# Type 2 Myocardial Infarction: Navigating Diagnostic Pathways and Therapeutic Crossroads Between Invasive and Conservative Strategies

## TL;DR

This paper reviews how to diagnose and treat type 2 myocardial infarction, focusing on balancing invasive and conservative strategies for complex patients.

## Contribution

The paper provides a comprehensive and updated review of diagnostic and therapeutic approaches for T2MI, emphasizing individualized care.

## Key findings

- T2MI is a heterogeneous condition often seen in elderly patients with comorbidities.
- Current diagnostic and therapeutic strategies for T2MI lack standardized recommendations.
- Drug-coated balloon angioplasty and stentless PCI are discussed as alternatives for high-risk patients.

## Abstract

Type 2 myocardial infarction (T2MI) is defined as myocardial necrosis caused by an imbalance between oxygen supply and demand in the absence of acute atherothrombotic coronary occlusion/erosion. Unlike type 1 myocardial infarction (T1MI), T2MI comprises a heterogeneous group of clinical scenarios, often triggered by systemic or cardiac conditions, and it frequently affects elderly patients with a high burden of comorbidities. T2MI often underline multivessel coronary artery disease and, despite its growing clinical relevance, the diagnostic and therapeutic approach to T2MI remains challenging and lacks standardized recommendations. In this review, we present an updated and a comprehensive synthesis of current evidence on the diagnosis and management of T2MI, focusing on the role of coronary angiography and interventional strategies. We discuss the utility of high-sensitivity cardiac biomarkers, imaging modalities, and clinical risk scores to guide patient selection for invasive evaluation. Specific attention is given to conservative and alternative revascularization approaches—including drug-coated balloon angioplasty and stentless percutaneous coronary intervention (PCI)—in frail and high-bleeding-risk patients. The review emphasizes the need for individualized decision-making in a population where standard invasive strategies may not always be appropriate, and where a tailored balance between ischemic and hemorrhagic risk is crucial.