Mortality in ST-Segment Elevation Myocardial Infarction With Nonobstructive Coronary Arteries and Mimickers
Odayme Quesada1,2, Mehmet Yildiz2, Timothy D Henry2
1Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio.
Insights
Patients with ST-segment elevation myocardial infarction (STEMI) and myocardial infarction with nonobstructive coronary arteries (MINOCA) face a higher mortality risk. This study found MINOCA associated with increased mortality compared to obstructive coronary artery disease, while MINOCA mimickers showed similar risks.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- The prognosis for patients experiencing ST-segment elevation myocardial infarction (STEMI) with nonobstructive coronary arteries (MINOCA) remains poorly understood.
- Understanding the differences in outcomes between MINOCA, MINOCA mimickers, and obstructive coronary artery disease is crucial for patient management.
Purpose of the Study:
- To compare the 5-year mortality rates among patients presenting with STEMI due to MINOCA, MINOCA mimickers, and obstructive coronary artery disease.
- To identify potential differences in clinical characteristics and prognosis within these STEMI subgroups.
Main Methods:
- A retrospective analysis of a prospective registry-based cohort study involving consecutive STEMI activations across three Midwest STEMI programs.
- Patients were categorized into MINOCA, MINOCA mimickers (e.g., takotsubo cardiomyopathy, myocarditis), or obstructive disease based on coronary angiography and troponin levels.
- Adjusted Cox regression analysis was employed to assess 5-year mortality risk.
Main Results:
- The study included 8560 STEMI patients: 95.2% obstructive disease, 1.4% MINOCA, and 3.8% MINOCA mimickers.
- At 5-year follow-up, mortality rates were 16% for obstructive disease, 18% for MINOCA, and 18% for MINOCA mimickers.
- Adjusted analysis revealed a 1.93-fold higher 5-year mortality hazard risk for MINOCA compared to obstructive disease, with no significant difference for MINOCA mimickers.
Conclusions:
- STEMI patients presenting with MINOCA have a significantly higher risk of mortality compared to those with obstructive coronary artery disease.
- The mortality risk for MINOCA mimickers was similar to that of obstructive coronary artery disease.
- Further research is warranted to elucidate the underlying pathophysiologic mechanisms in the high-risk MINOCA population.
Importance:
The clinical characteristics and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) with nonobstructive coronaries (MINOCA) are largely unknown.
Objective:
To assess differences in 5-year mortality in patients presenting with STEMI due to MINOCA and MINOCA mimickers as compared with obstructive disease.
Design, Setting, And Participants:
A retrospective analysis of a prospective registry-based cohort study of consecutive STEMI activations at 3 regional Midwest STEMI programs. STEMI without a culprit artery and elevated troponin levels were categorized as MINOCA (absence of coronary artery stenosis >50% and confirmed or suspected coronary artery plaque disruption, epicardial coronary spasm, or coronary embolism/thrombosis) or MINOCA mimickers (takotsubo cardiomyopathy, myocarditis, or nonischemic cardiomyopathy). Data were analyzed from March 2003 to December 2020.
Main Outcomes And Measures:
Adjusted Cox regression analysis was used to assess 5-year mortality risk in STEMI presenting with MINOCA and MINOCA mimickers in comparison with obstructive disease.
Results:
Among 8560 consecutive patients with STEMI, mean (SD) age was 62 (14) years, 30% were female (2609 participants), and 94% were non-Hispanic White (4358 participants). The cohort included 8151 patients with STEMI due to obstructive disease (95.2%), 120 patients with MINOCA (1.4%), and 289 patients with MINOCA mimickers (3.8%). Patients were followed up for a median (IQR) of 7.1 (3.6-10.7) years. Patients with MINOCA and MINOCA mimickers were less likely to be discharged with cardiac medications compared with obstructive disease. At 5-year follow-up, mortality in STEMI presenting with obstructive disease (1228 participants [16%]) was similar to MINOCA (20 participants [18%]; χ21 = 1.1; log-rank P = .29) and MINOCA mimickers (52 participants [18%]; χ21 = 2.3; log-rank P = .13). In adjusted Cox regression analysis compared with obstructive disease, the 5-year mortality hazard risk was 1.93 times higher in MINOCA (95% CI, 1.06-3.53) and similar in MINOCA mimickers (HR, 1.08; 95% CI, 0.79-1.49).
Conclusions And Relevance:
In this large multicenter cohort study of consecutive clinical patients with STEMI, presenting with MINOCA was associated with a higher risk of mortality than obstructive disease; the risk of mortality was similar in patients with MINOCA mimickers and obstructive disease. Further investigation is necessary to understand the pathophysiologic mechanisms involved in this high-risk STEMI population.
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