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Coronary Artery and Cardiac Disease in Patients With Type 2 Myocardial Infarction: A Prospective Cohort Study
Anda Bularga1, John Hung1, Marwa Daghem1
1BHF Centre for Cardiovascular Science (A.B., J.H., M.D., S.S., C.T., R.W., T.S., M.N.M., T.F., A.V.F., J.C., W.S.J., F.E.S., M.W., C.T., A.H.B., D.E.N., M.R.D., N.L.M., A.R.C.), University of Edinburgh, United Kingdom.
Insights
Type 2 myocardial infarction (MI) diagnosis is common, but management is unclear. Imaging reveals coronary artery disease in most patients, highlighting a need for evidence-based treatments to improve outcomes.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Medicine
Background:
- Type 2 myocardial infarction (MI) arises from oxygen supply-demand imbalance.
- Increasing use of high-sensitivity troponin assays leads to more frequent diagnoses.
- Significant clinical uncertainty exists regarding the investigation and management of Type 2 MI.
Purpose of the Study:
- To investigate the prevalence of coronary artery disease (CAD) in patients diagnosed with Type 2 MI.
- To characterize cardiac findings and underlying causes in Type 2 MI.
- To identify opportunities for improved treatment strategies.
Main Methods:
- Prospective cohort study of 8064 patients with elevated troponin.
- Included 100 patients with provisional Type 2 MI diagnosis.
- Utilized coronary and cardiac imaging (angiography, MRI, echocardiography) for diagnosis and cause adjudication.
Main Results:
- Coronary imaging identified coronary artery disease in 68% of Type 2 MI patients.
- Left ventricular systolic dysfunction was present in 34% of patients.
- Significant proportions of patients had previously unrecognized CAD (60%) and LV dysfunction (84%), with low rates of evidence-based treatment.
Conclusions:
- Systematic imaging in Type 2 MI reveals high rates of underlying coronary artery disease and left ventricular dysfunction.
- A majority of patients have unrecognized cardiac conditions.
- Initiation of evidence-based treatments offers substantial potential to improve clinical outcomes in Type 2 MI.
Background:
Type 2 myocardial infarction is caused by myocardial oxygen supply-demand imbalance, and its diagnosis is increasingly common with the advent of high-sensitivity cardiac troponin assays. Although this diagnosis is associated with poor outcomes, widespread uncertainty and confusion remain among clinicians as to how to investigate and manage this heterogeneous group of patients with type 2 myocardial infarction.
Methods:
In a prospective cohort study, 8064 consecutive patients with increased cardiac troponin concentrations were screened to identify patients with type 2 myocardial infarction. We excluded patients with frailty or renal or hepatic failure. All study participants underwent coronary (invasive or computed tomography angiography) and cardiac (magnetic resonance or echocardiography) imaging, and the underlying causes of infarction were independently adjudicated. The primary outcome was the prevalence of coronary artery disease.
Results:
In 100 patients with a provisional diagnosis of type 2 myocardial infarction (median age, 65 years [interquartile range, 55-74 years]; 43% women), coronary and cardiac imaging reclassified the diagnosis in 7 patients: type 1 or 4b myocardial infarction in 5 and acute myocardial injury in 2 patients. In those with type 2 myocardial infarction, median cardiac troponin I concentrations were 195 ng/L (interquartile range, 62-760 ng/L) at presentation and 1165 ng/L (interquartile range, 277-3782 ng/L) on repeat testing. The prevalence of coronary artery disease was 68% (63 of 93), which was obstructive in 30% (28 of 93). Infarct-pattern late gadolinium enhancement or regional wall motion abnormalities were observed in 42% (39 of 93), and left ventricular systolic dysfunction was seen in 34% (32 of 93). Only 10 patients had both normal coronary and normal cardiac imaging. Coronary artery disease and left ventricular systolic dysfunction were previously unrecognized in 60% (38 of 63) and 84% (27 of 32), respectively, with only 33% (21 of 63) and 19% (6 of 32) on evidence-based treatments.
Conclusions:
Systematic coronary and cardiac imaging of patients with type 2 myocardial infarction identified coronary artery disease in two-thirds and left ventricular systolic dysfunction in one-third of patients. Unrecognized and untreated coronary or cardiac disease is seen in most patients with type 2 myocardial infarction, presenting opportunities for initiation of evidence-based treatments with major potential to improve clinical outcomes.
Registration:
URL: https://www.
Clinicaltrials:
gov; Unique identifier: NCT03338504.
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