Magdy El-Masry

Prof. of Cardiology

Tanta University

A Changing Philosophy

Nonobstructive disease is not a false positive. It's not benign.

Non-obstructive Coronary Arteries

Myocardial Infarction Ischemia

Normal coronary angiogram. A smooth patent covetable left main, LAD, and circumflex projected from the screen. Next to these innocent-appearing vessels was a distinctly sinister

IVUS study from the same angiogram demonstrating plaque rupture and ulceration.

The finding of angiographicallysmooth coronary arteries does

not preclude an aetiologic role of thrombotic disease in MINOCA.

What we can see is only 5% of the total coronary tree.

? Coronary Microvascular Dysfunction

Non-obstructive Coronary Arteries

Mechanisms for ischemic heart disease in women.*Plaque disruption denotes plaque rupture or plaque erosion

Diagnostic Criteria For

Myocardial Infarction With Non-obstructive Coronary Arteries “MINOCA”

A potential problem with current AMI criteria is their central focus upon troponins, since clinicians encounter elevated troponins in clinical scenarios other than AMI.

Circulation. 2017;135:1490–1493.

MINOCA: A case study of a 55-year-old woman with an anterior STEMI presentation.

MINOCA should be considered as a ‘working diagnosis’, analogous to heart failure, and thus prompts further evaluation regarding its underlying mechanism(s).

MINOCA: A case study of a 55-year-old woman with an anterior STEMI presentation.

MINOCA Etiology

Etiology of MINOCA : Differential diagnosis work up

Recommended diagnostic and therapeutic algorithm for myocardial infarction with non-obstructive coronary arteries.

Diagnostic test flow chart in MINOCA.

Diagnostic test flow chart in MINOCA , Cont.

CMR imaging is a key investigation in identifying the underlying cause

Coronary angiography portraying subtle lesion (arrow) involving the mid LAD

Cardiac MRI revealing LGE of the mid to distal anteroseptal wall (arrows). Still frames from horizontal long axis (top row) and short axis (bottom row) are consistent with mid to distal LAD infarction

Ann Clin Lab Res. 2016, 4: 3.

Bar graph of published studies showing the diagnostic significance of CMR imaging in MINOCA patients. Data presented as percentage (%).

Cardiac magnetic resonance (CMR) imaging findings in patients with MINOCA.

Management

A fundamental consideration is

identifying the underlying cause of

this heterogeneous syndrome

because that will determine

appropriate therapy.

All-Cause Mortality in Patients With MINOCA or MI-CAD

Data presented as percentage (%) and 95% confidence intervals (%) withodds ratio (OR) and P values. MI-CAD indicates myocardial infarction with coronary artery disease; and MINOCA, myocardial infarction with nonobstructive coronary arteries

Circulation 2015;131(10):861–870

MINOCA : is not a benign condition?

Guarded Prognosis

Hence patients with MINOCA should receive the same clinical attention as AMI patients who have single- or double-vessel disease and not merely

dismissed as having an insignificant clinical condition.

Although the outcome of MINOCA strongly depends on the underlying cause, its overall

prognosis is serious, with a 1 year mortality of about 3.5%.

Circulation. 2017;135:1481–1489

Dr. Noel Bairey Merz is the director of the Barbra Streisand Women's Heart Center at Cedars Sinai and is a leader in female cardiovascular treatment. "In a session on New Practice Patterns in Clinical Cardiology at the European Society of Cardiology 2017

Congress, she gave a presentation titled "A Women's Clinic for Heart Disease." Her talk outlined three distinct sub clinic options where women with heart disease can seek help: The MINOCA (myocardial infarction without obstructive coronary artery disease)

clinic, the HFpEF (heart failure with preserved ejection fraction) clinic, and the APO (adverse pregnancy outcomes) clinic."

We have an evidence gap,

“she concluded”

MINOCA research needed !