Universal Definition of MI

ESC/ACCF/AHA/WHF Expert Consensus Document

(2012) divides myocardial infarction into five
different subtypes:
ST Elevation Myocardial InfarctionSTEMIType I
Non-ST Elevation Myocardial InfarctionNSTEMIType I
Type II
Type III
Type IV
Type V
Review of ECG Interpretation
 Characteristics of STEMI (Type I)

Plaque rupture
Intraluminal coronary artery thrombus formation
Associated ECG changes
Spontaneous MI related to atherosclerotic plaque rupture,
ulceration, fissuring, erosion, or dissection with associated
thrombus leading to decreased distal flow and ensuing
myocyte necrosis.
This may be on occasion associated with non-occlusive
CAD
 STEMI on ECG

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 STEMI ECG Criteria

2 mm of ST segment elevation in 2
contiguous precordial leads in men (1.5 mm
for women)
1mm in other leads (2 contiguous)
An initial Q wave or abnormal R wave
develops over a period of several hours to
days.
Within the first 1-2 weeks (or less), the ST
segment gradually returns to the isoelectric
baseline, the R wave amplitude becomes
markedly reduced, and the Q wave deepens.
In addition, the T wave becomes inverted.
 STEMI ECG Criteria

In addition to patients with ST elevation on

the ECG, two other groups of patients with
an acute coronary syndrome are
considered to have an STEMI:
those with new or presumably new left bundle
branch block
those with a true posterior MI
An elevation in the concentration of
troponin or CK-MB is required for the
diagnosis of acute MI
 STEMI ECG Criteria

Anterior STEMI: ST elevation in the precordial

leads + I and aVL (LAD territory)
Posterior STEMI: reciprocal ST depressions in
V1-V3 (ST elevation in post leads), may have
component of inferior ischemia as well (ST
elevations in II, III and aVF)
Often occurs w/ inferior MI (L Cx)
Inferior STEMI: ST elevation in II. III and aVF (+
ST elevation in R-sided precordial leads),
reciprocal changes in I and aVL (R coronary
or L Cx)
 STEMI

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 Characteristics of NSTEMI (Type I)

Evidence of necrosis consistent with acute ischemia

A rise and/or fall of cardiac enzyme (specifically
troponin I) plus any ONE of these findings meets MI
requirements:
Symptoms of ischemia
New (or presumed new) significant ST-segment/T-wave
changes OR a new LBBB
Pathological Q waves
Radiologic evidence of loss of viable myocardial tissue at
the cellular level OR new regional wall motion abnormality
Intracoronary thrombus by angiography or autopsy
Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., & White, H. D. (2012). Third universal
definition of myocardial infarction. Circulation, 126. pp. 2020-2035. doi 10.1161//cur,0b013e3182e1058
 Pathologic Q Waves

Any Q-wave in leads V2V3 0.02 s or QS complex

in leads V2 and V3

Q-wave 0.03 s and > 0.1 mV deep or QS complex

in leads I, II, aVL, aVF, or V4V6 in any two leads of a
contiguous lead grouping (I, aVL,V6; V4V6; II, III,
and aVF)

R-wave 0.04 s in V1V2 and R/S 1 with a

concordant positive T-wave in the absence of a
conduction defect
Pathologic Q Waves
 NSTEMI

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 NSTEMI (Type I)

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 Characteristics of Type II

Instance of myocardial injury with necrosis when a

condition other than CAD contributes to an imbalance
between myocardial oxygen supply and/or demand
Coronary endothelial dysfunction
Coronary artery spasm
Coronary embolism
Tachy-/brady-arrhythmias
Anemia
Respiratory failure
Hypotension
Hypertension with our without LVH
 Characteristics of Type III

Cardiac death with symptoms suggestive of

ischemia and presumed new EKG ischemic
changes or new LBBB

Death occurred before cardiac enzymes were

obtained or before the values had increased
 Characteristics of Type IVa

MI associated with PCI defined by an elevation of

cTn values of >5X 99th percntile URL in patients with
a normal baseline cTn
>20% if the baseline value is elevated and
are stable or falling in addition:
Symptoms of MI
New ECG changes or new LBBB
Aniographic evidence of loss of patency
Imaging demonstration loss of viable
myocardium or new regional wall motion
abnormality
 Characteristics of Type IVb

MI associated with stent thrombosis detected by

angiography or autopsy in the setting of MU with a
rise and or fall of cardiac enzymes
 Characteristics of Type V

MI associated with CABG

Defined by elevation of cardiac biomarker >10x
99th percentile URL in patents with normal baseline
values in addition:
New pathological Q waves or new LBBB
Angiographic evidence of new graft or new
native coronary artery occlusion
Imaging evidence of loss of viable myocardium
or new regional wall motion abnormality.
 Characteristics of Unstable Angina

The traditional term of unstable angina was

first used 3 decades ago and was meant to
signify the intermediate state between
myocardial infarction and the more chronic
state of stable angina.

Unstable angina is considered to be an

acute coronary syndrome in which there is
no release of the enzymes and biomarkers
of myocardial necrosis.
 Selecting the Appropriate Algorithm

STEMI preferred treatment in a center with PCI

capability:
PTCA with a target door to wire time <90 minutes.
Fibrinolics are an acceptable choice
Medical management for certain patient
populations

NSTEMI primary PCI is acceptable

Medical management is an acceptable choice
 Non-Pharmacologic Interventions

Percutaneous transluminal coronary angioplasty

(PTCA)

Intra-aortic balloon pump

Coronary artery bypass graft (CABG)

 Pharmacologic Interventions
STEMI
Fibrinolytics
Unfractionated heparin
Dual platelet inhibition
Beta blockade
ACE inhibition for LV dysfunction
Consideration of minerocorticoid receptor
antagonism for LV dysfunction, e.g. EF < 40%
Spironolactone or Inspra (epleronone)
Statin
Non-Pharmacologic Interventions NSTEMI

Percutaneous transluminal angioplasty

Coronary artery bypass grafting

 Pharmacologic Interventions
NSTEMI
Dual platelet inhibition
Aspirin and Plavix or other thienopyridine
Beta blockade
Nitrates
ACE inhibition for LV dysfunction
Consideration of minerocorticoid receptor
antagonism for LV dysfunction, e.g. EF < 40%
Spironolactone or Inspra (epleronone)
Statin
Fractionated or unfractionated heparin
 Treatment of USA

For all practical purposes, the treatment algorithm

for NSTEMI is appropriate for unstable angina