Myocardial Infarction With Normal Coronary Arteries Research Articles

What dictates prognosis in myocardial ischemic syndromes: myocardial ischemia or coronary atherosclerosis?

Myocardial ischemic syndromes are the main cause of death worldwide, with a rising incidence in developing countries. But why and how people with myocardial ischemic syndromes die or suffer major adverse cardiovascular events, namely myocardial infarction and sudden cardiac death, is still an incompletely resolved question. The intricacy of the issue arises at least somewhat from the relationship between angina pectoris, coronary atherosclerosis, and transient myocardial ischemia on the one hand and subsequent myocardial infarction, ischemic heart failure, and death on the other; a cause-effect relationship is not necessarily implied. The question has important prognostic and therapeutic implications because a proper identification of causes and mechanisms allows us to optimize the workup of patients and the therapeutic targets. Studies of conditions of myocardial infarction with normal coronary arteries (MINOCA) and angina with normal coronary arteries can be instrumental to resolving some of these unknowns. Such analyses convey the concept that coronary atherosclerosis, even when subclinical and usually considered prognostically irrelevant, has, conversely, important adverse prognostic implications. They also highlight, however, an important role for myocardial ischemia, which—when appropriately detected—alters prognosis unfavorably on top of coronary atherosclerosis. L

Myocardial Infarction with non-obstructed coronaries - atypical presentation of pheochromocytoma.

Although pheochromocytoma classically presents with headaches, palpitations and paroxysmal hypertension, atypical presentations such as cardiomyopathy, stroke and subarachnoid haemorrhage have been infrequently documented. We present in this case report, an uncommon presentation of pheochromocytoma with myocardial infarction with normal coronary arteries (MINOCA). A 79-year-old woman presented with central crushing chest pain radiating to left arm associated with headache, palpitations, sweating and difficulty in breathing. For 2 years, she experienced brief episodes of headache, tinnitus, dizziness, palpitations, and sweating that spontaneously resolved. Clinical examination was unremarkable except for high blood pressure (210/105 mmHg). Her electrocardiogram showed T wave inversions from V1 to V6 and elevated troponins (774 ng/L at baseline and 932 ng/L 3 h from baseline (normal <16 ng/L) in keeping with a diagnosis of non-ST elevated myocardial infarction. Coronary angiography showed normal coronary arteries. Patient was hence treated as myocardial infarction with normal coronaries (MINOCA). Despite appropriate treatment for MINOCA, she continued to experience episodic headaches, palpitations, dizziness and erratic blood pressures (particularly severe hypertension shortly after beta-blocker administration). Further investigations revealed raised urine noradrenaline of 4724 nmol/24 h (<554 nmol/24 h) and urine adrenaline of 92863 nmol/24 h (<77 nmol/24 h). Computerised tomography demonstrated a well-defined rounded mass in right adrenal gland morphological of pheochromocytoma. She underwent laparoscopic right adrenalectomy with histology confirming pheochromocytoma. This case highlights the importance of thorough investigation for the underlying cause for MINOCA. In patients with unexplained erratic blood pressure control, pheochromocytoma should be considered as a differential diagnosis. Pheochromocytoma is rare tumour that often presents with non-specific symptoms. It is important to investigate underlying cause of MINOCA. Thorough history is the key to diagnosis.

Microcirculation and Heart Failure.

The idea of coronary microcirculation playing a role in the pathophysiology of heart failure dates from decades ago, with authors hypothesizing that structural and functional alterations in the coronary microcirculation could potentially contribute to heart failure. It is known that in a wide range of primary cardiomyopathies, from dilated to hypertrophic, there are pathological alterations in myocardial vasculature structure and function, playing a role in the clinical course of the disease. Needless to say, many patients with normal epicardial coronary arteries can suffer from coronary microvascular dysfunction, that could lead to a wide variety of clinical problems - from impaired functional capacity to stable and unstable angina, Takotsubo syndrome, myocardial infarction with normal coronary arteries and can also end up with either acute or chronic heart failure. Furthermore, nowadays, it has been recognized that pathophysiology of the heart failure with preserved ejection fraction (HFpEF) is mainly due to the myocardial microcirculatory impairment. In heart failure with reduced ejection fraction (HFrEF) neurohumoral mechanisms affecting the peripheral vasculature have been identified as important factors in the development and progression of heart failure, leading to unfavourable remodelling, and thus some of them being important treatment targets. Among many new clinical scenarios where both myocardial and peripheral microcirculation play an important role, raising field of implantable continuous flow assist devices opens many questions and implies better understanding of their effects of microcirculation, as they usually lead to the improvement of end organ dysfunction caused by previous heart failure, which is probably through the positive effects of peripheral microcirculation.

Myocardial Infarction with Normal Coronary Arteries (MINOCA): Lessons for the Clinician

Myocardial Infarction with Normal Coronary Arteries (MINOCA): Lessons for the Clinician

Risk Factors and Markers for Acute Myocardial Infarction With Angiographically Normal Coronary Arteries

Myocardial Infarction with normal coronary arteries (MINCA) is common with a prevalence of 1% to 12% of all myocardial infarctions. The pathogenic mechanisms of MINCA are still unknown, but endothelial dysfunction has been suggested as a possible cause. To investigate risk factors and markers for MINCA, we conducted a case-control study. Considering the reported low prevalence of classical risk factors for coronary heart disease (CHD) in some but not all studies, our hypothesis was that endothelial function and intima-media thickness (IMT) were better, respectively lower, than CHD controls. One hundred patients with MINCA fulfilling diagnostic criteria according to the European Society of Cardiology/American Collage of Cardiology/American Heart Association universal definition of myocardial infarction with myocarditis excluded by cardiac magnetic resonance imaging were investigated. Risk factors, endothelial function (EndoPAT), and IMT were compared to gender- and age-matched patients with myocardial infarction and CHD, respectively healthy controls. Smoking, hypertension, impaired glucose tolerance and diabetes mellitus, inflammatory disease, and psychiatric disorders were more common in patients with MINCA than in healthy controls. In contrast to patients with CHD, the lipid profile was antiatherogenic with low low-density lipoprotein and high high-density lipoprotein cholesterol. There were no major differences between the groups regarding endothelial function and IMT that were in the normal range. In conclusion, the present study showed that MINCA was associated with many established cardiovascular risk factors without major differences in atherosclerosis markers. MINCA patients recalled a high prevalence of emotional stress before admission that together with previous psychiatric vulnerability and female gender speaks strongly in favor of Takotsubo syndrome being an important cause of MINCA.

Acute myocardial infarction with angiographically normal coronary arteries: what are we missing?

Myocardial infarction with normal coronary arteries (MINCA) can be observed in a relevant subset of patients with MI. It can be considered a syndrome, since it includes several clinical entities with specific pathogenetic mechanisms. Its prevalence is extremely variable, accounting for 5-25% of all acute myocardial infarctions. MINCA may arise from epicardial, microvascular, or myocardial localizations. Clinical history, echocardiography, coronary angiography and left ventriculography represent the first diagnostic step; however, additional tests are often required to confirm the diagnosis. The prognosis is extremely variable, depending on the causes of MINCA. Therefore, the identification of the correct etiology of MINCA is crucial to stratify patients appropriately and, hence, select the best treatment approach. In this review article, the pathogenesis, diagnosis, prognosis and therapy of MINCA are discussed, highlighting that coronary angiography alone is not sufficient for the complete understanding of the pathogenic mechanisms.

Normal coronary myocardial infarct is innocent or guilty? A case of ventricular septal rupture secondary to normal coronary myocardial infarction

Prognosis of cases of myocardial infarction with normal coronary arteries (MINCA) is known to be better than acute myocardial infarction cases with obstructive coronary lesions. A MINCA case causing ventricular septal rupture is rare. Herein, we present a 70-year-old female MINCA case which caused ventricular septal rupture which is a fatal complication of acute myocardial infarction.<Learning objective: Acute myocardial infarction, whether it is atherosclerotic or non atherosclerotic, has a high mortality rate when complicated with ventricular septal rupture. Complications of acute myocardial infarction should be observed cautiously and specific risk factors for ventricular septal rupture need to be investigated.>

False Positive ST-Segment Elevation Myocardial Infarction

False Positive ST-Segment Elevation Myocardial Infarction

Risk Factors for Myocardial Infarction With Normal Coronary Arteries and Myocarditis Compared With Myocardial Infarction With Coronary Artery Stenosis

The interest and awareness of myocardial infarction with normal coronary arteries (MINCA) have increased recently due to the frequent use of coronary angiography, the description of Takotsubo stress cardiomyopathy, and new sensitive troponin analyses. The prevalence of MINCA in all patients with myocardial infarction (MI) was registered during a 3-month period in the Stockholm metropolitan area in Sweden. The results showed that MINCA is more common than previously thought (7%) and affecting one third of every woman with MI. Patients with myocarditis were younger and more often presented with signs of inflammation such as elevated C-reactive protein and fever. Myocarditis constitutes an important differential diagnosis for coronary artery disease. There is a need for larger studies of MINCA, including investigation with cardiac magnetic resonance imaging, to establish prevalence and pathological process in this important subgroup of MI.

Myocardial infarction with angiographically normal coronary arteries.

Myocardial infarction with ‘normal’ coronary arteries (MINCA) typically occurs in the under-50s1. Usually there is no history of angina or previous myocardial infarction (MI), and risk factors for ischaemic heart disease (IHD) may be absent2. Symptoms and electrocardiographic (ECG) findings are similar to those of MI with angiographic coronary disease, though the infarct sizes tend to be smaller3. The rate of post-MI complications, such as malignant arrhythmias, heart failure and hypotension, is lower and the long-term prognosis is more favourable3,4. MINCA can be classified into four groups based on risk factors for IHD and angiographic findings: No risk factors for IHD with absolutely normal coronary arteries Risk factors for IHD with absolutely normal coronary arteries No risk factors for IHD with mild coronary artery disease Risk factors for IHD with mild coronary artery disease.