Harmony R Reynolds1,2, Akiko Maehara3,4, Raymond Y Kwong5, Tara Sedlak6, Jacqueline Saw6, Nathaniel R Smilowitz1,2, Ehtisham Mahmud7, Janet Wei8, Kevin Marzo9, Mitsuaki Matsumura3, Ayako Seno5, Anais Hausvater1,2, Caitlin Giesler10, Nisha Jhalani4, Catalin Toma11, Bryan Har12, Dwithiya Thomas13, Laxmi S Mehta14, Jeffrey Trost15, Puja K Mehta16, Bina Ahmed17, Kevin R Bainey18, Yuhe Xia19, Binita Shah2, Michael Attubato2, Sripal Bangalore2, Louai Razzouk2, Ziad A Ali3,4, Noel Bairey Merz8, Ki Park20, Ellen Hada1, Hua Zhong19, Judith S Hochman1,2. 1. Sarah Ross Soter Center for Women's Cardiovascular Research (H.R.R., N.R.S., A.H., E.H., J.S.H.), New York University Grossman School of Medicine, NY. 2. Leon H. Charney Division of Cardiology, Department of Medicine (H.R.R., N.R.S., A.H., B.S., M.A., S.B., L.R., J.S.H.), New York University Grossman School of Medicine, NY. 3. Cardiovascular Research Foundation, New York, NY (A.M., M.M., Z.A.A.). 4. Columbia University, New York, NY (A.M., N.J., Z.A.A.). 5. Brigham and Women's Hospital, Boston, MA (R.Y.K., A.S.). 6. Vancouver General Hospital, British Columbia, Canada (T.S., J.S.). 7. University of California San Diego Health, La Jolla (E.M.). 8. Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (J.W., N.B.M.). 9. New York University Winthrop Hospital, New York University Long Island School of Medicine, Mineola (K.M.). 10. Ascension Medical Group, Austin, TX (C.G.). 11. University of Pittsburgh Department of Medicine, PA (C.T.). 12. University of Calgary, Alberta, Canada (B.H.). 13. St Luke's University Healthcare, Bethlehem, PA (D.T.). 14. Ohio State University Wexner Medical Center, Powell, OH (L.S.M.). 15. Johns Hopkins Medical Center, Baltimore, MD (J.T.). 16. Emory Women's Heart Center, Atlanta, GA (P.K.M.). 17. Santa Barbara Cardiovascular Medical Group, CA (B.A.). 18. Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B.). 19. Department of Population Health (Y.X., H.Z.), New York University Grossman School of Medicine, NY. 20. University of Florida, Gainesville (K.P.).
Abstract
BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. METHODS: In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. RESULTS: Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). CONCLUSIONS: Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.
BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. METHODS: In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. RESULTS: Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). CONCLUSIONS: Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.
Entities:
Keywords:
coronary vessels; magnetic resonance imaging; myocardial infarction; tomography, optical coherence; women
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