For decades, a clean coronary angiogram has been viewed as reassuring — often interpreted as evidence of a healthy heart. However, cardiologists are now warning that this long-held assumption can be dangerously misleading. A significant number of patients experience full-blown heart attacks despite showing no major blockages on routine angiography, a condition known as MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries).
“A clean angiogram doesn’t always mean a safe heart,” says Dr. Rahul Sharma, Additional Director, Cardiology, CK Birla Hospitals, Jaipur. He explains that patients with MINOCA often present classic heart attack symptoms such as chest pain, ECG changes and elevated cardiac enzymes, even though their coronary arteries appear normal. “These are real heart attacks, not false alarms,” he stresses.
Globally, MINOCA is estimated to account for 5–10% of all myocardial infarctions, yet awareness remains low among patients and, at times, even within healthcare systems.
Unlike conventional heart attacks caused by fixed blockages in large coronary arteries, MINOCA arises from mechanisms that are frequently invisible on standard angiography. These include temporary coronary artery spasms, microvascular dysfunction, plaque erosion, blood clots that dissolve before imaging, or spontaneous tears in the artery wall.
“Angiography is excellent for detecting major blockages, but it doesn’t tell the full story,” explains Dr. Ashok Malpani, Cardiologist, CK Birla Hospitals, BM Birla Heart Hospital. He notes that conditions such as coronary spasm, microvascular disease and spontaneous coronary artery dissection can cause significant heart muscle damage even when arteries look normal. Elevated troponin levels, a key marker of heart injury, should never be ignored simply because angiography appears clear.
MINOCA tends to affect patients who do not fit the traditional heart attack profile. Women, younger individuals and people without common risk factors such as diabetes, smoking or high cholesterol are disproportionately affected. This often leads to delayed diagnosis or premature reassurance.
Experts emphasise that a normal angiogram should not mark the end of evaluation. Advanced investigations such as cardiac MRI, intracoronary imaging and vasospasm testing are crucial for identifying hidden damage and guiding targeted treatment. Without these tests, patients risk being undertreated, increasing the likelihood of repeat events or long-term complications such as heart failure.
Cardiologists also reject the notion that MINOCA represents a “mild” heart attack. While treatment strategies may vary based on the underlying cause, the condition requires the same urgency, follow-up and lifestyle modification as traditional myocardial infarctions.
Listening to symptoms and seeking further evaluation when pain persists can be lifesaving, doctors say. As awareness of MINOCA grows, experts hope fewer heart attacks will be overlooked simply because they do not follow the conventional pattern.
