Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden (P.T.).
University of Adelaide, Central Adelaide Local Health Network, Basil Hetzel Institute, Australia (J.F.B.).
Circ Cardiovasc Imaging. 2024 Jul;17(7):e016463. doi: 10.1161/CIRCIMAGING.123.016463. Epub 2024 Jul 16.
The working diagnosis Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA) is being increasingly recognized with the common use of high-sensitivity troponins and coronary angiography, accounting for 5% to 10% of all acute myocardial infarction presentations. Cardiac magnetic resonance (CMR) imaging is pivotal in patients presenting with suspected MINOCA, mainly to delineate those with a nonischemic cause, for example, myocarditis and Takotsubo syndrome, from those with true ischemic myocardial infarction, that is, MINOCA. The optimal timing for CMR imaging in patients with suspected MINOCA has been uncertain and, until recently, not been examined prospectively. Previous retrospective studies have indicated that the diagnostic yield decreases with time from the acute event. The SMINC studies (Stockholm Myocardial Infarction with Normal Coronaries) show that CMR should be performed early in all patients with the working diagnosis of MINOCA, with the possible exception of patients who are clearly identified as having Takotsubo syndrome as determined by echocardiography. In addition to CMR imaging, other investigations of importance in selected patients may be pulmonary artery computed tomography to exclude pulmonary embolism, optical coherence tomography to identify plaque disruption, and acetylcholine provocation to identify coronary artery spasm. Imaging of patients with the working diagnosis MINOCA, which is centered on CMR together with supplemental investigations, results in a clear diagnosis in approximately three-quarters of the patients. This is a good example of personalized medicine, because a correct diagnosis will not only increase the satisfaction of the individual patient but also result in optimizing treatment without harming the patient.
工作诊断 非阻塞性冠状动脉心肌梗死（MINOCA）随着高敏肌钙蛋白和冠状动脉造影的广泛应用而越来越被认识，占所有急性心肌梗死表现的 5%至 10%。心脏磁共振（CMR）成像在疑似 MINOCA 患者中具有重要作用，主要是为了从真正的缺血性心肌梗死（即 MINOCA）中确定那些具有非缺血性病因的患者，例如心肌炎和心尖球形综合征。疑似 MINOCA 患者的 CMR 成像最佳时机一直不确定，直到最近才进行前瞻性研究。以前的回顾性研究表明，诊断率随急性事件后时间的推移而降低。SMINC 研究（斯德哥尔摩正常冠状动脉心肌梗死）表明，所有疑似 MINOCA 的患者都应早期进行 CMR，除非通过超声心动图明确诊断为心尖球囊样综合征的患者除外。除 CMR 成像外，在某些患者中，其他重要的检查可能包括肺动脉计算机断层扫描以排除肺栓塞、光学相干断层扫描以识别斑块破裂，以及乙酰胆碱激发以识别冠状动脉痉挛。对疑似 MINOCA 的患者进行成像，以 CMR 为中心，辅以补充检查，大约有四分之三的患者可以明确诊断。这是个性化医疗的一个很好的例子，因为正确的诊断不仅会增加个体患者的满意度，还会优化治疗而不会伤害患者。
