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. 2022 Aug 17;50(1):130–159. doi: 10.1007/s00259-022-05914-6

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© The Author(s) 2024

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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Fig. 1 — Proposed diagnostic algorithm for acute coronary syndrome. In case a STEMI is suspected, urgent ICA is recommended [235]. In case a NSTEMI is suspected, the diagnostic approach depends on the clinical likelihood of CAD, ECG findings, and troponin measurement [25]. If the clinical likelihood is low, ECG-triggered contrast-enhanced CT can rule out simultaneously coronary stenosis, aortic dissection, and pulmonary embolism (triple rule-out) [25]. If the clinical likelihood is intermediate-to-high, ICA must be discussed, urgently or semi-urgently. If no coronary stenosis is found on ICA, MINOCA should be suspected. A first step consists of thoroughly reviewing the ICA to search for subtle signs of SCAD, coronary embolization, or plaque disruption, using IVUS or OCT, when available [32, 236]. After symptom resolution and exclusion of other causes, invasive provocative testing using acetylcholine, ergonovine, or methylergonovine can help to establish a definitive diagnosis. Nevertheless, it should be used with caution and only by experienced operators, and in all cases never in the acute setting of the episode [29]. LV angiography can also provide important information such as segmental hypokinesia suggesting epicardial abnormality, apical or midventricular ballooning being in favor of TTC cardiomyopathy, and a more diffuse hypokinesia sometimes suggesting a microvascular impairment [237]. If a diagnosis cannot be established, advanced noninvasive imaging is required. CMR can show patterns of ischemia/infarct, evidence MINOCA causes [82, 83], and rule out differential diagnosis such as TTC and myocarditis [26, 30, 83]. MPI can also be used in the acute/subacute setting, after symptom resolution and normalization of ECG and troponin [238]. Abbreviations: ACS: acute coronary syndrome; CAD: coronary artery diseases; CMR: cardiac magnetic resonance; CCTA: coronary computed tomography angiography; CT: computed tomography; ECG: electrocardiogram; ICA: invasive coronary angiography; IVUS: intravascular ultrasound ; LV: left ventricle; LVEDP: left ventricular end-diastolic pressure; MI: myocardial infarction; MINOCA: myocardial infarction with no obstructive coronary artery disease; MPI: myocardial perfusion imaging; N: normal; NSTEMI: non ST-elevation myocardial infarction; OCT: optical coherence tomography; PET: positron emission tomography; SCAD: spontaneous coronary artery dissection; SPECT: single-photon emission computed tomography; STEMI: ST-elevation myocardial infarction; TTC: Takotsubo cardiomyopathy