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The Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) Classification System

A Taxonomy for Young Women With Acute Myocardial Infarction
Originally published8 Sep 2015Circulation. 2015;132:1710–1718
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Abstract

Background—

Current classification schemes for acute myocardial infarction (AMI) may not accommodate the breadth of clinical phenotypes in young women.

Methods and Results—

We developed a novel taxonomy among young adults (≤55 years) with AMI enrolled in the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study. We first classified a subset of patients (n=600) according to the Third Universal Definition of MI using a structured abstraction tool. There was heterogeneity within type 2 AMI, and 54 patients (9%; including 51 of 412 women) were unclassified. Using an inductive approach, we iteratively grouped patients with shared clinical characteristics, with the aims of developing a more inclusive taxonomy that could distinguish unique clinical phenotypes. The final VIRGO taxonomy classified 2802 study participants as follows: class 1, plaque-mediated culprit lesion (82.5% of women; 94.9% of men); class 2, obstructive coronary artery disease with supply-demand mismatch (2a: 1.4% women; 0.9% men) and without supply-demand mismatch (2b: 2.4% women; 1.1% men); class 3, nonobstructive coronary artery disease with supply-demand mismatch (3a: 4.3% women; 0.8% men) and without supply-demand mismatch (3b: 7.0% women; 1.9% men); class 4, other identifiable mechanism (spontaneous dissection, vasospasm, embolism; 1.5% women, 0.2% men); and class 5, undetermined classification (0.8% women, 0.2% men).

Conclusions—

Approximately 1 in 8 young women with AMI is unclassified by the Universal Definition of MI. We propose a more inclusive taxonomy that could serve as a framework for understanding biological disease mechanisms, therapeutic efficacy, and prognosis in this population.

Footnotes

Dr Murugiah is currently affiliated with the Department of Internal Medicine, Yale School of Medicine, New Haven, CT.

Guest Editor for this article was Wendy Post, MD, MS.

The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.016502/-/DC1.

Correspondence to Harlan M. Krumholz, MD, SM, Department of Internal Medicine, Yale School of Medicine, 1 Church St, Ste 200, New Haven, CT 06510. E-mail

References

  • 1. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction: National Registry of Myocardial Infarction 2 Participants.N Engl J Med. 1999;341:217–225. doi: 10.1056/NEJM199907223410401.CrossrefMedlineGoogle Scholar
  • 2. Vaccarino V, Horwitz RI, Meehan TP, Petrillo MK, Radford MJ, Krumholz HM. Sex differences in mortality after myocardial infarction: evidence for a sex-age interaction.Arch Intern Med. 1998;158:2054–2062.CrossrefMedlineGoogle Scholar
  • 3. Gupta A, Wang Y, Spertus JA, Geda M, Lorenze N, Nkonde-Price C, D’Onofrio G, Lichtman JH, Krumholz HM. Trends in acute myocardial infarction in young patients and differences by sex and race, 2001 to 2010.J Am Coll Cardiol. 2014;64:337–345. doi: 10.1016/j.jacc.2014.04.054.CrossrefMedlineGoogle Scholar
  • 4. Hochman JS, McCabe CH, Stone PH, Becker RC, Cannon CP, DeFeo-Fraulini T, Thompson B, Steingart R, Knatterud G, Braunwald E. Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB: TIMI Investigators: Thrombolysis in Myocardial Infarction.J Am Coll Cardiol. 1997;30:141–148.CrossrefMedlineGoogle Scholar
  • 5. Humphries KH, Pu A, Gao M, Carere RG, Pilote L. Angina with “normal” coronary arteries: sex differences in outcomes.Am Heart J. 2008;155:375–381. doi: 10.1016/j.ahj.2007.10.019.CrossrefMedlineGoogle Scholar
  • 6. Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries.Circulation. 2015;131:861–870. doi: 10.1161/CIRCULATIONAHA.114.011201.CrossrefMedlineGoogle Scholar
  • 7. Jeremias A, Gibson CM. Narrative review: alternative causes for elevated cardiac troponin levels when acute coronary syndromes are excluded.Ann Intern Med. 2005;142:786–791.CrossrefMedlineGoogle Scholar
  • 8. Alcalai R, Planer D, Culhaoglu A, Osman A, Pollak A, Lotan C. Acute coronary syndrome vs nonspecific troponin elevation: clinical predictors and survival analysis.Arch Intern Med. 2007;167:276–281. doi: 10.1001/archinte.167.3.276.CrossrefMedlineGoogle Scholar
  • 9. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; the Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction.Circulation. 2012;126:2020–2035.CrossrefMedlineGoogle Scholar
  • 10. Kerensky RA, Wade M, Deedwania P, Boden WE, Pepine CJ; Veterans Affairs Non-Q-Wave Infarction Strategies in-Hospital (VANQWISH) Trial Investigators. Revisiting the culprit lesion in non-Q-wave myocardial infarction: results from the VANQWISH trial angiographic core laboratory.J Am Coll Cardiol. 2002;39:1456–1463.CrossrefMedlineGoogle Scholar
  • 11. Lichtman JH, Lorenze NP, D’Onofrio G, Spertus JA, Lindau ST, Morgan TM, Herrin J, Bueno H, Mattera JA, Ridker PM, Krumholz HM. Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study design.Circ Cardiovasc Qual Outcomes. 2010;3:684–693. doi: 10.1161/CIRCOUTCOMES.109.928713.LinkGoogle Scholar
  • 12. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research.Circulation. 2009;119:1442–1452. doi: 10.1161/CIRCULATIONAHA.107.742775.LinkGoogle Scholar
  • 13. Patton MQQualitative Research and Evaluation Methods. Thousand Oaks, CA: Sage Publications; 2002.Google Scholar
  • 14. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory.Health Serv Res. 2007;42:1758–1772. doi: 10.1111/j.1475-6773.2006.00684.x.CrossrefMedlineGoogle Scholar
  • 15. Rubenstein LV, Kahn KL, Harrison ER, Sherwood MJ, Rogers WH, Brook RHStructured Implicit Review of the Medical Record: A Method for Measuring the Quality of Inhospital Medical Care and a Summary of Quality Changes Following Implementation of the Medicare Prospective Payment System. Santa Monica, CA: RAND; 1991.Google Scholar
  • 16. Hutchinson A, Coster JE, Cooper KL, McIntosh A, Bath P, Walters SJ, Pearson M. Implicit and explicit case note review: two sides of the same coin?In: Creating and Designing the Healthcare Experience: The International Ergonomics Association. Strasbourg; 2008.Google Scholar
  • 17. Ashton CM, Kuykendall DH, Johnson ML, Wray NP. An empirical assessment of the validity of explicit and implicit process-of-care criteria for quality assessment.Med Care. 1999;37:798–808.CrossrefMedlineGoogle Scholar
  • 18. Agency for Health Care Policy and Research. Using Clinical Practice Guidelines to Evaluate Quality of Care. U.S. Department of Health and Human Services. Public Health Service; 1995;2.Google Scholar
  • 19. Strauss AL, Corbin JBasics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications; 1998.Google Scholar
  • 20. Glaser BG, Strauss ALThe Discovery of Grounded Research: Strategies for Qualitative Research. New York, NY: Aldine De Gruyter; 1967.Google Scholar
  • 21. O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso JE, Tracy CM, Woo YJ, Zhao DX; CF/AHA Task Force. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation. 2013;127:529–555. doi: 10.1161/CIR.0b013e3182742c84.CrossrefMedlineGoogle Scholar
  • 22. American Heart Association: Quality of Care and Outcomes Research Scientific Sessions. Poster Presentation.June 2-4, 2014. Baltimore, MD.Google Scholar
  • 23. Pilote L, Karp I. GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: From bench to beyond-Premature Acute Coronary SYndrome).Am Heart J. 2012;163:741–746.e2. doi: 10.1016/j.ahj.2012.01.022.CrossrefMedlineGoogle Scholar
  • 24. Dovey SM, Meyers DS, Phillips RL, Green LA, Fryer GE, Galliher JM, Kappus J, Grob P. A preliminary taxonomy of medical errors in family practice.Qual Saf Health Care. 2002;11:233–238.CrossrefMedlineGoogle Scholar
  • 25. Hayward RA, McMahon LF, Bernard AM. Evaluating the care of general medicine inpatients: how good is implicit review?Ann Intern Med. 1993;118:550–556.CrossrefMedlineGoogle Scholar
  • 26. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer.JAMA. 2001;286:415–420.CrossrefMedlineGoogle Scholar
  • 27. Reynolds HR, Srichai MB, Iqbal SN, Slater JN, Mancini GB, Feit F, Pena-Sing I, Axel L, Attubato MJ, Yatskar L, Kalhorn RT, Wood DA, Lobach IV, Hochman JS. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease.Circulation. 2011;124:1414–1425. doi: 10.1161/CIRCULATIONAHA.111.026542.LinkGoogle Scholar
  • 28. Shah AS, Griffiths M, Lee KK, McAllister DA, Hunter AL, Ferry AV, Cruikshank A, Reid A, Stoddart M, Strachan F, Walker S, Collinson PO, Apple FS, Gray AJ, Fox KA, Newby DE, Mills NL. High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study.BMJ. 2015;350:g7873.CrossrefMedlineGoogle Scholar
  • 29. Sandoval Y, Smith SW, Thordsen SE, Apple FS. Supply/demand type 2 myocardial infarction: should we be paying more attention?J Am Coll Cardiol. 2014;63:2079–2087. doi: 10.1016/j.jacc.2014.02.541.CrossrefMedlineGoogle Scholar
  • 30. Della Rocca DG, Pepine CJ. What causes myocardial infarction in women without obstructive coronary artery disease?Circulation. 2011;124:1404–1406. doi: 10.1161/CIRCULATIONAHA.111.055855.LinkGoogle Scholar
  • 31. Pepine CJ, Anderson RD, Sharaf BL, Reis SE, Smith KM, Handberg EM, Johnson BD, Sopko G, Bairey Merz CN. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women’s Ischemia Syndrome Evaluation) study.J Am Coll Cardiol. 2010;55:2825–2832. doi: 10.1016/j.jacc.2010.01.054.CrossrefMedlineGoogle Scholar
  • 32. Shaw LJ, Min JK, Narula J, Lin F, Bairey-Merz CN, Callister TQ, Berman DS. Sex differences in mortality associated with computed tomographic angiographic measurements of obstructive and nonobstructive coronary artery disease: an exploratory analysis.Circ Cardiovasc Imaging. 2010;3:473–481. doi: 10.1161/CIRCIMAGING.109.860981.LinkGoogle Scholar
  • 33. Schindler TH, Nitzsche EU, Schelbert HR, Olschewski M, Sayre J, Mix M, Brink I, Zhang XL, Kreissl M, Magosaki N, Just H, Solzbach U. Positron emission tomography-measured abnormal responses of myocardial blood flow to sympathetic stimulation are associated with the risk of developing cardiovascular events.J Am Coll Cardiol. 2005;45:1505–1512. doi: 10.1016/j.jacc.2005.01.040.CrossrefMedlineGoogle Scholar
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