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cardio.nstemi.minoca.v1

MINOCA — MI with Non-Obstructive Coronary Arteries

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.nstemi.core.v1 — narrowed to MINOCA per Tamis-Holland AHA 2019 PMID 30922983 + ESC 2023 ACS PMID 37622670. ACS criteria + non-obstructive coronaries (<50%) on angiography; ~5–10% of MI cohort; female-enriched. Defining workup pivot: cardiac MRI Lake Louise + LGE for tissue characterisation, IVUS / OCT during cath for plaque disruption / SCAD detection, intracoronary acetylcholine provocation for vasospasm, embolic source workup (TEE / bubble study). Treatment is aetiology-specific: plaque disruption → standard ACS bundle; vasospasm → CCB + nitrate + AVOID β-blocker; embolic → AC for source; SCAD → conservative; takotsubo overlap → supportive. Inherits parent ACS pathway pre-cath; pivots to cause-finding pathway on negative cath; routes back to parent / SCAD / takotsubo engines depending on aetiology. Universal ASA + statin while aetiology clarified; DAPT only when plaque disruption confirmed. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 14 etiology variant.

Entry points (4)

  • imaging
    Diagnostic angiography after NSTEMI/STEMI shows stenosis <50% in all major epicardial vessels — MINOCA per ESC 2023 + AHA 2019 (PMID 30922983)
    angio_no_obstructive_cad_after_acs
  • lab_abnormality
    hsTn rise/fall + ischaemic ECG / symptoms + non-obstructive coronaries — triggers MINOCA cause-finding workup
    hstn_rise_with_ischaemic_features_no_obstruction
  • symptom
    Recurrent ACS-pattern chest pain in patient with prior non-obstructive cath — re-evaluate for MINOCA aetiology shift
    recurrent_acs_pattern_with_known_non_obstructive_cad
  • imaging
    Cardiac MRI Lake Louise oedema + LGE pattern after negative cath — confirms MINOCA aetiology (myocarditis vs takotsubo vs infarct LGE)
    cmri_lake_louise_pattern_after_negative_cath

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    MINOCA spans wide age range; younger female predominance; informs cause-finding pre-test probabilities (SCAD younger women, plaque disruption older)
  • sexrequired
    demographic • used at CONTEXT
    Female sex enriched in MINOCA cohort (35–50% of MINOCA per CIAO); SCAD overwhelmingly female; vasospasm female-skewed in some populations
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension may indicate takotsubo with LVOT obstruction (β-blocker contraindicated) or cardiogenic shock — both alter pathway
  • hrrequired
    vital • used at CONTEXT
    Tachyarrhythmia in MINOCA setting raises supply-demand (type-2) overlap; AF raises embolic source suspicion
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    Defines NSTEMI per 4th UDMI (PMID 30153967) rise/fall criteria — MUST meet ACS criteria to be MINOCA (else label is INOCA)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Gates contrast load for cMRI / repeat cath / IVUS; KDIGO 2026 baseline
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline before any AC and to rule out concurrent infection (myocarditis mimic)
  • d_dimer
    lab • used at BRANCHING_WORKUP
    PE mimic / embolic source evaluation; elevated D-dimer prompts CT-PA before final MINOCA labelling
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    ECG pattern guides aetiology (transient ST elevation that resolves → vasospasm; persistent T-wave inversion → myocarditis vs takotsubo)
  • angio_with_intracoronary_imagingrequired
    imaging • used at INITIAL_WORKUP
    Coronary angiography is the entry criterion (<50% stenosis); IVUS or OCT during the same procedure recommended for plaque disruption / SCAD detection (CIAO + OCTAVIA)
  • cmri_with_lake_louise_lgerequired
    imaging • used at BRANCHING_WORKUP
    Cardiac MRI is the cornerstone cause-finding test in MINOCA per AHA 2019 PMID 30922983 — Lake Louise oedema + LGE distribution discriminates infarct (subendocardial / transmural LGE) from myocarditis (subepicardial / midwall LGE) from takotsubo (no LGE + apical ballooning)
  • tte_with_strainrequired
    imaging • used at INITIAL_WORKUP
    Echo for wall-motion pattern (apical ballooning → takotsubo; segmental → infarct distribution; global → myocarditis); GLS sensitive for early dysfunction
  • tee_or_bubble_study_for_pfo
    imaging • used at BRANCHING_WORKUP
    Embolic source workup — PFO with right-to-left shunt, atrial septal aneurysm, LAA thrombus; informs anticoagulation decision
  • vasospasm_provocation_acetylcholine
    imaging • used at BRANCHING_WORKUP
    Intracoronary acetylcholine 20–100 µg provocation — gold-standard test for coronary vasospasm; positive triggers CCB + nitrate regimen and β-blocker avoidance
  • recent_emotional_or_physical_stressorrequired
    history • used at CONTEXT
    Stressor with apical ballooning suggests takotsubo overlap — different management pathway
  • thrombophilia_or_cancer_historyrequired
    history • used at CONTEXT
    Hypercoagulable state raises embolic / coronary thrombus aetiology; cancer-associated thrombosis specifically

12-phase flow (12)

  1. 1FRAME
    Confirm MINOCA: ACS criteria met per 4th UDMI 2018 + non-obstructive coronaries (<50% stenosis) on angiography per AHA 2019 PMID 30922983 + ESC 2023 PMID 37622670 — exclude obstructive CAD as the cause
    inputs: hs_troponin_serial, angio_with_intracoronary_imaging
    advance: MINOCA criteria confirmed
  2. 2ENTRY
    Triage as ACS during initial cath; on negative cath, pivot to MINOCA cause-finding pathway and continue ASA + statin while aetiology clarified
    inputs: age, sex
    actions: acs_pathway
    advance: MINOCA pathway initiated
  3. 3CONTEXT
    Demographic and risk factors that re-shape pre-test probabilities — sex (SCAD risk), recent stressor (takotsubo), thrombophilia / cancer (embolic), substance use (vasospasm), AF history (embolic)
    inputs: sbp, hr, creatinine_egfr, recent_emotional_or_physical_stressor, thrombophilia_or_cancer_history
    advance: Context complete
  4. 4RED_FLAGS
    Cardiogenic shock (rare but possible — takotsubo with LVOT obstruction is a treatment trap because conventional ACS bundle worsens it); life-threatening arrhythmia; mechanical complication; recurrent severe vasospasm with VT/VF
    inputs: sbp
    actions: cardiogenic_shock, chest_pain
    advance: Red-flag screen complete
  5. 5INITIAL_WORKUP
    Standard NSTEMI initial labs + serial ECG + transthoracic echo with strain + IVUS or OCT during the index cath (recommended per AHA 2019); coronary angiography is entry criterion
    inputs: ecg_serial, hs_troponin_serial, creatinine_egfr, cbc, angio_with_intracoronary_imaging, tte_with_strain
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Initial workup complete + non-obstructive cath documented
  6. 6BRANCHING_WORKUP
    Cause-finding — cardiac MRI Lake Louise + LGE (cornerstone per AHA 2019); vasospasm provocation if pattern suggests; bubble study / TEE if embolic suspected; D-dimer + CT-PA if PE in differential
    inputs: cmri_with_lake_louise_lge, tee_or_bubble_study_for_pfo, vasospasm_provocation_acetylcholine, d_dimer
    actions: acute_valvular_emergency
    advance: Aetiology assigned
  7. 7DIFFERENTIAL
    Plaque disruption with autolysis vs vasospasm vs microvascular dysfunction vs embolic vs SCAD vs takotsubo overlap vs supply-demand (type-2 MI) vs myocarditis (which technically reclassifies away from MINOCA)
    advance: Aetiology label committed
  8. 8RISK_STRATIFICATION
    HEART / TIMI / GRACE band-mapped — many MINOCA patients fall in low-intermediate band by clinical features, but cMRI evidence of infarct upgrades to "true MI" outcome trajectory
    inputs: age, sbp, hr, creatinine_egfr, hs_troponin_serial
    actions: calc.heart, calc.timi_nstemi, calc.grace
    advance: Risk band documented
  9. 9TREATMENT
    Aetiology-specific: plaque disruption → standard ACS bundle (ASA + P2Y12 + statin + ACEi/BB); vasospasm → CCB + long-acting nitrate + AVOID β-blocker; microvascular → CCB + nitrate ± ranolazine; embolic → anticoagulation for source; SCAD → conservative + DAPT only if intervention (route to SCAD engine); takotsubo → supportive (route to takotsubo engine)
    inputs: creatinine_egfr, cbc
    advance: Aetiology-specific bundle initiated
  10. 10DISPOSITION
    CICU vs telemetry depending on hemodynamics; cMRI may need to be scheduled outpatient if acute access limited (still INPATIENT preferred per AHA 2019)
    advance: Disposition documented
  11. 11MONITORING
    Telemetry for arrhythmia (vasospasm episodes); repeat hsTn to peak; daily exam; cMRI scheduled if not yet done; vasospasm provocation scheduled if pattern suggests
    inputs: creatinine_egfr, cbc
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Cardiology follow-up + cardiac rehab; cMRI repeat at 3–6 mo if takotsubo (recovery confirmation); vasospasm patients need CCB adherence reinforcement and trigger avoidance; prognosis better than obstructive MI but recurrence ~5–8% / yr
    advance: Outpatient follow-up booked + aetiology-specific plan handed off