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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
0
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120
1 3 5 7 9 11 13 15 17 19 21 23 25 27
Series1
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1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55
Series1
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1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55
Series1
Series2
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