Sex-related MINOCA and MIOCA differences.
Several international guidelines recommend invasive treatment after diagnosing an acute coronary syndrome (ACS). The first studies that described acute myocardial infarction (AMI) without obstructive epicardial coronary disease reported a 10% incidence rate.
Based on this significant prevalence, it was recommended that this diagnosis be classified as MINOCA for patients who met the fourth definition of AMI and in whom angiography did not show epicardial stenosis greater than 50%. In turn, when compared with AMI with obstructive disease (MIOCA), these patients had a better prognosis.
This entity has historically been more associated with women, with a female prevalence of 50% in MINOCA as opposed to 25% in MIOCA. The aim of this study was to identify and describe sex differences in diagnosis, treatment, and long-term events in patients with MINOCA compared with MIOCA.
A cohort of patients with ST-segment elevation and non-ST-segment elevation ACS (NSTEACS), who underwent coronary angiography, was studied at the Freeman Hospital, Newcastle, United Kingdom. According to angiographic findings, these patients were subsequently classified as MINOCA and MIOCA. The primary endpoint was all-cause mortality at 1 year and at long-term follow-up. Secondary endpoints were first readmission for AMI or heart failure event.
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The study included 13,202 participants; 68.2% of subjects were male with a mean age of 68 years and 31.2% were female with a mean age of 73 years. The mean follow-up was 4.62 years. In the MIOCA group, 62.9% of patients were diagnosed with NSTEACS. There were 10.9% of patients with a diagnosis of MINOCA and the remaining 89.1% had MIOCA. Patients with a diagnosis of MINOCA had fewer risk factors compared with the MIOCA group (HBP 38% vs. 59%; p < 0.001; hypercholesterolaemia 23% vs. 48%; p < 0.001; diabetes 14% vs. 24%; p < 0.001). Patients who experienced MIOCA had a greater burden of morbidity (including COPD, peripheral vascular disease, and heart failure).
When performing the invasive study, there was a higher rate of transfemoral access in women (15% vs. 9.5%), and when evaluating the severity of MINOCA, female sex was associated with greater cardiogenic shock (2.7% vs 3.6%, p = 0.012).
Patients with MINOCA had fewer in-hospital (2.8% vs. 5.1%; p < 0.05) and procedure-related (0.9 vs. 3%) complications. While in MIOCA, women had a higher rate of complications compared with men (4.1% vs. 2.9%, p < 0.001). There were differences in terms of sex in the number of readmissions for AMI or heart failure at 1 year (both in MIOCA and MINOCA).
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In patients with obstructive disease, all-cause mortality was significantly higher in women than in men (3.2% vs. 2.1%; p < 0.001), and so was in the post-hospital mortality follow-up at 1 year (9.2% vs. 6.9%, p < 0.001) and in the long term (14.2% vs. 11.2%, p < 0.001). In patients with MINOCA, there were no significant differences in mortality according to sex. Men with MINOCA had a higher risk of mortality at long-term follow-up than men with MIOCA (hazard ratio: 1.52; 95% confidence interval [CI]: 1.11-2.07; p = 0.009).
Patients discharged from hospitalization with optimal medical treatment for secondary prevention were 55% more likely to survive than women with MIOCA. In turn, women with MIOCA were 50% more likely to suffer from in-hospital mortality than men (adjusted odds ratio 1.50; 95% CI: 1.09-2.07; p = 0.014).
Conclusions
The incidence of MINOCA was similar to that reported in earlier studies (around 10%), with a similar incidence among men and women. Patients with MINOCA experienced fewer in-hospital complications, whereas mortality did not vary with respect to MIOCA. Likewise, the rate of readmission for AMI or HF was similar, with no differences according to sex.
These results should emphasize that MINOCA is not a benign entity. Women with MINOCA had an unfavorable prognosis compared with men, with a higher mortality rate. Consequently, the follow-up of these patients should be stricter.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Reference: Michael Lawless, Yolande Appelman, John F Beltrame, Eliano P Navarese, Hanna Ratcovich, Chris Wilkinson, Vijay Kunadian, Sex differences in treatment and outcomes amongst myocardial infarction patients presenting with and without obstructive coronary arteries: a prospective multicentre study, European Heart Journal Open, Volume 3, Issue 2, March 2023, oead033, https://doi.org/10.1093/ehjopen/oead033.
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