Which test is especially useful in identifying the underlying cause of MINOCA?

• A. Echocardiography
• B. CMR
• C. Nuclear imaging
• D. CCTA

Answer: (B)

In MINOCA, pinpointing the exact cause requires tissue-level clues, not just anatomy. Cardiac MRI provides comprehensive tissue characterization that lets you distinguish ischemic injury from inflammation or nonischemic cardiomyopathy in one test. Edema imaging shows acute injury, and the pattern of late gadolinium enhancement reveals scar distribution. Ischemic injury from a coronary territory typically shows subendocardial or transmural LGE within that vascular territory. In contrast, myocarditis or nonischemic conditions often produces subepicardial or mid-wall LGE not confined to a single coronary territory. This combination of edema plus specific LGE patterns allows you to identify whether the underlying problem is true infarction, myocarditis, Takotsubo, or another cardiomyopathy, guiding management much more precisely than anatomy alone.

Echocardiography can assess function but lacks the tissue-specific detail to distinguish these etiologies. Nuclear imaging and CCTA provide perfusion or anatomy data, but they don’t offer the same definitive tissue characterization as MRI, which is why CMR is especially useful in identifying the underlying cause of MINOCA.