Coronary computed tomography angiography in myocardial infarction with non-obstructive coronary arteries: a multicentric cohort study

Background Coronary computed tomography angiography (CCTA) offers a non-invasive way to detect coronary lesions potentially causing myocardial infarction with non-obstructive coronary arteries (MINOCA), but its early diagnostic role remains unclear. Purpose To evaluate the value of combining early CCTA and cardiac magnetic resonance (CMR) in a non-invasive approach for MINOCA. Methods This prospective, multicentric, observational study evaluated MINOCA patients undergoing invasive coronary angiography (ICA), followed within 7 days by CMR and CCTA. Non-ischaemic aetiologies were excluded. CCTA assessed high-risk plaques (HRP), myocardial bridges (MB), and spontaneous coronary artery dissection (SCAD)<50%. Patients were grouped as MINOCA-CT+ or MINOCA-CT− based on CCTA findings. The primary endpoint was concordance between CCTA-detected lesions and CMR-identified ischaemic damage in the same territory, compared with ICA. Diagnostic performance was further evaluated via ROC analysis. Results Among 77 confirmed MINOCA patients, 42 (54.6%) had coronary lesions on CCTA. HRP were found in 35 (45.5%), MB in 7 (9%), and no SCAD. MINOCA-CT+ patients had greater total plaque volume than MINOCA-CT−. CMR showed ischaemic damage in 56 patients (72.7%). MINOCA-CT+ patients exhibited greater myocardial edema (4.3% vs 9.2% of the left ventricle; P=0.003) and infarct size (2.44% vs 6%; P=0.003). Concordance between CCTA lesions and CMR ischaemic pattern was 49.4% (vs 45.5% with ICA; P=0.084 per-patient, P=0.029 per-vessel). Concordance between CCTA lesion documentation and CMR ischaemic damage localization was 49.4% (vs 45.5% with ICA; P=0.084 per-patient, P=0.029 per-vessel). CCTA’s positive predictive value for detecting ischaemic damage on CMR was 91% (per-patient) and 78% (per-vessel); negative predictive value was 49% and 89%, respectively—both superior to ICA. ROC analysis confirmed CCTA's strong performance (AUC 0.74 per-patient, 0.78 per-vessel). Conclusion Combined CCTA and CMR identified ischaemic injury and coronary abnormalities in a substantial proportion of MINOCA patients. CCTA demonstrated strong diagnostic value in revealing coronary mechanisms underlying ischaemic damage.