Faculty Bibliography

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.

BACKGROUND:Sex differences in early mortality after myocardial infarction (MI) vary by age. MI with nonobstructive coronary arteries (MINOCA [<50% stenosis]) is more common among younger patients and women, and MINOCA has a better prognosis than MI with obstructive coronary artery disease (MI-CAD). The relationship between age, sex, and obstructive CAD status and outcomes post-MI has not been established. METHODS AND RESULTS/RESULTS:Adults who underwent coronary angiography for acute ST-segment-elevation and non-ST-segment-elevation MI in the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines) from 2007 to 2014 were identified. Patients with cardiac arrest, thrombolytic therapy, prior revascularization, or missing demographic or angiographic data were excluded. The primary outcome was all-cause, in-hospital mortality. Secondary outcomes included major adverse cardiovascular events. Demographics, clinical history, presentation, and in-hospital treatments were compared by sex and CAD status (MI-CAD or MINOCA). Mortality and major adverse cardiovascular outcomes were analyzed by age, sex, and CAD status. Among 322 523 patients with MI, MINOCA occurred in 18 918 (5.9%). MINOCA was more common in women than men (10.5% versus 3.4%; P<0.0001), and women had higher mortality than men overall (3.6% versus 2.4%; P<0.0001). In-hospital mortality was lower after MINOCA than MI-CAD (1.1% versus 2.9%; P<0.0001). Among patients with MI-CAD, women had higher mortality than men (3.9% versus 2.4%; P<0.0001) while no sex difference in mortality was observed with MINOCA (1.1% versus 1.0%; P=0.84). The higher risk of post-MI death among women with MI-CAD was most pronounced at younger ages. CONCLUSIONS:MINOCA was associated with lower mortality than MI-CAD. Higher risk of post-MI death among women in comparison to men was restricted to patients with MI-CAD.

The present review synthesizes evidence and discusses issues related to health care quality and equity for women, including minority population subgroups. The principle of "sameness" or women and men receiving equitable, high-quality care is a near-term target, but optimal population health cannot be achieved without consideration of the unique, gendered structural determinants of health and the development of unique care pathways optimized for women. The aim of this review is to promote enhanced awareness, develop critical thinking in sex and gender science, and identify strategic pathways to improve the cardiovascular health of women. Delineation of the components of high-quality health care, including a women-specific research agenda, remains a vital part of strategic planning to improve the lives of women at risk for or living with cardiovascular disease.

BACKGROUND: Coronary artery calcification as assessed by computed tomography (CT) is a validated predictor of cardiovascular risk, whether identified on a dedicated cardiac study or on a routine non-gated chest CT. The prevalence of incidentally detected coronary artery calcification on non-gated chest CT imaging and consistency of reporting have not been well characterized. HYPOTHESIS: Coronary calcification is present on chest CT in some patients not taking statin therapy and may be under-reported. METHODS: Non-gated chest CT images dated 1/1/2012 to 1/1/2013 were retrospectively reviewed. Demographics and medical history were obtained from charts. Patients with known history of coronary revascularization and/or pacemaker/defibrillator were excluded. Two independent readers with cardiac CT expertise evaluated images for the presence and anatomical distribution of any coronary calcification, blinded to all clinical information including CT reports. Original clinical CT reports were subsequently reviewed. RESULTS: Coronary calcification was identified in 204/304 (68%) chest CTs. Patients with calcification were older and had more hyperlipidemia, smoking history, and known coronary artery disease. Of patients with calcification, 43% were on aspirin and 62% were on statin medication at the time of CT. Coronary calcification was identified in 69% of reports when present. CONCLUSIONS: A high prevalence of coronary calcification was found in non-gated chest CT scans performed for non-cardiac indications. In one-third, coronary calcification was not mentioned in the clinical report when actually present. In this population of patients with cardiac risk factors, standard reporting of the presence of coronary calcification may provide an opportunity for risk factor modification.