Clinical features and outcomes of patients with type 2 myocardial infarction: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial

Patrícia O. Guimarães, Sergio Leonardi, Zhen Huang, Lars Wallentin, Frans Van de Werf, Phil Aylward, Claes Held, Robert A. Harrington, David J. Moliterno, Paul W. Armstrong, Harvey D. White, Karen P. Alexander, Renato D. Lopes, Kenneth W. Mahaffey, Pierluigi Tricoci

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background Type 2 myocardial infarction (MI) is characterized by an imbalance between myocardial blood supply and demand, leading to myocardial ischemia without coronary plaque rupture, but its diagnosis is challenging. Methods In the TRACER trial, patients with non–ST-segment elevation acute coronary syndromes were included. We aimed to describe provoking factors, cardiac biomarker profiles, treatment patterns, and clinical outcomes of patients with type 2 MIs. MI events during trial follow-up were adjudicated by an independent clinical events classification committee (CEC) and were classified according to the Third Universal Definition of MI. Using available source documents retrieved as part of the CEC process, we performed a retrospective chart abstraction to collect details on the type 2 MIs. Cox regression models were used to explore the association between MI type (type 1 or type 2) and cardiovascular death. Results Overall, 10.3% (n = 1327) of TRACER participants had a total of 1579 adjudicated MIs during a median follow-up of 502 days (interquartile range [IQR] 349-667). Of all MIs, 5.2% (n = 82) were CEC-adjudicated type 2 MIs, occurring in 76 patients. The incidence of type 2 MI was higher in the first month following randomization, after which the distribution became more scattered. The most frequent potential provoking factors for type 2 MIs were tachyarrhythmias (38.2%), anemia/bleeding (21.1%), hypotension/shock (14.5%), and hypertensive emergencies (11.8%). Overall, 36.3% had a troponin increase >10× the upper limit of normal. Coronary angiography was performed in 22.4% (n = 17) of patients during hospitalizations due to type 2 MIs. The hazard of cardiovascular death was numerically higher following type 2 MI (vs. no MI, adj. HR 11.82, 95% CI 5.71-24.46; P <.0001) than that of type 1 MI (vs. no MI, adj. HR 8.90, 95% CI 6.93-11.43; P <.0001). Conclusions Type 2 MIs were more prevalent in the first month after ACS, were characterized by the presence of triggers and infrequent use of an invasive strategy, and were associated with a high risk of death. Further efforts are needed to better define the role and implications of type 2 MI in both clinical practice and research.

LanguageEnglish
Pages28-35
Number of pages8
JournalAmerican Heart Journal
Volume196
DOIs
Publication statusPublished - 1 Feb 2018

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Guimarães, Patrícia O. ; Leonardi, Sergio ; Huang, Zhen ; Wallentin, Lars ; de Werf, Frans Van ; Aylward, Phil ; Held, Claes ; Harrington, Robert A. ; Moliterno, David J. ; Armstrong, Paul W. ; White, Harvey D. ; Alexander, Karen P. ; Lopes, Renato D. ; Mahaffey, Kenneth W. ; Tricoci, Pierluigi. / Clinical features and outcomes of patients with type 2 myocardial infarction : Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. In: American Heart Journal. 2018 ; Vol. 196. pp. 28-35.
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title = "Clinical features and outcomes of patients with type 2 myocardial infarction: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial",
abstract = "Background Type 2 myocardial infarction (MI) is characterized by an imbalance between myocardial blood supply and demand, leading to myocardial ischemia without coronary plaque rupture, but its diagnosis is challenging. Methods In the TRACER trial, patients with non–ST-segment elevation acute coronary syndromes were included. We aimed to describe provoking factors, cardiac biomarker profiles, treatment patterns, and clinical outcomes of patients with type 2 MIs. MI events during trial follow-up were adjudicated by an independent clinical events classification committee (CEC) and were classified according to the Third Universal Definition of MI. Using available source documents retrieved as part of the CEC process, we performed a retrospective chart abstraction to collect details on the type 2 MIs. Cox regression models were used to explore the association between MI type (type 1 or type 2) and cardiovascular death. Results Overall, 10.3{\%} (n = 1327) of TRACER participants had a total of 1579 adjudicated MIs during a median follow-up of 502 days (interquartile range [IQR] 349-667). Of all MIs, 5.2{\%} (n = 82) were CEC-adjudicated type 2 MIs, occurring in 76 patients. The incidence of type 2 MI was higher in the first month following randomization, after which the distribution became more scattered. The most frequent potential provoking factors for type 2 MIs were tachyarrhythmias (38.2{\%}), anemia/bleeding (21.1{\%}), hypotension/shock (14.5{\%}), and hypertensive emergencies (11.8{\%}). Overall, 36.3{\%} had a troponin increase >10× the upper limit of normal. Coronary angiography was performed in 22.4{\%} (n = 17) of patients during hospitalizations due to type 2 MIs. The hazard of cardiovascular death was numerically higher following type 2 MI (vs. no MI, adj. HR 11.82, 95{\%} CI 5.71-24.46; P <.0001) than that of type 1 MI (vs. no MI, adj. HR 8.90, 95{\%} CI 6.93-11.43; P <.0001). Conclusions Type 2 MIs were more prevalent in the first month after ACS, were characterized by the presence of triggers and infrequent use of an invasive strategy, and were associated with a high risk of death. Further efforts are needed to better define the role and implications of type 2 MI in both clinical practice and research.",
author = "Guimar{\~a}es, {Patr{\'i}cia O.} and Sergio Leonardi and Zhen Huang and Lars Wallentin and {de Werf}, {Frans Van} and Phil Aylward and Claes Held and Harrington, {Robert A.} and Moliterno, {David J.} and Armstrong, {Paul W.} and White, {Harvey D.} and Alexander, {Karen P.} and Lopes, {Renato D.} and Mahaffey, {Kenneth W.} and Pierluigi Tricoci",
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Guimarães, PO, Leonardi, S, Huang, Z, Wallentin, L, de Werf, FV, Aylward, P, Held, C, Harrington, RA, Moliterno, DJ, Armstrong, PW, White, HD, Alexander, KP, Lopes, RD, Mahaffey, KW & Tricoci, P 2018, 'Clinical features and outcomes of patients with type 2 myocardial infarction: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial', American Heart Journal, vol. 196, pp. 28-35. https://doi.org/10.1016/j.ahj.2017.10.007

Clinical features and outcomes of patients with type 2 myocardial infarction : Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. / Guimarães, Patrícia O.; Leonardi, Sergio; Huang, Zhen; Wallentin, Lars; de Werf, Frans Van; Aylward, Phil; Held, Claes; Harrington, Robert A.; Moliterno, David J.; Armstrong, Paul W.; White, Harvey D.; Alexander, Karen P.; Lopes, Renato D.; Mahaffey, Kenneth W.; Tricoci, Pierluigi.

In: American Heart Journal, Vol. 196, 01.02.2018, p. 28-35.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Clinical features and outcomes of patients with type 2 myocardial infarction

T2 - American Heart Journal

AU - Guimarães, Patrícia O.

AU - Leonardi, Sergio

AU - Huang, Zhen

AU - Wallentin, Lars

AU - de Werf, Frans Van

AU - Aylward, Phil

AU - Held, Claes

AU - Harrington, Robert A.

AU - Moliterno, David J.

AU - Armstrong, Paul W.

AU - White, Harvey D.

AU - Alexander, Karen P.

AU - Lopes, Renato D.

AU - Mahaffey, Kenneth W.

AU - Tricoci, Pierluigi

PY - 2018/2/1

Y1 - 2018/2/1

N2 - Background Type 2 myocardial infarction (MI) is characterized by an imbalance between myocardial blood supply and demand, leading to myocardial ischemia without coronary plaque rupture, but its diagnosis is challenging. Methods In the TRACER trial, patients with non–ST-segment elevation acute coronary syndromes were included. We aimed to describe provoking factors, cardiac biomarker profiles, treatment patterns, and clinical outcomes of patients with type 2 MIs. MI events during trial follow-up were adjudicated by an independent clinical events classification committee (CEC) and were classified according to the Third Universal Definition of MI. Using available source documents retrieved as part of the CEC process, we performed a retrospective chart abstraction to collect details on the type 2 MIs. Cox regression models were used to explore the association between MI type (type 1 or type 2) and cardiovascular death. Results Overall, 10.3% (n = 1327) of TRACER participants had a total of 1579 adjudicated MIs during a median follow-up of 502 days (interquartile range [IQR] 349-667). Of all MIs, 5.2% (n = 82) were CEC-adjudicated type 2 MIs, occurring in 76 patients. The incidence of type 2 MI was higher in the first month following randomization, after which the distribution became more scattered. The most frequent potential provoking factors for type 2 MIs were tachyarrhythmias (38.2%), anemia/bleeding (21.1%), hypotension/shock (14.5%), and hypertensive emergencies (11.8%). Overall, 36.3% had a troponin increase >10× the upper limit of normal. Coronary angiography was performed in 22.4% (n = 17) of patients during hospitalizations due to type 2 MIs. The hazard of cardiovascular death was numerically higher following type 2 MI (vs. no MI, adj. HR 11.82, 95% CI 5.71-24.46; P <.0001) than that of type 1 MI (vs. no MI, adj. HR 8.90, 95% CI 6.93-11.43; P <.0001). Conclusions Type 2 MIs were more prevalent in the first month after ACS, were characterized by the presence of triggers and infrequent use of an invasive strategy, and were associated with a high risk of death. Further efforts are needed to better define the role and implications of type 2 MI in both clinical practice and research.

AB - Background Type 2 myocardial infarction (MI) is characterized by an imbalance between myocardial blood supply and demand, leading to myocardial ischemia without coronary plaque rupture, but its diagnosis is challenging. Methods In the TRACER trial, patients with non–ST-segment elevation acute coronary syndromes were included. We aimed to describe provoking factors, cardiac biomarker profiles, treatment patterns, and clinical outcomes of patients with type 2 MIs. MI events during trial follow-up were adjudicated by an independent clinical events classification committee (CEC) and were classified according to the Third Universal Definition of MI. Using available source documents retrieved as part of the CEC process, we performed a retrospective chart abstraction to collect details on the type 2 MIs. Cox regression models were used to explore the association between MI type (type 1 or type 2) and cardiovascular death. Results Overall, 10.3% (n = 1327) of TRACER participants had a total of 1579 adjudicated MIs during a median follow-up of 502 days (interquartile range [IQR] 349-667). Of all MIs, 5.2% (n = 82) were CEC-adjudicated type 2 MIs, occurring in 76 patients. The incidence of type 2 MI was higher in the first month following randomization, after which the distribution became more scattered. The most frequent potential provoking factors for type 2 MIs were tachyarrhythmias (38.2%), anemia/bleeding (21.1%), hypotension/shock (14.5%), and hypertensive emergencies (11.8%). Overall, 36.3% had a troponin increase >10× the upper limit of normal. Coronary angiography was performed in 22.4% (n = 17) of patients during hospitalizations due to type 2 MIs. The hazard of cardiovascular death was numerically higher following type 2 MI (vs. no MI, adj. HR 11.82, 95% CI 5.71-24.46; P <.0001) than that of type 1 MI (vs. no MI, adj. HR 8.90, 95% CI 6.93-11.43; P <.0001). Conclusions Type 2 MIs were more prevalent in the first month after ACS, were characterized by the presence of triggers and infrequent use of an invasive strategy, and were associated with a high risk of death. Further efforts are needed to better define the role and implications of type 2 MI in both clinical practice and research.

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