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FIT Insights

Heart Attacks with Open Arteries:

A Problem Disproportionally Affecting Young Women

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a clinical syndrome in which patients present with the signs and symptoms of a heart attack, but, via angiography, are found to have open arteries1. MINOCA is thought to represent about 1-14% of all heart attacks and is more common in young female patients and ethnic minorities1, 2. MINOCA is a working diagnosis, with multiple different possible causes, including spasm of the coronary artery, disease of the smaller heart vessels, blood clots, takotsubo or broken heart syndrome, coronary artery tear or smaller plaques in the arteries1, 3. The sex differences seen in the rate of MINOCA highlights the unique types of heart attacks that are more commonly seen in women. Prior studies have shown care gaps in the diagnosis, treatment and outcomes of female patients with heart attacks4. In particular, young female patients with heart attacks have been identified as a vulnerable population at continued risk of adverse outcomes5.

In their manuscript, Safdar et al. analyzed the rate and outcomes of young patients (aged 18-55) with heart attacks who were found to have MINOCA as compared to patients with heart attacks caused by blockages in the coronary arteries (MI-CAD) using a cohort of 1,985 patients from the Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO)  study6.

The VIRGO study was a large multi-center observational study of young patients with heart attacks who underwent coronary angiography. They defined MINOCA as any patients without blockages <50% or any patients with alternative types of heart attacks such as coronary artery spasm and coronary dissection. They identified 299 (11.2%) MINOCA patients who met inclusion criteria and 2,374 patients with MI-CAD. Of the MINOCA patients, they identified the cause of heart attack in only 25% of cases. MINOCA patients were younger, more likely to be female, non-white, and with less underlying cardiovascular risk factors such as diabetes and high blood pressure. They were also found to have more clotting disorders. There was no difference in history of autoimmune disorders or complications of pregnancy between the two groups. Chest pain was the most common symptom reported by both groups. Women had 5 times higher odds of presenting with MINOCA than men. Interestingly, outcomes were similar among MINOCA and MI-CAD patients, including mortality, quality of life and perceived stress at 1 month and 12 months after the heart attack.

This study is the first to look at a large cohort of young MINOCA patients and confirms many of the known characteristics. The finding of unknown cause of MI in three quarters of the patients highlights an important knowledge gap in the field of MINOCA. As Agewall et al, detailed in the European Society of Cardiology (ESC) position paper, MINOCA is a working diagnosis; additional diagnostic testing is required to determine the etiology of MI1. It is valuable to consider advanced testing such as cardiac Magnetic Resonance Imaging (MRI) to look for signs of inflammation or scarring.

At NYU, we’re conducting a research study called the Women’s Heart Attack Research Program (HARP) to better understand the causes of heart attack in these women. To do this, we are using a special imaging procedure at the time of angiography called Intracoronary Optical Coherence Tomography (OCT) and cardiac MRI within one week of the heart attack. It is necessary to understand what caused the event to individualize care and provide the necessary treatment. Too often, I encounter MINOCA patients who are frustrated by the uncertainty surrounding their diagnosis. Often, they are told they did not even have a heart attack. This study, in addition to several others, proves that MINOCA patients are, in fact, at elevated risk after their event. These events also have important repercussions on quality of life and stress levels that also should be considered and monitored closely.  It is important these patients are educated appropriately about their heart event; this  may help encourage healthy lifestyle changes, adherence to medications, and follow up with their doctor.
 

Author

Anais Hausvater, MD

Dr. Anais Hausvater, is a cardiology research fellow at NYU School of Medicine. She is sponsored by an American Heart Association grant focused on heart disease in women.

Reference

  1. Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, Atar D, Kaski JC, Sechtem U, Tornvall P and Pharmacotherapy WGoC. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J. 2017;38:143-153.
  2. Pasupathy S, Air T, Dreyer RP, Tavella R and Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015;131:861-70.
  3. Reynolds HR. Mechanisms of myocardial infarction without obstructive coronary artery disease. Trends Cardiovasc Med. 2014;24:170-6.
  4. Berger JS, Elliott L, Gallup D, Roe M, Granger CB, Armstrong PW, Simes RJ, White HD, Van de Werf F, Topol EJ, Hochman JS, Newby LK, Harrington RA, Califf RM, Becker RC and Douglas PS. Sex differences in mortality following acute coronary syndromes. JAMA. 2009;302:874-82.
  5. D'Onofrio G, Safdar B, Lichtman JH, Strait KM, Dreyer RP, Geda M, Spertus JA and Krumholz HM. Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation. 2015;131:1324-32.
  6. Safdar B, Spatz ES, Dreyer RP, Beltrame JF, Lichtman JH, Spertus JA, Reynolds HR, Geda M, Bueno H, Dziura JD, Krumholz HM and D'Onofrio G. Presentation, Clinical Profile, and Prognosis of Young Patients With Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): Results From the VIRGO Study. J Am Heart Assoc. 2018;7.