Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Unveiling Sex-Specific Differences in Pathophysiology, Diagnosis, and Management

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an increasingly recognized condition, with a higher incidence in women, characterized by myocardial injury without significant coronary artery obstruction. Sex-specific differences play a critical role in its pathophysiology, clinical presentation, and response to treatment. While the underlying mechanisms of MINOCA are diverse—including coronary microvascular dysfunction, coronary spasm, plaque rupture, coronary dissection, and thromboembolism—women are more frequently affected by non-atherosclerotic causes, particularly coronary microvascular dysfunction and spontaneous coronary dissection. Etiological investigations, including coronary angiography with intracoronary imaging, functional tests and physiology assessment, are crucial for identifying underlying causes, and advanced non-invasive techniques, such as cardiac magnetic resonance imaging, provide valuable insights. Current therapeutic strategies, including antiplatelet agents, beta-blockers, and statins, are largely extrapolated from studies in obstructive coronary artery disease, with limited evidence on their efficacy in MINOCA, particularly in women. This review explores sex-specific differences in the pathophysiology, diagnostic evaluation, and management of MINOCA, emphasizing the need for tailored approaches to improve outcomes.