Myocardial Infarction with Non-Obstructive Coronary Arteries Mechanisms for ischemic heart disease in women. CMR imaging in MINOCA

1. Magdy El-Masry
Prof. of Cardiology
Tanta University

2. A Changing Philosophy
Nonobstructive disease is not a false positive. It's not benign.
Non-obstructive Coronary Arteries
Myocardial InfarctionIschemia

3. Normal coronary angiogram. A smooth patent covetable left main, LAD, and circumflex
projected from the screen. Next to these innocent-appearing vessels was a distinctly sinister
IVUS study from the same angiogram demonstrating plaque rupture and ulceration.
The finding of angiographically
smooth coronary arteries does
not preclude an aetiologic role of
thrombotic disease in MINOCA.

4. What we can see is only 5% of the total coronary tree.
? Coronary
Microvascular Dysfunction
Non-obstructive Coronary Arteries

5. Mechanisms for ischemic heart disease in women.
*Plaque disruption denotes plaque rupture or plaque erosion

6. Diagnostic Criteria For
Myocardial Infarction With Non-obstructive Coronary Arteries “MINOCA”

7. A potential problem with current AMI criteria is their
central focus upon troponins, since clinicians encounter
elevated troponins in clinical scenarios other than AMI.

8. Circulation. 2017;135:1490–1493.

9. MINOCA:
A case study of a 55-year-old woman with an anterior STEMI presentation.

10. MINOCA should be considered as a ‘working diagnosis’,
analogous to heart failure, and thus prompts further
evaluation regarding its underlying mechanism(s).

12. MINOCA:
A case study of a 55-year-old woman with an anterior STEMI presentation.

13. MINOCA Etiology

14. Etiology of MINOCA : Differential diagnosis work up

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

18. Diagnostic test flow chart in MINOCA.

19. Diagnostic test flow chart in MINOCA , Cont.

20. CMR imaging is a key investigation
in identifying the underlying cause

21. Coronary angiography portraying subtle
lesion (arrow) involving the mid LAD
Cardiac MRI revealing LGE of the mid to distal
anteroseptal wall (arrows).
Still frames from horizontal long axis (top
row) and short axis (bottom row) are
consistent with mid to distal LAD infarction
Ann Clin Lab Res. 2016, 4: 3.

22. Bar graph of published studies showing the diagnostic significance
of CMR imaging in MINOCA patients.
Data presented as percentage (%).
Cardiac magnetic resonance (CMR) imaging findings in patients with MINOCA.

23. Management
A fundamental consideration is
identifying the underlying cause of
this heterogeneous syndrome
because that will determine
appropriate therapy.

24. All-Cause Mortality in Patients With MINOCA or MI-CAD
Data presented as percentage (%) and 95% confidence intervals (%) with
odds ratio (OR) and P values.
MI-CAD indicates myocardial infarction with coronary artery disease; and
MINOCA, myocardial infarction with nonobstructive coronary arteries
Circulation 2015;131(10):861–870
MINOCA : is not a benign condition?

25. Guarded Prognosis
Hence patients with MINOCA should receive the
same clinical attention as AMI patients who have
single- or double-vessel disease and not merely
dismissed as having an insignificant clinical
condition.
Although the outcome of MINOCA strongly
depends on the underlying cause, its overall
prognosis is serious, with a 1 year mortality of
about 3.5%.

26. Circulation. 2017;135:1481–1489

32. Dr. Noel Bairey Merz is the director of the Barbra Streisand Women's Heart Center at Cedars Sinai and is a leader in female
cardiovascular treatment. "In a session on New Practice Patterns in Clinical Cardiology at the European Society of Cardiology 2017
Congress, she gave a presentation titled "A Women's Clinic for Heart Disease." Her talk outlined three distinct sub clinic options
where women with heart disease can seek help: The MINOCA (myocardial infarction without obstructive coronary artery disease)
clinic, the HFpEF (heart failure with preserved ejection fraction) clinic, and the APO (adverse pregnancy outcomes) clinic."
We have an
evidence gap,
“she concluded”
MINOCA
research
needed !