Incremental value of coronary computed tomography angiography in addition to invasive coronary angiography in MINOCA

Patients with the working diagnosis myocardial infarction with nonobstructive coronary arteries (MINOCA) have diverse underlying causes warranting further investigations. Despite the documented superiority of coronary computed tomography angiography (CCTA) over invasive coronary angiography (ICA) in plaque detection, the former is not routinely recommended for MINOCA patients, highlighting a knowledge gap regarding CCTA's incremental value. The objective of this study is to assess the prevalence and extent of coronary atherosclerosis in MINOCA patients using CCTA, and to evaluate the incremental value of CCTA over ICA alone in detecting coronary atherosclerosis. The data from 163 MINOCA patients who underwent both CCTA and ICA in two prospective studies were retrospectively analyzed to compare the occurrence and distribution of coronary atherosclerotic plaques detected with ICA versus CCTA, evaluating CCTA's incremental value. CCTA detected coronary atherosclerosis in 48% of subjects; ICA did so in 47%. Notable disagreement, reflected by kappa values of 0.34 (95% confidence interval [CI] 0.19-0.48) across all segments and 0.41 (95% CI 0.27-0.55) for proximal segments (both p < 0.0001), highlighted discrepancies between CCTA and ICA in the detection of atherosclerosis presence and location. Combining CCTA with ICA provided significant incremental value in detecting atherosclerosis in coronary segments (p < 0.001). MINOCA patients frequently exhibit non-obstructive coronary plaques. Agreement between CCTA and ICA is poor. CCTA provides valuable additional information on atherosclerotic segments. Therefore, CCTA should be recognized as a complementary tool to ICA, aiding risk assessment and treatment decisions in the context of MINOCA.