Combining optical coherence tomography, left ventricular angiography/echo, and cardiac magnetic resonance identified an underlying cause in 62% of MINOCA patients, compared to 20% with OCT alone.
Cohort (n=183)
Yes
Does a structured diagnostic protocol including OCT, LVA/echo, and CMR improve the diagnostic yield in patients with MINOCA?
A structured diagnostic protocol integrating OCT, LVA/echo, and CMR successfully identifies the underlying cause in 62% of patients with MINOCA.
Absolute Event Rate: 62% vs 20%
Abstract Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a diagnostic and therapeutic dilemma as frequently no overt cause is identified for the clinical presentation. ESC guidelines recommend to follow a structured diagnostic protocol to determine the underlying final diagnosis. Purpose This study aims to assess the diagnostic yield of a protocol including optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) beyond initial coronary angiography for MINOCA in contemporary practice. Methods In this multicenter cohort study, MINOCA patients who underwent coronary angiography at a university medical center between December 2020 and June 2024 were enrolled. Local protocol recommended ad-hoc OCT and/or CMR. Left ventricular angiography (LVA) and cardiac echo were also considered for screening tako-tsubo cardiomyopathy. Coronary functional testing (CFT) was performed only in case of persistent angina. OCT-derived coronary culprit lesions were defined as those with plaque rupture, plaque erosion, thrombus, eruptive calcified nodule, spontaneous coronary artery dissection (SCAD), intraplaque hemorrhage, layered fibrotic plaque (LFP), and epicardial spasm (intimal bumping) (Ref. 1). Causes identified by CMR included myocardial infarction, myocarditis, tako-tsubo, and other non-ischemic cardiomyopathy. Results A total of 183 patients with MINOCA were included. Median age was 63 years (interquartile range 25-90), and 60% was female. OCT was performed in 112/183 patients (61%), of which two-vessel OCT was performed in 33 patients (29%) and three-vessel OCT was performed in 12 patients (11%). A culprit was detected by OCT in 36/112 patients (32%). A lesion-level analysis showed plaque rupture (n=5), plaque erosion (n=5), thrombus (n=13), eruptive calcified nodule (n=2), SCAD (n=2), intraplaque hemorrhage (n=9), LFP (n=20), and epicardial spasm (n=7). The culprit detection rate was 30% in single-vessel OCT, 30% in two-vessel OCT, and 50% in three-vessel OCT. LVA/echo was done in 112/183 patients (61%), demonstrating tako-tsubo in 32 patients (29%). CMR was performed in 104/183 patients (57%). Of note, a cause was identified by CMR in 64 patients (62%), including 45% myocardial infarction, 22% myocarditis, 8% tako-tsubo, and 25% other non-ischemic cardiomyopathy. Two patients were performed CFT, of which 1 was diagnosed with epicardial spasm. In the overall 183 patients, increased diagnostic yield was confirmed (20% with OCT vs 37% with OCT and LVA/echo vs 62% when combining OCT, LVA/echo and CMR). Conclusions Our results provide important insights in the diagnostic value of a MINOCA protocol in contemporary practice of patients with MINOCA. First, the integration of multiple diagnostic tests results in an identified cause in 62%. Second, multiple testing increases the diagnostic yield. Finally, there are potential improvements in the incorporation of the protocol.
Nishimiya et al. (Sat,) conducted a cohort in Myocardial infarction with non-obstructive coronary arteries (MINOCA) (n=183). Structured diagnostic protocol (OCT, LVA/echo, and CMR) vs. OCT alone was evaluated on Diagnostic yield (identification of underlying cause). Combining optical coherence tomography, left ventricular angiography/echo, and cardiac magnetic resonance identified an underlying cause in 62% of MINOCA patients, compared to 20% with OCT alone.