Pharmacologic Management of Type 2 Myocardial Infarction: An Underdefined Frontier

Abstract: Type 2 myocardial infarction (T2MI) results from myocardial oxygen supply–demand imbalance in the absence of acute atherothrombotic plaque rupture and is associated with substantial short-term and long-term mortality. Although increasingly recognized with the widespread use of high-sensitivity cardiac troponin assays, optimal pharmacologic management of T2MI remains poorly defined. We performed a narrative review evaluating pharmacologic treatment patterns and outcomes in adults with adjudicated or clinically coded T2MI. Evidence consistently demonstrates a high prevalence of underlying coronary artery disease in T2MI, with up to two-thirds of patients exhibiting significant coronary artery stenosis. Despite this overlap with ischemic heart disease, prescription rates of antiplatelet agents, statins, β-blockers, and renin–angiotensin–aldosterone system inhibitors are substantially lower in T2MI compared with type 1 myocardial infarction. Observational data suggest that statins, β-blockers, renin–angiotensin–aldosterone system inhibitors, and combination secondary prevention strategies may be associated with improved survival, whereas evidence supporting routine antiplatelet or anticoagulant therapy remains limited and inconsistent. Overall, T2MI represents a high-risk and underrecognized clinical entity for which pharmacologic management is largely extrapolated from type 1 myocardial infarction and coronary artery disease. Prospective, T2MI-focused studies are urgently needed to define optimal secondary prevention strategies and improve clinical outcomes.