Characterization of patients with acute myocardial infarction without coronary artery disease

Caracterización de pacientes con infarto agudo del miocardio sin enfermedad coronaria obstructiva

Introduction: Often when assessing thoracic pain, some patients presenting with increased levels of troponin show no significant lesions by coronary angiography. This phenomenon is reported in 9% of cases. The objective of this study is to describe the clinical features and etiology of these cases.
Methodology: Descriptive observational study. Patients admitted to 2 tertiary care hospitals with an acute myocardial infarction diagnosis who underwent some type of coronary stratification strategy between June 2013 and February 2015 were included. Patients with increased levels of troponin I and coronary angiography showing no significant lesions of coronary arteries were selected.
Results: A total of 111 acute myocardial infarction patients were included, 21 (19%) were classified as AMI without coronary artery disease (CAD); of which 85.7% experimented a typical thoracic pain as clinical manifestation, the man/woman ratio was 4:1, mean age was 58 years (between 40 and 79 years). The 62% (13/21) had hypertension, 33% (7/21) dyslipidemia and 28% (6/21) heart failure. The most relevant associated symptom was dyspnea (61%, 13/21). Etiology was confirmed in 62% (13/21), particularly associated with cardiac failure and pulmonary embolism. Microvascular disease was considered in 8 cases (38%).
Conclusions: We found a high proportion of acute myocardial infarction without CAD.
Etiology is similar to that described, predominantly, heart failure and tachyarrhythmias.
Distinguishing between this entity and an obstructive disease is complex given they share similar clinical manifestations and diagnostic test results. A better characterization of microvascular disease is required.

1. Erhardt L, Herlitz J, Bossaert L, Halinen M, Keltai M, Koster R, et al. Task force on the management of chest pain. Eur Heart J. 2002 Aug;23:1153–76.

2. Tosteson AN, Goldman L, Udvarhelyi IS, Lee TH. Cost-effectiveness of a coronary care unit versus an intermediate care unit for emergency department patients with chest pain. Circulation. 1996;94:143–50.

3. Newby LK, Jesse RL, Babb JD, Christenson RH, de Fer TM, Diamond GA, et al. ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: A report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2012;60:2427–63.

4. Bugiardini R, Manfrini O, De Ferrari GM. Unanswered questions for management of acute coronary syndrome: Risk stratification of patients with minimal disease or normal findings on coronary angiography. Arch Intern Med. 2006;166:1391–5.

5. Patel MR, Chen AY, Peterson ED, Newby LK, Pollack CV Jr, Brindis RG, et al. Prevalence, predictors, and outcomes of patients with non-ST-segment elevation myocardial infarction and insignificant coronary artery disease: Results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative. Am Heart J. 2006;152:641–7.

6. Planer D, Mehran R, Ohman EM, White HD, Newman JD, Xu K, et al. Prognosis of patients with non–ST-segment–elevation myocardial infarction and nonobstructive coronary artery disease: Propensity-matched analysis from the acute catheterization and urgent intervention triage strategy trial. Circ Cardiovasc Interv. 2014;7:285–93.

7. Beltrame JF. Assessing patients with myocardial infarction and non obstructed coronary arteries (MINOCA). J Intern Med. 2013;273:182–5.

8. Bakshi TK, Choo MK, Edwards CC, Scott AG, Hart HH, Armstrong GP. Causes of elevated troponin I with a normal coronary angiogram. Intern Med J. 2002;32:520–5.

9. Lanza GA, Crea F. Acute coronary syndromes without obstructive coronary atherosclerosis: The tiles of a complex puzzle. Circ Cardiovasc Interv. 2014;7:278–81.

10. Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015;131:861–70.

11. López N, Tenorio C, Franco G. Características clínicas y pronóstico a un año de pacientes con síndrome coronario agudo sin elevación del segmento ST y arterias coronarias sanas. Rev Colomb Cardiol. 2011;18:316–23.

12. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Circulation. 2012;126:2020–35.

13. DeWood MA, Spores J, Notske R, Mouser LT, Burroughs R, Golden MS, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. NEngl J Med. 1980;303:897–902.

14. DeWood MA, Stifter WF, Simpson CS, Spores J, Eugster GS, Judge TP, et al. Coronary arteriographic findings soon after non-Q-wave myocardial infarction. N Engl J Med. 1986;315:417–23.

15. Agewall S, Giannitsis E, Jernberg T, Katus H. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J. 2011;32:404–11.

16. Thygesen K, Mair J, Giannitsis E, Mueller C, Lindahl B, Blankenberg S, et al. How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Heart J. 2012;33: 2252–7.

17. Sheifer SE, Canos MR, Weinfurt KP, Arora UK, Mendelsohn FO, Gersh BJ, et al. Sex differences in coronary artery size assessed by intravascular ultrasound. Am Heart J. 2000;139:649–53.

18. Ohlow MA, Wong V, Brunelli M, von Korn H, Farah A, Memisevic N, et al. Acute coronary syndrome without critical epicardial coronary disease: Prevalence, characteristics, and outcome. Am J Emerg Med. 2015;33:150–4.