TY - JOUR
T1 - Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction with Nonobstructive Coronary Arteries in Women
AU - Reynolds, Harmony R.
AU - Maehara, Akiko
AU - Kwong, Raymond Y.
AU - Sedlak, Tara
AU - Saw, Jacqueline
AU - Smilowitz, Nathaniel R.
AU - Mahmud, Ehtisham
AU - Wei, Janet
AU - Marzo, Kevin
AU - Matsumura, Mitsuaki
AU - Seno, Ayako
AU - Hausvater, Anais
AU - Giesler, Caitlin
AU - Jhalani, Nisha
AU - Toma, Catalin
AU - Har, Bryan
AU - Thomas, Dwithiya
AU - Mehta, Laxmi S.
AU - Trost, Jeffrey
AU - Mehta, Puja K.
AU - Ahmed, Bina
AU - Bainey, Kevin R.
AU - Xia, Yuhe
AU - Shah, Binita
AU - Attubato, Michael
AU - Bangalore, Sripal
AU - Razzouk, Louai
AU - Ali, Ziad A.
AU - Merz, Noel Bairey
AU - Park, Ki
AU - Hada, Ellen
AU - Zhong, Hua
AU - Hochman, Judith S.
N1 - Funding Information:
Dr Reynolds reports nonfinancial support from Abbott Vascular and Siemens related to the submitted work and nonfinancial support from BioTelemetry, outside the submitted work. Dr Maehara has received an institutional research grant from and is a consultant for Abbott Vascular and Boston Scientific. Dr Saw has received unrestricted research grant support (Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, National Institutes of Health, Michael Smith Foundation of Health Research, University of British Columbia Division of Cardiology, AstraZeneca, Abbott Vascular, Boston Scientific, and Servier), speaker honoraria (AstraZeneca, Boston Scientific, and Abbott Vascular), consultancy and advisory board memberships (AstraZeneca, Abbott Vascular, Boston Scientific, Gore, Baylis, and FEops), and proctorship honoraria (Abbott Vascular and Boston Scientific). Dr Smilowitz reports consulting and advisory board membership for Abbott Vascular. Dr Mahmud reports for Abbott Vascular Clinical trial support as site principal investigator. Dr Wei reports being a consultant for an Abbott advisory board on coronary microvascular dysfunction (paid to institution). Mr. Matsumura reports being a consultant for Terumo. Dr Toma reports consulting for Phillips/Volcano. Dr Shah serves on the advisory board for Philips Volcano. Dr Attubato is a consultant for Medtronic, Boston Scientific, and Philips. Dr Bangalore is on an advisory board for Abbott Vascular, Biotronik, Pfizer, Amgen, and REATA and receives grant support from Abbott Vascular and REATA. Dr Ali has institutionally directed grant support from the National Institutes of Health/National Heart, Lung, and Blood Institute, Abbott, Boston Scientific, and Cardiovascular Systems Inc; receives speaker fees from AstraZeneca; is an advisor to Amgen and Boston Scientific; and holds equity in Shockwave Medical. Dr Merz reports honorarium and consulting (paid to N.B.M.) from iRhythm (board director) and Med Intelligence (Caladrius lecture) and also honorarium and consulting (paid to Barbra Streisand Women’s Heart Center) from Bayer Advisory Board (advisory board). Dr Hochman is the principal investigator for the ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) for which, in addition to support by National Heart, Lung, and Blood Institute grant, there were in-kind donations for participating sites from Abbott Vascular; Medtronic, Inc; St Jude Medical, Inc; Volcano Corporation; Arbor Pharmaceuticals; AstraZeneca Pharmaceuticals; Merck Sharp & Dohme; Omron Healthcare; and Amgen, as well as financial donations from Arbor Pharmaceuticals and AstraZeneca Pharmaceuticals. The other authors have nothing to disclose.
Funding Information:
The study was funded by American Heart Association Go Red for Women Strategically Focused Research Network grant 16SFRN27810006. The pilot phase enrollment was funded by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant UL1TR001445. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Optical coherence tomography catheters were provided for use in the study by Abbott Vascular.
Publisher Copyright:
© 2021 Lippincott Williams and Wilkins. All rights reserved.
PY - 2021/2/16
Y1 - 2021/2/16
N2 - Background: Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. Methods: In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. Results: Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). Conclusions: Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.
AB - Background: Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. Methods: In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. Results: Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). Conclusions: Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.
KW - coronary vessels
KW - magnetic resonance imaging
KW - myocardial infarction
KW - tomography, optical coherence
KW - women
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UR - http://www.scopus.com/inward/citedby.url?scp=85099866791&partnerID=8YFLogxK
U2 - 10.1161/CIRCULATIONAHA.120.052008
DO - 10.1161/CIRCULATIONAHA.120.052008
M3 - Article
C2 - 33191769
AN - SCOPUS:85099866791
SN - 0009-7322
VL - 143
SP - 624
EP - 640
JO - Circulation
JF - Circulation
IS - 7
ER -