Myocardial infarctionMyocardial infarction

New conceptsNew concepts

New definitionsNew definitions

Coronary Disease presentationsCoronary Disease presentations

AnginaAngina Myocardial infarctionMyocardial infarction Sudden cardiac deathSudden cardiac death

Coronary Disease presentationsCoronary Disease presentations

AnginaAnginastablestableunstableunstable

Myocardial infarctionMyocardial infarction Sudden cardiac deathSudden cardiac death

Coronary Disease presentationsCoronary Disease presentations

AnginaAnginastablestableunstableunstable

Myocardial infarctionMyocardial infarction‘full-thickness’, ‘transmural’, Q-wave‘full-thickness’, ‘transmural’, Q-wave‘partial-thickness’, subendocardial’‘partial-thickness’, subendocardial’

Sudden cardiac deathSudden cardiac death

Coronary Disease presentationsCoronary Disease presentations

AnginaAnginastablestableunstableunstable

Myocardial infarctionMyocardial infarctionSTEMISTEMINSTEMINSTEMI

Sudden cardiac deathSudden cardiac death

Acute Coronary SyndromeAcute Coronary Syndrome

No ST Elevation ST Elevation

Unstable Angina NQMI QMI

Traditional definition of MITraditional definition of MI

Symptoms of myocardial ischemiaSymptoms of myocardial ischemia Elevation of cardiac ‘enzymes’ in bloodElevation of cardiac ‘enzymes’ in blood Typical ECG patternsTypical ECG patterns

New definitions of MINew definitions of MI

Consensus document published in April 2000 Consensus document published in April 2000 by the American College of Cardiology and by the American College of Cardiology and the European Society of Cardiologythe European Society of Cardiology

Criteria for acute, evolving or recent MICriteria for acute, evolving or recent MI Criteria for established MICriteria for established MI

Acute, evolving or recent MIAcute, evolving or recent MI

Typical rise and fall of biochemical markers of Typical rise and fall of biochemical markers of myocardial necrosis, CK-MB or Troponin myocardial necrosis, CK-MB or Troponin associated with at least associated with at least oneone of the following of the followingischaemic symptomsischaemic symptomsnew pathological Q wavesnew pathological Q wavesECG changes indicative of ischaemiaECG changes indicative of ischaemiacoronary artery interventioncoronary artery intervention

oror Pathological findings of an acute MIPathological findings of an acute MI

Established MIEstablished MI

Development of new pathological Q waves in Development of new pathological Q waves in serial ECGsserial ECGs

oror Pathologic findings of a healed or healing MIPathologic findings of a healed or healing MI

Cardiac biomarkersCardiac biomarkers

CK-MBCK-MB Troponin T (or I)Troponin T (or I)

Total CK, LDH and ASAT all invalidTotal CK, LDH and ASAT all invalid

CK-MBCK-MB

Improved sensitivity over earlier enzyme Improved sensitivity over earlier enzyme estimationsestimations

All enzyme measurements have a background All enzyme measurements have a background level of ‘noise’ - ie. normal rangelevel of ‘noise’ - ie. normal range

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CK-MBCK-MB

Improved sensitivity over earlier enzyme Improved sensitivity over earlier enzyme estimationsestimations

All enzyme measurement have a background All enzyme measurement have a background level of ‘noise’ - ie. normal rangelevel of ‘noise’ - ie. normal range

11stst detected 2 - 3hrs post MI, and elevation detected 2 - 3hrs post MI, and elevation persists for 1 - 2 dayspersists for 1 - 2 days

TroponinTroponin

= a protein (not an enzyme)= a protein (not an enzyme) Troponin T and I (cardiac troponins) are Troponin T and I (cardiac troponins) are not not

detectable in the blood of healthy subjectsdetectable in the blood of healthy subjects Reliable lab test for T ; not for IReliable lab test for T ; not for I 11stst detectable 3 – 4 hrs post MI, and persists detectable 3 – 4 hrs post MI, and persists

for 7 – 14 daysfor 7 – 14 days Troponin T elevated (ie detectable) in Troponin T elevated (ie detectable) in

conditions other than acute infarctionconditions other than acute infarction

Secondary ischaemic cardiac injurySecondary ischaemic cardiac injury

Coronary interventionCoronary intervention Coronary artery spasmCoronary artery spasm Coronary artery Coronary artery

embolusembolus Coronary artery Coronary artery

inflammationinflammation Coronary artery Coronary artery

dissectiondissection Direct coronary artery Direct coronary artery

traumatrauma

SympathomimeticsSympathomimetics Pulmonary embolusPulmonary embolus End-stage renal failureEnd-stage renal failure Rhythm disturbancesRhythm disturbances Acute heart failureAcute heart failure Extreme endurance Extreme endurance

exerciseexercise

Non-ischaemic cardiac injuryNon-ischaemic cardiac injury

Myocarditis – multiple causesMyocarditis – multiple causes Cardiac traumaCardiac trauma

directdirectcardiac surgerycardiac surgery

Metabolic / toxicMetabolic / toxicrenal failurerenal failure

Clinical featuresClinical features

Spontaneous ischaemic episode, usually Spontaneous ischaemic episode, usually lasting > 20 minuteslasting > 20 minutes

Coronary artery interventionCoronary artery interventionangiography, angioplasty, stenting angiography, angioplasty, stenting

ECG features of myocardial ECG features of myocardial ischaemia that may ischaemia that may MIMI

New ST elevation in at least two contiguous New ST elevation in at least two contiguous leads, measuring >= 0.2mV in leads Vleads, measuring >= 0.2mV in leads V11 – V – V33, ,

or >= 0.1mV in all other leadsor >= 0.1mV in all other leads= STEMI= STEMI

Absence of ST elevation, but with either ST Absence of ST elevation, but with either ST depression or T wave abnormalitiesdepression or T wave abnormalities

= NSTEMI= NSTEMI

ECG features of established MIECG features of established MI

In absence of confoundersIn absence of confounders(LBBB, LVH, and WPW syndrome)(LBBB, LVH, and WPW syndrome)

any Q wave in Vany Q wave in V11 – V – V33,,

or Q waves of >= 1mm for >= 30msecor Q waves of >= 1mm for >= 30msec

in two other contiguous leadsin two other contiguous leads

Pathological Q wave

Normal Q wave

Normal ECG

ST elevation ST depression

Normal ST segment

pathologypathology

6 hours elapse before myocardial necrosis 6 hours elapse before myocardial necrosis becomes evident on histopathologybecomes evident on histopathology

Three phases – acute / healing / healedThree phases – acute / healing / healed Size – microscopic / small / medium / largeSize – microscopic / small / medium / large

imagingimaging

EchocardiographyEchocardiography Radionuclide angiographyRadionuclide angiography Single-photo emission computed tomographySingle-photo emission computed tomography

= SPECT= SPECT

Key points in the new definitions of Key points in the new definitions of myocardial infarctionmyocardial infarction

Any myocardial necrosis constitutes an Any myocardial necrosis constitutes an infarctioninfarction

Infarctions other than ‘spontaneous’ are Infarctions other than ‘spontaneous’ are includedincluded

Specific clinical situations Specific clinical situations not yet definednot yet defined

MI post-CABG, based on post-operative MI post-CABG, based on post-operative CK-MB or troponin levelsCK-MB or troponin levels

Threatened and aborted infarctionThreatened and aborted infarction Silent infarctionSilent infarction Sudden ischaemic cardiac deathSudden ischaemic cardiac death

Myocardial Infarction Redefined - A Consensus Document of the Joint European Society of Cardiology / American College of Cardiology Committee for the Redefinition of Myocardial Infarction

Journal of the American College of Cardiology

36:959-969 2000