The definitions of disease have been updated about once every five years, so a revision this year would be timely. Presumably, new definitions will separate out at least some MINOCA.
What is the
origin of these new terms: myocardial infarction with non-obstructive coronary
arteries (MINOCA) and ischemia and no obstructive coronary artery disease
(INOCA)?
It has been
common for cardiologists to describe patients with chest pain and abnormal
stress tests, but mild or no CAD on catheterization, as “false positives.”
However, studies have long shown that such patients have a worse prognosis than
patients with normal stress tests. In recognition of this fact, these patients
have now been designated as “INOCA.”
MINOCA patients have been particularly common
with the advent of sensitive troponin testing. For the most part, cardiologists
have done reasonably well in identifying the causes of the troponin elevations,
though many cases have remained troubling, and some have still been written off
as false positives. The term itself was coined in 2013.
It often
applies to type 2 MI. What are the causes of MINOCA and INOCA? Generally
speaking, INOCA is associated with conventional cardiac risk factors such as
hypertension, hyperlipidemia, and obesity. It is much more common in women.
Underlying mechanisms may involve decreased coronary flow reserve and elevated
platelet reactivity. Coronary intravascular ultrasound can reveal more
extensive atherosclerosis than is appreciated on angiography, due to positive
remodeling. This may indicate a diffuse inflammatory state in the vessels.
MINOCA encompasses a heterogeneous group of
issues, including: Plaque rupture without severe obstruction, but with
resultant vasospasm, microscopic thromboembolism, or thrombosis with
spontaneous thrombolysis. Technically a type 1 MI Vasospasm without plaque
rupture Thromboembolism due to thrombophilic state Coronary dissection, if not
visible on angiography Takotsubo (stress) cardiomyopathy Type 2 MI with other
primary diagnosis (e.g. sepsis, hypertensive crisis, arrhythmia, severe
valvular disease) Pulmonary embolism and myocarditis can cause this picture,
but are not considered to produce myocardial infarction. In this context, what
do coders and clinical documentation integrity specialists need to know about
MINOCA and INOCA – and when? These diagnoses only come into consideration after
cardiac catheterization (and perhaps infrequently after coronary CT) since they
require objective evidence of non-obstructive CAD. Thus, catheterizations that
do not result in percutaneous intervention or CABG should be scrutinized.
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