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Myocardial Infarction without Coronary Arterial Obstruction: The Mysterious MINOCA

Disclosure: None
Pub Date: Wednesday, March 27, 2019
Author: Joseph S. Alpert, MD
Affiliation: University of Arizona, Sarver Heart Center

Citation

Tamis-Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM, Lerman A, Cushman M, Kumbhani DJ, Arslanian-Engoren C, Bolger AF, MD, Beltrame JF, on behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on  Epidemiology and Prevention, and Council on Quality of Care and Outcomes Research. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. [published online ahead of print March 27, 2019]. Circulation. doi: 10.1161/CIR.0000000000000670.

Article Text

The first time that I heard the term MINOCA, it made me think that perhaps this referred to an ancient civilization in Greece contemporaries of the Minoans on Crete. I imagined the following headline: “Archeologists unearth the remains of one of the cities of Minoca in northern Greece”. Of course, for cardiologists, MINOCA has nothing to do with ancient Greece. Rather, MINOCA refers to the 5-10% of acute myocardial infarction (MI) patients with minimal to no discernable high grade, critical, coronary arterial stenoses (Myocardial INfarction with Nonobstructed Coronary Arteries. The majority of these patients reported in the medical literature are post-menopausal females, and exactly what is appropriate therapy for these individuals remains unclear. Angioplasty is not a viable therapeutic intervention for a MINOCA patient since there is an absence of high-grade coronary arterial stenoses or occlusions. However, despite the lack of severe coronary arterial stenoses, MINOCA patients frequently do have manifestations of atherosclerotic disease in other territories, for example, peripheral vascular disease1. In addition, mortality rates are substantial for MONICA patients in the years following their MINOCA event. In the nationwide, Swedish SWEDEHEART registry (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapy), 14% of these patients died during a 4.5 year followup1.

Although not termed MINOCA in the past, this entity has been known for many years2 with a number of possible pathophysiologic mechanisms suggested, including transient coronary arterial spasm, coronary arterial embolization, endothelial dysfunction, coronary arterial dissection, and even occlusion of a small coronary arterial branch that was missed on angiography. A number of clinical observers have even suggested that some of these individuals might have had a Takatsubo event, a myocardial injury in the absence of clinically significant coronary arterial obstruction. However, patients with Takatsubo syndrome were excluded from the analysis of Nordenskjold et al1. Recently, the 4th edition of the Universal Definition of Myocardial Infarction devoted a separate section to MINOCA3 and worked closely with the authors of the present AHA statement to make sure that the material in the two documents was consistent. Because the underlying pathophysiology and optimal therapy for these patients remains unclear, additional research in this area is needed.

The majority of MINOCA patients described in the literature are older women with atherosclerotic risk factors such as diabetes mellitus, hypertension, and hyperlipidemia. In a recently published investigation in The American Journal of Medicine, the SWEDEHEART investigators extracted information from their national registry concerning MINOCA patients who had suffered a recurrent MI. They observed that approximately 6% of MINOCA patients subsequently suffered a second MI4. Coronary angiography at the time of the second MI revealed that half of the MINOCA patients with a recurrent MI had developed clinically important coronary arterial stenoses since their last coronary angiogram. In other words, there had been progression of the atherosclerotic disease process in half of the patients. The second MI occurred on average approximately 2 years after the initial MINOCA event. As noted above, the prognosis for MINOCA patients was not benign and worsened further with the second MI. Twenty-two percent of the MINOCA patients in the SWEDEHEART registry who developed a re-infarction died during a 3.5 year follow-up. Half of the deaths were from cardiovascular causes.

Recently, Opolski and colleagues studied 38 patients with MINOCA with optical coherence tomography (OCT) and magnetic resonance5 imaging. OCT is a technique that enables visualization of the coronary arterial lumen. These investigators observed that MINOCA patients often had atherosclerotic plaque disruption and thrombosis as well as evidence for ischemic injury of the myocardium (type 1 myocardial infarction). To date, there have been no randomized, double-blind trials of therapy in patients with MINOCA. However, the SWEDEHEART investigators did observe that patients who received evidence-based therapy (EBMT) for MI, that is, beta blockers, renin-angiotensin system blockade, and statins, had better long-term outcomes compared with MINOCA patients who did not receive EBMT6. There are a number of large retrospective and prospective trials underway studying this enigmatic and interesting syndrome7. Hopefully, these studies will increase our understanding of the pathophysiology of MINOCA and thereby lead to effective therapy.

References

  1. Nordenskjold AM, Baron T, Eggers KM, Jernberg T, Lindahl B:  Predictors of adverse outcome in patients with myocardial infarction with non-obstructive coronary artery (MINOCA) disease.  Int J Cardiol 2018, 261:18-23.
  2. Alpert JS:  Myocardial infarction with angiographically normal coronary arteries.  Arch Int Med 1994, 154:265-269.
  3. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction:  Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018 Oct 30,72(18):2231-2264. doi: 10.1016/j.jacc.2018.08.1038. Epub 2018 Aug 25. No abstract available. PMID:30153967.
  4. Nordenskjöld AM, Lagerqvist B, Baron T, Jernberg T, Hadziosmanovic N, Reynolds HR, Tornvall P, Lindahl B:  Reinfarction in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) – coronary findings and prognosis. Am J Med Oct 24 2018. pii: S0002-9343(18)30962-8. doi: 10.1016/j.amjmed.2018.10.007. [Epub ahead of print]  PMID: 30367850.
  5. Opolski MP, Spiewak M, Marczak M, Debski A, Knaapen P, Schumacher SP: Mechanisms of Myocardial Infarction in Patients With Nonobstructive Coronary Artery Disease: Results From the Optical Coherence Tomography Study. JACC Cardiovasc Imaging. 2018 Oct 12. pii: S1936-878X(18)30750-2. doi: 10.1016/j.jcmg.2018.08.022. [Epub ahead of print].
  6. Lindahl B, Baron T, Erlinge D, Hadziosmanovic N, Nordenskjold A, Gard A, Jernberg T. Medical therapy for secondary prevention and long?term outcome in patients with myocardial infarction with nonobstructive coronary artery disease. Circulation. 2017,135:1481–1489.
  7. Serpytis, R, Serpytis P, Chen, QM, Alpert, JS. Lithuanian study of MINOCA patients. In progress.

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --