The first approach for Type-2 myocardial infarction (T2MI) consists of the elimination of the condition determining the oxygen supply/demand mismatch. However, the long-term impact of medical therapy with beta blockers, statins, aspirin, and P2Y12 inhibitors, used in the case of Type-1 myocardial infarction has been poorly investigated and remains unclear. We, therefore, sought to assess the impact of medical therapy on 1-year mortality in patients with T2MI using a meta-regression analysis. A meta-regression analysis was performed with studies involving in patients with T2MI: 1-year all-cause mortality, rates of beta blockers, statins, aspirin, and P2Y12 inhibitors use were recorded and analyzed. After careful study selection, 8 observational studies were pooled in the analysis, including 3,756 in patients. During meta-regression analysis, a borderline correlation between rates of aspirin, P2Y12 inhibitors, and statins use and 1-year mortality (p = 0.087, p = 0.05, and p = 0.067, respectively) was found; no significant correlation was found at multivariable analysis. In conclusion, in a meta-regression analysis, no significant correlation was found between rates of use of usual drug therapy indicated for Type-1 myocardial infarction (statins, aspirin, P2Y12 inhibitors, β-blockers) and 1-year mortality in T2MI patients.
Background
According to the universal definition of myocardial infarction (MI), acute myocardial infarction (AMI) is classified into 5 different types on the basis of pathology and clinical aspects. Type-1 myocardial infarction (T1MI) is caused by acute coronary plaque rupture and thrombosis. On the other hand, Type-2 myocardial infarction (T2MI) is associated with an oxygen demand/supply mismatch. Several causes of T2MI are described but according to its definition, this type of MI is not related to coronary thrombosis. The prevalence of T2MI varies between 2% and 75% of all patients with AMI; this finding probably depends on differences in clinical setting, diagnostic criteria, and troponin assays used. , Most observational studies show that the incidence of T2MI in AMI patients is increasing, probably for the increased sensitivity of troponin assays but also because in patients tend to be older and with higher comorbidity. In general, the T2MI population is older, with a female prevalence and higher mortality in comparison with T1MI. The management of T2MI is not evidence based. Ideally, the first line approach consists of the elimination of the cause of oxygen demand/supply mismatch, for example, the correction of anemia or hypoxemia. The role of percutaneous coronary intervention, which is considered the best treatment for T1MI, is poorly investigated. A meta-regression showed a positive impact on long-term survival in T2MI patients. The impact of medical therapy routinely used for T1MI as statins, antiplatelet, β-blocker, on outcomes of T2MI patients is unclear. We, therefore, aimed to assess the impact of medical therapy (statins, beta blockers, antiplatelet drugs) on 1-year mortality in T2MI in patients with a meta-regression analysis.
Methods
Following the Preferred Reporting Items for Systemic Reviews and Meta-Analysis document, we searched PubMed for all studies involving T2MI patients. We used “type 2 myocardial infarction” as search terms. Only English-language articles were taken into consideration. Moreover, we evaluated meta-analyses involving T2MI patients and references of the selected articles to obtain additional studies. All the studies specifying absolute 1-year all-cause mortality and the rate of medical therapy with beta blockers, statins, aspirin, and P2Y12 inhibitors in T2MI patients were included. All articles were independently examined by 2 authors (M.M., N.D.B.). Two authors graded the selected studies for bias (Cochrane Handbook for Systematic Review of Interventions). The number of participants, average age, gender distribution, main cardiovascular risk factors, medical treatment including statins, aspirin, other antiplatelet drugs, beta blockers, and rate of percutaneous coronary intervention were collected ( Table 1 ).
| Study | Period | Design and Setting | n | Age (Mean) | Male | CKD | DM | ASA | Other PLT inh | Bb | Ace inh | Statins | PCI | 1-year Mortality |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Stein et al | 2014 | prospective Survey Analysis/ ICCU and cardiology wards | 127 | 75 | 57% | 36% | 48% | 68% | 39% | 57% | 54% | 68% | 32% | 12 |
| Saaby et al | 2014 | prospective observational study/ clinical wards | 119 | 75 | 63% | 23% | 53% | 13% | 46% | 40% | 40% | 3% | 44 | |
| Baron et al | 2015 | real life registry study/cardiac or medical ICU | 1,043 | 76 | 53% | 44% | 27% | 74% | 47% | 82% | 49% | 43% | 12% | 25 |
| Shah et al | 2015 | prespecified analysis/ cardiac center | 429 | 72 | 52% | 16% | 22% | 49% | 14% | 28% | 39% | 46% | 0% | 31 |
| Lopez-Cuenca et al | 2016 | retrospective/ cardiology wards | 117 | 72 | 52% | 44% | 65% | 41% | 78% | 48% | 83% | 9% | 23 | |
| Radovanovic et al | 2017 | prospective observational study/ICCU, cardiology and internal medicine wards | 1,091 | 71 | 64% | 14% | 26% | 91% | 73% | 55% | 52% | 65% | 51% | 11 |
| Arora et al | 2018 | retrospective/ hospitalizations for NSTEMI | 264 | 73 | 48% | 25% | 42% | 73% | 34% | 78% | 72% | 12% | 13 | |
| Furie et al | 2019 | retrospective/ general medical wards | 206 | 79 | 8% | 36% | 48% | 79% | 55% | 68% | 61% | 1% | 39 |
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