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MINOCA - Differential Diagnosis — EECC MCQ

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ModerateCoronary Artery DiseaseMINOCA - Differential DiagnosisEECC

A 50-year-old woman presents with acute chest pain and troponin rise. Coronary angiography shows unobstructed coronary arteries. Cardiac MRI performed 5 days later shows mid-wall late gadolinium enhancement in the inferolateral wall with corresponding oedema on T2-weighted imaging. What is the most likely diagnosis?

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Correct answer: A — Acute myocarditis

The CMR findings are diagnostic: mid-wall (non-ischaemic pattern) LGE with corresponding T2 oedema indicates an active inflammatory process consistent with acute myocarditis. MINOCA due to plaque disruption would show subendocardial or transmural LGE in a coronary territory distribution. Takotsubo typically shows oedema without significant LGE. Cardiac sarcoidosis shows patchy mid-wall/epicardial LGE but usually without acute oedema in this pattern. The 2025 ESC Myocarditis/Pericarditis Guidelines emphasise CMR as the cornerstone for non-invasive diagnosis of myocarditis.

Reference: ESC (2025): Guidelines for the Management of Myocarditis and Pericarditis