ESC Position on MI With Nonobstructive Coronary Arteries
- Agewall S, Beltrame JF, Reynolds HR, et al.
- ESC Working Group Position Paper on Myocardial Infarction With Non-Obstructive Coronary Arteries. Eur Heart J 2016;Apr 28:[Epub ahead of print].
The following are key points to remember about this position paper on myocardial infarction with nonobstructive coronary arteries (MINOCA) from the European Society of Cardiology:
- Among patients presenting with ST-segment elevation myocardial infarction (STEMI), the majority have coronary artery occlusion by angiography. In contrast, in patients presenting with NSTEMI, approximately 25% have evidence of coronary artery occlusion. Approximately 10% of patients presenting with acute MI (AMI) have no significant obstructive coronary artery disease (CAD). A diagnosis of MINOCA can be made in patients presenting with features consistent with AMI and a coronary angiogram demonstrating nonobstructive CAD.
- The following criteria are needed for a diagnosis MINOCA: a positive cardiac biomarker such a cardiac troponin at least one value above the 99th percentile with a serial rise and fall, along with clinical evidence of ischemia (symptoms, ST-T wave changes, development of pathologic Q waves, imaging evidence of new loss of viable myocardium or new wall motion abnormality, intracoronary thrombus evident on angiography or at autopsy, or nonobstructive coronary arteries on angiography.
- While males outnumber females for AMI with obstructive CAD, the number of males is only slightly higher than females among patients with MINOCA.
- Nonobstructive coronary arteries on angiography are defined as the absence of obstructive CAD on angiography (i.e., no coronary artery stenosis ≥50%) in any potential infarct-related artery. This includes patients with normal coronary arteries (no stenosis >30%) or mild coronary atherosclerosis (stenosis >30% but <50%).
- Potential causes of elevated troponins include coronary etiologies such as plaque rupture, coronary artery spasm, spontaneous coronary dissection, coronary causes, acute aortic dissection with coronary extension, coronary microvascular disorders, spontaneous coronary thrombosis–thrombophilia disorders, coronary emboli, sympathomimetic agents (such as cocaine, or methamphetamines), and noncoronary causes such as myocarditis, takotsubo cardiomyopathy, cardiomyopathies, cardiac trauma, strenuous exercise, tachyarrhythmias, cardiotoxins (such as chemotherapeutic agents) associated with extracardiac disorders, stroke, pulmonary embolism, sepsis, adult respiratory distress syndrome, and end-stage renal failure.
- Multimodalities are often required to diagnose and evaluate MINOCA. Beyond coronary angiograms, use of echocardiograms, magnetic resonance imaging, computed tomography, and intravascular ultrasound frequently assist the clinician in detecting the etiology of MINOCA. Given the estimated prevalence of up to 13% of AMI patients having MINOCA, a better understanding regarding the mechanisms and management of these patients is warranted.
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