Accuracy of Angiographic Identification of Culprit Lesions in Women With MINOCA

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) accounts for 6% to 15% of acute coronary syndromes and disproportionately affects women. Although coronary culprit lesions are present in 45% of patients with MINOCA, multivessel optical coherence tomography (OCT) is infrequently performed. We evaluated whether interventional cardiologists can identify coronary arteries with culprit lesions using invasive coronary angiography in women with MINOCA. METHODS: Women with MINOCA who had a coronary culprit lesion identified by multivessel OCT were included. A core laboratory confirmed and localized OCT-defined culprit lesions using angiographic coregistration. Two interventional cardiologists blinded to OCT findings independently reviewed invasive coronary angiography, before and after review of ECG and transthoracic echocardiography, to identify the culprit artery. RESULTS: Among 64 women with MINOCA (median age 64 years; 97% non-ST-segment elevation MI), OCT-defined culprit lesions were most frequently located in the left anterior descending (50.8%) or right coronary (35.4%) arteries. At least 1 interventional cardiologist identified the culprit artery in 54.7% of patients (95% CI, 42.6%–66.3%); both identified it in 28.1% (95% CI, 18.6%–40.1%). The addition of ECG and transthoracic echocardiography data did not improve accuracy ( P =0.40 and P =0.97). Culprit arteries were identified by at least 1 cardiologist in 87.5% of plaque rupture cases. Only 11% of circumflex lesions were identified. CONCLUSIONS: Interventional cardiologists could not reliably identify culprit arteries using coronary angiography in women with MINOCA, even after ECG and transthoracic echocardiography review. Our findings suggest that invasive angiography alone should not guide vessel selection for intracoronary imaging and support multivessel imaging when evaluating MINOCA. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02905357.