Unveiling the invisible culprit: a multimodality approach for myocardial infarction with non-obstructive coronary arteries diagnosis-a case report

Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) affects up to 10% of patients undergoing coronary angiography for acute myocardial infarction. Despite the lack of obstructive lesions, these patients face significant risks, requiring thorough diagnostic evaluations, often using both invasive and non-invasive methods. Recent guidelines emphasize the importance of performing intravascular imaging, coronary functional testing (CFT), and cardiac magnetic resonance (CMR) in the working diagnosis of MINOCA. Case summary A 48-year-old woman presented with chest pain, elevated cardiac troponins, and signs of non-ST-elevation myocardial infarction. Echocardiography showed normal left ventricular ejection fraction with focal inferior-lateral mid-apical hypokinesia and no significant valvular heart disease. Coronary angiography revealed normal arteries with hypoplasia of the right coronary artery. Further testing, including CMR and CFT with acetylcholine provocation, confirmed severe coronary spasm, diagnosing epicardial vasospastic angina causing MINOCA. Discussion Diagnosing MINOCA is challenging and requires a multimodal approach. Invasive testing can reveal vasospasm or microvascular dysfunction. This case emphasizes the need for repeated imaging and functional tests to reach a diagnosis. Calcium channel blockers like diltiazem are commonly used in treatment.