Assessment of Oxygen Supply-Demand Imbalance and Outcomes Among Patients With Type 2 Myocardial Infarction
Anda Bularga, Caelan Taggart, Filip Mendusic, Dorien M Kimenai, Ryan Wereski, Matthew T.H. Lowry, Kuan Ken Lee, Amy V. Ferry, Stacey Stewart, David McAllister, Anoop Shah, Atul Anand, David E. Newby, Nicholas L. Mills, Andrew R. Chapman, High-Sensitivity Troponin in the Evaluation of Patients with Suspected Acute Coronary Syndrome (High-STEACS) Investigators, Fiona E. Strachan, Christopher Tuck, Dimitrios Doudesis, Dennis Sandeman, Philip D Adamson, Jack Andrews, Alastair J. Moss, Mohamed Anwar, John Hung, Catherine L. Stables, Catalina A. Vallejo, Athanasios Tsanas, Lucy Marshal, Takeshi Fujisawa, Mischa Hautvast, Jean McPherson, Lynn McKinley, Keith A.A. Fox, Colin Berry, Simon Walker, Christopher J. Weir, Ian Ford, Alasdair Gray, Paul Collinson, Fred S Apple, Alan Reid, Anne Cruikshank, Iain Findlay, Shannon Amoils, Donogh Maguire, Jennifer S. Stevens, John Norrie, Jonathan Malo, Colin Fischbacher, Bernard Croal, Stephen J Leslie, Catriona Keerie, Richard Parker, Allan Walker, Ronnie Harkess, Tony Wackett, Roma A. Armstrong, Marion Flood, Laura Stirling, Claire MacDonald, Imran Sadat, Frank Finlay, Heather Charles, Pamela Linksted, Stephen G. Young, Bill Alexander, Chris Duncan
Abstract
Importance: Type 2 myocardial infarction occurs owing to multiple factors associated with myocardial oxygen supply-demand imbalance, which may confer different risks of adverse outcomes. Objective: To evaluate the prevalence and outcomes of different factors associated with oxygen supply-demand imbalance among patients with type 2 myocardial infarction. Design, Setting, and Participants: In this secondary analysis of a stepped-wedge, cluster randomized clinical trial conducted at 10 secondary and tertiary care hospitals in Scotland, 6096 patients with an adjudicated diagnosis of type 1 or type 2 myocardial infarction from June 10, 2013, to March 3, 2016, were identified, and the findings were reported on August 28, 2018. The trial enrolled consecutive patients with suspected acute coronary syndrome. The diagnosis of myocardial infarction was adjudicated according to the Fourth Universal Definition of Myocardial Infarction and the primary factor associated with oxygen supply-demand imbalance in type 2 myocardial infarction was defined. This secondary analysis was not prespecified. Statistical analysis was performed from July 7 to 30, 2020. Intervention: Implementation of a high-sensitivity cardiac troponin I assay. Main Outcomes and Measures: All-cause death at 1 year according to the factors associated with oxygen supply-demand imbalance among patients with type 2 myocardial infarction. Results: Of 6096 patients (2602 women [43%]; median age, 70 years [IQR, 58-80 years]), 4981 patients had type 1 myocardial infarction, and 1115 patients had type 2 myocardial infarction. The most common factor associated with oxygen supply-demand imbalance was tachyarrhythmia (616 of 1115 [55%]), followed by hypoxemia (219 of 1115 [20%]), anemia (95 of 1115 [9%]), hypotension (89 of 1115 [8%]), severe hypertension (61 of 1115 [5%]), and coronary mechanisms (35 of 1115 [3%]). At 1 year, all-cause mortality occurred for 15% of patients (720 of 4981) with type 1 myocardial infarction and 23% of patients (285 of 1115) with type 2 myocardial infarction. Compared with patients with type 1 myocardial infarction, those with type 2 myocardial infarction owing to hypoxemia (adjusted odds ratio [aOR], 2.35; 95% CI, 1.72-3.18) and anemia (aOR, 1.83; 95% CI, 1.14-2.88) were at greatest risk of death, whereas those with type 2 myocardial infarction owing to tachyarrhythmia (aOR, 0.83; 95% CI, 0.65-1.06) or coronary mechanisms (aOR, 1.07; 95% CI, 0.17-3.86) were at similar risk of death as patients with type 1 myocardial infarction. Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, mortality after type 2 myocardial infarction was associated with the underlying etiologic factor associated with oxygen supply-demand imbalance. Most type 2 myocardial infarctions were associated with tachyarrhythmia, with better prognosis, whereas hypoxemia and anemia accounted for one-third of cases, with double the mortality of type 1 myocardial infarction. These differential outcomes should be considered by clinicians when determining which cases need to be managed if patient outcomes are to improve. Trial Registration: ClinicalTrials.gov Identifier: NCT01852123.