Objective 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.
Methods 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.
Results 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).
Conclusions 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.
Trial registration number NCT00335452.
- acute coronary syndromes
- acute myocardial infarction
- coronary artery disease
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Presented at An abstract of this study was presented at the European Society of Cardiology Congress 2019 in Paris (https://academic.oup.com/eurheartj/article-abstract/40/Supplement_1/ehz748.0145/5596076?redirectedFrom=fulltext).
Contributors MB: conceptualisation, methodology, validation, formal analysis, writing (original draft), visualisation; PG: conceptualisation, methodology, software, validation, formal analysis, data curation, writing (review and editing); WB: investigation, data curation, writing (review and editing); GS: investigation, data curation, writing (review and editing); J-FT: investigation, writing (review and editing); CJ: investigation, writing (review and editing); CBG and DF: investigation, data curation, writing (review and editing); AK, AB, PP, GDP, VV, MF and TM: investigation, writing (review and editing); SY: investigation, methodology, resources, data curation, writing (review and editing), project administration, funding acquisition; SRM: conceptualisation, methodology, validation, investigation, resources, data curation, writing (original draft), supervision, project administration, funding acquisition. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Funding The CURRENT-OASIS 7 trial was sponsored by Sanofi and Bristol-Myers Squibb.
Competing interests MB received research grants from the University of Basel, the Freie Akademische Gesellschaft Basel and Bangerter-Rhyner Stiftung, consulting and speaking fees from Astra-Zeneca, Bayer and Amgen. PG received research grants from Amarin, Bayer, Merck, Sanofi, and Servier and speaking or consulting fees from Amarin, Amgen, AstraZeneca, Bayer/Janssen, Boehringer-Ingelheim, Bristol-Myers-Squibb, Idorsia, Lilly, Merck, Novartis, Novo-Nordisk, Pfizer, Regeneron, Sanofi and Servier. CBG reports grants from Duke University, grants and personal fees from Sanofi Aventis, grants and personal fees from Bristol Myers Squibb during the conduct of the study. AB received investigator’s, consulting and speaking fees from Sanofi-Aventis, Bristol-Myers Squibb and AstraZeneca.
Patient consent for publication Not required.
Ethics approval The trial complied with the Declaration of Helsinki. It was approved by national regulatory authorities and the ethics committees at the participating centres. All patients provided written informed consent (ClinicalTrials.gov).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
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