CC Cardiol Croat Cardiologia Croatica Cardiol. Croat. 1848-543X 1848-5448 Croatian Cardiac Society CC 2019 14_9-10_217-9 10.15836/ccar2019.217 Extended Abstract Characterization of patients with myocardial infarction with non-obstructive coronary arteries – experience from the Croatian branch of the ISACS-CT Registry VinkovićIneshttps://doi.org/0000-0003-1705-82951* LončarićFiliphttps://doi.org/0000-0002-7865-11082 MjehovićPetrahttps://doi.org/0000-0003-4908-46741 SabljakDorjahttps://doi.org/0000-0002-7785-55553 VlahovićVedranahttps://doi.org/0000-0002-8021-48553 SalaiGrgurhttps://doi.org/0000-0002-7782-16463 KlarićKlarahttps://doi.org/0000-0002-4180-692X3 RadićTonihttps://doi.org/0000-0002-2695-39643 PavasovićSašahttps://doi.org/0000-0002-3705-02261 JakušNinahttps://doi.org/0000-0001-7304-11271 FabijanovićDorahttps://doi.org/0000-0003-2633-34391 PlanincIvohttps://doi.org/0000-0003-0561-67041 ČikešMajahttps://doi.org/0000-0002-4772-55491 MiličićDavorhttps://doi.org/0000-0001-9101-15701 University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain University of Zagreb School of Medicine, Zagreb, CroatiaKEYWORDS: acute coronary syndrome, non-obstructive coronary disease. ADDRESS FOR CORRESPONDENCE: Ines Vinković, Klinički bolnički centar Zagreb, Kišpatićeva 12, HR-10000 Zagreb, Croatia. / Phone: +385-91-8905-037 / E-mail: iness.vinkovic@gmail.com 102019 14 9-10 217 219 12092019 16092019 2019 Croatian Cardiac Society

Background and Aim: There are still wide knowledge gaps in myocardial infarction with non-obstructive coronary arteries (MINOCA) - a heterogeneous entity seen in 1-10% of patients with acute coronary syndrome (ACS) (1). The aim is to determine characteristics of MINOCA in the Croatian branch of the ISACS-CT registry, and compare them to age- and gender-matched patients with unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI).

Patients and Methods: The study included 2487 patients with ACS. MINOCA was defined by simultaneous cardiac troponin levels >0.014 ng/L, symptoms of ischemia or significant ST-T changes in the ECG, and an absence of coronary artery stenosis of ≥ 50% on angiography. Age and gender-matching was performed from the remaining cohort by randomly sampling patients from the UA, STEMI and NSTEMI subgroups, based on the mean age ± 5 years and the gender ratio of the MINOCA group.

Results: MINOCA was seen in 2.5% (n=63) of the cohort, initially categorized as UA (37%), NSTEMI (48%) and STEMI (16%). Median age was 62 (53, 71) years, 56% male. After age- and gender-matching, there were 36 UA (10% of the UA cohort), 135 NSTEMI (15%) and 198 STEMI (16%) patients in the ACS control subgroups. MINOCA patients had a lower prevalence of diabetes, hypertension, dyslipidemia, chronic kidney disease and tobacco use as compared to UA and NSTEMI. MINOCA patients used less antiplatelets, beta-blockers and statins before hospitalization. MINOCA and STEMI subgroups had a high incidence of chest pain symptoms and a short time from symptom onset to hospitalization. In the first 24h of hospitalization, less MINOCA patients were treated with antiplatelets and statins, and at discharge, they were less frequently prescribed with antiplatelet drugs compared to UA and NSTEMI (Table 1). In-hospital mortality was low, with no deaths in MINOCA and UA patients, and 2 and 3 deaths in NSTEMI and STEMI, respectively.

Baseline characteristics and the comparison of patients with myocardial infarction with non-obstructive coronary arteries, unstable angina, ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction.
VARIABLES MINOCA(n=63) UA(n=36) NSTEMI(n=135) STEMI(n=198) P-value Misssing
ACS type UA 37 - - - 0
NSTEMI 48 - - - 0
STEMI 16 - - - 0
General characteristics Age 62 60 62 62 0.692 0
Male gender 56 56 56 56 1 0
BMI 28.7 31.2 29.3 27.7 0.001 36
Systolic blood pressure at admission 145 150 140 140 0.003 20
Family history of CAD 27 31 31 26 ns 0
Diabetes 18 28 36 23 0.017 0
Insulin therapy 2 8 11 7 0.087 0
Hypertension or on th 77 92 82 76 0.118 1
Smoking or ex-smoker 36 56 42 62 <0.001 6
Hypercholestroleamia or on therapy 58 86 69 53 <0.001 5
Angina classified by CCS 7 13 14 5 0.057 13
Unstable angina at rest 8 49 11 2 <0.001 8
Heart failure NYHA 2+ 5 3 3 2 0.412 7
COPD 2 6 6 7 0.539 7
Chronic kidney disease 5 12 12 4 0.028 7
Theraphy before admission Aspirin 35 43 32 18 0.002 6
Other antiplatlet therapy 18 24 10 6 0.006 8
ACEi 49 57 47 40 0.249 6
Beta-blockers 44 49 41 22 <0.001 6
Statins 30 39 32 18 0.007 6
ACS presentation Two or more 20 mins chest pain episodes in the previous 24 hrs 21 48 50 41 0.014 33
Onset <6 hours 63 44 46 70 <0.001 3
Chest pain 97 92 90 98 0.004 1
Abnormal ECG 46 46 63 99 <0.001 1
LBBB 4 0 1 5 0.514 6
ST elevation 19 6 4 81 <0.001 0
ST depression 10 14 22 15 0.147 0
Q wave 5 11 8 15 0.074 0
T wave inversion 3 17 26 10 <0.001 0
Initial descision for PCI treatment 63 83 86 99 <0.001 0
Therapy at admission Nitrates 45 57 47 34 0.021 10
Aspirin 24h 100 100 96 96 0.394 2
Clopidogrel 71 86 90 69 <0.001 2
Other antiplatelet therapy 10 9 13 46 <0.001 3
Statins 24 84 97 95 95 0.030 1
ACEi 24h 82 86 74 71 0.127 3
Beta blockers 24h 76 81 75 66 0.122 2
GP IIb/IIIa 3 12 10 50 <0.001 7
VARIABLES MINOCA(n=63) UA(n=36) NSTEMI(n=135) STEMI(n=198) P-value Misssing
Lab results Troponin T 0.07 0.02 0.18 0.35 <0.001 15
Troponin T peak 0.2 0.04 0.7 3.64 <0.001 25
CRP 2 38 30 25 0.001 35
CRP-peak 4 39 33 58 0.005 52
Creatinemia 90 88 90 80 0.024 5
WBC 7.5 8.9 9.0 11.3 <0.001 5
Hemoglobin 139 143 140 141 0.606 5
Cholesterol 4.7 5.1 5.2 5.0 0.419 15
Tryglicerides 1.28 1.61 1.63 1.40 0.001 15
HDL-C 1.3 1.17 1.10 1.17 0.003 15
LDL-C 2.87 3.68 3.71 3.68 0.322 15
Kaliemia 4.2 4.3 4.3 4.1 0.020 19
Na 140 140 140 139 <0.001 21
CK peak 207 161 165 1229 <0.001 42
Theraphy at discharge Aspirin at discharge 94 100 97 96 0.446 0
Clopidogrel at discharge 44 89 87 54 <0.001 0
Other antiplatelet therapy at discharge 0 8 8 47 <0.001 1
Anticoagulants at discharge 21 11 7 18 0.012 0
ACEi at discharge 81 81 81 81 ns 1
Beta-blockers at discharge 79 81 84 80 0.804 0
Statins at discharge 89 97 95 94 0.360 1
Other lipid lowering drugs at discharge 3 6 12 8 0.202 0
Diuretics at discharge 24 36 28 27 0.624 2
Antiarrhythmics at discharge 18 17 12 8 0.533 2
Outcomes Duration of hospitalisation 4 (2, 5) 3 (2, 5) 4 (3, 7) 5 (1, 7) 0.005 0
EF at discharge 55 60 55 50 <0.001 22
Hospital mortality 0 0 2 3 0.573 0
MINOCA - Myocardial infarction with non-obstructive coronary arteries; UA - Unstable angina; STEMI - ST-segment elevation myocardial infarction; NSTEMI - Non-ST-segment elevation myocardial infarction; ACS - Acute coronary syndrome; BMI - Body mass index; CAD - Coronary artery disease; CCS - Canadian Cardiovascular Society; NYHA - New York Heart Association; COPD - Chronic obstructive pulmonary disease; ACEi - Angiotensin-converting-enzyme inhibitor; ECG – Electrocardiogram; LBBB - Left bundle branch block; GP IIb/IIIa - Glycoprotein IIb/IIIa; WBC - White blood cells; EF - Ejection fraction

Conclusion: MINOCA patients are mainly categorized as UA and NSTEMI at presentation, but have less comorbidities, more pronounced symptoms of typical chest pain, a shorter time from symptoms to hospitalization, lower levels of statin and antiaggregation prescription at admission, and antiaggregation at discharge. In-hospital mortality confirms MINOCA as low risk, however, long-term registry follow-up is needed to learn about longer term outcomes.

LITERATURE AgewallSBeltrameJFReynoldsHRNiessnerARosanoGCaforioAL WG on Cardiovascular Pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J. 2017 Jan 14;38(3):143–53. 10.1093/eurheartj/ehw14928158518