AHA Statement on MINOCA Provides a Standard Definition, Clinical Care Algorithms

In an effort to more cohesively define the assessment and treatment of patients who present with MI without obstructive coronary disease—a condition termed MINOCA—an expert committee has published a scientific statement including what they hope will be clinically useful algorithms for more successful management of this population.

“As an interventional cardiologist, it's not uncommon for me to see patients come to the cath lab with signs and symptoms of a heart attack who have elevation in the enzymes, and then when they get the cardiac cath, they'll have nonobstructive disease or normal coronaries,” writing committee chair Jacqueline Tamis-Holland, MD (Mount Sinai Saint Luke’s Hospital, New York, NY), told TCTMD. “Then later on you'll hear the house staff tell the patient: ‘Oh everything's fine, you don't need anything, go home.’”

The reality is that even if physicians are aware of MINOCA as a term, they are unlikely to know exactly what it means in context, much less how to go about treating it, she said.

“It just seems like the care is very varied depending on the place you're at and just sort of depending on the clinical acumen of the physician [and] the whole team in terms of what's causing things,” Tamis-Holland explained. “I kind of felt that it was important for us to bring attention to the medical community, and even to the patients, the fact that there is a condition called MINOCA [and] you need to look into what the underlying etiology is, one, so you can give feedback to the patient . . . and, two, because if you identify what the underlying problem is, you might be able to improve the outcome.”

The European Society of Cardiology published a position paper on MINOCA in 2017, and while it addresses some of the issues surrounding clinical management of the condition, Tamis-Holland said that the United States needed its own statement due to differences in practice and insurance models.

Standardizing a Definition

Published online March 27, 2019, ahead of print in Circulation, the American Heart Association (AHA) statement reports that 5% to 6% of acute MI cases are patients with MINOCA, who typically are less likely to have electrocardiographic ST-segment deviations and also have smaller degrees of troponin elevation compared with MI patients with obstructive CAD.

While there is no “typical” MINOCA population, these patients tend to be younger and more often female, Tamis-Holland said.

The statement authors emphasize the importance of defining MINOCA given that these patients typically fare better than those with obstructive CAD but also since the etiologies of disease are vast and evidence-based treatment options are lacking. “Standardization of the definition of MINOCA is clinically pragmatic, has operational utility, and serves a key purpose in promoting clinical awareness and research into the condition,” they write.

The most important take-home message from this statement is for physicians to “stop, listen to what the patient is saying, and put the whole clinical picture together,” Tamis-Holland said. “Isolated elevated troponin does not mean you had a heart attack, but on the other hand, if you had the whole picture suggestive of a heart attack—and it's definitely a heart attack and not something else—then try to figure out what it is.” That may mean further testing to definitively exclude MI using angiography, LV functional assessment, or contrast cardiac MRI. Alternatively, if MINOCA is suspected, coronary function tests, intravascular imaging, and potentially MRI are appropriate.

As for determining the etiology of MINOCA, most physicians know about vasospasm and spontaneous coronary artery dissection, Tamis-Holland explained. “[But] plaque rupture may be something that a lot of people don't recognize or realize—that just because the angiogram doesn't show a severe narrowing, or just because there's no clear evidence on the angiogram for plaque rupture, it doesn't mean it can't occur.”

This kind of understanding is necessary because “maybe not everybody who has MINOCA needs a beta-blocker and not everybody who has MINOCA needs dual antiplatelets,” Tamis-Holland said. “You kind of need to think about what the etiology is and individualize care.”

Patient Awareness and Treatment

Increased patient awareness of MINOCA is also something that Tamis-Holland and colleagues are seeking with the publication of this statement. “I would imagine that it's very confusing when somebody says, ‘Oh you might have had a heart attack, but, oh, you didn't have blockages in your arteries,’” she said. “So, I think it's important for patients to be aware that there is a condition called MINOCA and that when physicians are telling you ‘Don't worry. You didn't have any blockages so everything's fine,’ they may fall into the category that maybe the testing may be needed, and they may not.”

Going into the future, the writing committee says they would like to see the creation of a specific diagnostic code for MINOCA so that it can be included in administrative databases and large registries for further study.

“This would provide the ability to detect patients with MINOCA, for clinical research and billing purposes, and would enable hospitals to pursue higher levels of reimbursement, if necessary, to offset the cost of additional diagnostic studies in these patients,” they write. “To balance the increased use of resources needed to establish the underlying cause of MINOCA, we hope that by identifying the cause, providers will more efficiently target disease-specific therapies, ultimately leading to an improvement in clinical outcomes and lower downstream costs.”

Also, future studies should focus both on “how best to treat MINOCA in general, and if you know the particular cause for your MINOCA like vasospasm or whatever, how best to treat that—whether all patients should be on aspirin, whether all patients should be on dual antiplatelets, et cetera,” Tamis-Holland said.

“I just really hope that this just raises the awareness of MINOCA in the physician community so people are more sort of conscious of doing the right thing and doing the right testing, and it also raises awareness in the patients, because I'm sure that very few patients have heard of this and have thought to say to their doctors: ‘Well, what's going on?’” she concluded.