Myocardial infarction with non-obstructive coronary arteries: what is the prognosis?

Giampaolo Niccoli1,2 and Paolo G. Camici3*

1Universita’ Cattolica del Sacro Cuore, Rome, Italy;
2Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; 3Universita’ Vita-Salute e Ospedale San Raffaele, IRCCS Milano, Italy

Findings

Review article of:

Definition, diagnosis and prognosis of MINOCA

(myocardial injury with non occluded coronary arteries)

Bottom line

A normal recent angiogram does not equal no myocardial ischemia

What is the paper about

Pathological explanation of minoca and diagnostic workup (precision medicine)

Pathology

Epicardial mechanism:

unstable plaque

Coronary artery dissection

Epicardial vasospasm

Microvascular mechanism:

Intrinsic: spasm, Takazubo, Coronary artery thrombembolism

Extrinsic: Myocarditis

Unclear origin

 

Diagnostic pathway

 First level investigations:

ECG, trop, Echo, angiogram and ventriculogram

 Second level investigations:

Intravascular ultrasound, optical coherence tomography, coronary vasomotor tests

Cardiac MRI

Findings

Conflicting evidence regarding the prognosis of MINOCA

• Likely dependent on Pathophysiology leading to myocardial hypoperfusion
• no standardized second level investigations (often exact diagnosis unclear)  large variety in inclusion and exclusion criteria in compared article\

High risk subset with epicardial mechanism

elevated CRP can indicate repeat occlusion due to inflammatory response

close follow up recommended

High risk group microvasculature mechanism

ongoing angina symptoms affect quality of life

mortality greater after discharge then in average population of same age

Weakness

No clear point taken regarding the prognosis but rises awareness of minoca

Take home point

Recent normal angiogram (level one investigation) does not exclude myocardial injury

Knowledge of inflammatory markers can assist in risk stratification of unstable thrombus