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Third universal definition of myocardial infarction

Kristian Thygesen, Joseph S. Alpert, Allan S. Jaffe, Maarten L. Simoons, Bernard R. Chaitman, Harvey D. White, , , Kristian Thygesen, Joseph S. Alpert, Harvey D. White, , Allan S. Jaffe, Hugo A. Katus, Fred S. Apple, Bertil Lindahl, David A. Morrow, , Bernard R. Chaitman, Peter M. Clemmensen, Per Johanson, Hanoch Hod, , Richard Underwood, Jeroen J. Bax, Robert O. Bonow, Fausto Pinto, Raymond J. Gibbons, , Keith A. Fox, Dan Atar, L. Kristin Newby, Marcello Galvani, Christian W. Hamm, , Barry F. Uretsky, Ph. Gabriel Steg, William Wijns, Jean-Pierre Bassand, Phillippe Menasché, Jan Ravkilde, , E. Magnus Ohman, Elliott M. Antman, Lars C. Wallentin, Paul W. Armstrong, Maarten L. Simoons, , James L. Januzzi, Markku S. Nieminen, Mihai Gheorghiade, Gerasimos Filippatos, , Russell V. Luepker, Stephen P. Fortmann, Wayne D. Rosamond, Dan Levy, David Wood, , Sidney C. Smith, Dayi Hu, José-Luis Lopez-Sendon, Rose Marie Robertson, Douglas Weaver, Michal Tendera, Alfred A. Bove, Alexander N. Parkhomenko, Elena J. Vasilieva, Shanti Mendis, , Jeroen J. Bax, Helmut Baumgartner, Claudio Ceconi, Veronica Dean, Christi Deaton, Robert Fagard, Christian Funck-Brentano, David Hasdai, Arno Hoes, Paulus Kirchhof, Juhani Knuuti, Philippe Kolh, Theresa McDonagh, Cyril Moulin, Bogdan A. Popescu, Željko Reiner, Udo Sechtem, Per Anton Sirnes, Michal Tendera, Adam Torbicki, Alec Vahanian, Stephan Windecker, , Joao Morais, Carlos Aguiar, Wael Almahmeed, David O. Arnar, Fabio Barili, Kenneth D. Bloch, Ann F. Bolger, Hans Erik Bøtker, Biykem Bozkurt, Raffaele Bugiardini, Christopher Cannon, James de Lemos, Franz R. Eberli, Edgardo Escobar, Mark Hlatky, Stefan James, Karl B. Kern, David J. Moliterno, Christian Mueller, Aleksandar N. Neskovic, Burkert Mathias Pieske, Steven P. Schulman, Robert F. Storey, Kathryn A. Taubert, Pascal Vranckx, Daniel R. Wagner
DOI: http://dx.doi.org/10.1093/eurheartj/ehs184 First published online: 25 August 2012

Abbreviations and acronyms

ACCF
American College of Cardiology Foundation
ACS
acute coronary syndrome
AHA
American Heart Association
CAD
coronary artery disease
CABG
coronary artery bypass grafting
CKMB
creatine kinase MB isoform
cTn
cardiac troponin
CT
computed tomography
CV
coefficient of variation
ECG
electrocardiogram
ESC
European Society of Cardiology
FDG
fluorodeoxyglucose
h
hour(s)
HF
heart failure
LBBB
left bundle branch block
LV
left ventricle
LVH
left ventricular hypertrophy
MI
myocardial infarction
mIBG
meta-iodo-benzylguanidine
min
minute(s)
MONICA
Multinational MONItoring of trends and determinants in CArdiovascular disease)
MPS
myocardial perfusion scintigraphy
MRI
magnetic resonance imaging
mV
millivolt(s)
ng/L
nanogram(s) per litre
Non-Q MI
non-Q wave myocardial infarction
NSTEMI
non-ST-elevation myocardial infarction
PCI
percutaneous coronary intervention
PET
positron emission tomography
pg/mL
pictogram(s) per millilitre
Q wave MI
Q wave myocardial infarction
RBBB
right bundle branch block
sec
second(s)
SPECT
single photon emission computed tomography
STEMI
ST elevation myocardial infarction
ST–T
ST-segment –T wave
URL
upper reference limit
WHF
World Heart Federation
WHO
World Health Organization
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Introduction

Myocardial infarction (MI) can be recognised by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology. It is a major cause of death and disability worldwide. MI may be the first manifestation of coronary artery disease (CAD) or it may occur, repeatedly, in patients with established disease. Information on MI rates can provide useful information regarding the burden of CAD within and across populations, especially if standardized data are collected in a manner that distinguishes between incident and recurrent events. From the epidemiological point of view, the incidence of MI in a population can be used as a proxy for the prevalence of CAD in that population. The term ‘myocardial infarction’ may have major psychological and legal implications for the individual and society. It is an indicator of one of the leading health problems in the world and it is an outcome measure in clinical trials, observational studies and quality assurance programmes. These studies and programmes require a precise and consistent definition of MI.

In the past, a general consensus existed for the clinical syndrome designated as MI. In studies of disease prevalence, the World Health Organization (WHO) defined MI from symptoms, ECG abnormalities and cardiac enzymes. However, the development of ever more sensitive and myocardial tissue-specific cardiac biomarkers and more sensitive imaging techniques now allows for detection of very small amounts of myocardial injury or necrosis. Additionally, the management of patients with MI has significantly improved, resulting in less myocardial injury and necrosis, in spite of a similar clinical presentation. Moreover, it appears necessary to distinguish the various conditions which may cause MI, such as ‘spontaneous’ and ‘procedure-related’ MI. Accordingly, physicians, other healthcare providers and patients require an up-to-date definition of MI.

In 2000, …