MINOCA: diagnosi, terapia e follow-up - Alessandra Chinaglia - Cardio ...
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MINOCA: diagnosi, terapia e follow-up
Alessandra Chinaglia
MINOCA = Myocardial infarction with non-obstructive coronary arteries
….senza ostruzione coronarica > 50%
Quanti sono i MINOCA ?
SWEDEHEART registry
5830 (9.6%) / 60,467 patients
1/10 dei pazienti con IMA
The American Journal of Medicine (2018) 131, 524–532
Japanese ROADDPC discharge database
14,045 (10.2%) / 137,678 AMI patients
International Journal of Cardiology xxx (xxxx) xxx
28 publications
MINOCA più donne e più giovani
di IMA con ostruzione coronarica
Circulation. 2015;131:861-870. DOI: 10.1161/
1. Diagnosi 2. Prognosi 3. Terapia
58 anni, maschio
In PS per episodio di intenso dolore epigastrico, dispnea e malessere
Ipertensione arteriosa in terapia, obesità
Da 4 giorni episodi di dolore epigastrico oppressivo con dispnea, sempre da sforzo, a rapida regressione con il riposo
Troponina 0.7 (< 0.1)
D-dimero>2000
MINOCA is a working diagnosis and should lead the treating physician to
investigate underlying causes
NON CARDIACHE CARDIACHE CORONARICHE
NON CORONARICHE
Embolia polmonare Dissezione coronarica
Trombofilie Miocardite Spasmo coronarico
IMA di tipo II Takotsubo Embolia coronarica
Anemia FA tachicardica Placca ulcerata non
Ins. Respiratoria Stenosi aortica ostruttiva
Shock
Ipertensione
Sepsi
Catecolamine
RMN permette di escludere
miocardite nel 33%
Circulation. 2015;131:861-870. DOI: 10.1161/
388 consecutive patients with MINOCA
Age 56 ± 17
Capacità della RMN di
25% myocarditis identificare la causa in
25% MI
elevata % di casi
25% cardiomyopathy
26% normal CMR
performed at a median of
37 days from presentation
J Am Coll Cardiol Img 2019;12:1973–82Spasmo coronarico in 1 caso su 4 Circulation. 2015;131:861-870. DOI: 10.1161/
80 MINOCA patients mean age 63.0± 10.7 years, 40 (50%) male Acetylcholine test in 43 (53.7%) patients Ergonovine test in 37 (46.3%) patients positive in 37 (46.2%) European Heart Journal (2018) 39, 91–98
European Heart Journal (2018) 39, 91–98
Trombofiia nel 14% dei casi Circulation. 2015;131:861-870. DOI: 10.1161/
European Heart Journal (2017) 38, 143–153
1. Diagnosi 2. Prognosi 3. Terapia
Mortalità MINOCA minore di IMA
con ostruzione coronarica
ma significativa
Circulation. 2015;131:861-870. DOI: 10.1161/SWEDEHEART
Mortalità CV, IMA, e HF nei
MINOCA minore di IMA
con ostruzione coronarica
ma maggiore dei pazienti non IMA
Journal of Internal Medicine, 2019, 285; 419–428/SWEDEHEART
MACEwas defined as all-cause mortality, rehospitalization for acute MI, ischemic stroke and heart failure.
2147 patients (24%) experienced a new MACE and 1254 patients (14%) died during the mean
follow-up of 4.5 years
Age, smoking, previous MI, ECG changes at
admission, reduced LVEF, creatinine, CRP
Age, diabetes, hypertension, smoking, previous MI, previous
stroke, COPD, PVD, dementia, previous or present cancer, ECG
changes at admission, reduced LVEF, creatinine, CRP and
lower levels of total cholesterol.
International Journal of Cardiology 261 (2018) 18–23SWEDEHEART
Valore di troponina aiuta a
stratificare il rischio
Q1:acute myocardial infarction patients aged 18 to 55 years
299 2690 (11.1%) MINOCA
J Am Heart Assoc. 2018;7: e009174MH mental health
RE role emotional;
SF social function
VT vitality
Am J Cardiol 2017;120:341e346SWEDEHEART
9092 patients with MINOCA
570 (6.3%) MINOCA patients hospitalized due to a recurrent MI
The American Journal of Medicine (2019) 132:335−3461. Diagnosi 2. Prognosi 3. Terapia
TERAPIA IN BASE ALLA DIAGNOSI
SWEDEHEART
5830 patients MINOCA vs 54,637 AMI CAD
follow-up at 6 to 10 weeks after the hospitalization
The American Journal of Medicine (2018) 131, 524–532SWEDEHEART
Blood pressure; LDL cholesterol levels in the target ranges,
nonsmoking, and participation in exercise training.
The American Journal of Medicine (2018) 131, 524–532SWEDEHEART registry
STATINE ACE INIBITORI
La terapia con statine,
ACE inibitori e
betabloccanti potrebbe
essere favorevole
BETABLOCCANTI DAPT
Circulation. 2017;135:1481–1489.Conclusioni • MINOCA = danno ischemico miocardico senza ostruzione coronarica • Eziologia eterogenea (cause coronariche, cardiache, non cardiache, IMA II tipo) • Necessario approfondire la diagnosi eziologica (Cath lab, CMR, Lab, Clinica) • Prognosi non sempre buona • Predittori: fattori di rischio, troponina • Terapia: 1) eziologica 2) controllo dei fattori di rischio
The diagnosis of MINOCA, like the diagnosis of MI, indicates that there is an ischemic mechanism responsible for the myocyte injury (ie, nonischemic causes such as myocarditis have been excluded). Furthermore, the diagnosis of MINOCA necessitates that obstructive CAD has not been inadvertently overlooked (eg, spontaneous coronary artery dissection). The prevalence of MINOCA is estimated to be 6% to 8% among patients diagnosed with MI and more common in women than men, as well as in patients presenting with NSTEMI compared with those presenting with STEMI.96–98 Atherosclerotic plaque disruption and coronary thrombosis may be a cause of MINOCA (ie, type 1 MI). However, coronary spasm and spontaneous coronary dissection may be involved as well (ie, type 2 MI). along with other possible causes. Additional coronary imaging and functional testing methods may be useful to elucidate the mechanisms of ischemia in MINOCA.46
European Heart Journal: Acute Cardiovascular Care 2019, Vol. 8(1) 54–
2690 patients undergoing angiography, 2374 (88.4%) had
acute myocardial infarction patients aged 18 to 55 years MICAD,
299 (11.1%) had MINOCA, and 17 (0.6%) remained unclassified
Women had 5 times higher odds of having MINOCA than men
(14.9% versus 3.5%; odds ratio: 4.84; 95% confidence interval,
3.29–7.13).
J Am Heart Assoc. 2018;7:
e009174SWEDEHEART
9092 unique patients with MINOCA of 199,163 MI admissions
in total. The 570 (6.3%) MINOCA
patients who were hospitalized due to a recurrent MI
constituted the study group.
The American Journal of Medicine (2019) 132:335−346European Heart Journal: Acute Cardiovascular Care 2019, Vol. 8(1) 54–
SWEDEHEART
Out of 199,163 MI admissions, 9092 consecutive unique
patientswith MINOCA were identified. The mean agewas 65.5 years and 62%werewomen.
International Journal of Cardiology 261 (2018) 18–23Consecutive patients with acute myocardial infarction admitted
to a cardiac unit at all 73 hospitals in Sweden between January
1, 2011 and December 31, 2013
SWEDEHEART registry
The American Journal of Medicine, Vol 129, No 4, April 2016You can also read
