Systematic Review and Meta-Analysis: Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA), Ischemia with Non- Obstructive Coronary Arteries (INOCA), and Related Conditions Including Coronary Microvascular Dysfunction

Abstract Myocardial infarction with non-obstructive coronary arteries (MINOCA) and ischemia with non- obstructive coronary arteries (INOCA) represent heterogeneous syndromes characterized by myocardial ischemia or infarction in the absence of significant epicardial coronary artery obstruction. These conditions, along with related entities such as coronary microvascular dysfunction (CMD) and vasospastic angina, pose diagnostic and therapeutic challenges due to multifactorial pathophysiology. This systematic review and meta-analysis compiles contemporary evidence on prevalence, mechanisms, clinical outcomes, and management strategies. We searched electronic databases for studies published up to July 2025, identifying 56 eligible studies. The pooled prevalence of MINOCA among acute myocardial infarctions was ~ 6.8%, while INOCA comprised nearly half of patients undergoing angiography for suspected ischemia. Long-term mortality in MINOCA was lower than in obstructive myocardial infarction but remained significant (approximately 4% per year). CMD emerged as a common underlying mechanism in both syndromes. Management approaches emphasizing standard secondary prevention and targeted therapies (e.g. calcium channel blockers for vasospasm, lifestyle modification for microvascular angina) showed promise in improving outcomes and reducing recurrent angina. These findings underscore the need for advanced diagnostic tools and personalized treatments to improve prognosis in affected patients.