Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions

Abstract

Acute coronary syndromes constitute a variety of myocardial injury presentations that include a subset of patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA). This acute coronary syndrome differs from type 1 myocardial infarction (MI) regarding patient characteristics, presentation, physiopathology, management, treatment, and prognosis. Two-thirds of MINOCA subjects present ST-segment elevation; MINOCA patients are younger, are more often female and tend to have fewer cardiovascular risk factors. Moreover, MINOCA is a working diagnosis, and defining the aetiologic mechanism is relevant because it affects patient care and prognosis. In the absence of relevant coronary artery disease, myocardial ischaemia might be triggered by an acute event in epicardial coronary arteries, coronary microcirculation, or both. Epicardial causes of MINOCA include coronary plaque disruption, coronary dissection, and coronary spasm. Microvascular MINOCA mechanisms involve microvascular coronary spasm, takotsubo syndrome (TTS), myocarditis, and coronary thromboembolism. Coronary angiography with non-significant coronary stenosis and left ventriculography are first-line tests in the differential study of MINOCA patients. The diagnostic arsenal includes invasive and non-invasive techniques. Medical history and echocardiography can help indicate vasospasm or thrombosis, if one finite coronary territory is affected, or specify TTS if apical ballooning is present. Intravascular ultrasound, optical coherence tomography, and provocative testing are encouraged. Cardiac magnetic resonance is a cornerstone in myocarditis diagnosis. MINOCA is not a benign diagnosis, and its polymorphic forms differ in prognosis. MINOCA care varies across centres, and future multi-centre clinical trials with standardized criteria may have a positive impact on defining optimal cardiovascular care for MINOCA patients.

Acute myocardial injury after administration of intravenous epinephrine for allergic reaction

“…Mechanisms of microvascular myocardial infarction with non-obstructive coronary arteries involve microvascular coronary spasm, Takotsubo syndrome, myocarditis, and coronary thromboembolism. 9 We believe this temporal relationship is more in favor of epinephrine as the cause of chest pain and myocardial injury rather than Kounis syndrome since the patient was treated for anaphylaxis in a previous admission with antihistamines, and her chest pain did not begin until after administration of epinephrine. The patient denied chest pain with her allergic symptoms, and the nature of the chest pain changed dramatically after the administration of epinephrine into a “sharp, pressing” pain.…”

Association Between Obstructive Sleep Apnea-Hypopnea Syndrome and Outcomes in Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease

“…km area and serves about six million residents. MINOCA was diagnosed with the following criteria in line with a position paper of European Society on cardiology: (1) the diagnostic criteria involving the Fourth Universal Definition of Myocardial Infarction criteria; (2) coronary angiography with no artery lesions ≥ 50% in any infarct-related artery; (3) no other clinically overt specific cause that can explain acute presentation (22). The exclusion criteria were extremely strict in the present study: (1) mimic myocardial infarction, such as sepsis, pulmonary embolism, cardiac contusion, overlooked obstructive CAD, coronary emboli/thrombus, Takotsubo syndrome, and myocarditis (4); (2) cognitive disorder or mental confusion;…”

“…Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) is a distinct entity with multiple causes defined by acute presentation of myocardial infarction with no remarkable stenosis of coronary artery on coronary angiography (stenosis < 50%) (1)(2)(3). In June 2019, the American Heart Association (AHA) has systematically described recommendations for contemporary diagnosis and management of MINOCA, and they have broadened our horizon to understand this heterogeneous disease (4).…”

Association Between Obstructive Sleep Apnea-Hypopnea Syndrome and Outcomes in Patients with Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease

“…Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) is a distinct entity with multiple causes defined by acute presentation of myocardial infarction with no remarkable stenosis of coronary artery on coronary angiography (stenosis < 50%). [1][2][3] In June 2019, the American Heart Association (AHA) has systematically described recommendations for contemporary diagnosis and management of MINOCA, and they have broadened our horizon to understand this heterogeneous disease. 4 More than 660000 percutaneous coronary intervention (PCI) procedures were performed in China in 2017, and approximately 10% of emergency coronary angiography results showed the absence of evident obstructive coronary stenosis.…”