4th Universal MIUniversal Definition of Myocardial infarction, 2018

1. 4th Universal MI
Universal Definition of Myocardial infarction, 2018
Dr. Han Naung Tun, MBBS, MD
ESC Clinical and Research Working Groups
ESC Representative of the Heart Failure Specialist of Tomorrow for Myanmar
(2018-2020)

3. Conflict of Interest
I have nothing to declare

4. History of definitions of MI
 In the late 19th century, post-mortem examinations showed a
possible relationship between thrombotic occlusion of CAD and MI
 In the 20th century, the first clinical descriptions appeared between
the formation of a thrombus in a coronary artery and its associated
clinical features .
 Over the years , 1950-70s, WHO established a primary ECG based
definition of MI

5. Epidemiological Approach Clinical Approach
ESC 2018

6. Myocardial Injury
 Evidence of elevated cardiac troponin values (cTn) with at least one
value above 99th percentile upper reference limit (URL)
 The myocardial injury is considered acute if there is a rise and/for fall
of cTn values
 Biomarker release is substantially dependent on blood flow, there is
significant variability in time to peak value

7. Very early
sampling
Early sampling Later sampling Very late sampling
Acute Myocardial
Infarct
Chronic myocardial
injury
99th percentile
URL
Cardiac Trop
(cTn)
Time from onset of symptoms (hours)

8. 4th Universal MI Definitions
 Type 1 MI - MI caused by CAD by atherosclerotic plaque
disruption(rupture or erosion).
 Type 2 MI - MI caused by ischemic myocardial injury in the context of a
mismatch between oxygen supply and demand.
 Type 3 MI - Patients who suffer cardiac death ,with symptoms of
myocardial ischemia accompanied by presumed new ischemic ECG
changes or Ventricular Fibrillation, but die before blood samples for
biomarkers can be obtained or before increased cardiac biomarkers can
be obtained.

9. Type 4 MI - MI associated with interventional procedures
Type 4a - MI associated with Percutaneous Coronary Intervention (PCI)
Type 4b - MI due to stent thrombosis
Type 4c - MI due to stent restenosis
Type 5 MI - MI associated with CABG

10. Type 1 MI - MI caused by CAD by atherosclerotic
plaque disruption(rupture or erosion)

11. Criteria for type 1 MI
 Detection of a rise and/or fall cTn with at least one value above the
99th percentile and with at least one of the following
Symptoms of acute MI;
New ischemic ECG changes;
Development of pathological Q wave;
Imaging evidence of new loss of viable myocardial or new regional wall motion
abnormality;
Identification of coronary thrombus by Angiography;

12. Myocardial Infarction type 1
Plaque rupture/erosion with non-
occlusive thrombus
Plaque rupture/erosion with occlusive
thrombus
NSTEMI>>>STEMIBentzon J.F., Otsuka F., Virmani R., Falk E. (2014) Mechanisms of
plaque formation and rupture. Circ Res 114:1852–1866.

13. Coronary angiography under PCI
Type 1 MI

14. Type 2 MI - MI caused by ischemic myocardial injury in
the context of a mismatch between oxygen supply and
demand

15. Criteria for type 2 MI
 Detection of a rise and/or fall of cTn with at least one value above
the 99th percentile URL, and evidence of an imbalance between
myocardial oxygen supply and demand unrelated to coronary
thrombosis, requiring at least one of the following
Symptoms of acute MI;
New ischemic ECG changes;
Development of pathological Q wave;
Imaging evidence of new loss of viable myocardial or new regional wall motion
abnormality;

16. Atherosclerosis and oxygen supply/ demand imbalance
Oxygen supply/ demand imbalance alone
Non-atherosclerotic coronary dissection
Vasospasm or coronary microvascular dysfunction
Myocardial Infarction type 2
Saw J., Mancini G.B., Humphries K.H. (2016) Contemporary review
on spontaneous coronary artery dissection. J Am Coll Cardiol

17. Normal Coronary Vasculature
MINOCA

18. What is MINOCA ?

19. Myocardial Infarction with Non-
obstructive Coronary Arteries (MINOCA)
 Universal AMI Criteria
 Non- obstructive coronary arteries on angiography, defined as
coronary artery stenosis < 50%
 No clinically specific cause

20. Myocardial necrosis +Plaque
disruption
Myocardial necrosis +Normal
coronaries or stable CAD
Type 1 MI Type 2 MI

21. Framework for type 2 myocardial infarction
Januzzi J.L., Sandoval Y. (2017) J Am Cardiol Coll 70:1569–
1572

22. Future ICD10 Code for
myocardial injury
Spectrum of Myocardial Injury, ranging from
no Injury to Myocardial Infarction
Myocardial Injury

23. A Model for interpreting Myocardial Injury

24. Cardiac Magnetic
Resonance Images
Gadolinium-based
contrasts wash out from
myocardium with
increased extracellular
space such as fibrosis,
thus enhancing areas of scar
(white arrows).
Kim HW, Faraneh-Far A , et alJ Am Coll Cardiol. 2009;55:1–
16.
Beek AM, et al. Heart. 2010;96:237–43

25. Type 3 MI - Patients who suffer cardiac death ,with
symptoms of myocardial ischemia accompanied by
presumed new ischemic ECG changes or Ventricular
Fibrillation, but die before blood samples for
biomarkers can be obtained or before increased
cardiac biomarkers can be obtained.

26. Criteria for type 3 MI
Patients who suffer cardiac death, with symptoms suggestive of
myocardial ischemia accompanied by presumed new ischaemic ECG
changes or ventricular fibrillation, but die before blood samples for
biomarkers can be obtained, or before increases in cardiac
biomarkers can be identified, or MI is detected by autopsy
examination.

27. Original investigations addressing the incidence of type 3 MI are
sparse, but a study showed an annual incidence below 10/100000
person-years and a frequency of 3 – 4% among all types of MI
Jangaard N., Sarkisian L., et al . Am J Med 130:862.e9–
862.e14.
frequency of 3 – 4%

28. Heart cross section at ventricle level; posterior portion
corresponds to upper part in photograph. Partially myocardial
infarct , limited by with arrows, is observed . Green arrows
indicate ventricular rupture in necrotic region

29. Type 4 MI - MI associated with interventional
procedures

30. Myocardial infarction associated with percutaneous coronary intervention
(type 4a myocardial infarction)
Stent/scaffold thrombosis associated with percutaneous coronary intervention
(type 4b myocardial infarction)
Restenosis associated with percutaneous coronary intervention (type 4c
myocardial infarction)

31. In patients with elevated pre-procedure cTn in whom the cTn
level are stable (≤20% variation) or falling, the post-procedure
cTn must rise by >20%. However, the absolute post-
procedural value must still be at least five times the 99th
percentile URL.
+
New ischemic
ECG changes
Development of
new pathological
Q waves
Imaging evidence of
new loss of viable
myocardium or new
regional wall motion
abnormality
one of the following elements is required:
flow-limiting complication
;coronary dissection,
occlusion of a major
epicardial artery or a side
branch
occlusion/thrombus,
disruption of collateral
flow, or distal embolization.
PCI-related MI ≤48 h after the index procedure (type 4a MI)

32. A subcategory of PCI-related MI is stent/scaffold thrombosis,
type 4b MI, as documented by angiography or autopsy using
the same criteria utilized for type 1 MI.
acute,0–
24h
subacute,
> 24 h to
30 days
late, > 30
days to 1
year
very late
> 1 year
Garcia-Garcia H.M., et al , Circulation 2018;137:2635–50
Stent/scaffold thrombosis with PCI

33. Type 4b = subacute
stent thrombosis (D1)

34. This PCI-related MI type is designated as type 4c MI, defined as focal or
diffuse restenosis, or a complex lesion associated with a rise and/or fall of
cTn values above the 99th percentile URL applying, the same criteria
utilized for type 1 MI
Restenosis associated with
percutaneous coronary intervention

35. Type 5 MI - MI associated with CABG

36. Criteria for CABG-related MI < 48 h after the
index procedure (type 5 MI)
elevation of cTn
values > 10 times the 99th percentile URL in patients
with normal baseline cTn values. In patients with
elevated pre-procedure cTn in whom cTn levels are stable
(# 20% variation) or falling, the post-procedure cTn
must rise by > 20%

37. Development of new
pathological Q waves
Angiographic documented
new graft occlusion or
new native coronary
artery occlusion
Imaging evidence of new
loss of viable myocardium
or new regional wall
motion abnormality
one of the following elements is required:

38. Arrow 1 indicates the onset of the Q wave. Arrow 2 Indicates the
onset of the ST-segment or J-point.
The difference between points 1 and 2 denotes the magnitude of the
ST-segment elevation
Assessment of ST-segment
elevation

39. ESC 2018 , Expert Consensus Document

40. More information on www.escardio.org/guidelines

41. Kristian Thygesen* (Denmark)
Joseph S. Alpert* (USA)
Allan S. Jaffe (USA)
Bernard R. Chaitman (USA)
Jeroen J. Bax (The Netherlands)
David A. Morrow (USA)
Harvey D. White* (New Zealand)
Hans Mickley (Denmark)
Filippo Crea (Italy)
Frans Van de Werf (Belgium)
Chiara Bucciarelli-Ducci (UK)
Hugo A. Katus (Germany)
William S. Weintraub (USA)
Fausto J. Pinto (Portugal)
Elliott M. Antman (USA)
Christian W. Hamm (Germany)
Raffaele De Caterina (Italy)
James L. Januzzi Jr (USA)
Fred S. Apple (USA)
Maria Angeles Alonso Garcia (Spain)
S. Richard Underwood (UK)
John M. Canty Jr (USA)
Alexander R. Lyon (UK)
P.J. Devereaux (Canada)
Jose Luis Zamorano (Spain)
Bertil Lindahl (Sweden)
Authors/Task
Force Members/
Chairpersons

42. Highlight and Summary
Myocardial Injury, more precisely defined, future ICD 10 code
New type 4c infarction = troponin rise with coronary restenosis after PCI
New imaging techniques (CMR und CTA) adopted
Better definition of type 2 infarction and differentiation from injury
Further work and needed to revise for practical implementation due to high
complexity

43. Thank You