Overall Changes of the Universal Myocardial Infarction Definition

Transcription

1 Overall Changes of the Universal Myocardial Infarction Definition Professor Kristian Thygesen, FESC, FACC, FAHA Aarhus University Hospital, Aarhus, DK Co-Chairman of The Global MI Task Force

2 Declaration of interest 2011/12 Research Projects sponsored by Danish Heart Foundation TRYG Fonden Roche Diagnostics Event Adjudication in Studies sponsored by St. Jude Edwards Lifesciences Roche Pharma Servier CERC The Medicines Company Danish Heart Foundation Aarhus University Hospital Research Fund

3 Changing Criteria for Definition of Myocardial Infarction Primarily ECG approach Primarily Biomarker Approach First WHO Def Fifth WHO Def WHO Monica Def ESC-ACC Redef Univ MI Def Third Univ MI Def

4 Universal Definition of Myocardial Infarction Consensus Documents

5 Definition of Myocardial Infarction Pathology Acute myocardial infarction is defined as myocardial cell death due to prolonged myocardial ischemia

6 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 99 th percentile upper reference limit and with at least one of the following: Ischemic symptoms ECG changes of new ischemia (new ST-T changes or new LBBB) Development of pathologic Q waves in the ECG Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Identification of an intracoronary thrombus by angiography or autopsy

7 Biomarkers for Detection of Myocardial Infarction Preferably Detection of rise and/or fall of cardiac Troponin (I or T) with at least one value above the 99 th percentile of the upper reference limit measured with a coefficient of variation 10% When cardiactroponin is not available Detection of rise and/or fall of CKMB mass with at least one value above the 99 th percentile of the upper reference limit measured with a coefficient of variation 10%

8 Elevations of Cardiac Troponin Values because of Myocardial Injury Injury related to primary myocardial ischemia (MI type 1) Injury related to supply/demand imbalance of myocardial ischemia (MI type 2) Injury not related to myocardial ischemia Multifactorial or indeterminate myocardial injury

9 Elevations of Cardiac Troponin Values because of Myocardial Injury

10 Tachy-/bradyarrhythmia Cardiac procedure Non-cardiac major procedure Heart failure Myocardial Infarction MIM Myocardial Injury Renal failure Myocardial injury with cell death marked by cardiac troponin elevation Clinical evidence of acute myocardial ischemia with rise and/or fall of cardiac troponin

11 Myocardial Infarction Type 1 Spontaneous myocardial infarction related to atherosclerotic plaque rupture, fissuring, or dissection with resulting intraluminal thrombus in one or more coronary arteries leading to decreased myocardial blood flow with ensuing myocyte necrosis

12 Myocardial Infarction Type 2 Myocardial infarction where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, e.g. coronary artery spasm, tachy-/brady-arrhythmia, anaemia, respiratory failure, hypotension or hypertension

13 Differentiation between MI Types 1 and 2 according to the Condition of the Coronary Arteries Plaque rupture with thrombus MI Type 1 Vasospasm or endothelial dysfunction Fixed atherosclerosis and supply-demand imbalance MI Type 2 MI Type 2 Supply-demand imbalance alone MI Type 2

14 Myocardial Infarction Type 3 Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes or new LBBB but death occurring before blood samples could be obtained or before cardiac biomarkers could rise

15 Myocardial Infarction Type 4a PCI-related MI is defined by elevation of cardiac troponin values >5 X 99 th percentile URL. In addition, either (i) symptoms suggestive of myocardial ischemia or (ii) new ischaemic ECG changes or (iii) angiographic findings consistent with a procedural complication or (iv) imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality R

16 Myocardial Infarction Type 4b Myocardial infarction related to stent-thrombosis is detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarkers with at least one value >99 th percentile URL R

17 Myocardial Infarction Type 5 CABG-related MI is defined by elevation of cardiac troponin values >10 X 99 th percentile URL. In addition, either (i) new pathological Q waves or new LBBB, or (ii) angiographic documented new graft or new native coronary artery occlusion, or (iii) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

18 ST Segment Elevation Criteria New ST elevation at the J point in 2 contiguous leads with the following cut-points: 0.1 mv in all leads except leads V 2 V 3 in men and women In leads V 2 -V 3, 0.2 mv in men 40 years and 0.25 mv in men <40 years In leads V 2 -V 3, 0.15 mv in women Age and gender specific

19 Non-ST Segment Elevation Criteria New horizontal or down-sloping ST segment depression 0.05 mv in 2 contiguous leads OR T inversion 0.1 mv in 2 contiguous leads with prominent R wave or R/S ratio >1

20 ECG Criteria for Prior Myocardial Infarction Any Q wave 0.02 sec or QS complex in leads V 2 -V 3, or Q wave 0.03 sec and 0.1 mv deep or QS complex in leads I, II, avl, avf or V 4 V 6 in any 2 leads of a contiguous lead grouping (I, avl; V 1 V 6 ; II, III, avf), or R wave 0.04 sec in V 1 V 2 and R/S 1 with a concordant positive T wave

21 Imaging Evidence of Acute Myocardial Infarction Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in the presence of elevated cardiac troponin values and in the absence of non-ischemic causes

22 Tabulation of MI Types with Multiples of 99 th Percentile of Troponin Values

23 Definition of Myocardial Infarction Special Categories Reinfarction An AMI that occurs 28 days of an incident or a recurrent MI is termed reinfarction Recurrent MI An AMI that occurs >28 days after an incident AMI is termed recurrent MI Silent MI Asymptomatic patients who develop new pathologic Q wave criteria for MI or reveal evidence of MI by cardiac imaging, that cannot be directly attributed to a coronary revascularization should be termed silent MI

24 Definition of Myocardial Infarction in various Settings Assessment of MI in patients undergoing cardiac procedures, e. g. TAVI, Mitral clip, Ablation of arrhythmias Myocardial infarction associated with noncardiac procedures Myocardial infarction in an intensive care unit Myocardial injury or infarction associated with heart failure

25 Third Universal Definition of Myocardial Infarction Simultaneous Publications European Heart Journal Circulation Journal of American College of Cardiology Nature Reviews Cardiology Global Heart Online 25 August 2012, hard copies October 2012

26 Compositions of the Global MI Task Force Executive Group K Thygesen DK JS Alpert US HD White NZ Global Perspective Group SC Smith US D Hu China J-L Lopez-Sendon ES RM Robertson US D Weaver US M Tendera PL AA Bove US AN Parkhomenko UA EJ Vasilieva RU S Mendis CH Heart Failure Group JL Januzzi US MS Nieminen FI M Gheorghiade US G Filippatos GR Biomarker Group AS Jaffe US HA Katus DE FS Apple US B Lindahl SE DA Morrow US Classification Group KA Fox UK D Atar NO LK Newby US M Galvani IT CW Hamm DE Trial Group PW Armstrong CA EM Antman US LC Wallentin SE EM Ohman US ML Simoons NL ECG Group B Chaitman US PM Clemmensen DK P Johanson SE H Hod IL Intervention Group BF Uretsky US PG Steg FR J-P Bassand FR W Wijns BE P Menasché FR J Ravkilde DK Imaging Group R Underwood UK JJ Bax NL R Bonow US F Pinto PT R Gibbons US Epidemiology Group RV Luepker US SP Fortmann US WD Rosamond US D Levy US D Wood UK