title: Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease.
abstract: BACKGROUND
  There is no angiographically demonstrable obstructive coronary artery disease (CAD) in a significant minority of patients with myocardial infarction, particularly women. We sought to determine the mechanism(s) of myocardial infarction in this setting using multiple imaging techniques.
  
  
  RESULTS
  Women with myocardial infarction were enrolled prospectively, before angiography, if possible. Women with ≥50% angiographic stenosis or use of vasospastic agents were excluded. Intravascular ultrasound was performed during angiography; cardiac magnetic resonance imaging was performed within 1 week. Fifty women (age, 57±13 years) had median peak troponin of 1.60 ng/mL; 11 had ST-segment elevation. Median diameter stenosis of the worst lesion was 20% by angiography; 15 patients (30%) had normal angiograms. Plaque disruption was observed in 16 of 42 patients (38%) undergoing intravascular ultrasound. There were abnormal myocardial cardiac magnetic resonance imaging findings in 26 of 44 patients (59%) undergoing cardiac magnetic resonance imaging, late gadolinium enhancement (LGE) in 17 patients, and T2 signal hyperintensity indicating edema in 9 additional patients. The most common LGE pattern was ischemic (transmural/subendocardial). Nonischemic LGE patterns (midmyocardial/subepicardial) were also observed. Although LGE was infrequent with plaque disruption, T2 signal hyperintensity was common with plaque disruption.
  
  
  CONCLUSIONS
  Plaque rupture and ulceration are common in women with myocardial infarction without angiographically demonstrable obstructive coronary artery disease. In addition, LGE is common in this cohort of women, with an ischemic pattern of injury most evident. Vasospasm and embolism are possible mechanisms of ischemic LGE without plaque disruption. Intravascular ultrasound and cardiac magnetic resonance imaging provide complementary mechanistic insights into female myocardial infarction patients without obstructive coronary artery disease and may be useful in identifying potential causes and therapies. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00798122.
authors: Cardiovascular Clinical Research Center, 530 First Ave SKI-9R, New York, NY 10016, USA. Harmony.Reynolds@NYUMC.org
authors: Harmony R
authors: HR
authors: Reynolds
authors: Monvadi B
authors: MB
authors: Srichai
authors: Sohah N
authors: SN
authors: Iqbal
authors: James N
authors: JN
authors: Slater
authors: G B John
authors: GB
authors: Mancini
authors: Frederick
authors: F
authors: Feit
authors: Ivan
authors: I
authors: Pena-Sing
authors: Leon
authors: L
authors: Axel
authors: Michael J
authors: MJ
authors: Attubato
authors: Leonid
authors: L
authors: Yatskar
authors: Rebecca T
authors: RT
authors: Kalhorn
authors: David A
authors: DA
authors: Wood
authors: Iryna V
authors: IV
authors: Lobach
authors: Judith S
authors: JS
authors: Hochman
mesh_terms: D000328:Adult; D000368:Aged; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis; D003329:Coronary Vasospasm / Q000150:complications / Q000175:diagnosis; D004562:Electrocardiography; D004617:Embolism / Q000150:complications / Q000175:diagnosis; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000209:etiology*; D017202:Myocardial Ischemia / Q000150:complications* / Q000175:diagnosis*; D058226:Plaque, Atherosclerotic / Q000150:complications / Q000175:diagnosis; D011446:Prospective Studies; D054549:Takotsubo Cardiomyopathy / Q000150:complications / Q000175:diagnosis; D018084:Ultrasonography, Interventional