MINOCA with ST elevation (STE-MINOCA) in contemporary practice: clinical profile and early outcomes

Background A significant proportion of patients presenting with ST-elevation myocardial infarction (STEMI) undergo emergent coronary angiography despite no obstructive culprit lesion can be identified. Data on their clinical profile, underlying diagnoses and early outcomes remain limited. Methods In this single-center retrospective sutdy, consecutive STEMI patients undergoing coronary angiography between 2015 and 2024 were analyzed. Patients without an identifiable culprit lesion were classified as MINOCA with ST elevation (STE-MINOCA) and categorized according to final discharge diagnosis. Clinical characteristics and in-hospital mortality were assessed across diagnostic entities. Results Among 1,403 STEMI patients undergoing coronary angiography, 105 (7.5%) had no identifiable culprit lesion. Compared with patients with culprit lesion, STE-MINOCA patients were younger (57.6 ± 18.5 vs. 65.3 ± 13.3 years, p<0.001) and had higher left ventricular ejection fraction (48.3 ± 14.1% vs. 41.1 ± 10.9%, p<0.001). The proportion of female patients did not differ significantly between groups (p=0.381). STE-MINOCA patients presented less frequently with cardiogenic shock (p<0.001) or preceding CPR (p=0.024). Culprit lesion status was not independently associated with in-hospital mortality after adjustment for age and cardiogenic shock (OR 1.01, 95% CI 0.45–2.29, p=0.982). Among STE-MINOCA patients, the most common diagnoses were inflammatory myopericardial syndrome (IMPS) (27%), Takotsubo cardiomyopathy (15%), and non-cardiac conditions including pulmonary embolism or aortic pathology (20%), non-ischemic cardiomyopathy (10%), and coronary vasospasm or embolism (11%) (Figure 1). Clinical profiles differed substantially across entities (Table 1). Patients with Takotsubo cardiomyopathy were predominantly female (87.5%) and had reduced LVEF (33.3 ± 12%). IMPS patients showed preserved LVEF (54.1 ± 11.5%) and no in-hospital deaths. In contrast, non-cardiac causes were associated with the highest rates of cardiogenic shock (21%) and in-hospital mortality (23.8%). Overall in-hospital mortality among STE-MINOCA patients was 9.5%, but ranged from 0% in inflammatory etiologies to 23.8 % in non-cardiac conditions (Table 1). Conclusion Approximately 8% of patients presenting with ST-segment elevation showed no identifiable culprit lesion on angiography. Although overall clinically less unstable than patients with a culprit lesion, STE-MINOCA patients represent a highly heterogeneous population with entity-specific clinical profiles and markedly different early outcomes. Particularly non-cardiac etiologies carry substantial short-term risk, underscoring the need for rapid differential diagnostic evaluation beyond coronary angiography.