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Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA)

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Abstract

Background

Up to 30% of patients with acute coronary syndrome have no culprit lesion. Coronary microvascular spasm is an alternative cause for such a clinical presentation. However, this has rarely been investigated systematically. The aim of our study was to assess the frequency of coronary microvascular spasm in patients with NSTEMI without culprit lesion (MINOCA) by intracoronary acetylcholine testing (ACH-test).

Methods

Between 2014 and 2017, 940 patients with NSTEMI underwent coronary angiography and 125 (13%) had no culprit lesion (< 50% stenosis on visual assessment). Of the latter, 29 patients had other causes for the clinical presentation (e.g. tako-tsubo-syndrome or myocarditis). The remaining 96 patients were recruited for the study and underwent ACH-testing according to a standardized protocol.

Results

The ACH-test was normal in 40 (42%) and abnormal in the remaining 56 (58%) patients. Of the latter, 26 patients (46%) had epicardial spasm (epicardial narrowing ≥ 90%, reproduction of symptoms and ischemic ST-segment changes) and 30 (54%) microvascular spasm (ischemic ST-shifts and angina without epicardial vasoconstriction ≥ 90%). The peak high-sensitive troponin-T concentration was 113 (42–255) pg/ml. Patients with coronary spasm had more often a positive family history compared to those without and patients with epicardial compared to microvascular spasm were more often smokers.

Conclusion

Coronary microvascular spasm is frequently found in patients with NSTEMI without culprit lesion and represents a likely cause of myocardial injury. ACH-testing is useful for detection of vasomotor disorders allowing tailored treatment with calcium antagonists and/or nitrates in addition to secondary prevention to improve symptoms and prognosis.

Graphic abstract

Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA)

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Abbreviations

ACS:

Acute coronary syndrome

AHA:

American heart association

NSTEMI:

Non-ST-elevation myocardial infarction

URL:

Upper reference limit

GFR:

Glomerular filtration rate

TTS:

Tako-tsubo-syndrome

ACH:

Acetylcholine

LCA:

Left coronary artery

RCA:

Right coronary artery

ECG:

Electrocardiogram

MRI:

Magnetic resonance imaging

MINOCA:

Myocardial infarction with nonobstructed coronary arteries

MI:

Myocardial infarction

PCI:

Percutaneous coronary intervention

TIA:

Transient ischemic attack

LVEF:

Left ventricular ejection fraction

NOAC:

Novel oral anticoagulant

ACE:

Angiotensin-converting-enzyme

CCB:

Calcium channel blocker

SVT:

Supraventricular tachycardia

AS:

Aortic stenosis

HNCM:

Non-obstructive hypertrophic cardiomyopathy

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Funding

This work was done with support from the Robert-Bosch-Foundation (KKF 770) and the Berthold-Leibinger-Foundation.

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Authors and Affiliations

  1. Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany

    Giancarlo Pirozzolo, Andreas Seitz, Anastasios Athanasiadis, Raffi Bekeredjian, Udo Sechtem & Peter Ong

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  1. Giancarlo Pirozzolo
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  2. Andreas Seitz
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  3. Anastasios Athanasiadis
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  4. Raffi Bekeredjian
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  5. Udo Sechtem
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  6. Peter Ong
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Correspondence to Peter Ong.

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On behalf of all authors, the corresponding author states that there is no conflict of interest.

Additional information

This work was done with support from the Robert-Bosch-Foundation (KKF 770) and the Berthold-Leibinger-Foundation.

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Pirozzolo, G., Seitz, A., Athanasiadis, A. et al. Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA). Clin Res Cardiol 109, 246–254 (2020). https://doi.org/10.1007/s00392-019-01507-w

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  • DOI: https://doi.org/10.1007/s00392-019-01507-w

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