Using OCT, cardiac MRI can identify the underlying causes of MINOCA in women

Among women with MI with non-obstructive coronary arteries, approximately 85% had potential mechanisms identified when they underwent coronary OCT and cardiac MRI, according to the results of the HARP-MINOCA study.

Harmony R. Reynolds

For the prospective observational study, the researchers analyzed women with MI. All 301 women enrolled had invasive coronary angiography, which determined that 170 had less than 50% stenosis in all major arteries. All women without obstructive CAD then underwent OCT to identify culprit lesions and CMR to identify ischemic and non-ischemic myocardial lesions, and the researchers combined all images to attempt to identify the mechanism of MINOCA. Harmony R. Reynolds, MD, associate professor of medicine, associate director of the Cardiovascular Clinical Research Center and director of the Sarah Ross Soter Center for Women’s Cardiovascular Disease at NYU Langone Health, he said during a press conference at the American Heart Association’s virtual science sessions.

The results were published simultaneously in Circulation.

Reynolds said about 1 in 10 MI in women is MINOCA, but there are a wide range of causes including non-obstructive plaque, coronary artery spasm, coronary dissection, thrombus or thromboembolism, myocarditis, and takotsubo syndrome, so identify the cause. precise is important because the optimal treatments are different for each.

“In the 4 years following a MINOCA event, previous studies show that the risk of a major adverse cardiovascular event is 24% and the risk of death over 5 years is 11%,” he said. “Right now, however, different doctors are communicating different messages about MINOCA to patients and may mistakenly say that the event was not a heart attack. I had a patient who was told her arteries were open and she was given Xanax. ”

Among the 170 women with MINOCA, 145 had OCT with adequate image quality and 116 of those who had OCT also had CMR.

Of the women who had OCT, 46.2 percent had identified a definite or probable culprit injury, Reynolds said. Of the women who had CMR, 74.1% had abnormal findings and 53.4% ​​had an ischemic cause for abnormalities such as heart attack or myocardial edema in a coronary territory, while 20.7% had a non-ischemic cause for abnormalities such as myocarditis, takotsubo syndrome or non-ischemic cardiomyopathy, she said.

Using both OCT and CMR, 84.5% of women identified a cause of MINOCA, superior to OCT alone (P. <.001) and CMR only (P. = .001), according to the researchers.

Of the 116 women who had OCT and CMR, 63.7% had an ischemic etiology of MINOCA, 20.7% had a non-ischemic etiology, and 15.5% had no identified mechanism, Reynolds said.

“OCT and CMR provided useful diagnostic information independently and in combination,” Reynolds said at the press conference. “Identifying a detailed diagnosis helps doctors select treatment and helps patients understand which medications may be useful. OCT and CMR together provide strong scientific support for the hypothesis that plaque rupture can cause heart attacks, even in plaques that do not severely block the artery. About half of the women [in this study] had not identified any OCT culprits. This was likely due to a coronary spasm or thromboembolism, or perhaps the OCT missed it. The mechanisms of MINOCA in women were often similar to the mechanisms of MI with obstructive CAD, so it is important that these women receive prevention. “

Martha Gulati

During a presentation by the discussant at the press conference, Martha Gulati, MD, MS, FAHA, FACC, FASPC, division chief of cardiology for the University of Arizona College of Medicine – Phoenix and medical executive director for the Banner – University Medicine Heart Institute, said the study is important because “MINOCA occurs in up to 15% of all heart attacks. heart, and is much more common in women. Hopefully understanding the cause will help us treat them properly. The lack of obstruction does not mean that the heart attack is benign. We really need this information to better treat these patients. “.

Reference:

Perspective

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Julia Grapsa, MD, PhD, FACC

HARP-MINOCA findings have implications for secondary prevention in women with MINOCA, which can be targeted at the most likely underlying causes as demonstrated in this study. The findings support the European Society of Cardiology’s recent recommendation to follow a diagnostic algorithm to identify the underlying cause of a MINOCA presentation, to facilitate treatment based on the underlying cause or causes of MI.

OCT and CMR provided complementary and independent information on the mechanisms of MI in women with MINOCA in this study. The finding that 40% of women with normal CMR had a culprit OCT lesion illustrates the potential for OCT outcomes to change the management of MINOCA patients. However, clinical trials are needed to investigate the effects of specific therapies on outcomes.

Comprehensive imaging such as with OCT and CMR should be implemented in the guidelines as part of the MINOCA diagnostic algorithm. Nowadays, we detect a significant percentage of MINOCA in the community and careful medical history and imaging can provide the differential diagnosis with coronary heart disease.

MINOCA is an umbrella term used to describe heart attacks that are not caused by clogged arteries: a comprehensive imaging algorithm is critical to setting up the differential diagnosis. This will facilitate clinical practice but also prevention in a significant percentage of women.

Julia Grapsa, MD, PhD, FACC

Associate Professor of Cardiology, University College London

Attending Cardiologist, Guys and St. Thomas NHS Hospitals Trust, London

Editor-in-Chief, JACC: Case Reports

Disclosures: Grapsa does not report any relevant financial information.

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