Myocardial infarction with non-obstructive coronary arteries: the past, present and the future.


  • KIVIRJIK Irina IMSP Institutul de Cardiologie



myocardial infarction, non-obstructive coronary arteries, MINOCA


Myocardial infarction with non-obstructive coronary arteries (MINOCA) involves clinical documentation of an AMI and demonstration of the absence of anatomically significant stenosis (<50% of lumen diameter) on coronary angiography. As it has a heterogeneity of etiologic factors, the mechanisms of MINOCA as well as the performance of diagnostic algorithms and therapeutic strategies have been extensively studied. The importance of personal management strategy for each patient is presented alongside stratification of risks of recurrent cardiovascular events. This statement provides a general view on MINOCA based on the newest published data.

Author Biography

KIVIRJIK Irina, IMSP Institutul de Cardiologie

Laboratorul științific Urgențe cardiace


DeWood M. A. et al., “Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction,” N. Engl. J. Med., 1980, vol. 303, no. 16, pp. 897–902.

Parikh J. A. et al., “Coronary arteriographic findings soon after non Q wave myocardial infarction.,” Indian Heart J., 1989, vol. 41, no. 5, pp. 280–283.

Agewall S. et al., “ESC working group position paper on myocardial infarction with non-obstructive coronary arteries,” Eur. Heart J., 2017, vol. 38, no. 3, pp. 143–153.

Thygesen K. et al., “Fourth Universal Definition of Myocardial Infarction (2018),” Circulation, , 2018, vol. 138, no. 20, pp. e618–e651.

Gross H., Sternberg W. H., “Myocardial infarction without significant lesions of coronary arteries,” Arch. Intern. Med., 1939, vol. 64, no. 2, pp. 249–267.

McCabe J. M. et al., “Prevalence and factors associated with false-positive ST-segment elevation myocardial infarction diagnoses at primary percutaneous coronary intervention–capable centers: a report from the Activate-SF registry,” Arch. Intern. Med., 2012, vol. 172, no. 11, pp. 864–871.

Agewall S. et al., “Myocardial infarction with angiographically normal coronary arteries,” Atherosclerosis, 2011, vol. 219, no. 1, pp. 10–14.

Beltrame J. F., “Assessing patients with myocardial infarction and nonobstructed coronary arteries (MINOCA),” J. Intern. Med., 2013, vol. 273, no. 2, pp. 182–185.

Bugiardini R., Merz C. N. B., “Angina with ‘normal’ coronary arteries: a changing philosophy,” JAMA, 2005, vol. 293, no. 4, pp. 477–484.

Marzilli M., “Chronic ischemic heart disease,”Hear. Metab., 2009, no. 42, p. 3.

Bugiardini R., Manfrini O., De Ferrari G. M., “Unanswered Questions for Management of Acute Coronary Syndrome Risk Stratification of Patients With Minimal Disease or Normal Findings on Coronary Angiography.” [Online]. Available:

Pasupathy S., Air T., Dreyer R. P., Tavella R., Beltrame J. F., “Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries,” Circulation, 2015, vol. 131, no. 10, pp. 861–870.

Pizzi C. et al., “Nonobstructive Versus Obstructive Coronary Artery Disease in Acute Coronary Syndrome: A Meta-Analysis,” J. Am. Heart Assoc., 2016, vol. 5, no. 12.

Gehrie E. R. et al., “Characterization and outcomes of women and men with non-ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative,” Am. Heart J., 2009, vol. 158, no. 4, pp. 688–694.

Smilowitz N. R. 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),” Circ. Cardiovasc. Qual. Outcomes, 2017, vol. 10, no. 12.

Patel M. R. et al., “Prevalence, predictors, and outcomes of patients with non-ST-segment elevation myocardial infarction and insignificant coronary artery disease: results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative,” Am. Heart J., 2006, vol. 152, no. 4, pp. 641–647.

Planer D. et al., “Prognosis of patients with non-ST-segment-elevation myocardial infarction and nonobstructive coronary artery disease: propensity-matched analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial,” Circ. Cardiovasc. Interv., 2014, vol. 7, no. 3, pp. 285–293.

Nordenskjöld A. M., Baron T., Eggers K. M., Jernberg T., Lindahl B., “Predictors of adverse outcome in patients with myocardial infarction with non-obstructive coronary artery (MINOCA) disease,” Int. J. Cardiol., vol. 261, pp. 18–23, Jun. 2018, doi: 10.1016/J.IJCARD.2018.03.056.

“Start SWEDEHEART.” swedeheart/.

Scalone G., Niccoli G., Crea F., “Editor’s ChoicePathophysiology, diagnosis and management of MINOCA: an update,” Eur. Hear. journal. Acute Cardiovasc. care, 2019, vol. 8, no. 1, pp. 54–62 .

Jia H. et al., “In vivo diagnosis of plaque erosion and calcified nodule in patients with acute coronary syndrome by intravascular optical coherence tomography,” J. Am. Coll. Cardiol., 2013, vol. 62, no. 19, pp. 1748–1758.

Tamis-Holland J. E. 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, vol. 139, no. 18, pp. E891–E908.

Reynolds H. R. et al., “Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease,” Circulation, 2011, vol. 124, no. 13, pp. 1414–1425.

Ouldzein H. 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, vol. 61, no. 1, pp. 20–26.

Niccoli G., Scalone G., Crea F., “Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management,” Eur. Heart J., 2015, vol. 36, no. 8, pp. 475–481.

Montone R. A. et al., “Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests,” Eur. Heart J., 2018, vol. 39, no. 2, pp. 91–98.

Pristipino C. et al., “Major racial differences in coronary constrictor response between japanese and caucasians with recent myocardial infarction,” Circulation, 2000, vol. 101, no. 10, pp. 1102–1108.

Lanza G. A. et al., “Current clinical features, diagnostic assessment and prognostic determinants of patients with variant angina,” Int. J. Cardiol., 2007, vol. 118, no. 1, pp. 41–47.

J. Saw et al., “Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging,” Catheter. Cardiovasc. Interv., vol. 87, no. 2, pp. E54–E61, Feb. 2016, doi: 10.1002/CCD.26022.

Saw J. et al., “Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence,” J. Am. Coll. Cardiol., 2017, vol. 70, no. 9, pp. 1148–1158.

Havakuk O., Goland S., Mehra A., Elkayam U., “Pregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases,” Circ. Cardiovasc. Interv., 2017, vol. 10, no. 3.

Saw J. et al., “Spontaneous coronary artery dissection: association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes,” Circ. Cardiovasc. Interv., 2014, vol. 7, no. 5, pp. 645–655.

Saw J., Aymong E., Mancini G. B. J., Sedlak T., Starovoytov A., Ricci D., “Nonatherosclerotic coronary artery disease in young women,” Can. J. Cardiol., 2014, vol. 30, no. 7, pp. 814–819.

Tweet M. S. et al., “Clinical features, management, and prognosis of spontaneous coronary artery dissection,” Circulation, 2012, vol. 126, no. 5, pp. 579–588.

Mohri M. et al., “Angina pectoris caused by coronary microvascular spasm,” Lancet (London, England), 1998, vol. 351, no. 9110, pp. 1165–1169.

Ong P. et al., “International standardization of diagnostic criteria for microvascular angina,” Int. J. Cardiol., 2018, vol. 250, pp. 16–20.

Vidal-Perez R. et al., “Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions,” World J. Cardiol., 2019, vol. 11, no. 12, pp. 305–315.

Masumoto A., Mohri M., Takeshita A., “Threeyear follow-up of the Japanese patients with microvascular angina attributable to coronary microvascular spasm,” Int. J. Cardiol., 2001, vol. 81, no. 2–3, pp. 151–156.

Shibata T. et al., “Prevalence, Clinical Features, and Prognosis of Acute Myocardial Infarction Attributable to Coronary Artery Embolism,” Circulation, 2015, vol. 132, no. 4, pp. 241–250.

Safdar B. et al., “Elevated renalase levels in patients with acute coronary microvascular dysfunction A possible biomarker for ischemia,” Int. J. Cardiol., 2019, vol. 279, pp. 155–161.

Jȩdrychowska M. et al., “ST-segment elevation myocardial infarction with non-obstructive coronary arteries: Score derivation for prediction based on a large national registry,” PLoS One, 2021, vol. 16, no. 8.

Espinosa Pascual M. J. et al., “P882Predictors of myocardial infarction with non-obstructive coronary arteries (MINOCA),” Eur. Heart J., 2019, vol. 40, no. Supplement_1.