Myocardial Infarction with Nonobstructive Coronary Arteries

Aka: Myocardial Infarction with Nonobstructive Coronary Arteries, MINOCA

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II. Definitions

  1. Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA)
    1. Term first assigned in 2013 to describe a common Coronary Angiography finding
    2. Positive biomarkers and MI findings with <50% coronary stenosis on angiography, and no alternative diagnosis

III. Epidemiology

  1. MINOCA accounts for 15% of Myocardial Infarctions
  2. Female predominance (RR 5)
  3. Younger patients (mean age 61 years old)
  4. Ethnicity: More common in black and hispanic patients

IV. Findings

  1. NSTEMI in 70-80% of cases
  2. Often lack typical CAD risk factors (e.g. Hypertension, Hyperlipidemia)
    1. However, many MINOCA patients do have Diabetes Mellitus or Obesity

V. Diagnosis: Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA)

  1. Positive cardiac biomarkers (e.g. Troponin) AND
  2. Clinical evidence of Myocardial Infarction AND
  3. No significant epicardial Coronary Artery stenosis on coronary angiogram (<50%) AND
  4. No alternative diagnosis for the MI presentation

VI. Causes

  1. Coronary Artery Plaque Disruption
  2. Coronary Artery embolism or thrombosis
  3. Coronary Artery Vasospasm
  4. Coronary Microvascular Dysfunction
  5. Spontaneous Coronary Artery Dissection (SCAD)

VII. Differential Diagnosis

  1. Takotsubo Cardiomyopathy
  2. Myocarditis
  3. Nonischemic Cardiomyopathy

VIII. Management

  1. See Takotsubo Cardiomyopathy
  2. See Spontaneous Coronary Artery Dissection
  3. See Myocarditis
  4. See Coronary Artery Vasospasm
  5. General Measures
    1. Treat based on underlying cause
    2. Tobacco Cessation
    3. Cardiac Rehabilitation
    4. Avoid stimulants (e.g. Cocaine, Methamphetamines, pseudophedrine)
    5. Avoid other triggering medications (e.g. Triptans)
  6. Coronary Artery Plaque Disruption is treated in similar way to obstructive coronary disease (but without stenting)
    1. Aspirin (or Dual Antiplatelet Therapy)
    2. High Intensity Statin
  7. Left Ventricular Dysfunction
    1. See Heart Failure
    2. Beta Blockers
    3. ACE Inhibitors or Angiotensin Receptor Blockers
  8. Coronary embolism or thrombosis
    1. Antithrombotic agents (Anticoagulation)
    2. Address underlying mechanisms for Thrombophilia
  9. Coronary Microvascular Dysfunction
    1. Beta Blockers or Calcium Channel Blockers
    2. Long Acting Nitrates
    3. Consider Ranolazine as second-line agent

IX. References

  1. Yildiz (2022) Front Cardiovasc Med 9:1032436 +PMID: 36457805 [PubMed]

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