Review

Myocardial infarction with nonobstructive coronary arteries: Current management strategies

Kevin G. Buda, DO, Sanjoyita Mallick, DO and Louis P. Kohl, MD
Cleveland Clinic Journal of Medicine December 2024, 91 (12) 743-753; DOI: https://doi.org/10.3949/ccjm.91a.19127

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    The patient’s initial electrocardiogram showing borderline ST-segment elevation, which did not, however, meet the criteria for ST-segment elevation myocardial infarction (ie, ST-segment elevation ≥ 1 mm [0.1 mV] above the baseline in at least 2 contiguous leads [except V2 and V3]).

  • Figure 2
    Figure 2

    Coronary angiography. On the left, a right anterior oblique caudal view of the left coronary artery, and on the right, a left anterior oblique caudal view of the right coronary artery (RCA), showing no obstructive lesions in the main branches of either.

    Cx = circumflex; LAD = left anterior descending; LM = left main; PL = posterolateral; PDA = posterior descending artery

  • Figure 3
    Figure 3

    American Heart Association “traffic light” algorithm for the diagnosis of myocardial infarction with nonobstructive coronary arteries (MINOCA). Red excludes nonischemic etiologies, yellow suggests slowing down to evaluate for alternate diagnoses that can mimic MINOCA, and green suggests a confirmed diagnosis of MINOCA.

    aConsider fractional flow reserve.

    Reprinted with permission from Tamis-Holland JE, Jneid H, Reynolds HR, et al. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation 2019; 139(18):e891–e908. doi:10.1161/CIR.0000000000000670. ©2019 American Heart Association, Inc.

  • Figure 4
    Figure 4

    Delayed cardiac magnetic resonance imaging after administration of gadolinium (top, short-axis view; bottom, long-axis view), which demonstrates subendocardial enhancement (scar, white arrows) in the mid-septum amid otherwise normal-appearing left ventricular myocardium (black).

  • Figure 5
    Figure 5

    Cardiac magnetic resonance imaging. Anterior-posterior cranial view showing no epicardial obstructive coronary artery disease.

Tables

  • TABLE 1

    Myocardial infarction with nonobstructive coronary arteries (MINOCA): Potential mimics and causes

    In a patient with a cardiac troponin level > 99th percentile, a rise or fall of troponin, and objective evidence of ischemia, consider the following:
    Mimics (not MINOCA)
    Myocarditis    		Causes of MINOCA
    Coronary microvascular disease
    Takotsubo syndrome
    Other cardiomyopathies
    Overlooked obstructive disease: distal or small epicardial vessel occlusions not well visualized on angiography, a positive fractional flow reserve (ie, ≤ 0.80) in a moderate lesion    		Plaque disruption (type 1 myocardial infarction)
    Supply-demand mismatch (type 2 myocardial infarction without obstruction)
    Spontaneous coronary artery dissection
    Coronary vasospasm
    Thromboembolic disease

    • Based on information from reference 11.

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