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Myocardial infarction with nonobstructive coronary arteries (MINOCA) has multiple potential underlying causes which can be subdivided into coronary, myocardial and non-cardiac disorders. On the basis of three case descriptions, we show that additional investigations are crucial in determining the underlying mechanism and starting suitable treatment. Depending on clinical presentation, risk factors and medical history, an LV angiogram, a provocation test with intracoronary acetylcholine and a cardiac MRI can contribute to finding the correct diagnosis. We further present a diagnostic algorithm to guide the clinician in the management of patients presenting with MINOCA.

In patients with posterior wall myocardial infarction due to an occlusion of the circumflex coronary artery, a standard ECG does not show ST-elevation in half of the cases.Two male patients aged 55 and 52 years were admitted to our hospital because of chest pain and suspected myocardial infarction. In both patients, standard electrocardiograms (ECGs) showed no signs of ischemia. Pharmacological treatment with acetylsalicylic acid, heparin, clopidogrel and nitroglycerin did not relieve their chest pain. Echocardiography and the posterior ECG leads revealed signs of ischemia in the posterior wall. Coronary angiography revealed that the circumflex coronary artery was totally occluded in both patients. They were treated successfully by percutaneous coronary intervention.In approximately 50% of patients with myocardial infarction due to occlusion of the circumflex coronary artery, ST-segment elevation is limited or absent on the standard 12-lead ECG. These two cases emphasise that posterior ECG and echocardiography are valuable tools for detecting posterior wall infarction.

Two young patients, a 23-year-old man and a 30-year-old woman, without any risk factors for coronary artery disease, apart from the woman being a smoker, were admitted to our hospital because of acute myocardial infarction (MI) due to spontaneous dissection of a coronary artery (SDCA). The first patient developed acute chest pain while playing soccer. The second patient had unspecific chest pain in the preceding four weeks and was admitted after successful resuscitation with ventricular fibrillation. Both patients were treated with primary percutaneous coronary intervention. SDCA is a rare cause of MI and sudden cardiac death with an indistinguishable presentation due to plaque rupture. The majority of cases occur in young women. It is associated with various pathophysiological mechanisms and can manifest during pregnancy, in the postpartum period, in collagen diseases, cocaine abuse, severe hypertension, smoking, oral contraceptives, heavy exercise, or vasospasm. Treatment, pharmacological or with revascularization, is based on the severity of the dissection. Patients who survive the acute phase have good long-term prognoses.