PROgnostic Value of Precision Medicine in Patients With Myocardial Infarction and Non-obStructive Coronary artEries: the PROMISE Trial.
Phase: PHASE4
Conditions: Myocardial Infarction With Non-Obstructive Coronary Arteries
Sponsor: Fondazione Policlinico Universitario Agostino Gemelli IRCCS

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
1 
 
      
GENERAL INFORMATIONS 
1. Title:  PROgnostic value of precision medicine in patients with Myocardial Infarction and 
non-obStructive coronary artEries: the PROMISE study. 
 
2. Trial Registration: The study will be registered on ClinicalTrials.gov, and the study page 
updated with the study results if possible. 
 
3. Version: 3_06_May_2021 
 
4. Founding: Co-founded study (project “ Ricerca Finalizzata 2019”, Ministry of Health)  
 
5.a  Principal Investigator (PI) of the Promoter Center:  
Rocco Antonio Montone 1 (roccoantonio.montone@policlinicogemelli.it) , MD, PhD 
Department of Cardiovascular Medicine 
Intensive Cardiology Unit 
Fondazione Policlinico Universitario A. Gemelli IRCCS 
L.go A. Gemelli, 1 – 00168 Rome, Italy 
Tel. +39-06-30154187 
Fax. +39-06-3055535 
Co-PI of the Promoter Center: Dr. Francesca Graziani1 (francesca.graziani@policlinicogemelli.it) 
 
1 Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia. 
 
5b-c. Sponsor: Italian Ministry of Health 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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5d. The PIs of the participating centers are responsible for conducting the clinical trial in accordance 
with the ICH-E6 guidelines and the GCP rules. They are involved in the design and planning of the 
clinical trial and are responsible for all trial-related medical decisions at their clinical site. 
Furthermore, they are responsible for training all staff involved in the conduct of the trial at their site 
and for reporting all adverse effects (SAEs) to the Investigator. The authors of the protocol are solely 
responsible for the collection, management, analysis and interpretation of the data; in writing reports 
and deciding to submit reports for publication. 
 
Date: May 6, 2021 
 
 
 
 
Signature 
 
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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6. Abstract 
Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents 
about 6-8% of patients presenting with myocardial infarction. Initially believed to be a benign 
condition, is now becoming clear that MINOCA is associated with a significant risk of mortality, 
rehospitalization, disability and angina burden, with high socioeconomic costs. However, to date 
there are no prospective clinical trials in this population and treatment of these patients is not still 
defined, also because there are multiple pathogenic mechanisms underlying MINOCA.  
Objectives: The aim of our study is to evaluate if the use of a precision-medicine approach with a 
specific therapy tailored on the underlying pathogenic mechanism will improve the quality-of-life in 
MINOCA patients (primary objective). We further aim at investigating wherever a precision-
medicine approach will improve the prognosis, healthcare related costs, and if that a different profile 
of plasma biomarkers and microRNAs may serve as diagnostic tools for detecting specific causes of 
MINOCA and to assess response to therapy (secondary objectives). Finally, beyond its pivotal role 
in differential diagnosis, we hypothesize that cardiac magnetic resonance (CMR) may provide a 
morphological and functional cardiac characterization as well as help in the prognostic stratification 
(secondary objective). 
Methods: We will include 180 patients aged >18 years hospitalized for MINOCA randomized 1:1 to 
a "precision medicine approach" consisting of a comprehensive diagnostic work-up, analysis of 
circulating biomarkers and micro RNA expression profile and pharmacological treatment specific for 
the underlying cause versus a "standard approach" consisting of routine diagnostic work-up and 
standard medical treatment. 
 
 
 
 
 
 
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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INTRODUCTION 
6.a Randomized multicenter prospective superiority phase IV trial comparing “precision medicine 
approach” versus “standard of care” in improving the prognosis and/or the quality-of-life of patients 
presenting with MINOCA. Patients will be randomized 1:1 to “precision medicine approach” 
consisting of a comprehensive diagnostic work up aim at elucidating the pathophysiological 
mechanism of MINOCA and consequently a tailored pharmacological approach versus “standard of 
care” consisting of standard diagnostic algorithm and therapy for myocardial infarction. 
6.b Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) 
represents about 6-8% of all patients presenting with acute myocardial infarction (MI) referred for 
coronary angiography. MINOCA is defined by the evidence of MI with normal or near normal 
coronary arteries on angiography, in absence of a specific alternate diagnosis for the clinical 
presentation (i.e. sepsis, myocarditis, pulmonary embolism). Notably, there is a variety of causes 
underlying MINOCA including coronary plaque rupture/erosion, epicardial or microvascular spasm, 
and coronary embolism. Therefore, MINOCA should not be considered as a single entity but a 
heterogeneous working diagnosis that requires a comprehensive evaluation to elucidate the potential 
underlying cause. Several studies have shown that MINOCA patients have 1-year mortality and 
rehospitalization rate similar to those patients with acute MI with obstructive coronary artery disease 
(MICAD). Furthermore, approximately 25% of patients with MINOCA will experience angina in the 
subsequent 12 months, at least as high as reported in patients with MICAD, with a significant impact 
on quality of life and healthcare related costs. Angina symptoms have also relevant socioeconomics 
consequences because patients with angina without evidence of CAD have the same increased 
probability of future disability pension and premature exit from the workforce as patients with 
obstructive CAD. This is of crucial importance, because MINOCA patients are usually younger than 
patients with MICAD. A comprehensive evaluation and a multimodality assessment aiming at 
uncovering the aetiology should be pursued, in order to implement tailored therapeutic approaches 
targeted to the specific underlying cause. Indeed, the management of MICAD has well-established 
evidence-based guidelines, while the management of MINOCA has a limited evidence-based 
literature, with no prospective randomized controlled trials undertaken to date. In particular, a 
precision medicine approach is important in MINOCA patients because of the multiple causes 
underlying this condition. Importantly, a precision-medicine approach had already proved its efficacy 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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in patients with stable angina and non-obstructive CAD. Indeed, the landmark Coronary 
Microvascular Angina (CorMicA) trial showed that in these patients a strategy of adjunctive invasive 
testing for disorders of coronary function linked with stratified medical therapy led to improvement 
in patient outcomes, including reduction in angina severity and better quality of life. If a similar 
precision-medicine approach is effective also in patients with MINOCA has never been assessed.   
We previously demonstrated that patients with a positive provocative test for epicardial or 
microvascular spam had a higher occurrence of future cardiac events, thus identifying high-risk 
MINOCA patients that may need a more aggressive therapy. Moreover, biochemical profile of 
MINOCA patients is still largely unknown and whatever exist a unique profile associated with 
specific pathophysiological mechanisms remains unknown. Endothelin-1 (ET-1) and neuropeptide Y 
(NPY) are endogenous vasoactive substances regulating coronary vasomotion involved in coronary 
spasm. On the other hand, elevated plasma levels of soluble CD40L and C-reactive protein (CRP) are 
involved in inflammatory activation during MI with plaque rupture. Moreover, also circulating 
miRNA may be associated with specific pathophysiological mechanisms of MINOCA, and may 
represent new promising diagnostic tools. Particularly, the up-regulation of miR-16 and miR-26a and 
the down-regulation of miR-1 and miR-133, have been reported to characterize coronary 
microvascular spasm, whereas, miR-145 and miR-222 may help in identifying patients with 
epicardial spasm. Finally, miR-155-5p, miR-483-5p and miR-451a have been suggested as novel 
biomarkers for the early identification of plaque rupture. However, miRNA assessment in MINOCA 
patients has never been performed. In the absence of dedicated randomized controlled trials, current 
guidelines do not specifically address the issue about acute and long-term management of patients 
with MINOCA. The effects of secondary preventive treatments proven beneficial in patients with 
MICAD are unknown in MINOCA patients. The "one-size-fits-all" approach used for MICAD 
treatment may not apply uniformly to all MINOCA patients, which instead should be "personalized" 
depending on the underlying pathophysiological mechanism responsible for the clinical presentation. 
Thus, the next key step in the management of MINOCA is to demonstrate the benefits of tailored 
therapies on cardiovascular and quality-of-life outcomes. With this prospectively designed trial, we 
have the opportunity to test the prognostic value of a targeted therapeutic approach based on the 
identification of the underlying cause. Of importance, the results deriving from our trial may open 
the way for a new pathophysiology-driven approach with cause-target therapies personalized for the 
mechanisms of MINOCA. 
6.c There is a limited agreement regarding the acute and long-term medical management of patients 
with MINOCA. The results of a large observational study of MINOCA patients from the 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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SWEDEHEART registry have shown a significantly lower rate of cardiovascular events associated 
with the use of statins and ACEi/ARB, a trend for a lower event rate with the use of ß- blockers, while 
dual antiplatelet therapy (DAPT), a cornerstone of therapy for MICAD patients, failed to improve 
prognosis. An important limitation of this study is the heterogeneous nature of MINOCA cohort, 
without discerning the mechanism leading to myocardial infarction. Given these therapeutic 
shortcomings in this evolving area of clinical research, multicentre randomized clinical trials are 
needed to determine the optimal medical therapy for MINOCA based on the specific cause of the 
syndrome. Importantly, a precision-medicine approach had already proved its effectiveness in 
patients with stable angina and/or signs of ischemia but no obstructive coronary artery disease 
(INOCA). Indeed, the CorMicA trial showed that in patients with INOCA a strategy of adjunctive 
invasive testing for disorders of coronary function linked with stratified medical therapy led to 
improvements in patient outcomes, including reduction in angina severity and better quality of life. 
Similarly, the identification of functional alterations of coronary circulation is relevant in the clinical 
setting of MINOCA. We previously demonstrated that MINOCA patients with a positive test result 
(epicardial or microvascular spam) had a significantly higher occurrence of cardiovascular events, 
thus identifying a high-risk subset of patients that may need a more aggressive therapy and a closer 
follow-up. 
Moreover, information about cardiac structure and function as well as plasma biochemical 
profile associated with the different causes of MINOCA is scantly. Beyond its role in differential 
diagnosis, CMR may help in the morphological and functional cardiac characterization as well as in 
the prognostic stratification. Biochemical profile of patients with MINOCA is still unidentified and 
whatever exist a unique profile associated with specific pathophysiological mechanisms remains 
unknown. Endothelin-1 (ET-1) and neuropeptide Y (NPY) are endogenous vasoactive substances 
regulating coronary vasomotion, with higher circulating levels in patients with coronary 
microvascular and epicardial spasm. Elevated plasma levels of soluble CD40L and CRP, two 
inflammatory biomarkers associated with inflammation and thrombus formation, have been described 
in patients with MI due to acute plaque destabilization. Recent findings have shown that levels of 
specific circulating miRNA may have a close association with specific pathophysiological 
mechanisms of myocardial infarction (i.e. plaque rupture, microvascular spam or epicardial spasm). 
Particularly, a unique signature, comprising the up- regulation of miR-16 and miR-26a and the down-
regulation of miR-1 and miR-133, has been reported to characterize coronary microvascular spasm, 
whereas miR-145 and miR-222 may help to identify patients with epicardial spasm. Finally, a recent 
study identified miR-155-5p, miR-483-5p and miR-451a, as novel biomarkers for the early 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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identification of plaque rupture. However, the role of circulating plasma biomarkers and miRNA in 
MINOCA patients has never been investigated.  
7. Study objectives: 
Primary objectives: 
● To test if a precision-medicine approach with a careful investigation of the MINOCA 
aetiology and consequent aetiology-based treatment may result in improved quality of life 
outcomes. 
Secondary objectives: 
● To evaluate if the use of a precision-medicine approach with a specific therapy tailored on 
the MINOCA pathogenic mechanism will improve the prognosis. 
● To assess if a precision-medicine approach with a careful investigation of the MINOCA 
aetiology and consequent aetiology-based treatment may result in reducing healthcare 
related costs. 
● To test wherever a plasma circulating biomarker profile may be able to differentiate between 
the different causes of MINOCA, helping to identify the underlying pathophysiological 
mechanisms and to stratify prognosis and response to medical therapy. 
● To test wherever cardiac magnetic resonance (CMR) may provide a morphological and 
functional cardiac characterization as well as help in the prognostic stratification in 
MINOCA. 
 
8. Study design: Randomized multicenter prospective superiority phase IV trial comparing 
“precision medicine approach” versus “standard of care” in improving the prognosis and/or the 
quality-of-life of patients presenting with MINOCA. Patients will be randomized 1:1 to “precision 
medicine approach” vs “standard approach”.  
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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METHODS: PARTECIPANTS, INTERVENTIONS, OUTCOMES 
9. Setting: IRCCS Fondazione Policlinico Universitario A. Gemelli (Promoter Coordinating Centre 
), Centro Cardiologico Monzino IRCCS, IRCCS Policlinico San Donato 
Number of patients enrolled: The study will include 180 patients (expected 60 patients per center, 
but enrolment is competitive) aged >18 years hospitalized for MINOCA.  
10. Inclusion criteria: 
● Ability to give informed consent to the study 
● Age > 18y 
● MINOCA diagnosis, defined as: 
o Acute myocardial infarction (based on Fourth Universal Definition of Myocardial 
Infarction Criteria):  
o Evidence of non-obstructive coronary artery disease on angiography (i.e., no 
coronary artery stenosis >50%) in any major epicardial vessel.  
o No specific alternate diagnosis for the clinical presentation (i.e. non-ischemic causes 
of myocardial injury such as sepsis, pulmonary embolism, and myocarditis). 
Exclusion criteria: 
● Inability or limited capacity to give informed consent to the study 
● Age < 18 y 
● Pregnant and breast-feeding women or patients considering becoming pregnant during the 
study period will be excluded. For women of childbearing potential, the use of a highly 
effective contraceptive measure is required in order to be included in the study. “Highly 
effective contraceptive” is defined in accordance with the recommendations of the Clinical 
Trial Facilitation Group as a contraceptive measure with a failure rate of less than 1% per 
year (https://www.hma.eu/fileadmin/dateien/Human_Medicines/01-
About_HMA/Working_Groups/CTFG/2020_09_HMA_CTFG_Contraception_guidance_Ve
rsion_1.1_updated.pdf). 
● Alternate diagnosis for the clinical presentation (i.e. non-ischemic causes of myocardial 
injury such as sepsis, pulmonary embolism, valve disease, hypertrophic cardiomyopathy and 
myocarditis). Also patients presenting with Takotsubo syndrome will be excluded. 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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● Contraindication to contrast-enhanced CMR, eg, severe renal dysfunction (glomerular 
filtration rate <30 mL/min), non–CMR-compatible pacemaker or defibrillator. 
● Contraindication to drugs administrated: e.g a history of hypersensitivity to drugs 
administrated or its excipients, significant renal and/or hepatic disease. 
● Patients with comorbidities having an expected survival <1-year will be excluded. 
 
Withdrawal criteria : 
Subjects may be withdrawn from the study at discretion of the Investigator if one of the following 
criteria applies: 
● Patients voluntary to stop participate to the study protocol. 
●  Progression of patient’s disease or need to change medical therapy. 
● Intolerable adverse effects.Pregnancy or intention of becoming pregnant at any time of the 
study.. Patients enrolled will have to communicate to the investigator if they get pregnant at any 
time of the study to be excluded by the study protocol.  
Stopping rules 
Premature termination of the clinical trial could be considered if the sponsor believes that it is 
necessary to terminate the clinical trial as a result of the observed efficacy of the treatment (benefit), 
of a likelihood of failing to reject the null hypothesis (futility), evidence of severe adverse effects of 
treatments administrated (harm) or when the clinical trial proved to be impracticable (e.g difficulty 
in patients enrolment). 
11a. Intervention(s): 
Patients with myocardial infarction undergoing to clinically indicated coronary angiography will be 
asked to sign the informed consent to the study before the coronary angiography/ventriculography 
and enrolled only after MINOCA diagnosis. MINOCA patients will be then randomized 1:1 (using 
an online software available 24h/24h) to: 
A. "Precision medicine approach" consisting of: 
Comprehensive diagnostic work-up with: 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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● Coronary angiography and ventriculography in all patients 
● OCT (if coronary plaque rupture/erosion is suspected) at the time of coronary angiography 
in the cath-lab. 
● Acetylcholine provocative test (to assess the presence of coronary vasospasm) at the time of 
coronary angiography in the cath-lab. 
● TE-Echo and/or CE-Echo (if distal/microvascular embolization is suspected) during the 
hospitalization at the echo laboratory 
● Blood sampling for circulating biomarkers and miRNA expression profile at the time of 
coronary angiography or within 12 hours from coronary angiography. Blood sampling will 
be processed and analysed in the research laboratory of the Department of Cardiovascular 
Science. Biological aliquots will be preserved at XBiogem Biobank at Fondazione 
Policlinico Universitario A. Gemelli IRCCS, Rome. 
● Trans-thoracic echocardiography in all patients during the index hospitalization 
● CMR in all cases during the index hospitalization. 
Targeted pharmacological treatment specific for the underlying cause: 
● DAPT ± stent implantation (if required), statins, beta-blockers, ACEi/ARB (in case of 
evidence of plaque rupture/erosion) 
● CCB and/or nitrates (in case of documentation of coronary vasospasm) 
● Anticoagulation (in case of coronary embolism).  
B. "Standard approach" consisting of: 
Routine diagnostic work-up with: 
● Coronary angiography and ventriculography  
● Transthoracic echocardiography in all patients during the index hospitalization 
● CMR with contrast media only if clinically indicated (i.e. to exclude myocarditis or takotsubo 
syndrome) 
Standard medical treatment with: 
● DAPT in all patients  
● Beta-blockers (if indicated by the clinical context, i.e. documentation of left ventricular 
ejection fraction <50%, tachycardia).  

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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● High intensity statins in all patients 
● ACEi/ARB (if clinically indicated).  
Pharmacological strategy will be started after the coronary angiography during the index 
hospitalization. All the procedures will be done by cardiologists with experience in the specific 
field. All three enrolling centers already have a high proficiency in performing all the procedures 
required for this study. 
Interventional Procedures: 
● Coronary angiography: coronary angiography will be performed via the transradial or 
transfemoral approach with the use of a 6F sheath. Coronary angiography will be performed 
within 90 minutes from hospital admission in patients presenting with persistent ST-segment 
elevation, and within 48 hours in patients presenting with non-ST-segment elevation. 
Unfractionated heparin (initial weight-adjusted intravenous bolus of 60 IU/Kg, with repeat 
boluses to achieve an activated clotting time of 250 to 300 seconds) was administered in all 
patients. If evidence of plaque rupture  
● Percutaneous coronary intervention (PCI): PCI with stent implantation will be considered in 
selected cases with evidences of plaque rupture 
● OCT imaging: OCT imaging will be performed in the culprit artery in all patients randomized 
to the “precision medicine approach” with angiographic aspect of complex atheromatous 
plaque suggestive of plaque rupture. A 0.014-inch guidewire will be placed distally in the 
target vessel and an intracoronary injection of 200 µg of nitroglycerine will be performed. 
Frequency domain OCT (FD-OCT) images are acquired by a commercially available system 
(C7 System, LightLab Imaging Inc/ St Jude Medical, Westford, MA) connected to an OCT 
catheter (C7 Dragonfly; LightLab Imaging Inc/ St Jude Medical, Westford, MA), which was 
advanced to the culprit lesion. The FD-OCT run will be performed using the integrated 
automated pullback device at 20 mm/s. During image acquisition, coronary blood flow will 
be replaced by continuous flushing of contrast media directly from the guiding catheter at a 
rate of 4 ml/s with a power injector in order to create a virtually blood-free environment. 
Plaque rupture will be defined by the presence of fibrous cap discontinuity with a clear 
communication between the lumen and inner core of a plaque or with a cavity formation 
within the plaque. Plaque erosion will be identified by the presence of attached thrombus 
overlying an intact and visualized plaque, luminal surface irregularity at the culprit lesion in 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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the absence of thrombus, or attenuation of underlying plaque by thrombus without superficial 
lipid or calcification immediately proximal or distal to the site of thrombus. Considering that 
OCT does not provide an adequate resolution to identify the endothelial lining, the definition 
of plaque erosion should be considered a diagnosis of exclusion, requiring the absence of 
fibrous cap rupture. Thrombus will be defined as an irregular mass (diameter > 250 µm) either 
attached to the luminal surface or floating within the lumen. 
● TT-Echocardiography: TT-Echo will be used to calculate left and right ventricular and atrial 
dimensions, left and right ventricular systolic function, transmitral flow Doppler spectra, 
mitral and tricuspidal valve annulus tissue Doppler spectra, ejection time and stroke volume, 
inferior vena cava, aorta and pulmonary artery diameters and Doppler spectra, according to 
the recommendations of the American Society of Echocardiography. 
● TE/contrast echocardiography: In patients with angiographic evidence of distal 
microembolization, TE-Echo consisting of an echocardiographic probe inserted in to the 
oesophagus will be used to detect a hidden cardioembolic source (i.e. left atrial thrombus); in 
patients with suspected left ventricular source of cardioembolism, contrast echocardiography 
consisting of a 0.3ml solution of SONOVUE will be used. 
● Acetylcholine provocative test: ACh will be administered in a stepwise manner into the left 
coronary artery (LCA) (20–200 μg) or into the right coronary artery (RCA) (20–50 μg) over 
a period of 3 min with a 2–3 min interval between injections. Coronary angiography will be 
performed 1 min after each injection of these agents and/or when chest pain and/or ischaemic 
ECG shifts were observed. The decision of testing with provocative test LCA or RCA as first 
will be left to the discretion of the physicians; both LCA and RCA will be tested if the first 
test was negative. Angiographic responses during the provocative test will be assessed in 
multiple orthogonal views in order to detect the most severe narrowing and/or analysed by 
using computerized quantitative coronary angiography (QCA-CMS, Version 6.0, Medis-
Software, Leiden, The Netherlands).  
● Cardiac magnetic resonance: CMR will be performed during hospital stay on a 1.5-T system 
equipped with a 32-channel cardiac coil. Patients underwent conventional CMR including 
cine, T2-weighted, first pass perfusion, and conventional breath-held late gadolinium 
enhancement (LGE). 
● Circulating biomarkers: Blood sampling for circulating biomarkers and miRNA expression 
profile at the time or within 12 hours of coronary angiography. Blood sampling will be 
processed and analysed in the research laboratory of the Department of Cardiovascular 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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Science. Biological aliquots will be preserved at XBiogem Biobank at Fondazione Policlinico 
Universitario A. Gemelli IRCCS, Rome (see section 33). 
Risk analysis, possible problems and solutions:  
● OCT is a safe invasive intracoronary imaging tool. Complications during manipulation inside 
coronary arteries are rare. This procedure will be performed by experienced operators to 
improve its safety. 
● CMR with intravenous gadolinium administration is a safe procedure, associated with a low 
risk of renal damage, also in patients with severe kidney disease, and allergic reactions. These 
side effects may, however, be prevented and treated appropriately. 
● A transesophageal echocardiogram (TEE) uses echocardiography to assess the structure and 
function of the heart. It is associated with a rare risk of complication, such as bleeding, airway 
difficulty, arrhythmias and local trauma. The risk of complications will be reduced by using 
an experienced sonographer and by excluding patients with Echo TE contraindications 
(oesophageal varices, oesophageal obstruction or stricture, or radiation therapy to the area of 
the esophagus). Contrast echocardiography refers to diagnostic ultrasound of the heart that is 
performed in conjunction with any acoustically active particle, including agitated saline and 
is not associated with any complication. 
● Acetylcholine provocative test with intracoronary acetylcholine administration is associated 
with a very low risk of ischemic and/or arrhythmic events. However, recent studies confirmed 
that this test is safe and complications are rare, also in patients admitted with a diagnosis of 
MINOCA. Our center published a recent paper demonstrating the safety of this procedure and 
its prognostic relevance in MINOCA patients (see references). Occurrence of 
bradyarrhythmias (defined as bradycardia with heart rate < 50 bpm or second- or third-degree 
AV block lasting more than 3 s), atrial fibrillation and ventricular tachycardia (defined as 
three or more consecutive premature ventricular complexes) during the provocative are rare 
and if complications occur, patient will be treated appropriately with vasodilator 
pharmacological agents able to counteract the pharmacological effect of acetylcholine. 
Pharmacological interventions: 
All the drugs used for this trial are already widely used in cardiology clinical practice and will follow 
the AIFA indications for which the specific medication has been approved (see RCP attached). All 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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the study drugs will be stored according to GCP in the center's experimental pharmacy and collected 
at the time of use. 
● Dual antiplatelet therapy: acetylsalicylic acid (loading dose 250mg intravenously followed 
by 75mg orally) + P2Y12 receptor inhibitor (i.e. Clopidogrel, 300 or 600mg loading dose 
orally, followed by 75 mg orally daily). 
● Statins (i.e. atorvastatin; dosages titrated on the patient’s clinical characteristics) 
● Beta-blockers (i.e. bisoprolol; dosages titrated on blood pressure, ECG, heart rate)  
● ACEi/ARB (i.e. ramipril; dosages titrated on blood pressure, ECG, heart rate) 
● CCB (i.e. diltiazem; dosages titrated on blood pressure, ECG, heart rate) and/or nitrates 
(nitroglycerine; dosages titrated on blood pressure, ECG, heart rate) 
● Anticoagulation (i.e. warfarin; the selection of the anticoagulant agent will be based on the 
clinical scenario, contraindications etc.) 
Patients could receive any of the medications belonging to the same drug class. 
11.b The dosage of the drugs will be modified following adverse events, at the request of the 
participants, in presence of an improvement or worsening of the disease. 
11.c There are no concomitant medications contraindicated. For each patient concomitant 
medications will be recorded at baseline and at any time of follow up. Moreover, the presence of 
interactions between drugs administrated or concomitant medications which may influence the 
outcome of the study will be evaluated by the investigator at baseline and at any time of follow up”. 
12. Outcomes of interests:  
Primary endpoints: 
● Angina status and quality of life (evaluated using the Seattle Angina Questionnaire [SAQ]) at 
1-year follow-up in patients with MINOCA.  
 
* To reduce the risk of detection and performance bias, a team of 2 cardiologists blinded to group 
allocation and belonging to an external cardiology unit will submit and collate the questionnaires 
from study participants. 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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Secondary endpoints: 
● Rates of major adverse cardiovascular events (MACE; composite of all-cause mortality; re-
hospitalization for myocardial infarction, stroke or heart failure; repeated coronary 
angiography) at 1-year follow-up in MINOCA patients.  
● Healthcare primary and secondary related-costs (including costs for tests, procedures and 
outpatient visits or medicines) and socioeconomic burden of MINOCA patients.  
● Ability of different circulating biomarkers (ET-1, NPY, CRP, sCD40L and miRNA [miR-16, 
miR-26a, miR-145, miR-222, miR-155-5p, miR-483-5p and miR-451]) as diagnostic 
biomarker and stratification tool for specific causes of MINOCA.  
● Ability of CMR in evaluating different mechanisms of MINOCA and their prognostic value.  
13. Study Flow Chart  
This is a multicenter Italian randomized clinical study in which patients with MINOCA will be 
enrolled after a careful check of the inclusion and exclusion criteria. The flow chart of the study is 
resumed in the following Figure and schematized in the next sections: 
 
 
 

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Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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Study timeline 
 
 
T 0 (index hospitalization for MINOCA): 
During the index hospitalization the study investigators, after a careful evaluation of the inclusion 
and exclusion criteria of the patients, will collect:  
- 
Anagraphic data 
- 
Personal information: weight, height, BMI 
- 
Vital parameters (blood pressure, heart rate, oxygen saturation) 
- 
Therapy at admission and at discharge (concomitant medications included) 
- 
Cardiovascular risk factors: family history of early coronary artery disease (first degree 
relative with a history of myocardial infarction <60 years), diabetes mellitus [fasting blood 
glucose >126 mg/dL or treated diabetes mellitus (intake of a diabetic diet or oral 
hypoglycaemic agents), according to the American Diabetes Association (ADA) criteria], 
hypercholesterolemia (total cholesterol >200 mg/dL or treated hypercholesterolemia), 
smoking (current), and hypertension (systolic blood pressure >140 mmHg and/or diastolic 
blood pressure >90 mmHg or treated hypertension). 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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- 
Relevant comorbidities: anaemia, chronic kidney disease, atrial fibrillation, history of 
stroke/TIA, peripheral vascular disease 
- 
ECG features (ST segment elevation/depression or T wave inversions, atrioventricular blocks, 
arrhythmias) 
- 
Trans-thoracic color-Doppler echocardiography (chamber volumes, systolic and diastolic 
function) 
- 
Data on coronary angiography and ventriculography (presence/absence of non-obstructive 
CAD, micro vs epicardial coronary spasm, “hazy” angiographic images, TIMI flow, LVEDP) 
- 
Laboratory data (creatinine, full blood count, Troponin I peak, CK-MB peak, NT-proBNP, 
CRP) 
For patients randomized to “precision medicine approach”: 
● OCT (if coronary plaque rupture/erosion is suspected) at the time of coronary angiography 
in the cath-lab. 
● Acetylcholine provocative test (to assess the presence of coronary vasospasm) at the time of 
coronary angiography in the cath-lab. 
● TE-Echo and/or CE-Echo (if distal/microvascular embolization is suspected) during the 
hospitalization at the echo laboratory 
● CMR with contrast media: anatomical and morphological data 
● Blood sampling for circulating biomarkers and miRNA expression profile at the time or 
within the 12 hours from coronary angiography. Blood sampling will be processed and 
analysed in the research laboratory of the Department of Cardiovascular Science. Biological 
aliquots will be preserved at XBiogem Biobank at Fondazione Policlinico Universitario A. 
Gemelli IRCCS, Rome. 
For patients randomized to Routine diagnostic work-up: 
● Coronary angiography and ventriculography  
● Transthoracic echocardiography in all patients during the index hospitalization 
● CMR with contrast media only if clinically indicated (i.e. to exclude myocarditis or takotsubo 
syndrome) 
T1_ Follow-up phone interview at 3 months (90 +/- 5 gg) 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
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- 
Collection of MACE at follow-up 
- 
Collection of ongoing medical therapy  
- 
Registration of adverse events  
T2_ Follow-up phone interview at 6 months (180 +/- 5 gg) 
- 
Collection of MACE at follow-up 
- 
Collection of ongoing medical therapy  
- 
Registration of adverse events  
T3_ Follow-up phone interview at 9 months (270 +/- 5 gg) 
- 
Collection of MACE at follow-up 
- 
Collection of ongoing medical therapy  
- 
Registration of adverse events  
T4_ Follow-up clinical visit at 12 months (365 +/- 5 gg) 
- 
Personal information: weight, height, BMI 
- 
Collection of ongoing medical therapy  
- 
Compilation of SAQ score  
- 
Collection of MACE at follow-up 
- 
Registration of adverse events 
 
 
 
 
 
 
 
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
19 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Assessment  
Screening 
and 
randomizatio
n 
Follow-up 
phone 
interview_ T1 
(3 months) 
Follow-up 
phone 
interview_ T2 
(6 months) 
Follow-up phone 
interview_ T3 
(9 months) 
Visit of End 
of Follow-up
(12 months) 
Days 
0 
90 +/- 5 gg 
180+/- 5 gg 
270+/- 5 gg 
365+/- 5 gg
Weeks 
0 
12 
24 
36 
52 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
20 
 
Informed consent 
Inclusion criteria 
Anagraphic data   
Personal 
information 
(weight, height,BMI) 
Clinical history 
Clinical examination 
Vital signs 
Ongoing medical therapy 
(concomitant medications 
included) 
x 
x 
x 
x 
 
x 
x 
x 
x 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
x 
 
 
 
 
x 
 
 
 
 
x 
Patients 
assigned 
to  
“Standard approach" 
ECG features 
Transthoracic 
Echocardiography 
Coronary angiography and 
ventriculography 
CMR with contrast    media 
(if clinically indicated) 
 
Laboratory 
data 
(creatinine, 
full 
blood 
count, Troponin I peak, 
CK-MB peak, NTproBNP, 
CRP) 
 
x 
x 
 
x 
 
x 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients 
assigned 
to  
“Precision-medicine 
approach" 
 
OCT (if coronary plaque 
rupture/erosion 
is 
suspected) 
 
 
 
 
x 
 
 
 
x 
 
 
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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Acetylcholine provocative 
test (to assess the presence  
of coronary vasospasm) 
 
TE-Echo and/or CE-Echo 
(if 
distal/microvascular 
embolization is suspected) 
 
CMR with contrast    media 
(if clinically indicated) 
 
Blood 
sampling 
for 
circulating 
biomarkers 
and miRNA expression 
profile 
 
 
 
 
x 
 
 
 
x 
 
 
x 
 
 
Collection of MACE  
 
Adverse events 
 
SAQ score 
 
x 
 
x 
 
 
 
 
x 
 
x 
 
x 
 
x 
 
 
x 
 
x 
 
 
x 
 
x 
 
x 
 
 
 
 
 
 
 
SAQ score: 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
23 
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
24 
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
25 
 
 
Definition of the MACE  
MACE analysis includes: 
● All cause death:  
o Cardiac death (in which a direct cause attributable to cardiac disease is present); 
o Sudden cardiac death (in which cardiac death occurred out of the hospital and 
suddenly; or in the hospital due to ventricular arrhythmias unrelated to other 
concomitant cardiac conditions); 
o Non-cardiac death (in which the event of death is considered not to be a direct 
consequence of cardiac disease); 
● Hospitalization in which the main diagnosis is myocardial infarction, stroke or heart failure; 
● Repeated coronary angiography. 
The analysis will consider time to first event and time to each event. 
Safety parameters will include data deriving from history and physical examination performed at each 
visit, laboratory data and results of functional and imaging tests. To enhance detection of adverse 
events between visits, all patients will be encouraged to contact the research team at any time with 
concerns or any perceived changes in their healthcare status. 
14. Sample size calculation: Sample size calculation for the primary endpoint: to detect a mean 
group difference of change in SAQ score of 9 U, we calculated that a sample size of 70 patients per 
group (140 patients total) gave 80% power to detect a between-group difference in SAQ. This 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
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calculation assumed a 2-tailed 5% significance level. This projected calculation assumed an SD of 19 
U and was consistent with previous studies (see landmark CorMicA trial). However, we extended the 
sample size at 180 patients to avoid any reduction of statistical power due to patients lost at follow-
up or due to poor compliance to medical therapy. 
15. Timeline: At 36 months all patients will be enrolled and will have completed the follow-up. The 
study will be considered ended after the date of last patient last visit (LPLV). Blood samples will be 
analysed for assessment of circulating biomarkers and miRNA to detect associations with specific 
mechanisms underlying MINOCA, for stratification of prognosis and to evaluate response to medical 
therapy. Furthermore, CMR sequences will be analysed to detect functional and structural 
characteristics associated with specific mechanisms underlying MINOCA and with for stratification 
of prognosis. 
 
 
 
 
 
 
 
 
 
 
 
 
 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
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METHODS: INTERVENTION ALLOCATION 
16-17 Randomization 
Trained staff in the catheter laboratory will use a web-based randomization tool, available 24h/24h at 
any of the enrolling sites, to immediately randomize the patient after the index coronary angiography 
revealing non obstructive CAD, to “precision medicine approach” versus “standard approach” (open 
label approach: both patients and physicians will know the allocated treatment arm). 
METHODS: DATA COLLECTION, MANAGEMENT AND ANALYSIS  
18. Data collection: Data collection will be carried out through an electronic CRF (eCRF). The 
investigator or an authorized member of the investigation team must sign all completed eCRFs with 
a digital signature (a password will be provided by the data management center at the start of the 
study). The management of clinical data will be carried out in accordance with the data cleaning 
procedures, both for the data recorded in the eCRFs and from other sources. Appropriate 
computerized software will be used to verify the accuracy of the database. Investigators will be asked 
for incomplete, inconsistent or missing data. 
Source Documents (SDs): Investigators have to maintain information in the patient's medical record 
that corroborates the data collected in the eCRF. To meet these demands, the following is a list of 
information that must be recorded and shown to monitors and regulatory inspectors as needed: 
Clinical history / physical condition of the participant before inclusion in the study with sufficient 
detail to verify the inclusion and exclusion criteria; clinical notes dated and signed on the day of entry 
into the study, protocol number, clinical site, number assigned to the patient and a declaration 
certifying the signature of the informed consent; record of abnormal laboratory tests; reported adverse 
events and their resolution; including supporting documents such as discharge sheet, catheterization 
reports, ECG, echocardiography and CMR reports; laboratory results; condition of the patient upon 
completion or withdrawal from the study. 
Case Report Form: All requested data will be carefully recorded by authorized personnel 
documented in the Authorized signature log in the eCRF. 
19. Confidentiality: All data and information collected during this study concerning the participant 
must adhere to the privacy protection standards, based on the application of the Italian laws on the 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
28 
 
confidentiality of the participating subjects and the European General Data Protection Regulation 
(GDPR). All data used for the analysis and the study summary will be anonymous and without 
specific references to the names of participants. Access to the subjects' personal files will be limited 
to authorized personnel, investigators and research staff. Authorized personnel from regulatory 
agencies have the right to inspect and copy all records relevant to this study, but every effort must be 
made to remove the subjects' personal data. 
Record Storing: All information in the eCRF, study records, reports and SDs that support the eCRF 
must be kept in the files of the investigator responsible in accordance with national requirements, and 
will be stored further in accordance with national and international guidelines as described in the 
Investigator Site Agreement. This documentation must be accessible if required by international 
regulatory authorities. The documentation and data collected must be kept for at least 15 years after 
the completion or suspension of the trial itself. 
20. Statistical analysis 
The study population will comprise participants who had provided 
informed consent. There will be no interim analyses, and the trial 
enrolment will be considered complete after the pre-specified 
recruitment target was met. Data will be reported as mean ± SD, median 
(25th, 75th percentile), or frequency and percentage. Continuous outcome 
measures recorded at baseline and 6 months will be compared between 
randomized groups using a mixed effects linear regression model, 
including a random effect for patients, and fixed effects for time point 
(baseline or follow-up), randomized group, and their interaction. The 
baseline-adjusted intervention effect will be estimated as the 
interaction term from this model. Categorical outcomes will be 
compared between randomized groups using Fisher exact tests with 
additional calculation of relative risk estimation of effect size. We will 
perform 2-tailed analysis and considered a p value ≤0.05 to be 
significant. Statistical analyses will be performed using SPSS program. 
METHODS: MONITORING 

PI Dr. R. A. Montone 
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21.a Data Monitoring 
By monitoring we mean the act of supervising the progress of a clinical trial, and ensuring that it is 
conducted and reported in accordance with the protocol, the Standard Operating Procedures (SOPs), 
the Good Clinical Practice (GCP), the Good Manufacturing Practice (GMP) and applicable 
regulations. The purpose is to verify that: 
• 
The rights and health of human subjects are respected 
• 
The data reported is accurate, complete and verifiable on source documents 
• 
The conduct of the trial complies with the approved protocol / amendments / GCP / GMP 
/ and requests from regulatory authorities 
• 
The quality of the trial is verified over time 
Monitoring will be carried out by the respective CTUs (Clinical Trial Units) at the sites or by the 
CRO delegated for this purpose. 
A monitoring plan and SOPs describing in detail the documents and data to be monitored will be 
developed to ensure homogeneous monitoring. 
An initiation visit before the start of the trial, visits during and at the end of the trial (close-out visit) 
are provided for each center. Regular telephone conferences between the CTUs / CROs will ensure 
the harmonization of procedures. 
All data and source documents will be made accessible to the monitors and any questions posed 
during monitoring can be answered by any participant. 
Data Monitoring Committee (DMC) 
The DMC will consist of an independent group of 3 experts consisting of a clinical cardiologist expert 
in cardiovascular emergencies, an interventional cardiologist, and a clinical cardiologist expert in 
biostatistics. The DMC has experience in managing acute patients undergoing coronary 
revascularization and conducting a clinical trial. The DMC is responsible for monitoring the safety 
of participants and the conduct of the PROMISE trial. The DMC provides recommendations on the 
advisability of continuing the clinical trial or of adopting protocol changes necessary to maintain the 
safety of enrolled patients. The composition of the DMC will be defined before the start of the clinical 
trial. The initial DMC meeting will occur at the start of the trial and will convene once annually, to 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
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30 
 
examine the accumulated safety and enrollment data, review study progress, and discuss all the 
factors that might impact continuation of the study as designed. 
21. It is the responsibility of the PI to report any changes in the research activity and unanticipated 
problems concerning the risk to human beings; including planned or untimely conclusion of the study 
and final report. Premature interruption of the study must be reported within 15 days. The regular 
term of the study will be communicated to AIFA (OsSC) and the CEC within 90 days. The final study 
report will be reported within 1 year of the end of the study. 
22. Adverse events  
According to Article 2 of Directive 2001/20/EC “adverse event” is defined as follows:  
‘Any untoward medical occurrence in a patient or clinical trial subject administered a medicinal 
product and which does not necessarily have a causal relationship with this treatment’. 
“An adverse event can therefore be any unfavourable and unintended sign (including an abnormal 
laboratory finding, for example), symptom or disease temporally associated with the use of a 
medicinal product, whether or not considered related to the medicinal product”. 
 
Adverse reactions  
An ‘adverse reaction’ is defined according to Article 2(n) of Directive 2001/20/EC as follows: 
“All untoward and unintended responses to an investigational medicinal product related to any dose 
administered”. 
The definition implies a reasonable possibility of a causal relationship between the event and the 
IMP. 
Serious Adverse Events/Reactions (SAEs/SARs) 
A ‘serious adverse event/reactions’ is defined in Article 2 of Directive 2001/20/EC as follows: 
“Any untoward medical occurrence or effect that at any dose results in death, is life-threatening, 
requires hospitalisation or prolongation of existing hospitalisation, results in persistent or significant 
disability or incapacity, or is a congenital anomaly or birth defect. 

PI Dr. R. A. Montone 
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These characteristics/consequences have to be considered at the time of the event. For 
example, regarding a life-threatening event, this refers to an event in which the subject was 
at risk of death at the time of the event; it does not refer to an event which hypothetically 
might have caused death if it were more severe”. 
Some medical events may jeopardise the subject or may require an intervention to prevent one of 
the above characteristics/consequences. Such events (hereinafter referred to as ‘important medical 
events’) should also be considered as ‘serious’ in accordance with the definition. Medical and 
scientific judgement should be exercised in deciding whether an event is ‘serious’ in accordance 
with these criteria. 
 
Reports of serious adverse events (SAEs) must be immediately notified to the PI of the 
Coordinating Center regardless of the attribution by the Investigator of a causal relationship with 
the product under study.  
The causal relationship with the product under study will be defined as follows: 
● related: after careful evaluation, a safe relationship emerges with the use of the product 
under study, 
● not related: due to causes not related to the product under study. 
Unexpected adverse reactions 
An unexpected adverse reaction is defined by the Article 2(p) of Directive 2001/20/EC as follows:  
“An adverse reaction, the nature or severity of which is not consistent with the applicable product 
information (e.g. investigator’s brochure for an unauthorised investigational product or summary of 
product characteristics for an authorised product)”. 
23. Management and reporting of Serious Adverse Events/Reactions  
Any adverse event will be assessed, for 
• 
seriousness, for serious adverse event and serious adverse reaction qualification, 

PI Dr. R. A. Montone 
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Title: PROMISE study 
 
32 
 
• 
relatedness with the study drug (related/unrelated), for suspected adverse reaction, 
qualification  
• 
expectedness, referring to safety reference document, and as per protocol, for suspected 
unexpected adverse drug reaction - SUSAR identification.  
In accordance with Article 16 of Directive 2001/20/EC the investigator is responsible for reporting 
to PI of the Coordinating Centre all serious adverse events in relation to subjects treated by him in 
the clinical trial as it reads as follows:  
“The investigator shall report all serious adverse events immediately to the sponsor except for those 
that the protocol or investigator’s brochure identifies as not requiring immediate reporting.”. 
Moreover, any related or possibly related or unrelated Serious Adverse Events occurring during the 
clinical study should be immediately reported to the PI of the study coordinating center within a 24 
hours following knowledge of the serious adverse event. Immediate reporting should allow to take 
the appropriate measures to address potential new risks in a clinical trial. The Investigator will 
always provide an assessment of causality between the experimental drug/event. It is mandatory for 
the Principal Investigator (and/or designees) to notify fatal events to the applicable EC. 
The communication must be sent via email using the Serious Adverse Events form from the 
investigators involved in the study. 
The form must be sent via email to the following recipient: 
• Attention of Dr. Rocco Antonio Montone: email: promise.trial@policlinicogemelli.it  
It will be the responsibility of the PI of the coordinating center of the study to follow up on the 
report by completing and sending the following forms to the Ethics Committees: 
● INITIAL SAE REPORT from SAE occurred during the study to the Ethics Committees 
involved (included in the Investigator's Study File); 
● Follow-up REPORT on additional information from the Center to the PI of the coordinating 
center and from this to the Ethics Committees involved (included in the Investigator's Study 
File); 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
33 
 
● FINAL REPORT on the final and conclusive information to the Ministry from the Center to 
the PI of the Health Coordinating Center (AC) and to the Ethics Committees involved 
(included in the Investigator's Study File). 
 
Serious unexpected adverse drug reactions (SUSAR) will be reported to the Competent Authorities, 
via Eudravigilance and the Ethical Committee within 7 days for fatal and life-threating SUSAR, 15 
days for other SUSARs.  
 
All serious adverse events, serious adverse reactions and SUSARs will be presented as listing and a 
Developmental Safety Annual Report – DSUR will be issued annually from the study approval lock 
date to AIFA (Agenzia Italiana del Farmaco) and to the applicable Ethics Committees.  
RISK AND BENEFIT OF THE STUDY PROTOCOL 
The study involves risks of possible adverse events related to the pharmacological therapies 
administrated and the interventional procedure performed, which, however, are addressed in an expert 
and high-volume center (e.g. risks related to coronary angiography procedure, OCT or acetylcholine 
provocative test for patients randomized to “precision-medicine approach ”,CMR, transesophageal 
echocardiography or transthoracic echocardiography with contrast medium, which however do not 
expose to ionizing radiation, venous blood draw which could lead to discomfort, pain or small bruises 
at the puncture site). However, with this prospectively designed trial, we have the opportunity to test 
the prognostic value of a targeted therapeutic approach based on the identification of the underlying 
cause. Of importance, the results deriving from our trial may open the way for a new pathophysiology-
driven approach with cause-target therapies personalized for the mechanism of MINOCA. Therefore, 
we retain that the benefits of a precision-medicine approach for the treatment of MINOCA will 
outweigh all the possible risks associated with this clinical study”. 
 
ETHICAL CONSIDERATIONS AND RESULTS SHARING 
The study will be conducted in 3centers in Italy. The authorization by AIFA (OsSC), competent 
authority on the matter, the single opinion expressed by the coordinating center and the opinions 
expressed by the respective ethics committees of the clinical centers involved regarding the conduct 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
34 
 
of the study will be transmitted, in writing and complete, in all their parts, to the Investigator before 
the start of the study. 
24. Research Ethical Approval 
 Competent Ethical Committee (CEC): The investigator/ PI responsible for each participating 
center ensures that the institutional ethics committee has provided a favorable opinion. No changes 
to the protocol will be made without the prior approval of the Investigator, authorization from AIFA 
(OsSC) and from the Ethics Committee of the coordinating center and subsequently by the other 
CECs of the centers involved, except when it is necessary to prevent apparently immediate risk to 
study participants. In this case, to prevent any serious risk for the patient, the modification to the 
protocol can be implemented immediately but at the same time submitted to AIFA (OsSC) and to the 
coordinating EC and to the other ECs involved. Premature interruption of the study must be reported 
within 15 days. The regular term of the study will be communicated to AIFA (OsSC) and the CEC 
within 90 days. The final study report will be reported within 1 year of the end of the study. 
Competent authorities: The approval of the Italian Medicines Agency (AIFA-OsSC) will be 
obtained before the start of the clinical trial. Severe and unexpected adverse reactions (SAEs), related 
to the use of the study drugs, are subject to rapid reporting. They will be communicated to the 
competent authorities by the PI of the clinical site to the PI of the coordinating Clinical Center from 
the study (s) to the Minister of Health (CA) and to all CEs, where necessary. All other events will be 
reported in the annual safety report. The description and seriousness of the events, anticipated or not, 
the causal association and the dosage will be included in the report. Reactions to fatal or life-
threatening drugs will be reported as soon as possible, but no later than 7 calendar days. All the others, 
however, no later than 15 calendar days. The regular term of the study will be reported to the 
authorities within 90 days and the final report submitted within 1 year of the end of the study. 
Ethical conduct of the study: The study will be conducted in accordance with the protocol and 
principles set out in the latest available version of the Declaration of Helsinki, in the latest version 
available guidelines of Good Clinical practice (GCP) issued by the ICH, in the latest updates of 
national laws / regulations and respecting the dictates of the Italian competent authority. The CEC 
and regulatory authorities will receive periodic and annual safety reports and will be informed about 
the interruption / suspension of the study in accordance with local requirements. 
25. Amendments to the Protocol 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
35 
 
The investigator (Dr. Montone) is authorized to make amendments to the protocol. The PIs of each 
site are allowed to make suggestions for any amendments. Important changes to the protocol (eg 
change of eligibility criteria, outcomes, statistical analysis) will be communicated within 5 days to 
the parties involved (investigators, competent authorities (AIFA-OsSC) and CEC, study participants, 
online registers, regulatory authorities). Substantial amendments will only be implemented after 
approval by the CEC and the competent authority. In emergency conditions, deviations from the 
protocol to protect the rights, safety and well-being of participants may be made without the prior 
approval of the sponsor or the CEC / CEA. Such deviations must be documented and promptly 
reported to the sponsor, AIFA-OsSC and the CEA. All non-substantial amendments will be 
communicated to AIFA-OsSC as soon as possible and to the CEC in the context of the Development 
Safety Update Report (DSUR). 
26. Patient Information and Informed Consent and Consent to the Processing of Personal Data 
The PIs of each clinical site will explain to patients the nature of the study, its rationale, the procedures 
involved, the duration, the potential risks and benefits, and any possible inconvenience both orally 
and by means of a written form (Patient Information: Each patient will be informed about the 
voluntary participation in the study and the possibility, at any time, to withdraw from the study 
without incurring any deterioration in the quality of medical assistance and treatments. The patient's 
data will be anonymized after the withdrawal of informed consent and the patient will be informed 
about any alternative treatments. Patients should be informed that other authorized individuals, in 
addition to their doctor, may review their personal data and will issue a consent to the processing of 
personal data in this regard. All study participants will be provided with sufficient information to 
make an informed decision about participating in the study. They will be given the opportunity to 
discuss treatment options and participation in the study with relatives or other trusted persons. The 
patient information sheet, the consent form and the consent form for the processing of personal data 
will be submitted to the respective CEC and the competent authorities (OsSC) for review and 
approval. The participant's formal consent, accompanied by the appropriate approved forms, must be 
obtained before submitting the participant to any procedure. Participants should read and consider the 
information received before dating and signing the consent form and attached forms, a copy of which 
will be provided to them. The consent form and the attached forms will also be signed by the 
investigator (or his delegate) and will be kept in the official documents of the study. 
27. Confidentiality and Data Protection  
Direct access to the SD will be guaranteed for the purposes of monitoring, audits and inspections. 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
36 
 
The investigator supports and abides by the principle of the participant's right to privacy and 
compliance with privacy regulations. In particular, the anonymity of the participants will be 
guaranteed if data is presented at scientific meetings or if they are published in scientific journals. 
The medical information obtained as a result of the study is to be considered confidential and its 
disclosure to third parties is prohibited. Confidentiality will be further guaranteed by the use of 
identification codes of the subjects to be matched to processing data in digital files. 
For verification purposes, relevant agencies (AIFA-OsSC), or CECs may request access to parts of 
the clinical records relevant to the study, including the participants' medical history. 
28. Conflicts of Interest 
Investigators participating in the study must ensure that they have no agreement or no 
economic interest, direct or indirect, with the manufacturers of the study drugs. 
29. Audits and inspections  
Responsible ethics committees, sponsor and authorities have the right to inspect the practice 
and / or manufacturing sites at any time before, during and after clinical conduct. There will be no 
further audits beyond monitoring and inspections. The study documentation and Source Data (SD) 
will be accessible to auditors / inspectors (including CECs and CAs) and questions will be answered 
during the inspection. All parties involved must treat participant data as strictly confidential. 
Insurance 
The promoter will be responsible for providing insurance coverage for the study for all the enrolling 
sites. 
31. Publication Policy 
The steering committee and investigators undertake to publish and disseminate the study 
results. The PROMISE study is a multicenter, randomized study. All public submissions, manuscript 
generation and submission will be led by the PI, who will create and coordinate a publication 
committee. This study represents a shared effort between investigators and collaborators and, as such, 
the parties agree that any party's recommendations regarding the manuscript or text should be taken 
into account in preparing the final scientific paper for submission or publication. The final database 
will be kept at the University of Sacred Heart, Rome, which will not release data or material relevant 
to the study without the permission of the PI. All PIs will be on the list of co-authors on all abstracts 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
37 
 
and publications. Therefore, their adherence to the publication is required. Publication and / or 
submissions based on single clinical site data are not permitted until the results of the multicenter 
study are published. All data from individual sites will need to be generated from the central database 
- local databases are not allowed. All proposals for publications and presentations deriving from or 
related to the study must be submitted to the Steering Committee for review and approval prior to 
submission for presentation or publication. The Steering Committee will receive the material of each 
submission / publication proposal prior to submission / submission, in time to be reviewed by all 
parties. 
 
32. Informed consensus  
See the files attached. 
All patients must date and sign informed consent first to enter the studio and before any activity 
related to experimentation.  
In case of amendments that could directly affect the continued participation in the trial by the person, 
further consent must be obtained from the same. 
 
33. Management of biological materials 
Blood sample collection: 42 mL venous blood samples will be collected at the time of coronary 
angiography or within 12 hours from coronary angiography. Biochemical profile for evaluating the 
expression of Endothelin-1 (ET-1) and Neuropeptide Y (NPY), C-Reactive Protein (CRP), soluble 
CD40 ligand (sCD40L) will performed on plasma and serum samples at baseline with ELISA kit. 
Peripheral blood mononuclear cells (PBMC) will be isolated from EDTA blood by density gradient 
centrifugation. Serum and PBMC expression levels for deregulated miRNAs will be performed on 
the same samples to test circulating levels of miR-16, miR-26a, miR-145, miR-222, miR-155-5p, 
miR-483-5p and miR-451a with Serum microRNA microarray commercial kit. Coded plasma, serum 
and PBMC samples will be stored at -80°C at FPG XBiogem Biobanc. 
All experiments and analysis will be performed at the “Cellular and molecular cardiology laboratory” 
of the Department of Cardiovascular Science. Coded plasma, serum and PBMC sample from patients 
enrolled in the other centers (Centro Cardiologico Monzino IRCCS and IRCCS Policlinico San 

PI Dr. R. A. Montone 
Protocol v.3 06/05/2021 
Title: PROMISE study 
 
38 
 
Donato) will be collected with the same protocol for procedure standardization and will be shipped 
to our Unit. 
 
34. Ethical considerations:  
The trial will be conducted in accordance with the protocol designed for ensure adherence to Good 
Clinical Practice as indicated in the attachments:  
  ICH Harmonized Tripartite Guidelines for Good Clinical Practice, 1996. Note for Guidance on 
Good Clinical Practice CPMP / ICH / 135/95  
  EU Directive 2001/20 / EC, 2005/28 / EC  
  Declaration of Helsinki (1964, and its amendments and clarifications).  
The PI, or his delegate, accepts, by signing the protocol, to respect as reported. 
 
35. References 
1. Tamis-Holland JE, Jneid H, Reynolds HR, et al. Contemporary Diagnosis and 
Management of Patients With Myocardial Infarction in the Absence of Obstructive 
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36. Study Promoter: IRCCS Fondazione Policlinico Universitario A. Gemelli  
Principal Investigator Site: Fondazione Policlinico Universitario Agostino Gemelli (FPG-IRCCS); 
Largo Francesco Vito, n. 1 – 00168 – Roma. 
Other investigator sites involved in the study: 
o IRCCS Centro Cardiologico Monzino: 
Principal Investigator: Dr. Nicola Cosentino nicola.cosentino@cardiologicomonzino.it 
Via Carlo Parea, 4 – 20138 Milano (MI) 
o IRCCS Policlinico San Donato: 
Principal Investigator: Dr. Mario Bollati  mario.bollati@gmail.com  

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      Piazza Edmondo Malan, 2 – 20097 San Donato Milanese (MI)