3/26/2014

Third Universal Definition of Myocardial Infarction: Clinical Classification of Myocardial Infarction

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Third Universal Definition of Myocardial Infarction

Kristian Thygesen, Joseph S. Alpert, Allan S. Jaffe, M aarten L. Simoons, Bernard R. Chaitman, Harvey D. White J Am Coll Cardiol. 2012;60(16):1581-1598. Disclosures

Journal of the American College of Cardiology

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Third Universal Definition of Myocardial Infarction: Clinical Classification of Myocardial Infarction

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Abstract and Introduction Pathological Characteristics of Myocardial Ischemia and Infarction Biomarker Detection of Myocardial Injury With Necrosis Clinical Features of Myocardial Ischemia and Infarction Clinical Classification of Myocardial Infarction Electrocardiographic Detection of Myocardial Infarction Prior Myocardial Infarction Silent Myocardial Infarction Conditions That Confound the ECG Diagnosis of Myocardial Infarction Imaging Techniques Diagnostic Criteria for Myocardial Infarction With PCI (MI Type 4) Diagnostic Criteria for Myocardial Infarction With CABG (MI Type 5) Assessment of MI in Patients Undergoing Other Cardiac Procedures Myocardial Infarction Associated With Non-cardiac Procedures Myocardial Infarction in the Intensive Care Unit Recurrent Myocardial Infarction Reinfarction Myocardial Injury or Infarction Associated With Heart Failure Application of MI in Clinical Trials and Quality Assurance Programs Public Policy Implications of the Adjustment of the MI Definition Global Perspectives of the Definition of Myocardial Infarction
References

Clinical Classification of Myocardial Infarction

For the sake of immediate treatment strategies, such as reperfusion therapy, it is usual practice to designate MI in patients with chest discomfort, or other ischemic symptoms that develop ST elevation in two contiguous leads (see ECG section), as an 'ST elevation MI' (STEMI). In contrast, patients without ST elevation at presentation are usually designated as having a 'non-ST elevation MI' (NSTEMI). Many patients with MI develop Q waves (Q wave MI), but others do not (non-Q MI). Patients without elevated biomarker values can be diagnosed as having unstable angina. In addition to these categories, MI is classified into various types, based on pathological, clinical and prognostic differences, along with different treatment strategies (Table 2).

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Spontaneous Myocardial Infarction (MI Type 1)

This is an event related to atherosclerotic plaque rupture, ulceration, fissuring, erosion, or dissection with resulting intraluminal thrombus in one or more of the coronary arteries, leading to decreased myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis. The patient may have underlying severe CAD but, on occasion (5 to 20%), nonobstructive or no CAD may be found at angiography, particularly in women.[23,24,25]

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Myocardial Infarction Secondary to an Ischemic Imbalance (MI Type 2)

In instances of myocardial injury with necrosis, where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, the term 'MI type 2' is employed (Figure 2). In critically ill patients, or in patients undergoing major (non-cardiac) surgery, elevated values of cardiac biomarkers may appear, due to the direct toxic effects of endogenous or exogenous high circulating catecholamine levels. Also coronary vasospasm and/or endothelial dysfunction have the potential to cause MI.[2628]
Figure 2. Differentiation between myocardial infarction (MI) types 1 and 2 according to the condition of the coronary arteries.
(Enlarge Image)

Cardiac Death Due to Myocardial Infarction (MI Type 3)

Patients who suffer cardiac death, with symptoms suggestive of myocardial ischemia accompanied by presumed new ischemic ECG changes or new LBBBbut without available biomarker valuesrepresent a challenging diagnostic group. These individuals may die before blood samples for biomarkers can be obtained, or before elevated cardiac biomarkers can be identified. If patients present with clinical features of myocardial ischemia, or with presumed new ischemic ECG changes, they should be classified as having had a fatal MI, even if cardiac biomarker evidence of MI is lacking.

Myocardial Infarction Associated With Revascularization Procedures (MI Types 4 and 5)

Periprocedural myocardial injury or infarction may occur at some stages in the instrumentation of the heart that is required during mechanical revascularization procedures, either by PCI or by coronary artery bypass grafting (CABG). Elevated cTn values may be detected following these procedures, since various insults may occur that can lead to myocardial injury with necrosis.[29-32] It is likely that limitation of such injury is beneficial to the patient: however, a threshold for a worsening prognosis, related to an asymptomatic increase of cardiac biomarker values in the absence of procedural complications, is not well defined.[3335] Subcategories of PCI-related MI are connected to stent thrombosis and restenosis that may happen after the primary procedure.

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Third Universal Definition of Myocardial Infarction: Clinical Classification of Myocardial Infarction

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J Am Coll Cardiol. 2012;60(16):1581-1598. 2012 Elsevier Science, Inc.

2006 American College of Cardiology

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