Download PDF
Int J Angiol 2024; 33(04): 211-221
DOI: 10.1055/s-0041-1724040
Review Article

Myocardial Infarction with Nonobstructive Coronary Artery Disease—Definition, Etiopathogenesis, Diagnosis, and Management

Patrick Baghdasaryan
1   Division of Cardiology, University of California Riverside School of Medicine, CA
,
Balaji Natarajan
1   Division of Cardiology, University of California Riverside School of Medicine, CA
,
Madlena Nalbandian
2   Internal Medicine, St. Mary Medical Center, Long Beach, CA
,
Padmini Varadarajan
1   Division of Cardiology, University of California Riverside School of Medicine, CA
,
Ramdas G. Pai 
1   Division of Cardiology, University of California Riverside School of Medicine, CA
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a complex clinical syndrome that is characterized by evidence of acute myocardial infarction in the absence of significant epicardial coronary artery disease on angiography. The term “MINOCA” encompasses a group of heterogeneous diseases with varying underlying mechanisms and each with its own pathophysiology. Overlooked plaque rupture or erosion and coronary vasospasm are the most common causes of MINOCA and can be diagnosed by routine intracoronary imaging and vasoreactivity testing, respectively. Coronary microvascular dysfunction is a less recognized, albeit an important cause of morbidity in patients presenting with MINOCA. Although MINOCA is a rare presentation of acute coronary syndrome, it is not a benign disorder and can have adverse consequences if untreated. In this article, we aim to review the pathogenesis, clinical characteristics, and finally propose a systematic approach in the diagnosis and management of patients with MINOCA.

Keywords

MINOCA - acute myocardial infarction - plaque rupture - coronary vasospasm - microvascular dysfunction - spontaneous coronary artery dissection - coronary embolism

Authors' Contributions

Dr. Baghdasaryan and Dr. Natarajan contributed equally to the manuscript.




Publication History

Article published online:
03 March 2021

© 2021. International College of Angiology. This article is published by Thieme.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Thygesen K, Alpert JS, Jaffe AS. et al; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018; 72 (18) 2231-2264
    CrossrefPubMedSearch in Google Scholar
  • 2 Tamis-Holland JE, Jneid H, Reynolds HR. et al; American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; and Council on Quality of Care and Outcomes Research. 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
    PubMedSearch in Google Scholar
  • 3 Chokshi NP, Iqbal SN, Berger RL. et al. Sex and race are associated with the absence of epicardial coronary artery obstructive disease at angiography in patients with acute coronary syndromes. Clin Cardiol 2010; 33 (08) 495-501
    CrossrefPubMedSearch in Google Scholar
  • 4 Smilowitz NR, Mahajan AM, Roe MT. et al. Mortality of myocardial infarction by sex, age, and obstructive coronary artery disease status in the ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines). Circ Cardiovasc Qual Outcomes 2017; 10 (12) e003443
    CrossrefPubMedSearch in Google Scholar
  • 5 Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation 2015; 131 (10) 861-870
    CrossrefPubMedSearch in Google Scholar
  • 6 Safdar B, Spatz ES, Dreyer RP. et al. Presentation, clinical profile, and prognosis of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): results from the VIRGO study. J Am Heart Assoc 2018; 7 (13) e009174
    CrossrefPubMedSearch in Google Scholar
  • 7 Gasior P, Desperak A, Gierlotka M. et al. Clinical characteristics, treatments, and outcomes of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA): results from a Multicenter National Registry. J Clin Med 2020; 9 (09) E2779
    CrossrefPubMedSearch in Google Scholar
  • 8 Gulati R, Behfar A, Narula J. et al. Acute myocardial infarction in young individuals. Mayo Clin Proc 2020; 95 (01) 136-156
    CrossrefPubMedSearch in Google Scholar
  • 9 Reynolds HR, Srichai MB, Iqbal SN. et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation 2011; 124 (13) 1414-1425
    CrossrefPubMedSearch in Google Scholar
  • 10 Kubo T, Imanishi T, Takarada S. et al. Assessment of culprit lesion morphology in acute myocardial infarction: ability of optical coherence tomography compared with intravascular ultrasound and coronary angioscopy. J Am Coll Cardiol 2007; 50 (10) 933-939
    CrossrefPubMedSearch in Google Scholar
  • 11 Rodriguez-Granillo GA, Serruys PW, Garcia-Garcia HM. et al. Coronary artery remodelling is related to plaque composition. Heart 2006; 92 (03) 388-391
    CrossrefPubMedSearch in Google Scholar
  • 12 Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U. Coronary artery spasm as a frequent cause of acute coronary syndrome: the CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) study. J Am Coll Cardiol 2008; 52 (07) 523-527
    CrossrefPubMedSearch in Google Scholar
  • 13 Al-Khatib SM, Stevenson WG, Ackerman MJ. et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2018; 138 (13) e210-e271
    PubMedSearch in Google Scholar
  • 14 Lanza GA, Careri G, Crea F. Mechanisms of coronary artery spasm. Circulation 2011; 124 (16) 1774-1782
    CrossrefPubMedSearch in Google Scholar
  • 15 Montone RA, Niccoli G, Fracassi F. et al. Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart J 2018; 39 (02) 91-98
    PubMedSearch in Google Scholar
  • 16 Ong P, Safdar B, Seitz A, Hubert A, Beltrame JF, Prescott E. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res 2020; 116 (04) 841-855
    CrossrefPubMedSearch in Google Scholar
  • 17 Chen K, Miller EJ, Sadeghi MM. PET-based imaging of ischemic heart disease. PET Clin 2019; 14 (02) 211-221
    CrossrefPubMedSearch in Google Scholar
  • 18 Rahman H, Corcoran D, Aetesam-Ur-Rahman M, Hoole SP, Berry C, Perera D. Diagnosis of patients with angina and non-obstructive coronary disease in the catheter laboratory. Heart 2019; 105 (20) 1536-1542
    CrossrefPubMedSearch in Google Scholar
  • 19 Hayes SN, Kim ESH, Saw J. et al; American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council. Spontaneous coronary artery dissection: current state of the science: a scientific statement from the American Heart Association. Circulation 2018; 137 (19) e523-e557
    CrossrefPubMedSearch in Google Scholar
  • 20 Stepien K, Nowak K, Wypasek E, Zalewski J, Undas A. High prevalence of inherited thrombophilia and antiphospholipid syndrome in myocardial infarction with non-obstructive coronary arteries: comparison with cryptogenic stroke. Int J Cardiol 2019; 290: 1-6
    CrossrefPubMedSearch in Google Scholar
  • 21 Barr PR, Harrison W, Smyth D, Flynn C, Lee M, Kerr AJ. Myocardial infarction without obstructive coronary artery disease is not a benign condition (ANZACS-QI 10). Heart Lung Circ 2018; 27 (02) 165-174
    CrossrefPubMedSearch in Google Scholar
  • 22 Kosmas N, Manolis AS, Dagres N, Iliodromitis EK. Myocardial infarction or acute coronary syndrome with non-obstructive coronary arteries and sudden cardiac death: a missing connection. Europace 2020; 22 (09) 1303-1310
    CrossrefPubMedSearch in Google Scholar
  • 23 Pustjens TFS, Appelman Y, Damman P. et al. Guidelines for the management of myocardial infarction/injury with non-obstructive coronary arteries (MINOCA): a position paper from the Dutch ACS working group. Neth Heart J 2020; 28 (03) 116-130
    CrossrefPubMedSearch in Google Scholar
  • 24 Ong P, Camici PG, Beltrame JF. et al; Coronary Vasomotion Disorders International Study Group (COVADIS). International standardization of diagnostic criteria for microvascular angina. Int J Cardiol 2018; 250: 16-20
    CrossrefPubMedSearch in Google Scholar
  • 25 Ford TJ, Stanley B, Good R. et al. Stratified medical therapy using invasive coronary function testing in angina: the CorMicA trial. J Am Coll Cardiol 2018; 72 (23 Pt A): 2841-2855
    CrossrefPubMedSearch in Google Scholar
  • 26 Pepine CJ, Anderson RD, Sharaf BL. et al. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women's Ischemia Syndrome Evaluation) study. J Am Coll Cardiol 2010; 55 (25) 2825-2832
    CrossrefPubMedSearch in Google Scholar
  • 27 Talebi S, Moreno P, Dominguez AC, Tamis-Holland JE. The imaging toolbox to assess patients with suspected myocardial infarction in the absence of obstructive coronary artery disease (MINOCA). Curr Cardiol Rep 2020; 22 (11) 134
    CrossrefPubMedSearch in Google Scholar
  • 28 Kwong RY, Chan AK, Brown KA. et al. Impact of unrecognized myocardial scar detected by cardiac magnetic resonance imaging on event-free survival in patients presenting with signs or symptoms of coronary artery disease. Circulation 2006; 113 (23) 2733-2743
    CrossrefPubMedSearch in Google Scholar
  • 29 Gerbaud E, Arabucki F, Nivet H. et al. OCT and CMR for the diagnosis of patients presenting with MINOCA and suspected epicardial causes. JACC Cardiovasc Imaging 2020; 13 (12) 2619-2631
    CrossrefPubMedSearch in Google Scholar
  • 30 Opolski MP, Spiewak M, Marczak M. et al. Mechanisms of myocardial infarction in patients with nonobstructive coronary artery disease: results from the optical coherence tomography study. JACC Cardiovasc Imaging 2019; 12 (11 Pt 1): 2210-2221
    CrossrefPubMedSearch in Google Scholar
  • 31 Pasupathy S, Tavella R, McRae S, Beltrame JF. Myocardial infarction with non-obstructive coronary arteries - diagnosis and management. Eur Cardiol 2015; 10 (02) 79-82
    CrossrefPubMedSearch in Google Scholar
  • 32 Reynolds HR, Maehara A, Kwong RY. et al. Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of MINOCA in women. Circulation 2020; [Epub ahead of print: 14 Nov 2020]
    CrossrefPubMedSearch in Google Scholar
  • 33 Grodzinsky A, Arnold SV, Gosch K. et al. Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease. Eur Heart J Qual Care Clin Outcomes 2015; 1 (02) 92-99
    CrossrefPubMedSearch in Google Scholar
  • 34 Larsen AI, Nilsen DW, Yu J. et al. Long-term prognosis of patients presenting with ST-segment elevation myocardial infarction with no significant coronary artery disease (from the HORIZONS-AMI trial). Am J Cardiol 2013; 111 (05) 643-648
    CrossrefPubMedSearch in Google Scholar
  • 35 Rossini R, Capodanno D, Lettieri C. et al. Long-term outcomes of patients with acute coronary syndrome and nonobstructive coronary artery disease. Am J Cardiol 2013; 112 (02) 150-155
    CrossrefPubMedSearch in Google Scholar
  • 36 Pelliccia F, Pasceri V, Niccoli G. et al. Predictors of mortality in myocardial infarction and nonobstructed coronary arteries: a systematic review and meta-regression. Am J Med 2020; 133 (01) 73-83.e4
    CrossrefPubMedSearch in Google Scholar
  • 37 Andersson HB, Pedersen F, Engstrøm T. et al. Long-term survival and causes of death in patients with ST-elevation acute coronary syndrome without obstructive coronary artery disease. Eur Heart J 2018; 39 (02) 102-110
    CrossrefPubMedSearch in Google Scholar
  • 38 Kang WY, Jeong MH, Ahn YK. et al; Korea Acute Myocardial Infarction Registry Investigators. Are patients with angiographically near-normal coronary arteries who present as acute myocardial infarction actually safe?. Int J Cardiol 2011; 146 (02) 207-212
    CrossrefPubMedSearch in Google Scholar
  • 39 Planer D, Mehran R, Ohman EM. et al. Prognosis of patients with non-ST-segment-elevation myocardial infarction and nonobstructive coronary artery disease: propensity-matched analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial. Circ Cardiovasc Interv 2014; 7 (03) 285-293
    CrossrefPubMedSearch in Google Scholar
  • 40 Nordenskjöld AM, Lagerqvist B, Baron T. et al. Reinfarction in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): coronary findings and prognosis. Am J Med 2019; 132 (03) 335-346
    CrossrefPubMedSearch in Google Scholar
  • 41 Xing L, Yamamoto E, Sugiyama T. et al. EROSION study (Effective Anti-Thrombotic Therapy Without Stenting: Intravascular Optical Coherence Tomography-Based Management in Plaque Erosion): a 1-year follow-up report. Circ Cardiovasc Interv 2017; 10 (12) e005860
    CrossrefPubMedSearch in Google Scholar
  • 42 Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345 (07) 494-502
    CrossrefPubMedSearch in Google Scholar
  • 43 Yasue H, Takizawa A, Nagao M. et al. Long-term prognosis for patients with variant angina and influential factors. Circulation 1988; 78 (01) 1-9
    CrossrefPubMedSearch in Google Scholar
  • 44 Beltrame JF, Crea F, Camici P. Advances in coronary microvascular dysfunction. Heart Lung Circ 2009; 18 (01) 19-27
    CrossrefPubMedSearch in Google Scholar
  • 45 Lerman A, Burnett Jr JC, Higano ST, McKinley LJ, Holmes Jr DR. Long-term L-arginine supplementation improves small-vessel coronary endothelial function in humans. Circulation 1998; 97 (21) 2123-2128
    CrossrefPubMedSearch in Google Scholar
  • 46 Kurtoglu N, Akcay A, Dindar I. Usefulness of oral dipyridamole therapy for angiographic slow coronary artery flow. Am J Cardiol 2001; 87 (06) 777-779 , A8
    CrossrefPubMedSearch in Google Scholar
  • 47 Cannon III RO, Quyyumi AA, Mincemoyer R. et al. Imipramine in patients with chest pain despite normal coronary angiograms. N Engl J Med 1994; 330 (20) 1411-1417
    CrossrefPubMedSearch in Google Scholar
  • 48 Ong P, Athanasiadis A, Sechtem U. Pharmacotherapy for coronary microvascular dysfunction. Eur Heart J Cardiovasc Pharmacother 2015; 1 (01) 65-71
    CrossrefPubMedSearch in Google Scholar
  • 49 Tweet MS, Eleid MF, Best PJ. et al. Spontaneous coronary artery dissection: revascularization versus conservative therapy. Circ Cardiovasc Interv 2014; 7 (06) 777-786
    CrossrefPubMedSearch in Google Scholar
  • 50 Agewall S, Beltrame JF, Reynolds HR. et al; WG on Cardiovascular Pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J 2017; 38 (03) 143-153
    PubMedSearch in Google Scholar
  • 51 Lindahl B, Baron T, Erlinge D. et al. Medical therapy for secondary prevention and long-term outcome in patients with myocardial infarction with nonobstructive coronary artery disease. Circulation 2017; 135 (16) 1481-1489
    CrossrefPubMedSearch in Google Scholar
  • 52 Choo EH, Chang K, Lee KY. et al; KAMIR-NIH Investigators. Prognosis and predictors of mortality in patients suffering myocardial infarction with non-obstructive coronary arteries. J Am Heart Assoc 2019; 8 (14) e011990
    CrossrefPubMedSearch in Google Scholar
  • 53 Paolisso P, Bergamaschi L, Saturi G. et al. Secondary prevention medical therapy and outcomes in patients with myocardial infarction with non-obstructive coronary artery disease. Front Pharmacol 2020; 10: 1606
    CrossrefPubMedSearch in Google Scholar