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Original article
DOI: 10.1016/j.rec.2020.10.008
Available online 19 December 2020
Long-term outcome of patients with NSTEMI and nonobstructive coronary arteries by different angiographic subtypes
Pronóstico a largo plazo de pacientes con IAMSEST y coronarias sin lesiones obstructivas según los distintos subtipos angiográficos
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Sergio García-Blasa,b,c,
Corresponding author
sergiogarciablas@gmail.com

Corresponding author: Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Avenida Blasco Ibáñez 17, 46010 Valencia, Spain.
, Jessika González D’Gregorioa,b,c, Clara Bonanada,b,d, Agustín Fernández-Cisnala,b,c, Ernesto Valeroa,b,c, Gema Miñanaa,b,c,d, Anna Mollarb,c, Julio Núñeza,b,c,d, Juan Sanchisa,b,c,d
a Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
b Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
c Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
d Departamento de Medicina, Universidad de Valencia, Valencia, Spain
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Figures (1)
Tables (6)
Table 1. Baseline characteristics: previous medical history
Table 2. Baseline characteristics on presentation and during admission
Table 3. Revascularization and treatment at discharge
Table 4. Univariate Cox regression. Impact of MINOCA and angiographic subtypes on the presence of MACE and its individual components (death, reinfarction, and revascularization) during follow-up (n=591).
Table 5. Cox regression. Predictive model of the presence of MACE during follow-up (n=591).
Table 6. Univariate Cox regression. Impact of angiographic subtypes of MINOCA in the presence of MACE within the MINOCA group during follow-up (n=121).
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Abstract
Introduction and objectives

Discordant data have been reported on the prognosis of myocardial infarction with nonobstructive coronary arteries (MINOCA). Moreover, few data are available on the impact of angiographic subtypes. The objectives of this study were to assess the prognostic impact on the long-term follow-up of the diagnosis of MINOCA and its angiographic subtypes.

Methods

We included 591 consecutive patients with non–ST-segment elevation myocardial infarction (NSTEMI) who underwent coronary angiography. MINOCA was classified according to angiographic findings as smooth coronary arteries, mild irregularities (< 30% stenosis), and moderate atherosclerosis (30%-49% stenosis). The primary endpoint was a composite of mortality, nonfatal myocardial infarction, and revascularization (MACE) at a median of 5 years of follow-up.

Results

A total of 121 patients (20.5%) showed no obstructive lesions. MINOCA was associated with a lower occurrence of MACE (P=.014; HR, 0.63; 95%CI, 0.44-0.91) and was confirmed as an independent factor in the multivariate analysis (P=.018; HR, 0.63; 95%CI, 0.43-0.92). On analysis of the separate components of the main endpoint, MINOCA was significantly associated with a lower rate of myocardial infarction and revascularization, but not with mortality. Analysis of angiographic subtypes among MINOCA patients showed that smooth coronary arteries were a statistically significant protective factor on both univariate and multivariate analysis, while mild irregularities and 30% to 49% plaques were associated with a higher risk of MACE.

Conclusions

MINOCA is associated with a lower rate of MACE, driven by fewer reinfarctions and revascularizations. Within the angiographic subtypes of MINOCA, smooth arteries were independently associated with a lower number of MACE.

Keywords:
Myocardial infarction with nonobstructive coronary arteries (MINOCA)
Non–ST-segment elevation myocardial infarction
Coronary artery disease
Abbreviations:
CA
MACE
MINOCA
NSTEMI
Tn
Resumen
Introducción y objetivos

Hay evidencia discordante sobre el pronóstico del infarto sin lesiones coronarias obstructivas (MINOCA). Además, existen pocos datos del impacto de sus subtipos angiográficos. Los objetivos del estudio son evaluar el impacto pronóstico del MINOCA y sus subtipos angiográficos en el seguimiento a largo plazo.

Métodos

Se incluyó a 591 pacientes consecutivos con IAMSEST a los que se realizó una coronariografía. Los pacientes con MINOCA se clasificaron según la angiografía en: coronarias lisas, irregularidades leves (estenosis<30%) y ateroesclerosis moderada (estenosis del 30-49%). El objetivo primario fue un combinado de mortalidad, infarto de miocardio y revascularización (MACE) en una mediana de seguimiento de 5 años.

Resultados

En total, 121 pacientes (20,5%) no tenían lesiones obstructivas. El MINOCA se asoció con una menor ocurrencia de MACE (p=0,014; HR=0,63; IC95%, 0,44-0,91) y fue un factor independiente en el análisis multivariado (p=0,018; HR=0,63; IC95%, 0,43-0,92). Al analizar los componentes individuales, el MINOCA se asoció significativamente con menores tasas de infarto de miocardio y revascularización, pero no con la mortalidad. El análisis de los subtipos angiográficos mostró que las arterias coronarias lisas eran un factor protector significativo tanto en el análisis univariante como en el multivariado, mientras que las irregularidades leves y las estenosis del 30-49% se asociaron con mayor riesgo de MACE.

Conclusiones

El diagnóstico de MINOCA se asocia con una tasa de MACE más baja debida a un menor número de reinfartos y revascularizaciones. De los subtipos angiográficos, las arterias lisas se asociaron de manera independiente con un menor número de MACE.

Palabras clave:
Infarto agudo de miocardio sin lesiones coronarias obstructivas (MINOCA)
Infarto agudo de miocardio sin elevación del segmento ST
Enfermedad coronaria

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