Interplay Between Myocardial Bridging and Coronary Spasm in Patients With Myocardial Ischemia and Non-Obstructive Coronary Arteries: Pathogenic and Prognostic Implications

Rocco A Montone, Filippo Luca Gurgoglione, Marco Giuseppe Del Buono, Riccardo Rinaldi, Maria Chiara Meucci, Giulia Iannaccone, Giulia La Vecchia, Massimiliano Camilli, Domenico D'Amario, Antonio Maria Leone, Rocco Vergallo, Cristina Aurigemma, Antonino Buffon, Enrico Romagnoli, Francesco Burzotta, Carlo Trani, Filippo Crea, Giampaolo Niccoli, Rocco A Montone, Filippo Luca Gurgoglione, Marco Giuseppe Del Buono, Riccardo Rinaldi, Maria Chiara Meucci, Giulia Iannaccone, Giulia La Vecchia, Massimiliano Camilli, Domenico D'Amario, Antonio Maria Leone, Rocco Vergallo, Cristina Aurigemma, Antonino Buffon, Enrico Romagnoli, Francesco Burzotta, Carlo Trani, Filippo Crea, Giampaolo Niccoli

Abstract

Background Myocardial bridging (MB) may represent a cause of myocardial ischemia in patients with non-obstructive coronary artery disease (NOCAD). Herein, we assessed the interplay between MB and coronary vasomotor disorders, also evaluating their prognostic relevance in patients with myocardial infarction and non-obstructive coronary arteries (MINOCA) or stable NOCAD. Methods and Results We prospectively enrolled patients with NOCAD undergoing intracoronary acetylcholine provocative test. The incidence of major adverse cardiac events, defined as the composite of cardiac death, non-fatal myocardial infarction, and rehospitalization for unstable angina, was assessed at follow-up. We also assessed angina status using Seattle Angina Questionnaires summary score. We enrolled 310 patients (mean age, 60.6±11.9; 136 [43.9%] men; 169 [54.5%] stable NOCAD and 141 [45.5%] MINOCA). MB was found in 53 (17.1%) patients. MB and a positive acetylcholine test coexisted more frequently in patients with MINOCA versus stable NOCAD. MB was an independent predictor of positive acetylcholine test and MINOCA. At follow-up (median, 22 months; interquartile range, 13-32), patients with MB had a higher rate of major adverse cardiac events, mainly driven by a higher rate of hospitalization attributable to angina, and a lower Seattle Angina Questionnaires summary score (all P<0.001) compared with patients without MB. In particular, the group of patients with MB and a positive acetylcholine test had the worst prognosis. Conclusions Among patients with NOCAD, coronary spasm associated with MB may predict a worse clinical presentation with MINOCA and a higher rate of hospitalization attributable to angina at long-term follow-up with a low rate of hard events.

Keywords: MINOCA; acute coronary syndrome; coronary spasm; myocardial bridging; myocardial ischemia; prognosis.

Conflict of interest statement

None.

Figures

Figure 1. Myocardial bridging and coronary spasm…
Figure 1. Myocardial bridging and coronary spasm among patients with NOCAD with myocardial ischemia undergoing acetylcholine provocative test.
A, Incidence of myocardial bridging, positive acetylcholine provocative test, MINOCA, and stable non‐obstructive coronary artery disease among patients with myocardial ischemia and non‐obstructive coronary artery disease enrolled in our study. B, Incidence of a positive response at acetylcholine test, epicardial spasm or microvascular spasm according to the presence or absence of myocardial bridging. MB+ indicates myocardial bridging presence; MB−, myocardial bridging absence; MINOCA, myocardial infarction and non‐obstructive coronary arteries; and NOCAD, non‐obstructive coronary artery disease.
Figure 2. Survival Kaplan–Meier curves for major…
Figure 2. Survival Kaplan–Meier curves for major adverse cardiac events according to the presence or absence of myocardial bridging (A), and according to the presence/absence of myocardial bridging and positive/negative response at acetylcholine provocative test (B).
Ach indicates acetylcholine; MACE, major adverse cardiac events; MB+, myocardial bridging presence; and MB−, myocardial bridging absence.
Figure 3. Curves are compared by the…
Figure 3. Curves are compared by the log‐rank test.
We had no patient loss at follow‐up. Occurrence of major adverse cardiac events at follow‐up (A) and Seattle Angina Questionnaires summary score at 1‐year (B) according to the presence/absence of myocardial bridging and positive/negative response at acetylcholine provocative test. Ach indicates acetylcholine; MACE, major adverse cardiac events; MB+, myocardial bridging presence; MB−, myocardial bridging absence; and SAQ. Seattle Angina Questionnaires.
Figure 4. Clinical and prognostic implications of…
Figure 4. Clinical and prognostic implications of the interplay between myocardial bridging and coronary spasm in patients with myocardial ischemia and non‐obstructive coronary artery disease.
CAD indicates coronary artery disease; MACE, major adverse cardiac events; and MINOCA, myocardial infarction and non‐obstructive coronary arteries.

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