This document discusses myocardial infarction with non-obstructive coronary arteries (MINOCA). Early coronary angiography identifies an occluded vessel in most patients with STEMI but in up to 10% of AMI patients, no vessel is occluded. These patients have MINOCA. The document outlines potential causes of MINOCA including coronary artery spasm, embolism, thrombophilia, and takotsubo cardiomyopathy. It provides diagnostic criteria for different causes and recommends diagnostic tests and treatments tailored to the identified cause. The prevalence of MINOCA among all MI cases is approximately 6% but ranges from 1-14%. Prognosis varies depending on the underlying cause.

1. (MINOCA)
Myocardial Infarction with
Non-Obstructive CoronaryArteries
Fellow : Đỗ Duy Hồng

2. Angiographic Findings in Acute MI
-Early coronary angiography
performed during acute MI (AMI)
identifies an occluded vessel in most
patients with ST elevation MI (STEMI)
and less frequently in those with non-
STEMI
-However, in up to 10 % of patients
with clinical diagnostic features of
AMI, early angiography does not
reveal an occluded vessel or possibly
any evidence of CAD
-These patients constitute an intriguing
subgroup referred to as MI with non-
obstructive coronary arteries
(MINOCA)
87%
32%
98% 97%
0%
20%
40%
60%
80%
100%
Occluded Vessel Obstructive CAD
( >70%)
AngiographicAbnormality
STEMI NSTEMI
Adapted from DeWood et al – Q wave (1980) & Non-Q wave (1986) New Engl J Med
I

4. Mechanisms for ischemic heart disease

6. Diagnostic criteria for MINOCA

7. MINOCA Etiology

8. DOI: 10.1161/CIRCULATIONAHA.114.011201
Prevalence of MINOCA

9. DOI: 10.1161/CIRCULATIONAHA.114.011201
Prevalence of MINOCA
33% of them presented as STEMI

10. Cardiovascular Risk Factors in Patients With MINOCA
DOI: 10.1161/CIRCULATIONAHA.114.011201

11. MINOCA : is not a benign condition?

13. Observational study of MINOCA patients recorded in the SWEDEHEART registry
Circulation. 2017;135:1481–1489

14. Recommended diagnostic and therapeutic algorithm for myocardial infarction with non-obstructive coronary arteries

15. Coronary plaque disease
What we can see is only 5% of the total coronary tree

16. Coronary plaque disease
Not All Plaque Rupture Is Angiographilcally Evident

17. Coronary plaque disease

18. Cause of MINOCA
Coronary artery spasm
- CAS reflects a vascular smooth muscle hyperreactivity to
endogenous vasospastic substances but may also occur in the context of
exogenous vasospastic agents (e.g. cocaine or metamphetamines).
- The diagnostic test with intracoronary ergonovine and acetylcholine
(Ach) .
- Non-specific vasodilators such nitrates and calcium antagonists
constitute the standard treatment .
- In selected cases, stent implantation or partial sympathetic
denervation can be employed.

19. COVADIS diagnostic criteria for vasospastic angina

20. Coronary artery embolism
- Coronary artery embolism (CE) is an uncommon cause of acute
MI that often affects the microcirculation, although
angiographically visible embolization of epicardial coronary artery
branches may occur
- It should be suspected in patients with MINOCA and one of the
following conditions associated with high risk of systemic
embolism: prosthetic heart valves, atrial fibrillation (AF), dilated
cardiomyopathy with apical thrombus, rheumatic heart disease with
mitral stenosis, infective endocarditis, and atrial myxoma
- Transthoracic, transesophageal, and contrast-enhanced
echocardiography are the cornerstone methods for detection of
cardiac sources of embolism as causes of MINOCA

21. Thrombophilia
-Hypercoagulable state might predispose to thrombus
formation
- Factor V Leiden is the most common risk factor for venous
thrombosis but it has been also associated with MINOCA in
younger patients
-Protein C and S deficiency, as well as enhanced Factor VII
activity, have been occasionally related to MINOCA.
-Thrombophilia screening studies in patients with MINOCA
have reported a 14% prevalenceof these inherited disorders

22. Takotsubo cardiomyopathy
- Takotsubo cardiomyopathy often presents as an ACS
with ST-segment changes
- Clinical presentation is characterized by acute, reversible
heart failure associated with myocardial stunning, in the
absence of occlusive CAD usually as the result of severe
emotional or physical stress
-Therapeutic strategies may include the avoidance of
sympathomimetic agent , the use of cardio-selective b-
blockers in those with left ventricular outflow tract
obstruction, ACE inhibitors in those with persistent left
ventricular dysfunction, mechanical support in those with
cardiogenic shock, and consideration of short-term anti-
thrombotic medications given potential prothrombotic
mechanisms

23. Takotsubo cardiomyopathy

24. Myocarditis

26. Diagnostic tests, therapeutic treatments stratified for specific causes of MINOCA.

28. Conclusions
Myocardial infarction with no obstructive coronary atherosclerosis
(MINOCA) is a syndrome with multiple potential causes
The prevalence of MINOCA among all cases of MI is about 6 percent
and ranges between 1 and 14 percent
The prognosis is variable, depending on the cause
The management of the patient is determined by the cause, if one is
identified

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