Copyright
©The Author(s) 2019.
World J Cardiol. Dec 26, 2019; 11(12): 305-315
Published online Dec 26, 2019. doi: 10.4330/wjc.v11.i12.305
Published online Dec 26, 2019. doi: 10.4330/wjc.v11.i12.305
Table 1 Myocardial infarction with non-obstructive coronary arteries classification, management overview, prevalence and suggested therapy
Mechanism | Diagnosis | Prevalence in coronary syndromes | Therapy |
Epicardial causes | |||
Coronary artery disease | IVUS/OCT, FFR/iFR | 5%-20% of MI | Antiplatelet therapy, statins, ACEi/ARB, beta-blockers |
Coronary dissection | IVUS/OCT | 25% of MI in women under 50 yr of age | Beta-blocker and simple antiplatelet therapy |
Coronary artery spasm | Intracoronary nitrates, intracoronary Ach or ergonovine test by experienced teams | 3%–95% of MI depending on the registry | Calcium antagonists, nitrates |
Microvascular causes | |||
Microvascular coronary spasm | Objective evidence of ischaemia (ECG, LV wall motion abnormalities, PET). Impaired microvascular function (CFR, intracoronary Ach test, abnormal CMR, slow coronary flow) | As high as 25% depending on the registry | Beta-blockers and nitrates, calcium antagonist, possibly ranolazine |
Takotsubo syndrome | Ventriculography, echocardiography, troponin, B-natriuretic peptide, CMR | 1%-3% of general STEMI, 5%-6% women with STEMI, concomitant CAD 10%-29% | Heart failure treatment, mechanical support in cardiogenic shock |
Myocarditis | CMR, EMB, viral serologies, high c-reactive protein | 33% of MINOCA when determined by CMR | Heart failure treatment if complication, autoimmune therapy in autoimmune forms |
Coronary embolism | History of potential thromboembolic sources, thrombophilia screen, TTE, TOE, bubble contrast echography | 2.9% MI | Antiplatelet therapy, anticoagulation, transcatheter closure or surgical repair |
Table 2 International takotsubo syndrome diagnostic criteria
Diagnostic criteria |
Left ventricular dysfunction usually extending beyond a single coronary territory. |
Sometimes triggered by emotional, physical or combined stress. |
Acute neurologic disorders, including pheochromocytoma, may become triggers. |
New ECG abnormalities. Rare cases can present with without ECG shifts. |
Moderate troponin elevation. Usually, significantly high brain natriuretic peptide. |
Can have concomitant CAD. |
No evidence of infectious myocarditis usually excluded by CMR. |
Mostly present in postmenopausal women. |
Table 3 International takotsubo syndrome diagnostic score
Criteria | Points | Diagnosis probability |
Female sex | 25 points | ≤ 70 points |
Emotional stress | 24 points | |
Low/intermediate | ||
Physical stress | 13 points | |
TTS probability | ||
No ST-segment depression | 12 points | |
Psychiatric disorders | 11 points | > 70 points |
Neurologic disorders | 9 points | |
High TTS probability | ||
QTc prolongation | 6 points |
Table 4 European Society of Cardiology 2013 Myocarditis Task Force definition of clinically suspected myocarditis
Presence of ≥ 1 clinical presentation and ≥ 1 diagnostic criteria: |
Clinical presentation: |
Acute coronary-like syndrome |
New onset or worsening unexplained heart failure |
Chronic unexpected heart failure over 3 mo duration |
Life-threatening unexplained conditions (including arrhythmias, aborted sudden death, cardiogenic shock) |
Diagnostic criteria: |
ECG/Holter/stress test shifts: Any degree atrioventricular block or bundle branch block, ST/T or Q wave changes, sinus arrest, cardiac arrest rhythms, low voltage, frequent premature beat or supraventricular tachycardia |
Elevated cardiac troponins |
Functional and structural abnormalities on cardiac imaging |
Oedema and/or late gadolinium enhancement of myocarditis pattern in CMR |
- Citation: Vidal-Perez R, Abou Jokh Casas C, Agra-Bermejo RM, Alvarez-Alvarez B, Grapsa J, Fontes-Carvalho R, Rigueiro Veloso P, Garcia Acuña JM, Gonzalez-Juanatey JR. Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions. World J Cardiol 2019; 11(12): 305-315
- URL: https://www.wjgnet.com/1949-8462/full/v11/i12/305.htm
- DOI: https://dx.doi.org/10.4330/wjc.v11.i12.305