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

Abstract

Patients with myocardial infarction and nonobstructive 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.

Dilemma of Interpretation of High Sensitivity Troponin in Non-ST Elevated Myocardial Infarction

“…Acute coronary syndrome with normal or near normal coronary arteries (ACSNNOCA) commonly known as Myocardial Infarction/Injury with Non-obstructive Coronary Arteries (MINOCA) also known as Troponin positive non obstructive coronary artery (TP-NOCA), can be caused by etiologies of coronary disorders, myocardial disorders or non-cardiac disorders. [1][2][3] These etiologies include coronary spasm, microvascular dysfunction, myocarditis, hypertensive heart disease, stroke, sepsis, pulmonary embolism in addition to others. Moreover, these diseases overlap with type 2 myocardial infarction.…”

“…Moreover, these diseases overlap with type 2 myocardial infarction. [1,4] Therefore, the challenge arises in making a decision whether the patient is suffering a myocardial injury, ischemia or infarction requiring intervention. [1] These challenging situations have increased currently with the introduction of high sensitivity cardiac troponin assay in view of its low speci city.…”

“…[1,4] Therefore, the challenge arises in making a decision whether the patient is suffering a myocardial injury, ischemia or infarction requiring intervention. [1] These challenging situations have increased currently with the introduction of high sensitivity cardiac troponin assay in view of its low speci city. [1] In a review article by Pasupathy et al the prevalence of MINOCA was reported as 6%, ranging from 1-15%.…”

“…[1] These challenging situations have increased currently with the introduction of high sensitivity cardiac troponin assay in view of its low speci city. [1] In a review article by Pasupathy et al the prevalence of MINOCA was reported as 6%, ranging from 1-15%. Moreover, 14% of patients with acute myocardial infarction have been found to have non-obstructive coronary artery disease de ned as coronary stenosis of less than 50%.…”

“…Research has shown that two third of patient with MOINCA present and are admitted as Non-ST Elevation Myocardial Infarction (NSTEMI). [1,3] Risk strati cation in patients with NSTEMI is of extreme importance especially since multiple scores have been developed; Thrombolysis in Myocardial Infarction score (TIMI), HEART score and Global Registry of Acute Coronary Events (GRACE). [4] Moreover, risk strati cation is emphasized as VIRGO study found the prevalence of MINOCA to be ve times more in women than men and in patients with lower traditional cardiac risk factors and by another study which found MINOCA to be higher in younger patients.…”