Korean Circ J.  2024 Nov;54(11):693-706. 10.4070/kcj.2024.0085.

Pre-Hospital Delay and Outcomes in Myocardial Infarction With Nonobstructive Coronary Arteries

• Oh S
• Cho KH
• Kim MC
• Sim DS
• Hong YJ
• Kim JH
• Ahn Y
• Jeong MH

• KMID: 2560650
• DOI: http://doi.org/10.4070/kcj.2024.0085

Abstract

Background and Objectives
Real-world evidence on the relationship between delayed hospitalization and outcomes in myocardial infarction with nonobstructive coronary arteries (MINOCA) is lacking. Hence, we aimed to evaluate the clinical characteristics of patients with MINOCA and the 2-year mortality outcomes in this patient population according to the symptom-to-door time (SDT).
Methods
Overall, 861 patients with MINOCA from 2 Korean nationwide observational registries (2011–2020) were included and categorized as early or late presenters. Late presentation was defined as SDT ≥12 hours in patients with ST-segment elevation myocardial infarction (STEMI) and SDT ≥24 hours in patients with non-STEMI. The primary outcome was 2-year all-cause mortality. Propensity score matching (PSM) and age-sex adjusted analysis were used to determine whether late presentation independently affected mortality. Multivariate logistic regression analysis was used to examine the independent factors correlated with late presentation.
Results
In unadjusted data, late presenters had a notably higher risk of 2-year all-cause mortality than early presenters (hazard ratio [HR], 2.44; 95% confidence interval [CI], 1.47–4.08). This trend persisted in age-sex adjusted analysis (adjusted HR, 2.29; 95% CI, 1.36–3.84) and PSM-adjusted analysis (adjusted HR, 2.18; 95% CI, 1.05–4.53). The positive independent factors for late presentation included female sex, no emergency medical service use and high creatinine level, whereas the negative independent factor was a dyslipidemia.
Conclusions
Late presentation is associated with higher mortality in patients with MINOCA. Multidisciplinary efforts are needed to reduce pre-hospital delay, thereby improving the clinical outcomes in these patients.

Keyword

Adverse effects; Cardiovascular disease; Myocardial infarction; Time-to-treatment; Treatment outcome

Figure

• 

  Figure 1 Study flowchart.AMI = acute myocardial infarction; CAD = coronary artery disease; KAMIR-NIH = Korea Acute Myocardial Infarction Registry-National Institutes of Health; KAMIR-V = Korea Acute Myocardial Infarction Registry-V; MINOCA = myocardial infarction without obstructive coronary arteries; NSTEMI = non-ST-segment elevation myocardial infarction; SDT = symptom-to-door time; STEMI = ST-segment elevation myocardial infarction.

• 

  Figure 2 Kaplan–Meier survival curves in unadjusted and PSM-adjusted analyses. Late presenters had a higher incidence rate of all-cause death in unadjusted, sex-age population-adjusted, and PSM-adjusted analyses.PSM = propensity score matching.

Reference

1. Oh S, Hyun DY, Cho KH, Kim JH, Jeong MH. Long-term outcomes in ST-elevation myocardial infarction patients treated according to hospital visit time. Korean J Intern Med. 2022; 37:605–617. PMID: 34781424.

2. Kunadian V, Chieffo A, Camici PG, et al. An EAPCI Expert consensus document on ischaemia with non-obstructive coronary arteries in collaboration with European Society of Cardiology working group on coronary pathophysiology and microcirculation endorsed by coronary vasomotor disorders international study group. EuroIntervention. 2021; 16:1049–1069. PMID: 32624456.

3. Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015; 131:861–870. PMID: 25587100.

4. Talebi S, Jadhav P, Tamis-Holland JE. Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA): a review of the present and preview of the future. Curr Atheroscler Rep. 2021; 23:49. PMID: 34226967.

5. Choo EH, Chang K, Lee KY, et al. Prognosis and predictors of mortality in patients suffering myocardial infarction with non-obstructive coronary arteries. J Am Heart Assoc. 2019; 8:e011990. PMID: 31284804.

6. Redfors B, Mohebi R, Giustino G, et al. Time delay, infarct size, and microvascular obstruction after primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction. Circ Cardiovasc Interv. 2021; 14:e009879. PMID: 33440999.

7. Cha JJ, Bae S, Park DW, et al. Clinical outcomes in patients with delayed hospitalization for non-ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2022; 79:311–323. PMID: 35086652.

8. Cho KH, Han X, Ahn JH, et al. Long-term outcomes of patients with late presentation of ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2021; 77:1859–1870. PMID: 33858622.

9. Oh S, Jeong MH, Cho KH, et al. Outcomes of nonagenarians with acute myocardial infarction with or without coronary intervention. J Clin Med. 2022; 11:1593. PMID: 35329920.

10. Collet JP, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42:1289–1367. PMID: 32860058.

11. Lee SH, Kim HK, Jeong MH, et al. Pre-hospital delay and emergency medical services in acute myocardial infarction. Korean J Intern Med. 2020; 35:119–132. PMID: 31766823.

12. McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Garvin BJ. Women’s early warning symptoms of acute myocardial infarction. Circulation. 2003; 108:2619–2623. PMID: 14597589.

13. Pampel FC. Global patterns and determinants of sex differences in smoking. Int J Comp Sociol. 2006; 47:466–487. PMID: 21874066.

14. Oh S, Kim JH, Cho KH, et al. Association between baseline smoking status and clinical outcomes following myocardial infarction. Front Cardiovasc Med. 2022; 9:918033. PMID: 35935630.

15. O’Donnell CJ. Family history, subclinical atherosclerosis, and coronary heart disease risk: barriers and opportunities for the use of family history information in risk prediction and prevention. Circulation. 2004; 110:2074–2076. PMID: 15477424.

16. Mohammed O, Alemayehu E, Ebrahim E, et al. Atherogenic dyslipidemia and associated risk factors among hypertensive patients of five health facilities in Northeast Ethiopia. PLoS One. 2023; 18:e0277185. PMID: 36787318.

17. Wang TJ, Nam BH, D’Agostino RB, et al. Carotid intima-media thickness is associated with premature parental coronary heart disease: the Framingham Heart Study. Circulation. 2003; 108:572–576. PMID: 12874190.

18. Montone RA, Niccoli G, Fracassi F, et al. Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart J. 2018; 39:91–98. PMID: 29228159.

19. Choi JS, Kim CS, Park JW, et al. Renal dysfunction as a risk factor for painless myocardial infarction: results from Korea Acute Myocardial Infarction Registry. Clin Res Cardiol. 2012; 101:795–803. PMID: 22555520.

20. Schömig A, Ndrepepa G, Kastrati A. Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial infarction. Eur Heart J. 2006; 27:1900–1907. PMID: 16868009.

21. Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Lancet. 1986; 1:397–402. PMID: 2868337.

22. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Lancet. 1994; 343:311–322. PMID: 7905143.

23. Pfeffer MA, Greaves SC, Arnold JM, et al. Early versus delayed angiotensin-converting enzyme inhibition therapy in acute myocardial infarction. The healing and early afterload reducing therapy trial. Circulation. 1997; 95:2643–2651. PMID: 9193433.

24. Lenderink T, Boersma E, Gitt AK, et al. Patients using statin treatment within 24 h after admission for ST-elevation acute coronary syndromes had lower mortality than non-users: a report from the first Euro Heart Survey on acute coronary syndromes. Eur Heart J. 2006; 27:1799–1804. PMID: 16820364.

25. Lindahl B, Baron T, Erlinge D, et al. Medical therapy for secondary prevention and long-term outcome in patients with myocardial infarction with nonobstructive coronary artery disease. Circulation. 2017; 135:1481–1489. PMID: 28179398.

26. Biswas S, Andrianopoulos N, Duffy SJ, et al. Impact of socioeconomic status on clinical outcomes in patients with ST-segment-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes. 2019; 12:e004979. PMID: 30606051.

27. Ohama A, Mizuguchi Y, Hashimoto S, et al. Impact of living alone on the care and outcomes of patients with ST-elevation myocardial infarction. J Cardiol. 2020; 75:628–634. PMID: 31866189.

28. Pelliccia F, Pasceri V, Niccoli G, et al. Predictors of mortality in myocardial infarction and nonobstructed coronary arteries: a systematic review and meta-regression. Am J Med. 2020; 133:73–83.e4. PMID: 31260664.

29. Cleland JG, Bunting KV, Flather MD, et al. Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials. Eur Heart J. 2018; 39:26–35. PMID: 29040525.

30. Emdin CA, Callender T, Cao J, McMurray JJ, Rahimi K. Meta-analysis of large-scale randomized trials to determine the effectiveness of inhibition of the renin-angiotensin aldosterone system in heart failure. Am J Cardiol. 2015; 116:155–161. PMID: 25937349.