Role of Cardiac Imaging in Myocardial Infarction With Non‐Obstructive Coronary Arteries

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a dynamic and evolving clinical entity, defined by two key components: the presence of acute myocardial infarction and the absence of obstructive coronary artery disease. Contrary to earlier perceptions of MINOCA as a benign condition, accumulating evidence underscores its association with significant morbidity and major adverse cardiac events. Recent clinical guidelines advocate for a structured, three-step "traffic light" approach to differentiate non-cardiac causes of elevated cardiac troponins from ischemic and non-ischemic cardiac entities. Cardiac magnetic resonance (CMR), with its unparalleled tissue characterization capabilities, plays a pivotal role in identifying ischemic patterns, including regional wall motion abnormalities, myocardial edema, and late gadolinium enhancement, facilitating differentiation from non-ischemic causes such as Takotsubo cardiomyopathy and acute myocarditis. The combination of CMR with intravascular imaging has been shown to be the most effective approach for identifying the underlying ischemic mechanisms of MINOCA. Furthermore, CMR provides critical prognostic insights, enabling the identification of patients at elevated risk for adverse cardiovascular outcomes. The integration of CMR into the diagnostic and management pathways of MINOCA holds substantial promise for the improvement of patient outcomes and advancing our understanding of this multifaceted clinical entity.