1. Myocardial infarction New concepts New definitions

2. Coronary Disease presentations Angina Angina Myocardial infarction Myocardial infarction Sudden cardiac death Sudden cardiac death

3. Coronary Disease presentations Angina stable unstable Angina stable unstable Myocardial infarction Myocardial infarction Sudden cardiac death Sudden cardiac death

4. Coronary Disease presentations Angina stable unstable Angina stable unstable Myocardial infarction ‘full-thickness’, ‘transmural’, Q-wave ‘partial-thickness’, subendocardial’ Myocardial infarction ‘full-thickness’, ‘transmural’, Q-wave ‘partial-thickness’, subendocardial’ Sudden cardiac death Sudden cardiac death

5. Coronary Disease presentations Angina stable unstable Angina stable unstable Myocardial infarction STEMI NSTEMI Myocardial infarction STEMI NSTEMI Sudden cardiac death Sudden cardiac death

6. Acute Coronary Syndrome No ST Elevation ST Elevation Unstable Angina NQMI QMI

9. Traditional definition of MI Symptoms of myocardial ischemia Symptoms of myocardial ischemia Elevation of cardiac ‘enzymes’ in blood Elevation of cardiac ‘enzymes’ in blood Typical ECG patterns Typical ECG patterns

10. New definitions of MI Consensus document published in April 2000 by the American College of Cardiology and the European Society of Cardiology Consensus document published in April 2000 by the American College of Cardiology and the European Society of Cardiology Criteria for acute, evolving or recent MI Criteria for acute, evolving or recent MI Criteria for established MI Criteria for established MI

11. Acute, evolving or recent MI Typical rise and fall of biochemical markers of myocardial necrosis, CK-MB or Troponin associated with at least one of the following ischaemic symptoms new pathological Q waves ECG changes indicative of ischaemia coronary artery intervention or Typical rise and fall of biochemical markers of myocardial necrosis, CK-MB or Troponin associated with at least one of the following ischaemic symptoms new pathological Q waves ECG changes indicative of ischaemia coronary artery intervention or Pathological findings of an acute MI Pathological findings of an acute MI

12. Established MI Development of new pathological Q waves in serial ECGs or Development of new pathological Q waves in serial ECGs or Pathologic findings of a healed or healing MI Pathologic findings of a healed or healing MI

13. Cardiac biomarkers CK-MB CK-MB Troponin T (or I) Troponin T (or I) Total CK, LDH and ASAT all invalid Total CK, LDH and ASAT all invalid

14. CK-MB Improved sensitivity over earlier enzyme estimations Improved sensitivity over earlier enzyme estimations All enzyme measurements have a background level of ‘noise’ - ie. normal range All enzyme measurements have a background level of ‘noise’ - ie. normal range

18. CK-MB Improved sensitivity over earlier enzyme estimations Improved sensitivity over earlier enzyme estimations All enzyme measurement have a background level of ‘noise’ - ie. normal range All enzyme measurement have a background level of ‘noise’ - ie. normal range 1 st detected 2 - 3hrs post MI, and elevation persists for 1 - 2 days 1 st detected 2 - 3hrs post MI, and elevation persists for 1 - 2 days

19. Troponin = a protein (not an enzyme) = a protein (not an enzyme) Troponin T and I (cardiac troponins) are not detectable in the blood of healthy subjects Troponin T and I (cardiac troponins) are not detectable in the blood of healthy subjects Reliable lab test for T ; not for I Reliable lab test for T ; not for I 1 st detectable 3 – 4 hrs post MI, and persists for 7 – 14 days 1 st detectable 3 – 4 hrs post MI, and persists for 7 – 14 days Troponin T elevated (ie detectable) in conditions other than acute infarction Troponin T elevated (ie detectable) in conditions other than acute infarction

20. Secondary ischaemic cardiac injury Coronary intervention Coronary intervention Coronary artery spasm Coronary artery spasm Coronary artery embolus Coronary artery embolus Coronary artery inflammation Coronary artery inflammation Coronary artery dissection Coronary artery dissection Direct coronary artery trauma Direct coronary artery trauma Sympathomimetics Sympathomimetics Pulmonary embolus Pulmonary embolus End-stage renal failure End-stage renal failure Rhythm disturbances Rhythm disturbances Acute heart failure Acute heart failure Extreme endurance exercise Extreme endurance exercise

21. Non-ischaemic cardiac injury Myocarditis – multiple causes Myocarditis – multiple causes Cardiac trauma direct cardiac surgery Cardiac trauma direct cardiac surgery Metabolic / toxic renal failure Metabolic / toxic renal failure

22. Clinical features Spontaneous ischaemic episode, usually lasting > 20 minutes Spontaneous ischaemic episode, usually lasting > 20 minutes Coronary artery intervention angiography, angioplasty, stenting Coronary artery intervention angiography, angioplasty, stenting

23. ECG features of myocardial ischaemia that may  MI New ST elevation in at least two contiguous leads, measuring >= 0.2mV in leads V 1 – V 3, or >= 0.1mV in all other leads = STEMI New ST elevation in at least two contiguous leads, measuring >= 0.2mV in leads V 1 – V 3, or >= 0.1mV in all other leads = STEMI Absence of ST elevation, but with either ST depression or T wave abnormalities = NSTEMI Absence of ST elevation, but with either ST depression or T wave abnormalities = NSTEMI

24. ECG features of established MI In absence of confounders (LBBB, LVH, and WPW syndrome) In absence of confounders (LBBB, LVH, and WPW syndrome) any Q wave in V 1 – V 3, or Q waves of >= 1mm for >= 30msec in two other contiguous leads

25. Pathological Q wave Normal Q wave Normal ECG ST elevationST depression Normal ST segment

26. pathology 6 hours elapse before myocardial necrosis becomes evident on histopathology 6 hours elapse before myocardial necrosis becomes evident on histopathology Three phases – acute / healing / healed Three phases – acute / healing / healed Size – microscopic / small / medium / large Size – microscopic / small / medium / large

27. imaging Echocardiography Echocardiography Radionuclide angiography Radionuclide angiography Single-photo emission computed tomography = SPECT Single-photo emission computed tomography = SPECT

28. Key points in the new definitions of myocardial infarction Any myocardial necrosis constitutes an infarction Any myocardial necrosis constitutes an infarction Infarctions other than ‘spontaneous’ are included Infarctions other than ‘spontaneous’ are included

29. Specific clinical situations not yet defined MI post-CABG, based on post-operative CK-MB or troponin levels MI post-CABG, based on post-operative CK-MB or troponin levels Threatened and aborted infarction Threatened and aborted infarction Silent infarction Silent infarction Sudden ischaemic cardiac death Sudden ischaemic cardiac death

31. 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