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MINOCA - Ischaemic Subtype — EECC MCQ

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HardCoronary Artery DiseaseMINOCA - Ischaemic SubtypeEECC

A 48-year-old woman with no traditional cardiovascular risk factors presents with chest pain, troponin rise, and unobstructed coronary arteries on angiography. CMR shows subendocardial LGE in the LAD territory with corresponding oedema but no mid-wall or epicardial LGE. What is the most likely final diagnosis?

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Correct answer: A — MINOCA due to coronary plaque disruption with transient thrombosis or coronary spasm causing a true ischaemic infarction

The CMR pattern is critical for distinguishing MINOCA subtypes. Subendocardial LGE following a coronary territory distribution indicates true myocardial infarction despite non-obstructive coronary arteries — this is MINOCA in its true sense (MI with Non-Obstructive Coronary Arteries). Potential mechanisms include plaque disruption with transient thrombosis (most common, identifiable by IVUS/OCT), coronary spasm, or spontaneous coronary embolism. Myocarditis produces mid-wall or epicardial LGE in a non-coronary distribution. Takotsubo typically shows oedema without significant LGE. The 2023 ESC ACS Guidelines recommend systematic investigation of MINOCA including CMR and consideration of IVUS/OCT/provocative testing.

Reference: ESC (2023): Guidelines for the Management of Acute Coronary Syndromes