Associazione Nazionale Medici Cardiologi Ospedalieri




Zagarese Giorgia Verona (Vr) – Ospedale Civile Maggiore | Candelora Andrea Rovereto (Tn) – Ospedale Santa Maria Del Carmine | Vinco Giulia Rovereto (Tn) – Ospedale Santa Maria Del Carmine | Giovannelli Cristiana Rovereto (Tn) – Ospedale Santa Maria Del Carmine | Angheben Carlo Rovereto (Tn) – Ospedale Santa Maria Del Carmine | Moggio Paolo Rovereto (Tn) – Ospedale Santa Maria Del Carmine | Musuraca Gerardo Rovereto (Tn) – Ospedale Santa Maria Del Carmine | Cemin Claudio Rovereto (Tn) – Ospedale Santa Maria Del Carmine | Del Greco Maurizio Rovereto (Tn) – Ospedale Santa Maria Del Carmine |

Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) accounts for 5-6% of all myocardial infarctions. The causes that can lead to this diagnosis are many and not always clearly identifiable; in fact, despite optimal work-up, the cause of MINOCA remains undetermined in 8-25% of patients and diagnosis represents a real challenge for the cardiologist clinician. Because patients with MINOCA have clinical outcomes comparable to those with myocardial infarction with obstructive coronary artery disease, they should undergo a careful diagnostic work-up in order to set up a therapy related to the specific diagnosis.


A 51-years old woman presented to the emergency room after a sudden onset of an oppressive, prolonged and non-radiating chest pain, with gradual resolution after intravenous nitroderivates therapy. Smoking was the only cardiovascular risk factor. A recent uncomplicated COVID 19 infection (2 months before hospital admission) was the only event reported in clinical history.

Physical examination was unremarkable with the exception of an apical mid-end systolic murmur. The electrocardiogram was normal and the Troponin T peak was 391 pg/ml. An echocardiogram showed a normal biventricular function without alterations of segmental kinetics and mitral valve prolapse with moderate degree regurgitation.

The patient was admitted to the Intensive Care Unit department and underwent a coronary angiography study with evidence of main epicardial coronaries free from stenosing atherosclerotic lesions.

In addition, a cardiac magnetic resonance (CMR) was performed before discharge, with evidence of normal biventricular systolic function in the presence of limited area of ​​late enhancement with ischemic pattern at the level of the middle segment of the inferolateral wall of the left ventricle without edema.

In the light of the clinical instrumental picture, a diagnosis of MINOCA was made.


This clinical case is an example of how sometimes the cause relating to a MINOCA cannot always be well identified. However, the multi-imaging approach and in particular the resonance allowed to identify a localized area of ​​late enhancement with an ischemic type pattern. The origin of the ischemia could be dated from a picture of distal embolization, from a microvascular disease or from a myocardial stretching due to prolapse.