Global Disparities in Diagnostic and Therapeutic Strategies for Myocardial Infarction With Non-obstructive Coronary Arteries: An International Survey

Abstract

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) requires multimodality evaluation, including cardiac magnetic resonance (CMR), intracoronary (IC) imaging, and coronary function testing (CFT). However, real-world uptake of these guideline-recommended modalities varies widely. We conducted a global survey to characterize practice variation in MINOCA evaluation and management across demographic characteristics, continents, and economic settings.

Methods

A 16-item online survey targeting cardiologists and cardiology trainees was distributed globally between August and December 2024. Respondents provided information on demographic characteristics, institutional context, and routine diagnostic and therapeutic strategies for MINOCA. Descriptive statistics, χ² tests, and multiple regression analysis were used to assess associations.

Results

A total of 329 cardiology professionals from 6 continents participated (69.6% interventional cardiologists; 45.9% practicing in high-income countries [HIC]). Overall, 64.1% of respondents reported routine statin use and 55.6% reported beta-blocker use in MINOCA management. Advanced diagnostic modalities demonstrated substantial geographic variation. Europe reported the highest use of CMR (80.6%) and CFT (38.9%), whereas IC imaging was most frequently reported in North America (44.1%). Respondents from HIC reported greater routine use of CMR (56.3% vs 31.6%), IC imaging (41.7% vs 28.9%), and CFT (31.1% vs 13.2%) compared with those from lower-income settings (all P < .01). In multivariable analyses, HIC status remained the strongest independent predictor of routine CMR use (odds ratio [OR], 3.95; 95% CI, 2.34-6.68), IC imaging use (OR, 3.01; 95% CI, 1.74-5.20), and CFT use (OR, 2.29; 95% CI, 1.26-4.14). Academic or teaching hospital affiliation was independently associated with higher CMR use (OR, 2.19; 95% CI, 1.07-4.51), while female respondents reported higher odds of CFT use (OR, 1.89; 95% CI, 1.01-3.54).

Conclusions

Significant global disparities exist in the diagnostic evaluation of MINOCA. After adjustment, economic context emerged as the most consistent determinant of advanced diagnostic modality use. These findings highlight persistent structural barriers to the implementation of guideline-recommended MINOCA evaluation and underscore the need for strategies that expand access to advanced diagnostics and promote standardized evaluation pathways across diverse health care settings.