Canadian Cardiovascular Society/Canadian Women's Heart Health Alliance Clinical Practice Update on Myocardial Infarction With No Obstructive Coronary Artery Disease (MINOCA).

Myocardial infarction with no obstructive coronary artery disease (MINOCA) represents 6%-15% of all acute coronary syndromes, and women are disproportionately represented. MINOCA is an encompassing preliminary diagnosis, and emerging evidence supports a more expansive comprehensive diagnostic and therapeutic clinical approach. The current clinical practice update summarizes the latest evidence regarding the epidemiology, clinical presentation, and diagnostic evaluation of MINOCA. A cascaded approach to diagnostic workup is outlined for clinicians, for noninvasive and invasive diagnostic pathways, depending on clinical setting and local availability of diagnostic modalities. Evidence concerning the nonpharmacological and pharmacological treatment of MINOCA are presented and summarized according to underlying cause of MINOCA, with practical tips on the basis of expert opinion, outlining a real-life, evidence-based, comprehensive approach to management of this challenging condition.

Sex, Gender, and Women's Heart Health: How Women's Heart Programs Address the Knowledge Gap.

This article aims to bridge existing knowledge gaps that impact clinical cardiovascular care and outcomes for women in Canada. The authors discuss various aspects of women's heart health, emphasizing the efficacy of multidisciplinary care in promoting women's well-being. The article also identifies the impact of national women's heart health campaigns and the value of peer support in improving outcomes. The article addresses the particular risks that women face, such as pregnancy-related complications and hormone replacement therapy, all of which are associated with cardiovascular events, and highlights the differences in ischemic symptoms between men and women. Despite improvements in acute event outcomes, challenges persist in accessing timely ambulatory care, particularly for women. Canada has responded to these challenges by introducing Women Heart Programs, which offer tailored programs, support groups, and specialized testing. However, these programs remain few in number and are found only in urban settings. Overall, this review identifies sex and gender factors related to women's heart health, underscoring the importance of specialized programs and multidisciplinary care in improving women's cardiovascular health.

Cet article vise à répondre aux incertitudes actuelles qui se répercutent sur les soins cardiovasculaires et les issues cliniques chez les femmes au Canada. Les auteurs abordent différents aspects de la santé cardiaque des femmes, mettant l'accent sur l'efficacité des soins multidisciplinaires pour améliorer le bien-être des femmes. L'article présente également l'effet des campagnes nationales sur la santé cardiaque des femmes et l'importance de l'entraide entre collègues pour améliorer les résultats. L'article traite des risques particuliers touchant les femmes, comme les complications liées à la grossesse et l'hormonothérapie substitutive, qui sont toutes associées à des événements cardiovasculaires, et il souligne les différences entre les hommes et les femmes pour ce qui est des symptômes ischémiques. Bien que des améliorations aient été observées quant à l'issue des événements aigus, des difficultés persistent sur le plan de l'accès rapide à des soins ambulatoires, surtout pour les femmes. Le Canada a répondu à ces difficultés en créant des programmes pour la santé cardiaque des femmes, qui offrent des services adaptés, des groupes de soutien et des analyses spécialisées. Cependant, ils sont encore peu nombreux et accessibles seulement en milieu urbain. Dans l'ensemble, cette analyse définit les facteurs liés au sexe et au genre qui interviennent dans la santé cardiaque des femmes, soulignant l'importance de mettre en place des programmes spécialisés et des soins multidisciplinaires pour améliorer la santé cardiovasculaire des femmes.

The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes.

Background: Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women. Methods: This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD. Results: A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD. Conclusions: The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.

Contexte: Au Canada, la cardiopathie est la principale cause de décès prématuré chez les femmes. La cardiopathie ischémique est catégorisée comme suit : infarctus du myocarde (IM) en l'absence de coronaropathie obstructive (MINOCA), ischémie sans obstruction des artères coronaires (INOCA) et athérosclérose coronaire obstructive accompagnée d'un IM ou sans IM. La présente étude vise à examiner la prévalence des facteurs de risque classiques et non classiques de cardiopathie ischémique et leurs liens avec le (M)INOCA, comparativement à l'athérosclérose coronaire obstructive accompagnée d'un IM ou sans IM chez les femmes jeunes. Méthodologie: Cette étude portait sur des femmes qui avaient prématurément (55 ans ou moins) souffert d'un (M)INOCA ou d'une coronaropathie obstructive confirmés par coronarographie et qui étaient inscrites au registre de la Leslie Diamond Women's Heart Health Clinic (WHC) ou qui participaient à l'étude visant à éviter les événements cardiovasculaires en Colombie-Britannique (Study toAvoid CardiovascularEvents inBC; SAVEBC). Des modèles de régression univariés et multivariés ont été utilisés pour explorer les associations entre les facteurs de risque et les probabilités de (M)INOCA, ainsi que d'athérosclérose coronaire obstructive accompagnée ou non d'un IM. Résultats: Au total, 254 femmes inscrites de 2015 à 2022 ont été recensées, soit 77 présentant une INOCA et 37, un MINOCA selon le registre WHC, et 66 présentant une athérosclérose coronaire obstructive sans IM et 74, une athérosclérose coronaire obstructive accompagnée d'un IM selon l'étude SAVEBC. Les analyses de régression ont démontré que les migraines et la prééclampsie ou l'hypertension gestationnelle étaient les facteurs de risque les plus importants associés à une probabilité la plus élevée de (M)INOCA comparativement à une coronaropathie obstructive. En revanche, la présence d'un diabète et d'un tabagisme actuel ou passé était associée à la probabilité la plus élevée de coronaropathie prématurée. Conclusions: Il existe d'importantes différences pour ce qui est des profils de facteurs de risque des patientes ayant prématurément souffert d'un (M)INOCA en comparaison d'une coronaropathie obstructive.

Female Risk Factors for Post-Infarction Depression and Anxiety: Trial Design.

INTRODUCTION: Female patients are at elevated risk for adverse mental health outcomes following hospital admission for ischemic heart disease. These psychosocial characteristics are correlated with unacceptably higher rates of cardiovascular (CV) morbidity and mortality. Guidelines to address mental health following acute coronary syndrome (ACS) can only be developed with the aid of studies elucidating which subgroups of female patients are at the highest risk. METHODS/DESIGN: The Female Risk factors for post-Infarction Depression and Anxiety (FRIDA) Study is a prospective multicenter questionnaire-based study of female participants admitted to hospital with ACS. Data are collected within 72 h of admission as well as at 3 and 6 months. At baseline, participants complete a sociodemographic questionnaire, social support survey, and Hospital Depression and Anxiety Scale (HADS). Follow-up will consist of a demographic questionnaire, HADS, changes to health status, and quality of life indicators. Statistical analysis will include descriptive and inferential methods to observe baseline distributions and significance between groups. DISCUSSION/CONCLUSION: Our primary outcome is to determine if specific CV and sociodemographic factors correlate with increased depression and anxiety scores (HADS-D >7; HADS-A >7) at baseline. Our secondary aim is to determine if increased HADS scores at baseline and follow-up correlate with 3 and 6-month health and quality of life outcomes. A total of 2,000 patients will be enrolled across seven study sites. The aim of the FRIDA Study is to understand which groups of female patients have the highest rates of depression and anxiety following ACS to better inform care.

One-Year Prospective Follow-up of Women With INOCA and MINOCA at a Canadian Women's Heart Centre.

BACKGROUND: Many women with cardiac chest pain and ischemia or myocardial infarction have no obstructive coronary artery disease (INOCA or MINOCA). Studies suggest that these patients have a decreased quality of life and are at increased risk of cardiovascular events. Our study reports 1-year quality of life, frequency of angina, and outcomes following entry into a multidisciplinary Women's Heart Centre (WHC). METHODS: Patients with INOCA and MINOCA completed questionnaires on baseline demographics and clinical presentation. At 1-year, frequency of chest pain, quality of life, depression and anxiety symptoms, and cardiovascular outcomes were reported and compared with baseline. RESULTS: A total of 154 women with nonobstructive coronary artery disease were included in this study (112 patients with INOCA and 42 with MINOCA). Median age was 59 years, and the most common referral was for chest pain (94% in INOCA and 66% in MINOCA). At baseline, 64% of patients with INOCA and 43% of patients with MINOCA did not have specific diagnoses. Following investigations in the WHC, 71.4% of patients with INOCA established a new or a changed diagnosis (most common was coronary microvascular dysfunction at 68%), whereas 60% of patients with MINOCA established new or changed diagnoses (the most common of which was coronary vasospasm at 60%). At 1-year, participants had significantly decreased chest pain, improved quality of life, and improved mental health. CONCLUSIONS: A multidisciplinary WHC significantly increases the yield of a specific diagnosis in patients with INOCA and MINOCA. Further, attending a WHC could significantly improve the clinical and psychological outcomes of women with INOCA and MINOCA.

Differences in Demographics and Outcomes Between Men and Women With Spontaneous Coronary Artery Dissection.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction (MI) that most frequently affects women. The characteristics of men with SCAD are less well described. OBJECTIVES: The aim of this study was to describe the characteristics of men with SCAD. METHODS: We compared baseline demographics, clinical presentation, angiographic findings and cardiovascular outcomes of men and women in the Canadian SCAD Study. Major adverse cardiovascular events (MACE) were composite of death, MI, stroke or transient ischemic attack, heart failure hospitalization, and revascularization. RESULTS: Of 1,173 patients with SCAD, 123 (10.5%) were men. Men with SCAD were younger than women (mean age 49.4 ± 9.6 years vs 52.0 ± 10.6 years; P = 0.01). Men had lower rate of prior MI than women (0.8% vs 7.0%; P = 0.005). Men were less likely to have fibromuscular dysplasia (FMD) (27.8% vs 52.7%; P = 0.001), depression (9.8% vs 20.2%; P = 0.005), emotional stress (35.0% vs 59.3%; P < 0.001), or high score on the Perceived Stress Scale (3.5% vs 11.0%; P = 0.025) but were more likely to report isometric physical stress (40.2% vs 24.0%; P = 0.007). There was no difference in angiographic types of SCAD, but men had more circumflex artery (44.4% vs 30.9%; P = 0.001) and fewer right coronary artery (11.8% vs 21.7%; P = 0.0054) dissections. At median follow-up of 3.0 (IQR: 2.0-3.8) years, men had fewer hospital presentations with chest pain (10.6% vs 24.8%; P < 0.001). There were no differences in in-hospital events or follow-up MACE (7.3% vs 12.7%; P = 0.106). CONCLUSIONS: Ten percent of SCAD patients were men. Men were younger and more likely to have a physical trigger but were less likely to have FMD, depression, or an emotional trigger. Men had less recurrent chest pain but no significant difference in MACE.

Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes.

Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.

A Practical Approach to Invasive Testing in Ischemia With No Obstructive Coronary Arteries (INOCA).

Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.

Jusqu'à 65 % des femmes et environ 30 % des hommes présentent une ischémie sans coronaropathie obstructive (INOCA [ischemia with no obstructive coronary artery disease]) révélée à la faveur d'une angiographie coronarienne invasive réalisée pour une angine stable. L'INOCA peut être attribuable à une dysfonction microvasculaire coronaire ou à un vasospasme coronaire. Malgré l'absence de coronaropathie obstructive, les patients atteints d'une INOCA présentent un risque accru de décès toutes causes confondues et d'événements indésirables, notamment l'angine récurrente et des événements cardiovasculaires. Ces patients sont souvent soumis à des examens répétés, dont le cathétérisme cardiaque, ce qui représente des dépenses de santé à vie qui rivalisent avec celles associées aux coronaropathies obstructives. Dans bien des cas, l'INOCA échappe au diagnostic et n'est pas traité. Dans le présent article de synthèse, nous nous penchons sur les symptômes et le pronostic de l'INOCA. Nous proposons une méthode systématique d'évaluation diagnostique de ces patients et résumons les modalités de sa prise en charge thérapeutique, notamment un traitement adapté aux mécanismes physiopathologiques sous-jacents.

A case report of pericardial constriction with coexisting severe left main coronary artery disease.

Background: Constrictive pericarditis (CP) is a rare condition in which the pericardium becomes progressively fibrotic and non-compliant leading to impaired ventricular filling and overt heart failure. While CP shares many clinical and haemodynamic similarities with restrictive cardiomyopathy, differentiation of these diseases is crucial as CP is potentially curative through pericardiectomy. Here, we present a case of proven pericardial constriction with atypical haemodynamics in a patient presenting with heart failure and severe left main coronary artery disease (CAD). Case summary: A 69-year-old female with a history of hypertension and paroxysmal atrial fibrillation presented with persistent heart failure refractory to diuretics. Ischaemic and infiltrative work-up were found to be negative with magnetic resonance imaging demonstrating trace pericardial fluid and thickening of the pericardium. Echocardiogram and right-heart catheterization demonstrated atypical haemodynamics suggestive of but not conclusive for CP, with coronary angiogram demonstrating severe left main CAD. Ultimately, the patient underwent coronary artery bypass grafting along with pericardiectomy and pericardial biopsy demonstrating constrictive physiology. Discussion: We suspect the inconclusive nature of the echocardiogram and cardiac catheterization was likely secondary to severe CAD impairing left ventricular relaxation and dampening ventricular interdependence. As such, clinicians should consider the possibility of coexistent severe CAD in patients with a clinical suspicion of CP, but inconclusive haemodynamics.

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 5: Sex- and Gender-Unique Manifestations of Cardiovascular Disease.

This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women.

Dans le présent chapitre d'Atlas sont récapitulés les aspects et les manifestations uniques, associés au sexe et certains associés au genre, des maladies cardiovasculaires (MCV) chez les femmes. Les MCV sont la cause principale de décès prématurés chez les femmes au Canada. De nombreuses différences quant aux symptômes et à la physiopathologie existent entre les sexes. Nous avons réalisé une revue de la littérature pour déterminer les différences entre les sexes dans les symptômes et la physiopathologie, et les manifestations uniques des MCV chez les femmes. Bien que les femmes atteintes d'une cardiopathie ischémique puissent éprouver des douleurs thoraciques, la description des symptômes, le délai entre l'apparition des symptômes et l'obtention de soins médicaux, et les symptômes prodromiques sont souvent différents de ceux des hommes. Les causes de l'angine et de l'infarctus du myocarde non liées à l'athérosclérose telles que la dissection spontanée de l'artère coronaire sont principalement observées chez les femmes. La coronaropathie obstructive et non obstructive, l'anévrisme aortique et la maladie artérielle périphérique montrent de plus mauvaises issues chez les femmes que chez les hommes. Des différences entre les sexes sont observées dans la cardiopathie valvulaire et les cardiomyopathies. Le diagnostic d'insuffisance cardiaque avec fraction d'éjection préservée est plus souvent posé chez les femmes qui présentent un meilleur taux de survie après un diagnostic d'insuffisance cardiaque. L'accident vasculaire cérébral (AVC) pourrait survenir tout au long de la vie des femmes, qui sont exposées à un risque plus élevé d'incapacités liées à l'AVC et de mortalité par âge. Il existe des différences uniques entre les sexes et les genres pour ce qui est des symptômes et de la physiopathologie des MCV chez les femmes. Lors de l'évaluation des manifestations des MCV, il faut tenir compte de ces différences puisqu'elles influencent la prise en charge et le pronostic des maladies cardiovasculaires chez les femmes.

Sex Disparity Among Canadian Cardiologists in Academic Medicine: Differences in Scholarly Productivity and Academic Rank.

Background Women remain relatively underrepresented in all subspecialties of academic medicine. While sex disparity is prevalent in a number of specialties, the association between academic productivity and sex in academic cardiology has not been assessed in the Canadian context. Methods Academic faculty of accredited Canadian Resident Matching Service (CaRMS) programs were included from cardiology division websites across 17 universities. Cardiology faculty members' names, academic ranks, leadership positions, and sex were obtained from each institutions' website. The Elsevier database Scopus© was used to extract the Hirsch index (H-index), years of active research, and number of publications of each faculty member. The H-index was used as a metric of academic output and research productivity. Univariate regression was run with the H-Index as the outcome of interest, and multiple linear regression analysis was used to determine factors associated with higher H-index. Results Sex was identified for 1,040 members, of whom 836 (80%) were male. Male members had higher numbers of publications (p <0.001). There was a trend for males in a leadership position to have a higher H-index (p = 0.07). Median H-index was lower for women (p = 0.02). Males across assistant and associate professor ranks had a higher H-index. Women achieving professor rank demonstrated greater productivity with a higher median H-index (p = 0.002). Conclusions There is a prevalent sex gap in academic cardiology with regard to scholarly productivity and academic achievement. Factors that may help narrow the sex gap need to be identified and corrective measures implemented to enhance sex equity.

Impact of regionalizing ST-elevation myocardial infarction care on sex differences in reperfusion times and clinical outcomes.

BACKGROUND: Women with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention historically experience worse in-hospital outcomes compared to men. HYPOTHESIS: Implementation of a regional STEMI system will reduce care gaps in reperfusion times and in-hospital outcomes between women and men. METHODS: 1928 patients (413 women, 21.4%) presented with an acute STEMI between June 2007 and March 2016. The population was divided into an early cohort (n = 728 patients, 2007-May 2011), and a late cohort (n = 1200 patients, June 2011-2016). The primary endpoints evaluated were reperfusion times and in-hospital outcomes. RESULTS: Compared to men, women experienced significant delays in first medical contact (FMC) to arrival at the emergency room (26.0 vs. 22.0 min, p < 0.001) and FMC-to-device (109 vs. 101 min p = 0.001). Women had higher incidences of post-PCI heart failure and death compared to men (p < 0.05). Following multivariable adjustment, no mortality difference was observed for women versus men (adjusted OR; 0.82; 95% confidence interval [CI], 0.51-1.34; p = 0.433) or for early versus late cohorts (adjusted OR; 1.04; 95% CI, 0.68-1.60; p = 0.856). CONCLUSION: Following STEMI regionalization, women continued to experience significantly longer reperfusion times, although there was no difference in adjusted mortality. These results highlight the ongoing disparity of STEMI care between women and men, and suggest that regionalization alone is insufficient to close sex-based care gaps.

Contemporary use of guideline-based higher potency P2Y12 receptor inhibitor therapy in patients with moderate-to-high risk non-ST-segment elevation myocardial infarction: Results from the Canadian ACS reflective II cross-sectional study.

BACKGROUND: After myocardial infarction, guidelines recommend higher-potency P2Y12 receptor inhibitors, namely ticagrelor and prasugrel, over clopidogrel. HYPOTHESIS: We aimed to determine the contemporary use of higher-potency antiplatelet therapy in Canadian patients with non-ST-elevation myocardial infarction (NSTEMI). METHODS: A total of 684 moderate-to-high risk NSTEMI patients were enrolled in the prospective Canadian ACS Reflective II registry at 12 Canadian hospitals and three clinics in five provinces between July 2016 and May 2018. Multivariable logistic regression modeling was performed to assess factors independently associated with higher-potency P2Y12 receptor inhibitor use at discharge. RESULTS: At hospital discharge, 78.3% of patients were treated with a P2Y12 receptor inhibitor. Among patients discharged on a P2Y12 receptor inhibitor, use of higher-potency P2Y12 receptor inhibitor was 61.4%. After adjustment, treatment in-hospital with PCI (OR 4.48, 95%CI 3.34-6.03, p < .0001) was most strongly associated with higher use of higher-potency P2Y12 receptor inhibitor, while oral anticoagulant use at discharge (OR 0.03, 95%CI 0.01-0.12, p < .0001), and atrial fibrillation (OR 0.40, 95%CI 0.17-0.98, p = .046) were most strongly associated with lower use of higher-potency P2Y12 receptor inhibitor. Use of higher-potency P2Y12 receptor inhibitor varied across provinces (range, 21.6%-78.9%). DISCUSSION: In contemporary Canadian practice, approximately 60% of moderate-to-high risk NSTEMI patients discharged on a P2Y12 receptor inhibitor are treated with a higher-potency P2Y12 receptor inhibitor. In addition to factors that increase risk of bleeding, interprovincial differences in practice patterns were associated with use of higher-potency P2Y12 receptor inhibitor at discharge. Opportunities remain for further optimization of evidence-based, guideline-recommended antiplatelet therapy use.

Use of Preventive Medications in Patients With Nonobstructive Coronary Artery Disease: Analysis of the PROMISE Trial.

BACKGROUND: Nonobstructive coronary artery disease (NOCAD) is commonly found on coronary computed tomography angiography (CCTA) during evaluation for coronary artery disease (CAD). There are no guidelines for the medical management of NOCAD, and practice is variable. We aimed to compare patterns of preventive medication use and continuation after identifying NOCAD vs normal coronaries or obstructive CAD on CCTA. METHODS: We analyzed data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial dataset, restricted to patients with ≥2 follow-up visits after CCTA. We categorized patients as having either obstructive CAD, NOCAD, or normal coronaries. The primary outcome was the proportion of patients reporting continued use of combination preventive medications, defined as a statin, an antithrombotic, and a renin-angiotensin system blocker throughout follow-up after CCTA. Secondary outcomes included the proportion of visits reporting combination therapy and individual medications. RESULTS: We included 4388 patients, with a mean follow-up of 2.3 years. Most patients had NOCAD (48.6%), with normal coronaries in 38.9%, and obstructive CAD in 10.1%. Among NOCAD patients, the mean age was 61 years, and 47.2% were women. A total of 9.1% of NOCAD patients continued combination therapy, vs 12.4% with obstructive CAD, and 3.3% with normal coronaries (P < 0.001), primarily due to lower use of statins and antithrombotic agents. Similarly, patients with obstructive CAD, NOCAD, and normal coronaries reported using combination therapy during a mean of 35%, 24%, and 9% of visits, respectively (P < 0.001). CONCLUSIONS: Few patients with NOCAD identified by CCTA used or continued combination preventive cardiovascular medications. Patients with NOCAD represent an at-risk population with potential for optimization of preventive medications.

INTRODUCTION: La coronaropathie non obstructive (NOCAD, de l'anglais nonobstructive coronary artery disease) est fréquemment observée à l'angiographie coronarienne par tomodensitométrie (coro-TDM) durant l'évaluation de la coronaropathie. Comme il n'y a pas de lignes directrices sur la prise en charge médicale de la NOCAD, la pratique varie. Nous avions pour objectif de comparer les profils de consommation de médicaments préventifs et leur maintien après le diagnostic de la NOCAD vs les coronaires normales ou la coronaropathie obstructive à la coro-TDM. MÉTHODES: Nous avons analysé les données de l'essai PROspective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) qui étaient limitées aux patients ayant ≥ 2 visites de suivi après la coro-TDM. Nous avons réparti les patients en 3 catégories : la coronaropathie obstructive, la NOCAD ou les coronaires normales. Le principal critère de jugement était la proportion de patients qui rapportaient une consommation continue de médicaments combinés préventifs, à savoir une statine, un antithrombotique et un bloqueur du système rénine-angiotensine tout au long du suivi après la coro-TDM. Les critères secondaires étaient la proportion de visites auxquelles les patients rapportaient un traitement combiné et des médicaments individualisés. RÉSULTATS: Nous avons sélectionné 4388 patients, qui avaient un suivi moyen de 2,3 ans. La plupart des patients avaient une NOCAD (48,6 %), à coronaires normales chez 38,9 %, et une coronaropathie obstructive chez 10,1 %. Parmi les patients qui avaient une NOCAD, l'âge moyen était de 61 ans, et 47,2 % d'entre eux étaient des femmes. Un total de 9,1 % de patients atteints d'une NOCAD poursuivaient le traitement combiné vs 12,4 % des patients atteints d'une coronaropathie obstructive, et 3,3 % des patients qui avaient des coronaires normales (P < 0,001), principalement en raison de la plus faible consommation de statines et d'antithrombotiques. De même, les patients atteints d'une coronaropathie obstructive, d'une NOCAD et qui avaient des coronaires normales rapportaient de façon respective suivre un traitement combiné durant une moyenne de 35 %, de 24 % et de 9 % des visites (P < 0,001). CONCLUSIONS: Peu de patients atteints d'une NOCAD diagnostiquée au moyen de la coro-TDM utilisaient ou continuaient les médicaments combinés en prévention des maladies cardiovasculaires. Les patients atteints d'une NOCAD constituent une population exposée au risque qui présente un potentiel d'optimisation des médicaments préventifs.

Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women.

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. METHODS: In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. RESULTS: Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). CONCLUSIONS: Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.

Impact of Female Sex on Clinical Presentation and Ablation Outcomes in the CIRCA-DOSE Study.

OBJECTIVES: This study sought to evaluate sex-specific differences in atrial fibrillation (AF) presentation and catheter ablation outcomes in the prospective, multicenter, randomized CIRCA-DOSE (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration) study. BACKGROUND: Similar to other cardiovascular conditions, significant sex-specific differences have been observed in the epidemiology, pathophysiology, presentation, and natural history of AF. Unfortunately, there are major gaps in our understanding of the pathophysiological basis for the observed sex-specific differences and their implications on therapy and prognosis. METHODS: This study examined sex-specific differences in AF presentation, symptom severity and health-related quality of life, symptomatic and asymptomatic arrhythmia recurrence, AF burden, and health care utilization. RESULTS: Freedom from any atrial tachyarrhythmia and symptomatic atrial tachyarrhythmia were similar between male (hazard ratio: 1.18; 95% confidence interval: 0.85 to 1.64; p = 0.39) and female patients (hazard ratio: 1.00; 95% confidence interval: 0.62 to 1.59; p = 0.92). Post-ablation, the median AF burden (percentage time in AF) was 0.00% (interquartile range: 0.00% to 0.16%) in male patients and 0.00% (interquartile range: 0.00% to 0.17%) in female patients, with no difference observed between the sexes (p = 0.30). Periprocedural complications occurred twice as frequently in female patients (3.5% vs. 7.0%; p = 0.18). In comparison to male patients, female patients reported a significantly worse symptom score and quality of life at baseline and all follow-up intervals, but they derived similar magnitude of improvement post-ablation. There was no difference between male and female patients with respect to emergency department visits, hospitalization, cardioversion, or repeat ablation. CONCLUSIONS: When compared with male patients, female patients have significantly worse symptom scores and quality of life at baseline. Despite this, female patients with symptomatic paroxysmal AF derive similar benefit in freedom from recurrent arrhythmia and similar improvements in quality of life following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration [CIRCA-DOSE]; NCT01913522).

Coronary Flow Reserve in Patients With Prior Spontaneous Coronary Artery Dissection and Recurrent Angina.

Background A significant proportion of patients with spontaneous coronary artery dissection (SCAD) have ongoing chronic chest pain despite healing of their dissection. We sought to determine whether coronary microvascular dysfunction contributes to post-SCAD chronic chest pain by performing coronary reactivity testing in the cardiac catheterization laboratory. Methods and Results Eighteen patients consented to coronary reactivity testing at least 3 months post-SCAD. Coronary flow reserve (CFR) and index of microcirculatory resistance were measured in the previously affected SCAD artery and 1 non-SCAD artery. CFR <2.5 was defined as diagnostic of coronary microvascular dysfunction. An abnormal index of microcirculatory resistance was defined as >25 units. Seventeen women underwent coronary reactivity testing (1 had chronic dissection and was excluded). All presented with myocardial infarction and 2 underwent coronary stenting during the initial SCAD event. Fibromuscular dysplasia was present in 70.6% upon screening renal, iliac, and cerebrovascular arteries. Twelve patients (70.6%) had CFR <2.5 and 13 (76.5%) had an index of microcirculatory resistance >25 in at least 1 artery. There was no difference in the frequency of a low CFR measurement between SCAD and non-SCAD arteries. Conclusions Among patients with chronic chest pain after an SCAD event, >70% had coronary microvascular dysfunction as indicated by abnormal CFR or index of microcirculatory resistance in at least 1 coronary artery on invasive coronary reactivity testing. Presence of coronary microvascular dysfunction in both SCAD and non-SCAD arteries suggests that underlying microvascular abnormalities from vasculopathies such as coronary fibromuscular dysplasia may be the underlying etiology.

Predicted Versus Observed Major Adverse Cardiac Event Risk in Women With Evidence of Ischemia and No Obstructive Coronary Artery Disease: A Report From WISE (Women's Ischemia Syndrome Evaluation).

Background Primary prevention risk scores are commonly used to predict cardiovascular (CVD) outcomes. The applicability of these scores in patients with evidence of myocardial ischemia but no obstructive coronary artery disease is unclear. Methods and Results Among 935 women with signs and symptoms of ischemia enrolled in WISE (Women's Ischemia Syndrome Evaluation), 567 had no obstructive coronary artery disease on angiography. Of these, 433 had had available risk data for 6 commonly used scores: Framingham Risk Score, Reynolds Risk Score, Adult Treatment Panel III, Atherosclerotic Cardiovascular Disease, Systematic Coronary Risk Evaluation, Cardiovascular Risk Score 2. Score-specific CVD rates were assessed. For each score, we evaluated predicted versus observed event rates at 10-year follow-up using c statistic. Recalibration was done for 3 of the 6 scores. The 433 women had a mean age of 56.9±9.4 years, 82.5% were white, 52.7% had hypertension, 43.6% had dyslipidemia, and 16.9% had diabetes mellitus. The observed 10-year score-specific CVD rates varied between 5.54% (Systematic Coronary Risk Evaluation) to 28.87% (Framingham Risk Score), whereas predicted event rates varied from 1.86% (Systematic Coronary Risk Evaluation) to 6.99% (Cardiovascular Risk Score 2). The majority of scores showed moderate discrimination (c statistic 0.53 for Atherosclerotic Cardiovascular Disease and Systematic Coronary Risk Evaluation; 0.78 for Framingham Risk Score) and underestimated risk (statistical discordance -58% for Adult Treatment Panel III; -84% for Atherosclerotic Cardiovascular Disease). Recalibrated Reynolds Risk Score, Atherosclerotic Cardiovascular Disease, and Framingham Risk Score had improved performance, but significant underestimation remained. Conclusions Commonly used CVD risk scores fail to accurately predict CVD rates in women with ischemia and no obstructive coronary artery disease. These results emphasize the need for new risk assessment scores to reliably assess this population.