Hidden Infarctions: Understanding and Managing Myocardial Infarction with Non-Obstructive Coronary Arteries Through a Multimodal Lens

Myocardial infarction with non-obstructive coronary arteries (MINOCA) accounts for 5–15% of myocardial infarctions and disproportionately affects women and minority populations. It is defined by clinical evidence of myocardial ischemia with <50% coronary stenosis on angiography and carries morbidity and mortality comparable to obstructive coronary artery disease–related MI. This narrative review summarizes current diagnostic and management strategies for MINOCA, with emphasis on prognostic assessment using multimodal cardiac imaging and blood biomarkers. A review of key evidence and guidelines was conducted to evaluate established diagnostic approaches and treatments for common etiologies, including plaque disruption, coronary vasospasm, microvascular dysfunction, and spontaneous coronary artery dissection. Early use of cardiac magnetic resonance imaging, optical coherence tomography, and intravascular ultrasound improves diagnostic accuracy and facilitates the identification of underlying mechanisms. However, treatment remains highly individualized due to heterogeneity in etiology and limited evidence guiding therapy. Prognosis varies by cause but is consistently associated with significant long-term cardiovascular risk. Key challenges include diagnostic variability, delayed imaging, and a lack of standardized treatment protocols. Future priorities include randomized trials of mechanism-directed therapies and the development of standardized diagnostic algorithms incorporating functional testing and advanced imaging. Recognition of MINOCA as a distinct clinical entity and early, mechanism-based evaluation are essential to improving outcomes in this diverse, historically underrecognized population.