Heart, Lung and Circulation
Editorial| Volume 27, ISSUE 6, P649-651, June 2018

How Can You Have a Myocardial Infarction Without Significant Coronary Artery Disease? Whither MINOCA

      This may seem a simple question that a medical student might ask on a ward round but, like all fundamental questions, the answer is much more complex. Indeed, the attending cardiologist on the ward round may respond with (a) it’s not a myocardial infarction (MI); (b) it’s missed obstructive coronary artery disease (CAD); (c) minor atherosclerotic CAD is responsible; (d) non-atherosclerotic mechanisms such as spasm are involved; or, (e) I am not certain, since we need more research! Even more disquieting is what the patient is told and the formal diagnosis included in the discharge letter, since both will have an important impact on patient care.


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        • Beltrame J.F.
        Assessing Patients with Myocardial Infarction and Non-obstructed Coronary Arteries (MINOCA).
        J Intern Med. 2013; 273: 182-185
        • Agewall S.
        • Beltrame J.F.
        • Reynolds H.R.
        • Niessner A.
        • Rosano G.
        • Caforio A.L.
        • et al.
        ESC working group position paper on myocardial infarction with non-obstructive coronary arteries.
        Eur Heart J. 2017; 38: 143-153
        • Pasupathy S.
        • Air T.
        • Dreyer R.P.
        • Tavella R.
        • Beltrame J.F.
        Response to Letter Regarding Article, “Systematic Review of Patients Presenting With Suspected Myocardial Infarction and Nonobstructive Coronary Arteries”.
        Circulation. 2015; 132: e232
        • Pasupathy S.
        • Air T.
        • Dreyer R.P.
        • Tavella R.
        • Beltrame J.F.
        Systematic Review of Patients Presenting with Suspected Myocardial Infarction and Non-Obstructive Coronary Arteries (MINOCA).
        Circulation. 2015; 131: 861-870
        • Chung S.L.
        • Lei M.H.
        • Chen C.C.
        • Hsu Y.C.
        • Yang C.C.
        Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED.
        Am J Emerg Med. 2013; 31: 825-829
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • Simoons M.L.
        • Chaitman B.R.
        • White H.D.
        Third Universal Definition of Myocardial Infarction.
        Circulation. 2012;
        • Tornvall P.
        • Gerbaud E.
        • Behaghel A.
        • Chopard R.
        • Collste O.
        • Laraudogoitia E.
        • et al.
        Myocarditis or “true” infarction by cardiac magnetic resonance in patients with a clinical diagnosis of myocardial infarction without obstructive coronary disease: A meta-analysis of individual patient data.
        Atherosclerosis. 2015; 241: 87-91
        • Guagliumi G.
        • Capodanno D.
        • Saia F.
        • Musumeci G.
        • Tarantini G.
        • Garbo R.
        • et al.
        Mechanisms of atherothrombosis and vascular response to primary percutaneous coronary intervention in women versus men with acute myocardial infarction: results of the OCTAVIA study.
        JACC Cardiovasc Interv. 2014; 7: 958-968
        • Reynolds H.R.
        • Srichai M.B.
        • Iqbal S.N.
        • Slater J.N.
        • Mancini G.B.
        • Feit F.
        • et al.
        Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease.
        Circulation. 2011; 124: 1414-1425
        • Ouldzein H.
        • Elbaz M.
        • Roncalli J.
        • Cagnac R.
        • Carrie D.
        • Puel J.
        • et al.
        Plaque rupture and morphological characteristics of the culprit lesion in acute coronary syndromes without significant angiographic lesion: analysis by intravascular ultrasound.
        Ann Cardiol Angeiol (Paris). 2012; 61: 20-26
        • Crea F.
        • Libby P.
        Acute Coronary Syndromes: The Way Forward From Mechanisms to Precision Treatment.
        Circulation. 2017; 136: 1155-1166
        • Van De Water N.S.
        • French J.K.
        • Lund M.
        • Hyde T.A.
        • White H.D.
        • Browett P.J.
        Prevalence of factor V Leiden and prothrombin variant G20210A in patients age <50 years with no significant stenoses at angiography three to four weeks after myocardial infarction.
        J Am Coll Cardiol. 2000; 36: 717-722
        • Beltrame J.F.
        • Crea F.
        • Kaski J.C.
        • Ogawa H.
        • Ong P.
        • Sechtem U.
        • et al.
        The Who, What, Why, When, How and Where of Vasospastic Angina.
        Circ J. 2016; 80: 289-298
        • Fearon W.F.
        • Shah M.
        • Ng M.
        • Brinton T.
        • Wilson A.
        • Tremmel J.A.
        • et al.
        Predictive value of the index of microcirculatory resistance in patients with ST-segment elevation myocardial infarction.
        J Am Coll Cardiol. 2008; 51: 560-565
        • Carrick D.
        • Haig C.
        • Ahmed N.
        • Carberry J.
        • Yue May V.T.
        • McEntegart M.
        • et al.
        Comparative Prognostic Utility of Indexes of Microvascular Function Alone or in Combination in Patients With an Acute ST-Segment-Elevation Myocardial Infarction.
        Circulation. 2016; 134: 1833-1847
        • Beltrame J.F.
        • Limaye S.B.
        • Horowitz J.D.
        The coronary slow flow phenomenon - a new coronary microvascular disorder.
        Cardiology. 2002; 97: 197-202
        • Lindahl B.
        • Baron T.
        • Erlinge D.
        • Hadziosmanovic N.
        • Nordenskjold A.
        • Gard A.
        • et al.
        Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease.
        Circulation. 2017; 135: 1481-1489