Role of cardiac CT in the diagnostic evaluation and risk stratification of patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): rationale and design of the MINOCA-GR study

Georgios P Rampidis, Polydoros Ν Kampaktsis, Konstantinos Kouskouras, Athanasios Samaras, Georgios Benetos, Andreas Α Giannopoulos, Theodoros Karamitsos, Alexandros Kallifatidis, Antonios Samaras, Ioannis Vogiatzis, Stavros Hadjimiltiades, Antonios Ziakas, Ronny R Buechel, Catherine Gebhard, Nathaniel R Smilowitz, Konstantinos Toutouzas, Konstantinos Tsioufis, Panagiotis Prassopoulos, Haralambos Karvounis, Harmony Reynolds, George Giannakoulas, Georgios P Rampidis, Polydoros Ν Kampaktsis, Konstantinos Kouskouras, Athanasios Samaras, Georgios Benetos, Andreas Α Giannopoulos, Theodoros Karamitsos, Alexandros Kallifatidis, Antonios Samaras, Ioannis Vogiatzis, Stavros Hadjimiltiades, Antonios Ziakas, Ronny R Buechel, Catherine Gebhard, Nathaniel R Smilowitz, Konstantinos Toutouzas, Konstantinos Tsioufis, Panagiotis Prassopoulos, Haralambos Karvounis, Harmony Reynolds, George Giannakoulas

Abstract

Introduction: Myocardial infarction with non-obstructive coronary arteries (MINOCA) occurs in 5%-15% of all patients with acute myocardial infarction. Cardiac MR (CMR) and optical coherence tomography have been used to identify the underlying pathophysiological mechanism in MINOCA. The role of cardiac CT angiography (CCTA) in patients with MINOCA, however, has not been well studied so far. CCTA can be used to assess atherosclerotic plaque volume, vulnerable plaque characteristics as well as pericoronary fat tissue attenuation, which has not been yet studied in MINOCA.

Methods and analysis: MINOCA-GR is a prospective, multicentre, observational cohort study based on a national registry that will use CCTA in combination with CMR and invasive coronary angiography (ICA) to evaluate the extent and characteristics of coronary atherosclerosis and its correlation with pericoronary fat attenuation in patients with MINOCA. A total of 60 consecutive adult patients across 4 participating study sites are expected to be enrolled. Following ICA and CMR, patients will undergo CCTA during index hospitalisation. The primary endpoints are quantification of extent and severity of coronary atherosclerosis, description of high-risk plaque features and attenuation profiling of pericoronary fat tissue around all three major epicardial coronary arteries in relation to CMR. Follow-up CCTA for the evaluation of changes in pericoronary fat attenuation will also be performed. MINOCA-GR aims to be the first study to explore the role of CCTA in combination with CMR and ICA in the underlying pathophysiological mechanisms and assisting in diagnostic evaluation and prognosis of patients with MINOCA.

Ethics and dissemination: The study protocol has been approved by the institutional review board/independent ethics committee at each site prior to study commencement. All patients will provide written informed consent. Results will be disseminated at national meetings and published in peer-reviewed journals.

Trial registration number: NCT4186676.

Trial registration: ClinicalTrials.gov NCT04186676 NCT04186676.

Keywords: computed tomography; coronary heart disease; myocardial infarction.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
CCTA patterns in patients who initially diagnosed with MINOCA. (1) Totally normal coronary arteries, (2) coronary artery anomalies and myocardial bridges, (3) diffuse non-obstructive coronary atherosclerosis and ‘high-risk’ plaques, (4) missed obstructive coronary artery disease and (5) pericoronary fat attenuation profiling. CCTA, cardiac CT angiography; MINOCA, myocardial infarction with non-obstructive coronary arteries.
Figure 2
Figure 2
High-risk plaque features on coronary CTA. The analysis of ECG-synchronised coronary CTA images permits accurate assessment of both the presence and degree of luminal obstruction and the presence, morphology and composition of coronary atherosclerosis, including high-risk plaque features, such as positive remodelling, low CT attenuation plaque, ‘napkin-ring’ sign, and spotty calcium. CTA, CT angiography; HU, Hounsfield units.
Figure 3
Figure 3
Methodology for computing Coronary Artery Volume index (CAVi). The coronary artery vessel tree is segmented from the CCTA dataset and the coronary artery volume (ie, lumen) is calculated for all vessels and branches ≥1.5 mm in diameter. LV myocardial mass is extracted from the CCTA dataset and computed with a dedicated software. Finally, CAVi is computed by dividing coronary artery volume over LV mass. CCTA, cardiac CT angiography; LV, left ventricle.
Figure 4
Figure 4
Leiden CTA risk score. An example of Leiden CTA risk score calculation. The new, comprehensive CTA score is calculated by addition of the individual segment scores, which are obtained by multiplication of the plaque weight factor, the stenosis weight factor, and the location weight factor. Leiden CTA risk score calculator is available at: http://18.224.14.19/calcApp/. CTA, CT angiography; R-PDA, right posterior descending artery; RCA, right coronary artery; LCA, left coronary artery; LAD, left anterior descending; LCx, left circumflex; R-PLB, right posterolateral branch.
Figure 5
Figure 5
CT-adapted Gensini score calculation. An example of Gensini score calculation from CCTA dataset (curved multiplanar reconstruction) in a MINOCA patient. CCTA, cardiac CT angiography; MINOCA, myocardial infarction with non-obstructive coronary arteries; R-PDA, right posterior descending artery; RCA, right coronary artery; LCA, left coronary artery; LAD, left anterior descending; LCx, left circumflex; R-PLB, right posterolateral branch.
Figure 6
Figure 6
Timeline from protocol submission to study end.

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