Myocardial infarction with non-obstructive coronary arteries (MINOCA) accounts for up to 10% of acute infarcts, yet empirical therapy often fails because multiple distinct etiologies present identically. In the randomized PROMISE trial published in the European Heart Journal, patients with MINOCA underwent multimodal phenotyping—combining optical coherence tomography, coronary vasoreactivity testing, and cardiac magnetic resonance—followed by mechanism-targeted therapy versus conventional empirical care. Diagnostic workup identified a specific mechanism in ~80% of patients (epicardial spasm in 35.6%, plaque disruption in 22.2%, and spontaneous dissection in 13.3%) and reclassified initial diagnoses in over 75% of cases.

Stratified targeted treatment achieved a significant +9.38 point improvement in Seattle Angina Questionnaire health status scores over standard management. These results…