Editor’s Choice- Pathophysiology, diagnosis and management of MINOCA: an update

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a syndrome with different causes, characterised by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography. Its prevalence ranges between 5% and 25% of all myocardial infarction. The prognosis is extremely variable, depending on the cause of MINOCA. The key principle in the management of this syndrome is to clarify the underlying individual mechanisms to achieve patient-specific treatments. Clinical history, electrocardiogram, cardiac enzymes, echocardiography, coronary angiography and left ventricular angiography represent the first level diagnostic investigations to identify the causes of MINOCA. Regional wall motion abnormalities at left ventricular angiography limited to a single epicardial coronary artery territory identify an 'epicardial pattern'whereas regional wall motion abnormalities extended beyond a single epicardial coronary artery territory identify a 'microvascular pattern'. The most common causes of MINOCA are represented by coronary plaque disease, coronary dissection, coronary artery spasm, coronary microvascular spasm, Takotsubo cardiomyopathy, myocarditis, coronary thromboembolism, other forms of type 2 myocardial infarction and MINOCA of uncertain aetiology. This review aims at summarising the diagnosis and management of MINOCA, according to the underlying physiopathology.