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Nonobstructive coronary artery disease and risk of myocardial infarction.

Publication ,  Journal Article
Maddox, TM; Stanislawski, MA; Grunwald, GK; Bradley, SM; Ho, PM; Tsai, TT; Patel, MR; Sandhu, A; Valle, J; Magid, DJ; Leon, B; Bhatt, DL ...
Published in: JAMA
November 5, 2014

IMPORTANCE: Little is known about cardiac adverse events among patients with nonobstructive coronary artery disease (CAD). OBJECTIVE: To compare myocardial infarction (MI) and mortality rates between patients with nonobstructive CAD, obstructive CAD, and no apparent CAD in a national cohort. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of all US veterans undergoing elective coronary angiography for CAD between October 2007 and September 2012 in the Veterans Affairs health care system. Patients with prior CAD events were excluded. EXPOSURES: Angiographic CAD extent, defined by degree (no apparent CAD: no stenosis >20%; nonobstructive CAD: ≥1 stenosis ≥20% but no stenosis ≥70%; obstructive CAD: any stenosis ≥70% or left main [LM] stenosis ≥50%) and distribution (1, 2, or 3 vessel). MAIN OUTCOMES AND MEASURES: The primary outcome was 1-year hospitalization for nonfatal MI after the index angiography. Secondary outcomes included 1-year all-cause mortality and combined 1-year MI and mortality. RESULTS: Among 37,674 patients, 8384 patients (22.3%) had nonobstructive CAD and 20,899 patients (55.4%) had obstructive CAD. Within 1 year, 845 patients died and 385 were rehospitalized for MI. Among patients with no apparent CAD, the 1-year MI rate was 0.11% (n = 8, 95% CI, 0.10%-0.20%) and increased progressively by 1-vessel nonobstructive CAD, 0.24% (n = 10, 95% CI, 0.10%-0.40%); 2-vessel nonobstructive CAD, 0.56% (n = 13, 95% CI, 0.30%-1.00%); 3-vessel nonobstructive CAD, 0.59% (n = 6, 95% CI, 0.30%-1.30%); 1-vessel obstructive CAD, 1.18% (n = 101, 95% CI, 1.00%-1.40%); 2-vessel obstructive CAD, 2.18% (n = 110, 95% CI, 1.80%-2.60%); and 3-vessel or LM obstructive CAD, 2.47% (n = 137, 95% CI, 2.10%-2.90%). After adjustment, 1-year MI rates increased with increasing CAD extent. Relative to patients with no apparent CAD, patients with 1-vessel nonobstructive CAD had a hazard ratio (HR) for 1-year MI of 2.0 (95% CI, 0.8-5.1); 2-vessel nonobstructive HR, 4.6 (95% CI, 2.0-10.5); 3-vessel nonobstructive HR, 4.5 (95% CI, 1.6-12.5); 1-vessel obstructive HR, 9.0 (95% CI, 4.2-19.0); 2-vessel obstructive HR, 16.5 (95% CI, 8.1-33.7); and 3-vessel or LM obstructive HR, 19.5 (95% CI, 9.9-38.2). One-year mortality rates were associated with increasing CAD extent, ranging from 1.38% among patients without apparent CAD to 4.30% with 3-vessel or LM obstructive CAD. After risk adjustment, there was no significant association between 1- or 2-vessel nonobstructive CAD and mortality, but there were significant associations with mortality for 3-vessel nonobstructive CAD (HR, 1.6; 95% CI, 1.1-2.5), 1-vessel obstructive CAD (HR, 1.9; 95% CI, 1.4-2.6), 2-vessel obstructive CAD (HR, 2.8; 95% CI, 2.1-3.7), and 3-vessel or LM obstructive CAD (HR, 3.4; 95% CI, 2.6-4.4). Similar associations were noted with the combined outcome. CONCLUSIONS AND RELEVANCE: In this cohort of patients undergoing elective coronary angiography, nonobstructive CAD, compared with no apparent CAD, was associated with a significantly greater 1-year risk of MI and all-cause mortality. These findings suggest clinical importance of nonobstructive CAD and warrant further investigation of interventions to improve outcomes among these patients.

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Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

November 5, 2014

Volume

312

Issue

17

Start / End Page

1754 / 1763

Location

United States

Related Subject Headings

  • Risk Factors
  • Retrospective Studies
  • Prognosis
  • Patient Readmission
  • Myocardial Infarction
  • Middle Aged
  • Male
  • Humans
  • Hospitalization
  • General & Internal Medicine
 

Citation

APA
Chicago
ICMJE
MLA
NLM
Maddox, T. M., Stanislawski, M. A., Grunwald, G. K., Bradley, S. M., Ho, P. M., Tsai, T. T., … Rumsfeld, J. S. (2014). Nonobstructive coronary artery disease and risk of myocardial infarction. JAMA, 312(17), 1754–1763. https://doi.org/10.1001/jama.2014.14681
Maddox, Thomas M., Maggie A. Stanislawski, Gary K. Grunwald, Steven M. Bradley, P Michael Ho, Thomas T. Tsai, Manesh R. Patel, et al. “Nonobstructive coronary artery disease and risk of myocardial infarction.JAMA 312, no. 17 (November 5, 2014): 1754–63. https://doi.org/10.1001/jama.2014.14681.
Maddox TM, Stanislawski MA, Grunwald GK, Bradley SM, Ho PM, Tsai TT, et al. Nonobstructive coronary artery disease and risk of myocardial infarction. JAMA. 2014 Nov 5;312(17):1754–63.
Maddox, Thomas M., et al. “Nonobstructive coronary artery disease and risk of myocardial infarction.JAMA, vol. 312, no. 17, Nov. 2014, pp. 1754–63. Pubmed, doi:10.1001/jama.2014.14681.
Maddox TM, Stanislawski MA, Grunwald GK, Bradley SM, Ho PM, Tsai TT, Patel MR, Sandhu A, Valle J, Magid DJ, Leon B, Bhatt DL, Fihn SD, Rumsfeld JS. Nonobstructive coronary artery disease and risk of myocardial infarction. JAMA. 2014 Nov 5;312(17):1754–1763.
Journal cover image

Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

November 5, 2014

Volume

312

Issue

17

Start / End Page

1754 / 1763

Location

United States

Related Subject Headings

  • Risk Factors
  • Retrospective Studies
  • Prognosis
  • Patient Readmission
  • Myocardial Infarction
  • Middle Aged
  • Male
  • Humans
  • Hospitalization
  • General & Internal Medicine