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Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) as per Guidelines

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) as per Guidelines

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a new entity recently trending in the field of interventional cardiology. According to the latest 2017 ESC guidelines, MINOCA is a working diagnosis and is defined as non-obstructive (< 50% stenosis) infarct-related artery (IRA) demonstrated in coronary angiography in a patient diagnosed to have acute myocardial infarction (AMI) as per Universal AMI criteria.

Around 1-14% of patients with acute myocardial infarction (AMI) may have non-obstructive coronaries in coronary angiography. MINOCA occurs commonly in young women with dyslipidemia. The following are the mechanisms for causing MINOCA: (1) plaque rupture, erosion, embolism or coronary dissection involving epicardial coronary arteries; (2) coronary vasospasm leading to the imbalance between oxygen supply and demand; (3) coronary microvascular spasm; and (4) myocardial injuries like myocarditis or Takotsubo syndrome.

A few additional tests, besides coronary angiography, may provide the etiological diagnosis of MINOCA.

  • A detailed echocardiography may be performed initially.
  • Apical ballooning in left ventricular angiography may suggest Takotsubo cardiomyopathy but normalization of findings during follow up is required for the diagnosis.
  • Intravascular Ultrasound (IVUS) and Optical Coherence Tomography (OCT) may unravel coronary dissection, thrombosis, plaque rupture, plaque fissure etc.
  • Provocative spasm tests with acetylcholine or ergonovine are useful to rule out coronary artery spasm. Pressure studies may reveal coronary microvascular dysfunction.
  • Cardiac MRI may identify subendocardial infarction, myocarditis etc by providing information like wall motion abnormalities, delayed myocardial enhancement infarction, presence of edema, myocardial scar/fibrosis etc.
  • Further useful investigations would be blood tests like D-dimer to rule out the possibility of pulmonary embolism, screening for thrombophilia disorders and inflammatory marker levels; screening for substance abuse like cocaine; endomyocardial biopsy for fulminant myocarditis.

The 1-year mortality of MINOCA is 3.5% and hence patients with MINOCA should not be ignored as those with the non-obstructive coronary disease because the prognosis is not great.3 Patients with MINOCA should be managed like AMI patients with the single-vessel disease or double-vessel disease.

Dr. Babu Ezhumalai

The author is MD, DM, FNB, FACC, FESC, FSCAI,(Cardiology) and is Consultant Heart Failure & Interventional Cardiologist, Fortis Malar Hospital. He is a member Editorial Board, Cardiology at Specialty Medical Dialogues.

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Meghna Singhania
Meghna A Singhania is the founder and Editor-in-Chief at Medical Dialogues. An Economics graduate from Delhi University and a post graduate from London School of Economics and Political Science, her key research interest lies in health economics, and policy making in health and medical sector in the country. She can be contacted at Contact no. 011-43720751
Disclaimer: The views expressed in the above article are solely those of the author/agency in his/her private capacity and DO NOT represent the views of Speciality Medical Dialogues.
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