023/2/1
Y1 - 2023/2/1
N2 - Background and aims: The prognostic impact of nonobstructive coronary artery disease (CAD), as opposed to normal coronary arteries, on long-term outcomes of patients with myocardial infarction with no obstructive coronary arteries (MINOCA) is unclear. We aimed to address the association between nonobstructive-CAD and major adverse events (MAE) following MINOCA. Methods: We conducted a retrospective cohort study of consecutive MINOCA patients admitted to a large referral medical center between 2005 and 2018. Patients were classified according to coronary angiography as having either normal-coronaries or nonobstructive-CAD. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS). Results: Of the 1544 MINOCA patients, 651 (42%) had normal coronaries, and 893 (58%) had CAD. The mean age was 61.2 ± 12.6 years, and 710 (46%) were females. Nonobstructive-CAD patients were older and less likely to be females, with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal-failure (p < 0.05). At a median follow-up of 7 years, MAE occurred in 203 (23%) patients and 67 (10%) patients in the nonobstructive-CAD and normal-coronaries groups, respectively (p < 0.01). In multivariable models, nonobstructive -CAD was significantly associated with long-term MAE [adjusted-hazard-ratio (aHR):1.67, 95% confidence-interval (95%CI):1.25–2.23; p < 0.001]. Other factors associated with a higher MAE-risk were older-age (aHR:1.05,95%CI:1.03–1.06; p < 0.001) and left ventricular ejection-fraction<40% (aHR:3.04,95%CI:2.03–4.57; p < 0.001), while female-sex (aHR:0.72, 95%CI: 0.56–0.94; p=0.014) and sinus rhythm at presentation (aHR:0.66, 95%CI: 0.44–0.98; p=0.041) were associated with lower MAE-risk. Conclusions: In MINOCA, nonobstructive-CAD is independently associated with a higher MAE-risk than normal-coronaries. This finding may promote risk-stratification of patients with nonobstructive-CAD-MINOCA who require tighter medical follow-up and treatment optimization.
AB - Background and aims: The prognostic impact of nonobstructive coronary artery disease (CAD), as opposed to normal coronary arteries, on long-term outcomes of patients with myocardial infarction with no obstructive coronary arteries (MINOCA) is unclear. We aimed to address the association between nonobstructive-CAD and major adverse events (MAE) following MINOCA. Methods: We conducted a retrospective cohort study of consecutive MINOCA patients admitted to a large referral medical center between 2005 and 2018. Patients were classified according to coronary angiography as having either normal-coronaries or nonobstructive-CAD. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS). Results: Of the 1544 MINOCA patients, 651 (42%) had normal coronaries, and 893 (58%) had CAD. The mean age was 61.2 ± 12.6 years, and 710 (46%) were females. Nonobstructive-CAD patients were older and less likely to be females, with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal-failure (p < 0.05). At a median follow-up of 7 years, MAE occurred in 203 (23%) patients and 67 (10%) patients in the nonobstructive-CAD and normal-coronaries groups, respectively (p < 0.01). In multivariable models, nonobstructive -CAD was significantly associated with long-term MAE [adjusted-hazard-ratio (aHR):1.67, 95% confidence-interval (95%CI):1.25–2.23; p < 0.001]. Other factors associated with a higher MAE-risk were older-age (aHR:1.05,95%CI:1.03–1.06; p < 0.001) and left ventricular ejection-fraction<40% (aHR:3.04,95%CI:2.03–4.57; p < 0.001), while female-sex (aHR:0.72, 95%CI: 0.56–0.94; p=0.014) and sinus rhythm at presentation (aHR:0.66, 95%CI: 0.44–0.98; p=0.041) were associated with lower MAE-risk. Conclusions: In MINOCA, nonobstructive-CAD is independently associated with a higher MAE-risk than normal-coronaries. This finding may promote risk-stratification of patients with nonobstructive-CAD-MINOCA who require tighter medical follow-up and treatment optimization.
KW - All-cause death
KW - Myocardial infarction with no obstructive coronary arteries (MINOCA)
KW - Nonobstructive coronary artery disease (nonobstructive-CAD)
KW - Recurrent acute coronary syndrome (ACS)
UR - http://www.scopus.com/inward/record.url?scp=85146353033&partnerID=8YFLogxK
U2 - 10.1016/j.atherosclerosis.2023.01.005
DO - 10.1016/j.atherosclerosis.2023.01.005
M3 - Article
C2 - 36652749
AN - SCOPUS:85146353033
SN - 0021-9150
VL - 366
SP - 8
EP - 13
JO - Atherosclerosis
JF - Atherosclerosis
ER -
