Faculty Bibliography

BACKGROUND:Elevated stress is associated with adverse cardiovascular disease outcomes and accounts in part for the poorer recovery experienced by women compared with men after myocardial infarction (MI). Psychosocial interventions improve outcomes overall but are less effective for women than for men with MI, suggesting the need for different approaches. Mindfulness-based cognitive therapy (MBCT) is an evidence-based intervention that targets key psychosocial vulnerabilities in women including rumination (i.e., repetitive negative thinking) and low social support. This article describes the rationale and design of a multicenter randomized controlled trial to test the effects of telephone-delivered MBCT (MBCT-T) in women with MI. METHODS:We plan to randomize 144 women reporting elevated perceived stress at least two months after MI to MBCT-T or enhanced usual care (EUC), which each involve eight weekly telephone sessions. Perceived stress and a set of patient-centered health outcomes and potential mediators will be assessed before and after the 8-week telephone programs and at 6-month follow-up. We will test the hypothesis that MBCT-T will be associated with greater 6-month improvements in perceived stress (primary outcome), disease-specific health status, quality of life, depression and anxiety symptoms, and actigraphy-based sleep quality (secondary outcomes) compared with EUC. Changes in mindfulness, rumination and perceived social support will be evaluated as potential mediators in exploratory analyses. CONCLUSIONS:If found to be effective, this innovative, scalable intervention may be a promising secondary prevention strategy for women with MI experiencing elevated perceived stress.

Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.

BACKGROUND:Prior trials comparing a strategy of optimal medical therapy with or without revascularization have not shown that revascularization reduces cardiovascular events in patients with stable ischemic heart disease (SIHD). However, those trials only included participants in whom coronary anatomy was known prior to randomization and did not include sufficient numbers of participants with significant ischemia. It remains unknown whether a routine invasive approach offers incremental value over a conservative approach with catheterization reserved for failure of medical therapy in patients with moderate or severe ischemia. METHODS:The ISCHEMIA trial is a National Heart, Lung, and Blood Institute supported trial, designed to compare an initial invasive or conservative treatment strategy for managing SIHD patients with moderate or severe ischemia on stress testing. Five thousand one-hundred seventy-nine participants have been randomized. Key exclusion criteria included estimated glomerular filtration rate (eGFR) <30 mL/min, recent myocardial infarction (MI), left ventricular ejection fraction <35%, left main stenosis >50%, or unacceptable angina at baseline. Most enrolled participants with normal renal function first underwent blinded coronary computed tomography angiography (CCTA) to exclude those with left main coronary artery disease (CAD) and without obstructive CAD. All randomized participants receive secondary prevention that includes lifestyle advice and pharmacologic interventions referred to as optimal medical therapy (OMT). Participants randomized to the invasive strategy underwent routine cardiac catheterization followed by revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery, when feasible, as selected by the local Heart Team to achieve optimal revascularization. Participants randomized to the conservative strategy undergo cardiac catheterization only for failure of OMT. The primary endpoint is a composite of cardiovascular (CV) death, nonfatal myocardial infarction (MI), hospitalization for unstable angina, hospitalization for heart failure, or resuscitated cardiac arrest. Assuming the primary endpoint will occur in 16% of the conservative group within 4 years, estimated power exceeds 80% to detect an 18.5% reduction in the primary endpoint. Major secondary endpoints include the composite of CV death and nonfatal MI, net clinical benefit (primary and secondary endpoints combined with stroke), angina-related symptoms and disease-specific quality of life, as well as a cost-effectiveness assessment in North American participants. Ancillary studies of patients with advanced chronic kidney disease and those with documented ischemia and non-obstructive coronary artery disease are being conducted concurrently. CONCLUSIONS:ISCHEMIA will provide new scientific evidence regarding whether an invasive management strategy improves clinical outcomes when added to optimal medical therapy in patients with SIHD and moderate or severe ischemia.

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/RESULTS:=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/BACKGROUND:URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.

Objective: We studied young patients with acute myocardial infarction (AMI) to compare the clinical characteristics and outcomes between MINOCA versus obstructive disease (MI-CAD), and among MINOCA patients by sex and subtype. Design, Setting, and Participants: VIRGO, a prospective observational study of patients 18-55 years of age presenting with an AMI was conducted between 2008-2012 in 103 hospitals using a 2:1 women to men enrollment ratio. Using an angiographically-driven taxonomy, we defined patients as MI-CAD if revascularized or plaque >=50%. MINOCA included AMI patients with <50% obstruction or a non-plaque mechanism, e.g., spontaneous coronary artery dissection [SCAD]. Patients without angiogram or receiving thrombolytics pre-angiogram were excluded. Outcomes and Measures: Overall and sex-specific comparisons of 1-and 12-month mortality, functional (Seattle angina questionnaire [SAQ]) and psychosocial (perceived stress and depression) status. Results: Of 2,690 patients undergoing angiography, 2,374 (88.4%) were MI-CAD, 299 (11.1%) MINOCA and 17(0.6%) remained unclassified. Women compared with men and non-whites compared with whites had about 5-and 2-times higher odds of having MINOCA (14.9% vs 3.5%; OR 4.84; 95% CI 3.29, 7.13), and (14.9% vs 10.0%; OR:1.57,95% CI 1.21,2.04) respectively. MINOCA patients were 9 times more likely to be without traditional cardiac risk factors (8.7% vs 1.3%; p < 0.001) but more predisposed to hypercoagulable states than MI-CAD (3.0% vs 1.3%; p=0.036). MINOCA patients were 1.6 times more likely to present with NSTEMI than MI-CAD (78.6% vs 47.9%; p < 0.001). Women with MI-CAD were significantly more likely than MINOCA to be menopausal (55.2 vs. 41.2%; p < 0.001), or had history of gestational diabetes (16.8% vs. 11.0%; p=0.028). The MINOCA mechanisms varied, 75 (25.1%) had a non-plaque mechanism identified (61 SCAD, 11 coronary artery spasm, 3 embolization) while the majority remained undefined. Clinical profiles and management of MINOCA varied by mechanism. Overall mortality was 1.7% and adjusted 12-month SAQ quality of life score was not significantly different (76.5 vs 73.5 for MINOCA and MI-CAD respectively; p=0.06). Women with MINOCA reported higher perceived stress than men with MINOCA at 12-months (mean score 21.5 vs 17.3; p=0.03) and similar perceived stress to women with MI-CAD. Conclusion and Relevance: Young patients with MINOCA/SCAD were more likely women, non-white, had fewer traditional cardiac risk factors than MI-CAD patients and yet had clinical outcomes that were comparable to MI-CAD. MINOCA patients showed a heterogeneous profile in phenotypes and management when investigated for underlying mechanisms, warranting further research

BACKGROUND: Type 2 myocardial infarction (MI) is defined by a rise and fall of cardiac biomarkers and evidence of ischemia without unstable coronary artery disease (CAD) because of a mismatch in myocardial oxygen supply and demand. Myocardial injury is similar but does not fulfill the clinical criteria for MI. There is uncertainty in terms of the clinical characteristics, management, and outcomes of type 2 MI and myocardial injury in comparison with type 1 MI. PATIENTS AND METHODS: Patients admitted to a Veterans Affairs tertiary care hospital with a rise and fall in cardiac troponin were identified. MI and injury subtypes, presentation, management, and outcomes were determined. RESULTS: Type 1 MI, type 2 MI, and myocardial injury occurred in 137, 146, and 175 patients, respectively. Patients with type 2 MI were older (P=0.02), had lower peak cardiac troponin (P<0.001), and were less likely to receive aspirin and statin at discharge (P<0.001) than type 1 MI survivors. All-cause mortality (median follow-up: 1.8 years) was not different between patient groups (type 1 MI mortality: 29.9%, type 2 MI: 30.8%, myocardial injury: 29.7%; log rank P=0.94). A significant proportion of deaths were attributed to cardiovascular causes in all subgroups (type 1 MI: 34.1%, type 2 MI: 17.8%, myocardial injury: 30.8%). CONCLUSION: Patients with type 2 MI and myocardial injury were less likely to receive medical therapy for CAD than those with type 1 MI. No differences in all-cause mortality among MI subtypes were observed. Additional studies to determine optimal medical therapy and risk stratification strategies for these high-risk populations are warranted.