Implications of a new clinical classification of acute myocardial infarction

Figures

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  Figure 1. Alluvial plot illustrating the reclassification of patients with a diagnosis of Type 2 myocardial infarction into spontaneous and secondary myocardial infarction or no myocardial infarction. Patients with spontaneous myocardial infarction had evidence of acute coronary pathology (acute atherothrombosis, coronary embolism, spontaneous coronary dissection, and coronary vasospasm). Patients with secondary myocardial infarction had either evidence of obstructive coronary artery disease or functional consequences of myocardial injury with new left ventricular systolic impairment or evidence of infarct pattern late gadolinium enhancement on cardiac magnetic resonance imaging with or without regional wall motion abnormality. Two patients classified as no myocardial infarction had evidence of previous infarction with late gadolinium enhancement.

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  Figure 2. Case of spontaneous myocardial infarction (A), secondary myocardial infarction (B), and no myocardial infarction (C). (A) A 65-year-old patient with a recent diagnosis of atrial fibrillation and prior history of hypertension, Type 2 diabetes mellitus, and chronic obstructive pulmonary disease presented with chest pain at rest. They were found to be in sinus rhythm with ST-segment elevation across the anterior leads. Coronary angiography demonstrated abrupt occlusion of the left anterior descending artery, and thrombectomy was performed to restore coronary perfusion. Optical coherence tomography imaging demonstrated minimal atherosclerosis with no evidence of plaque rupture, and the patient was anticoagulated with apixaban. The peak cardiac troponin I concentration was 32 201 ng/L. Cardiac magnetic resonance imaging revealed near transmural late gadolinium enhancement in the mid-to-apical antero-septum with evidence of left ventricular systolic impairment (ejection fraction 48%). The final diagnosis was spontaneous myocardial infarction secondary to coronary embolism. (B) An 82-year-old patient with a history of angina and peripheral vascular disease presented with sudden onset…

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  Figure 3. Survival free from death, myocardial infarction, or heart failure hospitalization in patients with spontaneous and secondary myocardial infarction and those without myocardial infarction. Kaplan–Meier curves illustrating survival free from all-cause death, myocardial infarction, or hospitalization with heart failure in patients with a clinical diagnosis of Type 2 myocardial infarction reclassified following cardiac imaging as having spontaneous, secondary, or no myocardial infarction according to the new clinical classification.