Learning objectives
To learn the definition and different causes of Troponin-positive chest pain with Non-Obstructive Coronary Arteries (TpNOCA).
To understand the role of cardiovascular magnetic resonance (CMR) in diagnosing TpNOCA.
Background
The term TpNOCA (Troponin-positive chest pain with Non-Obstructive Coronary Arteries) is an acronym that refers to three categories:
Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA).
MINOCA “mimics”.
Extracardiac pathologies.
All groups can clinically manifest as an acute coronary syndrome (ACS) and are defined by two premises [1]:
Increased biomarkers of myocardial damage (ultrasensitive troponin).
No evidence of coronary artery obstruction (stenosis ≥50% of the vessel diameter or FFR <0.8 [2]) on invasive coronary angiography (ICA).
Prior to unveiling the true reason for a disease, TpNOCA...
Findings and procedure details
A. DIAGNOSIS AND RECOMMENDATIONS
Once the clinical scenario of a TpNOCA appears, the first thing to do is to reconsider the clinical context and exclude alternative diagnoses (i.e. sepsis, pulmonary embolism and stroke among other non-cardiac entities that increase troponins). The next step is to exclude a missed obstruction or another non-ischemic myocardial injury mechanism. Finally, as a diagnosis of exclusion, we call it MINOCA, so it is necessary to go further and try to clarify the aetiology [1,4].
(Level 1A recommendation) – Coronary CT...
Conclusion
CMR imaging is a valuable tool that can help delineate causes in patients labelled as MINOCA as it is a non-specific diagnosis with many different pathophysiological causes.
CMR provides information beyond the anatomical, functional, and haemodynamic assessment:
Reference standard for establishing the efficacy of invasive interventions.
Predictors of post-infarction adverse remodelling (extent of infarction, presence of transmural infarction and microvascular obstruction, MVO).
Prognostic markers (LV volume and function, infarct size, myocardial salvage, MVO).
Detection of complications after infarction.
Therefore, CMR plays a key role in...
Personal information and conflict of interest
C. Urtasun Iriarte:
Nothing to disclose
M. B. Barrio Piqueras:
Nothing to disclose
A. Ezponda Casajus:
Nothing to disclose
M. Jiménez Vázquez:
Nothing to disclose
C. Mbongo:
Nothing to disclose
N. Cherrez:
Nothing to disclose
P. Del Nido Recio:
Nothing to disclose
M. R. López de la Torre Carretero:
Nothing to disclose
G. Bastarrika Alemañ:
Nothing to disclose
References
Tamis-Holland, J. E., Jneid, H., Reynolds, H. R., Agewall, S., Brilakis, et al (2019). Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. Circulation, 139(18), E891–E908.
Ihdayhid, A. R., Norgaard, B. L., Gaur, S., Leipsic, J., Nerlekar, N., Osawa, K., et al (2019). Prognostic value and risk continuum of noninvasive fractional flow reserve derived from coronary CT angiography. Radiology, 292(2), 343–351.
Pasupathy, S., Air, T., Dreyer, R. P., Tavella,...