Presentation, Clinical Profile, and Prognosis of Young Patients With Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): Results From the VIRGO Study

Basmah Safdar, Erica S Spatz, Rachel P Dreyer, John F Beltrame, Judith H Lichtman, John A Spertus, Harmony R Reynolds, Mary Geda, Héctor Bueno, James D Dziura, Harlan M Krumholz, Gail D'Onofrio, Basmah Safdar, Erica S Spatz, Rachel P Dreyer, John F Beltrame, Judith H Lichtman, John A Spertus, Harmony R Reynolds, Mary Geda, Héctor Bueno, James D Dziura, Harlan M Krumholz, Gail D'Onofrio

Abstract

Background: We compared the clinical characteristics and outcomes of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) versus obstructive disease (myocardial infarction due to coronary artery disease [MI-CAD]) and among patients with MINOCA by sex and subtype.

Methods and results: Between 2008 and 2012, VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) prospectively enrolled acute myocardial infarction patients aged 18 to 55 years in 103 hospitals at a 2:1 ratio of women to men. Using an angiographically driven taxonomy, we defined patients as having MI-CAD if there was revascularization or plaque ≥50% and as having MINOCA if there was <50% obstruction or a nonplaque mechanism. Patients who did not have an angiogram or who received thrombolytics before an angiogram were excluded. Outcomes included 1- and 12-month mortality and functional (Seattle Angina Questionnaire [SAQ]) and psychosocial status. Of 2690 patients undergoing angiography, 2374 (88.4%) had MI-CAD, 299 (11.1%) had MINOCA, and 17 (0.6%) remained unclassified. Women had 5 times higher odds of having MINOCA than men (14.9% versus 3.5%; odds ratio: 4.84; 95% confidence interval, 3.29-7.13). MINOCA patients were more likely to be without traditional cardiac risk factors (8.7% versus 1.3%; P<0.001) but more predisposed to hypercoaguable states than MI-CAD patients (3.0% versus 1.3%; P=0.036). Women with MI-CAD were more likely than those with MINOCA to be menopausal (55.2% versus 41.2%; P<0.001) or to have a history of gestational diabetes mellitus (16.8% versus 11.0%; P=0.028). The MINOCA mechanisms varied: a nonplaque mechanism was identified for 75 patients (25.1%), and their clinical profiles and management also varied. One- and 12-month mortality with MINOCA and MI-CAD was similar (1-month: 1.1% and 1.7% [P=0.43]; 12-month: 0.6% and 2.3% [P=0.68], respectively), as was adjusted 12-month SAQ quality of life (76.5 versus 73.5, respectively; P=0.06).

Conclusions: Young patients with MINOCA were more likely women, had a heterogeneous mechanistic profile, and had clinical outcomes that were comparable to those of MI-CAD patients.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.

Keywords: acute myocardial infarction; myocardial infarction with nonobstructive coronary arteries; nonobstructive; prognosis; sex; women.

© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Comparison of young patients with myocardial infarction due to coronary artery disease (MI‐CAD) and myocardial infarction with nonobstructive coronary arteries (MINOCA) at baseline, 1 month, and 12 months for (A) mortality; psychosocial outcomes, including (B) depression and (C) perceived stress; and health status, including (D) physical limitations, (E) angina frequency, (F) treatment satisfaction, and (G) quality of life. PHQ‐9 indicates Patient Health Questionnaire; SAQ, Seattle Angina Questionnaire.
Figure 2
Figure 2
Comparison of young men and women with myocardial infarction with nonobstructive coronary arteries at baseline, 1 month, and 12 months for (A) mortality; psychosocial outcomes, including (B) depression and (C) perceived stress; and health status, including (D) physical limitations, (E) angina frequency, (F) treatment satisfaction, and (G) quality of life. PHQ‐9 indicates Patient Health Questionnaire; SAQ, Seattle Angina Questionnaire.

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