Seshadri H, Gunasekaran D, Mohammad A, Rachoori S, Rajakumar HK. Myocardial ischemia in nonobstructive coronary arteries: A review of diagnostic dilemmas, current perspectives, and emerging therapeutic innovations. World J Cardiol 2025; 17(5): 106541 [DOI: 10.4330/wjc.v17.i5.106541]
Corresponding Author of This Article
Hamrish Kumar Rajakumar, Senior Researcher, Department of General Surgery, Government Medical College, Omandurar Government Estate, No. 169 Wallahjah Road, Police Quarters, Chennai 600002, Tamil Nadu, India. hamrishkumar2003@gmail.com
Research Domain of This Article
Cardiac & Cardiovascular Systems
Article-Type of This Article
Review
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Hariharan Seshadri, Institute of Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai 600003, Tamil Nadu, India
Dhaiyanitha Gunasekaran, Srinivas Rachoori, Hamrish Kumar Rajakumar, Department of General Surgery, Government Medical College, Omandurar Government Estate, Chennai 600002, Tamil Nadu, India
Abdulkader Mohammad, Department of Medicine, University of Novi Sad, Novi Sad 21000, Serbia
Author contributions: Rajakumar HK contributed to writing - reviewing and editing and supervision of the work; Seshadri H, Gunaserkaran D, Mohammad A, Rachoori S, and Rajakumar HK were responsible for data curation, investigation, resources, and conceptualization; Seshadri H, Gunaserkaran D, Mohammad A, and Rajakumar HK wrote the original draft; Gunaserkaran D and Rajakumar HK handled visualization.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hamrish Kumar Rajakumar, Senior Researcher, Department of General Surgery, Government Medical College, Omandurar Government Estate, No. 169 Wallahjah Road, Police Quarters, Chennai 600002, Tamil Nadu, India. hamrishkumar2003@gmail.com
Received: March 3, 2025 Revised: March 27, 2025 Accepted: May 7, 2025 Published online: May 26, 2025 Processing time: 84 Days and 3.3 Hours
Abstract
Myocardial infarction with nonobstructive coronary arteries is a unique presentation of acute coronary syndrome occurring in patients without significant coronary artery disease. Its pathophysiology involves atherosclerotic and nonatherosclerotic mechanisms such as plaque erosion, coronary microvascular dysfunction, vasospasm, spontaneous coronary artery dissection, autoimmune and inflammatory diseases, and myocardial oxygen supply-demand imbalance. A systematic approach to diagnosis is needed due to the diverse range of underlying causes. Cardiac troponins confirm the myocardial injury and coronary angiography rules out significant obstruction. Cardiac magnetic resonance imaging differentiates ischemic from nonischemic causes, and additional investigations, such as intravascular ultrasound, optical coherence tomography, and provocative testing, play a role in identifying the etiology to guide management strategies. Atherosclerotic cases require antiplatelet therapy and statins, vasospastic cases respond to calcium channel blockers, spontaneous coronary artery dissection is typically managed conservatively, and coronary microvascular dysfunction may require vasodilators. Lifestyle modifications and cardiac rehabilitation are essential for improving outcomes. The prognosis of patients experiencing recurrent events despite treatment is uncertain, but long-term outcomes depend on the etiology, highlighting the need for personalized management. Future research should focus on refining diagnostic protocols and identifying optimal therapeutic strategies. Randomized controlled trials are necessary to establish evidence-based treatments for different subtypes of myocardial infarction with nonobstructive coronary arteries.
Core Tip: Myocardial infarction with nonobstructive coronary arteries is difficult to diagnose, and strong clinical suspicion is necessary for accurate identification. The absence of standardized diagnostic protocols leads to inconsistencies in patient evaluation and management. Current diagnostic tools, including imaging and laboratory tests, often fail to provide definitive answers. The identification of easily accessible biomarkers could improve early detection and guide clinical decisions. Reliable markers would help differentiate myocardial infarction with nonobstructive coronary arteries from other cardiac conditions and streamline diagnosis. The lack of standardized guidelines complicates treatment, making management challenging. Further research is essential to establish evidence-based protocols.
