This handout is for minoca — mi with non-obstructive coronary arteries. Your care team identified this based on: diagnostic angiography after nstemi/stemi shows stenosis <50% in all major epicardial vessels — minoca per esc 2023 + aha 2019 (pmid 30922983).
Other reasons your team may use this plan: hstn rise/fall + ischaemic ecg / symptoms + non-obstructive coronaries — triggers minoca cause-finding workup; recurrent acs-pattern chest pain in patient with prior non-obstructive cath — re-evaluate for minoca aetiology shift; cardiac mri lake louise oedema + lge pattern after negative cath — confirms minoca aetiology (myocarditis vs takotsubo vs infarct lge).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| aspirin | 162–325 mg load → 81 mg | PO | load once → 81 mg daily | Standard ACS load when plaque disruption is the substrate; per AHA 2019 PMID 30922983 the antiplatelet decision in MINOCA is aetiology-driven — universal indefinite ASA in atherosclerotic-substrate MINOCA |
| ticagrelor | 180 mg load → 90 mg BID | PO | BID × 12 mo when DAPT indicated | PLATO PMID 19717846; AHA 2019 — DAPT only when atherosclerotic substrate confirmed (OCT plaque disruption / thrombus) or intervention performed; otherwise risk-benefit unclear |
| atorvastatin | 80 mg | PO | daily | PROVE-IT PMID 15007110; AHA 2019 — statin reduces recurrent MINOCA across aetiologies (atherosclerotic risk modification + endothelial benefit) |
| amlodipine | 5–10 mg | PO | daily | AHA 2019 + JCS vasospastic angina — long-acting CCB is first-line for vasospastic MINOCA; β-blocker avoided |
| diltiazem | 120–240 mg | PO | daily ER | AHA 2019 — non-DHP CCB targets coronary spasm; preferred when concomitant tachycardia or microvascular dysfunction |
| isosorbide_mononitrate | 30–60 mg | PO | daily ER | AHA 2019 — add long-acting nitrate to CCB for refractory vasospasm; nitrate-free interval to prevent tolerance |
| ranolazine | 500 mg BID → 1000 mg BID | PO | BID | AHA 2019 + MERLIN-TIMI substudies — ranolazine for microvascular angina refractory to CCB + nitrate; QT monitoring required |
| apixaban | 5 mg BID (2.5 mg BID if dose-reduction criteria) | PO | BID | AHA 2019 — anticoagulation for embolic-source MINOCA (AF, LAA thrombus); CHA2DS2-VASc-guided duration; DOAC preferred over warfarin in non-valvular AF |
| warfarin | 5 mg daily; INR 2–3 | PO | daily | AHA 2019 — warfarin for embolic-source MINOCA when DOAC unsuitable (mechanical valve, APS, severe renal impairment) |
| lisinopril | 5–10 mg | PO | daily | AHA 2019 — ACEi for LV dysfunction or concomitant HTN/DM in MINOCA; mortality benefit per HOPE / GISSI extrapolation |
Plan: MINOCA — aetiology-specific bundle (plaque disruption → ACS bundle; vasospasm → CCB + nitrate, AVOID β-blocker; embolic → AC for source; SCAD → conservative; takotsubo overlap → supportive)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: 2019 AHA Scientific Statement on MINOCA (Tamis-Holland PMID 30922983); ESC 2023 ACS Guideline (Byrne PMID 37622670); 2025 ACC/AHA ACS Guideline (Rao)