Multimodal Imaging in MI with Non-obstructive Coronary Arteries: Unraveling Pathophysiology and Guiding Management

MI with non-obstructive coronary arteries (MINOCA) represents a complex, heterogeneous syndrome with variable underlying mechanisms and substantial morbidity. The role of multimodality cardiovascular imaging in clarifying etiology and guiding therapy continues to evolve. Multimodality imaging offers insights into the pathophysiology of MINOCA. Coronary angiography remains the first-line diagnostic tool to exclude obstructive coronary disease, while adjunctive functional testing can identify epicardial or microvascular vasospasm. Echocardiography evaluates ventricular function, wall motion abnormalities, and embolic sources, whereas cardiac MRI differentiates ischemic from non-ischemic injury, detects myocardial edema, and assesses scar burden. Intravascular imaging can detect plaque rupture, erosion, or thrombus. Nuclear imaging modalities provide a quantitative assessment of microvascular perfusion and coronary flow reserve. Coronary CT angiography may further characterize non-obstructive plaque or coronary anomalies. This review summarizes the comprehensive evaluation of MINOCA. Integrating modalities can improve diagnostic accuracy, identify the underlying etiology, guide targeted therapy, and inform prognosis, underscoring the importance of a multimodal imaging approach.