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Leo I, Bisaccia G, Miaris N, Procopio MC, Licordari R, Bucciarelli-Ducci C. Imaging patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). Heart 2024; 110:209-217. [PMID: 37433660 DOI: 10.1136/heartjnl-2023-322835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) defines a heterogeneous group of atherosclerotic and non-atherosclerotic conditions, causing myocardial injury in the absence of obstructive coronary artery disease. Unveiling the mechanisms subtended to the acute event is often challenging; a multimodality imaging approach is helpful to aid the diagnosis. Invasive coronary imaging with intravascular ultrasound or optical coherence tomography should be used, when available, during index angiography to detect plaque disruption or spontaneous coronary artery dissection. Cardiovascular magnetic resonance has instead a key role among the non-invasive modalities, allowing the differentiation between MINOCA and its non-ischaemic mimics and providing prognostic information. This educational paper will provide a comprehensive review of the strengths and limitations of each imaging modality in the evaluation of patients with a working diagnosis of MINOCA.
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Affiliation(s)
- Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Giandomenico Bisaccia
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Neuroscience, Imaging and Clinical Sciences, "G d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Nikolaos Miaris
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Maria Cristina Procopio
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Licordari
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, Messina, Italy
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Xu X, Zhang G, Li Z, Li D, Chen R, Huang C, Li Y, Li B, Yu H, Chu XM. MINOCA biomarkers: Non-atherosclerotic aspects. Clin Chim Acta 2023; 551:117613. [PMID: 37871762 DOI: 10.1016/j.cca.2023.117613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) is an important subtype of myocardial infarction. Although comprising less than 50% stenosis in the main epicardial coronary arteries, it constitutes a severe health risk. A variety of approaches have been recommended, but definitive diagnosis remains elusive. In addition, the lack of a comprehensive understanding of underlying pathophysiology makes clinical management difficult and unpredictable. This review highlights ongoing efforts to identify relevant biomarkers in MINOCA to improve diagnosis, individualize treatment and better predict outcomes.
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Affiliation(s)
- Xiaojian Xu
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Guoliang Zhang
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Zhaoqing Li
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Daisong Li
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Ruolan Chen
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Chao Huang
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Yonghong Li
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Bing Li
- Department of Genetics and Cell Biology, Basic Medical College, Qingdao University, Qingdao 266000, China; Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao 266000, China.
| | - Haichu Yu
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China.
| | - Xian-Ming Chu
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266100, China; The Affiliated Cardiovascular Hospital of Qingdao University, Qingdao 266071, China.
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Rodríguez Candelario II, Perez-Aybar AE, Roman-Ramos JA. MINOCA: A Working Diagnosis. Cureus 2023; 15:e49695. [PMID: 38161900 PMCID: PMC10757752 DOI: 10.7759/cureus.49695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Cases of patients presenting with myocardial infarction (MI) without angiographic obstructive CAD are not trivial and have significant prevalence. "The Fourth Universal Definition of MI" (4UDMI) published in 2018 introduced MI with non-obstructive coronary arteries (MINOCA). The new section was of great importance as it validated the diagnosis by defining its criteria and recognizing its presence in the community and the need for further investigation. Given the nature of the diagnosis of MINOCA, coronary angiography provides limited information about prognosis and risk stratification for future major adverse cardiovascular events (MACE). Thus, additional imaging to understand the underlying etiology of MINOCA in conjunction with a better understanding of prognostic factors is necessary to expand on the current guidelines and aid in screening for possible complications, risk of MACE, and all-cause mortality. Discerning the etiology of the presentation is crucial, and physiologic studies, as well as additional imaging, are an important part of this evaluation. These modalities include intravascular studies such as optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), and imaging in the form of cardiac CT (CCT) and cardiac MRI (CMR). This step is essential to target treatment regimens more efficiently. The purpose of promoting multiple imaging modalities beyond traditional angiography is to address the working MINOCA diagnosis, with the finality of identifying the specific ischemic pathophysiology. MINOCA has multiple causative mechanisms, making it a heterogeneous collection of etiologies, resulting in acute MI: atherosclerotic, and non-atherosclerotic. This literature revision demonstrates that MINOCA prevalence and mortality are not trivial, and the diagnosis affects quality of life. MINOCA presents a definitive risk of MACE without proper stratification and targeted medical therapy. Several prognostic factors of morbidity and mortality in MI-CAD patients have been identified to correlate with MINOCA patients, especially inflammatory markers. MINOCA is not an exclusion diagnosis but a working diagnosis for which further imaging studies should be performed.
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Samaras A, Moysidis DV, Papazoglou AS, Rampidis G, Kampaktsis PN, Kouskouras K, Efthymiadis G, Ziakas A, Fragakis N, Vassilikos V, Giannakoulas G. Diagnostic Puzzles and Cause-Targeted Treatment Strategies in Myocardial Infarction with Non-Obstructive Coronary Arteries: An Updated Review. J Clin Med 2023; 12:6198. [PMID: 37834842 PMCID: PMC10573806 DOI: 10.3390/jcm12196198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a distinct subtype of myocardial infarction (MI), occurring in about 8-10% of spontaneous MI cases referred for coronary angiography. Unlike MI with obstructive coronary artery disease, MINOCA's pathogenesis is more intricate and heterogeneous, involving mechanisms such as coronary thromboembolism, coronary vasospasm, microvascular dysfunction, dissection, or plaque rupture. Diagnosing MINOCA presents challenges and includes invasive and non-invasive strategies aiming to differentiate it from alternative diagnoses and confirm the criteria of elevated cardiac biomarkers, non-obstructive coronary arteries, and the absence of alternate explanations for the acute presentation. Tailored management strategies for MINOCA hinge on identifying the underlying cause of the infarction, necessitating systematic diagnostic approaches. Furthermore, determining the optimal post-MINOCA medication regimen remains uncertain. This review aims to comprehensively address the current state of knowledge, encompassing diagnostic and therapeutic approaches, in the context of MINOCA while also highlighting the evolving landscape and future directions for advancing our understanding and management of this intricate myocardial infarction subtype.
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Affiliation(s)
- Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece; (A.S.); (D.V.M.); (A.S.P.); (G.R.); (G.E.); (A.Z.)
- Second Cardiology Department, Hippokration General Hospital of Thessaloniki, 546 42 Thessaloniki, Greece;
| | - Dimitrios V. Moysidis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece; (A.S.); (D.V.M.); (A.S.P.); (G.R.); (G.E.); (A.Z.)
- Third Cardiology Department, Hippokration General Hospital of Thessaloniki, 546 42 Thessaloniki, Greece;
| | - Andreas S. Papazoglou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece; (A.S.); (D.V.M.); (A.S.P.); (G.R.); (G.E.); (A.Z.)
| | - Georgios Rampidis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece; (A.S.); (D.V.M.); (A.S.P.); (G.R.); (G.E.); (A.Z.)
| | - Polydoros N. Kampaktsis
- Department of Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY 10032, USA;
| | - Konstantinos Kouskouras
- Department of Radiology, AHEPA University General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Georgios Efthymiadis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece; (A.S.); (D.V.M.); (A.S.P.); (G.R.); (G.E.); (A.Z.)
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece; (A.S.); (D.V.M.); (A.S.P.); (G.R.); (G.E.); (A.Z.)
| | - Nikolaos Fragakis
- Second Cardiology Department, Hippokration General Hospital of Thessaloniki, 546 42 Thessaloniki, Greece;
| | - Vasileios Vassilikos
- Third Cardiology Department, Hippokration General Hospital of Thessaloniki, 546 42 Thessaloniki, Greece;
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece; (A.S.); (D.V.M.); (A.S.P.); (G.R.); (G.E.); (A.Z.)
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Parwani P, Kang N, Safaeipour M, Mamas MA, Wei J, Gulati M, Naidu SS, Merz NB. Contemporary Diagnosis and Management of Patients with MINOCA. Curr Cardiol Rep 2023; 25:561-570. [PMID: 37067753 DOI: 10.1007/s11886-023-01874-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE OF REVIEW Myocardial infarction with nonobstructive coronary arteries (MINOCA) is defined as acute myocardial infarction (MI) with angiographically no obstructive coronary artery disease or stenosis ≤ 50%. MINOCA is diagnostically challenging and complex, making it difficult to manage effectively. This condition accounts for 6-8% of all MI and poses an increased risk of morbidity and mortality after diagnosis. Prompt recognition and targeted management are essential to improve outcomes and our understanding of this condition, but this process is not yet standardized. This article offers a comprehensive review of MINOCA, delving deep into its unique clinical profile, invasive and noninvasive diagnostic strategies for evaluating MINOCA in light of the lack of widespread availability for comprehensive testing, and current evidence surrounding targeted therapies for patients with MINOCA. RECENT FINDINGS MINOCA is not uncommon and requires comprehensive assessment using various imaging modalities to evaluate it further. MINOCA is a heterogenous working diagnosis that requires thoughtful approach to diagnose the underlying disease responsible for MINOCA further.
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Affiliation(s)
- Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA.
- Loma Linda University School of Medicine, Loma Linda, CA, USA.
| | - Nicolas Kang
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Mary Safaeipour
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Prognosis Research, University of Keele, Keele, UK
| | - Janet Wei
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Martha Gulati
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | - Noel Bairey Merz
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
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Jia F, Fei SF, Tong DB, Zhang S, Li JJ. Do Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries Have Similar Prognosis Compared to Ones with MI-CAD? Angiology 2022; 74:407-416. [PMID: 35993693 DOI: 10.1177/00033197221121191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute myocardial infarction (AMI) is a leading cause of morbidity and mortality worldwide and it is primarily caused by acute plaque disruption and coronary occlusion. Recent studies suggest that myocardial infarction with non-obstructive coronary arteries (MINOCA) also occurs but the underlying mechanisms have not been fully understood until recently. The evidence also suggests that the clinical outcomes of patients presenting with MINOCA are similar to AMI patients with obstructive coronary artery disease (MI-CAD), including all-cause mortality and major adverse cardiovascular events. The present narrative review considers the risk factors, pathological changes, and outcomes associated with MINOCA and compares them with MI-CAD.
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Affiliation(s)
- Fang Jia
- Department of Cardiology, 117850The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Si-Fan Fei
- Department of Cardiology, 117850The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - De-Bing Tong
- Department of Cardiology, 117850The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Sheng Zhang
- Department of Cardiology, 117850The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jian-Jun Li
- Cardio-Metabolic Center, 569172Fu Wai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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