Home Health News OCT and MRI Find an MI Cause in 85% of Women With MINOCA: HARP

OCT and MRI Find an MI Cause in 85% of Women With MINOCA: HARP

19 min read

The findings help a job for OCT on high of CMR, already urged by tips. How outcomes would possibly change stays unclear.

Multimodal imaging in women presenting with myocardial infarction with nonobstructive coronary arteries (MINOCA) on angiography recognized a mechanism of harm in almost 85% of women collaborating in the HARP research. That quantity is a putting determine for a situation that disproportionately impacts women and, for many years, noticed them being despatched residence from hospital emergency rooms with “false-positives” and no concrete prognosis.

A quantity of current tips already suggest extra imaging when MINOCA is identified on the premise of telltale signs and a troponin rise, even when no obstructions are discovered. HARP, demonstrating that cardiac MRI (CMR) and optical coherence tomography (OCT) present additive and complementary data, provides heft to these suggestions, mentioned lead investigator Harmony R. Reynolds, MD (NYU Grossman School of Medicine, New York, NY).

“Naturally I suppose it’s a giant deal,” Reynolds instructed TCTMD. “It’s my study. But I think it is very helpful for patients to know what’s wrong with them, and I’ve encountered many women who come for an additional opinion having been told the doctor was not sure if there was a heart attack or not, or was not sure how to treat it. And that generates a substantial amount of anxiety in people when a doctor says, ‘I’m not sure what’s wrong with you.’ Being able to give a more specific diagnosis to 85% of women with heart attack and open arteries will be very powerful in their care.” 

Others echoed that view through the main-event presentation. “Kudos to you,” session co-moderator Roxana Mehran, MD (Icahn School of Medicine at Mount Sinai, New York, NY), instructed Reynolds. “Finally we can say that this is not just crazy women. There is really something going on. . . . Making that diagnosis is going to be incredibly important.”

Reynolds introduced the outcomes as a late-breaking medical trial through the digital American Heart Association 2020 Scientific Sessions. The research was revealed concurrently in Circulation.

HARP Results

The purpose of the worldwide Women’s Heart Attack Research Program (HARP) research was to enroll women presenting with a prognosis of MI however no proof of stenoses 50% or better on coronary angiography. In all, 301 women at 16 websites have been enrolled and 170 have been identified with MINOCA throughout coronary angiography, prompting extra multivessel investigation with OCT adopted by CMR inside 1 week of the acute presentation.

I feel it is vitally useful for sufferers to know what’s fallacious with them. Harmony Reynolds

A particular or attainable offender lesion was recognized on OCT in 67 of the 145 women (46.2%) who had OCT outcomes of adequate picture high quality. Findings included plaque rupture (6%), thrombus with out rupture (3%), intraplaque cavity (21%), layered plaque (13%), intimal bump/spasm (2%), and spontaneous coronary artery dissection (1%).

Of the 116 women who additionally underwent CMR, 86 (74.1%) had irregular outcomes and 62 (53.4%) had abnormalities pointing to ischemia (infarction or myocardial edema in a coronary territory). A nonischemic sample was seen in 20.7%, suggesting myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy.

Ultimately, when OCT and CMR outcomes have been mixed, a believable trigger of MINOCA was recognized in a full 84.5% of women; the trigger was decided to be ischemic in origin in two-thirds of circumstances and nonischemic in 21%.

Following her presentation, Reynolds confused that she didn’t wish to underplay the importance of the CMR findings, even when the research’s principal purpose had been to determine a trigger for ischemic illness. “One in five had a nonischemic, alternate diagnosis and everyone loves to hear that they don’t need the whole complement of secondary prevention medications, so that’s really important.”

As Reynolds and colleagues observe in their paper, solely a small share of women with MINOCA in HARP had OCT indicators of coronary spasm and just one affected person was discovered to have coronary dissection. Of observe, nonetheless, OCT offender lesions have been much less generally discovered in women with regular coronary angiograms, and offender lesions have been no extra prone to be discovered in the most-occluded segments. “This is in line with our previous finding that offender lesions in women with MINOCA weren’t often positioned on the worst narrowing in that vessel, and means that focusing on of OCT to particular vessels primarily based on angiographic options will not be helpful,” they write. “Clinicians should not dismiss patients with smaller increases in troponin, who are as likely as those with larger increases to have an OCT-defined culprit lesion.”

Asked through the session concerning the potential utility of IVUS and CT angiography, Reynolds agreed that each might play a job. IVUS, she mentioned, is a good possibility at facilities with out entry to OCT, though it’s not but recognized how the 2 intravascular modalities evaluate in the setting of MINOCA. Cardiac CT could be useful when angiograms come again regular and there isn’t any possibility for intravascular imaging, notably if the affected person is reluctant to take a statin.

Caveats and Future Plans

Martha Gulati, MD (University of Arizona, Phoenix), discussant for the HARP outcomes, confused the strides made in current years in recognizing this phenomenon, which disproportionately impacts women.

“In the past there was no term for this. ‘Normal coronary arteries’ was what people were told and without any obstruction they left with no diagnosis, often told this was a false-positive, and they obviously did not receive any treatment. Now MINOCA is better defined, but as you already saw, MINOCA is not all the same. Technology and imaging can help us understand the pathophysiology, as the HARP investigators demonstrated.”

Finally we are able to say that this isn’t simply loopy women. Roxana Mehran

Gulati supplied a quantity of caveats, together with the truth that the HARP cohort included few STEMI sufferers, “and we know there is MINOCA in there”; fewer than two-thirds of the cohort had OCT of all three vessels, so the chance exists that some diagnoses have been missed; there was no management group of non-MINOCA sufferers to see if related abnormalities might be seen in “normal” arteries; and—“for once”— the cohort didn’t embrace males, making it unimaginable to find out if there are any sex-based variations.

Alice Ok. Jacobs, MD (Boston Medical Center, MA), who moderated a morning press convention, additionally zeroed in on sex-based variations, asking Reynolds why MINOCA is extra frequently identified in women.

Reynolds, in response, referred to as it a “fascinating question,” but to be answered. “I suspect it has something to do with the balance of blood clotting, with thrombosis and thrombolysis and also perhaps the tendency to spasm [in women versus men], but it’s definitely a very interesting question.”

Commenting on the research for TCTMD, Tom J. Ford, MBChB (Central Coast Local Health District/Gosford Hospital, New South Wales, Australia), praised the research for its strengths—the experience of the investigators, its potential, multicenter design, and the truth that it recruited sufferers previous to angiography. Its chief limitation, he famous, is its observational nature, so it could possibly’t reply the query of whether or not improved diagnostics result in adjustments in care that in the end enhance outcomes.

“I think the message is, if you have ischemic-type chest pain and the troponin has a rise and fall, then the patient has had a myocardial infarction,” he mentioned. “So if we take a step back from all the bells and whistles, the fancy coronary investigations and CMR, at the grass roots level, some of these patients may be falsely reassured in emergency [departments] or by physicians who say look, it’s a small troponin rise, it’s probably not of any clinical significance, but that patient would potentially need an explanation and also may benefit from treatment. But that would be something we should evaluate in larger studies.”

Reynolds agreed, noting to TCTMD that the CorMicA trial—led by Ford—”centered on the associated drawback of secure ischemia with nonobstructive coronary arteries, [and] discovered that high quality of life improved in sufferers given a particular prognosis and handled for that prognosis.” HARP, she continued, “was not designed to look at outcomes. I hope these results will set the stage for clinical trials in MINOCA to support stronger recommendations about diagnostic testing, and about medications [and their effect] on outcomes in the future.”

Guidelines and Practice

The 2020 European Society of Cardiology guidelines for non-ST elevation acute coronary syndromes suggest CMR in “all MINOCA patients without an obvious underlying cause,” a category IB advice, the authors observe. CMR can also be really useful in a 2019 AHA scientific statement on the prognosis and administration of MINOCA in addition to a 2016 European position paper. All three paperwork, nonetheless, give no formal suggestions on the use of OCT apart from to say that intravascular imaging “may be useful” or “valuable” if plaque disruption, plaque erosion, coronary dissection or thrombosis are suspected.

HARP makes the purpose that OCT insights are seemingly additive and complementary in this setting. “The finding that 40% of women with normal CMR had an OCT culprit lesion illustrates the potential for OCT findings to change management of MINOCA patients. However, clinical trials are needed to investigate the effects of specific therapies on outcomes.”

Gulati, after the main-event presentation, famous that a number of guideline paperwork are likely to characterize OCT as an various to CMR. “I do think that this needs to be updated,” she mentioned. “This stepwise approach is really important for coming up with the entirety of the reasons” for a MINOCA prognosis.

Ford identified that there are only a few ongoing randomized managed trials of MINOCA sufferers listed on ClinicalTrials.gov and none—that he was conscious of—which can be diagnostic methods as a way to enhance outcomes. Without these, he mentioned, it’s unlikely OCT would transfer up in the rules given how confined it’s to specialised facilities. In some circumstances, he mentioned, the more-detailed abnormalities picked up on OCT can truly be glimpsed as irregularities or anomalies on coronary angiography. “So in those kinds of patients, there might not be too much additional gain for doing an OCT if you’ve got an irregularity. You’re probably not going to stent it if it’s not obstructive.” But it does sign a necessity for preventive medicines.

Demonstrating an impact on laborious outcomes would have its challenges, he added, “but I think randomized controlled trials in this population would be helpful to identify the effect on patient understanding of illness, even if we weren’t looking at hard outcomes.”

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