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- Title
Nonobstructive Coronary Artery Disease and Risk of Myocardial Infarction.
- Authors
Maddox, Thomas M.; Stanislawski, Maggie A.; Grunwald, Gary K.; Bradley, Steven M.; Ho, P. Michael; Tsai, Thomas T.; Patel, Manesh R.; Sandhu, Amneet; Valle, Javier; Magid, David J.; Leon, Benjamin; Bhatt, Deepak L.; Fihn, Stephan D.; Rumsfeld, John S.
- Abstract
IMPORTANCE Little is known about cardiac adverse events among patients with nonobstructive coronary artery disease (CAD). OBJECTIVE To compare myocardial infarction (Ml) 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 Ml after the index angiography. Secondary outcomes included 1-year all-cause mortality and combined 1-year Ml 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 Ml. Among patients with no apparent CAD, the 1-year Ml rate was 0.11% (n = 8,95% Cl, 0.10%-0.20%) and increased progressively by 1-vessel nonobstructive CAD, 0.24% (n = 10, 95% Cl, 0.10%-0.40%); 2-vessel nonobstructive CAD, 0.56% (n = 13, 95% Cl, 0.30%-1.00%); 3-vessel nonobstructive CAD, 0.59% (n = 6,95% Cl, 0.30%-1.30%); 1-vessel obstructive CAD, 1.18% (n = 101, 95% Cl, 1.00%-1.40%); 2-vessel obstructive CAD, 2.18% (n = 110, 95% Cl, 1.80%-2.60%); and 3-vessel or LM obstructive CAD, 2.47% (n = 137, 95% Cl, 2.10%-2.90%). After adjustment, 1-year Ml 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 Ml of 2.0 (95% Cl, 0.8-5.1); 2-vessel nonobstructive HR, 4.6 (95% Cl, 2.0-10.5); 3-vessel nonobstructive HR, 4.5 (95% Cl, 1.6-12.5); 1-vessel obstructive HR, 9.0 (95% Cl, 4.2-19.0); 2-vessel obstructive HR, 16.5 (95% Cl, 8.1-33.7); and 3-vessel or LM obstructive HR, 19.5 (95% Cl, 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% Cl, 1.1-2.5), 1-vessel obstructive CAD (HR, 1.9; 95% Cl, 1.4-2.6), 2-vessel obstructive CAD (HR, 2.8; 95% Cl, 2.1-3.7), and 3-vessel or LM obstructive CAD (HR, 3.4; 95% Cl, 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 o f Ml and all-cause mortality. These findings suggest clinical importance of nonobstructive CAD and warrant further investigation of interventions to improve outcomes among these patients.
- Subjects
CORONARY disease; ADVERSE health care events; MYOCARDIAL infarction; ANGIOGRAPHY; DISEASES in veterans
- Publication
JAMA: Journal of the American Medical Association, 2014, Vol 312, Issue 17, p1754
- ISSN
0098-7484
- Publication type
Article
- DOI
10.1001/jama.2014.14681