Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA)
The Past, Present, and Future Management
This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
- coronary angiography
- coronary artery disease
- myocardial infarction
- myocardial ischemia
- secondary prevention angiography
Article, see p 1481
Myocardial infarction with nonobstructive coronary arteries (MINOCA) is clinically defined by the presence of the universal acute myocardial infarction (AMI) criteria, absence of obstructive coronary artery disease (≥50% stenosis), and no overt cause for the clinical presentation at the time of angiography (eg, classic features for takotsubo cardiomyopathy).1 With the more frequent contemporary use of coronary angiography in AMI, clinicians have been regularly confronted with this puzzling problem and seeking guidance in its management. An article by Lindahl et al2 in this issue of Circulation represents a major step forward in MINOCA and thereby warrants taking stock of the past, present, and future management strategies of this intriguing condition.
The pioneering early angiography studies of DeWood et al demonstrated that ST-segment–elevation myocardial infarction was often associated with an occluded epicardial artery, but this occurred less frequently in non–ST-segment–elevation myocardial infarction, although in both conditions obstructive coronary artery disease was evident in >95% of patients.3 These findings underscored the importance of the underlying atherothrombotic process and provided the impetus for major advances in AMI management over the next 35 years. However, when angiography failed to reveal the presence of obstructive atheroma or thrombosis in patients with clinical criteria for ST-segment–elevation myocardial infarction, some clinicians labeled these patients as having a false-positive ST-segment–elevation myocardial infarction diagnosis.4 Such a label implies that an AMI has not occurred (despite the clinical presentation) and therefore no further diagnostic investigation or cardiac therapy is required.
To avoid such diagnostic complacency, the diagnosis of MINOCA was coined5 with an emphasis on investigating these patients to identify the underlying cause of their AMI presentation. Providing a label for this clinical syndrome was the first …