Angina status and quality of life is better in patients who have myocardial infarction with non-obstructive coronary arteries (MINOCA) after receiving stratified treatment for the disease, the PROMISE trial shows. Stratified treatment is safe and also improves diagnostics and classification in patients with MINOCA. Rocco A. Monotone, MD, PhD, from the Policlinico Universitario A. Gemelli, Rome, presented these results on behalf of the PROMISE trial investigators during a late-breaking clinical trial session on Tuesday at the Transcatheter Cardiovascular Therapeutics (TCT) 2025 conference in San Francisco. Difficulties in MINOCA treatment Current guidelines for management of patients with MINOCA are based on observational studies and expert consensus on treatment strategies. MINOCA is a complex condition with multiple pathogenic mechanisms, Dr. Monotone explained during a TCT press conference Tuesday morning. The investigators in the PROMISE (PROgnostic value of precision medicine in patients with Myocardial Infarction and non-obStructive coronary arteriEs) trial examined patients with suspected diagnosis of MINOCA. Diagnostic criteria included acute myocardial infarction (MI), lack of stenosis >50% at coronary angiography and no alternative diagnosis for how patients presented during their clinical visits. Patients were randomized 1:1 to receive an advanced diagnostic workup to determine the mechanism of MINOCA plus tailored therapy to target that mechanism or standard of care, which included coronary angiography and standard therapy for acute coronary syndrome (dual or single antiplatelet therapy plus statins or beta blockers). Advanced diagnostic workups included optical coherence tomography (OCT) to determine unstable plaque, ACh provocation testing to determine epicardial or microvas spasm, cardiac magnetic resonance imaging (MRI) to confirm MI and transesophageal echocardiogram to determine if there was an embolism present. Tailored therapy was provided for each of these specific mechanisms. Differences in the change in angina status at 12-months follow-up was the primary endpoint in this study. This was analyzed using the Seattle Angina Questionnaire Summary Score (SAQ-SS). The secondary endpoint was the frequency of major adverse cardiovascular events (MACE) at 12-months. MACE was a composite of all-cause mortality, non-fatal MI, stroke, rehospitalization for heart failure (HF) and repeat coronary angiography. Patients were enrolled at 4 centers across Italy, and patients were enrolled and followed-up from July 2021 through June 2025. A total of 50 patients were randomized to stratified treatment (mean age=60.6 years, 40.0% female) and 51 patients were randomized to the standard of care (mean age=62.8 years, 55.3% female). Study results Patients in the stratified treatment group (SAQ change from baseline to 12-months: 12.5) had significantly better overall angina status at 12-months compared with the standard of care group (SAQ change from baseline to 12-months: 2.9) (95% confidence interval [CI]=6.81-11.95, p<0.001). This included quality of life (p=0.003) and treatment satisfaction (p<0.001) rates. The secondary endpoint of MACE had very different results. Both groups had similar rates of MACE at 12-months (p=0.186), including individual components of MACE. No patients had repeated coronary angiography in either group. No adverse events came from the advanced diagnostic workup. Additionally, the use of the stratified treatment reclassified 75.5% of cases in the group. Dr. Monotone noted a couple limitations of the study, including early trial termination and the open-label design. Overall, the PROMISE trial demonstrates the importance of stratified treatment in MINOCA patients to improve symptoms and quality of life. Patients who were stratified had improved angina status, and the stratified treatment was safe for all patients. This study was supported by a research grant from the Italian Ministry of Health. Image Caption: Rocco A. Monotone, MD, PhD, presents during a press conference Tuesday, October 28, at the Transcatheter Cardiovascular Therapeutics (TCT) 2025 conference in San Francisco. Image Credit: Screenshot by Bailey G. Salimes, CRTonline.org.