Is invasive coronary provocation testing cost-effective among MINOCA patients?

Is invasive coronary provocation testing cost-effective among MINOCA patients? Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/35/3334/5020747 by Ed 'DeepDyve' Gillespie user on 18 October 2018 DISCUSSION FORUM European Heart Journal (2018) 39, 3334 doi:10.1093/eurheartj/ehy304 Is invasive coronary provocation testing cost-effective among MINOCA patients? 1 2 1 Giuseppe Ciliberti *, Massimo Mancone , Federico Guerra , and Alessandro Capucci Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Ospedali Riuniti’, Via Conca 71, 60126, Ancona, Italy; and Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, ‘Sapienza’ University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy Online publish-ahead-of-print 29 May 2018 This commentary refers to ‘Patients with acute myocardial whereas a not significant effect in the reduction of adverse events infarction and non-obstructive coronary arteries: safety was seen by prescribing either beta-blockers and DAPT. and prognostic relevance of invasive coronary provocative We think that among Montone and colleagues’ accurately selected tests’, by RA Montone et al., pp. 91–98. . patients, the role of non-obstructive atherosclerosis could have been . more important than in the previous studies that were dealing with highly . 4 We have read with great interest ‘Patients with acute myocardial in- . heterogeneous population. Therefore, the relative under-treatment farction and non-obstructive coronary arteries: safety and prognostic . could be one of the reasons of the high event-rate found at follow-up. 1 . relevance of invasive coronary provocative tests’ by Montone et al., . Probably, calcium channel blockers on top of a full secondary prevention and we congratulate the authors for their interesting evaluation of therapy (as after an acute myocardial infarctionwithobstructive stenosis) patients with acute myocardial infarction without obstructive coron- would have improved the prognosis of these patients. ary artery disease (MINOCA) who underwent invasive coronary In conclusion, we agree with the authors to consider provocative provocative testing. testing in order to rule out spasm as safe and appropriate in They performed an accurate selection of MINOCA patients by MINOCA population, especially in the subset of ‘idiopathic excluding possible confounding diseases as myocarditis and MINOCA’. However, the evidence of a guarded prognosis affecting Takotsubo syndrome, thus focusing on a subgroup of patients with this population could have been biased by the lack of appropriate undefined diagnosis who can be considered as ‘idiopathic therapy at discharge. MINOCA’. Invasive coronary provocative testing revealed coronary Conflict of interest: none declared. spasm in 46.2% of selected patients and no complications were reported, confirming the safety of these tests. Notably, patients with References positive test had a significant worse prognosis over a median follow- 1. Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Camma` G, Lanza up of 3 years, compared with patients with negative test. GA, Crea F. Patients with acute myocardial infarction and non-obstructive coron- On the other hand, we would like to raise some concerns regarding ary arteries: safety and prognostic relevance of invasive coronary provocative . tests. Eur Heart J 2018;39:91–98. the therapy at hospital discharge. First, as stated by authors, only 59.5% 2. Ciliberti G, Capucci A. Letter by Ciliberti and Capucci Regarding Article, “Medical of patients with a positive test were discharged with statins and just therapy for secondary prevention and long-term outcome in patients with myo- 52.5% considering the whole population. Second, it is feasible to assume cardial infarction with nonobstructive coronary artery disease”. Circulation 2017; 136:1080–1081. that very few patients received dual antiplatelet therapy (DAPT), as thie- . 3. Ciliberti G, Seshasai SRK, Ambrosio G, Kaski JC. Safety of intracoronary provoca- nopyridines were prescribed only to one out of six patients with positive . tive testing for the diagnosis of coronary artery spasm. Int J Cardiol 2017;244: testing. Third, angiotensin converting enzyme inhibitors (ACE-Is) and . 77–83. 4. Lindahl B, Baron T, Erlinge D, Hadziosmanovic N, Nordenskjo¨ld AM, Gard A, angiotensin receptor blockers (ARBs) were poorly prescribed as well. . Jernberg T. Medical therapy for secondary prevention and long-term outcome in 4 . On this matter, Lindahl et al. recently demonstrated a clear bene- . patients with myocardial infarction with non-obstructive coronary artery fit in prescribing statins, ACE-Is and ARBs to MINOCA patients, . (MINOCA) disease. Circulation 2017;135:1481–1489. * Corresponding author. Tel: þ39 329 9651535, Fax: þ39 071 5965034, Email: ciliberti.giuseppe@libero.it Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Is invasive coronary provocation testing cost-effective among MINOCA patients?

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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
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Abstract

Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/35/3334/5020747 by Ed 'DeepDyve' Gillespie user on 18 October 2018 DISCUSSION FORUM European Heart Journal (2018) 39, 3334 doi:10.1093/eurheartj/ehy304 Is invasive coronary provocation testing cost-effective among MINOCA patients? 1 2 1 Giuseppe Ciliberti *, Massimo Mancone , Federico Guerra , and Alessandro Capucci Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Ospedali Riuniti’, Via Conca 71, 60126, Ancona, Italy; and Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, ‘Sapienza’ University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy Online publish-ahead-of-print 29 May 2018 This commentary refers to ‘Patients with acute myocardial whereas a not significant effect in the reduction of adverse events infarction and non-obstructive coronary arteries: safety was seen by prescribing either beta-blockers and DAPT. and prognostic relevance of invasive coronary provocative We think that among Montone and colleagues’ accurately selected tests’, by RA Montone et al., pp. 91–98. . patients, the role of non-obstructive atherosclerosis could have been . more important than in the previous studies that were dealing with highly . 4 We have read with great interest ‘Patients with acute myocardial in- . heterogeneous population. Therefore, the relative under-treatment farction and non-obstructive coronary arteries: safety and prognostic . could be one of the reasons of the high event-rate found at follow-up. 1 . relevance of invasive coronary provocative tests’ by Montone et al., . Probably, calcium channel blockers on top of a full secondary prevention and we congratulate the authors for their interesting evaluation of therapy (as after an acute myocardial infarctionwithobstructive stenosis) patients with acute myocardial infarction without obstructive coron- would have improved the prognosis of these patients. ary artery disease (MINOCA) who underwent invasive coronary In conclusion, we agree with the authors to consider provocative provocative testing. testing in order to rule out spasm as safe and appropriate in They performed an accurate selection of MINOCA patients by MINOCA population, especially in the subset of ‘idiopathic excluding possible confounding diseases as myocarditis and MINOCA’. However, the evidence of a guarded prognosis affecting Takotsubo syndrome, thus focusing on a subgroup of patients with this population could have been biased by the lack of appropriate undefined diagnosis who can be considered as ‘idiopathic therapy at discharge. MINOCA’. Invasive coronary provocative testing revealed coronary Conflict of interest: none declared. spasm in 46.2% of selected patients and no complications were reported, confirming the safety of these tests. Notably, patients with References positive test had a significant worse prognosis over a median follow- 1. Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Camma` G, Lanza up of 3 years, compared with patients with negative test. GA, Crea F. Patients with acute myocardial infarction and non-obstructive coron- On the other hand, we would like to raise some concerns regarding ary arteries: safety and prognostic relevance of invasive coronary provocative . tests. Eur Heart J 2018;39:91–98. the therapy at hospital discharge. First, as stated by authors, only 59.5% 2. Ciliberti G, Capucci A. Letter by Ciliberti and Capucci Regarding Article, “Medical of patients with a positive test were discharged with statins and just therapy for secondary prevention and long-term outcome in patients with myo- 52.5% considering the whole population. Second, it is feasible to assume cardial infarction with nonobstructive coronary artery disease”. Circulation 2017; 136:1080–1081. that very few patients received dual antiplatelet therapy (DAPT), as thie- . 3. Ciliberti G, Seshasai SRK, Ambrosio G, Kaski JC. Safety of intracoronary provoca- nopyridines were prescribed only to one out of six patients with positive . tive testing for the diagnosis of coronary artery spasm. Int J Cardiol 2017;244: testing. Third, angiotensin converting enzyme inhibitors (ACE-Is) and . 77–83. 4. Lindahl B, Baron T, Erlinge D, Hadziosmanovic N, Nordenskjo¨ld AM, Gard A, angiotensin receptor blockers (ARBs) were poorly prescribed as well. . Jernberg T. Medical therapy for secondary prevention and long-term outcome in 4 . On this matter, Lindahl et al. recently demonstrated a clear bene- . patients with myocardial infarction with non-obstructive coronary artery fit in prescribing statins, ACE-Is and ARBs to MINOCA patients, . (MINOCA) disease. Circulation 2017;135:1481–1489. * Corresponding author. Tel: þ39 329 9651535, Fax: þ39 071 5965034, Email: ciliberti.giuseppe@libero.it Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.

Journal

European Heart JournalOxford University Press

Published: Sep 14, 2018

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