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Third universal definition of myocardial infarction

Nature Reviews Cardiology volume 9, pages 620–633 (2012)Cite this article

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Myocardial infarction (MI) can be recognized 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 (Box 1). 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 programs. These studies and programs 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 health care providers and patients require an up-to-date definition of MI.

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Figure 1: This illustration shows various clinical entities—renal failure, heart failure, tachyarrhythmia or bradyarrhythmia, cardiac or noncardiac procedures—that can be associated with myocardial injury with cell death marked by cardiac troponin elevation.
Figure 2: Differentiation between MI types 1 and 2 according to the condition of the coronary arteries.

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Acknowledgements

Task Force members: Chairpersons: Kristian Thygesen (Denmark), Joseph S. Alpert (USA), Harvey D. White (New Zealand). Biomarker Subcommittee: Allan S. Jaffe (USA), Hugo A. Katus (Germany), Fred S. Apple (USA), Bertil Lindahl (Sweden), David A. Morrow (USA). ECG Subcommittee: Bernard R. Chaitman (USA), Peter M. Clemmensen (Denmark), Per Johanson (Sweden), Hanoch Hod (Israel). Imaging Subcommittee: Richard Underwood (UK), Jeroen J. Bax (The Netherlands), Robert O. Bonow (USA), Fausto Pinto (Portugal), Raymond J. Gibbons (USA). Classification Subcommittee: Keith A. Fox (UK), Dan Atar (Norway), L. Kristin Newby (USA), Marcello Galvani (Italy), Christian W. Hamm (Germany). Intervention Subcommittee: Barry F. Uretsky (USA), Ph. Gabriel Steg (France), William Wijns (Belgium), Jean-Pierre Bassand (France), Phillippe Menasché (France), Jan Ravkilde (Denmark). Trials & Registries Subcommittee: E. Magnus Ohman (USA), Elliott M. Antman (USA), Lars C. Wallentin (Sweden), Paul W. Armstrong (Canada), Maarten L. Simoons (The Netherlands). Heart Failure Subcommittee: James L. Januzzi (USA), Markku S. Nieminen (Finland), Mihai Gheorghiade (USA), Gerasimos Filippatos (Greece). Epidemiology Subcommittee: Russell V. Luepker (USA), Stephen P. Fortmann (USA), Wayne D. Rosamond (USA), Dan Levy (USA), David Wood (UK). Global Perspective Subcommittee: Sidney C. Smith (USA), Dayi Hu (China), José-Luis Lopez-Sendon (Spain), Rose Marie Robertson (USA), Douglas Weaver (USA), Michal Tendera (Poland), Alfred A. Bove (USA), Alexander N. Parkhomenko (Ukraine), Elena J. Vasilieva (Russia), Shanti Mendis (Switzerland).

ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax, (CPG Chairperson) (Netherlands), Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France), Bogdan A. Popescu (Romania), Željko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland).

Document Reviewers: Joao Morais, (CPG Review Coordinator) (Portugal), Carlos Aguiar (Portugal), Wael Almahmeed (United Arab Emirates), David O. Arnar (Iceland), Fabio Barili (Italy), Kenneth D. Bloch (USA), Ann F. Bolger (USA), Hans Erik Bøtker (Denmark), Biykem Bozkurt (USA), Raffaele Bugiardini (Italy), Christopher Cannon (USA), James de Lemos (USA), Franz R. Eberli (Switzerland), Edgardo Escobar (Chile), Mark Hlatky (USA), Stefan James (Sweden), Karl B. Kern (USA), David J. Moliterno (USA), Christian Mueller (Switzerland), Aleksandar N. Neskovic (Serbia), Burkert Mathias Pieske (Austria), Steven P. Schulman (USA), Robert F. Storey (UK), Kathryn A. Taubert (Switzerland), Pascal Vranckx (Belgium), Daniel R. Wagner (Luxembourg).

We are very grateful to the dedicated staff of the Practice Guidelines Department of the ESC.

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Authors and Affiliations

  1. Department of Cardiology, Aarhus University Hospital, Tage-Hansens Gade 2, DK-8000, Aarhus C, Denmark

    Kristian Thygesen

  2. Department of Medicine, University of Arizona College of Medicine, 1501 N. Campbell Avenue, P. O. Box 245037, Tucson, 85724, AZ, USA

    Joseph S. Alpert

  3. Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, 1030, Auckland, New Zealand

    Harvey D. White

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  1. Kristian Thygesen
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the Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction

Corresponding authors

Correspondence to Kristian Thygesen, Joseph S. Alpert or Harvey D. White.

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Competing interests

The members of the Task Force of the ESC, the ACCF, the AHA and the WHF have participated independently in the preparation of this document, drawing on their academic and clinical experience and applying an objective and clinical examination of all available literature. Most have undertaken—and are undertaking—work in collaboration with industry and governmental or private health providers (research studies, teaching conferences, consultation), but all believe such activities have not influenced their judgment. The best guarantee of their independence is in the quality of their past and current scientific work. However, to ensure openness, their relationships with industry, government and private health providers are reported as supplementary information online (www.nature.com/nrcardio). Expenses for the Task Force/Writing Committee and preparation of this document were provided entirely by the above-mentioned joint associations.

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Thygesen, K., Alpert, J., Jaffe, A. et al. Third universal definition of myocardial infarction. Nat Rev Cardiol 9, 620–633 (2012). https://doi.org/10.1038/nrcardio.2012.122

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