MINOCA not benign, should be treated as a syndrome
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Patients with MI or ischemia without obstructive CAD are at elevated risk for poor CV outcomes and doctors need to pinpoint the cause of ischemia, according to a speaker.
“MINOCA is a syndrome, not a diagnosis,” Martha Gulati, MD, MS, FACC, FAHA, FASPC, editor-in-chief of CardioSmart from the American College of Cardiology and president-elect of the American Society for Preventive Cardiology, said during a presentation at the virtual ASPC Congress on CVD Prevention.
Many doctors were taught in medical school that obstructive CAD is what leads to CV events, but “obstructive CAD is just one phenotype of CAD,” Gulati said in her presentation.
Patients with ischemia but no obstructive CAD (INOCA) “were labeled as false positives, and yet there are data across imaging modalities that have shown that when you have ischemia, whether or not you have obstruction, there is an elevated risk for cardiac events. We have cohort studies with INOCA showing that they have poor outcome, and by having more severity of ischemia, cardiac events increase, so we can’t think of it as something that’s benign,” she said.
Unfortunately, she said, U.S. guidelines “haven’t caught up with the data.”
Patients with INOCA and MINOCA, most commonly women, have diffuse atherosclerosis with generalized narrowing and generalized pressure drop, indicating that “men explode but women erode,” Gulati said.
If a patient is diagnosed with MINOCA, the cause could be one of many things, and doctors need to figure that out, she said, noting possible etiologies could be vasospasm, coronary microvascular disease, plaque rupture, plaque erosion, in situ thrombosis, spontaneous coronary artery dissection, stress or other cardiomyopathies or myocarditis.
In the HARP study, an imaging strategy of OCT and cardiac MRI identified the underlying etiology in 85% of women with MINOCA, Gulati said.
“Integration of aspects of both function and anatomy into cardiovascular imaging may improve detection of ischemic heart disease in women and provide management guidance for patients with INOCA,” Gulati said.
“This is not a benign process, but it is not a one disease process,” she said, noting that randomized controlled trials are needed to determine optimal medical therapy based on each underlying disease process. The SWEDEHEART observational cohort study found statins and ACE inhibitors/angiotensin receptor blockers conferred mortality benefits in patients with MINOCA, while beta-blockers were associated with a trend toward a mortality benefit and dual antiplatelet therapy was not associated with benefit, she noted.
References:
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Gulati M. Ischemic Heart Disease. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 23-25, 2021 (virtual meeting).
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