LETTER TO THE EDITOR

Letter by Ciliberti and Capucci Regarding Article, “Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease” Downloaded from http://circ.ahajournals.org/ by guest on September 13, 2017

To the Editor: We have read “Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease” by Lindahl and colleagues with great interest, and congratulate the authors for their accurate analysis of this large population of patients with myocardial infarction with nonobstructive coronary arteries (MINOCA).1 They retrospectively selected patients with MINOCA from the SWEDEHEART registry (the Swedish Web-system for Enhancement and Development of Evidencebased Care in Heart Disease Evaluated According to Recommended Therapies) thus obtaining a prevalence of 8.0%. For the first time, they clearly demonstrated an improvement in the prognosis of this population over a long follow-up period thanks to the use of largely available drugs, such as statins, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers. As the authors state, they have “no information in the registry on whether further examinations were performed after the hospitalization,” whereas a recent systematic review demonstrated that, when these patients underwent further investigations with the use of cardiovascular magnetic resonance, myocarditis occurred in 33%, Takotsubo cardiomyopathy occurred in 18%, and an ischemic pattern was found in 24%.2 Therefore there is a large heterogeneity in this population that could have affected the final results. However, we completely agree with the authors when they state that it would have been preferable to exclude myocarditis and Takotsubo cardiomyopathy. These are nowadays 2 well-known conditions with a growing literature and consensus on their management,3,4 thus their inclusion in the MINOCA definition appears to be at least arguable. Moreover, myocarditis and Takotsubo cardiomyopathy account for 50% to 60% of MINOCA,2 probably in the current study as well. In fact, very little is known about the rest of patients with MINOCA, in particular, with regard to the 20% to 30% in which diagnosis remains unclear.2 This nonmyocarditis, non-Takotsubo MINOCA or idiopathic MINOCA is probably a less heterogeneous group, in which the role of the nonobstructive atherosclerosis could be even more important, and probably among these patients there should be a maximum benefit of prognosis-effective drugs for the secondary prevention of obstructive coronary artery disease. Moreover, it is very interesting to note that these well-known effective therapies for obstructive coronary artery disease are also effective for patients with MINOCA, as demonstrated in this study. Do the authors think that this benefit is attributable to the intrinsic cardioprotective properties of these drugs, or is it related to the diffuse presence of nonobstructive atherosclerosis in this population? To answer this question, at least a separate analysis of patients with angiographically mildly diseased coronary arteries versus angiographically smooth coronary arteries should be conducted. 1080

September 12, 2017

Giuseppe Ciliberti, MD Alessandro Capucci, MD

Circulation is available at http://circ.ahajournals.org. © 2017 American Heart Association, Inc.

Circulation. 2017;136:1080–1081. DOI: 10.1161/CIRCULATIONAHA.117.029263

Letter to the Editor

DISCLOSURES None.

AFFILIATION Downloaded from http://circ.ahajournals.org/ by guest on September 13, 2017

From Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University, Ancona, Italy.

Circulation. 2017;136:1080–1081. DOI: 10.1161/CIRCULATIONAHA.117.029263

REFERENCES 1. Lindahl B, Baron T, Erlinge D, Hadziosmanovic N, Nordenskjöld A, Gard A, Jernberg T. Medical therapy for secondary prevention and long-term outcome in patients with myocardial infarction with nonobstructive coronary artery disease. Circulation. 2017;135:1481–1489. doi: 10.1161/CIRCULATIONAHA.116.026336. 2. 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. doi: 10.1161/ CIRCULATIONAHA.114.011201. 3. Lyon AR, Bossone E, Schneider B, Sechtem U, Citro R, Underwood SR, Sheppard MN, Figtree GA, Parodi G, Akashi YJ, Ruschitzka F, Filippatos G, Mebazaa A, Omerovic E. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2016;18:8–27. doi: 10.1002/ejhf.424. 4. Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, Fu M, Heliö T, Heymans S, Jahns R, Klingel K, Linhart A, Maisch B, McKenna W, Mogensen J, Pinto YM, Ristic A, Schultheiss HP, Seggewiss H, Tavazzi L, Thiene G, Yilmaz A, Charron P, Elliott PM; European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34:2636–2648, 2648a. doi: 10.1093/eurheartj/eht210.

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CORRESPONDENCE

In conclusion, these important findings by Lindahl and colleagues highlight the urgent need for a universal definition of MINOCA and encourage the efforts to focus on patients with idiopathic MINOCA, which can figure as an intriguing research model to investigate the role of atherosclerosis among patients with angiographically unobstructed coronary arteries, which, to date, has probably been overlooked.

Letter by Ciliberti and Capucci Regarding Article, ''Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease'' Giuseppe Ciliberti and Alessandro Capucci Downloaded from http://circ.ahajournals.org/ by guest on September 13, 2017

Circulation. 2017;136:1080-1081 doi: 10.1161/CIRCULATIONAHA.117.029263 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2017 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539

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Letter by Ciliberti and Capucci Regarding Article, "Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease".

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