Group D

Incomplete Diagnostic Work-up

This means the recommended tests to find the reason for your heart injury have not all been done yet (or were delayed/unavailable/declined). It’s common, and there’s a clear path to finish the work-up.

1) What does “incomplete” mean?

You meet criteria for a heart attack (a rise and fall in the blood test troponin, plus symptoms/ECG changes) and your coronary arteries were non-obstructed (less than 50% narrowed on the angiogram — the x-ray dye test). However, some useful tests are still outstanding — for example: CMR (cardiac MRI), OCT/IVUS (tiny cameras inside the artery), or coronary function testing (checks for small-vessel problems or artery spasm).

2) Why might tests be incomplete?

Service factors

  • Limited local access to CMR, OCT/IVUS or physiology labs
  • Out-of-hours presentation; early discharge; waiting lists
  • Need for referral to a regional specialist centre

Clinical factors

  • Kidney issues (contrast risk) or implants that affect MRI
  • Too unwell initially; infections or other priorities first
  • Spasm testing is delayed until it’s safe to perform

Preference & consent

  • You prefer to recover first, or to avoid certain procedures
  • Concerns about contrast agents, adenosine, or invasive tests
  • Travel/caring responsibilities make timing difficult

3) Commonly missing pieces

  • CMR (cardiac MRI) — shows inflammation, scarring and blood-flow patterns
  • OCT/IVUS — close-up artery views to spot plaque rupture/erosion, tiny clots, or SCAD (a tear in the artery wall)
  • Coronary function testing — CFR/IMR for small-vessel flow; acetylcholine testing for artery spasm (done in expert centres)
  • Repeat angiography/CTCA — in selected evolving or uncertain cases

Early CMR (ideally within days) gives the best information. Physiology/spasm testing is usually planned later as an outpatient when it’s safe and you feel better.

4) While you’re waiting — how we look after you

Interim care

  • Secondary prevention medicines (e.g., statin; ACE-inhibitor/ARB). An antiplatelet may be used if a plaque-related cause is suspected — this is balanced against bleeding risk.
  • Symptoms: beta-blocker or calcium-channel blocker can help chest discomfort while we clarify the cause.
  • Cardiac rehabilitation: guided activity, education, and confidence-building.

Plan & safety net

  • A written testing plan with rough timelines
  • Clear red-flag advice: worsening pain, fainting, severe breathlessness — seek urgent care
  • Bring tests forward if symptoms persist or return

5) Pathway to finish the work-up

  1. Confirm MI pattern (symptoms, ECG, rise/fall of troponin)
  2. Show arteries are non-obstructed (angiogram or CTCA)
  3. CMR to look for inflammation, scarring or stress-related changes (and to consider mimics like myocarditis or Takotsubo)
  4. OCT/IVUS if a small plaque event is suspected but unproven
  5. CFR/IMR and (if appropriate) acetylcholine spasm testing to check small-vessel function and artery tightening
  6. Team review to assign A1/A2/B1/C class and tailor therapy (e.g., vasodilators for spasm; antiplatelets/statins for plaque; other care for inflammatory causes)

6) What’s the outlook?

Outlook depends on the eventual cause. Completing the tests reduces uncertainty and guides targeted treatment. Many causes are highly treatable once identified, and having a plan often improves confidence in recovery.

7) Knowledge gaps & system priorities

  • Fair access to CMR, intracoronary imaging and function testing
  • Standard, time-bound referral pathways between centres
  • Shared decision-making tools that explain pros/cons in plain language
  • Training on contemporary MINOCA mechanisms and tests

Next steps

Ask your team for a written plan to complete your tests and when they’re likely to happen. You can also explore our research hub and meet others in the community forum.