AccScience Publishing / BH / Online First / DOI: 10.36922/BH025330045
Submit to BH
Cite this article
5
Download
90
Views
Journal Browser
Volume | Year
Issue
Search
Forthcoming Issue
Current Issue
View All
News and Announcements
View All
REVIEW ARTICLE

Beyond the blockage: A review of myocardial infarction with non-obstructive coronary arteries

Sai Lokesh Moraboina1 ,  Mehreen Junaid2 ,  Kalpana Kumari3 ,  Jeevan Kumar Sahni4 ,  Suman Khatri5 ,  Umme Aiman6 ,  Varsha Miriyala7 ,  Yusra Jumani8 ,  Ali Athar9*
Show Less
1 Department of Medicine, Faculty of Medicine, Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India
2 Department of Medicine, Faculty of Medicine, C.M.H. Lahore Medical College, Lahore, Punjab, Pakistan
3 Department of Pharmaceutical Sciences, Dow College of Pharmacy, Dow University of Health Sciences, Karachi, Sindh, Pakistan
4 Department of Medicine, Faculty of Medicine, Medical Academy named after S.I. Georgievsky, Vernadsky Crimean Federal University, Simferopol, Crimea, Russia
5 Department of Medicine, Faculty of Medicine, TMSS Medical College, Bogura, Rajshahi, Bangladesh
6 Department of Medicine, Faculty of Medicine, Bhaskar Medical College, Hyderabad, Telangana, India
7 Department of Medicine, Faculty of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, United States of America
8 Department of Medicine, Faculty of Medicine, Dow International Medical College, Karachi, Sindh, Pakistan
9 Department of Medicine, Faculty of Medicine, Shalamar Medical and Dental College, Lahore, Punjab, Pakistan
Brain & Heart, 025330045 https://doi.org/10.36922/BH025330045
Received: 11 August 2025 | Revised: 3 October 2025 | Accepted: 27 October 2025 | Published online: 14 November 2025
© 2025 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ )
Download PDF
XML
Cite
Abstract

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a syndrome in which patients have clear signs of heart muscle injury but show <50% stenosis on coronary angiography. We recognize it as a distinct condition that demands its own diagnostic and treatment approaches. Recent studies were reviewed to elucidate the pathophysiology, diagnostic criteria, and management strategies for MINOCA. PubMed, Scopus, and Google Scholar were searched for full-text, peer-reviewed articles on MINOCA’s pathophysiology and diagnostics. Keywords such as “non-obstructive coronary artery,” “ischemic heart diseases,” and “myocardial infarction” were used. Following the screening and synthesis of the selected papers, we found that MINOCA can result from ischemic causes—plaque disruption, vasospasm, microvascular dysfunction, spontaneous coronary artery dissection, and coronary embolism—as well as from non-ischemic causes, such as myocarditis and Takotsubo cardiomyopathy. The diagnostic evaluation of MINOCA relies on high-sensitivity troponin assays, coronary angiography, cardiac magnetic resonance (CMR) imaging, optical coherence tomography, and functional testing for vasomotor disorders. There are emerging biomarkers, including microRNAs, copeptin, and soluble suppression of tumorigenicity-2, that help refine the risk assessment. We concluded that MINOCA requires a stepwise diagnostic algorithm and personalized treatment methods tailored to the underlying cause, while advocating for early use of CMR imaging, targeted imaging or functional tests, and long-term follow-up. Future randomized trials are warranted to validate etiology-specific therapies and imaging-guided management strategies.

Keywords
Myocardial infarction
Non-obstructive coronary artery disease
Biomarkers
Heart muscle injury
Coronary vasospasm
Funding
None.
Conflict of interest
The authors declare they have no competing interests.
References
  1. Parwani P, Kang N, Safaeipour M, et al. Contemporary diagnosis and management of patients with MINOCA. Curr Cardiol Rep. 2023;25(6):561-570. doi: 10.1007/S11886-023-01874-X

 

  1. Tamis-Holland JE, Jneid H, Reynolds HR, 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;139(18):e891-e908. doi: 10.1161/CIR.0000000000000670

 

  1. Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015;131(10):861-870. doi: 10.1161/CIRCULATIONAHA.114.011201

 

  1. Foà A, Canton L, Bodega F, et al. Myocardial infarction with nonobstructive coronary arteries: From pathophysiology to therapeutic strategies. J Cardiovasc Med. 2023;24(Suppl 2):e134-e146. doi: 10.2459/JCM.0000000000001439

 

  1. Opolski MP, Spiewak M, Marczak M, et al. Mechanisms of myocardial infarction in patients with nonobstructive coronary artery disease: Results from the optical coherence tomography study. JACC Cardiovasc Imaging. 2019;12(11 Pt 1):2210-2221. doi: 10.1016/j.jcmg.2018.08.022

 

  1. Iwańczyk S, Woźniak P, Araszkiewicz A, Grygier M, Klotzka A, Lesiak M. Optical coherence tomography in the diagnosis of myocardial infarction with non-obstructive coronary arteries. Postepy Kardiol Interwencyjnej. 2022;18(3):192-200. doi: 10.5114/AIC.2022.121233

 

  1. Usui E, Matsumura M, Smilowitz NR, et al. Coronary morphological features in women with non-ST-segment elevation MINOCA and MI-CAD as assessed by optical coherence tomography. Eur Heart J Open. 2022;2(5):oeac058. doi: 10.1093/EHJOPEN/OEAC058

 

  1. Yoo SM, Jang S, Kim JA, Chun EJ. Troponin-positive non-obstructive coronary arteries and myocardial infarction with non-obstructive coronary arteries: Definition, etiologies, and role of CT and MR imaging. Korean J Radiol. 2020;21(12):1310-1321. doi: 10.3348/KJR.2020.0064

 

  1. Parlati ALM, Nardi E, Sucato V, et al. ANOCA, INOCA, MINOCA: The new frontier of coronary syndromes. J Cardiovasc Dev Dis. 2025;12(2):64. doi: 10.3390/JCDD12020064

 

  1. Yaker ZS, Lincoff AM, Cho L, et al. Coronary spasm and vasomotor dysfunction as a cause of MINOCA. EuroIntervention. 2024;20(2):e123-e134. doi: 10.4244/EIJ-D-23-00448

 

  1. di Fusco SA, Rossini R, Zilio F, et al. Spontaneous coronary artery dissection: Overview of pathophysiology. Trends Cardiovasc Med. 2022;32(2):92-100. doi: 10.1016/j.tcm.2021.01.002

 

  1. Matta A, Levai L, Elbaz M, et al. Spontaneous coronary artery dissection: A review of epidemiology, pathophysiology and principles of management. Curr Probl Cardiol. 2023;48(7):101682. doi: 10.1016/j.cpcardiol.2023.101682

 

  1. Herling de Oliveira LL, Correia VM, Nicz PFG, Soares PR, Scudeler TL. MINOCA: One size fits all? Probably not-a review of etiology, investigation, and treatment. J Clin Med. 2022;11(19):5497. doi: 10.3390/JCM11195497

 

  1. Stepien K, Nowak K, Wypasek E, Zalewski J, Undas A. High prevalence of inherited thrombophilia and antiphospholipid syndrome in myocardial infarction with non-obstructive coronary arteries: Comparison with cryptogenic stroke. Int J Cardiol. 2019;290:1-6. doi: 10.1016/j.ijcard.2019.05.037

 

  1. Todiere G, Barison A, Baritussio A, et al. Acute clinical presentation of nonischemic cardiomyopathies: Early detection by cardiovascular magnetic resonance. J Cardiovasc Med. 2023;24(Suppl 1):e36-e46. doi: 10.2459/JCM.0000000000001412

 

  1. Tognola C, Maloberti A, Varrenti M, Mazzone P, Giannattasio C, Guarracini F. Myocardial infarction with nonobstructive coronary arteries (MINOCA): Current insights into pathophysiology, diagnosis, and management. Diagnostics (Basel). 2025;15(7):942. doi: 10.3390/DIAGNOSTICS15070942

 

  1. Yang S, Bae L, Zhang L. Estrogen increases eNOS and NOx release in human coronary artery endothelium. J Cardiovas Pharmacol. 2000;36(2):242-247. doi: 10.1097/00005344-200008000-00015

 

  1. Matta A, Bouisset F, Lhermusier T, Campelo-Parada F, Elbaz M, Carrié D, et al. Coronary artery spasm: New insights. J Interv Cardiol. 2020;2020:5894586. doi: 10.1155/2020/5894586

 

  1. Agewall S, Beltrame JF, Reynolds HR, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J. 2017;38(3):143-153. doi: 10.1093/EURHEARTJ/EHW149

 

  1. Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367. doi: 10.1093/EURHEARTJ/EHAA575

 

  1. Reynolds HR, Maehara A, Kwong RY, et al. Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of myocardial infarction with nonobstructive coronary arteries in women. Circulation. 2021;143(7):624-640. doi: 10.1161/CIRCULATIONAHA.120.052008

 

  1. Montone RA, Niccoli G, Fracassi F, 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;39(2):91-98. doi: 10.1093/EURHEARTJ/EHX667

 

  1. Looi JL, Wong CW, Lee M, Khan A, Webster M, Kerr AJ. Usefulness of ECG to differentiate Takotsubo cardiomyopathy from acute coronary syndrome. Int J Cardiol. 2015;199:132-140. doi: 10.1016/j.ijcard.2015.07.046

 

  1. Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular magnetic resonance in nonischemic myocardial inflammation: Expert recommendations. J Am Coll Cardiol. 2018;72(24):3158-3176. doi: 10.1016/j.jacc.2018.09.072

 

  1. Mileva N, Paolisso P, Gallinoro E, et al. Diagnostic and prognostic role of cardiac magnetic resonance in MINOCA: Systematic review and meta-analysis. JACC Cardiovasc Imaging. 2023;16(3):376-389. doi: 10.1016/j.jcmg.2022.12.029

 

  1. Ford TJ, Stanley B, Good R, et al. Stratified medical therapy using invasive coronary function testing in angina: The CorMicA Trial. J Am Coll Cardiol. 2018;72(23 Pt A):2841-2855. doi: 10.1016/j.jacc.2018.09.006

 

  1. Taqueti VR, Di Carli MF. Coronary microvascular disease pathogenic mechanisms and therapeutic options: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72(21):2625-2641. doi: 10.1016/j.jacc.2018.09.042

 

  1. Fazzini L, Casula M, Cau R, et al. The detection rate of late gadolinium enhancement in Takotsubo syndrome: A systematic review and meta-analysis. Am J Cardiol. 2025;238:32-39. doi: 10.1016/j.amjcard.2024.11.017

 

  1. Wang J, Tan GJ, Han LN, Bai YY, He M, Liu HB. Novel biomarkers for cardiovascular risk prediction. J Geriatr Cardiol. 2017;14(2):135-150. doi: 10.11909/J.ISSN.1671-5411.2017.02.008

 

  1. Babatunde A, Rizvi A, Truong QA. Novel biomarkers: Utility in patients with acute chest pain and relationship to coronary artery disease on coronary CT angiography. Curr Cardiovasc Imaging Rep. 2014;7(7):9277. doi: 10.1007/S12410-014-9277-X

 

  1. Manginas A, Bei E, Chaidaroglou A, et al. Peripheral levels of matrix metalloproteinase-9, interleukin-6, and C-reactive protein are elevated in patients with acute coronary syndromes: Correlations with serum troponin I. Clin Cardiol. 2005;28(4):182-186. doi: 10.1002/CLC.4960280405

 

  1. Jenkins WS, Roger VL, Jaffe AS, et al. Prognostic value of soluble ST2 after myocardial infarction: A community perspective. Am J Med. 2017;130(9):1112.e9-1112.e15. doi: 10.1016/j.amjmed.2017.02.034

 

  1. Mutin M, Canavy I, Blann A, Bory M, Sampol J, Dignat-George F. Direct evidence of endothelial injury in acute myocardial infarction and unstable angina by demonstration of circulating endothelial cells. Blood. 1999;93(9):2951-2958.

 

  1. Werner N, Kosiol S, Schiegl T, et al. Circulating endothelial progenitor cells and cardiovascular outcomes. N Engl J Med. 2005;353(10):999-1007. doi: 10.1056/NEJMOA043814

 

  1. Reynolds HR, Smilowitz NR. Myocardial infarction with nonobstructive coronary arteries. Annu Rev Med. 2023;74:171-188. doi: 10.1146/ANNUREV-MED-042921-111727

 

  1. Khattab E, Karelas D, Pallas T, et al. MINOCA: A pathophysiological approach of diagnosis and treatment-a narrative review. Biomedicines. 2024;12(11):2457. doi: 10.3390/BIOMEDICINES12112457

 

  1. Yang P, Zhang S, Yin X, et al. Myocardial infarction with nonobstructive coronary arteries (MINOCA): A narrative review. Eur J Med Res. 2025;30(1):443. doi: 10.1186/S40001-025-02703-3

 

  1. Eggers KM, Baron T, Chapman AR, Gard A, Lindahl B. Management and outcome trends in type 2 myocardial infarction: An investigation from the SWEDEHEART registry. Sci Rep. 2023;13(1):7194. doi: 10.1038/S41598-023-34312-7

 

  1. Safdar B, Spatz ES, Dreyer RP, et al. Presentation, clinical profile, and prognosis of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): Results from the VIRGO study. J Am Heart Assoc. 2018;7(13):e009174. doi: 10.1161/JAHA.118.009174

 

  1. Masson W, Lobo M, Barbagelata L, Lavalle-Cobo A, Molinero G. Prognostic value of statin therapy in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): A meta-analysis. Acta Cardiol. 2022;77(6):480-487. doi: 10.1080/00015385.2021.1955480

 

  1. de Filippo O, Russo C, Manai R, et al. Impact of secondary prevention medical therapies on outcomes of patients suffering from Myocardial Infarction with NonObstructive Coronary Artery disease (MINOCA): A meta-analysis. Int J Cardiol. 2022;368:1-9. doi: 10.1016/j.ijcard.2022.08.034

 

  1. Nordenskjöld AM, Agewall S, Atar D, et al. Randomized evaluation of beta blocker and ACE-inhibitor/angiotensin receptor blocker treatment in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA-BAT): Rationale and design: MINOCA-BAT: Rationale and design. Am Heart J. 2021;231:96-104. doi: 10.1016/j.ahj.2020.10.059

 

  1. Lindahl B, Baron T, Erlinge D, et al. Medical therapy for secondary prevention and long-term outcome in patients with myocardial infarction with nonobstructive coronary artery disease. Circulation. 2017;135(16):1481-1489. doi: 10.1161/CIRCULATIONAHA.116.026336

 

  1. Choo EH, Chang K, Lee KY, et al. Prognosis and predictors of mortality in patients suffering myocardial infarction with non-obstructive coronary arteries. J Am Heart Assoc. 2019;8(14):e011990. doi: 10.1161/JAHA.119.011990

 

  1. Efthymiou I, Chiotis S, Vlachvei C, et al. Dual antiplatelet therapy and clinical outcomes in patients with myocardial infarction with nonobstructive coronary arteries: A systematic review and meta-analysis. Cardiol Rev. 2025. doi: 10.1097/CRD.0000000000000890

 

  1. Montenegro Sá F, Carvalho R, Santos L, et al. Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease - insights from a nationwide registry. Rev Port Cardiol (Engl Ed). 2020;39(12):679-684. doi: 10.1016/j.repc.2020.05.008

 

  1. Maremmani M, Ebrahimi R, Centola M, et al. Association of sodium-glucose cotransporter-2 inhibitors with mortality across the spectrum of myocardial infarction: A systematic review and meta-analysis. Cardiovasc Diabetol. 2025;24(1):29. doi: 10.1186/S12933-025-02592-0

 

  1. Jewulski J, Khanal S, Dahal K. Coronary vasospasm: A narrative review. World J Cardiol. 2021;13(9):456-463. doi: 10.4330/WJC.V13.I9.456

 

  1. Kumar V, Muhammad H, Fatima I, et al. Myocardial infarction with non-obstructive coronary arteries: A review. Brain Heart. 2025;3(3):5811. doi: 10.36922/bh.5811

 

  1. Lanza GA, Shimokawa H. Management of coronary artery spasm. Eur Cardiol Rev. 2023;18:e38. doi: 10.15420/ECR.2022.47

 

  1. Kumar V, Muhammad H, Khraisat O, et al. Prognostic factors of takotsubo syndrome: A review. Brain Heart. 2025. doi: 10.36922/BH025090012

 

  1. Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med. 2015;373(10):929-938. doi: 10.1056/NEJMOA1406761

 

  1. Hayes SN, Kim CESH, Saw J, et al. Spontaneous coronary artery dissection: Current state of the science: A scientific statement from the American Heart Association. Circulation. 2018;137(19):e523-e557. doi: 10.1161/CIR.0000000000000564

 

  1. Haris M, Hammad A, Kumar V. Pregnancy-associated coronary artery dissection (P-SCAD): A crucial differential diagnosis for chest pain during pregnancy. Brain Heart. 2025;3(1):4722. doi: 10.36922/bh.4722

 

  1. Vrints, C, Andreotti F, Koskinas KC, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415-3537. doi: 10.1093/eurheartj/ehae177

 

  1. Rao SV, O’Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771-e862. doi: 10.1161/CIR.0000000000001309

 

  1. He CJ, Zhu CY, Zhu YJ, et al. Effect of exercise-based cardiac rehabilitation on clinical outcomes in patients with myocardial infarction in the absence of obstructive coronary artery disease (MINOCA). Int J Cardiol. 2020;315:9-14. doi: 10.1016/j.ijcard.2020.05.019
Next article in this issue
Share
Back to top
Brain & Heart, Electronic ISSN: 2972-4139 Published by AccScience Publishing
We use cookies on our website to ensure you get the best experience.
Read more about our cookies here
Accept