Introduction
Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is a heterogeneous syndrome evoked via several different pathophysiological pathways. It is defined by the presence of clinical or laboratory evidence of MI and no significant coronary artery stenosis (lesions with diameter stenosis <50%).1
In recent years, focus on patients with MINOCA has increased. The prevalence of MINOCA among all MI cases is estimated to range between 5% and 15%.2 Unfortunately, this syndrome is related to various conditions that are challenging to identify, such as coronary microcirculatory dysfunction, epicardial coronary spasm, or plaque erosion.3 It is possible that inflammation also has an impact on the MINOCA prevalence.4 Quesada et al5 recently reported that the prevalence of ST-segment elevation MI (STEMI) with no culprit lesion on angiography among patients with COVID-19 was 21%. MINOCA is no longer perceived as a benign disorder, and cardiologists acknowledged that patients with this syndrome are characterized by long-term outcomes similar to those observed in individuals with obstructive coronary artery disease. In a recent Italian study,6 the rate of cardiac death was lower in the MINOCA group than in individuals with obstructive coronary artery disease (4.2% vs 8.4%; P = 0.03); however, there were no significant differences with respect to other end points, such as recurrent MI (17.3% vs 25.4%; P = 0.18), ischemic stroke (9.5% vs 3.7%; P = 0.12), or all-cause mortality (14.1% vs 20.7%; P = 0.26) during a median follow-up of 19.9 years.6 Other studies also confirmed these findings.7,8
SARS-CoV-2 infection is associated with an increased risk of thromboembolic complications. In some patients, thromboembolic processes may be responsible for the development of MINOCA.9 Other possible causes of MINOCA in the patients with COVID-19 include myocarditis,10 stress cardiomyopathy in the setting of severe illness,11 coronary artery plaque rupture, epicardial coronary spasm, spontaneous coronary artery dissection, and nonischemic cardiomyopathy.12 However, the potential influence of the COVID-19 pandemic on the rate and clinical outcomes of MINOCA remains unknown.
The present study aimed to compare the characteristics and 12-month clinical outcomes of patients with MINOCA treated before and during the COVID-19 pandemic.
Patients and methods
Data source
We retrospectively analyzed data from the Polish Registry of Acute Coronary Syndromes (PL-ACS)—a national, multicenter registry that collects information on patients hospitalized with ACS in Poland.13 PL-ACS is a joint venture of the Silesian Center of Heart Diseases in Zabrze and the Polish Ministry of Health, managed in cooperation with the National Health Fund (NHF). The registry was established in October 2003. In 2004, it was harmonized with the European Cardiology Audit and Registration Data Standards (CARDS). The present analysis involved consecutive patients included in the registry in 2019 and 2020. At that time, a total of 141 hospitals submitted data to the registry. The data were collected prospectively using electronic case report forms which included, among others, information on the medical history, comorbidities, initial presentation, results of coronary angiography, in-hospital treatment, and in-hospital outcomes. Data on posthospitalization all-cause mortality, including the date of death, were obtained from the NHF. The approval of an ethics committee was not required due to the retrospective design of the analysis.
Study population
All patients with a principal diagnosis of STEMI and non-STEMI (NSTEMI) according to the current guidelines of the European Society of Cardiology were considered for analysis. The exclusion criteria comprised age below 18 years at the time of hospitalization, a history of percutaneous coronary intervention (PCI) or coronary artery bypass grafting, as well as out-of-hospital cardiac arrest or heart failure on admission (Killip class 3 or 4). Only the patients who underwent cardiac catheterization were included in the analysis. The final cohort consisted of patients hospitalized for acute myocardial infarction (AMI) without obstructive coronary lesions (<50% diameter stenosis).
Statistical analysis
The MINOCA patients included in this analysis were stratified into 2 groups according to the year of admission (2019 vs 2020). Categorical variables were presented as numbers and percentages and were compared using the χ2 test or Fisher exact test, as appropriate. The normality of data distribution was assessed with the Shapiro–Wilk test. Since all quantitative variables were non-normally distributed, they were expressed as medians and interquartile ranges (IQRs), and the differences between the groups were compared using the Mann–Whitney test. The cumulative 12-month mortality was depicted using the Kaplan–Meier curves. The log-rank test was used to compare the 12-month mortality rates between the groups. Moreover, the Cox regression analysis was performed to identify independent factors associated with all-cause mortality at 12 months. Baseline characteristic variables (including demographics, medical history, comorbidities, and initial presentation) that reached a P value of less than 0.1 in the univariable model were included in the multivariable analysis. The final multivariable model was obtained using the backward variable selection method. The level of significance was set at a P value below 0.05 (2-tailed). All statistical analyses were performed using Statistica version 13.3 (TIBCO Software, Palo Alto, California, United States) and R software (The R Foundation for Statistical Computing, Vienna, Austria).
Results
Baseline characteristics
We retrospectively analyzed data of 51 734 patients with AMI included in the nationwide PL-ACS registry in 2019 and 2020. A working diagnosis of MINOCA was made in 3307 patients (6.4% of all AMI patients). After excluding individuals younger than 18 old and those after out-of-hospital cardiac arrest, we finally evaluated 3178 patients with MINOCA (6.1% of the total AMI group) (Figure 1). The rate of MINOCA was higher in 2019 (1903/28 115; 6.3%) than in 2020 (1275/20 441; 5.9%; P = 0.03).
Figure 1. Study flowchart
Abbreviations: AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; MINOCA, myocardial infarction with nonobstructive coronary arteries; PCI, percutaneous coronary intervention; PL-ACS, Polish Registry of Acute Coronary Syndromes; OHCA, out-of-hospital cardiac arrest
The median age of the study population was 68 years (IQR, 59.5–76.1), and 56.1% of the patients were women. The most common comorbidities were hypertension (66.3%), a history of smoking (52.2%, including 25.7% of current smokers), hypercholesterolemia (31.6%), type 2 diabetes (18.4%), and atrial fibrillation (13.7%). There were no differences between the groups (MINOCA 2019 vs MINOCA 2020) apart from the rate of hypercholesterolemia (33.9% vs 28.2%; P <0.001) and family history of cardiovascular diseases (5% vs 7%; P = 0.02) (Table 1).
Parameter | MINOCA patients | P value | ||||
|---|---|---|---|---|---|---|
Total (n = 3178) | 2019 (n = 1903) | 2020 (n = 1275) | ||||
Male sex | 1396 (43.9) | 843 (44.3) | 553 (43.4) | 0.61 | ||
Age, y | 68 (59.5–76.1) | 67.8 (59.2–76.4) | 68.2 (59.9–76) | 0.38 | ||
BMI, kg/m2 | 27.7 (24.7–31.1) | 27.7 (24.5–31.1) | 27.7 (24.8–31.1) | 0.8 | ||
Family history of CVD | 177 (5.8) | 91 (5) | 86 (7) | 0.02 | ||
Smoking | Current smoking | 713 (25.7) | 414 (25.2) | 299 (26.4) | 0.26 | |
Former smoking | 736 (26.5) | 422 (25.7) | 314 (27.7) | |||
Never-smoking | 1326 (47.8) | 805 (49.1) | 521 (45.9) | |||
Hypercholesterolemia | 922 (31.6) | 589 (33.9) | 333 (28.2) | <0.001 | ||
Hypertension | 2048 (66.3) | 1240 (67.2) | 808 (65.1) | 0.22 | ||
Diabetes or prediabetes | Type 2 diabetes | 575 (18.4) | 355 (19) | 220 (17.4) | 0.46 | |
Type 1 diabetes | 19 (0.6) | 12 (0.6) | 7 (0.6) | |||
Impaired fasting glucose | 54 (1.7) | 27 (1.4) | 27 (2.1) | |||
Impaired glucose tolerance | 33 (1.1) | 18 (1) | 15 (1.2) | |||
None | 2448 (78.2) | 1455 (77.9) | 993 (78.7) | |||
Chronic kidney disease (eGFR <60 ml/min/1.73 m2) | 168 (5.3) | 101 (5.3) | 67 (5.3) | 0.95 | ||
Previous myocardial infarction | 195 (6.2) | 120 (6.3) | 75 (5.9) | 0.63 | ||
Atrial fibrillation | 435 (13.7) | 257 (13.5) | 178 (14) | 0.7 | ||
Heart failure | 242 (7.7) | 135 (7.1) | 107 (8.5) | 0.17 | ||
Previous stroke | 159 (5) | 94 (4.9) | 65 (5.1) | 0.85 | ||
Peripheral artery disease | 114 (3.6) | 67 (3.5) | 47 (3.7) | 0.81 | ||
Data are presented as number (percentage) or median (interquartile range). Abbreviations: BMI, body mass index; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; others, see Figure 1 | ||||||
Types of myocardial infarction at presentation
Most patients presented with NSTEMI (90.7%), and chest pain was the most common symptom (81%). The median duration of symptoms before admission to the PCI center was 8.2 hours (IQR, 3.9–24.9), and the median door-to-catheter time was 3.7 hours (IQR, 1–13.3). Interestingly, these variables did not differ between the analyzed periods, that is, before and during the pandemic. More details are presented in Table 2.
Parameter | MINOCA | P value | |||
|---|---|---|---|---|---|
Total (n = 3178) | 2019 (n = 1903) | 2020 (n = 1275) | |||
MINOCA presentation | STEMI | 294 (9.3) | 180 (9.5) | 114 (8.9) | 0.62 |
NSTEMI | 2884 (90.7) | 1723 (90.5) | 1161 (91.1) | ||
Predominant symptoms before admission | Chest pain | 2574 (81) | 1579 (83) | 995 (78) | 0.01 |
Dyspnea | 370 (11.6) | 195 (10.2) | 175 (13.7) | ||
Fatigue | 56 (1.8) | 32 (1.7) | 24 (1.9) | ||
Syncope | 33 (1) | 22 (1.2) | 11 (0.9) | ||
Other symptoms | 111 (3.5) | 57 (3) | 54 (4.2) | ||
No symptoms | 34 (1.1) | 18 (0.9) | 16 (1.3) | ||
First medical contact | PCI-capable center (self-referral) | 281 (8.8) | 196 (10.3) | 85 (6.7) | <0.001 |
PCI-capable center (by EMS) | 895 (28.2) | 517 (27.2) | 378 (29.7) | ||
Non-PCI center | 1534 (48.3) | 930 (48.9) | 604 (47.4) | ||
Cardiology outpatient clinic | 266 (8.4) | 131 (6.9) | 135 (10.6) | ||
Primary health care center | 200 (6.3) | 128 (6.7) | 72 (5.7) | ||
Duration of symptoms before admission to a PCI center, h | 8.2 (3.9–24.9) | 8.2 (4–24.3) | 8.2 (3.8–26.2) | 0.62 | |
Door-to-catheter time, h | 3.7 (1–13.3) | 3.7 (1–13.6) | 3.7 (1–13) | 0.76 | |
Killip classification | Class 1 | 2905 (91.4) | 1742 (91.5) | 1163 (91.2) | 0.75 |
Class 2 | 273 (8.6) | 161 (8.5) | 112 (8.8) | ||
Rhythm on ECG | Sinus | 2823 (88.9) | 1693 (89) | 1130 (88.8) | 0.89 |
Paced | 29 (0.9) | 19 (1) | 10 (0.8) | ||
AF/AFl | 245 (7.7) | 143 (7.5) | 102 (8) | ||
Other | 78 (2.5) | 47 (2.5) | 31 (2.4) | ||
QRS changes on ECG | LBBB | 143 (4.5) | 95 (5) | 48 (3.8) | 0.26 |
RBBB | 129 (4.1) | 82 (4.3) | 47 (3.7) | ||
Other QRS changes | 513 (16.1) | 298 (15.7) | 215 (16.9) | ||
No QRS changes | 2393 (75.3) | 1428 (75) | 965 (75.7) | ||
ST-T changes on ECG | ST-segment elevation | 312 (9.8) | 187 (9.9) | 125 (9.8) | 0.34 |
ST-segment depression | 725 (22.8) | 432 (22.8) | 293 (23) | ||
T-wave inversion | 419 (13.2) | 247 (13) | 172 (13.5) | ||
Other ST-T changes | 1059 (33.4) | 616 (32.5) | 443 (34.7) | ||
No ST-T changes | 658 (20.7) | 416 (21.9) | 242 (19) | ||
LVEF, % | 55 (45–60) | 55 (45–60) | 54 (45–60) | 0.26 | |
Data are presented as number (percentage) or median (interquartile range). Abbreviations: AF, atrial fibrillation; AFl, atrial flutter; ECG, electrocardiography; LVEF, left ventriculr ejection fraction, EMS, Emergency Medical Service; LBBB, left bundle branch block; NSTEMI, non–ST-segment elevation myocardial infarction; RBBB, right bundle branch block; STEMI, ST-segment elevation myocardial infarction; others, see Figure 1 | |||||
In-hospital course
The overall all-cause in-hospital death rate was 1.4%, with no significant differences between the groups. However, in-hospital stroke was more frequently observed during the pandemic (0% vs 0.3%; P = 0.01). The frequency of other in-hospital complications was similar between the groups. Most participants were discharged on aspirin (85.6%), a β-blocker (73.1%), an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (70.2%), and a statin (62.7%), but only 50.6% of the patients received a P2Y12 inhibitor (Table 3).
Parameter | MINOCA | P value | ||
|---|---|---|---|---|
Total (n = 3178) | 2019 (n = 1903) | 2020 (n = 1275) | ||
Complications | ||||
Cardiogenic shock | 6 (0.2) | 3 (0.2) | 3 (0.2) | 0.62 |
Pulmonary edema | 2 (0.1) | 1 (0.1) | 1 (0.1) | 0.78 |
Acute mitral regurgitation | 5 (0.2) | 2 (0.1) | 3 (0.2) | 0.37 |
Free wall rupture | 6 (0.2) | 4 (0.2) | 2 (0.2) | 0.73 |
Ventricular septal rupture | 3 (0.1) | 2 (0.1) | 1 (0.1) | 0.81 |
Major bleeding | 23 (0.7) | 14 (0.7) | 9 (0.7) | 0.92 |
Outcomes | ||||
In-hospital stroke | 4 (0.1) | 0 | 4 (0.3) | 0.01 |
In-hospital recurrent MI | 2 (0.1) | 1 (0.1) | 1 (0.1) | 0.78 |
In-hospital cardiac arrest | 19 (0.6) | 8 (0.4) | 11 (0.9) | 0.11 |
All-cause in-hospital death | 46 (1.4) | 22 (1.2) | 24 (1.9) | 0.09 |
Noncardiovascular death | 6 (0.2) | 3 (0.2) | 3 (0.2) | 0.62 |
Medications at discharge | ||||
Aspirin | 2708 (85.6) | 1626 (85.9) | 1082 (85.1) | 0.55 |
P2Y12 inhibitor | 1607 (50.6) | 994 (52.2) | 613 (48.1) | 0.02 |
OAC | 434 (13.7) | 247 (13) | 187 (14.7) | 0.17 |
ACEI or ARB | 2231 (70.2) | 1352 (71) | 879 (68.9) | 0.20 |
β-Blocker | 2313 (73.1) | 1396 (73.7) | 917 (72.1) | 0.30 |
Statin | 1993 (62.7) | 1201 (63.1) | 792 (62.1) | 0.57 |
Data are presented as number (percentage). Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; MI, myocardial infarction; OAC, oral anticoagulant; others, see Figure 1 | ||||
Follow-up outcomes and predictive factors
The data on 12-month all-cause mortality were available for 3177 patients (99.9%). At the 12-month follow-up, the all-cause mortality rate in the whole study population was 9.9% (n = 315). There was no difference in the 12-month all-cause mortality in the patients with MINOCA treated before and during the pandemic (9.2% vs 11%; P = 0.09) (Figure 2). In the multivariable analysis, we identified the following predictive factors for all-cause death: male sex (hazard ratio [HR], 2.09; 95% CI, 1.43–3.05; P <0.001), age (HR, 1.07; 95% CI, 1.05–1.09; P <0.001), chronic kidney disease (HR, 2.07; 95% CI, 1.27–3.38; P = 0.004), peripheral artery disease (HR, 1.96; 95% CI, 1.1–3.47; P = 0.02), chest pain as the predominant symptom before admission (HR, 0.61; 95% CI, 0.42–0.88; P = 0.009), systolic blood pressure on admission (HR, 0.99; 95% CI, 0.986–0.9998; P = 0.04), heart rate on admission (HR, 1.01; 95% CI, 1.002–1.02; P = 0.02), STEMI on admission (HR, 2.10; 95% CI, 1.17–3.79), and ejection fraction (HR, 0.98; 95% CI, 0.97–0.997; P = 0.02) (Table 4).
Figure 2. Kaplan–Meier curves showing all-cause mortality rates in the patients with myocardial infarction with nonobstructive coronary arteries. Hazard ratio (HR) with a corresponding 95% CI refers to the effect of admission in 2020 (vs 2019) on all-cause mortality at 12 months in the multivariable Cox regression model.
Variable | Univariable model | Multivariable model | ||
|---|---|---|---|---|
HR (95% CI) | P value | HR (95% CI) | P value | |
Male sex | 1.27 (1.02–1.59) | 0.03 | 2.09 (1.43–3.05) | <0.001 |
Age (per 1-year increase) | 1.06 (1.05–1.07) | <0.001 | 1.07 (1.05–1.09) | <0.001 |
BMI (per 1 kg/m2 increase) | 0.97 (0.94–1) | 0.02 | – | – |
Family history of heart disease | 0.85 (0.5–1.42) | 0.53 | – | – |
Current smoking (vs former or never smoking) | 0.72 (0.54–0.97) | 0.03 | – | – |
Hypercholesterolemia | 0.89 (0.69–1.15) | 0.37 | – | – |
Hypertension | 0.82 (0.65–1.04) | 0.10 | – | – |
Diabetes | 1.61 (1.25–2.07) | <0.001 | – | – |
Chronic kidney disease | 3.18 (2.31–4.38) | <0.001 | 2.07 (1.27–3.38) | 0.004 |
Previous myocardial infarction | 1.22 (0.8–1.87) | 0.36 | – | – |
Atrial fibrillation | 1.90 (1.46–2.47) | <0.001 | 1.47 (0.93–2.34) | 0.10 |
Heart failure | 2.42 (1.79–3.27) | <0.001 | – | – |
Previous stroke | 1.67 (1.11–2.51) | 0.01 | – | – |
Peripheral artery disease | 2.67 (1.8–3.96) | <0.001 | 1.96 (1.1–3.47) | 0.02 |
Chest pain as the predominant symptom before admission | 0.57 (0.45–0.73) | <0.001 | 0.61 (0.42–0.88) | 0.009 |
PCI-capable center as a first medical contact | 1.04 (0.83–1.31) | 0.73 | – | – |
Duration of symptoms before admission to PCI center (per 1-hour increase) | 1 (1–1) | 0.97 | – | – |
Killip class 2 (vs class 1) | 2.59 (1.95–3.45) | <0.001 | – | – |
Systolic blood pressure on admission (per 1 mm Hg increase) | 0.988 (0.983–0.993) | <0.001 | 0.993 (0.99–0.9998) | 0.04 |
Heart rate on admission (per 1 bpm increase) | 1.01 (1.01–1.02) | <0.001 | 1.01 (1.002–1.02) | 0.02 |
Rhythm other than sinus | 1.52 (1.12–2.06) | 0.007 | 0.64 (0.36–1.15) | 0.14 |
LBBB or RBBB | 1.51 (1.07–2.11) | 0.02 | – | – |
STEMI (vs NSTEMI) | 2.07 (1.53–2.79) | <0.001 | 2.10 (1.17–3.79) | 0.01 |
Ejection fraction (per 1% increase) | 0.96 (0.95–0.97) | <0.001 | 0.98 (0.97–0.997) | 0.02 |
Hospital admission in 2020 (vs 2019) | 1.21 (0.97–1.51) | 0.09 | 1.32 (0.92–1.88) | 0.13 |
Abbreviations: see Tables 1 and 2 | ||||
Discussion
To our best knowledge, this is so far the largest all-comers population study providing data on the occurrence of MINOCA in patients treated before and during the COVID-19 pandemic. MINOCA is a challenging disease associated with significant morbidity and mortality. The concomitance of COVID-19 and MINOCA increases the risk of subsequent adverse events. It was reported that patients with MI and COVID-19 presented significantly higher morbidity and mortality than the patients with MI who did not suffer from COVID-19.14 However, our study showed that the percentage of MINOCA was higher in 2019 than in 2020 (6.3% vs 5.9%; P = 0.03). The all-cause in-hospital death rate was 1.4%, with no significant differences between the groups. At the 12-month follow-up, the all-cause mortality rate was 9.9% (n = 315). There was no difference in the 12-month all-cause mortality between the patients with MINOCA treated before and during the pandemic, only a trend toward a worse outcome in the patients treated in 2020 was observed (9.2% vs 11%; P = 0.09). Notably, the dramatic situation and the reduction in the number of ACS patients presenting to hospitals at the beginning of 2020, which resulted in an increase in mortality, might have largely contributed to the outcomes. The rate of MINOCA was at the lower range of the percentage of cases reported in other studies.6,15-17 In our analysis, we observed a striking decrease in the number of MI cases by 37.5% (28 115 in 2019 vs 20 441 in 2020), which was also noted in other national registries.18 The database endorsed by the Association of Cardiovascular Interventions of the Polish Cardiac Society and operated daily by the Jagiellonian University Medical College showed that the COVID-19 pandemic had had an enormous impact on interventional cardiology in Poland. A substantial decrease in the number of coronary angiography and PCI procedures across various indications, as well as underuse of modern imaging and physiological assessment techniques were observed. In comparison with 2019, 2020 brought a substantial decrease (by 25%) in the total number of reported coronary angiographies (172 521 vs 130 662), as well as of PCI procedures (101 716 vs 82 349).14,19 This was also observed in other countries where COVID-19 impacted the unplanned hospitalization rates. Wang et al20 reported a significant decrease in the overall hospitalization rate (–182 per 100 000), as well as a decline in the rate of unplanned hospitalizations (–39 per 100 000) and hospitalizations due to AMI (–1.32 per 100 000), stroke (–1.51 per 100 000), and heart failure (–8.7 per 100 000). The causes of these findings are multifactorial, and we should mention at least the following: patients’ fear of COVID-19 contraction, an excess of prepandemic hospitalizations, as well as pandemic mitigation measures, such as cancellation of nonurgent procedures and treatments. Also, the MINOCA symptoms might not be as severe and persistent as those of acute MI with total occlusion; therefore, it is possible that more patients decided not to report to emergency departments. Moreover, most patients did not present with STEMI, and when SARS-CoV-2 infection was confirmed, coronary angiography was often postponed, and COVID-19 could have been the cause of death. This also might have led to the fewer registered cases of MINOCA.
Previous studies showed increased rates of mortality and complications from acute MI and stroke during the pandemic, as compared with the preceding years.21-23 Thus, we expected to note an increase in in-hospital mortality rates from urgent, non–COVID-19–related conditions, such as acute MI and stroke. However, we did not find evidence of significant changes in the percentage of in-hospital mortality or the mean length of hospital stay after the implementation of COVID-19 containment measures, as compared with the prepandemic period.
Nevertheless, we must stress that despite relatively few MINOCA cases, mechanical complications have been observed, such as ventricular septal or free wall rupture. This is in accordance with previous reports and our recent systematic review on MINOCA complications.24 The literature search revealed 5 cases of intraventricular septal rupture, 3 cases of free wall rupture with pericardial effusion or cardiac tamponade, and 3 cases of bleeding complications (intracerebral or intestinal bleeding). Moreover, the rates of ventricular arrhythmia ranged from 2% to 13.8%, and the in-hospital death rate ranged from 0.9% to 6.4%.25
In the present study, the mortality rate among patients with MINOCA was around 10%, depending on the year of admission. On the other hand, in the recently published largest available MINOCA database, the 12-month mortality rate was approximately 3.5%.8 The difference might have been associated with worse diagnostic methods in Poland, mainly based on echocardiography and coronary angiography, and rarely supported by intravascular imaging and cardiac magnetic resonance. Another reason might be poor long-term monitoring of patients with ACS,26 since, as previously shown, the patients with close follow-up are characterized by better outcomes in Poland.27 In our study, the 12-month outcomes tended to be worse for the MINOCA patients treated in 2020, with male sex, age, chronic kidney disease, peripheral artery disease, and STEMI on admission as the most important factors associated with a poor prognosis.
Partially, as mentioned above, it may be due to impaired access to medical care after discharge, but also to the thrombotic risk associated with COVID-19. Early studies regarding SARS-CoV-2 described a correlation between coagulation parameter derangement and worse patient outcomes. Furthermore, postmortem examination of patients who died from COVID-19 demonstrated direct viral infection of the endothelial cells evoking diffuse endothelialitis, microcirculatory dysfunction, and widespread thrombotic microangiopathy. These abnormalities could be prognostic markers of thrombotic complications rather than of bleeding events.28 Literature data show that patients hospitalized for COVID-19 are characterized by an increased risk of venous thromboembolism (pulmonary embolism and deep vein thrombosis), as well as higher rates of arterial thromboembolism (MI, systemic arterial embolism, stroke, or acute limb ischemia).29-31
The present study has some limitations. The first one is its observational design. Second, the follow-up data were taken from the NHF, so we did not have access to detailed information on the causes of death or other end points, such as recurrent MI or repeated coronary angiography. Moreover, the lack of data on cardiac magnetic resonance, intracoronary imaging, microcirculation resistance, and provocative spasm testing prevented us from dividing the patients into subgroups based on the pathophysiological mechanisms. Finally, we did not have information on SARS-CoV-2 infection in the analyzed group of patients with MINOCA.
In conclusion, we observed a lower percentage of MINOCA cases and higher in-hospital stroke rates in the patients with MINOCA treated during the COVID-19 pandemic (2020). The possible association between worse clinical outcomes of the MINOCA patients treated during the pandemic and thromboembolic complications of SARS-Cov-2 infection needs further evaluation.
Jacek Bil, MD, PhD, FESC, Department of Invasive Cardiology, Center of Postgraduate Medical Education, ul. Wołoska 137, 02-507 Warszawa, Poland, phone: +48 47 722 11 00, email: biljacek@gmail.com
September 5, 2022.
December 12, 2022.
January 5, 2023.
None.
None.
JB and AK conceived the concept of the study. JK, AK, KB, MG, and RJG contributed to the design of the research. All authors were involved in data collection. KB and MG analyzed the data. JB and WW wrote the manuscript draft. All authors edited and approved the final version of the manuscript.
None declared.
Bil J, Kern A, Bujak K, et al. Clinical characteristics and 12-month outcomes of patients with myocardial infarction with nonobstructive coronary arteries before and during the COVID-19 pandemic. Pol Arch Intern Med. 2023; 133: 16405. doi:10.20452/pamw.16405
- 1.
- Bil J, Pietraszek N, Gil RJ, et al. Complete blood count-derived indices as prognostic factors of 5-year outcomes in patients with confirmed coronary microvascular spasm. Front Cardiovasc Med. 2022; 9: 933374.Crossref
- 2.
- Casolo G, Gabrielli D, Colivicchi F, et al. ANMCO position paper: prognostic and therapeutic relevance of non-obstructive coronary atherosclerosis. Eur Heart J Suppl. 2021; 23: C164-C175.Crossref
- 3.
- Bil J, Mozenska O, Segiet-Swiecicka A, Gil RJ. Revisiting the use of the provocative acetylcholine test in patients with chest pain and nonobstructive coronary arteries: a five-year follow-up of the AChPOL registry, with special focus on patients with MINOCA. Transl Res. 2021; 231: 64-75.Crossref
- 4.
- Atri D, Siddiqi HK, Lang JP, et al. COVID-19 for the cardiologist: basic virology, epidemiology, cardiac manifestations, and potential therapeutic strategies. JACC Basic Transl Sci. 2020; 5: 518-536.Crossref
- 5.
- Quesada O, Van Hon L, Yildiz M, et al. Sex differences in clinical characteristics, management strategies, and outcomes of STEMI with COVID-19: NACMI registry. J Soc Cardiovasc Angiogr Interv. 2022; 1: 100360.Crossref
- 6.
- Magnani G, Bricoli S, Ardissino M, et al. Long-term outcomes of early-onset myocardial infarction with non-obstructive coronary artery disease (MINOCA). Int J Cardiol. 2022; 354: 7-13.Crossref
- 7.
- Li M, He Y, Cheang I, et al. Clinical characteristics and outcome in patients with ST-segment and non-ST-segment elevation myocardial infarction without obstructive coronary artery: an observation study from Chinese population. BMC Cardiovasc Disord. 2022; 22: 21.Crossref
- 8.
- Pasupathy S, Lindahl B, Litwin P, et al. Survival in patients with suspected myocardial infarction with nonobstructive coronary arteries: a comprehensive systematic review and meta-analysis from the MINOCA Global Collaboration. Circ Cardiovasc Qual Outcomes. 2021; 14: e007880.Crossref
- 9.
- Vahdat S. A review of pathophysiological mechanism, diagnosis, and treatment of thrombosis risk associated with COVID-19 infection. Int J Cardiol Heart Vasc. 2022; 41: 101068.Crossref
- 10.
- Patone M, Mei XW, Handunnetthi L, et al. Risks of myocarditis, pericarditis, and cardiac arrhythmias associated with COVID-19 vaccination or SARS-CoV-2 infection. Nat Med. 2022; 28: 410-422.Crossref
- 11.
- Jabri A, Kalra A, Kumar A, et al. Incidence of stress cardiomyopathy during the coronavirus disease 2019 pandemic. JAMA Netw Open. 2020; 3: e2014780.Crossref
- 12.
- Tamis-Holland JE, Jneid H, Reynolds HR, et al. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation. 2019; 139: e891-e908.Crossref
- 13.
- Fojt A, Kowalik R, Gierlotka M, et al. Three-year mortality after acute myocardial infarction in patients with different diabetic status. Pol Arch Intern Med. 2021; 131: 16095.Crossref
- 14.
- Wanha W, Wybraniec M, Kaplon-Cieslicka A, et al. Myocardial infarction in the shadow of COVID-19. Cardiol J. 2020; 27: 478-480.
- 15.
- Bil J, Pietraszek N, Pawlowski T, Gil RJ. Advances in mechanisms and treatment options of MINOCA caused by vasospasm or microcirculation dysfunction. Curr Pharm Des. 2018; 24: 517-531.Crossref
- 16.
- Stepien K, Nowak K, Kachnic N, et al. Statin use in cancer patients with acute myocardial infarction and its impact on long-term mortality. Pharmaceuticals (Basel). 2022; 15: 919.Crossref
- 17.
- Gasior P, Desperak A, Gierlotka M, et al. Clinical characteristics, treatments, and outcomes of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA): results from a multicenter national registry. J Clin Med. 2020; 9: 2779.Crossref
- 18.
- Legutko J, Niewiara L, Bartus S, et al. Decline in the number of coronary angiography and percutaneous coronary intervention procedures in patients with acute myocardial infarction in Poland during the coronavirus disease 2019 pandemic. Kardiol Pol. 2020; 78: 574-576.Crossref
- 19.
- Siudak Z, Dudek D, Grygier M, et al. Interventional cardiology in Poland in 2020 – impact of the COVID-19 pandemic. Annual summary report of the Association of Cardiovascular Interventions of the Polish Cardiac Society and Jagiellonian University Medical College. Postepy Kardiol Interwencyjnej. 2021; 17: 131-134.Crossref
- 20.
- Wang SY, Seghieri C, Vainieri M, Groene O. Changes in acute myocardial infarction, stroke, and heart failure hospitalizations during COVID-19 pandemic in Tuscany - an interrupted time series study. Int J Public Health. 2022; 67: 1604319.Crossref
- 21.
- Primessnig U, Pieske BM, Sherif M. Increased mortality and worse cardiac outcome of acute myocardial infarction during the early COVID-19 pandemic. ESC Heart Fail. 2021; 8: 333-343.Crossref
- 22.
- Solano-Lopez J, Zamorano JL, Pardo Sanz A, et al. Risk factors for in-hospital mortality in patients with acute myocardial infarction during the COVID-19 outbreak. Rev Esp Cardiol (Engl Ed). 2020; 73: 985-993.Crossref
- 23.
- Bryndza M, Legutko J, Kleczynski P, et al. Impact of COVID-19 on the incidence of post-acute myocardial infarction mechanical complications. Ann Cardiothorac Surg. 2022; 11: 319-321.Crossref
- 24.
- Bryndza MA, Litwinowicz R, Bartus S, et al. Incidence of mechanical complications following myocardial infarction during the first two months of the COVID-19 pandemic in the Southern Poland region: a multicenter study. Kardiol Pol. 2021; 79: 66-68.Crossref
- 25.
- Bil J, Buller P, Gil RJ, et al. Acute complications in patients with myocardial infarction with non-obstructive coronary arteries: a systematic review with special focus on mechanical complications. Rev Cardiovasc Med. 2022; 23: 393.Crossref
- 26.
- Jankowski P, Topor-Madry R, Gasior M, et al. Management and predictors of clinical events in 75 686 patients with acute myocardial infarction. Kardiol Pol. 2022; 80: 468-475.Crossref
- 27.
- Jankowski P, Topor-Madry R, Gasior M, et al. Innovative managed care may be related to improved prognosis for acute myocardial infarction survivors. Circ Cardiovasc Qual Outcomes. 2021; 14: e007800.
- 28.
- Ackermann M, Verleden SE, Kuehnel M, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19. N Engl J Med. 2020; 383: 120-128.Crossref
- 29.
- Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020; 46: 1089-1098.Crossref
- 30.
- Agarwal G, Hajra A, Chakraborty S, et al. Predictors and mortality risk of venous thromboembolism in patients with COVID-19: systematic review and meta-analysis of observational studies. Ther Adv Cardiovasc Dis. 2022; 16: 17539447221105013.Crossref
- 31.
- Muthiah A, Ohnigian S, Reagan JL, Hsu A. Thrombosis in COVID 2022: an updated narrative review of current literature and inpatient management. R I Med J (2013). 2022; 105: 36-40.