Personalized treatment of myocardial infarction and non-obstructive coronary arteries: an unmet need in a high-risk population

Personalized treatment of myocardial infarction and non-obstructive coronary arteries: an unmet... DISCUSSION FORUM European Heart Journal (2018) 0, 1–1 doi:10.1093/eurheartj/ehy305 Personalized treatment of myocardial infarction and non-obstructive coronary arteries: an unmet need in a high-risk population Rocco A. Montone, Giampaolo Niccoli*, Gaetano A. Lanza, and Filippo Crea Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy This commentary refers to ‘Patients with acute myocardial predict events at follow-up, whereas a positive test response was a infarction and non-obstructive coronary arteries: safety significant independent predictor of events. This suggests that non- and prognostic relevance of invasive coronary provocative obstructive atherosclerosis may predispose to the occurrence of tests’, by RA Montone et al., pp. 91–98. functional coronary alterations, but an impaired vasoreactivity only may portend a worse prognosis in the highly selected subgroup of We appreciate the interest of Ciliberti et al. in our article about safety MINOCA patients included in our study, which does not exclude, and prognostic relevance of invasive coronary provocative tests in however, a prognostic role of non-obstructive atherosclerosis in the patients presenting with myocardial infarction and non-obstructive global unselected MINOCA population. coronary arteries (MINOCA). They raise concerns about the dis- In conclusion, future studies are warranted in order to establish charge therapy and the lack of any prognostic role of non-obstructive the optimal medical treatment of MINOCA patients. Talking about atherosclerosis. the ‘MINOCA population’ as a whole, however, is likely misleading. We agree that an optimal medical therapy might improve prognosis MINOCA patients constitute a heterogeneous population and, in MINOCA. However, no controlled trial has hitherto been conducted therefore, future clinical trials should include patients with a common regarding pharmacological therapy in MINOCA. Recent retrospective pathophysiologic mechanism in order to achieve results successfully data have suggested that statins, beta-blockers and renin–angiotensin– applicable in specific subgroups. aldosterone (RAA) system antagonists might have favourable effects in Conflict of interest: none declared. MINOCA patients. However, besides being uncontrolled, this study included the whole heterogeneous population of MINOCA, and it is un- . clear whether the results might entirely be applied to MINOCA caused . References 1. Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Camma` G, Lanza by vasomotor mechanisms. Indeed, the beneficial effects of statins in . GA, Crea F. Patients with acute myocardial infarction and non-obstructive coron- 3 . vasospastic angina patients are controversial, and no beneficial effects . ary arteries: safety and prognostic relevance of invasive coronary provocative are expected from beta-blockers and RAA system antagonists. . tests. Eur Heart J 2017;39:91–98. 2. Lindahl B, Baron T, Erlinge D, Hadziosmanovic N, Nordenskjo¨ld A, Gard A, Importantly, in our study calcium-antagonist discontinuation during Jernberg T. Medical therapy for secondary prevention and long-term outcome in follow-up was a relevant prognostic variable, whereas no relation with . patients with myocardial infarction with nonobstructive coronary artery disease. clinical outcome was found with the use of other drugs. Circulation 2017;135:1481–1489. 3. Oh MS, Yang JH, Lee DH, Park TK, Song YB, Hahn JY, Choi JH, Lee SH, Gwon We have also shown that non-obstructive atherosclerosis was HC, Choi SH. Impact of statin therapy on long-term clinical outcomes of vaso- more frequently found in patients with a positive response to pro- . spastic angina without significant stenosis: a propensity-score matched analysis. Int vocative tests. However, non-obstructive atherosclerosis failed to J Cardiol 2016;223:791–796. * Corresponding author. Tel: þ39 06 30154187, Fax: þ39 06 3055535, Email: gniccoli73@hotmail.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. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy305/5020746 by Ed 'DeepDyve' Gillespie user on 13 July 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Personalized treatment of myocardial infarction and non-obstructive coronary arteries: an unmet need in a high-risk population

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Oxford University Press
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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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0195-668X
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1522-9645
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10.1093/eurheartj/ehy305
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Abstract

DISCUSSION FORUM European Heart Journal (2018) 0, 1–1 doi:10.1093/eurheartj/ehy305 Personalized treatment of myocardial infarction and non-obstructive coronary arteries: an unmet need in a high-risk population Rocco A. Montone, Giampaolo Niccoli*, Gaetano A. Lanza, and Filippo Crea Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy This commentary refers to ‘Patients with acute myocardial predict events at follow-up, whereas a positive test response was a infarction and non-obstructive coronary arteries: safety significant independent predictor of events. This suggests that non- and prognostic relevance of invasive coronary provocative obstructive atherosclerosis may predispose to the occurrence of tests’, by RA Montone et al., pp. 91–98. functional coronary alterations, but an impaired vasoreactivity only may portend a worse prognosis in the highly selected subgroup of We appreciate the interest of Ciliberti et al. in our article about safety MINOCA patients included in our study, which does not exclude, and prognostic relevance of invasive coronary provocative tests in however, a prognostic role of non-obstructive atherosclerosis in the patients presenting with myocardial infarction and non-obstructive global unselected MINOCA population. coronary arteries (MINOCA). They raise concerns about the dis- In conclusion, future studies are warranted in order to establish charge therapy and the lack of any prognostic role of non-obstructive the optimal medical treatment of MINOCA patients. Talking about atherosclerosis. the ‘MINOCA population’ as a whole, however, is likely misleading. We agree that an optimal medical therapy might improve prognosis MINOCA patients constitute a heterogeneous population and, in MINOCA. However, no controlled trial has hitherto been conducted therefore, future clinical trials should include patients with a common regarding pharmacological therapy in MINOCA. Recent retrospective pathophysiologic mechanism in order to achieve results successfully data have suggested that statins, beta-blockers and renin–angiotensin– applicable in specific subgroups. aldosterone (RAA) system antagonists might have favourable effects in Conflict of interest: none declared. MINOCA patients. However, besides being uncontrolled, this study included the whole heterogeneous population of MINOCA, and it is un- . clear whether the results might entirely be applied to MINOCA caused . References 1. Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Camma` G, Lanza by vasomotor mechanisms. Indeed, the beneficial effects of statins in . GA, Crea F. Patients with acute myocardial infarction and non-obstructive coron- 3 . vasospastic angina patients are controversial, and no beneficial effects . ary arteries: safety and prognostic relevance of invasive coronary provocative are expected from beta-blockers and RAA system antagonists. . tests. Eur Heart J 2017;39:91–98. 2. Lindahl B, Baron T, Erlinge D, Hadziosmanovic N, Nordenskjo¨ld A, Gard A, Importantly, in our study calcium-antagonist discontinuation during Jernberg T. Medical therapy for secondary prevention and long-term outcome in follow-up was a relevant prognostic variable, whereas no relation with . patients with myocardial infarction with nonobstructive coronary artery disease. clinical outcome was found with the use of other drugs. Circulation 2017;135:1481–1489. 3. Oh MS, Yang JH, Lee DH, Park TK, Song YB, Hahn JY, Choi JH, Lee SH, Gwon We have also shown that non-obstructive atherosclerosis was HC, Choi SH. Impact of statin therapy on long-term clinical outcomes of vaso- more frequently found in patients with a positive response to pro- . spastic angina without significant stenosis: a propensity-score matched analysis. Int vocative tests. However, non-obstructive atherosclerosis failed to J Cardiol 2016;223:791–796. * Corresponding author. Tel: þ39 06 30154187, Fax: þ39 06 3055535, Email: gniccoli73@hotmail.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. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy305/5020746 by Ed 'DeepDyve' Gillespie user on 13 July 2018

Journal

European Heart JournalOxford University Press

Published: May 29, 2018

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