Chayakrit Krittanawong, MD, FACC, FAHA, FSCAI
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Myocardial infarction with non-obstructive coronary arteries (MINOCA): State-of-the-Art Review
The working diagnosis of Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is a heterogeneous clinical entity that includes true ischemic etiologies and MINOCA mimickers, and accounts for approximately 4-15% of all acute myocardial infarctions (MI). The underlying ischemic etiologies are diverse, ranging from atherosclerotic plaque disruption to non-atherosclerotic mechanisms such as coronary artery spasm, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary thrombosis or embolism. Although the risks of all-cause mortality and recurrent cardiac events are lower than in MI with obstructive coronary artery disease (MI-CAD), patients with MINOCA remain at significantly increased risk of adverse outcomes compared with the general population. Accurate diagnosis remains challenging due to overlapping clinical features with MINOCA mimickers and the lack of standardized diagnostic algorithms. Advanced imaging modalities, particularly early cardiac magnetic resonance imaging and intracoronary imaging techniques including optical coherence tomography and intravascular ultrasound, significantly enhance diagnostic precision by enabling detailed myocardial tissue characterization and identification of culprit lesions. However, management strategies remain controversial due to the absence of large randomized controlled trials dedicated to MINOCA and different underlying etiologies, resulting in treatment approaches that are mainly extrapolated from studies on MI-CAD and observational registry data. Standard MI therapies should not be uniformly applied to all patients with MINOCA; instead, management should be individualized according to the underlying mechanism. Future research should prioritize large-scale, mechanism-specific randomized trials, the validation of standardized diagnostic pathways, and the integration of multimodal imaging into routine clinical practice to improve outcomes for this diverse patient population.
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When Does Treating Tricuspid Regurgitation Change the Course of Heart Failure?
Background Transcatheter tricuspid valve interventions (TTVI) have transformed the management of severe tricuspid regurgitation (TR). Although randomized trials have consistently shown improvements in TR severity, symptoms, and quality of life, their effects on heart failure hospitalization (HFH) and mortality remain less certain. Methods We critically examined evidence from four randomized trials, TRISCEND II, TRILUMINATE, Tri.Fr, and TRIC-I-HF, comparing transcatheter tricuspid repair or replacement with medical therapy, with an emphasis on clinical outcomes, patient selection, and timing of intervention. Results TRISCEND II, TRILUMINATE, and Tri.Fr demonstrated substantial reductions in TR severity and improvements in patient-reported outcomes without significant reductions in mortality or HFH at 1 year. Extended follow-up from TRILUMINATE suggested fewer recurrent HFHs at 2 years (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.53–0.98). In contrast, TRIC-I-HF, which enrolled patients at increased risk for heart failure events, demonstrated improved freedom from death or first HFH at 3 years (52.4% vs. 21.0%; HR, 0.40; 95% CI, 0.29–0.55). These findings suggest that baseline clinical risk, disease stage, and duration of follow-up may influence the prognostic benefit of TR correction. However, open-label designs, treatment crossover, and differences in trial populations complicate interpretation. Conclusions Randomized evidence supports TTVI for improving symptoms and health status, while emerging data suggest potential prognostic benefits in selected high-risk patients. The next challenge is defining the optimal therapeutic window-intervening when TR becomes clinically consequential but before irreversible right ventricular dysfunction and end-organ damage develop. Refining patient selection through assessment of right ventricular reserve, pulmonary vascular disease, and systemic congestion will be essential to determine when TR correction meaningfully alters clinical outcomes.
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Artificial Intelligence in Cerebrovascular Diseases
In management of cerebrovascular diseases, artificial intelligence (AI) emerges and plays a role through advancements in prediction, imaging, diagnosis, and treatment. Revolutionized AI-based tools allow us to catch a glimpse of possibility of rapid clinical workflows in detection, reducing time to the treatment while improving diagnostic accuracy compared to conventional methods. AI has the potential to facilitate primary prevention, improve acute detection, and provide additional decision-making beyond acute care. This review synthesizes applications of AI in major cerebrovascular diseases, introducing an overview of its efficiency and limitations.