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Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) accounts for 5-10% of hospitalisations for acute MI. Despite guideline recommendations, diagnostic and management approaches vary. We aimed to characterise clinician preferences for MINOCA management.Methods We conducted a cross-sectional online survey of UK clinicians involved in MINOCA care between March and December 2020. To provide clinical context, two clinical vignettes (probable nonischaemic and ischaemic aetiologies, respectively) differing in age, ECG findings, presence of coronary atheroma, and plasma troponin concentration but without stated aetiology, were used to assess investigation preferences using 0-5 Likert scales. General management questions and free-text responses underwent manual thematic analysis by two independent reviewers.Results Of 146 respondents working in the NHS, 140 provided demographic data. Most were cardiology consultants (76/140, 54.3%) from tertiary centres (74/140, 52.9%). Echocardiography received high endorsement across both vignettes (Case A: 84/99 [84.8%] vs Case B: 81/88 [92.0%] giving score 5). Cardiac MRI preferences differed between vignettes: 54/101 (53.5%) gave highest endorsement for the younger patient with viral prodrome versus 17/86 (19.8%) for the older patient with atheroma ( P<0.001). Invasive coronary function testing was endorsed in 8% (8/100) and 12.5% (11/88), respectively, but no respondents endorsed routine Acetylcholine provocation testing in either vignette. Thematic analysis identified four themes: context-dependence of decisions, uncertainty regarding diagnostic utility, psychological burden on patients, and concerns about MINOCA terminology.Conclusions UK clinicians demonstrate considerable variation in MINOCA investigation strategies, with clinical phenotype strongly influencing CMR utilisation. Context dependence of decision making raises the possibility of unconscious bias in investigation selection leading to unwarranted variations in management. The proposed use of invasive coronary function testing remains underutilised. These findings support the need for standardised care pathways incorporating stricter case definitions and more precise terminology.Abstract 338 Figure 1