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Type 2 myocardial infarction is caused by an imbalance between myocardial oxygen supply and demand, and its diagnosis has become increasingly common with the advent of high-sensitivity cardiac troponin assays. Although this diagnosis is associated with poor outcomes, there is widespread uncertainty and confusion among clinicians about how to investigate and manage this heterogeneous group of patients with type 2 myocardial infarction. A recent prospective cohort study from Circulation investigated coronary artery disease and cardiac disease in patients with type 2 myocardial infarction.
Research Methods:
The study screened 8064 patients with serially elevated cardiac troponin levels to identify patients with type 2 myocardial infarction. Patients with frailty, renal failure, or liver failure were excluded. All study participants underwent coronary (invasive or computed tomographic angiography) and cardiac (magnetic resonance or echocardiography) imaging and independently determined the underlying cause of infarction. The primary outcome was the prevalence of coronary artery disease.
Findings:
In 100 patients with provisional diagnosis of type 2 myocardial infarction [median age, 65 years (interquartile range, 55-74 years); 43% women], Diagnoses were reclassified by coronary and cardiac imaging in 7 patients: 5 with type 1 or 4b myocardial infarction and 2 with acute myocardial injury.
In patients with type 2 myocardial infarction, cardiac troponin I levels were 195 ng/L (interquartile range, 62-760 ng/L) at presentation and at repeat 1165ng/L (interquartile range, 277-3782ng/L).
The prevalence of coronary artery disease was 68% (63 of 93), with obstructive 30% (28 of 93).
42% (39 of 93) observed late gadolinium enhancement or regional wall motion abnormalities in an infarct pattern, and 34% (32 of 93) had left ventricular systole disfunction. Only 10 patients had normal coronary and cardiac imaging. Coronary artery disease and left ventricular systolic dysfunction were not previously identified in 60% (38 of 63) and 84% (27 of 32), compared with 33% (21 of 63) and 19% (21 of 63). 6 out of 32) patients received evidence-based treatment.
In conclusion, systemic coronary and cardiac imaging of patients with type 2 myocardial infarction identified two-thirds of patients with coronary artery disease and one-third of patients with left ventricular Contractile dysfunction. The majority of patients with type 2 myocardial infarction have unrecognized and untreated coronary or cardiac disease, which provides an opportunity to initiate evidence-based therapy with great potential to improve clinical outcomes.
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