Typ 2 Myokardinfarkt. Thomas Nestelberger. Kardiolunch USB
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1 Typ 2 Myokardinfarkt Thomas Nestelberger Kardiolunch USB
2 Content I. Patient case presentation II. III. IV. Universal Definition of Myocardial Infarction Impact of Coronary Artery Disease on T2MI Definition Differentiation between Type 1 and Type 2 Myocardial Infarction
3 Patient case presentation #1 32 year old woman Since 2 hours some kind of chest discomfort, palpitations and shortness of breath First episode with this duration, former episodse occured only for seconds to minutes No medical history, no medication Risk factors: none Secretary in pharmaceutical industry Vitals: BP 130/95mmHg, Puls 180/min, Oxy 98% Examination: normal
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5 Lab results: Routine Lab Values incl. TSH within normal range Hs-cTnT Values: 0h: 21ng/L 1h: 28ng/L Procedure? Valsalva Maneuver failed Conversion in ncsr after 6mg of Adenosin Discharge home, Follow-Up in Rhythmussprechstunde
6 Patient case presentation #2 72 year old man Since 2 weeks thoracic pressure getting worse with exertion, no radiation Dyspnea with exertion since 2-3 days NYHA II CABG in 2008 (LIMA-RIVA, SVG- RCX) Risk factors: arterial hypertension, hypercholesterolaemia, former smoker (stopped in 2008, 40 PJ) Medication: Aspirin, Concor, Ramipril, Simvastatin Stopped his medication 2-3 weeks before Vitals: BP 205/95mmHg, Puls 90/min, Oxy 96% Examination: normal
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8 Lab results: Routine Lab Values within normal range Hs-cTnT Values: 0h: 21ng/L 1h: 28ng/L Procedure? Cath Lab MPS next morning Discharge home and re-start medication
9 SDS Score = 0 9
10 Lab results Patient #1: Hs-cTnT Values: 0h: 21ng/L 1h: 28ng/L Lab results Patient #2: Hs-cTnT Values: 0h: 21ng/L 1h: 28ng/L Roffi M. et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, EHJ 2015
11 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent STsegment elevation When using any troponin algorithm, these algorithms should only be used in conjunction with all available clinical information, including detailed assessment of chest pain characteristics and ECG!» Roffi M. et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, EHJ 2015
12 Universal Definition of Myocardial Infarction Acute myocardial infarction is defined as myocardial cell death due to prolonged myocardial ischaemia Thygesen K and the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction Eur Heart J 2012;33:
13 Universal Definition of Myocardial Infarction Detection of a rise and/or fall of cardiac biomarker values (preferably cardiac tro ponins) with at least one value above the 99th percentile upper reference limit ( URL) and with at least one of the following: Ischaemic symptoms ECG changes of new ischaemia (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 moti on abnormality Identification of an intracoronary thrombus by angiography or autopsy Thygesen K and the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction Eur Heart J 2012;33:
14 Universal Definition of Myocardial Infarction Chapman AR, et al. Assessment and classification of patients with myocardial injury and infarction in clinical practice, Heart 2016
15 Type 2 Myocardial Infarction In instances of myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between oxygen supply and/or demand. Thygesen K and the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction Eur Heart J 2012;33:
16 Underlying Mechanisms for T2MI Thygesen K and the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction Eur Heart J 2012;33:
17 Underlying Mechanisms for Myocardial Injury Thygesen K and the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction Eur Heart J 2012;33:
18 Criteria for Type 2 MI based on a supposed Imbalance between Supply and Demand of Myocardial Oxygen Conditions with supposed decreased myocardial O2 supply: Anaemia in case of haemoglobin <5.5 mmol/l for men, and <5.0 mmol/l for wom en Shock with systolic BP <90 mmhg together with signs of organ dysfunction Respiratory failure with apao2 <8 kpa together with clinical signs lasting 20 min Conditions with supposed increased myocardial O2 demand: Ventricular tachyarrhythmia lasting 20 min Supraventricular tachyarrhythmia lasting 20 min with ventricular rate >150 bpm Arterial hypertension with systolic BP >160 mmhg and concomitant LVH Saaby L et al. Am J Med 2013; 126:
19 Underlying Mechanisms for T2MI Saaby L et al. Am J Med 2013; 126:
20 Underlying Mechanisms for T2MI Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
21 Proportion of T2MI in several cohorts Yader Sandoval and Kristian Thygesen; Clinical Chemistry 63: (2017)
22 Chapman AR, et al. Assessment and classification of patients with myocardial injury and infarction in clinical practice, Heart 2016
23 Universal Definition of Myocardial Infarction Chapman AR, et al. Assessment and classification of patients with myocardial injury and infarction in clinical practice, Heart 2016
24 Saaby L et al. Am J Med 2014; 127: Mortality
25 Mortality Sandoval et al. Cardiac troponin changes to distinguish type 1 and type 2 myocardial infarction and 180-day mortality risk. EHJ-ACCA 2014, Vol. 3(4)
26 Mortality Chapman et al. Long Term Outcomes in Patients with Type 2 Myocardial Infarction and Myocardial Injury Circulation 2017
27 Chapman et al. Long Term Outcomes in Patients with Type 2 Myocardial Infarction and Myocardial Injury Circulation 2017
28 A: Prevalence of coronary artery disease among patients with T2MI undergoing coronary angiography B: proportion of patients with T2MI undergoing coronary angiography Yader Sandoval and Kristian Thygesen; Clinical Chemistry 63: (2017)
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30 Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
31 T1MI vs. T2MI -> 86% vs. 14% T1MI vs. T2MI -> 70% vs. 30% Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
32 Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
33 Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
34 Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
35 Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
36 Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
37 Nestelberger T, Boeddinghaus J et al. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. JACC Sept. 2017
38 Score for Prediction of T2MI Neumann et al. Discrimination of patients with type 2 myocardial infarction, European Heart Journal (2017)
39 Nestelberger, Boeddinghaus et al. Early Differentiation of Type 1 versus Type 2 Myocardial Infarction under preparation
40 Score for Prediction of T2MI Neumann et al. Discrimination of patients with type 2 myocardial infarction, European Heart Journal (2017)
41 Score for Prediction of T2MI SCORE Characteristic Categories Points Yes 1 Female Sex No 0 Yes 1 No radiating chest pain No 0 Yes 1 Hs-cTnI 40.8ng/l No 0 Yes 1 Heart Rate >120/min No 0 Yes 1 No previous coronary artery d No 0 Nestelberger, Boeddinghaus et al. Early Differentiation of Type 1 versus Type 2 Myocardial Infarction under preparation
42 Diagnostic performance of hs-ctn Nestelberger, Boeddinghaus et al. Early Differentiation of Type 1 versus Type 2 Myocardial Infarction under preparation
43 Nestelberger, Boeddinghaus et al. Early Differentiation of Type 1 versus Type 2 Myocardial Infarction under preparation
44 Yader Sandoval and Kristian Thygesen; Clinical Chemistry 63: (2017)
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46 Quo Vadis? Coming Soon Fourth Universal Definition of Myocardial Infarction
47 Grosser Dank an das gesamte CRIB Team
48
49 Thank you very much for your attention! #CRIBasel #Thomas_Nest
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