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The management of myocardial infarction with nonobstructive coronary arteries (MINOCA) represents a significant clinical challenge, occurring in 6-8% of myocardial infarction cases. This CME review examines the American Heart Association’s diagnostic algorithm and emphasizes the crucial role of cardiac magnetic resonance imaging in determining specific etiologies and guiding targeted treatments.
Key Points:
- MINOCA patients exhibit distinct demographics: they are typically younger, more often female (50% vs 25% in obstructive MI), and more likely to identify as Black, Hispanic, or Latino. Women are nearly 5 times more likely than men to present with MINOCA.
- The AHA’s “traffic light” diagnostic algorithm provides a structured approach:
- Red: Exclude non-ischemic etiologies (sepsis, PE, severe anemia)
- Yellow: Review angiogram and assess LV function
- Green: Determine specific MINOCA cause through additional testing
- Cardiac magnetic resonance imaging achieves definitive diagnosis in up to 75% of MINOCA cases, with diagnostic yield correlating to troponin elevation (48x upper limit of normal in MINOCA vs 14x in normal CMR).
- Treatment outcomes from the SWEDEHEART registry demonstrate that statins and ACE inhibitors/ARBs reduce major adverse cardiac events over 4 years, while dual antiplatelet therapy showed no significant benefit.
- Specific etiologies require targeted approaches: conservative management for spontaneous coronary artery dissection, calcium channel blockers for coronary spasm, and anticoagulation for thromboembolic disease.
HCN Medical Memo
The diagnosis and management of MINOCA require a systematic approach using the AHA’s traffic light algorithm, with cardiac magnetic resonance imaging playing a central role in determining specific etiologies and guiding targeted therapy.
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