| Objective:Myocardial infarction with no nonobstructive coronary arteries(MINOCA)is a distinct subpopulation of AMI who have no significant obstructions of coronary arteries.Recently,clinical studies regarding MINOCA,especially on Chinese patients,are scarce.This study aims to explore characteristics,prognosis,and novel risk factors in MINOCA patients.Here,the Part I shows clinical profiles and long-term outcomes after MINOCA.The potential sex gaps in MINOCA will also be discussed.Besides,the risk stratification of MINOCA remains unclear.We further explored whether the age,creatinine,and ejection fraction(ACEF)score[age(years)/ejection fraction(%)+1(if creatinine>176μmol/L)]could predict adverse outcomes after MINOCA.Methods:This was a single-center and observational cohort study.Overall,1179 eligible patients with MINOCA who underwent coronary angiography in Fuwai hospital from Jan 2015 to Dec 2019 were enrolled.The median follow-up was 41.7 months.The primary endpoint was a composite of major adverse cardiovascular events(MACE),including allcause death,nonfatal reinfarction,revascularization,nonfatal stroke,and hospitalization for unstable angina or heart failure.Baseline data and clinical outcomes in all patients were described.Patients were divided based on sex or ACEF score tertiles.The Cox regression,Kaplan-Meier curves,and ROC analyses were used.Results:We described the baseline characteristics of MINOCA(mean age of 55.7 years,male 73.5%,STEMI 40.2%,hypertension 53.4%,diabetes 15.9%,dyslipidemia 58.2%,prior MI 4.9%).Most of the patients received the secondary prevention treatments(usage of DAPT 92.5%,statins 95.8%,β-blocker 72.9%,ACEI or ARB 64.4%).Female patients had more risk profiles with regard to older age and higher rate of hypertension and diabetes compared with men.During the follow-up,168 patients experienced MACE(18 died,41 had reinfarction,12 suffered stroke,46 had revascularization,71 was hospitalized for UA and 48 hospitalized for HF).Women had a similar incidence of MACE compared to men(men vs.women:13.8%vs.15.3%,p=0.504).The multivariate Cox regression analysis showed that female sex was not associated with the risk of MACE(adjusted HR 1.02,95%CI:0.72-1.44,p=0.916).Further,patients with higher ACEF score tertiles had more rates of MACE(6.3%,12.5%and 23.8%,p<0.001).The adjusted risk of MACE increased with the rising ACEF score(for per 1 SD increase in ACEF score,HR 4.23,95%CI:3.37-5.30,p<0.001;1st tertile as reference,2nd tertile:HR 2.70,95%CI:1.38-5.29,p=0.004;3rd tertile:HR 5.35,95%CI:2.72-10.51,p<0.001).The ACEF score also yielded a good predictive value(AUC 0.79)for MACE and its discrimination were similar to GRACE score(AUC 0.81,p>0.05).Conclusion:Patients with MINOCA in our cohort seem to be younger,have fewer baseline risk factors,and have a higher rate to receive the optimal medical therapies.Even though,they were still at considerable risks for CV events.The clinical profiles regarding age and comorbidities differed between men and women,while the adjusted risk of MACE for both sexes were similar.Elevated ACEF score was associated with poor prognosis in MINOCA.This simple and valid risk score may help stratify high-risk patients with MINOCA.Objective:Multiple metabolic disorders including the abnormal metabolisms of glucose,lipid,uric acid and thyroid hormones play a key role in the development of coronary artery disease.This part aims to explore the prognostic value of cardiometabolic risk factors in a distinct population with myocardial infarction with nonobstructive coronaries(MINOCA).In particular,we will investigate the impact of prediabetes(pre-DM),triglyceride-glucose(TyG)index(a marker of insulin resistance),lipoprotein(a)[Lp(a)],hyperuricemia(HUA),and low triiodothyronine syndrome(LT3S)on the prognosis in MINOCA patients.Methods:Patients with MINOCA were divided according to glycemic status,TyG index tertiles,Lp(a)levels,presence of HUA,and presence of LT3S.Of these,glycemic status included normoglycemia(NG,HbA1c<5.7%),prediabetes(pre-DM,5.7%≤ HbA1c<6.5%),and diabetes(DM,HbA1c≥6.5%or diagnosed).TyG index was calculated as In[fasting triglyceride(mg/dL)×glucose(mg/dL)/2].Lp(a)was categorized as low,medium or high based on the value of 10 and 30mg/dL.HUA was defined as an elevated serum uric acid level≥ 420 μmol/L in men or≥ 357 μmol/L in women.LT3S was defined as reduced free T3(fT3<2.36pg/mL)with normal TSH values.Clinical characteristics and outcomes were compared.The Cox regression,Kaplan-Meier,and ROC analyses were performed.Results:During the median follow-up of 41.7 months,patients with pre-DM and DM had a significantly higher incidence of MACE compared with NG group(10.8%,16.1%,19.4%;p=0.003).After multivariate adjustment,both pre-DM and DM were associated with an increased risk of MACE(NG as reference;pre-DM:HR 1.45,95%CI:1.03-2.09,p=0.042;DM:HR 1.79,95%CI:1.20-2.66,p=0.005).Pre-DM was a robust predictor of MACE compared to NG.Meanwhile,pre-DM had a similar impact as DM on long-term prognosis after MINOCA.Second,patients with higher tertile levels of TyG index had a significantly higher rate of MACE(9.6%,14.9%,18.0%;p=0.003).After adjustment,elevated TyG index was significantly associated with an increased risk of MACE(for per 1SD increase in TyG index,HR 1.33,95%CI:1.04-1.69,p=0.020;tertile 1 as reference;tertile 2:HR 1.64,95%CI:1.06-2.53,p=0.025;tertile 3:HR 1.85,95%CI:1.17-2.93,p=0.008).Third,patients with higher Lp(a)levels had a significantly higher incidence of MACE(9.5%,14.6%,18.5%;p=0.002).The MACE risk increased with the rising Lp(a)levels even after multivariate adjustment(for per 1SD increase in Lp(a),HR 1.18,95%CI:1.01-1.37,p=0.029;low Lp(a)group as reference,medium Lp(a):HR 1.55,95%CI:1.02-2.40,p=0.047;high Lp(a):HR 2.07,95%CI:1.32-3.25,p=0.001).Fourth,patients with HUA had a significantly higher rate and adjusted risk of MACE(18.7%vs.12.8%,p=0.015;HR 1.49,95%CI:1.08-2.07,p=0.016)than patients without.Fifth,patients with LT3S had a significantly higher incidence of MACE(19.6%vs.12.9%;p=0.013).LT3S was closely associated with an increased risk of MACE even after multivariable adjustment(HR 1.50,95%CI:1.03-2.18,p=0.037).After propensity score matching,LT3S remained a robust risk factor of MACE(HR 1.53,95%CI:1.02-2.65,p=0.042).Moreover,the ROC curves showed the predictive value of the above cardiometabolic risk factors for MACE.Of these,the TyG index had a moderate discrimination.When adding Lp(a),HUA or LT3S into the Thrombolysis in Myocardial Infarction(TIMI)risk score,the combined risk model had a significant improvement in discrimination for MACE.Conclusion:Several metabolic disorders were robustly associated with a poor prognosis after MINOCA.Of these,pre-DM,high TyG index(insulin resistance),high Lp(a),HUA,and LT3S markedly increased the risk of MACE in MINOCA patients,and may serve as prognostic makers and facilitate risk stratification.In clinical practice,the management of these cardiometabolic factors should be emphasized in order to improve prognosis for this specific population. |
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