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Mount Sinai cardiologist: Nonobstructive heart attacks require more recognition
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Acute MI in the absence of obstructive CAD, or MINOCA, is observed in an estimated 5% to 6% of patients with acute infarction who are referred for coronary angiography. Unfortunately, some cardiologists are not well-versed in the diagnosis and treatment of this condition. The American Heart Association recently published a scientific statement on the diagnosis and management of patients with MINOCA, which is the most contemporary document on MINOCA, incorporating the definitions used by the 4th Universal Definition of Myocardial Infarction and providing a detailed algorithm to aid doctors in evaluating and treating MINOCA.
Cardiology Today spoke with Jacqueline E. Tamis-Holland, MD, associate professor of medicine at the Icahn School of Medicine at Mount Sinai, associate director of the cardiac catherization lab at Mount Sinai Saint Luke’s Hospital and chair of the writing group for the AHA scientific statement, to discuss how important it is to recognize MINOCA and how the scientific statement can aid in that effort.
Question: What are some of the takeaways from this AHA scientific statement?
Answer: The scientific statement provides a clear message to physicians emphasizing the importance of recognizing MINOCA and considering the possible causes for MINOCA in patients without obstructive CAD. Physicians must first carefully consider the clinical presentation and ensure that there are no other causes for the patient’s symptoms and enzyme elevation. Once MINOCA is confirmed, a thorough evaluation for the etiology should be pursued.
Q: Do any of the recommendations from the scientific statement have implications for clinical practice?
A: Absolutely. The statement emphasizes the need to incorporate clinical judgment and perform a careful evaluation of these patients. The statement provides an algorithm outlining the evaluation and treatment of these patients. This may include additional diagnostic tests such as a cardiac MRI or OCT or IVUS imaging. The bottom line is we need to understand these patients’ underlying problem so we can provide each patient with the most disease-specific therapies to prevent recurrence and improve outcomes.
Q: Why is the prevalence and treatment of MINOCA not as well-understood by cardiologists?
A: The term MINOCA has only been recently coined by John F. Beltrame, BMBS, PhD, FAHA, a co-author on this paper, in 2013. Obviously, patients had acute MIs with no blockages in their arteries before 2013, but we only recently began to recognize it as a real condition over the past 10 to 15 years.
This is because doctors and patients always equate an acute MI with a blockage in the artery. If there are no severe blockages, the immediate reflex is to assume that the patient did not have an acute MI at all. For some patients, this may be true. For example, a patient may have chest pain and an elevation in their heart enzymes mimicking a MI, but actually resulting from an inflammation in the heart. But in some cases, this is not true. The patient may have had a real acute MI as a result of an unusual condition, but not as a result of a severe blockage.
Q: Is there a certain patient population that MINOCA is more prevalent in?
A: MINOCA is more commonly noted in women or younger patients.
Q: Beyond what is mentioned in the scientific statement, what is some advice that cardiologists should consider when diagnosing and treating these patients?
A: Physicians need to be sure to take a careful history and consider all possible etiologies for the patient’s symptoms in a differential diagnosis. Always listen to the patient and provide individualized care.
Q: What further research is needed in MINOCA?
A: Studies need to be done to assess the long-term prognosis of patients with MINOCA and to specifically look at the prognosis based on the underlying etiology for the acute MI, for example, vasospasm, plaque rupture, coronary thrombosis, etc.
Additionally, we need to better understand the therapies that we should give to patients with MINOCA. At this time, we commonly treat patients with MINOCA with some of the same medications we give to patients who have an acute MI and severe coronary artery disease. Although some observational studies suggest a benefit from some of these medications, there are currently no randomized trials that have clearly shown that these medications will benefit patients with MINOCA as well. For this reason, several trials are ongoing to evaluate this. The MINOCA-BAT study will look at the benefits of beta-blockers and ACE inhibitors/angiotensin receptor blockers in patients with MINOCA.
Q: How can patients play an active role in their care?
A: Patients should be proactive about their care. Often times, patients are told by their doctor, “I think you are having a heart attack,” but then later, after the angiogram, they are told, “You probably did not have a heart attack after all because your arteries are normal.” Clearly, this can be confusing to the patient. Patients should be encouraged to ask questions so that they can better understand the cause for one’s symptoms. If patients understand that there is a condition called MINOCA, then they may realize the importance of ensuring their doctor is doing the proper testing for their condition. Patients should always feel comfortable questioning their doctor: “If I did not have a heart attack, what caused my symptoms?” – by Darlene Dobkowski
For more information:
Jacqueline E. Tamis-Holland, MD, can be reached at Mount Sinai Heart at Mount Sinai St. Luke's, 440 W. 114th St., Clark 2, Area H, New York, NY 10025; email: jacqueline.tamis-holland@mountsinai.org; Twitter: @HollandTamis.
Disclosures: Tamis-Holland reports no relevant financial disclosures. Please see the scientific statement for all other authors’ relevant financial disclosures.
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