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cardio.nstemi.minoca.v1PRODUCTION
cardio.nstemi.minoca.v1

MINOCA — MI with Non-Obstructive Coronary Arteries

cardiologyacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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Advance rule
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MINOCA criteria confirmed

Patient inputs (16)

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)

MINOCA spans wide age range; younger female predominance; informs cause-finding pre-test probabilities (SCAD younger women, plaque disruption older)

Female sex enriched in MINOCA cohort (35–50% of MINOCA per CIAO); SCAD overwhelmingly female; vasospasm female-skewed in some populations

Tachyarrhythmia in MINOCA setting raises supply-demand (type-2) overlap; AF raises embolic source suspicion

Stressor with apical ballooning suggests takotsubo overlap — different management pathway

Hypercoagulable state raises embolic / coronary thrombus aetiology; cancer-associated thrombosis specifically

Defines NSTEMI per 4th UDMI (PMID 30153967) rise/fall criteria — MUST meet ACS criteria to be MINOCA (else label is INOCA)

Gates contrast load for cMRI / repeat cath / IVUS; KDIGO 2026 baseline

Baseline before any AC and to rule out concurrent infection (myocarditis mimic)

ECG pattern guides aetiology (transient ST elevation that resolves → vasospasm; persistent T-wave inversion → myocarditis vs takotsubo)

Coronary angiography is the entry criterion (<50% stenosis); IVUS or OCT during the same procedure recommended for plaque disruption / SCAD detection (CIAO + OCTAVIA)

Echo for wall-motion pattern (apical ballooning → takotsubo; segmental → infarct distribution; global → myocarditis); GLS sensitive for early dysfunction

Hypotension may indicate takotsubo with LVOT obstruction (β-blocker contraindicated) or cardiogenic shock — both alter pathway

PE mimic / embolic source evaluation; elevated D-dimer prompts CT-PA before final MINOCA labelling

Embolic source workup — PFO with right-to-left shunt, atrial septal aneurysm, LAA thrombus; informs anticoagulation decision

Intracoronary acetylcholine 20–100 µg provocation — gold-standard test for coronary vasospasm; positive triggers CCB + nitrate regimen and β-blocker avoidance

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningminoca_vasospasm_provocation_positive_with_VT_VF
    Acetylcholine provocation positive AND VT/VF during spasm episode — high recurrence and sudden death risk; consider ICD evaluation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtakotsubo_overlap_pattern_with_LVOT_obstruction
    cMRI / echo shows apical ballooning with dynamic LVOT obstruction — conventional ACS bundle is a TRAP (β-blocker can paradoxically worsen LVOT; inotrope worsens obstruction)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningminoca_with_cardiogenic_shock
    SBP <90 + lactate ≥2 in MINOCA — rare; typically takotsubo with LVOT obstruction or fulminant myocarditis; conventional ACS-shock pathway must be modified
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverescad_discovered_during_minoca_workup
    OCT / IVUS during cath reveals spontaneous coronary artery dissection — manage CONSERVATIVELY (no PCI unless ongoing ischemia); route to SCAD engine; AVOID DAPT escalation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_minoca_event_within_12_months
    Recurrent MI without obstructive lesion within 12 mo despite aetiology-specific bundle — escalate workup (repeat cMRI, repeat acetylcholine, thrombophilia panel) and intensify therapy
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

MINOCA — aetiology-specific bundle (plaque disruption → ACS bundle; vasospasm → CCB + nitrate, AVOID β-blocker; embolic → AC for source; SCAD → conservative; takotsubo overlap → supportive)
axis: minoca_aetiology_phenotype
Selected axis "MINOCA — aetiology-specific bundle (plaque disruption → ACS bundle; vasospasm → CCB + nitrate, AVOID β-blocker; embolic → AC for source; SCAD → conservative; takotsubo overlap → supportive)" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162–325 mg load → 81 mg • PO • load once → 81 mg daily
    triggers: minoca_with_plaque_disruption_or_thrombus_on_oct
    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
    rxcui 1191
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo when DAPT indicated
    triggers: minoca_with_plaque_disruption_or_intervention
    PLATO PMID 19717846; AHA 2019 — DAPT only when atherosclerotic substrate confirmed (OCT plaque disruption / thrombus) or intervention performed; otherwise risk-benefit unclear
    rxcui 1116632
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO • daily
    triggers: minoca_confirmed_any_aetiology
    PROVE-IT PMID 15007110; AHA 2019 — statin reduces recurrent MINOCA across aetiologies (atherosclerotic risk modification + endothelial benefit)
    rxcui 83367
  • amlodipine
    first line
    dihydropyridine_ccb
    5–10 mg • PO • daily
    triggers: minoca_with_vasospasm_confirmed, positive_acetylcholine_provocation
    AHA 2019 + JCS vasospastic angina — long-acting CCB is first-line for vasospastic MINOCA; β-blocker avoided
    rxcui 104416
  • diltiazem
    first line
    non_dihydropyridine_ccb
    120–240 mg • PO • daily ER
    triggers: minoca_with_vasospasm_confirmed, microvascular_dysfunction_with_normal_LV
    AHA 2019 — non-DHP CCB targets coronary spasm; preferred when concomitant tachycardia or microvascular dysfunction
    rxcui 3443
  • isosorbide_mononitrate
    add on
    long_acting_nitrate
    30–60 mg • PO • daily ER
    triggers: minoca_with_vasospasm, persistent_microvascular_angina_on_CCB
    AHA 2019 — add long-acting nitrate to CCB for refractory vasospasm; nitrate-free interval to prevent tolerance
    rxcui 28004
  • ranolazine
    second line
    late_sodium_current_inhibitor
    500 mg BID → 1000 mg BID • PO • BID
    triggers: microvascular_dysfunction_refractory_to_CCB_and_nitrate
    AHA 2019 + MERLIN-TIMI substudies — ranolazine for microvascular angina refractory to CCB + nitrate; QT monitoring required
    rxcui 35829
  • apixaban
    comorbidity specific
    doac_factor_xa_direct
    5 mg BID (2.5 mg BID if dose-reduction criteria) • PO • BID
    triggers: embolic_source_AF_detected, PFO_with_paradoxical_embolism_pattern
    AHA 2019 — anticoagulation for embolic-source MINOCA (AF, LAA thrombus); CHA2DS2-VASc-guided duration; DOAC preferred over warfarin in non-valvular AF
    rxcui 1364430
  • warfarin
    second line
    vitamin_k_antagonist
    5 mg daily; INR 2–3 • PO • daily
    triggers: mechanical_valve, antiphospholipid_syndrome, doac_intolerant
    AHA 2019 — warfarin for embolic-source MINOCA when DOAC unsuitable (mechanical valve, APS, severe renal impairment)
    rxcui 11289
  • lisinopril
    add on
    acei
    5–10 mg • PO • daily
    triggers: minoca_with_LV_dysfunction_EF_lt_50, concomitant_HTN_or_DM
    AHA 2019 — ACEi for LV dysfunction or concomitant HTN/DM in MINOCA; mortality benefit per HOPE / GISSI extrapolation
    rxcui 29046

outpatient playbook — drug actions (4)

  1. 1. continue ASA + statin indefinitely
    aspirin 81 + atorvastatin 80 • PO • daily
    trigger: MINOCA confirmed atherosclerotic substrate
    AHA 2019
  2. 2. continue CCB + nitrate for vasospastic indefinitely
    amlodipine 10 OR diltiazem 360 + isosorbide mononitrate 60 • PO • daily
    trigger: Vasospastic MINOCA — recurrence common without sustained therapy
    JCS vasospastic angina + AHA 2019
  3. 3. continue OAC per source-specific duration
    apixaban 5 BID or warfarin INR 2–3 • PO • BID / daily
    trigger: Embolic-source MINOCA
    AHA 2019
  4. 4. add ezetimibe if LDL above target
    10 mg • PO • daily
    trigger: LDL >70 on max statin
    IMPROVE-IT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Diagnostic angiography after NSTEMI/STEMI shows stenosis <50% in all major epicardial vessels — MINOCA per ESC 2023 + AHA 2019 (PMID 30922983); 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**MINOCA — MI with Non-Obstructive Coronary Arteries** (cardio.nstemi.minoca.v1).
Phenotype framing: 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)
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **MINOCA — aetiology-specific bundle (plaque disruption → ACS bundle; vasospasm → CCB + nitrate, AVOID β-blocker; embolic → AC for source; SCAD → conservative; takotsubo overlap → supportive)**.
1. aspirin 162–325 mg load → 81 mg PO load once → 81 mg daily (antiplatelet_cox1, first line) — 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
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo when DAPT indicated (P2Y12_inhibitor, first line) — PLATO PMID 19717846; AHA 2019 — DAPT only when atherosclerotic substrate confirmed (OCT plaque disruption / thrombus) or intervention performed; otherwise risk-benefit unclear
3. atorvastatin 80 mg PO daily (statin_high_intensity, first line) — PROVE-IT PMID 15007110; AHA 2019 — statin reduces recurrent MINOCA across aetiologies (atherosclerotic risk modification + endothelial benefit)
4. amlodipine 5–10 mg PO daily (dihydropyridine_ccb, first line) — AHA 2019 + JCS vasospastic angina — long-acting CCB is first-line for vasospastic MINOCA; β-blocker avoided
5. diltiazem 120–240 mg PO daily ER (non_dihydropyridine_ccb, first line) — AHA 2019 — non-DHP CCB targets coronary spasm; preferred when concomitant tachycardia or microvascular dysfunction
6. isosorbide_mononitrate 30–60 mg PO daily ER (long_acting_nitrate, add on) — AHA 2019 — add long-acting nitrate to CCB for refractory vasospasm; nitrate-free interval to prevent tolerance
7. ranolazine 500 mg BID → 1000 mg BID PO BID (late_sodium_current_inhibitor, second line) — AHA 2019 + MERLIN-TIMI substudies — ranolazine for microvascular angina refractory to CCB + nitrate; QT monitoring required
8. apixaban 5 mg BID (2.5 mg BID if dose-reduction criteria) PO BID (doac_factor_xa_direct, comorbidity specific) — AHA 2019 — anticoagulation for embolic-source MINOCA (AF, LAA thrombus); CHA2DS2-VASc-guided duration; DOAC preferred over warfarin in non-valvular AF
9. warfarin 5 mg daily; INR 2–3 PO daily (vitamin_k_antagonist, second line) — AHA 2019 — warfarin for embolic-source MINOCA when DOAC unsuitable (mechanical valve, APS, severe renal impairment)
10. lisinopril 5–10 mg PO daily (acei, add on) — AHA 2019 — ACEi for LV dysfunction or concomitant HTN/DM in MINOCA; mortality benefit per HOPE / GISSI extrapolation

Setting playbook (outpatient) — Long-term aetiology-specific secondary prevention; recurrence ~5–8% / yr per AHA 2019; sustained CCB + nitrate (vasospastic), OAC duration per source (embolic), cardiac rehab maintenance
11. continue ASA + statin indefinitely aspirin 81 + atorvastatin 80 PO daily — MINOCA confirmed atherosclerotic substrate (AHA 2019)
12. continue CCB + nitrate for vasospastic indefinitely amlodipine 10 OR diltiazem 360 + isosorbide mononitrate 60 PO daily — Vasospastic MINOCA — recurrence common without sustained therapy (JCS vasospastic angina + AHA 2019)
13. continue OAC per source-specific duration apixaban 5 BID or warfarin INR 2–3 PO BID / daily — Embolic-source MINOCA (AHA 2019)
14. add ezetimibe if LDL above target 10 mg PO daily — LDL >70 on max statin (IMPROVE-IT)

Non-pharmacologic actions:
- Trigger avoidance reinforcement (smoking, cocaine, hyperventilation, cold exposure) for vasospastic
- Cardiac rehab attendance reinforcement
- Mediterranean / DASH diet counseling
- PFO closure team follow-up if applicable

AVOID / contraindication checks:
- Beta_blocker_AVOID_in_vasospastic_minoca (AHA 2019 + JCS vasospastic angina)
- Beta_blocker_CAUTION_in_takotsubo_with_LVOT_obstruction (Templin NEJM 2015 PMID 26332547 — IRIS registry)
- Nitrate_AVOID_with_concurrent_PDE5_inhibitor_within_24h (sildenafil) or 48h (tadalafil)
- Apixaban_AVOID_severe_renal_impairment_egfr_below_25 (drug label)
- Warfarin_avoid_active_bleeding (AHA 2022)
- Ranolazine_QT_caution_with_strong_3A4_inhibitors (drug label)

Monitoring

Regimen monitoring:
- Continuous ECG + SpO2 inpatient; peak hsTn + cMRI scheduling
- Repeat echo at 3–6 mo for takotsubo recovery confirmation
- BMP + Hgb on AC
- BP + HR titration of CCB / nitrate
- INR weekly during warfarin initiation; periodic for DOAC adherence

Setting (outpatient) monitoring:
- BMP at week 4 (if any new agent)
- Lipid at 4–8 wks
- Bleeding signs at every visit if on AC

Follow-up plan: 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
- Close-out criterion: Outpatient follow-up booked + aetiology-specific plan handed off

Monitoring phase: Telemetry for arrhythmia (vasospasm episodes); repeat hsTn to peak; daily exam; cMRI scheduled if not yet done; vasospasm provocation scheduled if pattern suggests

Disposition

Current setting: outpatient — Long-term aetiology-specific secondary prevention; recurrence ~5–8% / yr per AHA 2019; sustained CCB + nitrate (vasospastic), OAC duration per source (embolic), cardiac rehab maintenance

Disposition criteria:
- Lifelong follow-up; route to chronic CAD or HF engines if aetiology-specific complications develop

Escalation triggers (move to higher acuity):
- Recurrent chest pain → ED + cMRI re-evaluation
- New arrhythmia → cardiology
- Bleeding (BARC 2+) → reassess AC

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acetylcholine provocation positive AND VT/VF during spasm episode — high recurrence and sudden death risk; consider ICD evaluation
- [LIFE_THREATENING] cMRI / echo shows apical ballooning with dynamic LVOT obstruction — conventional ACS bundle is a TRAP (β-blocker can paradoxically worsen LVOT; inotrope worsens obstruction)
- [LIFE_THREATENING] SBP <90 + lactate ≥2 in MINOCA — rare; typically takotsubo with LVOT obstruction or fulminant myocarditis; conventional ACS-shock pathway must be modified

Citations

- 2019 AHA Scientific Statement on MINOCA (Tamis-Holland PMID 30922983); ESC 2023 ACS Guideline (Byrne PMID 37622670); 2025 ACC/AHA ACS Guideline (Rao) [PMID:30922983](https://pubmed.ncbi.nlm.nih.gov/30922983/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 30153967) [PMID:30153967](https://pubmed.ncbi.nlm.nih.gov/30153967/)
- Cited evidence (PMID 15007110) [PMID:15007110](https://pubmed.ncbi.nlm.nih.gov/15007110/)
- Cited evidence (PMID 19717846) [PMID:19717846](https://pubmed.ncbi.nlm.nih.gov/19717846/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2019 AHA Scientific Statement on MINOCA (Tamis-Holland PMID 30922983); ESC 2023 ACS Guideline (Byrne PMID 37622670); 2025 ACC/AHA ACS Guideline (Rao) — PMID:30922983
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 30153967) — PMID:30153967
  • Cited evidence (PMID 15007110) — PMID:15007110
  • Cited evidence (PMID 19717846) — PMID:19717846