Advances in Etiology and Prognosis of Myocardial Infarction with Non-obstructive Coronary Arteries

doi:10.12114/j.issn.1007-9572.2021.00.055

Abstract

Abstract: Myocardial infarction with non-obstructive coronary arteries（MINOCA）is a syndrome with multiple causes，which accounts for 5%-25% of acute myocardial infarction and arouses widespread concern in clinical practice in recent years.As the global definition of myocardial infarction has changed，the etiology of MINOCA may have also changed.Meanwhile，the prognosis of MINOCA remains unclear due to the influence of different causes.In this review，according to the Fourth Universal Definition of Myocardial Infarction and recent accumulating evidence on MINOCA，the etiology and diagnostic algorithm of MINOCA were further summarized，and the short-term middle-term and long-term prognosis of MINOCA were analyzed.We suggested that patients diagnosed with MINOCA should be evaluated to uncover the potential cause as far as possible for improving the prognosis，and hoped that further research would be carried out to explore the impact of different causes on the prognosis of MINOCA.

Key words: Myocardial infarction, Myocardial infarction with non-obstructive coronary arteries, Etiology, Prognosis

摘要： 冠状动脉非阻塞性心肌梗死（MINOCA）是一种多病因的临床综合征，其发病率约占急性心肌梗死的5%~25%，近年来在临床上引起普遍关注。由于最新的心肌梗死定义发生了一定变化，使得MINOCA的病因分类也随之有所不同，并且受不同病因的影响，MINOCA患者的预后情况目前尚无定论。本文结合第四版心肌梗死全球统一定义及近年来国内外MINOCA的相关研究，进一步总结归纳了MINOCA的病因及诊断流程，并对其短期预后、中长期预后分别进行了分析阐述，建议诊断为MINOCA的患者应积极探索其潜在病因，以期针对性治疗改善患者预后，并希望未来开展进一步研究探索MINOCA不同的病因对预后的影响。

关键词: 心肌梗死, 冠状动脉非阻塞性心肌梗死, 病因, 预后

ZHANG Yiman,HUANG Baotao,SHI Ruijuan, et al. Advances in Etiology and Prognosis of Myocardial Infarction with Non-obstructive Coronary Arteries　[J]. Chinese General Practice, 2021, 24(2): 132-137. DOI: 10.12114/j.issn.1007-9572.2021.00.055.
张依曼,黄宝涛,时瑞娟等. 冠状动脉非阻塞性心肌梗死的病因及预后研究进展[J]. 中国全科医学, 2021, 24(2): 132-137. DOI: 10.12114/j.issn.1007-9572.2021.00.055.

References

［1］MILLER R D，BURCHELL H B，EDWARDS J E.Myocardial infarction with and without acute coronary occlusion；a pathologic study［J］．AMA Arch Intern Med，1951，88（5）：597-604．
［2］BELTRAME J F.Assessing patients with myocardial infarction and nonobstructed coronary arteries（MINOCA）［J］．J Intern Med，2013，273（2）：182-185．
［3］AGEWALL S，BELTRAME J F，REYNOLDS H R，et al．ESC working group position paper on myocardial infarction with non-obstructive coronary arteries［J］．Eur Heart J，2017，38（3）：143-153．DOI：10.1093/eurheartj/ehw149.
［4］THYGESEN K，ALPERT J S，JAFFE A S，et al．Fourth universal definition of myocardial infarction（2018）［J］．J Am Coll Cardiol，2018，72（18）：2231-2264．DOI：10.1016/j.jacc.2018.08.1038.
［5］TAMIS-HOLLAND J E，JNEID H，REYNOLDS H R，et al．Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease：a scientific statement from the American Heart Association［J］．Circulation，2019，139（18）：e891-908．
［6］SCALONE G，NICCOLI G，CREA F.Editor's choice- pathophysiology，diagnosis and management of MINOCA：an update［J］．Eur Heart J Acute Cardiovasc Care，2019，8（1）：54-62．DOI：10.1177/2048872618782414.
［7］REYNOLDS H R，SRICHAI M B，IQBAL S N，et al．Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease［J］．Circulation，2011，124（13）：1414-1425．DOI：10.1161/circulationaha.111.026542.
［8］FALK E，NAKANO M，BENTZON J F，et al．Update on acute coronary syndromes：the pathologists' view［J］．Eur Heart J，2013，34（10）：719-728．DOI：10.1093/eurheartj/ehs411.
［9］IANNACCONE M，QUADRI G，TAHA S，et al．Prevalence and predictors of culprit plaque rupture at OCT in patients with coronary artery disease：a meta-analysis［J］．Eur Heart J Cardiovasc Imaging，2016，17（10）：1128-1137．
［10］WHITE S J，NEWBY A C，JOHNSON T W.Endothelial erosion of plaques as a substrate for coronary thrombosis［J］．Thromb Haemost，2016，115（3）：509-519．DOI：10.1160/th15-09-0765.
［11］YAMAMOTO E，YONETSU T，KAKUTA T，et al．Clinical and laboratory predictors for plaque erosion in patients with acute coronary syndromes［J］．J Am Heart Assoc，2019，8（21）：e012322．DOI：0.1161/jaha.119.012322.
［12］LEE T，MINTZ G S，MATSUMURA M，et al．Prevalence，predictors，and clinical presentation of a calcified nodule as assessed by optical coherence tomography［J］．JACC Cardiovasc Imaging，2017，10（8）：883-891．DOI：10.1016/j.jcmg.2017.05.013.
［13］OULDZEIN H，ELBAZ M，RONCALLI J，et al．Plaque rupture and morphological characteristics of the culprit lesion in acute coronary syndromes without significant angiographic lesion：analysis by intravascular ultrasound［J］．Ann Cardiol Angeiol，2012，61（1）：20-26．DOI：10.1016/j.ancard.2011.07.011.
［14］OPOLSKI M P，SPIEWAK M，MARCZAK M，et al．Mechanisms of myocardial infarction in patients with nonobstructive coronary artery disease：results from the optical coherence tomography study［J］．JACC Cardiovasc Imaging，2019，12（11 Pt 1）：2210-2221．DOI ：10.1016/j.jcmg.2018.08.022.
［15］XING L，YAMAMOTO E，SUGIYAMA T，et al．EROSION Study（effective anti-thrombotic therapy without stenting：intravascular optical coherence tomography-based management in plaque erosion）：a 1-year follow-up report［J］．Circ Cardiovasc Interv，2017，10（12）： e005860．
［16］MONTONE R A，NICCOLI G，FRACASSI F，et al．Patients with acute myocardial infarction and non-obstructive coronary arteries：safety and prognostic relevance of invasive coronary provocative tests［J］．Eur Heart J，2018，39（2）：91.
［17］NAM P，CHOI B G，CHOI S Y，et al．The impact of myocardial bridge on coronary artery spasm and long-term clinical outcomes in patients without significant atherosclerotic stenosis［J］．Atherosclerosis，2018，270：8-12．DOI：10.1016/j.atherosclerosis.2018.01.026.
［18］CHEN C，WEI J，ALBADRI A，et al．Coronary microvascular dysfunction- epidemiology，pathogenesis，prognosis，diagnosis，risk factors and therapy［J］．Circ J，2016，81（1）：3-11．
［19］MONTONE R A，NICCOLI G，RUSSO M，et al．Clinical，angiographic and echocardiographic correlates of epicardial and microvascular spasm in patients with myocardial ischaemia and non-obstructive coronary arteries［J］．Clin Res Cardiol，2020，109（4）：435-443．DOI：10.1007/s00392-019-01523-w.
［20］PIROZZOLO G，SEITZ A，ATHANASIADIS A，et al．Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion（MINOCA）［J］．Clin Res Cardiol，2020，109（2）：246-254．
［21］ONG P，CAMICI P G，BELTRAME J F，et al．International standardization of diagnostic criteria for microvascular angina［J］．Int J Cardiol，2018，250：16-20．DOI：10.1016/j.ijcard.2017.08.068.
［22］PASUPATHY S，AIR T，DREYER R P，et al．Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries［J］．Circulation，2015，131（10）：861-870．DOI：10.1161/circulationaha.114.011201.
［23］BILI A，MOSS A J，FRANCIS C W，et al．Anticardiolipin antibodies and recurrent coronary events：a prospective study of 1150 patients.Thrombogenic factors，and recurrent coronary events investigators［J］．Circulation，2000，102（11）：1258-1263．DOI：10.1161/01.cir.102.11.1258.
［24］STEPIEN K，NOWAK K，WYPASEK E，et al．High prevalence of inherited thrombophilia and antiphospholipid syndrome in myocardial infarction with non-obstructive coronary arteries：comparison with cryptogenic stroke［J］．Int J Cardiol，2019，290：1-6．DOI：10.1016/j.ijcard.2019.05.037.
［25］MEHTA P K，BELTRAME J F.Myocardial infarction with non-obstructive coronary arteries：a humbling diagnosis in 2018［J］．Heart，2019，105（7）：506-507．
［26］YANG C，ALFADHEL M，SAW J.Spontaneous coronary artery dissection：latest developments and new frontiers［J］．Curr Atheroscler Rep，2020，22（9）：49．
［27］SAW J，RICCI D，STAROVOTOV A，et al．Spontaneous coronary artery dissection：prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort［J］．JACC Cardiovasc Interv，2013，6（1）：44-52．DOI：10.1016/j.jcin.2012.08.017.
［28］SAW J，STAROVOYTOV A，HUMPHRIES K，et al．Canadian spontaneous coronary artery dissection cohort study：in-hospital and 30-day outcomes［J］．Eur Heart J，2019，40（15）：1188-1197．DOI：10.1093/eurheartj/ehz007.
［29］KRITTANAWONG C，KUMAR A，JOHNSON KW，et al．Conditions and factors associated with spontaneous coronary artery dissection（from a national population-based cohort study）［J］．Am J Cardiol，2019，123（2）：249-253．DOI：10.1016/j.amjcard.2018.10.012.
［30］NISHIGUCHI T，TANAKA A，TARUYA A，et al．Prognosis of spontaneous coronary artery dissection treated by percutaneous coronary intervention with optical coherence tomography［J］．J Cardiol，2017，70（6）：524-529．DOI：10.1016/j.jjcc.2017.03.009.
［31］MAHMOUD A N，TADURU S S，MENTIAS A，et al．Trends of incidence，clinical presentation，and in-hospital mortality among women with acute myocardial infarction with or without spontaneous coronary artery dissection：a population-based analysis［J］．JACC Cardiovasc Interv，2018，11（1）：80-90．
［32］SAW J，HUMPHRIES K，AYMONG E，et al．Spontaneous coronary artery dissection：clinical outcomes and risk of recurrence［J］．J Am Coll Cardiol，2017，70（9）：1148-1158．DOI：10.1016/j.jacc.2017.06.053.
［33］TARANTINI G，MIGLIORE F，CADEMARTIRI F，et al．Left anterior descending artery myocardial bridging：a clinical approach［J］．J Am Coll Cardiol，2016，68（25）：2887-2899．DOI：10.1016/j.jacc.2016.09.973.
［34］SCHWARZ E R，GUPTA R，HAAGER P K，et al．Myocardial bridging in absence of coronary artery disease：proposal of a new classification based on clinical-angiographic data and long-term follow-up［J］．Cardiology，2009，112（1）：13-21．DOI：10.1159/000137693.
［35］WILLIAMS M J A，BARR P R，LEE M，et al．Outcome after myocardial infarction without obstructive coronary artery disease［J］．Heart，2019，105（7）：524-530．DOI：10.1136/heartjnl-2018-313665.
［36］ANDERSSON H B，PEDERSEN F，ENGSTROM T，et al．Long-term survival and causes of death in patients with ST-elevation acute coronary syndrome without obstructive coronary artery disease［J］．Eur Heart J，2018，39（2）：102-110．
［37］BAINEY K R，WELSH R C，ALEMAYEHU W，et al．Population-level incidence and outcomes of myocardial infarction with non-obstructive coronary arteries（MINOCA）：insights from the Alberta contemporary acute coronary syndrome patients invasive treatment strategies（COAPT）study［J］．Int J Cardiol，2018，264：12-17．DOI：10.1016/j.ijcard.2018.04.004.
［38］SMILOWITZ N R，MAHAJAN A M，ROE M T，et al．Mortality of myocardial infarction by sex，age，and obstructive coronary artery disease status in the ACTION Registry-GWTG（acute coronary treatment and intervention outcomes network registry-get with the guidelines）［J］．Circ Cardiovasc Qual Outcomes，2017，10（12）：e003443．DOI：10.1161/circoutcomes.116.003443.
［39］苏斌杰，郭长峰，李海玲，等．冠状动脉非阻塞性心肌梗死患者的临床特征、治疗现状及院内预后分析［J］．国际心血管病杂志，2019，46（1）：47-51．DOI：10.3969/j.issn.1673-6583.2019.01.011.
［40］SAFDAR B，SPATZ E S，DREYER R P，et al．Presentation，clinical profile，and prognosis of young patients with myocardial infarction with nonobstructive coronary arteries（MINOCA）：results from the VIRGO study［J］．J Am Heart Assoc，2018，7（13）： e009174．DOI：10.1161/jaha.118.009174.
［41］DREYER R P，TAVELLA R，CURTIS J P，et al．Myocardial infarction with non-obstructive coronary arteries as compared with myocardial infarction and obstructive coronary disease：outcomes in a medicare population［J］．Eur Heart J，2020，41（7）：870-878．DOI：10.1093/eurheartj/ehz403.
［42］LINDAHL B，BARON T，ERLINGE D，et al．Medical therapy for secondary prevention and long-term outcome in patients with myocardial infarction with nonobstructive coronary artery disease［J］．Circulation，2017，135（16）：1481-1489．DOI：10.1161/circulationaha.116.026336.
［43］CHOO E H，CHANG K，LEE K Y，et al．Prognosis and predictors of mortality in patients suffering myocardial infarction with non-obstructive coronary arteries［J］．J Am Heart Assoc，2019，8（14）：e011990．DOI：10.1161/jaha.119.011990.
［44］CILIBERTI G，COIRO S，TRITTO I，et al．Predictors of poor clinical outcomes in patients with acute myocardial infarction and non-obstructed coronary arteries（MINOCA）［J］．Int J Cardiol，2018，267：41-45．DOI：10.1016/j.ijcard.2018.03.092.
［45］HJORT M，LINDAHL B，BARON T，et al．Prognosis in relation to high-sensitivity cardiac troponin T levels in patients with myocardial infarction and non-obstructive coronary arteries［J］．Am Heart J，2018，200：60-66．DOI：10.1016/j.ahj.2018.03.005.
［46］NORDENSKJOLD A M，BARON T，EGGERS K M，et al．Predictors of adverse outcome in patients with myocardial infarction with non-obstructive coronary artery（MINOCA）disease［J］．Int J Cardiol，2018，261：18-23．DOI：10.1016/j.ijcard.2018.03.056.

[1]	HAN Congcong, QIU Xinyu, SHAN Chunfang, SONG Ning, CHEN Qingjie, MULADILI· Abudureheman, LI Xiaomei, YANG Yining, ZHAO Qian. Impact of Metabolic Obesity Phenotype on Long-term Prognosis after Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome [J]. Chinese General Practice, 2026, 29(21): 2950-2958.
[2]	LIU Yang, ZHOU Guoping, LI Xiaoshi, LI Ping, ZHANG Xin. Impact of Acute Respiratory Distress Syndrome Etiology on the Prognostic Value of Driving Pressure: a Prospective Cohort Study [J]. Chinese General Practice, 2026, 29(19): 2638-2647.
[3]	YUAN Yujuan, TAO Jing, WANG Ying, PENG Hui, YANG Yining. Elevated Neutrophil Percentage to Albumin Ratio is Associated with In-hospital Outcomes in Patients with Acute Myocardial Infarction [J]. Chinese General Practice, 2026, 29(18): 2489-2497.
[4]	LUAN Xiaoqing, SUN Jingjing, LI Xiaoling, WANG Manxia. Research Progress on Potential Biomarkers of Neuromyelitis Optica Spectrum Disorder [J]. Chinese General Practice, 2026, 29(17): 2418-2424.
[5]	XIONG Siyu, LU Bing, JIANG Wenhong, YU Tingting. Study on the Relationship between Fructose-1, 6-Bisphosphate Aldolase A Expression before and after Targeted Drug Resistance in Lung Adenocarcinoma and Patient Prognosis [J]. Chinese General Practice, 2026, 29(14): 1883-1889.
[6]	SUN Xia, SHEN Wen, TANG Xiang, ZHONG Wei, WANG Kailin, DAI Zhiyin, ZHANG Chaopu, YUAN Wei, YUAN Guoyue. Analysis of Clinical Characteristics in Dilated Cardiomyopathy Patients with Different Weight Statuses and the Influence of Weight Management on the Prognosis [J]. Chinese General Practice, 2026, 29(11): 1448-1455.
[7]	XIA Ning, SHI Lan, DING Wanbao, ZHANG Jie, LONG Yi, DAI Hui, ZHANG Can, DAI Hailong. Clinical Characteristics and Prognosis of Patients with Amyloidosis [J]. Chinese General Practice, 2026, 29(09): 1161-1167.
[8]	WANG Lina, LEI Jingshu, LI Kuibao, WANG Ruiying, LI Xinmiao, WANG Fangfang, GUO Xiaorong, NIU Ruihao, ZHAO Wei, ZHOU Fangfang, ZHAO Jingjing, LEE CHONGYOU. Review on Inflammatory Response in Patients with Acute Myocardial Infarction [J]. Chinese General Practice, 2026, 29(06): 790-801.
[9]	LEI Chunxin, ZHANG Xiya, ZHANG Yan, CHEN Jiaqi, LIU Zihan, LUO Jing, TAO Qingwen. Clinical Characteristics and Influencing Factors of Primary Sjögren's Disease with Dryness and Blood-stasis Syndrome [J]. Chinese General Practice, 2026, 29(06): 718-725.
[10]	WANG Xue, YANG Chengming, WANG Ziyun, ZHOU Zhong. Analysis on Prognosis and Influencing Factors in Patients with Post-tuberculosis Bronchiectasis [J]. Chinese General Practice, 2026, 29(05): 606-611.
[11]	FU Jiyi, ZHENG Boyue, WU Jiafei, WANG Jun, LI Hui. Efficacy and Safety of a Combined Regimen of Histone Deacetylase Inhibitors Venetoclax and Azacitidine in Adult T-cell Acute Lymphoblastic Leukemia [J]. Chinese General Practice, 2026, 29(04): 483-489.
[12]	CEN Kaiyuan, FATIMAH Ahmedy, CHEN Hong, SHAO Mingchen, MEXMOLLEN Marcus, MOHD Fadzli Shukor. Exercise-based Cardiac Rehabilitation in Acute Myocardial Infarction Management: Global Perspectives, Multimodal Interventions, and Personalized Strategies [J]. Chinese General Practice, 2025, 28(36): 4627-4639.
[13]	ZHOU Qianmei, MIAO Kali, ZHONG Yongming, ZHANG Fuman, ZHANG Zhe, LI Chengyi. Gas6 Expression in Breast Cancer and Correlation with Clinical Pathological Features and Prognosis [J]. Chinese General Practice, 2025, 28(35): 4449-4456.
[14]	ZHAO Zhuo, WANG He. Research Progress on the Mechanism of HIF-2α in Cardiovascular Diseases [J]. Chinese General Practice, 2025, 28(33): 4241-4248.
[15]	JIA Gaopeng, CHEN Qiuyu. Construction and Validation of a Risk Prediction Model for Recurrent Angina after Percutaneous Coronary Intervention in Elderly Patients with Acute ST-segment Elevation Myocardial Infarction: Based on CYP2C19-related Genetic Testing [J]. Chinese General Practice, 2025, 28(30): 3779-3786.