Myocardial infarction with nonobstructive coronary arteries: current state of the problem and diagnostic approaches

The importance of the problem of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) increases yearly with accumulation of more statistical data. According to current knowledge, MINOCA on average comprises 6 % of all MI cases. According to the Fourth Universal Definition of MI and the consensus document of the MINOCA task team, MINOCA diagnosis can be made for combination of MI criteria with insignificant coronary artery disease established using coronary angiography and absence of another significant cause of elevated troponin level. As it is known, elevated troponin level in blood test can be caused by various pathological states of the cardiac and extra-cardiac nature. Therefore, every suspected MINOCA case must be confirmed. Among MINOCA diagnostic methods, apart from electrocardiography, echocardiography and coronary angiography necessary for MI verification, the most important are magnetic resonance imaging with intravenous Gadolinium contrast which allows to differentiate ischemic heart disease from other myocardial disorders of varied genesis. Additionally, the causes of every case of MINOCA can be determined using intravascular visualization methods (optical coherence tomography, intravascular ultrasound imaging). Considering vasospasm is one of the mechanisms of myocardial ischemia underlying MINOCA, pharmacological tests with acetylcholine, ergonovine can be of certain interest. Thrombophilia plays a significant role in MI and MINOCA genesis. Analysis of polymorphisms of genes participating in expression of blood coagulation proteins is of special importance. The necessity of determination of the causes of every MINOCA clinical case is based on the requirement for adequate therapy different for every pathological type.

1. Cheitlin M.D., McAllister H.A., de Castro C.M. Myocardial infarction without atherosclerosis. JAMA 1975;231(9):951—9. DOI: 10.1001/jama.1975.03240210031015.

2. Agewall S., Beltrame J.F., Reynolds H.R. et al. ESC working group position paper on myocardial infarction with nonobstructive coronary arteries. Eur Heart J 2017;38(3):143—53.

3. Pasupathy S., Air T., Dreyer R.P. et al. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation 2015;131(10):861—70.

4. Gehrie E.R., Reynolds H.R., Chen A.Y. 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;158(4):688-94. DOI: 10.1016/j.ahj.2009.08.004.

5. Thygesen K., Alpert J.S., Jaffe A.S. et al. Fourth universal definition of myocardial infarction(2018). Eur Heart J 2019;40(3):237-69. DOI: 10.1093/eurheartj/ehy462.

6. Agewall S., Giannitsis E., Jernberg T., Katus H. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J 2011;32(4):404—11. DOI: 10.1093/eurheartj/ehq456.

7. Pais J.L., Izquierdo Coronel B., Galan Gil D. et al. Psycho-emotional disorders as incoming risk factors for myocardial infarction with nonobstructive coronary arteries. Cardiol J 2018;12(1):24—31. DOI: 10.5603/CJ.a2017.0139.

8. Bogale N., Lempereur M., Sheikh I. et al. Optical coherence tomography (OCT) evaluation of intermediate coronary lesions in patients with NSTEMI. Cardiovasc Revasc Med 2016;17(2):113—8. DOI: 10.1016/j.carrev.2015.12.007.

9. Ouldzein H., Elbaz M., Roncalli J. 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;61(1):20—6. DOI: 10.1016/j.ancard.2011.07.011.

10. Opolski M.P., 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 2018 Oct 12. pii: S1936-878X(18)30750-2. DOI: 10.1016/j.jcmg.2018.08.022.

11. Pepi M., Evangelista A., Nihoyannopoulos P. et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2010;11(6):461 —76. DOI: 10.1093/ejechocard/jeq045.

12. Soliman O.I., Geleijnse M.L., Meijboom FJ. et al. The use of contrast echocardiography for the detection of cardiac shunts. Eur J Echocardiogr 2007;8(3):S2-12. DOI: 10.1016/j.euje.2007.03.006.

13. Abdelmoneim S.S., Mulvagh S.L. Techniques to improve left atrial appendage imaging. J Atr Fibrillation 2014;7(1):85—94. DOI: 10.4022/jafib.1059.

14. Pershina E.S., Sinitsyn V.E., Mershina E.A. et al. Myocardial dual-energy(DE) perfusion and delayed enhancement in detection of chronic myocardial scar tissue. Comparison with late gadolinium enhancement MRI. Meditsinskaya vizualizatsiya = Medical Visualization 2017;21(4):10—8. (In Russ.). DOI: 10.24835/1607-0763-2017-4-10-18.

15. Brolin E.B., Brismar T.B., Collste O. et al. Prevalence of myocardial bridging in patients with myocardial infarction and nonobstructed coronary arteries. Am J Cardiol 2015;116(12):1833-9. DOI: 10.1016/j.amjcard.2015.09.017.