Myocardial infarction with non-obstructive coronary arteries
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Myocardial infarction with non-obstructive coronary arteries (MINOCA) is referred to as a syndrome characterized by the clinical characteristics of myocardial infarction but with normal or at least almost normalcoronary arteries or no significant coronary arteriesstenosis on coronary angiography.
Epidemiology
The suggested prevalence ranges from 1-14% 1-3 with women being more commonly affected than men 4,5.
Clinical presentation
Patients present with features of acute myocardial infarction defined by the universal criteria for acute myocardial infarction 4 including a rise of cardiac troponin values above the 99th percentile and one of the following 1-3:
·
- typical clinical symptoms of myocardial ischaemia
· - new ischaemic ECG changes as
signifantsignificant ST-T changes or left bundle branch block· - new pathological Q-waves
The entity MINOCA is a working diagnosis with the following diagnostic criteria:
1. universal
-
universal criteria for acute myocardial infarction defined by a positive cardiac biomarker and confirmative clinical evidence
2. - non-obstructive coronary arteries on coronary angiography
3. - no clinically overt specific cause for the acute presentation
Complications
Complications of myocardial infarction with non-obstructive coronary arteries (MINOCA) include major adverse cardiac events (MACE) and death 1.
Pathology
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity with many different possible pathologic causes 1-3.
Once one of the aetiologies has become evident, the condition should be no longer termed this way.
Aetiology
Aetiologies include the following 1-3:
- coronary plaque disruption when no thrombus can be found (due to plaque rupture, erosion or ulceration)
- coronary dissection or intramural haematoma
- coronary artery spasms( due to hyper-reactivity to endogenous substances or exogenous vasospastic agents e.g. drugs)
- coronary embolism (due to hereditary or acquired thrombotic disorders, paradoxical embolism, valvular disease and/or vegetations, cardiac tumours etc. )
- supply-demand mismatch
(anaemia(tachyarrhythmia/bradyarrhythmia,tachy-brady-arrhythmiaanaemia, hypotension, shock, severe hypertension, cardiomyopathy etc.) - Tako-tsubo cardiomyopathy
- unrecognized myocarditis
- uncertain aetiology
Radiographic features
Imaging features of myocardial infarction with non-obstructive coronary arteries (MINOCA) include the following 1,4:
·
- new regional wall motion abnormality or a new loss of viable myocardium on imaging e.g. subendocardial late gadolinium enhancement
· - non-obstructive coronary arteries on angiography, defined as the absence of any coronary artery stenosis ≥50% in any infarct
related-related artery
UltrasoundEchocardiography
Cardiac echo can show new regional or global wall motion abnormalities and has a role in the search for the aetiology.
Intravascular ultrasound (IVUS) has an important role in the detection of plaque rupture and/or ulceration as well as the detection of coronary artery dissection.
Cardiac CT
In order to make the diagnosis myocardial infarction with non-obstructive coronary arteries (MINOCA), cardiac CT should not show any significant coronary artery obstruction in any of the potential infarct related-related arteries, even though the method is not part of the guidelines as yet 1,4.
In the search of the aetiology, it could be helpful in demonstrating coronary dissection or intramural haematoma as well as the demonstration of coronary plaque burden 3.
Coronary angiography (DSA)
As per definition myocardial infarction with non-obstructive coronary arteries (MINOCA), features a normal coronary angiogram or at least no significant coronary artery stenosis in any of the potential infarct related-related arteries.
Intravascular imaging as intravascular ultrasound (IVUS) or optical coherence tomography (OCT) havehas an important role in the workup, in particular in the detection of plaque rupture and/or ulceration as well as the detection of coronary artery dissection 2,3.
Provocative spasm testing can detect and confirm coronary vasospasm. However, the procedure should not be conducted in the acute stage of a myocardial infarction 3.
MRI
Due to its cardiac tissue characterization ability, cardiac MRI has an important role in the work upworkup of myocardial infarction with non-obstructive coronary arteries (MINOCA) 2,3. It can provide further clues in the search for the cause. The pattern of late gadolinium enhancement can suggest a typical infarct-related vascular pattern or might point towards a non-vascular or inflammatory type pattern or myocardial infiltrative disease 2,3.
However, about 8-67% of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) do not show any cardiac wall motion abnormalities, myocardial oedema or late gadolinium enhancement 2.
Radiology report
The radiological report should obviously describe and suggest possible underlying causes of the above condition if this is evident and withinon imaging.
Within the scope of this article is confined to the imaging methods besides coronary angiography and intravascular imaging.:
echocardiography
·
Echocardiography
- wall motion abnormalities and/or hypertrophy
· - valvular disease
· - valvular vegetations if present
· - cardiac thrombi
cardiac
Cardiac CT
·
- coronary plaque burden
· - coronary anomalies
· - possible myocardial bridging in particular in left ventricular hypertrophy
cardiac
Cardiac MRI
·
- wall motion abnormalities
· - presence myocardial oedema
· - presence and characterization of late gadolinium enhancement (vascular vs non-vascular patterns)
· - indicate possible diagnosis e.g. myocarditis, Tako-tsubo cardiomyopathy or other cardiomyopathies
·findings - findings are indicative of a possible source for coronary embolism as left ventricular thrombi cardiac valve disease, cardiac tumours, persistent foramen ovale (PFO) etc.
Treatment and prognosis
Obviously treatment of myocardial infarction with non-obstructive coronary arteries (MINOCA) varies with the underlying cause, which should be searched for.
Treatment options include the following 2:
·
- antiplatelet therapy, angiotensin receptor blocker and beta
blockers-blockers in case of coronary plaque disruption· - conservative treatment with antiplatelet therapy and beta
blockers-blockers in coronary artery dissection· - calcium antagonists, nitrates,
rhoRho-kinase inhibitors in coronary vasospasm· -
PFO closure device, antiplatelet therapy, anticoagulation in case of a coronary embolism
· - heart failure treatment in myocarditis or Tako-tsubo cardiomyopathy
· - reversal of the underlying cause in an underlying oxygen supply-demand mismatch
· - aspirin, statins and calcium antagonists in case of uncertain aetiology
The outcome of myocardial infarction with non-obstructive coronary arteries (MINOCA) is determined by the underlying aetiology, the overall prognosis is serious, though, with a 1 year-year mortality of about 3.5% 1,5.
Differential diagnosis
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a working diagnosis and due to its quite serious prognosis, it warrants a meticulous search of the underlying causes 1-3, which are the differential diagnosis in this entity.
See also
·
- myocardial infarction
· - myocarditis
· - Takotsubo cardiomyopathy
-<p>Myocardial infarction with non-obstructive coronary arteries (MINOCA) is referred to as a syndrome characterized by the clinical characteristics of myocardial infarction but with normal or at least almost normal coronary arteries on angiography.</p><p><strong>Epidemiology</strong></p><p>The suggested prevalence ranges from 1-14% <sup>1-3</sup> with women being more commonly affected than men <sup>4,5</sup>.</p><h4>Clinical presentation</h4><p>Patients present with features of acute myocardial infarction defined by the universal criteria for acute myocardial infarction <sup>4</sup> including a rise of cardiac troponin values above the 99<sup>th</sup> percentile and one of the following <sup>1-3</sup>:</p><p><!--[if !supportLists]-->· <!--[endif]-->typical clinical symptoms of myocardial ischaemia</p><p><!--[if !supportLists]-->· <!--[endif]-->new ischaemic ECG changes as signifant ST-T changes or left bundle branch block</p><p><!--[if !supportLists]-->· <!--[endif]-->new pathological Q-waves</p><p>The entity MINOCA is a working diagnosis with the following diagnostic criteria:</p><p><!--[if !supportLists]-->1. <!--[endif]--> universal criteria for acute myocardial infarction defined by a positive cardiac biomarker and confirmative clinical evidence</p><p><!--[if !supportLists]-->2. <!--[endif]-->non-obstructive coronary arteries on coronary angiography</p><p><!--[if !supportLists]-->3. <!--[endif]-->no clinically overt specific cause for the acute presentation</p><h5>Complications</h5><p>Complications of myocardial infarction with non-obstructive coronary arteries (MINOCA) include major adverse cardiac events (MACE) and death <sup>1</sup>.</p><h4>Pathology</h4><p>Myocardial infarction with non-obstructive coronary arteries (MINOCA) is heterogeneous clinical entity with many different possible pathologic causes <sup>1-3</sup>.</p><p>Once one of the aetiologies has become evident, the condition should be no longer termed this way.</p><h5>Aetiology</h5><p>Aetiologies include the following <sup>1-3</sup>:</p><p>coronary plaque disruption when no thrombus can be found (due to plaque rupture, erosion or ulceration)</p><p>coronary dissection or intramural haematoma</p><p>coronary artery spasms( due to hyper-reactivity to endogenous substances or exogenous vasospastic agents e.g. drugs)</p><p>coronary embolism (due to hereditary or acquired thrombotic disorders, paradoxical embolism, valvular disease and/or vegetations, cardiac tumours etc. )</p><p>supply-demand mismatch (anaemia, tachy-brady-arrhythmia, hypotension, shock, severe hypertension, cardiomyopathy etc.)</p><p>Tako-tsubo cardiomyopathy</p><p>unrecognized myocarditis</p><p>uncertain aetiology</p><p> </p><h4>Radiographic features</h4><p>Imaging features of myocardial infarction with non-obstructive coronary arteries (MINOCA) include the following <sup>1,4</sup>:</p><p><!--[if !supportLists]-->· <!--[endif]-->new regional wall motion abnormality or a new loss of viable myocardium on imaging e.g. subendocardial late gadolinium enhancement</p><p><!--[if !supportLists]-->· <!--[endif]-->non-obstructive coronary arteries on angiography, defined as absence of any coronary artery stenosis ≥50% in any infarct related artery</p><h5>Ultrasound</h5><p>Cardiac echo can show new regional or global wall motion abnormalities and has a role in the search for the aetiology.</p><p>Intravascular ultrasound (IVUS) has an important role in the detection of plaque rupture and/or ulceration as well as the detection of coronary artery dissection.</p><h5>CT</h5><p>In order to make the diagnosis myocardial infarction with non-obstructive coronary arteries (MINOCA) cardiac CT should not show any significant coronary artery obstruction in any of the potential infarct related arteries, even though the method is not part of the guidelines as yet <sup>1,4</sup>.</p><p>In the search of the aetiology it could be helpful in demonstrating coronary dissection or intramural haematoma as well as the demonstration of coronary plaque burden <sup>3</sup>.</p><h5>Coronary angiography (DSA)</h5><p>As per definition myocardial infarction with non-obstructive coronary arteries (MINOCA), features a normal coronary angiogram or at least no significant coronary artery stenosis in any of the potential infarct related arteries.</p><p>Intravascular imaging as intravascular ultrasound (IVUS) or optical coherence tomography (OCT) have an important role in the workup, in particular in the detection of plaque rupture and/or ulceration as well as the detection of coronary artery dissection <sup>2,3</sup>.</p><p>Provocative spasm testing can detect and confirm coronary vasospasm. However, the procedure should not be conducted in the acute stage of a myocardial infarction <sup>3</sup>.</p><h5>MRI</h5><p>Due to its cardiac tissue characterization ability cardiac MRI has an important role in the work up of myocardial infarction with non-obstructive coronary arteries (MINOCA) <sup>2,3</sup>. It can provide further clues in the search for the cause. The pattern of late gadolinium enhancement can suggest a typical infarct-related vascular pattern or might point towards a non-vascular or inflammatory type pattern or infiltrative disease <sup>2,3</sup>.</p><p>However, about 8-67% of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) do not show any cardiac wall motion abnormalities, myocardial oedema or late gadolinium enhancement <sup>2</sup>.</p><h4>Radiology report</h4><p>The radiological report should obviously describe and suggest possible underlying causes of the above condition if evident and within the scope of this article is confined to the imaging methods besides coronary angiography and intravascular imaging.</p><p>echocardiography</p><p><!--[if !supportLists]-->· <!--[endif]-->wall motion abnormalities and/or hypertrophy</p><p><!--[if !supportLists]-->· <!--[endif]-->valvular disease</p><p><!--[if !supportLists]-->· <!--[endif]-->valvular vegetations if present</p><p><!--[if !supportLists]-->· <!--[endif]-->cardiac thrombi</p><p>cardiac CT</p><p><!--[if !supportLists]-->· <!--[endif]-->coronary plaque burden</p><p><!--[if !supportLists]-->· <!--[endif]-->coronary anomalies</p><p><!--[if !supportLists]-->· <!--[endif]-->possible myocardial bridging in particular in left ventricular hypertrophy</p><p>cardiac MRI</p><p><!--[if !supportLists]-->· <!--[endif]-->wall motion abnormalities</p><p><!--[if !supportLists]-->· <!--[endif]-->presence myocardial oedema</p><p><!--[if !supportLists]-->· <!--[endif]-->presence and characterization late gadolinium enhancement (vascular vs non-vascular patterns)</p><p><!--[if !supportLists]-->· <!--[endif]-->indicate possible diagnosis e.g. myocarditis, Tako-tsubo cardiomyopathy or other cardiomyopathies</p><p><!--[if !supportLists]-->· <!--[endif]-->findings indicative of a possible source for coronary embolism as left ventricular thrombi cardiac valve disease, cardiac tumours, persistent foramen ovale etc.</p><h4>Treatment and prognosis</h4><p>Obviously treatment of myocardial infarction with non-obstructive coronary arteries (MINOCA) varies with the underlying cause, which should be searched for.</p><p>Treatment options include the following <sup>2</sup>:</p><p><!--[if !supportLists]-->· <!--[endif]-->antiplatelet therapy, angiotensin receptor blocker and beta blockers in case of coronary plaque disruption</p><p><!--[if !supportLists]-->· <!--[endif]-->conservative treatment with antiplatelet therapy and beta blockers in coronary artery dissection</p><p><!--[if !supportLists]-->· <!--[endif]-->calcium antagonists, nitrates, rho-kinase inhibitors in coronary vasospasm</p><p><!--[if !supportLists]-->· <!--[endif]-->closure device, antiplatelet therapy, anticoagulation in case of coronary embolism</p><p><!--[if !supportLists]-->· <!--[endif]-->heart failure treatment in myocarditis or Tako-tsubo cardiomyopathy</p><p><!--[if !supportLists]-->· <!--[endif]-->reversal of the underlying cause in an underlying oxygen supply-demand mismatch</p><p><!--[if !supportLists]-->· <!--[endif]-->aspirin, statins and calcium antagonists in case of uncertain aetiology</p><p>The outcome of myocardial infarction with non-obstructive coronary arteries (MINOCA) is determined by the underlying aetiology, the overall prognosis is serious though with a 1 year mortality of about 3.5% <sup>1,5</sup>.</p><h4>Differential diagnosis</h4><p>Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a working diagnosis and due to its quite serious prognosis it warrants a meticulous search of the underlying causes <sup>1-3</sup>, which are the differential diagnosis in this entity.</p><h4>See also</h4><p><!--[if !supportLists]-->· <!--[endif]-->myocardial infarction</p><p><!--[if !supportLists]-->· <!--[endif]-->myocarditis</p><p><!--[if !supportLists]-->· <!--[endif]-->Takotsubo cardiomyopathy</p>- +<p><strong>Myocardial infarction with non-obstructive coronary arteries (MINOCA)</strong> is referred to as a syndrome characterized by the clinical characteristics of <a href="/articles/myocardial-infarction">myocardial infarction</a> but with normal <a title="coronary arteries" href="/articles/coronary-arteries">coronary arteries</a> or no significant coronary stenosis on coronary angiography.</p><h4>Epidemiology</h4><p>The suggested prevalence ranges from 1-14% <sup>1-3</sup> with women being more commonly affected than men <sup>4,5</sup>.</p><h4>Clinical presentation</h4><p>Patients present with features of <a href="/articles/myocardial-infarction">acute myocardial infarction</a> defined by the universal criteria<sup>4</sup> including a rise of <a href="/articles/troponin">cardiac troponin</a> values above the 99<sup>th</sup> percentile and one of the following <sup>1-3</sup>:</p><ul>
- +<li>typical clinical symptoms of myocardial ischaemia</li>
- +<li>new ischaemic ECG changes as significant ST-T changes or left bundle branch block</li>
- +<li>new pathological Q-waves</li>
- +</ul><p>The entity MINOCA is a working diagnosis with the following diagnostic criteria:</p><ol>
- +<li>universal criteria for acute myocardial infarction defined by a positive cardiac biomarker and confirmative clinical evidence</li>
- +<li>non-obstructive coronary arteries on coronary angiography</li>
- +<li>no clinically overt specific cause for the acute presentation</li>
- +</ol><h5>Complications</h5><p>Complications of myocardial infarction with non-obstructive coronary arteries (MINOCA) include major adverse cardiac events (MACE) and death <sup>1</sup>.</p><h4>Pathology</h4><p>Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity with many different possible pathologic causes <sup>1-3</sup>.</p><p>Once one of the aetiologies has become evident, the condition should be no longer termed this way.</p><h5>Aetiology</h5><p>Aetiologies include the following <sup>1-3</sup>:</p><ul>
- +<li>coronary plaque disruption when no thrombus can be found (due to plaque rupture, erosion or ulceration)</li>
- +<li>coronary dissection or intramural haematoma</li>
- +<li>coronary artery spasms( due to hyper-reactivity to endogenous substances or exogenous vasospastic agents e.g. drugs)</li>
- +<li>coronary embolism (due to hereditary or acquired thrombotic disorders, paradoxical embolism, valvular disease and/or vegetations, cardiac tumours etc. )</li>
- +<li>supply-demand mismatch (tachyarrhythmia/bradyarrhythmia, anaemia, hypotension, shock, severe hypertension, cardiomyopathy etc.)</li>
- +<li><a href="/articles/takotsubo-cardiomyopathy">Tako-tsubo cardiomyopathy</a></li>
- +<li>unrecognized <a href="/articles/myocarditis">myocarditis</a>
- +</li>
- +<li>uncertain aetiology</li>
- +</ul><h4>Radiographic features</h4><p>Imaging features of myocardial infarction with non-obstructive coronary arteries (MINOCA) include the following <sup>1,4</sup>:</p><ul>
- +<li>new regional wall motion abnormality or a new loss of viable myocardium on imaging e.g. subendocardial <a href="/articles/late-gadolinium-enhancement-2">late gadolinium enhancement</a>
- +</li>
- +<li>non-obstructive coronary arteries on angiography, defined as the absence of any coronary artery stenosis ≥50% in any infarct-related artery</li>
- +</ul><h5>Echocardiography</h5><p>Cardiac echo can show new regional or global wall motion abnormalities and has a role in the search for the aetiology.</p><p>Intravascular ultrasound (IVUS) has an important role in the detection of plaque rupture and/or ulceration as well as the detection of <a href="/articles/coronary-artery-dissection">coronary artery dissection</a>.</p><h5>Cardiac CT</h5><p>In order to make the diagnosis myocardial infarction with non-obstructive coronary arteries (MINOCA), cardiac CT should not show any significant coronary artery obstruction in any of the potential infarct-related arteries, even though the method is not part of the guidelines as yet <sup>1,4</sup>.</p><p>In the search of the aetiology, it could be helpful in demonstrating coronary dissection or intramural haematoma as well as the demonstration of coronary plaque burden <sup>3</sup>.</p><h5>Coronary angiography (DSA)</h5><p>As per definition myocardial infarction with non-obstructive coronary arteries (MINOCA), features a normal coronary angiogram or at least no significant coronary artery stenosis in any of the potential infarct-related arteries.</p><p>Intravascular imaging as intravascular ultrasound (IVUS) or optical coherence tomography (OCT) has an important role in the workup, in particular in the detection of plaque rupture and/or ulceration as well as the detection of <a href="/articles/coronary-artery-dissection">coronary artery dissection</a> <sup>2,3</sup>.</p><p>Provocative spasm testing can detect and confirm coronary vasospasm. However, the procedure should not be conducted in the acute stage of a <a href="/articles/myocardial-infarction">myocardial infarction</a> <sup>3</sup>.</p><h5>MRI</h5><p>Due to its <a href="/articles/cardiac-tissue-characterization">cardiac tissue characterization</a> ability, cardiac MRI has an important role in the workup of myocardial infarction with non-obstructive coronary arteries (MINOCA) <sup>2,3</sup>. It can provide further clues in the search for the cause. The pattern of <a href="/articles/late-gadolinium-enhancement-2">late gadolinium enhancement</a> can suggest a typical infarct-related vascular pattern or might point towards a non-vascular or inflammatory type pattern or myocardial infiltrative disease <sup>2,3</sup>.</p><p>However, about 8-67% of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) do not show any cardiac wall motion abnormalities, <a href="/articles/myocardial-oedema">myocardial oedema</a> or <a href="/articles/late-gadolinium-enhancement-2">late gadolinium enhancement</a> <sup>2</sup>.</p><h4>Radiology report</h4><p>The radiological report should obviously describe and suggest possible underlying causes of the above condition if this is evident on imaging.</p><p>Within the scope of this article is confined to the imaging methods besides coronary angiography and intravascular imaging:</p><h6>Echocardiography</h6><ul>
- +<li>wall motion abnormalities and/or hypertrophy</li>
- +<li>valvular disease</li>
- +<li>valvular vegetations if present</li>
- +<li>cardiac thrombi</li>
- +</ul><h6>Cardiac CT</h6><ul>
- +<li>coronary plaque burden</li>
- +<li>coronary anomalies</li>
- +<li>possible myocardial bridging in particular in left ventricular hypertrophy</li>
- +</ul><h6>Cardiac MRI</h6><ul>
- +<li>wall motion abnormalities</li>
- +<li>presence myocardial oedema</li>
- +<li>presence and characterization of late gadolinium enhancement (vascular vs non-vascular patterns)</li>
- +<li>indicate possible diagnosis e.g. myocarditis, Tako-tsubo cardiomyopathy or other cardiomyopathies</li>
- +<li>findings are indicative of a possible source for coronary embolism as left ventricular thrombi cardiac valve disease, cardiac tumours, persistent foramen ovale (PFO) etc.</li>
- +</ul><h4>Treatment and prognosis</h4><p>Obviously treatment of myocardial infarction with non-obstructive coronary arteries (MINOCA) varies with the underlying cause, which should be searched for.</p><p>Treatment options include the following <sup>2</sup>:</p><ul>
- +<li>antiplatelet therapy, angiotensin receptor blocker and beta-blockers in case of coronary plaque disruption</li>
- +<li>conservative treatment with antiplatelet therapy and beta-blockers in coronary artery dissection</li>
- +<li>calcium antagonists, nitrates, Rho-kinase inhibitors in coronary vasospasm</li>
- +<li>PFO closure device, antiplatelet therapy, anticoagulation in case of a coronary embolism</li>
- +<li>heart failure treatment in <a title="Myocarditis" href="/articles/myocarditis">myocarditis</a> or <a title="Tako-tsubo cardiomyopathy" href="/articles/takotsubo-cardiomyopathy">Tako-tsubo cardiomyopathy</a>
- +</li>
- +<li>reversal of the underlying cause in an underlying oxygen supply-demand mismatch</li>
- +<li>aspirin, statins and calcium antagonists in case of uncertain aetiology</li>
- +</ul><p>The outcome of myocardial infarction with non-obstructive coronary arteries (MINOCA) is determined by the underlying aetiology, the overall prognosis is serious, though, with a 1-year mortality of about 3.5% <sup>1,5</sup>.</p><h4>Differential diagnosis</h4><p>Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a working diagnosis and due to its quite serious prognosis, it warrants a meticulous search of the underlying causes <sup>1-3</sup>, which are the differential diagnosis in this entity.</p><h4>See also</h4><ul>
- +<li>myocardial infarction</li>
- +<li>myocarditis</li>
- +<li>Takotsubo cardiomyopathy</li>
- +</ul>
References changed:
- 1. Ibanez B, James S, Agewall S et al. 2017 ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation. Eur Heart J. 2017;39(2):119-77. <a href="https://doi.org/10.1093/eurheartj/ehx393">doi:10.1093/eurheartj/ehx393</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28886621">Pubmed</a>
- 2. Scalone G, Niccoli G, Crea F. Editor’s Choice- Pathophysiology, Diagnosis and Management of MINOCA: An Update. European Heart Journal: Acute Cardiovascular Care. 2018;8(1):54-62. <a href="https://doi.org/10.1177/2048872618782414">doi:10.1177/2048872618782414</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29952633">Pubmed</a>
- 3. Agewall S, Beltrame J, Reynolds H et al. ESC Working Group Position Paper on Myocardial Infarction with Non-Obstructive Coronary Arteries. Eur Heart J. 2016;38(3):ehw149. <a href="https://doi.org/10.1093/eurheartj/ehw149">doi:10.1093/eurheartj/ehw149</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28158518">Pubmed</a>
- 4. Thygesen K, Alpert J, Jaffe A et al. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018;72(18):2231-64. <a href="https://doi.org/10.1016/j.jacc.2018.08.1038">doi:10.1016/j.jacc.2018.08.1038</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30153967">Pubmed</a>
- 5. Bugiardini R & Bairey Merz C. Angina With “Normal” Coronary Arteries. JAMA. 2005;293(4):477. <a href="https://doi.org/10.1001/jama.293.4.477">doi:10.1001/jama.293.4.477</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15671433">Pubmed</a>
- 6. Pasupathy S, Tavella R, Beltrame J. The What, When, Who, Why, How and Where of Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA). Circ J. 2016;80(1):11-6. <a href="https://doi.org/10.1253/circj.cj-15-1096">doi:10.1253/circj.cj-15-1096</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26597354">Pubmed</a>
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