For decades, the optimal treatment for MINOCA has remained uncertain. Findings from the PROMISE (Prospective Randomized Trial of Stratified Medicine in MINOCA) study, published in the European Heart Journal, provide the first randomized evidence supporting individualized therapy in this heterogeneous condition.

The multicenter trial randomized 101 patients with MINOCA (mean age 62 years; 48% women) to either stratified, etiology-based treatment or standard care. Ninety-two patients were included in the final analysis. After 12 months, the stratified treatment group achieved a +9.38-point higher Seattle Angina Questionnaire summary score (95% CI, 6.81–11.95; p < 0.001) compared with standard care. Major adverse cardiovascular events occurred in 2.2% of the stratified group versus 8.5% with standard care, a nonsignificant difference (p = 0.18).

The trial was terminated early due to clear clinical benefit and safety concerns in the control group. These findings highlight the importance of comprehensive diagnostic evaluation and etiology-directed therapy to improve symptom outcomes in patients with MINOCA.