Knowledge gaps in revascularization strategies in the setting of type II myocardial infarction: A common clinical dilemma in contemporary practices

Type II myocardial infarction (MI), caused by myocardial oxygen supply-demand imbalance rather than acute plaque rupture, represents a growing clinical challenge with high mortality but limited evidence-based management strategies. It requires a rise and/or fall in cardiac troponins with objective evidence of ischemia and should be distinguished from acute myocardial injury without ischemic features. Current guidelines provide limited, but largely diagnostic and principle-based guidance and do not provide trial-validated pathways for coronary evaluation or revascularization in type II MI with coexisting coronary artery disease. Observational studies suggest potential benefit of revascularization and secondary prevention, yet selection bias and procedural risks complicate decision-making. Emerging strategies, including the use of drug-coated balloon (DCB) angioplasty, may offer a balance between invasive therapy and bleeding risk in this high-risk population. This article highlights the diagnostic complexities, therapeutic dilemmas, and the urgent need for randomized trials to define optimal management pathways. A pragmatic framework is proposed, integrating systemic trigger correction, coronary evaluation, physiology-based testing, and individualized revascularization strategies, with emphasis on underutilized guideline-directed medical therapy. The proposed diagnostic and management framework is pragmatic and expert-opinion-based, reflecting current evidence gaps rather than validated trial data.