Cardiac Fibroblastoma Presenting as NSTEMI.

Background MINOCA's physiopathology, treatment and prognosis are yet to be completely understood. The aim of this study is to compare baseline characteristics and prognosis of MINOCA patients and those of patients with myocardial infarction (MI) and obstructive coronary arteries. Methods We analysed all consecutive patients with MI who underwent coronary angiography admitted in a University Hospital covering a population of 220.000 people during a period of 60 months. The database and the all the patient's angiographies were revised by a group of experts in order to adequate MINOCA to 2020 ESC Guidelines definition and the American Heart Association position paper. Results 680 patients, 68 of whom were MINOCA (10%) with a median of follow up of 31±16 months were analysed (see table 1). We found no differences in both groups' age. Female gender was more prevalent among MINOCA patients. The underlying mechanism in MINOCA was coronary spasm (17.6%), plaque rupture (13.2%), coronary embolism (7.4%), coronary dissection (2.9%), type II infarction (19.1%) or unknown (39.7%). Coronary arteries in MINOCA patients had no obstructions at all in 57.4%, and 30–50% obstruction in 42.6% of the cases. MINOCA patients didn't have higher prevalence of cancer, autoimmune or psychiatric diseases, dyslipidaemia, hypertension or inflammatory analytical parameters. However, we found significant differences in atrial fibrillation, migraine, connective tissue diseases, tobacco use and diabetes. We found no effect of stress in the development of MINOCA (measured with validated STAI and DS-14 scales). Symptoms at admission didn't differ between the two groups, but those with MINOCA had normal ECG more frequently. Prognosis showed relevant differences, as MINOCA patients had less major cardiovascular complications, such as inotropic requirements (0% Vs 4.8%, p=0.04), shock (0% vs 6.6%, p=0.013) and left ventricular dysfunction (11.8 vs 30.2, p=0.015). Furthermore, myocardial injury biomarkers' levels were, significantly lower in MINOCA patients. Death rates tend to be lower both in hospital (0% vs 3.1%, p=0.131) and during follow up (9.1% vs 11.5%, p=0.369). Conclusion Analysing MINOCA patients' clinical profile might help us understanding the underlying physiopathology, prognosis and treatment targets. In these patients, classic cardiovascular risk factors don't appear to be as important as in obstructive patients. At admission, we found no clinical differences that could help making an early diagnosis, even if those with normal ECG and lower levels of myocardial injury biomarkers are more likely to have non-obstructive coronary arteries. These patients seem to have better prognosis and lower myocardial injury than those with obstructive coronary arteries. Further research is needed to provide more evidence on the accurate treatment of these patients. Funding Acknowledgement Type of funding sources: None.

Over the past few years, much attention has been paid to the diagnosis and treatment of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA). Its prevalence achieves 5 — 15 %, and impact of risk factors of cardiovascular disease development on the MINOCA onset has some specific features. The following criteria are required to diagnose MINOCA: compliance with the MI criteria, absence of obstructive coronary artery disease (≥ 50 %) and exclusion of an alternative diagnosis. Myocardial ischemia is the underlying cause of cardiomyocyte damage during MINOCA. It can be caused by coronary artery thrombosis due to the rupture of atherosclerotic plaque (type 1 MI), spasm or spontaneous coronary artery dissection (type 2 MI). The aim of our study was to analyse risk factors and the incidence of MINOCA in patients with acute myocardial infarction. A retrospective analysis has been performed on 1358 histories of patients with MI who were hospitalized in Dnipropetrovsk Regional Clinical Center of Cardiology and Cardiac Surgery during the period of 2019 — 2020 years. From them, 60 (4.4 %) patients were selected based on MINOCA diagnostic criteria according to the European Society of Cardiology (2018). The mean age of patients was 58.6 ± 14 years. ST‑segment elevation MI (STEMI) was diagnosed in 87.2 %. Cardiac and non‑cardiac comorbidity has been investigated with the following results: atrial fibrillation (AF) was revealed in 13.3 % of patients, hypertension (AH) — in 85 %, history of coronary heart disease (CHD) — in 31.7 %, recurrent MI — in 11.7 %, chronic heart failure (CHF) — in 75 %, atherosclerosis of peripheral arteries — in 33.3 %, type 2 diabetes mellitus (DM 2) — in 20 %, obesity — in 40.7 %. The proportion of smokers was 43.8 %. According to the results of laboratory studies, dyslipidemia was diagnosed in 44.7 % of patients. According to coronary angiography, 55 % of patients had no coronary artery stenosis, 21.7 % had stenosis of one artery, and stenosis of two or more arteries was defined in 23.3 % of cases. The following distribution by lesions’ types was established: irregularities in the contours of arteries or stenosis up to 30 % in 35 % of cases; stenosis ≥ 30 < 50 % in 18.3 %, and slow evacuation of the contrast agent in 16.7 % of cases. Men prevailed in our research, which is inconsistent with the data of large observational studies, probably due to a small quantity of patients. Hypertension, chronic heart failure, tobacco smoking, obesity and dyslipidemia prevailed among the basic risk factors. Patients with MINOCA require careful evaluation to determine the causative agent and appropriate treatment choices. Conduction of large‑scale studies, in particular, randomized controlled observations, is reasonable and necessary to determine the optimal tactics for management patients with MINOCA.

Introduction Genetic factors play an important role in the development of myocardial infarction (MI), and a positive family history is a risk factor for MI. The significance of family history among patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is not known, and previous studies of family history in MI have not made a distinction between MINOCA and MI due to coronary artery disease (MI-CAD) based on angiographic findings. Purpose To investigate family history of MI with and without obstructive coronary arteries in patients with a working diagnosis of MINOCA. Methods A nationwide register-based case-control study of 15 462 MINOCA cases and 38 220 controls without MI with a non-obstructive coronary angiography due to chest pain, together with 204 424 MI-CAD cases, defined as MI with obstructive coronary arteries with a degree of stenosis >50%, between the years 1995-2020. Data from the Swedish coronary angiography and angioplasty register with information about angiographic findings was merged with information on first-degree relatives from the Swedish multi-generation register. Odds ratio (OR) was calculated with a 95% confidence interval (CI), to analyze the probability of MINOCA patients having first-degree relatives with 1) MINOCA, 2) MI-CAD, and 3) MI-CAD patients having first-degree relatives with MI-CAD. Logistic regression models adjusted for age, sex, hypertension, diabetes, hyperlipidemia and smoking status. Results A total of 161 MINOCA patients (1%) had ≥1 first-degree relative with MINOCA and the probability of having a positive family history of MINOCA did not differ compared to controls, with age and sex adjusted OR 1.08 (95% CI 0.89-1.31) and when adjusting for all covariates 1.08 (95% CI 0.87-1.34). Conversely, 1436 MINOCA patients (9%) had ≥1 first-degree relative with MI-CAD and the probability of having a positive family history of MI-CAD was higher compared to controls with age and sex adjusted OR 1.12 (95% CI 1.05-1.20) and when adjusting for all covariates OR 1.16 (95% CI 1.04-1.20). The sensitivity analysis showed that 24 972 MI-CAD (9%) patients had a positive family history of MI-CAD compared to controls, OR adjusted for age and sex 1.68 (95% CI 1.61-1.75), and OR adjusted for all covariates 1.68 (95% CI 1.60-1.75). Conclusions In this first study that examines family history of MINOCA, including data from over 250 000 coronary angiograms, a positive family history of MI-CAD was more common among patients with a working diagnosis of MINOCA compared to controls without MI and with non-obstructive coronary arteries. A family history of MINOCA was uncommon and was not associated with MINOCA. These results indicate that genetic factors and shared environmental factors within a family leading to CAD are important also for MINOCA, thus MI-CAD and MINOCA share underlying mechanisms.

Myocardial infarction with non-obstructive coronary arteries (MINOCAs) affects about 15% of patients diagnosed with myocardial infarction (MI). Patients with MINOCA often lack significant cardiac risk factors such as diabetes mellitus, cigarette smoking, and hypertension. Notable, MINOCA is common among female individuals, often occurring in younger women. This highlights the importance of considering MINOCA in women presenting with symptoms suggestive of MI, even in the absence of conventional risk factors. Precisely, MINOCA is not a distinct disease entity but rather a working diagnosis which necessitates further evaluation. MINOCA results from a heterogeneous group of conditions that ultimately result in ischemic injury to the myocardium and causes can be cardiac (e.g., coronary embolism) or non-cardiac (e.g., sepsis). Diagnosis involves coronary angiography to rule out obstructive coronary artery disease (CAD) and transesophageal echocardiography for the assessment of regional wall motion abnormalities. Cardiovascular magnetic resonance imaging can be performed to rule out acute myocarditis or takotsubo cardiomyopathy, which is non-ischemic cause of myocardial injury in MINOCA. Management of MINOCA is specific to the underlying cause and usually influenced by the degree of myocardial damage, and the prognosis is variable and depends largely on the underlying etiology. While some studies suggest that MINOCA patients may have a better short-term prognosis compared to those with MI and obstructive CAD, they still face a significant risk of long-term adverse cardiovascular events, including recurrent MI, heart failure, stroke, and death. Identifying the specific causes of MINOCA is crucial for accurate risk stratification and tailored management to improve patient outcomes.

Background Approximately 10% of patients with acute myocardial infarction do not have a culprit lesion. Such patients have been labelled as MINOCA (myocardial infarction with non-obstructive coronary arteries) and several pathophysiological etiologies have been described as potential explanations. This includes spontaneous coronary dissection, tako-tsubo-syndrome and coronary spasm. The latter can be diagnosed during invasive provocative testing. The aim of this study was to assess the frequency of coronary spasm and the safety of intracoronary provocation testing using acetylcholine in MINOCA patients compared to patients with stable angina and unobstructed coronary arteries. Methods Between 2007 and 2018 180 consecutive patients with either MINOCA or stable angina and unobstructed coronary arteries were enrolled. MINOCA was defined as acute onset of chest pain with either ST-segment elevation on the ECG or significant high sensitive troponin T elevation but no relevant epicardial stenosis (<50%) according to the current ESC guidelines. All patients underwent intracoronary acetylcholine provocation testing (ACH-test) in search of coronary spasm according to a standardized protocol immediately after diagnostic coronary angiography. Apart from systematic assessment of clinical, demographic and risk factor data, data regarding complications during the ACH-test were meticulously recorded. Results Eighty patients with MINOCA and 100 consecutive patients with stable angina were recruited (52% women, mean age 62±13 years). Overall, 59% had hypertension and 20% had diabetes. Comparison of clinical, demographic and risk factor data did not reveal any statistically significant differences except for a female preponderance in the stable patients (61% vs. 40%, p=0.007). The ACH-test revealed a coronary vasomotor disorder in 68% of cases. In 32% of cases the ACH-test was either inconclusive or negative. Epicardial spasm was found in 31% of patients with a higher prevalence among the MINOCA patients compared to the stable angina patients (41% vs. 23%, p=0.002). Microvascular spasm was found in 37% with a higher prevalence among the stable angina patients compared to the MINOCA cohort (49% vs. 23%, p=0.002). Assessment of complications during the ACH-test revealed that 13 MINOCA patients and 15 stable angina patients had minor complications such as intermittent atrioventricular block, sinusbradycardia, paroxysmal atrial fibrillation, ventricular ectopic beats or transient hypotension. Comparison of minor complications between the two groups did not reveal statistically significant differences (16% vs. 15%, p=0.839). None of the patients experienced any irreversible complications. Conclusion Coronary spasm is a frequent cause for MINOCA. Intracoronary spasm provocation testing using acetylcholine is feasible in such patients. The complication rate during ACH-testing in MINOCA patients is low and comparable to patients with stable angina. Acknowledgement/Funding Berthold-Leibinger-Foundation, Ditzingen, Germany

Aims Myocardial infarction with non-obstructive coronary arteries (MINOCA) is characterized by myocardial infarction features, troponin elevation, and coronary arteries with <50% stenosis. Over recent years, the concept of MINOCA has evolved into an umbrella term encompassing various mechanisms, rather than a single definitive diagnosis. It involves both coronary and non-coronary causes. This study aims to explore biomarker differences among these etiologies, proposing that inflammation-related biomarkers could provide a more precise approach to differentiating between them, thereby improving diagnosis and reducing mis/underdiagnosis. Currently, these biomarkers have not been specifically studied for each MINOCA etiology, but rather in a broader context. Methods This observational study included 72 MINOCA patients from a University Hospital between 2021-2023. According to ESC guidelines, MINOCA subtypes were classified as Takotsubo syndrome, myocarditis, ischemic MINOCA, type II-MINOCA, or undefined-MINOCA. IL-6, TNF-α, hs-CRP, CK and hs-troponin T levels were measured at admission, discharge, and two months later. Biomarker associations with MINOCA subtypes were evaluated using unadjusted and age- and sex-adjusted logistic regression models, with significance set at p<0.10 due sample size limitations. Results Among the 72 patients included, 17 were classified as ischemic MINOCA, 13 as type II-MINOCA, 10 as myocarditis, 8 as Takotsubo, and 24 as unknown origin. The mean age was 63 years, with 52% of patients being male. Comparing the characteristics of the five subgroups, type II-MINOCA was more common in older patients, while myocarditis was more prevalent in younger patients. The percentage of males was similar across all subtypes. Myocarditis patients had the highest peak levels of hs-Troponin T and CK at admission compared to other MINOCA groups. In Takotsubo syndrome, TNFα levels were the highest at admission. Regression models showed significant associations (see Table 1): At admission, higher IL-6, TNF-α, and hs-TnT levels were associated with Takotsubo syndrome (OR 1.7, OR 3.5, and OR 2.07, respectively). Myocarditis patients had elevated hs-Troponin T and CK levels (OR 2.04 and OR 3.57, respectively). The unknown group showed lower IL-6 and hs-Troponin T levels (OR 0.65 and OR 0.62, respectively), while ischemic MINOCA had lower TNF-α levels (OR 0.37). Type II-MINOCA was associated with higher hs-CRP and TNF-α levels at discharge (OR 1.57 and OR 6.13, respectively). No biomarker differences were observed during follow-up, except for type II-MINOCA, which continued to show elevated TNF-α levels (OR 3.06). See Figure 1. Conclusion This study identifies distinct biomarker profiles for different MINOCA subtypes, which may serve as key targets for future research, and provides important insights for subtype differentiation and diagnostic support.Tab1.Biomarkers' associations-subtypes Fig1.Biomarker levels in MINOCA subtypes

ObjectiveApproximately 10% of patients with myocardial infarction (MI) have no obstructive coronary artery disease. The prognosis and role of intensified antiplatelet therapy in those patients were evaluated.MethodsWe analysed data from...

This study sought to identify parameters that could guide towards an ischemic origin in patients hospitalized for myocardial infarction (MI) withnon-obstructivecoronary arteries (MINOCA). MINOCA is challenging in clinical practice, as the pathophysiology is multifaceted. A total of 135 patients with MINOCA who underwent cardiovascular magnetic resonance imaging (CMR) in a single tertiary University Hospital, were retrospectively included. The study cohort was classified into 4 groups according to theCMRdiagnosis (i.e., myocarditis, myocardial infarction, Takotsubo cardiomyopathy, normal or uncommon diagnosis). According to the CMR, 62% had myocarditis, 14.1% myocardial infarction, 4.4% of Takotsubo and 19.3% showed a normal CMR or uncommon diagnoses. In the multivariate analysis, three criteria were independently correlated with the underlying diagnosis of myocardial infarction: (1) the absence ofinflammatory response (HR: 5.71 IC95% [1.79-18.28]; p = 0.002), (2) the presence of coronary atheroma in invasive coronary angiography (HR: 6.56 IC95% [2.27-18.92]; p = 0.001) and (3) a peak of troponinratioelevated than normal levels of 150(HR: 4.12 IC95% [1.45-11.65]; p = 0.01). The prevalence of myocardial infarction in MINOCA was 4.9% in the absence of these three criteria, 3.4% with one of the criteria present, 34.5% with two criteria presentand 71.4% with all three criteria.The negative predictive value for MI was 96% in the presence of at least two criteria. Our study shows that the absence of inflammatory response, a high troponin and the presence of angiographic coronary atheroma are independently correlated with a myocardial infarction underlying cause of MINOCA.

Funding Acknowledgements Type of funding sources: None. Background and purpose Although cardiac rehabilitation (CR) after myocardial infarction (MI) has been proven to be beneficial, only a minority of patients participate. This study was performed to gain more knowledge about referral and participation rates for CR in patients with myocardial infarction with Nonobstructive Coronary Arteries(MINOCA). Methods All patients meeting the diagnostic MINOCA criteria and admitted between January 2017 and April 2019 were retrospectively analysed. They were divided into the 1) ‘Conclusive MINOCA’ (confirmed MI, (peri)myocarditis, cardiomyopathy, or miscellaneous) and 2) ‘Indeterminate MINOCA’ group. Patients who died in hospital were excluded. Referral and participation in CR was verified. Results Of the 196 included MINOCA patients, 110 (56%) were female and the mean age was 60±13.7 years. 62 Patients(31.6%) had conclusive MINOCA and 134 patients (68.4%) had indeterminate MINOCA. In Figure 1 the distribution of CR referral and participation is shown. Figure 2 shows the referral and participation rates for conclusive and indeterminate MINOCA patients. Conclusive MINOCA patients were more likely to be referred(79.0% vs. 61.9%, p=0.018) and participated more often in CR (45.2% vs. 26.1%, p=0.008). This relation was even stronger when confirmed MI was the final diagnosis as compared to the other MINOCA patients (referral91.3% vs. 64.2%, p=0.009; participation 69.6% vs. 27.2%, p<0.001). Conclusion Only one-third of MINOCA patients participate in CR. Referral and participation rates were significantly higher in MINOCA with confirmed underlying diagnosis (especially confirmed MI) as compared to MINOCA with indeterminate diagnosis. MINOCA patients should be more often referred to CR with a focus on MINOCA with indeterminate underlying diagnosis.

Introduction Myocardial infarction with non-obstructed coronary arteries (MINOCA) may occur in patients with a personal history of ischaemic heart disease, making diagnosis even more difficult. In addition, the role of cardiovascular risk factors, which are well known in patients with acute myocardial infarction with obstructed arteries (MICAD), is less well defined in MINOCA. The aim of this study is to define the clinical characteristics, risk factors and long-term prognosis in patients with MINOCA and previous acute coronary syndrome (ACS). Methods A prospective, analytical, observational study was designed. Included all patients admitted to our centre with ACS between 2016 and 2023 in which a coronary angiography was performed. Patients were classified as MINOCA according to the definition of the 2020 European ACS guidelines. MINOCA patients with and without a history of previous ischaemic heart disease were compared. At follow-up, MACE was defined as all-cause death, hospitalisation, reinfarction and stroke. The median follow-up was 43 [IQR 20-71]. Results A total of 136 patients were included, of whom 17 had a history of ACS. The proportion of men was significantly higher in the group with previous ACS (82% vs 48%; p=0.008). Patients with a history of ACS had higher rates of smoking (71% vs 51%, p=0.139), more night work (80% vs 39%, p=0.017) and less stress (33% vs 61%, p=0.152). They also had more peripheral vascular disease (24% vs 3%, p=0.005), diabetes (41% vs 19%, p=0.042), dyslipidaemia (71% vs 43%, p=0.04) and a higher rate of atrial fibrillation (29% vs 9%, p=0.032). However, despite a higher rate of previous ventricular dysfunction (24% vs 3%, p=0.005), they had lower troponin levels on admission (62 [IQR 37-368] vs 152 [IQR 49-424]). We found no differences in the other comorbidities analysed (Table 1). On admission, patients with previous ACS had significantly more non-ST-segment elevation (29% vs 10%, P=0.05) and received more beta-blocker treatment (82% vs 57%, p=0.046). When analysing the mechanism of infarction, patients without previous ACS were more likely to have vasospasm and coronary embolism. However, there was a significantly higher rate of type II AMI (41% vs 18%, p=0.044) in the group with previous ACS. During follow-up, patients with a history of ACS are more likely to have a new infarction (7% vs 3%, p=0.3) or stroke (14% vs 6%, p=0.2). There was also a trend towards a higher incidence of MACE in patients with prior ACS, although this did not reach statistical significance (HR 2.379, 95% IC 0,883-6,405) (Table 2). Conclusion MINOCA patients with a history of ACS have distinct and worse epidemiological features in which classic cardiovascular risk factors play a significant role, with more ventricular dysfunction and atrial fibrillation. In addition, they appear to have a worse prognosis with increased cardiovascular complications. That might suggest a more MICAD-like profile.

The term MINOCA (myocardial infarction with non-obstructive coronary arteries) defines acute myocardial infarction with angiographic evidence of no significant coronary artery stenosis. Heterogeneous diseases are labelled as MINOCA. Incidence and epidemiological aspects differ on the basis of etiological causes. MINOCA include plaque (causing <50% stenosis) rupture or erosion, coronary embolism and dissection, and coronary artery spasm. Diagnosis may require multiple diagnostic tools, including cardiac imaging or provocative tests, in addition to standard coronary angiography, according to clinical suspicion. Cardiac magnetic resonance plays a key role in confirming the diagnosis and excluding other diseases with similar clinical presentation. Prognosis is not as benign as previously thought, on the opposite it is characterized by morbidity and mortality rates similar to other forms of myocardial infarction. Once the causative mechanism has been identified, appropriate therapy can be delivered.

Myocardial infarction with nonobstructive coronary artery (MINOCA) is a heterogeneous disease with different pathophysiological mechanisms and prognosis. In recent years, it has been found that the incidence of major cardiovascular adverse events in MINOCA is similar to that of myocardial infarction with coronary artery disease (MI-CAD), and it is difficult to clarify the pathogenesis of both through coronary angiography (CAG). Therefore, the aim of this study is to investigate the clinical features, plaque characteristics and prognosis of patients with MINOCA and MI-CAD through optical coherence tomography (OCT). A total of 553 culprit lesions from AMI patients who underwent CAG and OCT were retrospectively analysed. Patients were subsequently divided into two groups: the MINOCA group and the MI-CAD group. The clinical characteristics, plaque characteristics and prognosis of the two groups were compared. The primary endpoint was defined as a composite of major adverse cardiac events (MACE), including cardiac death, non-fatal myocardial infarction, target lesion revascularization, stroke, and rehospitalisation for angina or heart failure. (1) Patients with MINOCA exhibited a lower incidence of ST-segment elevated myocardial infarction (STEMI) and a less frequent history of combined drug-eluting stent (DES) compared to those with MI-CAD. Additionally, they demonstrated lower levels of low density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglycerides (TG), peak troponin T (peak TnT) and peak creatine kinase (peak CK). The MINOCA group had more lesions in the left anterior descending (LAD) and fewer in the left circumflex (LCX). Additionally, they demonstrated a lower prevalence of multibranch vasculopathy and a diminished post-discharge use of aspirin, P2Y12 receptor inhibitors, beta-blockers, angiotensin converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARBs), and a higher proportion of conservative treatment compared to DES. The frequency of plaque rupture, calcified plaque, cholesterol crystals, macrophages infiltration, microvessels, thin-cap fibroatheroma (TCFA), and thrombus were found to be lower in the MINOCA group than in the MI-CAD group, with these differences being statistically significant (P < 0.05); (2) No significant difference was observed in the incidence of MACE at 30-days and 1 year between patients in the MINOCA and MI-CAD groups (P > 0.05). Compared with MI-CAD patients, MINOCA patients had fewer high-risk plaques on OCT and were more likely to be treated conservatively, with lower rates of stenting and less post-discharge pharmacological treatment. Both groups had similar rates of MACE at 30-day and 1 year, highlighting the importance of individualising treatment for MINOCA patients. Patients with MINOCA who develop MACE are more likely to exhibit high-risk OCT plaque features, with macrophage infiltration identified as an independent risk factor. OCT plaque features such as plaque rupture, plaque erosion, cholesterol crystals, macrophages, microvessels, TCFA may have played different roles in the progression of the two groups of patients.

Myocardial infarction with nonobstructive (<50% stenosis) coronary arteries (MINOCA) is a syndrome involving different etiologies: acute myocardial infarction (AMI) in approximately 26%, acute myocarditis in 27–33%, and takotsubo cardiomyopathy in approximately 9–11% of cases. In patients with MINOCA, cardiac magnetic resonance (CMR) has shown to establish a definitive diagnosis in 70% of patients, whereas around 30% of patients with MINOCA have normal CMR and a good clinical outcome. CMR allows accurate evaluation of wall motion abnormalities using steady-state free precession cine imaging, the presence of myocardial edema using T2-weighted imaging, and the identification of myocardial fibrosis through late gadolinium enhancement (LGE) sequences. In MINOCA patients with underlying AMI, coronary computed tomography angiography allows better evaluation of nonobstructive plaque burden than invasive coronary angiography and in some cases can identify ostial occlusion of small branches.

The working diagnosis Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA) is being increasingly recognized with the common use of high-sensitivity troponins and coronary angiography, accounting for 5% to 10% of all acute myocardial infarction presentations. Cardiac magnetic resonance (CMR) imaging is pivotal in patients presenting with suspected MINOCA, mainly to delineate those with a nonischemic cause, for example, myocarditis and Takotsubo syndrome, from those with true ischemic myocardial infarction, that is, MINOCA. The optimal timing for CMR imaging in patients with suspected MINOCA has been uncertain and, until recently, not been examined prospectively. Previous retrospective studies have indicated that the diagnostic yield decreases with time from the acute event. The SMINC studies (Stockholm Myocardial Infarction with Normal Coronaries) show that CMR should be performed early in all patients with the working diagnosis of MINOCA, with the possible exception of patients who are clearly identified as having Takotsubo syndrome as determined by echocardiography. In addition to CMR imaging, other investigations of importance in selected patients may be pulmonary artery computed tomography to exclude pulmonary embolism, optical coherence tomography to identify plaque disruption, and acetylcholine provocation to identify coronary artery spasm. Imaging of patients with the working diagnosis MINOCA, which is centered on CMR together with supplemental investigations, results in a clear diagnosis in approximately three-quarters of the patients. This is a good example of personalized medicine, because a correct diagnosis will not only increase the satisfaction of the individual patient but also result in optimizing treatment without harming the patient.

Reinfarction in Patients with Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Coronary Findings and Prognosis