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Optical CT (OCT) plus cardiac MRI (CMR) provide a more specific diagnosis in most women presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA).
The multimodal imaging strategy identified the underlying cause of MINOCA in 85% of women in the HARP-MINOCA study. Overall, 64% of the women had true MI and 21% had a non-ischemic alternative diagnosis, most commonly myocarditis.
“The OCTCMR findings correlated well with culprit lesions of OCT, demonstrating that culpable non-obstructive lesions often cause MINOCA,” said study author Harmony Reynolds, MD, director of the Sarah Ross Soter Center for Women’s Cardiovascular. Research from New York University Langone.
Dr Harmony Reynolds
The results were presented at the American Heart Association (AHA) virtual science sessions 2020 and published simultaneously in Circulation.
MINOCA occurs in up to 15% of patients with MI and is defined as MI that meets the universal definition but with less than 50% stenosis in all major epicardial arteries on angiography and no specific alternative diagnosis to explain the presentation.
It is three times more common in women than in men and also disproportionately affects Black, Hispanic, Maori and Pacific people. MINOCA has several causes, leading to uncertainty in diagnostic testing and treatment.
“Different doctors tell patients different messages about MINOCA and may mistakenly say that the event was not a heart attack,” Reynolds said at a previous news conference. “I had a patient who was told” your arteries are open “and they gave her Xanax.”
Under the Women’s Heart Attack Research Program (HARP), researchers enrolled 301 women with a clinical diagnosis of MI, of whom 170 were diagnosed with MINOCA during angiography and underwent OCT at that time, followed by CMR within 1 week of acute presentation.
All images were interpreted by an independent central laboratory blinded to other test results and clinical information. The final cohort included 145 women with interpretable OCT images.
Their mean age was 60 years, 49.7% were white non-Hispanic and 97% had a provisional diagnosis of non-ST segment myocardial infarction. Their median peak troponin level was 0.94 ng / mL.
OCT identified a definite or probable culprit injury in 46% of women, most commonly atherosclerosis or thrombosis. On multivariate analysis, the presence of a culprit lesion was associated with older age, abnormal site angiography results, and diabetes, but not the maximum troponin level or severity of angiographic stenosis.
Available CMR in 116 women showed evidence of heart attack or regional injury in 69%. Multivariate predictors of abnormal CMR were higher troponin peak and higher diastolic blood pressure, but not culprit OCT injury or severity of angiographic stenosis.
When the OCT and CMR results were combined, a cause of MINOCA was identified in 84.5% of the women. Three quarters of the causes were ischemic (64% MI) and one quarter nonischemic (15% myocarditis, 3% Takotsubo syndrome, and 3% non-ischemic cardiomyopathy). In the remaining 15%, no cause of MINOCA was identified.
To emphasize the effect multimodal imaging can have on treatment, Reynolds highlighted a 44-year-old woman with no risk factors for coronary artery disease who had chest pain in the context of heavy menstrual bleeding, low hemoglobin, and a troponin peak 3.25 ng / mL.
Unexpectedly, imaging revealed a rupture of the left anterior descending plate (LAD) in a thin hooded fibroateroma, causing a small transmural infarction at the end of the LAD.
“Without this diagnosis, it is unlikely that he would have received antiplatelet or statin therapy and could have received a diagnosis of supply and demand mismatch when the true diagnosis was MI,” Reynolds noted.
“We can finally say that it’s not just about crazy women. There really is something going on,” noted Roxana Mehran, MD, Icahn School of Medicine at Mount Sinai in New York City. “Now you have told us that this is most likely atherosclerosis for almost 85% of the cases. So make the diagnosis and of course make sure you treat these patients accordingly for the risk factor modification, really thinking about a broken plaque.” .
The combination of OCT and MRI can lead to a more specific diagnosis and better treatment, but it also increases costs and logistical considerations.
“The implementation challenges are that not all forms of testing are available in every medical center,” Reynolds said theheart.org | Medscape Cardiology. “Many centers have cardiac magnetic resonance imaging”, while “OCT is not currently available in most medical centers where heart attack patients are treated, but is available at specialized centers.”
Asked during the session on the use of CT angiography, Gulati said, “For me, CT is useful when I’m not sure if there is plaque because the angiogram looked really normal and there was no opportunity to I do intracoronary imaging. And sometimes that will help me, particularly if a patient doesn’t want to take a statin. “
Invited discussant Martha Gulati, MD, president-elect of the American Society for Preventive Cardiology, pointed out that the European Society of Cardiology’s MINOCA guidelines recommend OCT and CMR, while the AHA 2019 statement on MINOCA, of which she is co-author, also recommends OCT and CMR, but almost like one or the other.
“We’ve already mentioned that you should do cardiac MRI to try to make a diagnosis, but I think the combination of the two should be emphasized when we have the next draft of these guidelines. It will really help,” Gulati said. theheart.org | Medscape Cardiology.
“But using OCT, in particular, has to be in the context of MI. I don’t think you want to repeat a procedure,” he said. “So we really need it to become more widely available because at the time of an MI, you won’t necessarily know you won’t find an obstructive lesion.”
Gulati pointed out several unanswered questions, including whether the diagnosis was lost in some patients, why the OCT of all three vessels was only available in 59%, and how the use of high-sensitivity troponin, which was left to the individual institution, could affect the usefulness of OCT and CMR.
It is also unknown whether the mechanism is different for ST-segment elevation MI, as the study included very few cases, although MINOCA often occurs in this setting. Future OCT / CMR studies will also have to enroll men to determine potential sex differences, if any.
Commenting on the study for theheart.org | Medscape Cardiology, B. Hadley Wilson, MD, Sanger Heart & Vascular Institute in Charlotte, North Carolina, said, “There would need to be further justification for this invasive interventional procedure to make sure the benefits outweigh the risk of threading and an OCT catheter down patients without any significant angiographic block and to assure interventional cardiologists of its worth here. “
He pointed out that non-invasive CMR appears useful in diagnosing nearly three-quarters of these patients and perhaps could be done sooner to indicate which of those with an ischemic cause could benefit from invasive OCT at catheterization. This seems more relevant in patients with a high suspicion of recurrent coronary heart disease or MINOCA.
“Overall, we need to consider the expense, logistics and small risk of these combined modalities, particularly in daily practice, before making recommendations,” Wilson said. “Additionally, because OCT is much less available than intravascular ultrasound, a challenging market paradigm shift would be required to implement this multimodal imaging strategy at the regional and local levels in the US, including the additional costs. CMR and / or combination with OCT is warranted to address more judicious use of in these patients. “
The study was funded by the AHA through a grant from the Go Red for Women Strategically Focused Research Network. Reynolds reported in-kind donations from Abbott Vascular and Siemens related to the study and non-financial support of BioTelemetry outside the study. Gulati and Wilson reported that they have no relevant disclosures.
American Heart Association (AHA) Science Sessions 2020. Presented November 14, 2020.
Circulation. Published online November 14, 2020. Abstract
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