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| {{Infobox_Disease |
| | #redirect:[[ST elevation myocardial infarction diagnostic criteria#Modern Classification as to the Type of MI]] |
| Name = Myocardial infarction|
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| Image = Image15973.jpg|
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| Caption = Acute Myocardial infarction; Posterior wall. <br> [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]|
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| DiseasesDB = 8664 |
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| ICD10 = {{ICD10|I|21||i|20}}-{{ICD10|I|22||i|20}} |
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| ICD9 = {{ICD9|410}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000195 |
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| eMedicineSubj = med |
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| eMedicineTopic = 1567 |
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| eMedicine_mult = {{eMedicine2|emerg|327}} {{eMedicine2|ped|2520}} |
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| MeshID = |
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| }}
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| {{SI}}
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| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}
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| __NOTOC__
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| '''Associate Editor-In-Chief:''' {{CZ}}
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| ==Prior MI Classification Schemes==
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| There have been several prior classification schemes for characterizing MI:
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| 1. '''Transmural''' (necrosis of full thickness of ventricle) vs. '''non transmural''' (necrosis of partial thickness of ventricle)
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| 2. [[Q wave]] vs. '''non Q wave''': Based upon the development of electrocardiographic Q waves representing electrically inert tissue.
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| 3. [[ST elevation MI]] ([[STEMI]]) and [[Non ST elevation myocardial infarction]] ([[NSTEMI]])
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| At one time it was thought that Transmural MI and Q wave MI were synonymous. However, not all Q wave MIs are transmural, and not all transmural MIs are associated with Q waves.
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| Likewise, not all ST elevation [[MI]]s go on to cause [[q wave]]s. Non ST elevation MIs can result in [[q wave]]s.
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| Thus, ST elevation MI should not be equated with transmural MI or q wave MI. Likewise, Non ST elevation MI should not be equated with non transmural MI or non q wave MI. These 3 designations reflect three separate but overlapping characterization schemes.
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| ==New MI Clinical Classification System==
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| A new clinical evidence based classification system has been introduced by '''Thygesen K, Alpert JS, White HD, et al.''' and jointly sponsored by the American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology (ESC), and the World Heart Federation (WHF).<ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al''|title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007 |month=November |pmid=17951284|doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref>
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| ==Criteria for Diagnosis of Acute Myocardial Infarction==
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| The term myocardial infarction should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. Under these conditions any one of the following criteria meets the diagnosis for acute myocardial infarction. <ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al'' |title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007 |month=November |pmid=17951284 |doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref>
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| #Detection of rise and/or fall of cardiac biomarkers (preferably Troponin) with at least one of the following
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| #:a. Symptoms of [[ischemia]]
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| #:b. [[EKG]] changes indicative of ischemia as new ([[ST segment]] / [[T wave]] changes or new left bundle branch block [[LBBB]])
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| #:c. Development of pathological [[Q wave]]s
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| #:d. Imaging evidence of new viable myocardium or wall motion abnormality
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| #[[Sudden cardiac death|Sudden unexpected cardiac death]], including cardiac arrest, often with symptoms suggestive of myocardial [[ischemia]], accompanied by presumably new [[ST segment]] elevation, or new [[LBBB]], and/or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, if death has occurred before blood samples could be obtained, or at a time before the appearance of cardiac biomarkers in the blood
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| #In patients with normal baseline [[troponin]] values, a greater than 3 times increase above the 99th percentile of the upper limit of normal of cardiac biomarkers has been designated as the definition of [[PCI]] related myocardial infarction. A subtype related to documented stent thrombosis is recognized.
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| #For patients with [[CABG|CABG surgery]]; (In patients with normal baseline [[troponin]] values) increases of cardiac biomarkers greater than 5 times, (> 5 times the 99th percentile upper limit of normal) and either new [[Q wave|pathological Q waves]] or new [[LBBB]] or angiographically evidence of new graft or native vessel occlusion have been designated as defining [[CABG|CABG surgery]] related myocardial infarction. | |
| #Pathological findings of acute myocardial infarction.
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| ==Criteria for Prior Myocardial Infarction==
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| Any of the following criteria meets the diagnosis for prior myocardial infarction:<ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al'' |title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007 |month=November |pmid=17951284 |doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref>
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| *Development of new pathological [[Q wave]]s with or without symptoms
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| *Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract in the absence of a non ischemic cause.
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| *Pathological findings of healed or healing myocardial infarction.
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| ==Classification==
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| Clinically the various types of myocardial infarction can be classified as follow: <ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al'' |title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007 |month=November |pmid=17951284 |doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref>
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| #Spontaneous '''myocardial infarction''' related to [[ischemia]] due to a primary coronary event, such as plaque erosion and/or rupture, fissuring, or dissection.
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| #'''Myocardial infarction''' secondary to [[ischemia]] due to an imbalance of O<sub>2</sub> supply and demand, as from coronary spasm or [[embolism]], [[anemia]], [[arrhythmias]], [[hypertension]], or [[hypotension]]
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| #[[Sudden cardiac death|Sudden unexpected cardiac death]], including [[cardiac arrest]], often with symptoms suggesting [[ischemia]] with new [[STEMI|ST segment elevation]]; new [[left bundle branch block]]; or pathologic or angiographic evidence of fresh [[thrombus|coronary thrombus]] (in the absence of reliable biomarker findings)
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| #
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| #:a. '''Myocardial infarction''' associated with [[PCI|Percutaneous Coronary Interventions]] ([[PCI]])
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| #:b. '''Myocardial infarction''' associated with documented in stent thrombosis.
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| #'''Myocardial infarction''' associated with [[Cardiac surgery|Coronary Artery Bypass Graft surgery]]
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| ==Diagnostic Applications for Acute Myocardial Infarction==
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| ===Differential Diagnosis for [[EKG]] in Acute Myocardial Infarction===
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| Conditions that confound the EKG diagnosis of myocardial infarction are the following: <ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al'' |title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007 |month=November |pmid=17951284 |doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref>;
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| *A QS complex in lead V<sub>1</sub> is normal.
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| *A [[Q wave]] <0.03 s and <1/4 of the [[R wave]] amplitude in lead III is normal if the frontal [[QRS axis]] is between 30 and 0°.
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| *The [[Q wave]] may be normal in aVL if the frontal [[QRS axis]] is between 60 and 90°. Small septal [[Q wave]]s are non pathological [[Q wave]]s if <0.03 s and <1/4 of the [[R wave]] amplitude in leads I, aVL, aVF, and V<sub>4</sub>-V<sub>5</sub>-V<sub>6</sub>
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| *The following may be associated with Q/QS complexes in the absence of myocardial infarction:
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| :[[Wolff Parkinson White syndrome|Preexcitation syndromes]]
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| :[[Cardiomyopathy|Obstructive or dilated cardiomyopathy]]
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| :[[LBBB]]
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| :[[RBBB]]
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| :[[Left anterior fascicular block]]
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| :[[LVH]]
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| :[[RVH]]
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| :[[Myocarditis]]
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| :[[Cor pulmonale|Acute cor pulmonale]]
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| :[[Hyperkalemia]]
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| ===Diseases That May be Confused with Acute MI===
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| #Benign early repolarization (e.g. high take-off)
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| #[[Pericarditis]]
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| #[[LBBB]]
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| #[[Pulmonary embolism]]
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| #[[Myocarditis]]
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| #[[Brugada syndrome]]
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| #[[Wolff-Parkinson-White Syndrome|Preexcitation syndromes]]
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| #[[Subarachnoid hemorrhage]]
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| #[[Cholecystitis]]
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| #Electrolyte imbalance ([[hyperkalemia]])
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| #[[Lead placement errors|Lead misplacements]]
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| #Different lead configurations (e.g. modified Mason-Likar lead configurations)
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| #Misevaluation of [[J point]] variations
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| ==Evaluation of Biomarkers==
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| Myocardial cell death can be recognized by the appearance in the blood of different proteins released into the circulation from the damaged [[myocyte]]s: [[myoglobin]], cardiac [[troponin]] T ([[cTnT]]) and I ([[cTnI]]), [[CK]] ([[Creatine Kinase]]), [[LDH]] ([[Lactate Dehydrogenase]]), as well as many other enzyme markers of necrosis.<ref name="pmid10982533">{{cite journal |author=Jaffe AS, Ravkilde J, Roberts R, ''et al'' |title=It's time for a change to a troponin standard |journal=Circulation |volume=102 |issue=11 |pages=1216–20 |year=2000 |month=September |pmid=10982533 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=10982533}}</ref>
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| Myocardial infarction is diagnosed when blood levels of sensitive and specific biomarkers such as cardiac troponins (T and I) or CK-MB are increased in the clinical setting of acute myocardial ischemia. <ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al'' |title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007 |month=November |pmid=17951284 |doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref>
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| Although elevations in these biomarkers reflect myocardial necrosis, they do not indicate its mechanism. Thus, an elevated value of cardiac troponin in the absence of clinical evidence of ischemia should prompt a search for other etiologies of myocardial necrosis. <ref name="pmid17951284">{{cite journal |author=Thygesen K, Alpert JS, White HD, ''et al'' |title=Universal definition of myocardial infarction |journal=Circulation |volume=116 |issue=22 |pages=2634–53 |year=2007 |month=November |pmid=17951284 |doi=10.1161/CIRCULATIONAHA.107.187397 |url=}}</ref><ref name="pmid17384331">{{cite journal |author=Morrow DA, Cannon CP, Jesse RL, ''et al'' |title=National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Clinical characteristics and utilization of biochemical markers in acute coronary syndromes |journal=Circulation |volume=115 |issue=13 |pages=e356–75 |year=2007 |month=April |pmid=17384331 |doi=10.1161/CIRCULATIONAHA.107.182882 |url=}}</ref><ref name="pmid16814641">{{cite journal |author=Jaffe AS, Babuin L, Apple FS |title=Biomarkers in acute cardiac disease: the present and the future |journal=J. Am. Coll. Cardiol. |volume=48 |issue=1 |pages=1–11 |year=2006 |month=July |pmid=16814641 |doi=10.1016/j.jacc.2006.02.056 |url=}}</ref><ref name="pmid17084246">{{cite journal |author=Jaffe AS |title=Chasing troponin: how low can you go if you can see the rise? |journal=J. Am. Coll. Cardiol. |volume=48 |issue=9 |pages=1763–4 |year=2006 |month=November |pmid=17084246 |doi=10.1016/j.jacc.2006.08.006 |url=}}</ref><ref name="pmid17384332">{{cite journal |author=Apple FS, Jesse RL, Newby LK, Wu AH, Christenson RH |title=National Academy of Clinical Biochemistry and IFCC Committee for Standardization of Markers of Cardiac Damage Laboratory Medicine Practice Guidelines: Analytical issues for biochemical markers of acute coronary syndromes |journal=Circulation |volume=115 |issue=13 |pages=e352–5 |year=2007 |month=April |pmid=17384332 |doi=10.1161/CIRCULATIONAHA.107.182881 |url=}}</ref><ref name="pmid16556688">{{cite journal |author=Macrae AR, Kavsak PA, Lustig V, ''et al'' |title=Assessing the requirement for the 6-hour interval between specimens in the American Heart Association Classification of Myocardial Infarction in Epidemiology and Clinical Research Studies |journal=Clin. Chem. |volume=52 |issue=5 |pages=812–8 |year=2006 |month=May |pmid=16556688 |doi=10.1373/clinchem.2005.059550 |url=}}</ref>
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| ==Pathologic diagnosis of MI==
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| [[Image:Image15001.jpg|left|thumb|400px|Acute Myocardial infarction]]
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| <br clear="left"/>
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| [[Image:Image15533.jpg|left|thumb|400px|Myocardial infarction, fibrosis. Right Coronary Artery's territory]]
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| <br clear="left"/>
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| [[Image:Image15973.jpg|left|thumb|400px|Acute Myocardial infarction; Posterior wall]]
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| <br clear="left"/>
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| [[Image:Image15380.jpg|left|thumb|400px|Acute Myocardial infarction with PMNs]]
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| <br clear="left"/>
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| [[Image:Image15383.jpg|left|thumb|400px|Acute Myocardial infarction, coagulative necrosis]]
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| <br clear="left"/>
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| [[Image:Image917.JPG|left|thumb|400px|Gross example of myocardial infarction that is several weeks or perhaps months of age ]]
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| <br clear="left"/>
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| [[Image:Image918.JPG|left|thumb|400px|The same heart. Another view.]]
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| <br clear="left"/>
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| [[Image:Image919.JPG|left|thumb|400px|The same heart. Multi sliced view]]
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| <br clear="left"/>
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| [[Image:Image916.JPG|left|thumb|400px|The same heart. Microscopic view. H&E, medium magnification view of healing infarct.]]
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| <br clear="left"/>
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| [[Image:Image903.JPG|left|thumb|400px|Gross example of acute infarction in fixed heart. Lesion is reflow necrosis stone heart also has old scar ]]
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| <br clear="left"/>
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| [[Image:Image905.JPG|left|thumb|400px|Gross example of acute infarction in fixed heart. Lesion is reflow necrosis stone heart also has old scar. Multisliced view.]]
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| <br clear="left"/>
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| [[Image:Image15637.jpg|left|thumb|400px|Myocardial infarction, subacute phase.]]
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| <br clear="left"/>
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| [[Image:Image15644.jpg|left|thumb|400px|Myocardial infarction, subacute, granulation tissue.]]
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| <br clear="left"/>
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| [[Image:Image15645.jpg|left|thumb|400px|Myocardial infarction, subendocardial ischemia with swollen myocytes]]
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| <br clear="left"/>
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| [[Image:Image15646.jpg|left|thumb|400px|Myocardial infarction, mural thrombus]]
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| <br clear="left"/>
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| [[Image:Image15882.jpg|left|thumb|400px|Acute myocardial infarction, ischemic fibers demonstrated by aldehyde fuchsin stain]]
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| <br clear="left"/>
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| ==References==
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| {{Reflist|2}}
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| ==External links==
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| * [http://www.themdtv.org The MD TV: Comments on Hot Topics, State of the Art Presentations in Cardiovascular Medicine, Expert Reviews on Cardiovascular Research]
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| * [http://www.clinicaltrialresults.org Clinical Trial Results: An up to dated resource of Cardiovascular Research]
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| {{STEMI}}
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| [[tr:Akut miyokard enfarktüsünün klinik sınıflaması]]
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| [[Category:Emergency medicine]]
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| [[Category:Cardiology]]
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| [[Category:Intensive care medicine]]
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