A structured diagnostic protocol combining multiple modalities identified a final diagnosis in 59% of patients with MINOCA (P<0.01 for incremental yield).
Cohort (n=183)
Yes
Does a structured diagnostic protocol increase the diagnostic yield in patients with MINOCA?
A structured, multi-modality diagnostic protocol for MINOCA significantly increases the diagnostic yield, identifying a final diagnosis in 59% of patients.
p-value: p=<0.01
Background Current guidelines recommend a structured diagnostic protocol to determine the underlying final diagnosis for myocardial infarction with non-obstructive coronary arteries (MINOCA). Yet, a comprehensive diagnostic workup is often hindered by economic and time constraints, and real-world data is scarce. Objectives This study thus aimed to examine the diagnostic strategy of a structured protocol beyond initial invasive coronary angiography (ICA) for MINOCA. Methods This prospective multicenter cohort study enrolled MINOCA patients who underwent ICA between December 2020 and June 2024. The protocol with a stepwise approach recommended ad-hoc optical coherence tomography (OCT) for culprit lesion identification. Left ventricular angiography (LVA) or echocardiography were indicated for screening takotsubo syndrome (TTS). In case that no overt diagnosis was found, cardiac magnetic resonance (CMR) was performed to distinguish focal myocardial infarction from other diagnoses, including myocarditis, TTS, and other non-ischemic cardiomyopathy. Coronary functional testing (CFT) was considered in case of persistent angina. Results A total of 183 patients (60% female) were enrolled. The diagnostic yield per test was 19% with OCT (21/112), 29% with LVA and/or echocardiography (32/112), 62% with CMR (64/104), and 50% (1/2) with CFT. An incremental diagnostic yield in 183 patients was observed by combining modalities (11% with OCT alone versus 29% with OCT and LVA/echocardiography versus 58% with OCT, LVA/echocardiography and CMR versus 59% by adding CFT to all the imaging, P<0.01). Conclusions In conclusion, a structured diagnostic protocol with multiple diagnostic tests increases the diagnostic yield in the work-up of MINOCA, resulting in an identified final diagnosis in 59%.
Nishimiya et al. (2026) conducted a cohort in Myocardial infarction with non-obstructive coronary arteries (MINOCA) (n=183). Structured diagnostic protocol (OCT, LVA/echocardiography, CMR, CFT) was evaluated on Incremental diagnostic yield (p=<0.01). A structured diagnostic protocol combining multiple modalities identified a final diagnosis in 59% of patients with MINOCA (P<0.01 for incremental yield).