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.