Studies about MINOCA

Presentation of important studies, case studies and reports about MINOCA

Multiparametric Stress Echocardiography in the Diagnosis of IOCA and INOCA: Role of CFVR Measurement

With our case series, we would like to raise awareness of the existence of INOCA and to offer a diagnostic pathway for such patients to provide appropriate treatment to improve quality of life and survival. We propose a simple, entirely noninvasive pathway to assess coronary artery anatomy by cardiac computed tomography angiography and, once occlusive CAD was ruled out, refer for ischemia testing and CFVR measurement by multiparametric contrast-enhanced stress echocardiography to investigate CMD.

Contemporary Diagnosis and Management of Patients with MINOCA

MINOCA is not uncommon and requires comprehensive assessment using various imaging modalities to evaluate it further. MINOCA is a heterogenous working diagnosis that requires thoughtful approach to diagnose the underlying disease responsible for MINOCA further.

Clinical characteristics and prognosis of myocardial infarction with non-obstructive coronary arteries: A prospective single-center study

The frequency of MINOCA is high, with fewer CVRF, and it is linked to atrial fibrillation, psychosocial disorders, and pro-inflammatory conditions. Mid-term prognosis is worse than previously thought, with a similar proportion of MACE as compared to MIOCA, and even a higher rate of cardiovascular re-admissions.

Early-onset MINOCA: Prognostic implications and considerations for practice

MINOCA is a working diagnosis and should be confirmed only after carefully excluding nonischemic etiologies of myocardial injury (i.e., myocarditis), inadvertently overlooked coronary obstruction (i.e., occlusion of small/distal vessels), and other possible causes of troponin elevation (i.e., pulmonary embolism). Once these alternatives have been considered and discarded, a diagnosis of MINOCA can be made. Early investigation (i.e., within 7–14 days) by cardiac magnetic resonance (CMR) with late gadolinium enhancement is helpful to assess cardiac anatomy and differentiate infarct patterns (i.e., subendocardial/transmural) from nonischemic patterns (i.e., subepicardial/mid-wall).

yocardial infarction with non-obstructive coronary arteries (MINOCA) occurs in 5%–15% of all patients with acute myocardial infarction. Cardiac MR (CMR) and optical coherence tomography have been used to identify the underlying pathophysiological mechanism in MINOCA. The role of cardiac CT angiography (CCTA) in patients with MINOCA, however, has not been well studied so far. CCTA can be used to assess atherosclerotic plaque volume, vulnerable plaque characteristics as well as pericoronary fat tissue attenuation, which has not been yet studied in MINOCA.

The term myocardial infarction with non-obstructive coronary arteries (MINOCA), defines a puzzling event occurring in the absence of obstructive coronary artery disease on coronary angiography and without an overt potential cause. However, a practical diagnostic work-up is often difficult, due to the heterogeneous etiologies and pathophysiology of MINOCA. This review aims to provide a comprehensive overview focusing on epidemiology, etiopathogenesis, diagnostic tools and therapeutic strategies for subjects with MINOCA, in order to provide a prompt and accurate diagnostic work-up and an adequate therapeutic approach in this subset population. Despite further advances in diagnostic and therapeutic strategies, MINOCA remains a challenging conundrum in clinical practice. Clinicians should be aware of the different potential etiologies and pathogenic mechanisms of MINOCA, in order to carry out a comprehensive diagnostic work-up and implement a tailored therapeutic approach.

In the current review, we emphasize the importance of diagnostics and therapy in patients with ischaemia with no obstructive coronary arteries (INOCA). The importance of the diagnostic coronary function test (CFT) procedure is described, including future components including angiography-derived physiology and invasive continuous thermodilution. Furthermore, the main components of treatment are discussed. Future directions include the national registration ensuring a high quality of INOCA care, besides a potential source to improve our understanding of pathophysiology in the various phenotypes of coronary vascular dysfunction, the diagnostic CFT procedure, and treatment.

When acute myocardial injury is found in a clinical setting suggestive of myocardial ischaemia, the event is labelled as acute myocardial infarction (AMI), and the absence of coronary stenosis angiographically 50% or greater leads to the working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA). The initial diagnosis of MINOCA can be confirmed or ruled out based on the results of subsequent investigations. This narrative review discusses the downstream diagnostic approaches to MINOCA, and appraises strengths and limitations of invasive and non-invasive investigations for this condition. The aim of this article is to increase the awareness that establishing the underlying cause of a MINOCA is possible in the vast majority cases. Determining the cause of MINOCA and excluding other possible causes for cardiac troponin elevation has notable implications for tailoring secondary prevention measures aimed at improving the overall prognosis of AMI.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), as the name implies, is an acute myocardial infarction (MI) in the absence of significant coronary artery obstruction. Diagnosis and management of such cases have been challenging. There are many etiologies of MINOCA including coronary artery spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis or emboli, spontaneous coronary artery dissection, or cardiomyopathies. In this paper, the pathophysiology, diagnostic work-up, and clinical management for each subtype are described, and an overarching approach on how to evaluate and manage a patient presenting with MINOCA.

The Role of Cardiac Magnetic Resonance in Myocardial Infarction and Non-obstructive Coronary Arteries

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) accounts for 5–15% of all presentations of acute myocardial infarction. The absence of obstructive coronary disease may present a diagnostic dilemma and identifying the underlying etiology ensures appropriate management improving clinical outcomes. Cardiac magnetic resonance (CMR) imaging is a valuable, non-invasive diagnostic tool that can aide clinicians to build a differential diagnosis in patients with MINOCA, as well as identifying non-ischemic etiologies of myocardial injury (acute myocarditis, Takotsubo Syndrome, and other conditions). The role of CMR in suspected MINOCA is increasingly recognized as emphasized in both European and American clinical guidelines. In this paper we review the indications for CMR, the clinical value in the differential diagnosis of patients with suspected MINOCA, as well as its current limitations and future perspectives.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) was first described over 80 years ago. The term has been widely and inconsistently used in clinical practice, influencing various aspects of disease classification, investigation and management. MINOCA encompasses a heterogenous group of conditions that include both atherosclerotic and non-atherosclerotic disease resulting in myocardial damage that is not due to obstructive coronary artery disease. In many ways, it is a term that describes a moment in the diagnostic pathway of the patient and is arguably not a diagnosis. Central to the definition is also the distinction between myocardial infarction and injury. The universal definition of myocardial infarction distinguishes acute myocardial infarction, including those with MINOCA, from other causes of myocardial injury by the presence of clinical evidence of ischaemia. However, these ischaemic features are often non-specific causing diagnostic confusion, and can create difficulties for patient management and follow-up. The purpose of this review is to summarise our current understanding of MINOCA and highlight important issues relating to the diagnosis, investigation and management of patients with MINOCA.

Myocardial infarction in the absence of obstructive coronary artery disease is found in ≈5% to 6% of all patients with acute infarction who are referred for coronary angiography. There are a variety of causes that can result in this clinical condition. As such, it is important that patients are appropriately diagnosed and an evaluation to uncover the correct cause is performed so that, when possible, specific therapies to treat the underlying cause can be prescribed. This statement provides a formal and updated definition for the broadly labelled term MINOCA (incorporating the definition of acute myocardial infarction from the newly released “Fourth Universal Definition of Myocardial Infarction”) and provides a clinically useful framework and algorithms for the diagnostic evaluation and management of patients with myocardial infarction in the absence of obstructive coronary artery disease.

Myocardial infarction with non-obstructive coronary disease (MINOCA) represents a heterogeneous clinical conundrum representing about 6% of all acute myocardial infarction (MI) cases. Initially believed to be a benign condition associated with a favourable prognosis, it is now becoming clear that MINOCA is associated with a significant risk of mortality, rehospitalization, disability and angina burden at follow-up, with high socioeconomic costs, similar to those patients presenting with MI and obstructive coronary artery disease (CAD). In order to improve clinical outcomes and reduce the healthcare-related costs, it is mandatory to understand the burden of the problem and identify the specific causes of MINOCA so that therapy can be tailored on the underlying mechanism.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention.

yocardial ischemia may be caused not only by flow-limiting obstructions in the epicardial vessels, but also by a variety of non-obstructive mechanisms leading to a mismatch between myocardial oxygen demand and blood flow supply. This explains why a large proportion (up to 70%) of patients undergoing coronary angiography because of angina and demonstrated myocardial ischaemia do not have coronary artery disease with obstructive lesions.

Furthermore, myocardial infarction (MI) in the absence of obstructive coronary artery disease (MINOCA) can be found in ≈5% to 6% of all patients with acute infarction who are referred for coronary angiography.

We report the observation of an acute coronary syndrome in an 84-year-old woman evolving to an anterior myocardial infarction with persistent elevation of the ST segment (STEMI), without significant stenosis of the left descending coronary artery after manual aspiration of a distal thrombus. The diagnostic workflow secondary to this clinical condition of MINOCA (Myocardial Infarction with Non Obstructive Coronary Arteries), integrated, according to the very latest definition of myocardial infarction, in the infarcts subgroup type 2 (not linked to an athero-thrombotic event) led to the very high probability of the diagnosis of coronary embolism related to a chronic and untreated atrial fibrillation. The purpose of this article is to provide a formal and updated definition for the broadly labelled term MINOCA (incorporating the definition of AMI from the newly released “Fourth Universal Definition of Myocardial Infarction”) and to provide a clinically useful framework and algorithms pertaining to the diagnostic evaluation and management of these patients.

Sickle cell disease is an inherited disorder in which microvascular occlusion causes complications across multiple organ systems. Acute myocardial infarction is increasingly recognized as a feature of sickle cell disease. 1 Acute myocardial infarction is often clinically overshadowed by more substantial presentations of vasoocclusion such as musculoskeletal pain. 2 However, one-third of adults with sickle cell disease suffer from left ventricular dysfunction that may be related to recurrent micro-injury, which may have begun years prior to a heart failure presentation. 3 ,4 Pathological studies also have demonstrated degenerative myocardial changes, fibrosis, healed infarcts, and clogging of intramural (micro) coronary vessels by sickle cell aggregates. Quantification of myocardial iron deposition is the most recognizable use of cardiac magnetic resonance imaging (MRI) in sickle cell disease patients. The other unique advantage of cardiac MRI in sickle cell disease is its ability to assess myocardial tissue characteristics, making it an appealing modality to provide valuable data that could not be acquired previously without tissue biopsy.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a known clinical conundrum with limited investigation. Using a large population-based cohort, we examined the incidence, demographic profile, use of evidence-based medicines (EBM) and clinical outcomes of MINOCA patients. The population-level incidence of MINOCA is approximately 5%. Despite their apparently benign anatomic findings, efforts must be made to improve secondary prevention strategies to reduce the burden of long-term adverse outcomes in this population.

Pathology Queensland will introduce a new cardiac troponin assay to all Queensland Health hospital laboratories in late October 2018. The new Beckman Coulter Access hsTnI will replace the previous troponin assay, which will no longer be available after the change.

The objective of the SMINC-2 (Stockholm Myocardial Infarction With Normal Coronaries 2) study was to determine if more than 70% of patients with myocardial infarction with nonobstructed coronary arteries (MINOCA), investigated early with comprehensive cardiovascular magnetic resonance (CMR), could receive a diagnosis entirely by imaging. The results of the SMINC-2 study show that 77% of all patients with MINOCA received a diagnosis when imaged early with CMR, including advanced tissue characterization, which was a considerable improvement in comparison to the SMINC-1 study. This supports the use of early CMR imaging as a diagnostic tool in the investigation of patients with MINOCA. (Stockholm Myocardial Infarction With Normal Coronaries [SMINC]-2 Study on Diagnosis Made by Cardiac MRI [SCMINC-2

While patients with MINOCA have an increased risk of serious cardiovascular events and death, whether conventional secondary preventive therapies are beneficial has not been assessed in randomized trials. There is a limited basis for guideline recommendations in MINOCA. Furthermore, studies of routine clinical practice suggest that use of secondary prevention therapies in MINOCA varies considerably. Thus results from this trial may influence future treatment strategies and guidelines specific to MINOCA patients.

Diagnostic and Prognostic Role of Cardiac Magnetic Resonance in MINOCA: Systematic Review and Meta-Analysis

In patients with MINOCA, CMR has been demonstrated to add an important diagnostic and prognostic value, proving to be crucial for the diagnosis of this condition. 68% of patients with initial MINOCA were reclassified after the CMR evaluation. CMR-confirmed diagnosis of MINOCA was associated with an increased risk of major adverse cardiovascular events at follow-up.

Updates on MINOCA and INOCA through the 2022 publications in the International Journal of Cardiology

The syndromes of Myocardial Infarction or Ischemia with No Obstructive Coronary Artery Disease (aka as MINOCA and INOCA) have received increasing attention in recent years and several diagnostic uncertainties have been clarified . Contrary to what initially thought, there is now evidence that these patients suffer from major adverse cardiovascular events (MACE) that are not less serious than those in patients with obstructive coronary artery disease (CAD). A recent systematic review and meta-analysis of 82 studies in 8457 patients has shown that using a combination of noninvasive and invasive techniques it is possible to identify the pathogenetic mechanisms behind a diagnosis of MINOCA/INOCA in the majority of patients, although, in clinical practice, their application remains limited.

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) represents a significant proportion (up to 15%) of acute myocardial infarction (AMI) population. MINOCA is diagnosed in patients who fullfilled the fourth universal definition of AMI in the absence of significant obstructive coronary artery disease on coronary angiography. MINOCA is a group of heterogeneous diseases with different pathophysiological mechanisms requiring multimodality imaging. Left ventriculography, cardiac magnetic resonance imaging and intra-coronary imaging (IVUS, OCT) are useful tools playing a pivotal role in the diagnostic work-up. There are no standard guidelines on the management of MINOCA patients and the therapeutic approach is personalized, thereby detecting the underlying aetiology is fundamental to initiate an early appropriate cause-targeted therapy.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is common in clinical practice and accounts for about 10% of all patients presenting with myocardial infarction (MI). The absence of significant coronary stenosis should not be regarded as a benign feature. Patients with MINOCA are at increased risk of recurrent infarction and mortality and should not be dismissed as having a ‘false-positive’ diagnosis of MI. Prompt recognition of MINOCA is relevant because secondary prevention strategies can improve patients‘ prognosis. However, this entity remains difficult to clinically distinguish from other nonischemic conditions that manifest with similar symptoms and troponin elevation. Based on the consensus of international societies, a diagnosis of MINOCA should be reserved for patients with MI – according to the fourth universal definition – who also present no stenosis ≥50% in any major epicardial artery on coronary angiography.

Myocardial infarction with non-obstructive coronary artery disease

As a result of the increased use of coronary angiography in acute myocardial infarction in the last two decades, myocardial infarction with non-obstructive coronary arteries (MINOCA) has received growing attention in everyday clinical practice. At the same time, research interest in MINOCA has increased significantly. MINOCA is a heterogeneous disease entity seen in 5-10% of all patients with myocardial infarction, especially in women. Clinically, MINOCA may be difficult to distinguish from other non-ischaemic conditions that can cause similar symptoms and myocardial injury. There is still some confusion around the diagnosis, investigation and management of patients with MINOCA. The present review summarises the current knowledge of MINOCA regarding epidemiology, pathophysiology, investigation, and treatment, with a special focus on imaging modalities. In addition, remaining important knowledge gaps are highlighted.

Why names matter for women: MINOCA/INOCA (myocardial infarction/ischemia and no obstructive coronary artery disease)

Why names matter for women: MINOCA/INOCA (myocardial infarction/ischemia and no obstructive coronary artery disease)
The syndromes of myocardial infarction/myocardial ischemia with No Obstructive Coronary Artery Disease (MINOCA/INOCA) are increasingly evident. A majority of these patients have coronary microvascular dysfunction. These patients have elevated risk for a cardiovascular event (including acute coronary syndrome, myocardial infarction, stroke, and repeated cardiovascular procedures) and appear to be at higher risk for development of heart failure with preserved ejection fraction.
Terminology such as coronary artery disease or coronary heart disease is often synonymous with obstructive atherosclerosis in the clinician’s mind, leaving one at a loss to recognize or explain the phenomenon of MINOCA and INOCA with elevated risk. We review the available literature regarding stable and unstable ischemic heart disease that suggests that use of the ischemic heart disease (IHD) terminology matters for women, and should facilitate recognition of risk to provide potential treatment targets and optimized health.

Diagnosis and Management of MINOCA Patients

The following are key points to remember from this American Heart Association Scientific Statement on the diagnosis and management of myocardial infarction in the absence of obstructive coronary artery disease (MINOCA): MINOCA occurs in 5-6% of acute myocardial infarction (AMI) cases (range reported between 5-15%). Patients with MINOCA are often younger, more likely to be women, and less likely to have dyslipidemia.
Diagnosis of MINOCA should be made according to the Fourth Universal Definition of MI, in the absence of obstructive coronary artery disease (CAD) (no lesion ≥50%). The diagnosis of MINOCA should exclude: 1) other overt causes for elevated troponin (e.g., pulmonary embolism, sepsis, etc.), 2) overlooked obstructive coronary disease (e.g., distal stenosis or occluded small branches), and 3) nonischemic causes for myocyte injury (e.g., myocarditis).
Nonobstructive coronary disease by coronary angiography should be differentiated between patients with normal coronary arteries and minimal luminal irregularities (<30% stenosis) and mild to moderate coronary atherosclerosis (30% to <50%). FFR can be useful. Takotsubo syndrome should be considered separately since it is not considered an MI by the Fourth Universal Definition of MI.

OCT and CMR for the Diagnosis of Patients Presenting With MINOCA and Suspected Epicardial Causes

Among all patients presenting with myocardial infarction with nonobstructive coronary arteries (MINOCA), epicardial causes may be suspected when there is a correlation between electrocardiogram (ECG) changes and regional wall motion abnormalities (WMAs). We evaluated the diagnostic yield of intravascular optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) in this specific setting. OCT coupled with CMR can provide a clear substrate and/or diagnosis in the vast majority of patients presenting with MINOCA including ECG features of ischemia associated with corresponding WMAs.

Patients with myocardial infarction and non-obstructive coronary arteries (MINOCA), defined as angiographic stenosis <50%, represent a conundrum given the many potential underlying aetiologies. Possible causes of MINOCA can be subdivided into coronary, myocardial and non-cardiac disorders. MINOCA is found in up to 14% of patients presenting with an acute coronary syndrome. Clinical outcomes including mortality, and functional and psychosocial status, are comparable to those of patients with myocardial infarction and obstructive coronary arteries. However, many uncertainties remain regarding the definition, clinical features and management of these patients. This position paper of the Dutch ACS working group of the Netherlands Society of Cardiology aims to stress the importance of considering MINOCA as a dynamic working diagnosis and to guide the clinician in the management of patients with MINOCA by proposing a clinical diagnostic algorithm.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) as a relatively new disease entity distinguished from the group of acute coronary syndromes (ACS) is not a rare clinical problem and it requires in-depth diagnostics. MINOCA accounts for 5–10% of all ACS cases. MINOCA is most common between the ages of 50–60 and predominates in females. Coronary microvascular dysfunction and coronary vasospasm are among the potential mechanisms. The latest guidelines for the treatment of ACS in patients presenting without persistent ST-segment elevation emphasize the importance of searching for the causes of angina in patients with insignificant lesions in the coronary arteries by extending invasive diagnostics (e.g., acetylcholine provocation test) and using noninvasive diagnostics (e.g., CMR or SPECT). In the context of MINOCA, among the typical risk factors for coronary artery disease, arterial hypertension (HTN) seems to be the most important by inducing coronary microcirculation remodeling (mostly hypertrophy) and hence the narrowing of the lumen. Studies comparing patients with MINOCA and obstructive coronary artery disease (MI-CAD) in the context of risk factors, in particular HTN, were analyzed. In five out of nine analyzed studies, HTN occurred significantly more often in patients with MINOCA compared to patients with MI-CAD. The current pharmacotherapy recommendations focus on slowing the progression of coronary microvascular dysfunction (CMD), i.e., adequate treatment of risk factors and comorbidities, such as HTN.

Therefore, it seems reasonable to conduct studies directly analyzing the relationship between HTN and MINOCA
in order to improve diagnostics and establish appropriate pharmacotherapy that will improve prognosis.

Among the patients diagnosed as acute myocardial infarction by coronary angiography, 5%-25% of the patients did not find coronary artery obstructive lesions. These patients do not need PCI. The discovery and verification of clinical protocols for accurate identification of myocardial infarction in the absence of obstructive coronary artery disease（MINOCA）is a major issue that needs to be addressed.Novel biomarkers like grow stimulation expressed gene 2（ST2）can indicate the degree of coronary artery obstruction, copeptin is a biomarker of cardiac emergency state. No clinical studies have been conducted to evaluate whether the novel biomarkers combination regimen can diagnose or exclude MINOCA.

Our research aims to establish and validate a model for the recognition of MINOCA based on novel biomarkers (ST2, copeptin) and to evaluate the prognostic value of novel biomarkers among patients with acute chest pain.

Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is defined as MI according to the fourth universal definition of MI without coronary stenosis ≥50% on coronary angiography, and without a specific alternate diagnosis for the acute presentation. MINOCA is present in approximately 5–6% of patients with acute myocardial infarction, and frequently affects women (up to 50%). MINOCA patients are usually younger (mean age 58 years), and have a lower prevalence of traditional cardiovascular risk factors compared with patients with obstructive coronary artery disease. Black, Maori, Pacific race, or Hispanic ethnicities are more frequently affected.

Systematic work-up of patients with myocardial infarction and non-obstructive coronary artery disease (MINOCA) using cardiac magnetic resonance imaging (CMR) led to a more than six-fold increase in the detection rate of myocarditis. In this study, we expanded on our prior two-year analysis by including preceding and subsequent years. A novel diagnostic algorithm led to an average 4.9-fold increase in the rate of myocarditis detection in our hospital over the two subsequent years. This highlights that myocarditis continues to be underdiagnosed when CMR is not systematically used in patients with MINOCA.

Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) represents a relatively new entity in cardiovascular medicine. According to the fourth universal definition of myocardial infarction MINOCA is characterised by typical chest pain with the appearance of ST segment elevation on the electrocardiogram (ECG) but without any significant stenotic lesions on coronary angiography. MINOCA is a working diagnose as there are several potential lethal diseases like pulmonary embolism, aortic dissection, perymiocarditis, etc., that can have similar clinical presentation. This is why MINOCA requires further investigations and the use of contemporary diagnostic methods in order to make a definite diagnosis. The most commonly used non-invasive diagnostic procedures are transthoracic and transoesophageal echocardiography, computed tomography and cardiac magnetic resonance imaging. Sometimes MINOCA is caused by prolonged coronary arteries spasm – vasospastic angina. This condition requires further instigations such administration of intracoronary acetylcholine. This case report is an example taken from everyday clinical practice. A young man had a typical chest pain with ST segment elevation on ECG and high troponin levels in the blood. After echocardiography and invasive diagnostic procedure, we came to the conclusion that patient suffered from primyocaridtis.

Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) represents a heterogeneous clinical conundrum accounting for about 6%–8% of all acute MI who are referred for coronary angiography. Current guidelines and consensus documents recommend that these patients are appropriately diagnosed, uncovering the causes of MINOCA, so that specific therapies can be prescribed. Indeed, there are a variety of causes that can result in this clinical condition, and for this reason diagnostic cardiac imaging has an emerging critical role in the assessment of patients with suspected or confirmed MINOCA. In last years, different cardiac imaging techniques have been evaluated in this context, and the comprehension of their strengths and limitations is of the utmost importance for their effective use in clinical practice. Moreover, recent evidence is clearly suggesting that a multimodality cardiac imaging approach, combining different techniques, seems to be crucial for a proper management of MINOCA. However, great variability still exists in clinical practice in the management of patients with suspected MINOCA, also depending on the availability of diagnostic tools and local expertise.

Myocardial infarction with non-obstructive coronary arteries in hypertrophic cardiomyopathy vs Fabry disease

Little is known about prevalence and predictors of myocardial infarction with non-obstructive coronary arteries (MINOCA) in Fabry disease (FD) and hypertrophic cardiomyopathy (HCM). We assessed and compared the prevalence and predictors of MINOCA in a large cohort of HCM and FD patients. MINOCA was rare in HCM patients, and 6-fold more frequent in FD patients. MINOCA may be considered a red flag for FD and aid in the differential diagnosis from HCM.

Imaging patients with myocardial infarction with non-obstructive coronary arteries (MINOCA)

Myocardial infarction with non-obstructive coronary arteries (MINOCA) defines a heterogeneous group of atherosclerotic and non-atherosclerotic conditions, causing myocardial injury in the absence of obstructive coronary artery disease. Unveiling the mechanisms subtended to the acute event is often challenging; a multimodality imaging approach is helpful to aid the diagnosis. Invasive coronary imaging with intravascular ultrasound or optical coherence tomography should be used, when available, during index angiography to detect plaque disruption or spontaneous coronary artery dissection. Cardiovascular magnetic resonance has instead a key role among the non-invasive modalities, allowing the differentiation between MINOCA and its non-ischaemic mimics and providing prognostic information. This educational paper will provide a comprehensive review of the strengths and limitations of each imaging modality in the evaluation of patients with a working diagnosis of MINOCA.

One-Year Prospective Follow-up of Women With INOCA and MINOCA at a Canadian Women’s Heart Centre

A total of 154 women with nonobstructive coronary artery disease were included in this study (112 patients with INOCA and 42 with MINOCA). Median age was 59 years, and the most common referral was for chest pain (94% in INOCA and 66% in MINOCA). At baseline, 64% of patients with INOCA and 43% of patients with MINOCA did not have specific diagnoses. Following investigations in the WHC, 71.4% of patients with INOCA established a new or a changed diagnosis (most common was coronary microvascular dysfunction at 68%), whereas 60% of patients with MINOCA established new or changed diagnoses (the most common of which was coronary vasospasm at 60%). At 1-year, participants had significantly decreased chest pain, improved quality of life, and improved mental health.

Invasive Functional Coronary Assessment in Myocardial Ischemia with Non-Obstructive Coronary Arteries: from Pathophysiological Mechanisms to Clinical Implications

Despite ischemic heart disease (IHD) has been commonly identified as the consequence of obstructive coronary artery disease (OCAD), a significant percentage of patients undergoing coronary angiography because of signs and/or symptoms of myocardial ischemia do not have any significant coronary artery stenosis. Several mechanisms other than coronary atherosclerosis, including coronary microvascular dysfunction (CMD), coronary endothelial dysfunction and epicardial coronary vasospasm, can determine myocardial ischemia or even myocardial infarction in the absence of flow-limiting epicardial coronary stenosis, highlighting the need of performing adjunctive diagnostic tests at the time of coronary angiography to achieve a correct diagnosis. This review provides updated evidence of the pathophysiologic mechanisms of myocardial ischemia with non-obstructive coronary arteries, focusing on the diagnostic and therapeutic implications of performing a comprehensive invasive functional evaluation consisting of the assessment of both vasodilation and vasoconstriction disorders. Moreover, performing a comprehensive invasive functional assessment may have important prognostic and therapeutic implications both in patients presenting with myocardial ischemia with non-obstructive coronary arteries (INOCA) or myocardial infarction with non-obstructive coronary arteries (MINOCA), as the implementation of a tailored patient management demonstrated to improve patient’s symptoms and prognosis. However, given the limited knowledge of myocardial ischaemia with non-obstructive coronary arteries, there are no specific therapeutic interventions for these patients, and further research is warranted aiming to elucidate the underlying mechanisms and risk factors and to develop personalized forms of treatment.

MINOCA: a heterogenous group of conditions associated with myocardial damage

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): A Review of the Current Position

Myocardial infarction with nonobstructive coronary arteries (MINOCA) remains a puzzling clinical entity that is characterized by clinical evidence of myocardial infarction (MI) with normal or near-normal coronary arteries on angiography (stenosis <50%). Major advances in understanding this condition have been made in recent years. The precise pathogenesis is poorly understood and is being studied and examined further. Guidelines indicate that MINOCA is a group of heterogeneous diseases with different mechanisms of pathology. Since there are multiple possible pathological mechanisms, it is not certain that the classical secondary prevention and treatment strategy for MI with obstructive coronary artery disease (MI-CAD) is optimal for MINOCA patients. The prognosis and predictors for MINOCA patients remain unclear. Although the prognosis is slightly better for MINOCA patients than for MI-CAD patients, MINOCA isn’t always benign. The aim of this paper was to review the literature and evaluate MINOCA epidemiology, clinical features, etiology, diagnosis, treatment, and prognosis.

Diagnostic pathways in myocardial infarction with non-obstructive coronary artery disease (MINOCA)

MINOCA: The caveat of absence of coronary obstruction in myocardial infarction

Whether patients with MINOCA (myocardial infarction with non-obstructive coronary arteries) have better outcomes than patients with obstructive coronary artery disease remains contradictory. The current study focussed on the clinical profile and prognosis of MINOCA patients. Patients with MINOCA show an ‘intermediate’ risk profile with mortality rates in between those of both ACS groups. Hence, MINOCA should be recognised as a potential risk factor for mortality, requiring adequate treatment and follow-up.

The aim of this study was to determine the prevalence of myocarditis among patients presenting with myocardial infarction with nonobstructive coronary arteries (MINOCA) in relation to the angiographic severity of non-obstructive coronary artery disease (CAD). BACKGROUND MINOCA represents about 6% of all cases of acute myocardial infarction. Myocarditis is a diagnosis that may be identified by cardiac magnetic resonance (CMR) imaging in patients with a provisional diagnosis of MINOCA. METHODS A systematic review was performed to identify studies reporting the results of CMR findings in MINOCA patients with nonobstructive CAD or normal coronary arteries. Study-level and individual patient data meta-analyses were performed using fixed- and random-effects methods. RESULTS Twenty-seven papers were included, with 2,921 patients with MINOCA; CMR findings were reported in 2,866 (98.1%). Myocarditis prevalence was 34.5% (95% confidence interval [CI]: 27.2% to 42.2%) overall and was numerically higher in studies that defined MINOCA as myocardial infarction with angiographicalty normal coronary arteries compared with a definition that permitted nonobstructive CAD (45.9% vs. 32.3%; p = 0.16). In a meta-analysis of individual patient data from 9 of the 27 studies, the pooled prevalence of CMR-confirmed myocarditis was greater in patients with angiographically normal coronary arteries than in those with nonobstructive CAD (51% [95% CI: 47% to 56%] vs. 23% [95% CI: 18% to 27%]; p < 0.001). Men and younger patients with MINOCA were more likely to have myocarditis. Angiographicatly normal coronary arteries were associated with increased odds of myocarditis after adjustment for age and sex (adjusted odds ratio: 2.30; 95% CI: 1.12 to 4.71; p = 0.023). CONCLUSIONS Patients with a provisional diagnosis of MINOCA are more likely to have CMR findings consistent with myocarditis if they have angiographically normal coronary arteries. (C) 2020 by the American College of Cardiology Foundation.

Myocardial infarction with non-obstructive coronary artery (MINOCA) disease represents a heterogeneous clinical conundrum accounting for about 6% of all acute myocardial infarction (MI) cases. Initially believed to be a benign condition, is now becoming clear that MINOCA is associated with a non-negligible risk of mortality, rehospitalization, disability and angina burden at follow-up, with high socioeconomic costs. To date, there are no prospective clinical trials in this population and cannot be assumed that benefits observed in patients suffering from MI with obstructive coronary artery disease may successfully translate to this syndrome. Herein, we comment on the importance of the multimodality assessment to properly identify and treat the specific causes of MINOCA, in order to improve prognosis and the quality of life in these patients.

A 56-year-old male with a past medical history significant for hypertension and hyperlipidemia presented to the emergency department with progressively worsening dry cough, shortness of breath, and non-exertional pleuritic chest pain associated with chills, nausea, vomiting, diarrhea, and generalized bodyache for 2 weeks, worsened over last 24 hours. On evaluation, was found to be hypotensive (BP 76/60 mmHg). Labs showed leukocytosis (17,900/uL, Ref: 4000 – 11,000/uL), creatinine 3.2 mg/dL (Ref: 0.60 – 1.10 mg/dL), lactate 5.8 mmol/L (Ref: 0.5 – 2.2 mmol/L), and troponin 0.65 ng/mL (Ref: <0.03 ng/mL) with no ischemic changes on the electrocardiogram (EKG). Imaging including CT chest showed right lower lobe pneumonia. The patient was resuscitated with aggressive fluids and was started on pressors and antibiotics for septic shock and multiorgan failure. Transthoracic echocardiogram (TTE) demonstrated moderately reduced LVEF 35-40% with hypokinetic inferolateral wall. Heparin was initiated for concern for non-ST elevation myocardial infarction (NSTEMI).

Acquired ventricular septal defect (VSD) is a life-threatening condition that occurred after a myocardial infarction (MI). The timing of the intervention remains very debated but it is crucial to choose the right surgical technique to obtain a stable and complete repair. Our report suggests that MI’s mechanical complications can occur even after a MINOCA.

The term Myocardial infarction with non-obstructive coronary arteries (MINOCA) is defined as a syndrome caused by different factors and it is responsible of myocardial ischemic necrosis. The MINOCA is characterised by the absence of significant lesions of the coronary arteries (stenosis <50%) when a coronary angiogram is performed. The coronary angiography has some limitations in the diagnosis of the atherosclerosis as a cause for MINOCA and therefore the use of invasive coronary imaging like the intravascular ultrasound (IVUS) and the optical coherence tomography (OCT), has shown to have a higher diagnostic potential. With this article we want to evaluate the fundamental role of the intra-coronary imaging in the diagnosis of MINOCA.

Dual antiplatelet therapy (DAPT) is a mainstay for myocardial infarction (MI) therapy. However, in patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA), clear recommendations are lacking in the literature. This study aims to identify the cases in which DAPT is currently prescribed at discharge for MINOCA.

MI with non-obstructive coronary arteries (MINOCA) is caused by a heterogeneous group of vascular or myocardial disorders. MINOCA occurs in 5–15% of patients presenting with acute ST-segment elevation MI or non-ST segment elevation MI and prognosis is impaired. The diagnosis of MINOCA is made during coronary angiography following acute MI, where there is no stenosis ≥50% present in an infarct-related epicardial artery and no overt systemic aetiology for the presentation. Accurate diagnosis and subsequent management require the appropriate utilisation of intravascular imaging, coronary function testing and subsequent imaging to assess for myocardial disorders without coronary involvement. Although plaque-related MINOCA is currently managed with empirical secondary prevention strategies, there remains an unmet therapeutic need for targeted and evidence-based therapy for MINOCA patients and increased awareness of the recommended diagnostic pathway.

When acute myocardial injury is found in a clinical setting suggestive of myocardial ischemia, the event is labeled as acute myocardial infarction (MI), and the absence of ≥50% coronary stenosis at angiography or greater leads to the working diagnosis of myocardial infarction with non-obstructed coronary arteries (MINOCA). Determining the mechanism of MINOCA and excluding other possible causes for cardiac troponin elevation has notable implications for tailoring secondary prevention measures aimed at improving the overall prognosis of acute MI. The aim of this review is to increase the awareness that establishing the underlying cause of a MINOCA is possible in the vast majority of cases, and that the proper classification of any MI should be pursued. The initial diagnosis of MINOCA can be confirmed or ruled out based on the results of subsequent investigations. Indeed, a comprehensive clinical evaluation at the time of presentation, followed by a dedicated diagnostic work-up, might lead to the identification of the pathophysiologic abnormality leading to MI in almost all cases initially labeled as MINOCA. When a specific cause of acute MI is identified, cardiologists are urged to transition from the “all-inclusive” term “MINOCA” to the proper classification of any MI, as evidence now exists that MINOCA does not provide conceptual clarity for actionable decision-making in MI with angiographically normal coronary arteries.

Studies about MINOCA

Multiparametric Stress Echocardiography in the Diagnosis of IOCA and INOCA: Role of CFVR Measurement

Contemporary Diagnosis and Management of Patients with MINOCA

Clinical characteristics and prognosis of myocardial infarction with non-obstructive coronary arteries: A prospective single-center study

Early-onset MINOCA: Prognostic implications and considerations for practice

Role of cardiac CT in the diagnostic evaluation and risk stratification of patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): rationale and design of the MINOCA-GR study

Myocardial Infarction with Non-Obstructive Coronary Arteries: A Puzzle in Search of a Solution

Contemporary and future invasive coronary vasomotor function testing and treatment in patients with ischaemia with no obstructive coronary arteries

Diagnostic pathways in myocardial infarction with non-obstructive coronary artery disease (MINOCA)

Clinical presentation and management of myocardial infarction with nonobstructive coronary arteries (MINOCA): A literature review

The Role of Cardiac Magnetic Resonance in Myocardial Infarction and Non-obstructive Coronary Arteries

MINOCA: a heterogenous group of conditions associated with myocardial damage

Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association

MINOCA: Pathogenesis, diagnosis, clinical management and evolution towards precision medicine

Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women

New chapter: INOCA-MINOCA from diagnosis to treatment

Myocardial infarction, MINOCA: new definitions and recommandations

MINOCA in a Patient with Sickle Cell Disease

Population-level incidence and outcomes of myocardial infarction with non-obstructive coronary arteries (MINOCA): Insights from the Alberta contemporary acute coronary syndrome patients invasive treatment strategies (COAPT) study

Frequently asked questions about the new troponin assay

Early Comprehensive Cardiovascular Magnetic Resonance Imaging in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries

Randomized evaluation of beta blocker and ACE-inhibitor/angiotensin receptor blocker treatment in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA-BAT): Rationale and design

Diagnostic and Prognostic Role of Cardiac Magnetic Resonance in MINOCA: Systematic Review and Meta-Analysis

Updates on MINOCA and INOCA through the 2022 publications in the International Journal of Cardiology

Management of myocardial infarction with Nonobstructive Coronary Arteries (MINOCA): a subset of acute coronary syndrome patients

Early-onset MINOCA: Prognostic implications and considerations for practice

Myocardial infarction with non-obstructive coronary artery disease

Why names matter for women: MINOCA/INOCA (myocardial infarction/ischemia and no obstructive coronary artery disease)

Diagnosis and Management of MINOCA Patients

OCT and CMR for the Diagnosis of Patients Presenting With MINOCA and Suspected Epicardial Causes

Guidelines for the management of myocardial infarction/injury with non-obstructive coronary arteries (MINOCA): a position paper from the Dutch ACS working group

Arterial hypertension as a risk factor for myocardial infarction with non-obstructive coronary arteries (MINOCA)

Rapid Identification of MINOCA Based on Novel Biomarkers

MINOCA and spontaneous dissection: diagnosis and therapy

Systematic use of cardiac magnetic resonance imaging in MINOCA led to a five-fold increase in the detection rate of myocarditis: a retrospective study

Perimyocarditis versus Myocardial Infarction with ST Segment Elevation-MINOCA as a Starting Point

The evolving role of cardiac imaging in patients with myocardial infarction and non-obstructive coronary arteries

Myocardial infarction with non-obstructive coronary arteries in hypertrophic cardiomyopathy vs Fabry disease

Imaging patients with myocardial infarction with non-obstructive coronary arteries (MINOCA)

One-Year Prospective Follow-up of Women With INOCA and MINOCA at a Canadian Women’s Heart Centre

Invasive Functional Coronary Assessment in Myocardial Ischemia with Non-Obstructive Coronary Arteries: from Pathophysiological Mechanisms to Clinical Implications

MINOCA: a heterogenous group of conditions associated with myocardial damage

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): A Review of the Current Position

Diagnostic pathways in myocardial infarction with non-obstructive coronary artery disease (MINOCA)

MINOCA: The caveat of absence of coronary obstruction in myocardial infarction

Myocarditis in Relation to Angiographic Findings in Patients With Provisional Diagnoses of MINOCA

Diagnostic work-up and therapeutic implications in MINOCA: need for a personalized approach

A UNIQUE CASE OF MYOCARDIAL INFARCTION WITH NON-OBSTRUCTIVE CORONARY ARTERIES (MINOCA)

Successful early surgical treatment of a post-MINOCA ventricular septal defect

The role of IVUS and OCT in the patients with Myocardial infarction with non-obstructive coronary arteries (MINOCA)

Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease – insights from a nationwide registry

What an Interventionalist Needs to Know About MI with Non-obstructive Coronary Arteries

Why the Term MINOCA Does Not Provide Conceptual Clarity for Actionable Decision-Making in Patients with Myocardial Infarction with No Obstructive Coronary Artery Disease