Myocardial infarction with non-obstructive coronary artery disease

Abstract

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. KEYWORDS • clinical research • miscellaneous • risk stratificationEuroIntervention 2021;17:e875-e887 e 876 Abbreviations ACEI angiotensin-converting enzyme inhibitors ACS acute coronary syndromes ARB angiotensin receptor blockers CAD coronary artery disease CMD coronary microvascular disease CMR cardiac magnetic resonance imaging CT computed tomography CTCA computed tomography coronary angiography DAPT dual antiplatelet treatment IVUS intravascular ultrasound MACE major adverse cardiac events MI myocardial infarction MI-CAD myocardial infarction -coronary artery disease with significant stenosis MINOCA myocardial infarction with non-obstructive coronary arteries OCT optical coherence tomography PCI percutaneous coronary intervention PET positron emission tomography SCAD spontaneous coronary artery dissection

The Role of Antiplatelet Therapy in Patients With MINOCA

“…Furthermore, the American Heart Association (AHA) in 2019 published a scientific statement document of MINOCA ( 1 ). Ultimately, Bertil et al, have provided an updated review on MINOCA, focusing on the application of different images modalities ( 34 ). Table 1 shows a summary of the key recommendations for MINOCA and a selection of its etiologies.…”

Myocardial Infarction With Non-obstructive Coronary Arteries: An Updated Overview of Pathophysiology, Diagnosis, and Management

“…The pathophysiology of MINOCA is poorly understood, and it can be divided into the following four categories: epicardial coronary processes, demand and supply mismatch, coronary microvascular dysfunction, and unknown mechanism [ 10 ].…”

“…The epicardial coronary vessels processes causing MINOCA include coronary artery spasm, spontaneous coronary artery dissection (SCAD), plaque disruption, and in situ thrombosis [ 10 ].…”

“…The pathophysiology of coronary artery spasm involves vascular smooth muscle hyperreactivity to endogenous or exogenous stimuli (such as spasms induced by cocaine), imbalance of vagal and sympathetic tone, and endothelial dysfunction [ 11 - 12 ]. The spasm of an epicardial coronary artery is usually brief and causes transient ischemia, and in some cases, the prolonged spasm leads to persistent ischemia, which can cause MINOCA [ 10 ].…”

“…In contrast, plaque erosion is intraluminal thrombus formation with intact intima without signs of rupture [ 2 ]. The main mechanisms of MINOCA in patients with plaque disruption are thrombus formation, which can cause AMI via distal embolization, complete transient occlusion of coronary vessels with subsequent spontaneous thrombolysis, and coronary spasm [ 2 , 10 ].…”