New universal definition of myocardial infarction

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1 New universal definition of myocardial infarction L. K. Michalis, ΜRCP, FESC Professor of Cardiology, University of Ioannina

3 Changing Criteria for definition of MI Primarily clinical & ECG approach First WHO def Fifth WHO def WHO Monica def Primarily biomarker approach & emphasis on pathophysiology ESC /ACC Redef Univ MI Def Third Univ MI Def

4 Thygesen K et al. Eur Heart J 2012

5 Myocardial Infarction Prior myocardial infarction: the one scenario Sir, do you know that you have sustained a MI in the past? Acute myocardial infarction: the 4 more common scenarios Arriving in the A/E Dead on arrival or dead shortly after arrival During PCI MI related to a previous PCI During CABG

6 Concise Oxford Dictionary

7 Definition of Myocardial Infarction Myocardial infarction myocardial cell death due to prolonged myocardial ischemia

8 Acute myocardial infarction What we need in order to define it: Myocardial necrosis been verified by. Ischaemia, been verified by either: Symptoms ECG Imaging techniques Thrombus (angiography, autopsy)

9 Detection of myocardial necrosis Biochemistry Detection of sensitive and specific biomarkers in the blood: ctn CKMB

10 Biomarkers for detection of Myocardial Infarction Preferably troponin (I or T), >99 TH percentile When cardiac troponin is not available CKMB mass >99 TH The assays should have CV < 10% This is important in order to detect the rise or fall of the reported values

11 Detection of myocardial necrosis Biochemistry Detection of sensitive and specific biomarkers in the blood: ctn and if not available CKMB Can we stop here our attempt for definition? No, as ischaemia is not the only reason for myocardial necrosis Can we helped further by biochemistry? Yes, because myocardial necrosis due to ischaemia (MI) is related with increase / fall of the levels of the biomarkers

12 The whole spectrum of the condtions related with myocardial necrosis New

13 Elevations of Cardiac Troponin Values: The pathophysiology approach MI MI Not MI MI or simply necrosis?

14 It is recognized that the complexity of clinical circumstances may sometimes render it difficult to determine where individual cases may lie (with respect to myocardial infarction vs myocardial injury)

15 How ischaemia can cause MI? Not only in one way: So we have more than ones Types of MI

16 Universal Classification of Myocardial Infarction.

19 Differentiation between myocardial infarction (MI) types 1 and 2 according to the condition of the coronary arteries.

21 When do we say to the pt: Sir, I m sorry but you had a heart attact during PCI?

22 When do we say to the pt: Sir, I m sorry but your stent has been blocked? We need the MI (ischaemia & biochemisry) and the prove of the occluded stent

24 ECG and Myocardial Infarction Has it been forgotten altogether? Why ECG is important? Definition of Myocardial Infarction One of the essential means in order to diagnose ischaemia Tailor treatment ST elevation non ST elevation When do we need to get ECG? within 10 min post pt arrival many ECG in cases of chest pain tracking evolving changes post discharge time to intervention (arrhythmias, amount of ischaemia)

25 ECG Manifestations of Acute Myocardial Ischaemia. Thygesen K et al. Eur Heart J 2012

33 Definition of MI Special Categories Re-infarction Recurrent MI 28 days Silent MI Q / Imaging

35 *Evidence of ischaemia by symptoms and/or new electrocardiogram changes and/or new imaging corroboration. Thygesen K et al. Eur Heart J 2012;eurheartj.ehs154 Published on behalf of the European Society of Cardiology. change in cardiac troponin over time (δ)

36 Thank you

37 Common ECG Pitfalls in Diagnosing Myocardial Infarction. Thygesen K et al. Eur Heart J 2012

38 Criteria for Acute Myocardial Infarction detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin), with at least one value above the 99th percentile upper reference limit and with at least one of the following: Symptoms of ischemia New (or presumably new) significant ST/T changes or LBBB Development of pathological Q waves on ECG Imaging evidence of new loss of viable myocardium or regional wall motion abnormality Identification of intracoronary thrombus by angiography or autopsy

39 Tabulation in Clinical Trials of MI Types According to Multiples of the 99th Percentile Upper Reference Limit of the Applied Cardiac Biomarker. Thygesen K et al. Eur Heart J 2012

41 Defining the serum 99th percentile in a normal reference population measured by a highsensitivity cardiac troponin I assay Apple et al. Clin Biochem 2010 m Effect of Older Age on Diagnostic and Prognostic Performance of Highsensitivity Troponin T in Patients Presenting to an Emergency Department Normann J et al. Am Heart J 2012 f

43 Criteria for Acute Myocardial Infarction detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin), with at least one value above the 99th percentile upper reference limit and with at least one of the following: Symptoms of ischemia New (or presumably new) significant ST/T changes or LBBB Development of pathological Q waves on ECG Imaging evidence of new loss of viable myocardium or regional wall motion abnormality Identification of intracoronary thrombus by angiography or autopsy

The Universal Definition of Myocardial Infarction 3 rd revision, 2012

The Universal Definition of Myocardial Infarction 3 rd revision, 2012 Joseph S. Alpert, MD Professor of Medicine, University of Arizona College of Medicine, Tucson, AZ; Editor-in-Chief, American Journal