Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women
Harmony R Reynolds, Akiko Maehara, Raymond Y Kwong, Tara Sedlak, Jacqueline Saw, Nathaniel R Smilowitz, Ehtisham Mahmud, Janet Wei, Kevin Marzo, Mitsuaki Matsumura, Ayako Seno, Anais Hausvater, Caitlin Giesler, Nisha Jhalani, Catalin Toma, Bryan Har, Dwithiya Thomas, Laxmi S Mehta, Jeffrey Trost, Puja K Mehta, Bina Ahmed, Kevin R Bainey, Yuhe Xia, Binita Shah, Michael Attubato, Sripal Bangalore, Louai Razzouk, Ziad A Ali, Noel Bairey Merz, Ki Park, Ellen Hada, Hua Zhong, Judith S Hochman, Harmony R Reynolds, Akiko Maehara, Raymond Y Kwong, Tara Sedlak, Jacqueline Saw, Nathaniel R Smilowitz, Ehtisham Mahmud, Janet Wei, Kevin Marzo, Mitsuaki Matsumura, Ayako Seno, Anais Hausvater, Caitlin Giesler, Nisha Jhalani, Catalin Toma, Bryan Har, Dwithiya Thomas, Laxmi S Mehta, Jeffrey Trost, Puja K Mehta, Bina Ahmed, Kevin R Bainey, Yuhe Xia, Binita Shah, Michael Attubato, Sripal Bangalore, Louai Razzouk, Ziad A Ali, Noel Bairey Merz, Ki Park, Ellen Hada, Hua Zhong, Judith S Hochman
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.
Keywords: coronary vessels; magnetic resonance imaging; myocardial infarction; tomography, optical coherence; women.
Figures
![Figure 1.. Study flow.](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8627695/bin/nihms-1754593-f0001.jpg)
Figure 2.. Findings of OCT and CMR…
Figure 2.. Findings of OCT and CMR in women with MINOCA.
Findings of each core…
Figure 3.. Representative OCT images demonstrating the…
Figure 3.. Representative OCT images demonstrating the various types of culprit lesions in women with…
Figure 4.. Representative CMR images in women…
Figure 4.. Representative CMR images in women with MINOCA.
Figure 5.. OCT and CMR findings in…
Figure 5.. OCT and CMR findings in women with MINOCA (n=116).
Specific OCT culprit lesions…
Figure 6.. Representative cases of plaque disruption…
Figure 6.. Representative cases of plaque disruption causing MINOCA.
Figure 7.. Case with myocarditis on CMR…
Figure 7.. Case with myocarditis on CMR affecting the lateral wall and intimal bumping in…
- Letter by Nguyen et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Nguyen TH, Ong GJ, Horowitz JD. Nguyen TH, et al. Circulation. 2021 Sep 21;144(12):e205. doi: 10.1161/CIRCULATIONAHA.121.053409. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543064 No abstract available.
- Response by Reynolds et al to Letters Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Reynolds HR, Kwong RY, Maehara A, Smilowitz NR. Reynolds HR, et al. Circulation. 2021 Sep 21;144(12):e209-e210. doi: 10.1161/CIRCULATIONAHA.121.055516. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543066 No abstract available.
- Letter by Hamilton et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Hamilton GW, Tan S, Layland J. Hamilton GW, et al. Circulation. 2021 Sep 21;144(12):e207-e208. doi: 10.1161/CIRCULATIONAHA.121.054834. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543067 No abstract available.
- Letter by Matta et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Matta A, Elbaz M, Roncalli J. Matta A, et al. Circulation. 2021 Sep 21;144(12):e204. doi: 10.1161/CIRCULATIONAHA.120.053041. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543071 No abstract available.
- Letter by Allard-Ratick et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Allard-Ratick MP, McCarthy CP, Jang IK. Allard-Ratick MP, et al. Circulation. 2021 Sep 21;144(12):e206. doi: 10.1161/CIRCULATIONAHA.120.053480. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543073 No abstract available.
- Underlying Causes of Myocardial Infarction with Nonobstructive Coronary Arteries: Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging Pilot Study.Fluder-Wlodarczyk J, Milewski M, Roleder-Dylewska M, Haberka M, Ochala A, Wojakowski W, Gasior P. Fluder-Wlodarczyk J, et al. J Clin Med. 2022 Dec 17;11(24):7495. doi: 10.3390/jcm11247495. J Clin Med. 2022. PMID: 36556108 Free PMC article.
- Mechanisms of Myocardial Infarction in Patients With Nonobstructive Coronary Artery Disease: Results From the Optical Coherence Tomography Study.Opolski MP, Spiewak M, Marczak M, Debski A, Knaapen P, Schumacher SP, Staruch AD, Grodecki K, Chmielak Z, Lazarczyk H, Kukula K, Tyczynski P, Pregowski J, Dabrowski M, Kadziela J, Florczak E, Skrobisz A, Witkowski A. Opolski MP, et al. JACC Cardiovasc Imaging. 2019 Nov;12(11 Pt 1):2210-2221. doi: 10.1016/j.jcmg.2018.08.022. Epub 2018 Oct 17. JACC Cardiovasc Imaging. 2019. PMID: 30343070
- OCT and CMR for the Diagnosis of Patients Presenting With MINOCA and Suspected Epicardial Causes.Gerbaud E, Arabucki F, Nivet H, Barbey C, Cetran L, Chassaing S, Seguy B, Lesimple A, Cochet H, Montaudon M, Laurent F, Bar O, Tearney GJ, Coste P. Gerbaud E, et al. JACC Cardiovasc Imaging. 2020 Dec;13(12):2619-2631. doi: 10.1016/j.jcmg.2020.05.045. Epub 2020 Aug 19. JACC Cardiovasc Imaging. 2020. PMID: 32828786
- Diagnostic Value of Cardiac Magnetic Resonance Imaging and Intracoronary Optical Coherence Tomography in Patients With a Working Diagnosis of Myocardial Infarction With Non-obstructive Coronary Arteries - A Systematic Review and Meta-analysis.Machanahalli Balakrishna A, Ismayl M, Thandra A, Walters R, Ganesan V, Anugula D, Shah DJ, Aboeata A. Machanahalli Balakrishna A, et al. Curr Probl Cardiol. 2023 Jun;48(6):101126. doi: 10.1016/j.cpcardiol.2022.101126. Epub 2022 Feb 1. Curr Probl Cardiol. 2023. PMID: 35120967 Review.
- Role of Multimodality Imaging in the Assessment of Myocardial Infarction With Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography.Gudenkauf B, Hays AG, Tamis-Holland J, Trost J, Ambinder DI, Wu KC, Arbab-Zadeh A, Blumenthal RS, Sharma G. Gudenkauf B, et al. J Am Heart Assoc. 2022 Jan 4;11(1):e022787. doi: 10.1161/JAHA.121.022787. Epub 2021 Dec 31. J Am Heart Assoc. 2022. PMID: 34970915 Free PMC article. Review.
- MINOCA and INOCA: Role in Heart Failure.Almeida AG. Almeida AG. Curr Heart Fail Rep. 2023 May 18. doi: 10.1007/s11897-023-00605-1. Online ahead of print. Curr Heart Fail Rep. 2023. PMID: 37198520 Review.
- Dual Antiplatelet Therapy with Parenteral P2Y12 Inhibitors: Rationale, Evidence, and Future Directions.Alagna G, Mazzone P, Contarini M, Andò G. Alagna G, et al. J Cardiovasc Dev Dis. 2023 Apr 9;10(4):163. doi: 10.3390/jcdd10040163. J Cardiovasc Dev Dis. 2023. PMID: 37103042 Free PMC article. Review.
- Dynamic perfusion SPECT for functional evaluation in symptomatic patients with myocardial bridging.Xu R, Yang H, Zhang J, Chen S, Pang L, Wu Y, Pei Z, Shi H, Li C, Ge J. Xu R, et al. J Nucl Cardiol. 2023 Apr 24. doi: 10.1007/s12350-023-03241-3. Online ahead of print. J Nucl Cardiol. 2023. PMID: 37095328
- Sex differences in treatment and outcomes amongst myocardial infarction patients presenting with and without obstructive coronary arteries: a prospective multicentre study.Lawless M, Appelman Y, Beltrame JF, Navarese EP, Ratcovich H, Wilkinson C, Kunadian V. Lawless M, et al. Eur Heart J Open. 2023 Mar 27;3(2):oead033. doi: 10.1093/ehjopen/oead033. eCollection 2023 Mar. Eur Heart J Open. 2023. PMID: 37090058 Free PMC article.
- Contemporary Diagnosis and Management of Patients with MINOCA.Parwani P, Kang N, Safaeipour M, Mamas MA, Wei J, Gulati M, Naidu SS, Merz NB. Parwani P, et al. Curr Cardiol Rep. 2023 Jun;25(6):561-570. doi: 10.1007/s11886-023-01874-x. Epub 2023 Apr 17. Curr Cardiol Rep. 2023. PMID: 37067753 Free PMC article. Review.
- Multicenter Study
- Research Support, N.I.H., Extramural
- Research Support, Non-U.S. Gov't
- Aged
- Coronary Vessels / diagnostic imaging*
- Coronary Vessels / pathology
- Female
- Humans
- Magnetic Resonance Imaging / methods*
- Middle Aged
- Myocardial Infarction / diagnostic imaging*
- Myocardial Infarction / pathology
- Prospective Studies
- Tomography, Optical Coherence / methods*
- ClinicalTrials.gov/NCT02905357
- Full Text Sources
- Other Literature Sources
- Medical
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![Figure 2.. Findings of OCT and CMR…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8627695/bin/nihms-1754593-f0002.jpg)
Figure 3.. Representative OCT images demonstrating the…
Figure 3.. Representative OCT images demonstrating the various types of culprit lesions in women with…
Figure 4.. Representative CMR images in women…
Figure 4.. Representative CMR images in women with MINOCA.
Figure 5.. OCT and CMR findings in…
Figure 5.. OCT and CMR findings in women with MINOCA (n=116).
Specific OCT culprit lesions…
Figure 6.. Representative cases of plaque disruption…
Figure 6.. Representative cases of plaque disruption causing MINOCA.
Figure 7.. Case with myocarditis on CMR…
Figure 7.. Case with myocarditis on CMR affecting the lateral wall and intimal bumping in…
- Letter by Nguyen et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Nguyen TH, Ong GJ, Horowitz JD. Nguyen TH, et al. Circulation. 2021 Sep 21;144(12):e205. doi: 10.1161/CIRCULATIONAHA.121.053409. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543064 No abstract available.
- Response by Reynolds et al to Letters Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Reynolds HR, Kwong RY, Maehara A, Smilowitz NR. Reynolds HR, et al. Circulation. 2021 Sep 21;144(12):e209-e210. doi: 10.1161/CIRCULATIONAHA.121.055516. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543066 No abstract available.
- Letter by Hamilton et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Hamilton GW, Tan S, Layland J. Hamilton GW, et al. Circulation. 2021 Sep 21;144(12):e207-e208. doi: 10.1161/CIRCULATIONAHA.121.054834. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543067 No abstract available.
- Letter by Matta et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Matta A, Elbaz M, Roncalli J. Matta A, et al. Circulation. 2021 Sep 21;144(12):e204. doi: 10.1161/CIRCULATIONAHA.120.053041. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543071 No abstract available.
- Letter by Allard-Ratick et al Regarding Article, "Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women".Allard-Ratick MP, McCarthy CP, Jang IK. Allard-Ratick MP, et al. Circulation. 2021 Sep 21;144(12):e206. doi: 10.1161/CIRCULATIONAHA.120.053480. Epub 2021 Sep 20. Circulation. 2021. PMID: 34543073 No abstract available.
- Underlying Causes of Myocardial Infarction with Nonobstructive Coronary Arteries: Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging Pilot Study.Fluder-Wlodarczyk J, Milewski M, Roleder-Dylewska M, Haberka M, Ochala A, Wojakowski W, Gasior P. Fluder-Wlodarczyk J, et al. J Clin Med. 2022 Dec 17;11(24):7495. doi: 10.3390/jcm11247495. J Clin Med. 2022. PMID: 36556108 Free PMC article.
- Mechanisms of Myocardial Infarction in Patients With Nonobstructive Coronary Artery Disease: Results From the Optical Coherence Tomography Study.Opolski MP, Spiewak M, Marczak M, Debski A, Knaapen P, Schumacher SP, Staruch AD, Grodecki K, Chmielak Z, Lazarczyk H, Kukula K, Tyczynski P, Pregowski J, Dabrowski M, Kadziela J, Florczak E, Skrobisz A, Witkowski A. Opolski MP, et al. JACC Cardiovasc Imaging. 2019 Nov;12(11 Pt 1):2210-2221. doi: 10.1016/j.jcmg.2018.08.022. Epub 2018 Oct 17. JACC Cardiovasc Imaging. 2019. PMID: 30343070
- OCT and CMR for the Diagnosis of Patients Presenting With MINOCA and Suspected Epicardial Causes.Gerbaud E, Arabucki F, Nivet H, Barbey C, Cetran L, Chassaing S, Seguy B, Lesimple A, Cochet H, Montaudon M, Laurent F, Bar O, Tearney GJ, Coste P. Gerbaud E, et al. JACC Cardiovasc Imaging. 2020 Dec;13(12):2619-2631. doi: 10.1016/j.jcmg.2020.05.045. Epub 2020 Aug 19. JACC Cardiovasc Imaging. 2020. PMID: 32828786
- Diagnostic Value of Cardiac Magnetic Resonance Imaging and Intracoronary Optical Coherence Tomography in Patients With a Working Diagnosis of Myocardial Infarction With Non-obstructive Coronary Arteries - A Systematic Review and Meta-analysis.Machanahalli Balakrishna A, Ismayl M, Thandra A, Walters R, Ganesan V, Anugula D, Shah DJ, Aboeata A. Machanahalli Balakrishna A, et al. Curr Probl Cardiol. 2023 Jun;48(6):101126. doi: 10.1016/j.cpcardiol.2022.101126. Epub 2022 Feb 1. Curr Probl Cardiol. 2023. PMID: 35120967 Review.
- Role of Multimodality Imaging in the Assessment of Myocardial Infarction With Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography.Gudenkauf B, Hays AG, Tamis-Holland J, Trost J, Ambinder DI, Wu KC, Arbab-Zadeh A, Blumenthal RS, Sharma G. Gudenkauf B, et al. J Am Heart Assoc. 2022 Jan 4;11(1):e022787. doi: 10.1161/JAHA.121.022787. Epub 2021 Dec 31. J Am Heart Assoc. 2022. PMID: 34970915 Free PMC article. Review.
- MINOCA and INOCA: Role in Heart Failure.Almeida AG. Almeida AG. Curr Heart Fail Rep. 2023 May 18. doi: 10.1007/s11897-023-00605-1. Online ahead of print. Curr Heart Fail Rep. 2023. PMID: 37198520 Review.
- Dual Antiplatelet Therapy with Parenteral P2Y12 Inhibitors: Rationale, Evidence, and Future Directions.Alagna G, Mazzone P, Contarini M, Andò G. Alagna G, et al. J Cardiovasc Dev Dis. 2023 Apr 9;10(4):163. doi: 10.3390/jcdd10040163. J Cardiovasc Dev Dis. 2023. PMID: 37103042 Free PMC article. Review.
- Dynamic perfusion SPECT for functional evaluation in symptomatic patients with myocardial bridging.Xu R, Yang H, Zhang J, Chen S, Pang L, Wu Y, Pei Z, Shi H, Li C, Ge J. Xu R, et al. J Nucl Cardiol. 2023 Apr 24. doi: 10.1007/s12350-023-03241-3. Online ahead of print. J Nucl Cardiol. 2023. PMID: 37095328
- Sex differences in treatment and outcomes amongst myocardial infarction patients presenting with and without obstructive coronary arteries: a prospective multicentre study.Lawless M, Appelman Y, Beltrame JF, Navarese EP, Ratcovich H, Wilkinson C, Kunadian V. Lawless M, et al. Eur Heart J Open. 2023 Mar 27;3(2):oead033. doi: 10.1093/ehjopen/oead033. eCollection 2023 Mar. Eur Heart J Open. 2023. PMID: 37090058 Free PMC article.
- Contemporary Diagnosis and Management of Patients with MINOCA.Parwani P, Kang N, Safaeipour M, Mamas MA, Wei J, Gulati M, Naidu SS, Merz NB. Parwani P, et al. Curr Cardiol Rep. 2023 Jun;25(6):561-570. doi: 10.1007/s11886-023-01874-x. Epub 2023 Apr 17. Curr Cardiol Rep. 2023. PMID: 37067753 Free PMC article. Review.
- Multicenter Study
- Research Support, N.I.H., Extramural
- Research Support, Non-U.S. Gov't
- Aged
- Coronary Vessels / diagnostic imaging*
- Coronary Vessels / pathology
- Female
- Humans
- Magnetic Resonance Imaging / methods*
- Middle Aged
- Myocardial Infarction / diagnostic imaging*
- Myocardial Infarction / pathology
- Prospective Studies
- Tomography, Optical Coherence / methods*
- ClinicalTrials.gov/NCT02905357
- Full Text Sources
- Other Literature Sources
- Medical
![Figure 3.. Representative OCT images demonstrating the…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8627695/bin/nihms-1754593-f0003.jpg)
![Figure 4.. Representative CMR images in women…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8627695/bin/nihms-1754593-f0004.jpg)
![Figure 5.. OCT and CMR findings in…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8627695/bin/nihms-1754593-f0005.jpg)
Figure 6.. Representative cases of plaque disruption…
Figure 6.. Representative cases of plaque disruption causing MINOCA.
Figure 7.. Case with myocarditis on CMR…
Figure 7.. Case with myocarditis on CMR affecting the lateral wall and intimal bumping in…
![Figure 6.. Representative cases of plaque disruption…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8627695/bin/nihms-1754593-f0006.jpg)
![Figure 7.. Case with myocarditis on CMR…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8627695/bin/nihms-1754593-f0007.jpg)
Source: PubMed