Abstract

A case of ischemia with Non-Obstructive Coronary Arteries (INOCA) in a non-smoker 50-year-old female: Diagnostic challenges and management strategies

Author(s): Antonio Georgiev1*, Alsada Abazi1,3, Vegim Zhaku1,2

Myocardial Infarction/Ischemia with Non-Obstructive Coronary Arteries (MINOCA/ INOCA) is a form of acute Myocardial Infarction (MI) without significant coronary artery blockage, making it diagnostically challenging. Accounting in up to 15% of all MI cases, INOCA disproportionately affects women and thus requires prompt recognition and targeted management to improve outcomes.

Our case has to do with a 50-year-old female patient, a non-smoker, who presented with chest pain characterized by tightening and pressure lasting for 30 min. Initial Electrocardiogram (ECG) revealed ST-segment elevations in leads V2-V5 and elevated initially troponin levels from 5,400 to 14,375 ng/L upon admission to our clinic, further confirming myocardial injury. Cardiac imaging revealed dyskinesia at the apex of the left ventricle with ischemic lesions but excluded myocarditis and Takotsubo syndrome, leading to the diagnosis of INOCA. A cardiac MRI showed transmural necrotic ischemic zones and fibrotic changes in the left ventricular apex. Thus we proceeded with a coronary angiography, revealing no significant stenosis, without using advanced imaging techniques such as Optical Coherence Tomography (OCT), Intravascular Ultrasound (IVUS) and Fractional Flow Reserve (FFR).

Treatment for INOCA must be individualized and should be tailored to the underlying cause, with different pharmacological strategies suggested based on factors such as plaque disruption, coronary spasm, or microvascular dysfunction, with a focus on addressing the ischemic origin. Accurate diagnosis requires careful evaluation through advanced imaging techniques such as OCT, IVUS and FFR. Early and precise intervention, combined with long-term monitoring, can improve outcomes and reduce the risk of future cardiac events.