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When a diagnosis is not established following coronary angiography, MINOCA represents a working diagnosis as opposed to a final diagnosis. It is vital for clinicians to perform further assessments and investigations to establish the underlying cause of the MINOCA, which will allow a final diagnosis to be established and patients to be managed appropriately. Failure to identify the underlying cause of MINOCA may result in inadequate or inappropriate therapy. ICA is the recommended definitive diagnostic test for ACS patients. If the underlying cause of MINOCA is not established using ICA alone, further evaluation using left ventriculography (including measurement of LV end-diastolic pressure), functional assessment with measurement of microvascular function/coronary reactivity, and intravascular imaging can be useful to identify the underlying cause.456,538,539 The term ‘functional coronary angiography’ refers to the combination of coronary angiography with adjunctive tests (e.g. testing for coronary microvascular dysfunction and vasoreactivity) (Figure 16). Non-coronary, cardiac causes Coronary embolism Coronary microvascular dysfunction Coronary spasm Coronary thrombosis Myocardial bridging Plaque rupture/erosion Spontaneous coronary artery dissection Coronary causes Acute respiratory distress syndrome Allergic/hypersensitivity reactions End-stage renal failure Inflammation Pulmonary embolism Sepsis Stroke Non-cardiac causes Cardiac trauma Cardiomyopathy Cardiotoxins Myocarditis Strenuous exercise Takotsubo cardiomyopathy Transplant rejection Figure 15 Underlying causes for patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries. This figure outlines some of the potential differential diagnoses in patients with a working diagnosis of MINOCA after coronary angiography, but this list is not exhaustive. ESC Guidelines 3773 Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026