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Updated: Mar 18, 2026
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Imaging diagnoses and outcome in patients presenting for primary angioplasty but no obstructive coronary artery
Tarun K Mittal1, Luise Reichmuth2, Ben Ariff3
1Department of Cardiology & Cardiac Imaging, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, UK.
Insights
Many patients with suspected ST-elevation myocardial infarction (STEMI) lack obstructive coronary disease. Alternative diagnoses like cardiomyopathies and myopericarditis are common, necessitating further imaging for proper patient management.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Internal Medicine
Background:
- A subset of patients with suspected ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) do not exhibit obstructive coronary artery disease.
- Alternative cardiac and non-cardiac conditions can mimic STEMI, leading to misdiagnosis and delayed treatment.
Purpose of the Study:
- To investigate the prevalence and etiological spectrum of alternative diagnoses in patients with suspected STEMI but no obstructive coronary disease.
- To assess the outcomes associated with these alternative diagnoses in a large PPCI cohort.
Main Methods:
- Retrospective analysis of 5238 patients referred for PPCI between 2009 and 2012.
- Inclusion criteria: angiography without culprit lesion, no prior coronary artery disease.
- Data collection included troponin levels, multimodality imaging findings, and all-cause mortality.
Main Results:
- 575 patients (13.0%) met inclusion criteria. A diagnosis was established in 41.2% of these patients.
- Common diagnoses included cardiomyopathies (18%), myopericarditis (8.4%), myocardial infarction/coronary abnormality (4.9%), and severe valve disease (4%).
- Pulmonary embolism and type A aortic dissection were found in 1.2% and 0.7% of cases, respectively. Mortality was 7.0% over a mean follow-up of 42.6 months.
Conclusions:
- Patients presenting with suspected STEMI and normal coronary angiograms have diverse underlying conditions.
- These alternative diagnoses, including cardiomyopathies and inflammatory conditions, can carry significant risks.
- Multimodality imaging is crucial for accurate diagnosis and guiding management in this patient group.
Objective:
A proportion of patients with suspected ST-elevation myocardial infarction (STEMI) presenting for primary percutaneous coronary intervention (PPCI) do not have obstructive coronary disease and other conditions may be responsible for their symptoms and ECG changes. In this study, we set out to determine the prevalence and aetiology of alternative diagnoses in a large PPCI cohort as determined with multimodality imaging and their outcome.
Methods:
From 2009 to 2012, 5238 patients with suspected STEMI were referred for consideration of PPCI. Patients who underwent angiography but had no culprit artery for revascularisation and no previous history of coronary artery disease were included in the study. Troponin values, imaging findings and all-cause mortality were obtained from hospital and national databases.
Results:
A total of 575 (13.0%) patients with a mean age of 58±15 years (69% men) fulfilled the inclusion criteria. A specific diagnosis based on imaging was made in 237 patients (41.2%) including cardiomyopathies (n=104, 18%), myopericarditis (n=48, 8.4%), myocardial infarction/other coronary abnormality (n=27, 4.9%) and severe valve disease (n=23, 4%). Pulmonary embolism and type A aortic dissection were identified in seven (1.2%) and four (0.7%) cases respectively. A total of 40 (7.0%) patients died over a mean follow-up of 42.6 months.
Conclusions:
A variety of cardiac and non-cardiac conditions are prevalent in patients presenting with suspected STEMI but culprit-free angiogram, some of which may have adverse outcomes. Further imaging of such patients could thus be useful to help in appropriate management and follow-up.
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