The impact of the microvascular resistance on the measures of stenosis severity.

The relationship between measures of stenosis and microvascular resistance is of importance due to medical decisions being based on these values. This research investigates the impact of varying microvascular resistance on fractional flow reserve (FFR) and hyperaemic stenosis resistance (hSR). Microvascular resistance is classified using hyperaemic microvascular resistance (hMR). Additionally, hMR using the upstream pressure value (hMRPa) has also been calculated and is compared to hMR measured conventionally. Tests were conducted at three different degrees of stenosis (quantified by percent area) in a coronary flow circuit with varying downstream resistance to simulate the microvasculature. Pressure and flow values are recorded across the stenosed section, allowing for calculation of the diagnostic indexes. Results indicate that for a constant degree of stenosis, FFR would increase with increasing microvascular resistance while hSR would remain almost constant. hMRPa was found to approach hMR as the stenosis severity decreased, and the pressure gradient decreased. In the results shown here, with sufficiently high downstream resistance, an 84 % stenosis could produce an FFR value over 0.8. This result suggests that there is the potential for misdiagnosis of the severity of stenosis when combined with elevated microvascular resistance. Consequently, decisions on the clinical significance of a stenosis, classified by FFR, need to consider the effect of the microvascular resistance.

Evaluating the effect of coronary atherosclerosis on the occurrence of atrial fibrillation through coronary computed tomography angiography.

BACKGROUND: The direct impact of atherosclerotic lesions in coronary vessels on the occurrence of atrial fibrillation (AF) in patients without a history of acute myocardial ischemia, previous myocardial infarction, or revascularization procedures remains largely unknown. AIMS: To assess the risk and predictors of new-onset AF in patients with coronary atherosclerosis confirmed by coronary computed tomography angiography (CCTA). METHODS: We included consecutive patients referred for CCTA who had been observed and diagnosed with new-onset AF over 10 years. RESULTS: Of the 549 patients enrolled in the study, 208 (37.9%) were diagnosed with atherosclerotic lesions in the coronary vessels and 63 (11.5%) developed AF during the 10 years of observation. Patients with AF were older (61.8 [10.4] years vs. 58.3 [9.2] years; P = 0.005), had an enlarged left atrium in the anteroposterior dimension (38.2 [7.2] mm vs. 34.4 [5.4] mm; P < 0.001), and had a widened interventricular septum (12.3 [2.0] mm vs. 11.0 [2.1] mm; P < 0.001). We also found a significant correlation between the occurrence of AF in patients with coronary atherosclerotic lesions and with increased thickness of the interventricular septum relative to the posterior wall of the left ventricle (P = 0.017). CONCLUSIONS: Our data indicate an association between coronary atherosclerosis and the greater risk of AF in patients with increased thickness of the interventricular septum relative to the posterior wall of the left ventricle. This finding suggests that by using CCTA we can predict which patients are at higher risk of developing AF.

Unveiling the Rarity: An Anomaly of the Left Circumflex Artery Supplying Left Ventricular Apex and Presenting With Myocardial Infarction.

Coronary arteries are typically identified based on the myocardial territory they supply. In rare cases of coronary artery anomalies, the apex of the heart may be supplied by arteries other than the left anterior descending artery. While it is more common for the posterior descending artery from the right coronary artery to supply the apex, there are rare instances where the left circumflex (LCX) artery performs this function. This case report describes an unusual occurrence where the left ventricular apex is supplied by an obtuse marginal branch of the LCX artery. We present this case due to its rarity, unique presentation, and the challenges it poses for both medical and surgical management.

Technical principles, benefits, challenges, and applications of photon counting computed tomography in coronary imaging: a narrative review.

Background and Objective: The introduction of photon-counting computed tomography (PCCT) represents the most recent groundbreaking advancement in clinical computed tomography (CT). PCCT has the potential to overcome the limitations of traditional CT and to provide new quantitative imaging information. This narrative review aims to summarize the technical principles, benefits, and challenges of PCCT and to provide a concise yet comprehensive summary of the applications of PCCT in the domain of coronary imaging. Methods: A review of PubMed, Scopus, and Google Scholar was performed until October 2023 by using relevant keywords. Articles in English were considered. Key Content and Findings: The main advantages of PCCT over traditional CT are enhanced spatial resolution, improved signal and contrast characteristics, diminished electronic noise and image artifacts, lower radiation exposure, and multi-energy capability with enhanced material discrimination. These key characteristics have made room for improved assessment of plaque volume and severity of stenosis, more precise assessment of coronary artery calcifications, also preserved in the case of a reduced radiation dose, improved assessment of plaque composition, possibility to provide details regarding the biological processes occurring within the plaque, enhanced quality and accuracy of coronary stent imaging, and improved radiomic analyses. Conclusions: PCCT can significantly impact diagnostic and clinical pathways and improve the management of patients with coronary artery diseases (CADs).

Patent Foramen Ovale and Coronary Artery Spasm: A New Patent Foramen Ovale-associated Condition that May Explain the Mechanism of Vasospastic Angina.

Patent foramen ovale (PFO) may be an underlying factor in the pathogenesis of migraine, vasospastic angina, and Takotsubo cardiomyopathy. This article reviews the role that PFO may play in each of these clinical entities and discusses potential interventions. It also proposes a novel clinical syndrome wherein PFO may be the unifying link among migraine, coronary vasospasm, and Takotsubo cardiomyopathy in predisposed individuals.

Acute coronary syndrome due to coronary vasospasm: a case report.

Coronary vasospasm can lead to decreased cardiac perfusion and result in acute coronary syndrome. Here is a case of a 49-year-old man presented to the emergency department with epigastric pain and nausea with normal initial electrocardiogram. However, 6 h later, the patient experienced severe chest pain prompting a repeat electrocardiogram demonstrating inferior ST-segment elevation with troponin I levels peaked at 1.2 ng/ml (normal range: 0.00-0.02 ng/ml). Coronary angiography revealed angiographic stenosis in the left circumflex territory of a left dominant system which resolved with intracoronary nitroglycerin administration indicating ischemia with nonobstructive coronary arteries secondary to coronary vasospasm. He was discharged on isosorbide mononitrate and amlodipine therapy and had no recurrence of symptoms during follow-up.

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A Routine Coronary Angiography before Carotid Endarterectomy as an Example of Interdisciplinary Work: The Immediate Results of the Surgery.

The aim: to evaluate the incidence of obstructive lesions of the coronary arteries during routine coronary angiography (CAG) before carotid endarterectomy (CEA) and the incidence of perioperative complications. Materials and Methods: We examined a continuous sample of 498 patients before CEA who underwent an invasive evaluation of the coronary bed during CAG. Depending on the hemodynamic significance of coronary artery lesions, the patients were divided into three groups: group I-obstructive coronary artery disease (≥70%) (n = 309, 62.0%); group II-non-obstructive lesions of the coronary arteries (<70%) (n = 118, 23.7%); group III-intact coronary arteries (n = 71, 14.3%). The groups were compared with each other according to the data of the preoperative examination (clinical and anamnestic parameters, laboratory data and results of echocardiography), as well as according to the immediate results of the operation. In the hospital period, adverse cardiovascular events were assessed: death, myocardial infarction (MI), stroke, arrhythmias, atrial fibrillation or flutter (AF/AFL) and combined endpoint. Results: The groups differed significantly in the presence of symptoms of angina pectoris, myocardial infarction and myocardial revascularization procedures in their medical history and in the presence of chronic ischemia of the lower extremities. However, in the group of intact coronary arteries, the symptoms of angina were in 14.1% of patients, and a history of myocardial infarction was in 12.7%. Myocardial revascularization before CEA or simultaneously with it was performed in 43.0% of patients. As a result, it was possible to reduce the number of perioperative cardiac complications (mortality 0.7%, perioperative myocardial infarction 1.96%). Conclusions: The high incidence of obstructive lesions in the coronary arteries in our patients and the minimum number of perioperative complications favor routine CAG before CEA.

Double Anterior Interventricular Arteries: Prevalence and Morphological Types-A Dissection Study.

BACKGROUND: This study aimed to evaluate the prevalence of double anterior interventricular artery using the dissection method. METODE: A retrospective study was conducted between 2010 and 2024 at the Anatomy and Embryology Laboratory of the Victor Babes University of Medicine and Pharmacy in Timisoara. Eighty cases were analyzed for morphological variants of the coronary arteries, especially the anterior interventricular artery. RESULTS: Two cases of double anterior interventricular arteries were identified. In the first case, the two anterior interventricular arteries originated from the anterior interventricular branch of the left coronary artery. In the second case, an additional anterior interventricular artery with an aortic origin was found running along the lower third of the two interventricular grooves. This shape has not been described before in the specialized literature. CONCLUSIONS: Knowing the potential variations of the double left anterior descending artery is critical for interpreting cardiac imaging and choosing and planning percutaneous and surgical reperfusion strategies.

Diagnostic Yield and Clinical Utility of Coronary Angiography Versus Coronary Function Testing in Women With Angina and Nonobstructive Coronary Arteries.

BACKGROUND: Approximately 50% of women referred for invasive coronary angiography have angina and nonobstructive coronary arteries, which includes coronary microvascular dysfunction, vasospastic angina, and other vasomotor disorders. We sought to determine the real-world diagnostic yield of invasive coronary angiography and coronary function testing in women with angina and nonobstructive coronary arteries. METHODS AND RESULTS: From 2018 to 2023, we enrolled 198 women who underwent either coronary angiography (CA) alone (n=99) or coronary function testing (CFT; n=99). Mean±SD age was 62±10 years (CA alone) compared with 57±10 years (CFT). Coronary angiography was interpreted as nonobstructive coronary artery disease more frequently after CA alone (79% versus 52%). Of the women who underwent CFT, 82% (N=81) were found to have vasomotor disorders, including coronary microvascular dysfunction (27%), vasospastic angina (32%), mixed coronary microvascular dysfunction/vasospastic angina (16%), endothelial dysfunction (10%; without spasm), elevated resting flow (2%), or symptomatic myocardial bridging (4%). Compared with women undergoing CA alone, medications were changed more frequently after CFT at 24 hours (41% versus 65%; P=0.001) and between 24 hours and 30 days (30% versus 44%; P=0.04) with intensification of antianginal therapy (79% versus 92%; P<0.0001) and increased use of calcium channel blockers (36% versus 63%; P<0.0001). CONCLUSIONS: Our findings demonstrate that women presenting with suspected ischemic heart disease undergoing CA alone only received an anatomic diagnosis, whereas >80% of women undergoing CFT received a specific diagnosis of a coronary vasomotor disorder and greater intensification of antianginal therapy.

Accelerated 3D whole-heart non-contrast-enhanced mDIXON coronary MR angiography using deep learning-constrained compressed sensing reconstruction.

OBJECTIVES: To investigate the feasibility of a deep learning-constrained compressed sensing (DL-CS) method in non-contrast-enhanced modified DIXON (mDIXON) coronary magnetic resonance angiography (MRA) and compare its diagnostic accuracy using coronary CT angiography (CCTA) as a reference standard. METHODS: Ninety-nine participants were prospectively recruited for this study. Thirty healthy subjects (age range: 20-65 years; 50% female) underwent three non-contrast mDIXON-based coronary MRA sequences including DL-CS, CS, and conventional sequences. The three groups were compared based on the scan time, subjective image quality score, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). The remaining 69 patients suspected of coronary artery disease (CAD) (age range: 39-83 years; 51% female) underwent the DL-CS coronary MRA and its diagnostic performance was compared with that of CCTA. RESULTS: The scan time for the DL-CS and CS sequences was notably shorter than that of the conventional sequence (9.6 ± 3.1 min vs 10.0 ± 3.4 min vs 13.0 ± 4.9 min; p < 0.001). The DL-CS sequence obtained the highest image quality score, mean SNR, and CNR compared to CS and conventional methods (all p < 0.001). Compared to CCTA, the accuracy, sensitivity, and specificity of DL-CS mDIXON coronary MRA per patient were 84.1%, 92.0%, and 79.5%; those per vessel were 90.3%, 82.6%, and 92.5%; and those per segment were 98.0%, 85.1%, and 98.0%, respectively. CONCLUSION: The DL-CS mDIXON coronary MRA provided superior image quality and short scan time for visualizing coronary arteries in healthy individuals and demonstrated high diagnostic value compared to CCTA in CAD patients. CRITICAL RELEVANCE STATEMENT: DL-CS resulted in improved image quality with an acceptable scan time, and demonstrated excellent diagnostic performance compared to CCTA, which could be an alternative to enhance the workflow of coronary MRA. KEY POINTS: Current coronary MRA techniques are limited by scan time and the need for noise reduction. DL-CS reduced the scan time in coronary MR angiography. Deep learning achieved the highest image quality among the three methods. Deep learning-based coronary MR angiography demonstrated high performance compared to CT angiography.

Coronary Artery Dimensions on Computed Tomography Following the Neonatal Arterial Switch Operation for the Complete Transposition of the Great Arteries.

Coronary events are life-threatening long-term complications of the arterial switch operation for complete transposition of the great arteries. The aim of our study was to assess the dimensions of the reimplanted coronary arteries and their relationship with the various geometric characteristics to gain a better understanding of the involved mechanisms. Coronary computed tomography angiography (CCTA) scans of 78 asymptomatic pediatric patients were performed at the age of 10.7 (6.3-17.8) years. The position of the ostia, the branching angles, and the diameters of the coronary arteries were determined in a subgroup of 51 patients presenting the usual preoperative coronary anatomy. Mean Z-score of the left main coronary artery (LMCA), left anterior descending coronary artery (LAD), left circumflex coronary artery (LCX), and right coronary artery (RCA) diameters were 0.7 ± 1.2, - 0.4 ± 1.1, - 0.3 ± 1.1, and - 0.3 ± 1.1, respectively. The Z-score of the ostial LMCA diameter had a positive correlation with the remoteness from the main pulmonary artery (p < 0.001) and the branching angle (p = 0.001). The ostial diameter Z-score of the LMCA had a negative correlation with the interval between the arterial switch operation and the CCTA (p = 0.004). Even though most of the coronary diameters fell within the accepted range, which suggests normal overall development, acute branching angle and more anterior origin were associated with smaller ostial coronary artery diameter Z-scores. To prove the clinical relevance of the smaller ostial diameter of high-risk left coronary arteries and the decrease of ostial coronary artery Z-scores over time needs further follow-up studies.

Association Between Systemic Inflammation Response Index and Slow Coronary Flow Phenomenon in Patients with Ischemia and No Obstructive Coronary Arteries.

Background: Inflammation plays a key role in the pathogenesis of slow coronary flow phenomenon (SCFP). SCFP is a condition that can complicate the management of ischemia and no obstructive coronary arteries (INOCA), making it essential to identify reliable predictors. Although the systemic inflammation response index (SIRI) has been proven to relate to various cardiovascular diseases. However, the predictive value of SIRI for SCFP in patients with INOCA remains unclear. Methods: A total of 1422 patients with INOCA were consecutively included in this study. 89 individuals were diagnosed with SCFP (the SCFP group). A 1:2 age- and -sex-matched patients with INOCA and normal blood flow were selected as the control group (n=178). Plasma neutrophil, monocyte, and lymphocyte counts were collected so as to determine the value of SIRI. Results: Patients with SCFP had an elevated level of body mass index (BMI) and an increased incidence of smoking and diabetes. The SIRI was significantly higher in the SCFP group than in the controls (2.3±1.3 vs 1.8±1.3, p=0.002). The SIRI increased as the number of coronary arteries involved in the SCFP increased. Univariate analyses showed that BMI, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and SIRI were associated with SCFP. Multivariate logistic regression analysis revealed that BMI and SIRI were independent predictors of SCFP occurrence. The ROC curve showed that when the SIRI was > 1.140, the sensitivity and specificity were 87.6% and 60.1%, respectively, and the area under the ROC curve (AUC) was 0.644 (95% CI: 0.578-0.710, P < 0.001). Conclusion: The findings demonstrated that an increased SIRI may have a potential role in distinguishing SCFP in patients with INOCA. SIRI could improve the predictive value of SCFP compared to neutrophils, monocytes, and lymphocytes alone.

In-silico analysis of hemodynamic indicators in idealized stented coronary arteries for varying stent indentation.

In this work, we investigate the effects of stent indentation on hemodynamic indicators in stented coronary arteries. Our aim is to assess in-silico risk factors for in-stent restenosis (ISR) and thrombosis after stent implantation. The proposed model is applied to an idealized artery with Xience V stent for four indentation percentages and three mesh refinements. We analyze the patterns of hemodynamic indicators arising from different stent indentations and propose an analysis of time-averaged WSS (TAWSS), topological shear variation index (TSVI), oscillatory shear index (OSI), and relative residence time (RRT). We observe that higher indentations display higher frequency of critically low TAWSS, high TSVI, and non-physiological OSI and RRT. Furthermore, an appropriate mesh refinement is needed for accurate representation of hemodynamics in the stent vicinity. The results suggest that disturbed hemodynamics could play a role in the correlation between high indentation and ISR.

Myocardial Involvement in Catastrophic Antiphospholipid Syndrome during Pregnancy or Puerperium: A Case of a Young Breastfeeding Woman and Literature Review.

Catastrophic Antiphospholipid Syndrome (CAPS) is a rare complication that can occur in patients with Antiphospholipid Syndrome (APS). CAPS occurs even more rarely during pregnancy/puerperium and pregnant patients, even less likely to show cardiac involvement without signs of damage on ultrasound and angiography with non-obstructive coronary arteries. We present a case of a 26-year-old breastfeeding woman, the youngest described with CAPS and acute myocardial infarction, whose diagnosis was made with cardiac magnetic resonance imaging (CMRI). A literature review of pregnant patients with similar problems was performed. There are diagnostic and therapeutic difficulties in treating these patients. CMRI demonstrated a transmural late enhancement area. A combination of therapies led to rapid clinical improvement. CMRI is an underused tool that reaffirms the pathophysiology of CAPS and leads clinicians to the possibility of a diffuse thrombotic process. CAPS involves more organs with high mortality rates. CMRI could be optimized in order to reach an early diagnosis and the most effective treatment. This study provides real-world evidence of the feasibility of MRI in a primary care setting during pregnancy/puerperium. Evidence from this study may influence future APS screening and inform policymakers regarding the use of leading MRI technology in the detection of the thrombotic process in a primary care setting.

Use of biliary stents for large coronary arteries.

Dedicated coronary artery drug-eluting stents may be inadequate in coronary arteries >6 mm in diameter, due to the risk of stent undersizing if the stent is not fully expanded or to loss of radial strength or damage to the drug coating if the stent is expanded >6 mm. We present two patients with large coronary arteries who were successfully treated with biliary balloon expandable stents.

Myocardial Infarction With Non-obstructive Coronary Arteries: A Clinical Conundrum.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is defined by the presence of positive cardiac biomarkers with clinical evidence of infarction, the absence of significant coronary stenosis (≥50%) on angiography, and the lack of alternative diagnosis for the index presentation. MINOCA poses a diagnostic and therapeutic challenge due to the various pathophysiologic mechanisms underlying its presentation. Coronary artery plaque disruption is recognized as a crucial mechanism contributing to MINOCA. Plaque rupture and thrombus formation with subsequent myocardial ischemia may occur without significant luminal narrowing. A high index of suspicion is needed to make an early diagnosis. Here, a 68-year-old African American male patient presented with substernal chest pain, nonspecific ST segment changes on electrocardiogram, and elevation in cardiac biomarkers only one day after undergoing diagnostic cardiac catheterization that revealed non-obstructed coronary arteries. This case provides an example of MINOCA occurring secondary to suspected coronary artery plaque disruption in the setting of recent cardiac catheterization.

Anomalous Origin of the Right Coronary Artery From the Pulmonary Artery: Advantages of Multimodality Imaging.

Coronary anomalies are one of the most surprising yet challenging pediatric cardiology diagnoses. The anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is frequently underdiagnosed due to a lack of typical signs or symptoms. We present a case of ARCAPA in a healthy six-month-old girl during follow-up of a newly detected heart murmur. Echocardiography raised the suspicion of a coronary anomaly, but the diagnosis was unclear, so cardiac catheterization and computed tomography were performed, which posteriorly confirmed the diagnosis. The patient underwent surgical repair, and the short-term follow-up has been uneventful. Regular monitoring is essential due to the potential long-term complications of ARCAPA, including myocardial ischemia, heart failure, and sudden cardiac death, underscoring the importance of early diagnosis and continuous management.

Off-Label Use of Peripheral Paclitaxel Drug-Coated Balloons in Management of Recurrent Coronary In-Stent Restenosis.

Background: While not available for clinical use in the United States, dedicated drug-coated balloons (DCB) are currently under investigation for the management of coronary in-stent restenosis (ISR). Peripheral drug-coated balloons (P-DCB) have been used off-label for coronary ISR. Further data regarding this practice are needed. We aimed to describe outcomes in patients who underwent off-label P-DCB angioplasty for coronary ISR. Methods: We analyzed data on P-DCB angioplasty for coronary ISR at a single high-volume center between April 1, 2015, and December 30, 2017. Demographic and procedural details were collected, with systematic follow-up as clinically indicated. Results: Data from 31 patients treated with P-DCB angioplasty (mean age 68.0 ± 10.7 years) with coronary ISR (17 recurrent and 14 first time) were analyzed. Most patients presented with high-grade angina (81%) or myocardial infarction (13%). Treated ISR lesions were in native coronary arteries (68%), saphenous vein grafts (SVG, 23%), and the left internal mammary artery (10%). Diffuse intrastent ISR was common (69%) with a mean lesion length of 21.7 ± 12.4 mm. No postprocedural myocardial infarction occurred and 1 nonprocedural mortality occurred during index admission. At follow-up (median: 283, interquartile range [IQR]: 354 days), repeat angiography was performed in 19 patients (median: 212, IQR: 188 days), and 11 patients had target lesion recurrent ISR (Kaplan-Meier event-free survival estimate: 44.7%, 95% CI, 26.1%-76.5%). Conclusions: In the absence of availability of dedicated coronary DCB, treatment of coronary ISR using P-DCB angioplasty was feasible, although follow-up demonstrated continued risk for recurrent ISR in this high-risk population.

Neutrophil Percentage to Albumin Ratio as a Predictor for Coronary Slow Flow Phenomenon in Patients with Myocardial Ischemia with No Obstructive Coronary Arteries.

Background: Accumulating evidences suggest that low-grade inflammatory response plays a key role in the pathophysiology of coronary slow flow phenomenon (CSFP). As a new hematological inflammatory indicator, the neutrophil percentage to albumin ratio (NPAR) and its role in the occurrence and development of CSFP remains unclear. In this study, we aimed to investigate the predictive value of NPAR in the presence of CSFP in patients with myocardial ischemia and no obstructive coronary arteries (INOCA). Methods: In total, 1323 individuals with INOCA were included in this study. 85 patients developed CSFP were included in the CSFP group. 1:2 age-and sex-matched patients were selected from the absence of CSFP, with normal blood flow, as the control group. Clinical characteristics, laboratory parameters, and angiographic findings were compared between groups. NPAR was also calculated to explore its relationship with CSFP. Results: NPAR was significantly higher in the CSFP patients than in the controls (19.3±2.5 vs 16.7±1.8, p<0.001). The NPAR increased with the number of coronary arteries involved in CSFP. Multivariate logistic regression analysis showed that an elevated NPAR level was an independent predictor of CSFP (OR 1.915, 95% CI 1.612-2.275, P < 0.001). The ROC curve showed that when NPAR was > 17.39, the sensitivity and specificity were 90.6% and 78.8%, respectively, and the area under the ROC curve (AUC) was 0.860 (95% CI: 0.811-0.909, P < 0.001). The AUC of neutrophil percentage was 0.845 (95% CI: 0.794-0.897, p < 0.001), and that of albumin was 0.808 (95% CI: 0.753-0.864, p < 0.001). Conclusion: Elevated NPAR levels are an independent predictor of CSFP in patients with INOCA. NPAR could improve the predictive value of CSFP compared with neutrophil percentage or albumin ratio alone.

Myocardial Infarction With Non-obstructive Coronary Arteries (MINOCA): A Case Report and Comprehensive Discussion of Pathophysiology and Risk Factors.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) refers to the occurrence of myocardial infarction symptoms and signs despite angiographic findings showing normal or near-normal coronary arteries. Unlike the more commonly recognized myocardial infarction with coronary artery disease (MICAD), MINOCA often has a better prognosis; however, it is not without risk, as it is associated with increased mortality. We present a 72-year-old female who presented to the hospital with acute chest pain. Following a thorough diagnostic workup, including laboratory tests, left heart catheterization, and cardiac imaging, she was diagnosed with MINOCA. This case report provides a comprehensive review of the pathophysiological mechanisms underlying MINOCA, such as plaque disruption without significant stenosis, microvascular dysfunction, coronary artery spasm, coronary thrombosis or embolism, and spontaneous coronary artery dissection. Additionally, we explore the associated risk factors, highlighting the unconventional risk factors. MINOCA represents a diverse clinical condition with various causes and complex pathophysiology. The variability underscores the necessity for further research to deepen our understanding of this condition. Enhanced knowledge will lead to better diagnostic and treatment strategies, ultimately improving patient outcomes.