Third universal definition of myocardial infarction

Abbreviations and acronyms Definition of myocardial infarction Criteria for acute myocardial infarction Criteria for prior myocardial infarction Introduction Pathological characteristics of myocardial ischaemia and infarction Biomarker detection of myocardial injury with necrosis Clinical features of myocardial ischaemia and infarction Clinical classification of myocardial infarction Spontaneous myocardial infarction (MI type 1) Myocardial infarction secondary to an ischaemic imbalance (MI type 2) Cardiac death due to myocardial infarction (MI type 3) Myocardial infarction associated with revascularization procedures (MI types 4 and 5) Electrocardiographic detection of myocardial infarction Prior myocardial infarction Silent myocardial infarction Conditions that confound the ECG diagnosis of myocardial infarction Imaging techniques Echocardiography Radionuclide imaging Magnetic resonance imaging Computed tomography Applying imaging in acute myocardial infarction Applying imaging in late presentation of myocardial infarction 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 programmes Public policy implications of the adjustment of the MI definition Global perspectives of the definition of myocardial infarction Conflicts of interest Acknowledgements References American College of Cardiology Foundation acute coronary syndrome American Heart Association coronary artery disease coronary artery bypass grafting creatine kinase MB isoform cardiac troponin computed tomography coefficient of variation electrocardiogram European Society of Cardiology fluorodeoxyglucose hour(s) heart failure left bundle branch block left ventricle left ventricular hypertrophy myocardial infarction meta-iodo-benzylguanidine minute(s) Multinational MONItoring of trends and determinants in CArdiovascular disease) myocardial perfusion scintigraphy magnetic resonance imaging millivolt(s) nanogram(s) per litre non-Q wave myocardial infarction non-ST-elevation myocardial infarction percutaneous coronary intervention positron emission tomography pictogram(s) per millilitre Q wave myocardial infarction right bundle branch block second(s) single photon emission computed tomography ST elevation myocardial infarction ST-segment –T wave upper reference limit World Heart Federation World Health Organization Myocardial infarction (MI) can be recognised by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology. It is a major cause of death and disability worldwide. MI may be the first manifestation of coronary artery disease (CAD) or it may occur, repeatedly, in patients with established disease. Information on MI rates can provide useful information regarding the burden of CAD within and across populations, especially if standardized data are collected in a manner that distinguishes between incident and recurrent events. From the epidemiological point of view, the incidence of MI in a population can be used as a proxy for the prevalence of CAD in that population. The term ‘myocardial infarction’ may have major psychological and legal implications for the individual and society. It is an indicator of one of the leading health problems in the world and it is an outcome measure in clinical trials, observational studies and quality assurance programmes. These studies and programmes require a precise and consistent definition of MI. In the past, a general consensus existed for the clinical syndrome designated as MI. In studies of disease prevalence, the World Health Organization (WHO) defined MI from symptoms, ECG abnormalities and cardiac enzymes. However, the development of ever more sensitive and myocardial tissue-specific cardiac biomarkers and more sensitive imaging techniques now allows for detection of very small amounts of myocardial injury or necrosis. Additionally, the management of patients with MI has significantly improved, resulting in less myocardial injury and necrosis, in spite of a similar clinical presentation. Moreover, it appears necessary to distinguish the various conditions which may cause MI, such as ‘spontaneous’ and ‘procedure-related’ MI. Accordingly, physicians, other healthcare providers and patients require an up-to-date definition of MI. In 2000, the First Global MI Task Force presented a new definition of MI, which implied that any necrosis in the setting of myocardial ischaemia should be labelled as MI.1 These principles were further refined by the Second Global MI Task Force, leading to the Universal Definition of Myocardial Infarction Consensus Document in 2007, which emphasized the different conditions which might lead to an MI.2 This document, endorsed by the European Society of Cardiology (ESC), the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), and the World Heart Federation (WHF), has been well accepted by the medical community and adopted by the However, the development of more sensitive for markers of myocardial necrosis further such necrosis in the setting of the percutaneous coronary procedures or cardiac The Global MI Task Force has the by and new data the document, which now that very small amounts of myocardial injury or necrosis can be by biochemical markers MI is defined in as myocardial death due to the of myocardial death is a of to as or less in It myocardial necrosis can be by or necrosis of myocardial or on the of to the ischaemic or coronary the of the to and individual for and The leading to a infarction may the and Myocardial injury is of sensitive and biomarkers such as or the MB of creatine kinase are Cardiac troponin and are of the of myocardial and are in the of biomarkers in the injury leading to necrosis of myocardial the have been for of from the including of myocardial of troponin and of and of the myocardial necrosis due to myocardial ischaemia is designated as MI. of myocardial injury with necrosis may be in clinical conditions associated with myocardial amounts of myocardial injury with necrosis may be which are associated with heart failure or percutaneous or coronary These should be labelled as MI or a of the as myocardial as in It is that the of clinical may it to individual may within the of In it is to distinguish acute of which require a of from that to of such clinical associated with elevated values of is presented in The resulting in the myocardial injury should be in the This various clinical for heart or cardiac or non-cardiac procedures that can be associated with myocardial injury with death by cardiac troponin However, can be associated with myocardial infarction in of clinical of acute myocardial ischaemia with of cardiac of cardiac troponin values of myocardial injury of cardiac troponin values of myocardial injury The and for of or which has myocardial as well as clinical of a of the is to the diagnosis of acute is defined as a the of a reference population reference limit This is designated as the for the diagnosis of MI and be for with quality in The values for the defined by including for of the in can be in the for the or in should be presented as per litre or per millilitre to Criteria for the of values are can be defined from the of individual including as by coefficient of variation the for should be defined as allows for more sensitive and the detection of The of that have the of a more cause with the should be It is that and problems can elevated and values of for the of should be on first and are if further ischaemic occur, or the of the is the diagnosis of MI, a in values with one the is with a The of a is to distinguish from in that are associated with heart patients with failure or can have in These can be as in patients with MI, However, a or is necessary to the diagnosis of MI if a with a of MI late for the of the or on the of that a can be may elevated for or more the of values may be for troponin elevated with or a of values or in the of clinical of should a for other associated with myocardial such as or failure and other more disease that can be associated with elevated are in a is the is by with an is defined as a the which is designated as the for the diagnosis of values should be of myocardial ischaemia is the in the development of MI and from an imbalance between and Myocardial ischaemia in a clinical setting can be from the and from the ischaemic various of upper or or or an ischaemic such as or The associated with acute MI the is by of the it may be by or However, are for myocardial Accordingly, may be and to or MI may with as or cardiac for in the or and of patients is especially is a of cardiac the of such as it is to MI in patients with or other ischaemic that ST elevation in ECG as an elevation In patients ST elevation presentation are designated as a elevation patients with MI Q wave elevated values can be as In to MI is various on clinical and with different Universal classification of myocardial infarction Universal classification of myocardial infarction This is an to or with resulting in one or more of the coronary leading to myocardial or with necrosis. The may have CAD on to or CAD may be in In of myocardial injury with necrosis, a other CAD to an imbalance between myocardial the term type is In or in patients undergoing major elevated values of cardiac biomarkers may due to the of or coronary have the to cause between myocardial infarction (MI) types and to the of the coronary cardiac with of myocardial ischaemia by new ischaemic ECG or new a These may for biomarkers can be or elevated cardiac biomarkers can be patients with clinical features of myocardial or with new ischaemic ECG should be as a MI, if cardiac of MI is myocardial injury or infarction may in the of the heart that is revascularization by PCI or by coronary artery bypass grafting values may be various may that can lead to myocardial injury with It is that of such injury is to the a for a to an of cardiac values in the of is well of MI are to and that may the The ECG is an of the of patients with MI and should be and within clinical in the ECG acute myocardial ischaemic require of if the ECG presentation is in patients with an ECG should be if ECG of an are an for a in patients with ECG a ECG should be as a for or in the and Q the to the to the to the of as well as and to ST-segment or wave is associated with a of myocardial ischaemia and a ECG associated with acute myocardial ischaemia cardiac and and of wave artery and of and of coronary and prior myocardial necrosis can ECG of myocardial the ECG presentation should be to prior ECG The ECG by is to acute myocardial ischaemia or ST may be in other such as acute left ventricular hypertrophy left bundle branch block and new ST-segment elevation associated with ST-segment acute coronary and in myocardial injury with necrosis. in Q may due to myocardial in the of ECG abnormalities of myocardial ischaemia or infarction may be in the the the ST-segment or the The of myocardial ischaemia are wave and ST-segment wave with in is an that may the elevation of the Q may be an of acute ischaemia or acute MI with wave criteria for the diagnosis of acute myocardial ischaemia that may or may lead to MI. The point is used to the of the ST-segment or point elevation is in other and In elevation can be as as in or it with require different for point elevation in in and is less in to lead such as or such as and the of the right ventricle and the ECG of acute myocardial ischaemia of and ECG of acute myocardial ischaemia of and The criteria in require that the ST be in or more of ST elevation in lead and in lead the criteria of in a However, and of ST in in in may a It should be acute myocardial ischaemia may ST-segment to the criteria in one lead have less the ST in a of ST or wave acute myocardial ischaemia or MI, a single may the more ECG that might be with ST elevation or Q in lead are more ST in the of myocardial ischaemia or as well as ECG should be in patients that with ischaemic and a Electrocardiographic of myocardial ischaemia in the of a left artery is and is the the left the left and the left of is in patients with clinical for acute ECG or ST-segment in of ST elevation is in is a ST elevation and should be used in ST in may be of myocardial ischaemia especially the wave is elevation is In patients with and right ventricular right and should be ST elevation in criteria for the an of acute of may acute myocardial or may in abnormalities and should be in the The diagnosis of MI is more in the of However, ST-segment elevation or a ECG may be to the of acute MI in In patients with right bundle branch block abnormalities in are it to the of ischaemia in new ST elevation or Q are myocardial ischaemia or infarction should be in Q or in the of are of a prior MI in patients with ischaemic heart of The of the ECG diagnosis for MI is Q in or lead the Q are associated with ST or wave in the the of MI is for Q and that are are of prior MI if by in the lead MI such as the and have been used in epidemiological studies and clinical ECG associated with prior myocardial infarction criteria are used for ECG associated with prior myocardial infarction criteria are used for patients new Q wave criteria for MI ECG or of MI by cardiac imaging, that be to a coronary revascularization should be In Q wave MI for of MI and were associated with a significantly lead or may in to be new Q or as to a prior the diagnosis of a new Q wave MI should be by a ECG with lead or by an imaging and by ischaemic in lead is Q wave and of the wave in lead is if the is between and Q wave may be in if the is between and Q are Q and of the in and or cardiac left right ventricular acute or may be associated with Q or in the of MI. ECG abnormalities that myocardial ischaemia or MI are presented in ECG in myocardial infarction ECG in myocardial infarction imaging in patients with or MI, in the diagnosis and of MI. The is that myocardial and ischaemia lead to a of including myocardial death and by imaging are myocardial and and the of on the of or used imaging techniques in acute and infarction are myocardial perfusion scintigraphy single photon emission computed tomography and magnetic resonance imaging emission tomography and computed tomography are less is in and of the techniques to a or myocardial and the techniques provide a of of the of the techniques provide of myocardial such as to by or myocardial by The of is the of cardiac and in myocardial and can of the and can be used to myocardial perfusion and and imaging of and have been that techniques have been in the setting of to be including the and and the and The of the techniques is that are the of the of the a for small of MI. The are of myocardial perfusion and the techniques of MI and perfusion imaging a of myocardial and techniques that are to the of MI imaging of meta-iodo-benzylguanidine imaging of in ventricular and refined of myocardial The of an of myocardial and it has similar to in acute MI. can be used to myocardial perfusion and the in that is associated with the of prior MI. These techniques have been used in the setting of acute and imaging of myocardial by is to small of MI. It is of in myocardial disease that can MI, such as is as a of left ventricle imaging as with late imaging by This is may be for and with clinical features that with of acute the is used of myocardial perfusion is Imaging techniques can be useful in the diagnosis of acute MI of to abnormalities or of in the of elevated cardiac for biomarkers have been or may have of new of myocardial in the of the criteria for MI. and have a very and acute imaging techniques are useful for and of patients with MI. However, if biomarkers have been and are an acute MI and the imaging myocardial and may be by acute MI or by one or more of other including prior MI, acute or such as and or can lead to of or the of imaging for acute MI is conditions can be and a new is or can be to have in the setting of other features of acute MI. Echocardiography an of of acute such as heart or It is the imaging of for of acute MI, including myocardial acute ventricular and secondary to or Radionuclide imaging can be used to the of that is by acute is the of with imaging a measure of a a measure of and the between the to the that has been In of late presentation MI, the of or in the of of MI. The and of late for the detection of myocardial has a very In the to distinguish between and other of a between ischaemic heart disease and other myocardial Imaging techniques are useful for a diagnosis of MI. The detection of or ischaemia ventricular of PCI or it is by or Myocardial injury with necrosis may from or in as coronary of a major coronary artery or a of or and of or may be and or of the of myocardial of myocardial necrosis have been by The of myocardial injury with necrosis can be by of cardiac biomarkers the further can be as myocardial injury if the is or if are or In patients with elevation of cardiac values the PCI are of myocardial In values of cardiac especially were associated with However, are PCI and the the the an is well and it is such a a single is it is to further are due to the or to the the In it appears that the is by the These more for the new troponin In patients undergoing PCI with of within of the of ischaemia as by or ischaemic ST or new Q or of a such as of of of a or or imaging of new of or new defined as MI This of values is on clinical and implications of the of MI. a is PCI and the the the is in the of or imaging term ‘myocardial should be the values are elevated and are or a of is for the diagnosis of a type MI, as with data PCI is MI are or have and elevation of cardiac values may have However, data are to of MI is as by and a of values as MI type In to the of in to the of the PCI the of to to and to distinguish in the of the various of MI in the clinical setting of appears to be a is of on clinical can lead to myocardial injury with necrosis. These myocardial from or of the coronary or ischaemia to cardiac to myocardial injury by or failure to of the that are by studies that necrosis in setting is and in the In patients with values any of cardiac values CABG myocardial necrosis, that an of is to be to an This has been in clinical studies and the CABG were associated with outcome has been values were elevated to the or of the the of biomarkers for an MI to a in a or in the setting of In the is elevated of values are biomarkers in MI in In of the on in patients with elevation of Task Force by that values the first from a In new Q or new or new or new coronary artery or imaging of new of or new should be as of a MI Cardiac is with CABG with bypass and with CABG to The is more for for the principles from the definition of MI should be for the definition of MI abnormalities are in patients cardiac new Q in different MI or 2) should be if associated with elevated cardiac new abnormalities or procedures such as or may cause myocardial injury with necrosis, by to the and by ischaemia from coronary or It is to the more the elevation of the the the data on that are criteria have been for the diagnosis of MI However, that is it appears to the criteria for MI as for of myocardial injury with necrosis, by of or of the The of the injury with necrosis can be by an elevation of values in should be labelled as MI. MI is the major in major non-cardiac and is associated with a patients have a MI ischaemic MI is as associated with as is of cardiac biomarkers in prior to and major is of in that of patients have the and have an elevation and a of values of myocardial of patients undergoing major non-cardiac the that of the in are by a imbalance between myocardial and a of with a of MI type However, one of MI patients and leading to in of such that is to MI type the that in the to clinical and is of values are in patients in the intensive care unit and are associated with of the disease may MI type due to CAD and myocardial patients may have elevated values of cardiac due to myocardial injury with necrosis by or from Moreover, in MI type may It is a for the for a with single or to on a of the has elevated and the from the clinical should be to to for CAD or heart disease is is defined as the first MI. features of MI in the first an incident is as a new for epidemiological characteristics of MI an incident MI, it is to be a recurrent The term is used for an acute MI that within of an or recurrent The ECG diagnosis of the MI may be by the ECG Reinfarction should be ST elevation or new Q in associated with ischaemic for or of the ST-segment be in myocardial and should lead to ST or are and should be used to In patients in is from clinical or the MI, an of is should be the is or the of the diagnosis of a or of the in the the is the criteria for new acute MI on the elevated of myocardial injury with necrosis, may be in patients with may be in patients with with a the in with more such as in MI type is an cause of should be in the of an acute values in a with the diagnosis of MI type and be in with MI type have been to elevated in patients with MI type may from coronary or MI type or and due to has been to as well as and may with and and the diagnosis of MI, the and of elevation in is accepted to be an of in acute and of and should be as In the of an or should be and ECG with the of or MI type as the In elevated values should be with a of for MI type if a of the are or if it is by ischaemic symptoms, new ischaemic ECG or of myocardial on artery may be such may be used to troponin coronary are a type MI or a for troponin may be the other coronary is the of a in of the is to a diagnosis of acute MI due to is it to the for the In further such as myocardial perfusion coronary or is to the cause of the However, it may be to the for such In clinical trials, MI may be an or an definition for MI is of for clinical it a standardized for and across different The definition of MI as an MI type and MI type characteristics in the MI is the This MI type might be designated as an type defined as coronary or a associated with a of values and other CAD of or of a coronary artery with In different MI have been as and between and with to the definition of MI used as an in clinical is of of the definition to an individual clinical may be in and should have a should that a data for the various types of MI and the of or other biomarkers of the may be as in This of trials and in clinical trials of MI types to of the upper reference limit of the cardiac MI myocardial PCI percutaneous coronary CABG coronary artery bypass values are of death are defined values the MI limit PCI or is defined as coronary or a associated with a of values and other CAD of or of a coronary artery with in clinical trials of MI types to of the upper reference limit of the cardiac MI myocardial PCI percutaneous coronary CABG coronary artery bypass values are of death are defined values the MI limit PCI or is defined as coronary or a associated with a of values and other CAD of or of a coronary artery with different may be including in clinical trials, it is to the This troponin values across different the of the In patients undergoing cardiac the incidence of MI may be used as a measure of that a consistent definition is by in the quality assurance be and to type of to a to the different across of the definition of MI has a of implications for as well as for or diagnosis is the for further and for the The of patients with a diagnosis is the for health care and policy and of the of clinical is to a and which is by The to the definition of MI in In the of the term ‘myocardial infarction’ has sensitive have been to the diagnosis of acute MI is a clinical diagnosis on symptoms, ECG and sensitive biochemical as well as information from various imaging It is to the type of MI as well as the of the and the of CAD and other a diagnosis of MI. The information the and to more the that the has an MI. The are that and can be of have been to the MI. The classification of the various other associated with MI should lead to a of the clinical for patients with the conditions that can lead to myocardial necrosis, with elevation of It should be that the of the definition of MI may be associated with for the patients and in of psychological as well as and The diagnosis is associated with implications as to health and disability In to be of the to be and be and healthcare should to the of the definition to physicians, other health care and the general disease is a health the burden and of CAD in is of clinical criteria and biomarkers to and to the health of the The definition of MI for has and the data are consistent are for and The in are for However, to trends it is to have consistent and to biomarkers or other criteria the of the of for In with cardiac biomarkers and imaging techniques may be in a and the of ECG may be In the that or other are for as The the of the Universal MI Definition in more in and problems in the different of the world in the diagnosis and of acute MI require It is that the between and be in of disease. The of the Task Force of the the the and the have in the of document, on and clinical and an and clinical of have are in with and or health providers such have The of is in the quality of and However, to with and health providers are on the for the Task and of were by the are very to the of the of the