Cardiac magnetic resonance imaging in myocardial infarction with non-obstructive coronary arteries (MINOCA): current and evolving perspectives

Introduction: Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) represents a diagnostic challenge, requiring the exclusion of non-ischemic causes such as myocarditis, Takotsubo syndrome, and cardiomyopathies. Cardiac magnetic resonance (CMR) plays a pivotal role in differentiating MINOCA from these conditions by providing detailed tissue characterization to identify inflammation, edema, and fibrosis. This review explores the expanding role of CMR in diagnosing, reclassifying, and managing MINOCA, emphasizing its ability to guide treatment, improve prognosis, and aid risk stratification by identifying underlying causes. Areas covered: This narrative review discusses recent advancements in CMR protocols for suspected MINOCA, its role in distinguishing ischemic from non-ischemic causes of acute myocardial injury, and its emerging utility in risk stratification and personalized therapy. Relevant articles were searched in PubMed, Scopus, and Cochrane databases up to February 2025. Expert opinion: CMR is the noninvasive gold standard for diagnosing MINOCA. Its emerging role in evaluating coronary microcirculation, along with integrated approaches using coronary computed tomography, will further enhance the noninvasive assessment of MINOCA, in particular determining potential coronary and non-coronary etiologies.