Does dual antiplatelet therapy reduce the risk of death for MINOCA patients?

MINOCA stands for myocardial infarction with nonobstructive coronary arteries. It is a heart attack where the coronary arteries are not badly blocked. Because the cause is not a simple blockage, doctors are unsure which medicines help most. Dual antiplatelet therapy (DAPT) means taking two blood-thinning medicines together, usually aspirin plus another antiplatelet drug. The short answer: pooled studies suggest DAPT may lower the risk of dying from any cause in MINOCA patients, but it does not clearly prevent repeat heart attacks or major cardiovascular events ¹⁶⁷.

What the research says

A 2026 meta-analysis pooled six studies with 13,027 MINOCA patients and followed them for about 48 months. It found that DAPT was linked to a lower risk of all-cause death (hazard ratio 0.76, 95% CI 0.60 to 0.96) ¹⁶. A hazard ratio below 1.0 means the group on DAPT had fewer deaths. But the same analysis found no benefit for major adverse cardiovascular events (HR 1.00) or for repeat myocardial infarction (HR 1.03) ¹⁶.

An earlier 2022 meta-analysis of five observational studies (10,546 patients) reached a similar conclusion. DAPT was tied to a lower risk of all-cause death (HR 0.73, 95% CI 0.55 to 0.98) over a median follow-up of about 15.7 months ⁷. That analysis also found that none of the therapies it looked at, including DAPT, reduced the risk of acute myocardial infarction ⁷.

One large trial analysis looked at antiplatelet intensity rather than DAPT versus no DAPT. Among 1,599 MINOCA patients in a trial comparing standard-dose and double-dose clopidogrel, the abstract reports that 2.1% of patients in the double-dose group reached the primary outcome, but the comparison with standard dose is not fully reported in the available text ⁵. That analysis also found that MINOCA patients had lower rates of death, repeat heart attack, and major bleeding than patients with blocked arteries ⁵.

Other work shows why MINOCA is hard to study. A meta-analysis of 11 studies (12,081 patients) found that all-cause mortality was about 10% over a mean follow-up of 49 months, and that risk factors like older age, diabetes, and kidney markers predicted death ³. A small randomized trial called PROMISE tested a strategy of matching treatment to the underlying cause of MINOCA rather than standard care, and it was stopped early because of clear benefit in the treatment group ⁴. That trial focused on angina symptoms and overall outcomes, not DAPT specifically ⁴.

What to ask your doctor

• Does my type of MINOCA (for example, plaque erosion, spasm, or clot disorder) change whether DAPT is likely to help me?
• What does the evidence that DAPT may lower death risk but not repeat heart attacks mean for my own treatment plan?
• What bleeding risks should I watch for while on two antiplatelet medicines, given that MINOCA patients had lower major bleeding rates than blocked-artery patients in one large analysis ⁵?
• Are there other medicines, like statins or beta-blockers, that studies suggest may also affect my outlook ⁷?
• Should my treatment be tailored to the specific cause found in my workup, as tested in the PROMISE trial ⁴?