Type 2 MI Patients Often Miss Out on Seeing a Cardiologist

Fewer than two-thirds of patients hospitalized with type 2 MI at Massachusetts General Hospital in a recent 6-month period saw a cardiologist during their admission. And after discharge, most patients failed to get specialized heart care.

“Our analysis raises the possibility of gaps in care,” Cian P. McCarthy, MB BCh, BAO (Massachusetts General Hospital, Boston), and colleagues report in Circulation: Cardiovascular Quality and Outcomes.

For type 2 MI, caused not by plaque rupture but by supply/demand mismatch, “there are not a lot of validated treatment strategies,” senior author Jason H. Wasfy, MD (Massachusetts General Hospital), told TCTMD. “That’s an area of active research.” Adding to this lack of clarity, and accompanying confusion over diagnosis, is that type 2 MI can arise from many sources, from sepsis to bleeding.

At the moment, care is “sort of a grab bag: it’s a mix of different treatment strategies, different care processes,” Wasfy said. There are many hypotheses but little firm data on comparative effectiveness.

The question then is how best to get patients what they need, Wasfy said, and cardiologists have a role to play. “We have to educate our colleagues in other fields that type 2 MI is a really serious diagnosis. We casually call these cases ‘troponin leaks’ or ‘troponinemia.’ I worry about those terms a lot because they don’t reflect the . . . sobering prognosis of this disease condition. . . . We want to get the medical community away from this notion that type 2 myocardial infarction is not a real heart attack.”

Survival after type 2 MI is less than 40% at 5 years, he added. So in spite of the uncertainty over how best to address it, these patients “probably do need customized direction under the care of a cardiologist,” Wasfy stressed. He suggested that telehealth might prove useful at hospitals where cardiologists aren’t readily available.

We casually call these cases ‘troponin leaks’ or ‘troponinemia.’ I worry about those terms a lot because they don’t reflect the . . . sobering prognosis of this disease condition. Jason H. Wasfy

McCarthy and colleagues used electronic health records to evaluate treatment and outcomes among 359 patients diagnosed with type 2 MI at their center between October 2017 and May 2018. Medical records showed just 57.7% were seen by a cardiologist, 33.4% received a cardiology consultation, and 24.2% were admitted or transferred to a cardiology service.

Patients evaluated by a cardiologist were more apt to have CV risk factors and prior aspirin use, and when diagnosed, the type 2 MI tended to have more regional wall motion abnormalities on transthoracic echo (33.8% vs 11.2%; P < 0.001). Yet rates of chest pain, shortness of breath, and ischemic T-wave abnormalities were not affected by whether a cardiologist entered the picture.

Moreover, stress testing during the index admission was more common among cardiologist-treated patients (13.5% vs 3.3%; P = 0.002). So too were transthoracic echocardiography (80.2% vs 50.7%) and coronary angiography (21.3% vs zero; P < 0.001 for both).

Getting that specialized care also translated into patients being more likely to be discharged on medical therapy, including statins (74.5% vs 64.5%; P = 0.04), clopidogrel (14.0% vs 5.9%; P = 0.02), and beta-blockers (72.0% vs 55.9%; P = 0.002), with no differences use of aspirin or ACE inhibitors/ARBs.

By 1 year, all-cause mortality rates were similar regardless of whether patients did or didn’t see a cardiologist (11.6% vs 9.2%; P = 0.58).

“Our data highlight uncertainty about traditional ischemic therapies and the role of cardiologists in type 2 MI,” McCarthy et al conclude. “Given increasing frequency and high risk of patients, clinical trials are needed to identify effective strategies for the care of patients with type 2 MI, including the role of cardiovascular specialists in their care.”