In theory, the diagnosis of MINOCA is clearly separated from MI with obstructive CAD (MI-CAD) as well from myocardial injury of non-ischaemic causes, e.g., Takotsubo syndrome and myocarditis ( Central illustration, part A). MINOCA may be further subdivided into no or very minor atherosclerosis (0-30% stenosis) and minor atherosclerosis with 30-49% stenosis 4. The cut-off of 50% diameter stenosis for defining “obstructive CAD” in MINOCA is based on studies on what degree of stenosis is flow limiting and may cause ischaemia under stress 3. For the diagnosis of MINOCA, the fourth universal definition of myocardial infarction (UDMI) requires that the usual criteria for MI are met and, in addition, no stenosis ≥50% in a major epicardial artery is demonstrated on coronary angiography (i.e., non-obstructive coronary arteries) 2. Clinically, elevation of troponin is used as a surrogate for myocardial cell death and, hence, all myocardial injury detected by elevated troponin in the setting of acute myocardial ischaemia should be labelled as MI 2. Myocardial infarction is defined pathologically as myocardial cell death due to prolonged ischaemia. Furthermore, there is also some confusion and lack of consensus regarding the definition of MINOCA, which is important to bear in mind when interpreting the literature. Although knowledge about MINOCA is rapidly increasing, there are still fundamental gaps in our current knowledge. Although it has been known for a long time that myocardial infarction (MI) might occur in the absence of obstructive coronary artery disease (CAD) 1, awareness of and interest in the phenomenon among clinicians only gained momentum as coronary angiography became common in the management of acute MI. The first paper including the term “myocardial infarction with non-obstructive coronary arteries” (MINOCA) was published in 2013 by the end of 2020, 210 papers had been published. ![]() In addition, remaining important knowledge gaps are highlighted. The present review summarises the current knowledge of MINOCA regarding epidemiology, pathophysiology, investigation, and treatment, with a special focus on imaging modalities. There is still some confusion around the diagnosis, investigation and management of patients with MINOCA. Clinically, MINOCA may be difficult to distinguish from other non-ischaemic conditions that can cause similar symptoms and myocardial injury. MINOCA is a heterogeneous disease entity seen in 5-10% of all patients with myocardial infarction, especially in women. At the same time, research interest in MINOCA has increased significantly. ![]() ![]() As a result of the increased use of coronary angiography in acute myocardial infarction in the last two decades, myocardial infarction with non-obstructive coronary arteries (MINOCA) has received growing attention in everyday clinical practice.
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