Myocardial Infarction With Non-Obstructive Coronary Artery Disease: Exploration of the Etiology to Guide Therapy

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) occurs in up to 14% of patients presenting with acute myocardial infarction. Initially considered a favorable clinical diagnosis, MINOCA is now recognized as a condition that significantly impairs quality of life and is associated with an unfavorable prognosis, including significant risks of mortality, rehospitalization, disability, and recurrent angina, all contributing to high socioeconomic costs. MINOCA is a heterogeneous condition, with multiple identified underlying mechanisms, including epicardial or microvascular spasm, rupture or erosion of an atherosclerotic coronary plaque, coronary embolism, and spontaneous coronary artery dissection. Given this complexity, a comprehensive diagnostic workup that integrates clinical assessment, advanced imaging modalities, and invasive testing is necessary for the accurate identification of the specific cause of MINOCA and to guide the selection of an appropriate, individualized therapeutic strategy for each patient. This narrative review aims to explore the etiologies of MINOCA and provide clinicians with an up-to-date overview of therapeutic advances and targeted strategies for each underlying mechanism.