Autonomic neurocardiogenic syndrome is stonewalled by the universal definition of myocardial infarction

Table 1 Diagnostic criteria for type 1, type 2, and type 3 myocardial infarction according to the fourth universal definition of myocardial infarction

Criteria for type 1 MI, type 2 MI, type 3 MI according to the fourth universal definition of myocardial infarction[1]
Type 1 MI
Detection of a rise and/or fall of cTn values with at least one value above the 99th percentile URL and with at least one of the following:
Symptoms of acute myocardial ischaemia
New ischaemic ECG changes
Development of pathological Q waves
Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology
Identification of a coronary thrombus by angiography including intracoronary imaging or by autopsy
Type 2 MI
Detection of a rise and/or fall of cTn values with at least one value above the 99th percentile URL, and evidence of an imbalance between myocardial oxygen supply and demand unrelated to coronary thrombosis, requiring at least one of the following:
Symptoms of acute myocardial ischaemia
New ischaemic ECG changes
Development of pathological Q waves
Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic aetiology
Type 3 MI
Patients who suffer cardiac death, with symptoms suggestive of myocardial ischaemia accompanied by presumed new ischemic ECG changes or ventricular fibrillation but die before blood samples for biomarkers can be obtained, or before increases in cardiac biomarkers can be identified, or MI is detected by autopsy examination

MI: Myocardial infarction; ECG: Electrocardiogram; cTn: Cardiac troponin; URL: Upper reference limit.

Table 2 Diagnostic criteria and causes of myocardial infarction with non-obstructive coronary arteries

Diagnostic criteria and causes for myocardial infarction with non-obstructive coronary arteries according to the ESC working group position paper[3]
Diagnostic criteria:
The diagnosis of MINOCA is made immediately upon coronary angiography in a patient presenting with features consistent with an acute myocardial infarction, as detailed by the following criteria:
(1) AMI criteria
(a) Positive cardiac biomarker (preferably cardiac troponin) defined as a rise and/or fall in serial levels, with at least one value above the 99th percentile upper reference limit
(b) Corroborative clinical evidence of infarction evidenced by at least one of the following:
Symptoms of ischaemia
New or presumed new significant ST-T changes or new LBBB
Development of pathological Q waves
Imaging evidence of new loss of viable myocardium or new RWMA
Intracoronary thrombus evident on angiography or at autopsy
(2) Non-obstructive coronary arteries on angiography:
Defined as the absence of obstructive CAD on angiography, (i.e. no coronary artery stenosis ≥ 50%), in any potential infarct-related artery. This includes both patients with:
This includes both patients with:
Normal coronary arteries (no stenosis < 30%)
Mild coronary atheromatosis (stenosis > 30% but < 50%).
No clinically overt specific cause for the acute presentation:
At the time of angiography, the cause and thus a specific diagnosis for the clinical presentation is not apparent
Accordingly, there is a necessity to further evaluate the patient for the underlying cause of the MINOCA presentation
Causes
Plaque rupture or erosion
Coronary artery spasm
Thromboembolism
Coronary dissection
Takotsubo syndrome
Unrecognized myocarditis, and
Other forms of type-2 myocardial infarction

CAD: Coronary artery disease; ESC: European society of cardiology; MINOCA: Non-obstructive coronary arteries; RWMA: Regional wall motion abnormality; LBBB: Left bundle branch block; AMI: Acute myocardial infarction.