Cardiology Division, Heart Center - Luzerner Kantonsspital, Luzern, Switzerland.
Population Health Research Institute (PHRI), Hamilton, Ontario, Canada.
Heart. 2021 Nov;107(21):1739-1747. doi: 10.1136/heartjnl-2020-318045. Epub 2021 Jan 27.
Approximately 10% of patients with myocardial infarction (MI) have no obstructive coronary artery disease. The prognosis and role of intensified antiplatelet therapy in those patients were evaluated.
We analysed data from the Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events-Seventh Organisation to Assess Strategies in Ischaemic Symptoms trial randomising patients with ACS referred for early intervention to receive either double-dose (600 mg, day 1; 150 mg, days 2-7; then 75 mg/day) or standard-dose (300 mg, day 1; then 75 mg/day) clopidogrel. Outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) versus those with obstructive coronary artery disease (CAD) and their relation to standard-dose versus double-dose clopidogrel were evaluated. The primary outcome was cardiovascular (CV) death, MI or stroke at 30 days.
We included 23 783 patients with MI and 1599 (6.7%) with MINOCA. Patients with MINOCA were younger, presented more frequently with non-ST-segment elevation MI and had fewer comorbidities. All-cause mortality (0.6% vs 2.3%, p=0.005), CV mortality (0.6% vs 2.2%, p=0.006), repeat MI (0.5% vs 2.3%, p=0.001) and major bleeding (0.6% vs 2.4%, p<0.0001) were lower among patients with MINOCA than among those with obstructive CAD. Among patients with MINOCA, 2.1% of patients in the double-dose clopidogrel group and 0.6% in the standard-dose group experienced a primary outcome (HR 3.57, 95% CI 1.31 to 9.76), whereas in those with obstructive CAD, rates were 4.3% and 4.7%, respectively (HR 0.91, 95% CI 0.80 to 1.03; p value for interaction=0.011).
Patients with MINOCA are at lower risk of recurrent CV events compared with patients with MI with obstructive CAD. Compared with a standard clopidogrel-based dual antiplatelet therapy (DAPT) regimen, an intensified dosing strategy appears to offer no additional benefit with a signal of possible harm. Further randomised trials evaluating the effects of potent DAPT in patients with MINOCA are warranted.
NCT00335452.
约有 10%的心肌梗死（MI）患者不存在阻塞性冠状动脉疾病。评估了这些患者强化抗血小板治疗的预后和作用。
我们分析了 Clopidogrel 和 Aspirin Optimal Dose Usage to Reduce Recurrent Events-Seventh Organisation to Assess Strategies in Ischaemic Symptoms 试验的数据，该试验将接受早期介入治疗的 ACS 患者随机分配接受双剂量（第 1 天 600mg，第 2-7 天 150mg，然后每天 75mg）或标准剂量（第 1 天 300mg，然后每天 75mg）氯吡格雷。评估了无阻塞性冠状动脉疾病（MINOCA）与阻塞性冠状动脉疾病（CAD）的 MI 患者的结局及其与标准剂量与双剂量氯吡格雷的关系。主要结局为 30 天内心血管（CV）死亡、MI 或卒中。
我们纳入了 23783 例 MI 患者和 1599 例（6.7%）MINOCA 患者。MINOCA 患者更年轻，更常表现为非 ST 段抬高型 MI，且合并症更少。全因死亡率（0.6%比 2.3%，p=0.005）、CV 死亡率（0.6%比 2.2%，p=0.006）、再发 MI（0.5%比 2.3%，p=0.001）和大出血（0.6%比 2.4%，p<0.0001）在 MINOCA 患者中均低于 CAD 患者。MINOCA 患者中，双剂量氯吡格雷组有 2.1%的患者发生主要结局，标准剂量组有 0.6%（HR 3.57，95%CI 1.31 至 9.76），而 CAD 患者的发生率分别为 4.3%和 4.7%（HR 0.91，95%CI 0.80 至 1.03；p 值交互作用=0.011）。
与 MI 合并阻塞性 CAD 患者相比，MINOCA 患者发生 CV 事件的风险较低。与标准氯吡格雷双联抗血小板治疗（DAPT）方案相比，强化剂量策略似乎没有额外获益的迹象，反而可能有害。需要进一步的随机试验来评估在 MINOCA 患者中使用强效 DAPT 的效果。
NCT00335452。
