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Antiplatelet therapy in patients with myocardial infarction without obstructive coronary artery disease
Matthias Bossard1, Peggy Gao2, William Boden3,4
1Cardiology Division, Heart Center - Luzerner Kantonsspital, Luzern, Switzerland.
Insights
Patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) have a better prognosis than those with obstructive coronary artery disease. Intensified clopidogrel therapy did not improve outcomes in MINOCA patients and may increase harm.
Area of Science:
- Cardiology
- Clinical Trials
- Pharmacology
Background:
- Myocardial infarction (MI) without obstructive coronary artery disease (MINOCA) affects approximately 10% of MI patients.
- The prognosis and optimal treatment for MINOCA patients remain areas of active investigation.
Purpose of the Study:
- To evaluate the prognosis of MINOCA patients compared to those with obstructive coronary artery disease (CAD).
- To assess the role of intensified antiplatelet therapy (double-dose clopidogrel) versus standard-dose clopidogrel in MINOCA patients.
Main Methods:
- Analysis of data from the Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events-Seventh Organisation to Assess Strategies in Ischaemic Symptoms trial.
- Comparison of outcomes between MINOCA and obstructive CAD patients treated with standard-dose versus double-dose clopidogrel.
- Primary outcome: cardiovascular death, MI, or stroke at 30 days.
Main Results:
- MINOCA patients (n=1599) were younger, had fewer comorbidities, and experienced lower rates of all-cause mortality, CV mortality, repeat MI, and major bleeding compared to obstructive CAD patients (n=23783).
- Among MINOCA patients, the primary outcome occurred in 2.1% of the double-dose clopidogrel group versus 0.6% of the standard-dose group (HR 3.57).
- In contrast, obstructive CAD patients showed similar rates of the primary outcome in both clopidogrel groups (4.3% vs 4.7%).
Conclusions:
- MINOCA patients have a lower risk of recurrent cardiovascular events than patients with MI and obstructive CAD.
- Intensified clopidogrel dosing (double-dose) in MINOCA patients did not provide additional benefit and showed a potential signal of harm compared to standard-dose dual antiplatelet therapy (DAPT).
- Further randomized trials are needed to evaluate potent DAPT strategies in MINOCA patients.
Objective:
Approximately 10% of patients with myocardial infarction (MI) have no obstructive coronary artery disease. The prognosis and role of intensified antiplatelet therapy in those patients were evaluated.
Methods:
We analysed data from the Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events-Seventh Organisation to Assess Strategies in Ischaemic Symptoms trial randomising patients with ACS referred for early intervention to receive either double-dose (600 mg, day 1; 150 mg, days 2-7; then 75 mg/day) or standard-dose (300 mg, day 1; then 75 mg/day) clopidogrel. Outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) versus those with obstructive coronary artery disease (CAD) and their relation to standard-dose versus double-dose clopidogrel were evaluated. The primary outcome was cardiovascular (CV) death, MI or stroke at 30 days.
Results:
We included 23 783 patients with MI and 1599 (6.7%) with MINOCA. Patients with MINOCA were younger, presented more frequently with non-ST-segment elevation MI and had fewer comorbidities. All-cause mortality (0.6% vs 2.3%, p=0.005), CV mortality (0.6% vs 2.2%, p=0.006), repeat MI (0.5% vs 2.3%, p=0.001) and major bleeding (0.6% vs 2.4%, p<0.0001) were lower among patients with MINOCA than among those with obstructive CAD. Among patients with MINOCA, 2.1% of patients in the double-dose clopidogrel group and 0.6% in the standard-dose group experienced a primary outcome (HR 3.57, 95% CI 1.31 to 9.76), whereas in those with obstructive CAD, rates were 4.3% and 4.7%, respectively (HR 0.91, 95% CI 0.80 to 1.03; p value for interaction=0.011).
Conclusions:
Patients with MINOCA are at lower risk of recurrent CV events compared with patients with MI with obstructive CAD. Compared with a standard clopidogrel-based dual antiplatelet therapy (DAPT) regimen, an intensified dosing strategy appears to offer no additional benefit with a signal of possible harm. Further randomised trials evaluating the effects of potent DAPT in patients with MINOCA are warranted.
Trial Registration Number:
NCT00335452.
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