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The Imaging Toolbox to Assess Patients with Suspected Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA)

  • Management of Acute Coronary Syndromes (H Jneid, Section Editor)
  • Published:
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Abstract

Purpose of Review

This paper will review myocardial infarction with non-obstructive coronary arteries (MINOCAs) briefly, and then focus on the imaging tools that should be employed when caring for patients with suspected MINOCA.

Recent Findings

Diagnostic imaging has a critical role in assessing patients with suspected or confirmed MINOCA. The extent at which these diagnostic tests are used in any given patient will depend on the clinical acumen for the underlying condition, as well as the available resources.

Summary

There are myriad conditions that can lead to MINOCA; further testing to exclude other underlying causes of myocardial injury is crucial. Cardiovascular imaging may assist in identifying the etiological cause in cases where MINOCA remains the most likely diagnosis. A systematic approach to the diagnostic assessment will help to uncover the underlying diagnosis, guide therapy, and provide the patient and their families with appropriate feedback.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–425.

    PubMed  Google Scholar 

  2. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344–426.

    PubMed  Google Scholar 

  3. Smilowitz NR, Mahajan AM, Roe MT, Hellkamp AS, Chiswell K, Gulati M, et al. Mortality of myocardial infarction by sex, age, and obstructive coronary artery disease status in the ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines). Circulation Cardiovascular quality and outcomes. 2017;10:e003443.

    Article  Google Scholar 

  4. Safdar B, Spatz E, Dreyer R, Beltrame J, Lichtman J, Reynolds H, et al. Presentation, clinical profile and prognosis of young patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) - results from the variation in recovery: role of gender on outcomes of young AMI patients (VIRGO) study. J Am Heart Assoc. 2018;7(13):e009174. https://doi.org/10.1161/JAHA.118.009174.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015;131:861–70.

    Article  CAS  Google Scholar 

  6. Barr PR, Harrison W, Smyth D, Flynn C, Lee M, Kerr AJ. Myocardial infarction without obstructive coronary artery disease is not a benign condition (ANZACS-QI 10). Heart, lung & circulation. 2018;27:165–74.

    Article  Google Scholar 

  7. •• Tamis-Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM, et al. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation. 2019;139:e891–908 This paper suggests that the optimal assessment for patients with a MINOCA diagnosis should be aimed at determining the specific cause for each patient, after excluding other causes for elevation of troponin, so that targeted therapies can be used.

    Article  Google Scholar 

  8. Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart JEur Heart J. 2017;38:143–53.

    Google Scholar 

  9. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. The executive group on behalf of the joint ESC/ACC/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018;138(20):e618–51. https://doi.org/10.1161/CIR.0000000000000617.

    Article  PubMed  Google Scholar 

  10. Paolisso P, Bergamaschi L, Saturi G, D'Angelo EC, Magnani I, Toniolo S, et al. Secondary prevention medical therapy and outcomes in patients with myocardial infarction with non-obstructive coronary artery disease. Front Pharmacol. 2019;10:1606.

    Article  CAS  Google Scholar 

  11. Choo EH, Chang K, Lee KY, Lee D, Kim JG, Ahn Y, et al. Prognosis and predictors of mortality in patients suffering myocardial infarction with non-obstructive coronary arteries. J Am Heart Assoc. 2019;8:e011990.

    Article  Google Scholar 

  12. 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;135:1481–9.

    Article  Google Scholar 

  13. 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;61:20–6.

    Article  CAS  Google Scholar 

  14. Reynolds HR, Srichai MB, Iqbal SN, Slater JN, Mancini GB, Feit F, et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation. 2011;124:1414–25.

    Article  Google Scholar 

  15. Opolski MP, Spiewak M, Marczak M, Debski A, Knaapen P, Schumacher SP, et al. Mechanisms of myocardial infarction in patients with nonobstructive coronary artery disease: results from the optical coherence tomography study. JACC Cardiovasc Imaging. 2019 Nov;12(11 Pt 1):2210–21. https://doi.org/10.1016/j.jcmg.2018.08.022.

    Article  PubMed  Google Scholar 

  16. Jia H, Kubo T, Akasaka T, Yu B. Optical coherence tomography guidance in management of acute coronary syndrome caused by plaque erosion. Circ J. 2018;82:302–8.

    Article  Google Scholar 

  17. Alfonso F, Paulo M, Gonzalo N, Dutary J, Jimenez-Quevedo P, Lennie V, et al. Diagnosis of spontaneous coronary artery dissection by optical coherence tomography. J Am Coll Cardiol. 2012;59:1073–9.

    Article  Google Scholar 

  18. Iqbal SN, Feit F, Mancini GB, Wood D, Patel R, Pena-Sing I, et al. Characteristics of plaque disruption by intravascular ultrasound in women presenting with myocardial infarction without obstructive coronary artery disease. Am Heart J. 2014;167:715–22.

    Article  Google Scholar 

  19. Jang JH, Kim DH, Yang DH, Woo SI, Kwan J, Park KS, et al. Spontaneous coronary artery dissection by intravascular ultrasound in a patient with myocardial infarction. Korean J Internal Med. 2014;29:106–10.

    Article  Google Scholar 

  20. Buxton A, Goldberg S, Hirshfeld JW, Wilson J, Mann T, Williams DO, et al. Refractory ergonovine-induced coronary vasospasm: importance of intracoronary nitroglycerin. Am J Cardiol. 1980;46:329–34.

    Article  CAS  Google Scholar 

  21. Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Cammà G, et al. Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart JEur Heart J. 2018;39(2):91–8.

    CAS  Google Scholar 

  22. •• Dastidar AG, Baritussio A, De Garate E, Drobni Z, Biglino G, Singhal P, et al. Prognostic role of CMR and conventional risk factors in myocardial infarction with nonobstructed coronary arteries. JACC Cardiovasc Imaging. 2019;12(10):1973–82 This study highlights the potential benefit of using additional tests to further evaluate patients with MINOCA for better cause-based, tailored treatment. CMR is increasingly available and can confirm MI to categorize patients accurately according to MINOCA’s contemporary definition.

    Article  Google Scholar 

  23. Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J. 2017;38:143–53.

    PubMed  Google Scholar 

  24. Aldrovandi A, Cademartiri F, Arduini D, Lina D, Ugo F, Maffei E, et al. Computed tomography coronary angiography in patients with acute myocardial infarction without significant coronary stenosis. Circulation. 2012;126:3000–7.

    Article  Google Scholar 

  25. Evangelos K, OikonomouHenry W. West,Charalambos Antoniades Cardiac computed tomography assessment of coronary inflammation and other plaque features. Arterioscler Thromb Vasc Biol. 2019;39(11):2207–19.

    Article  Google Scholar 

  26. Kitagawa T, Yamamoto H, Horiguchi J, Ohhashi N, Tadehara F, Shokawa T, et al. Characterization of noncalcified coronary plaques and identification of culprit lesions in patients with acute coronary syndrome by 64-slice computed tomography. JACC Cardiovasc Imaging. 2009;2:153–60.

    Article  Google Scholar 

  27. Ko SM, Hwang SH, Lee HJ. Role of cardiac computed tomography in the diagnosis of left ventricular myocardial diseases. J Cardiovasc Imaging. 2019 Apr;27(2):73–92.

    Article  Google Scholar 

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Acknowledgments

We would like to thank Dr. Emmanouil Brilakis for providing the images for Fig. 3.

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Authors and Affiliations

  1. Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Soheila Talebi, Pedro Moreno & Jacqueline E. Tamis-Holland

  2. Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Abel Casso Dominguez

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  1. Soheila Talebi
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  2. Pedro Moreno
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  3. Abel Casso Dominguez
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  4. Jacqueline E. Tamis-Holland
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Corresponding author

Correspondence to Jacqueline E. Tamis-Holland.

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Video 1

Cine-angiogram of a 54-year-old patient with known history of non-obstructive CAD, presenting with chest pain and elevated cardiac biomarkers. Angiogram of the RCA demonstrates distal occlusion of the second right posterior-lateral artery, a finding that was not noted on initial review of the angiogram. (AVI 1034 kb)

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Talebi, S., Moreno, P., Dominguez, A.C. et al. The Imaging Toolbox to Assess Patients with Suspected Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA). Curr Cardiol Rep 22, 134 (2020). https://doi.org/10.1007/s11886-020-01379-x

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  • DOI: https://doi.org/10.1007/s11886-020-01379-x

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