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Introduction Myocardial infarction with non-obstructive coronary arteries (MINOCA) management is informed by Class I European Society of Cardiology (ESC) guideline recommendations. 1 MINOCA is a working diagnosis; the causal endotype should be pursued through invasive angiography with adjunctive intracoronary diagnostics and cardiac MRI or CT.Hypothesis: Recording MINOCA terminology is associated with guideline-directed care, whereas its absence associates with non-adherence.Aims To identify patients fulfilling diagnostic criteria for MINOCA and determine the proportion with MINOCA terminology recorded; to assess characteristics associated with non-use of terminology; and to evaluate whether terminology use is associated with ESC guideline adherence.Methods Service evaluation at a UK regional cardiothoracic centre. All troponin-positive ACS patients who underwent invasive coronary angiography (September–November 2023) with non-obstructive coronary arteries (<50% stenosis) were identified. Source clinical records were reviewed to confirm fulfilment of MINOCA diagnostic criteria and to assess terminology use, adjunctive investigations (cardiac MRI, coronary physiology, intravascular imaging), and final diagnosis. Groups were compared using chi-square/Fisher’s exact tests and Mann–Whitney U tests.Results During the study period, 775 patients underwent invasive coronary angiography for ACS indications. Of these, 97 patients (12.5%; median age 67 y [IQR 59–73], 59.0% female) met ESC diagnostic criteria for MINOCA ( table 1). Median peak hs-Tn was 377 ng/L (IQR 84–1184) and median LV ejection fraction 56% (IQR 48–60). MINOCA terminology was documented in medical records for 37/97 patients (38.1%). Use of MINOCA terminology was associated with younger age (61 vs 67 years, p=0.054), although not statistically significant.Overall, 32/97 patients (33.0%) underwent ≥1 adjunctive investigation (table 2). Patients with documented MINOCA terminology were more likely to undergo adjunctive testing (62.2% vs 15.0%, p<0.001), including cardiac MRI (54.1% vs 11.7%; OR 8.9) and coronary physiology (45.9% vs 3.3%; OR 24.6) (figure 1). When cardiac MRI was performed (n=27), a cause was identified in 85.2% of cases. Coronary physiology assessment (n=19) demonstrated abnormal IMR (≥20) in 50.0% and reduced CFR (<2.5) in 15.8%.A final endotype diagnosis (i.e. coronary plaque event, Takotsubo syndrome, or myocarditis) was ascribed in 62/97 patients (63.9%). The undifferentiated rate was 36.1% overall and was lower in the MINOCA-termed group (21.6% vs 45.0%, p=0.029) (figure 2).Conclusions Most patients fulfilling MINOCA criteria did not have MINOCA terminology recorded in the medical record. MINOCA terminology was associated with adoption of diagnostic investigation leading to a higher percentage of aetiological differentiation. There is scope to improve adherence to ESC guidelines. Increasing awareness may enhance MINOCA recognition and optimise clinical care.Reference Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44:3720–826. doi: 10.1093/eurheartj/ehad191Abstract 163 Figure 1Use of MINOCA Terminology in acute MI patients with no obstructive CAD and Use of adjunctive diagnostic tests by MINOCA terminology useAbstract 163 Figure 2Association of MINOCA terminology with guideline directed investigation and diagnostic differentiationAbstract 163 Table 1Characteristics of the acute MI cohort without obstructive coronary artery disease by MINOCA Terminology useCharacteristicsAllMINOCA Terminology UsedNo MINOCA Terminologyp-valueNumber of Patients, %9737 (38.1%)60 (61.9%) Age, years, median (IQR)67 (59-73)61 (52-71)67 (61-73)0.054Sex, female, n (%)57 (59.0%)20 (54.1%)37 (61.7%)0.598Ethnicity, white, n (%)93 (95.9%)34 (91.9%)59 (98.3%)0.154SIMD Quintile, median (IQR)3 (2-4)3 (1-4)3 (2-4)0.516QRISK3 %, median (IQR)14.2 (7.8-23.9)13.6 (5.9-24.3)14.4 (8.8-23.1)0.588HbA1c, mmol/mol, median (IQR)40 (37-43.5)40 (37-42)40 (37-44)0.836Peak hs-Tn ng/L, median (IQR)377 (84-1184)332 (81-744)441 (86-1360)0.629LV ejection fraction, %, median (IQR)56 (48-60)60 (55-63)55 (45-60)0.036Abstract 163 Table 2Rate of adjunctive investigation use and diagnosis differentiation by MINOCA terminology useInvestigations/OutcomesAllMINOCA Terminology UsedNo MINOCA Terminologyp-valueAdjunctive InvestigationsAny adjunctive test, n (%)32 (33.0%)23 (62.2%)9 (15.0%)<0.001Cardiac MRI, n (%)27 (27.8%)20 (54.1%)7 (11.7%)<0.001Coronary physiology, n (%)19 (19.6%)17 (45.9%)2 (3.3%)<0.001Intravascular imaging, n (%)1 (1.0%)0 (0.0%)1 (1.7%)1.000Outcome Differentiated diagnosis, n (%)62 (63.9%)29 (78.4%)33 (55.0%)0.029