Role of Multimodality Imaging in the Assessment of Myocardial Infarction With Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography

Abstract

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a heterogeneous clinical entity, encompassing multiple different causes, and a cause of substantial morbidity and mortality. Current guidelines suggest a multimodality imaging approach in establishing the underlying cause for MINOCA, which is considered a working diagnosis. Recent studies have suggested that an initial workup consisting of cardiac magnetic resonance and invasive coronary imaging can yield the diagnosis in most patients. Cardiac magnetic resonance is particularly helpful in excluding nonischemic causes that can mimic MINOCA including myocarditis and Takotsubo cardiomyopathy, as well as for long‐term prognostication. Additionally, intracoronary imaging with intravascular ultrasound or optical coherence tomography may be warranted to evaluate plaque composition, or evaluate for plaque disruption or spontaneous coronary dissection. The role of noninvasive imaging modalities such as coronary computed tomography angiography is currently being investigated in the diagnostic approach and follow‐up of MINOCA and may be appropriate in lieu of invasive coronary angiography in select patients. In recent years, many strides have been made in the workup of MINOCA; however, significant knowledge gaps remain in the field, particularly in terms of treatment strategies. In this review, we summarize recent society guideline recommendations and consensus statements on the initial evaluation of MINOCA, review contemporary multimodality imaging approaches, and discuss treatment strategies including an ongoing clinical trial.

Multimodality Imaging of Sudden Cardiac Death and Acute Complications in Acute Coronary Syndrome

“…CMR can play a key role in patients with acute myocardial infarction but also with chronic ischemic cardiomyopathy [ 4 , 5 , 98 , 99 , 100 , 101 ]. In particular, the additional value of CMR over echocardiography is represented by the possibility to identify reversible or irreversible damaged myocardial areas, the latter of which could potentially be a trigger of arrhythmias [ 102 , 103 ].…”

“…The assessment of myocardial damage using CMR in ischemic cardiomyopathy can be differentiated considering the acute or chronic setting [ 4 , 104 ]. In the acute setting, it is possible to evaluate the presence of myocardial edema, MVO and late gadolinium enhancement (LGE) [ 5 , 105 ]; in patients with chronic ischemic cardiomyopathy, LGE can be useful for evaluation of viability as well as the presence of heterogeneous LGE, which is associated with increased incidence of arrhythmias [ 5 ].…”

“…In the past, the evaluation of myocardial edema in clinical practice has been performed using T2 black blood sequences [ 106 ]. When acquiring T2 black blood (T2BB) sequences, myocardial edema is hyperintense, normal myocardium has normal signal intensity, while blood pool shows black signal intensity [ 5 ]. The acquisition of T2BB is routinely performed in clinical practice using T2 short-tau inversion recovery (T2 STIR) and T2 spectral adiabatic inversion recovery (T2 SPAIR).…”

“…Coronary artery disease (CAD) represents one of the most important causes of death, especially in low and middle-income countries, caused by acute coronary syndrome (ACS) or cardiac complication related to ACS [ 1 , 2 , 3 ]. Prevention of acute events or non-invasive evaluation after the development of ACS can be performed using a multimodality approach [ 4 , 5 ]. Theoretically, an approach based using different non-invasive technique in ACS could result in an economical advantage, reduction of invasive procedures, and identification of patients that can have poor outcome after ACS [ 6 ].…”

“…Electrocardiogram (ECG) and echocardiography still represent the first line techniques in the presence of ACS. Cardiac magnetic resonance (CMR) is mainly confined to the evaluation of acute myocardial infarction in the early stage [ 5 ]; in particular, the evaluation of myocardial tissue abnormalities such as the presence of myocardial edema, microvascular obstruction (MVO), and the presence of left ventricular thrombus, can play a key role in terms of prognostic stratification in the early stage [ 5 ]. In the acute setting, coronary computed tomography angiography (CCTA) can be extremely important to rule out CAD [ 7 ], identify presence of high-risk coronary plaque [ 8 ], or severe stenosis, that may lead to acute myocardial infarction [ 9 ].…”