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Third Universal Definition of Myocardial Infarction Journal of the American College of Cardiology Vol. 60, No. 16, 2012 © 2012 by the European Society of Cardiology, American College of Cardiology Foundation, ISSN 0735-1097/$36.00 American Heart Association, Inc., and the World Heart Federation http://dx.doi.org/10.1016/j.jacc.2012.08.001 Published by Elsevier Inc. EXPERT CONSENSUS DOCUMENT Third Universal Definition of Myocardial Infarction Kristian Thygesen, Joseph S. Alpert, Allan S. Jaffe, Maarten L. Simoons, Bernard R. Chaitman and Harvey D. White: the Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction Authors/ Kristian Thygesen (Denmark)* Trials & Registries Subcommittee: Task Force Joseph S. Alpert (USA)* E. Magnus Ohman (USA) Members Chairpersons Harvey D. White (New Zealand)* Elliott M. Antman (USA) Biomarker Subcommittee: Lars C. Wallentin (Sweden) Allan S. Jaffe (USA) Paul W. Armstrong (Canada) Hugo A. Katus (Germany) Maarten L. Simoons (The Netherlands) Fred S. Apple (USA) Heart Failure Subcommittee: Bertil Lindahl (Sweden) James L. Januzzi (USA) David A. Morrow (USA) Markku S. Nieminen (Finland) ECG Subcommittee: Mihai Gheorghiade (USA) Bernard R. Chaitman (USA) Gerasimos Filippatos (Greece) Epidemiology Subcommittee: Peter M. Clemmensen (Denmark) Russell V. Luepker (USA) Per Johanson (Sweden) Stephen P. Fortmann (USA) Hanoch Hod (Israel) Wayne D. Rosamond (USA) Imaging Subcommittee: Dan Levy (USA) Richard Underwood (UK) David Wood (UK) Jeroen J. Bax (The Netherlands) Global Perspective Subcommittee: Robert O. Bonow (USA) Sidney C. Smith (USA) Fausto Pinto (Portugal) Dayi Hu (China) Raymond J. Gibbons (USA) Jose-Luis Lopez-Sendon (Spain) Classification Subcommittee: Rose Marie Robertson (USA) Keith A. Fox (UK) Douglas Weaver (USA) Dan Atar (Norway) Michal Tendera (Poland) L. Kristin Newby (USA) Alfred A. Bove (USA) Marcello Galvani (Italy) Alexander N. Parkhomenko (Ukraine) Christian W. Hamm (Germany) Elena J. Vasilieva (Russia) Intervention Subcommittee: Shanti Mendis (Switzerland) Barry F. Uretsky (USA) Ph. Gabriel Steg (France) *Corresponding authors/co-chairpersons: Professor Kristian Thygesen, Department of Cardiology, Aarhus University Hospital, Tage-Hansens William Wijns (Belgium) Gade 2, DK-8000 Aarhus C, Denmark. Tel: ϩ45 7846-7614; fax: ϩ45 Jean-Pierre Bassand (France) 7846-7619: E-mail: [email protected]. Professor Joseph S. Alpert, De- partment of Medicine, Univ. of Arizona College of Medicine, 1501 N. Phillippe Menasche (France) Campbell Ave., P.O. Box 245037, Tucson AZ 85724, USA, Tel: ϩ1 ϩ Jan Ravkilde (Denmark) 520 626 2763, Fax: 1 520 626 0967, Email: [email protected]. Professor Harvey D. White, Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, 1030 Auckland, New Zealand. Tel: ϩ64 9 630 9992, Fax: ϩ64 9 630 9915, Email: harveyw@adhb. govt.nz. For permissions, please contact Elsevier’s permission de- partment: [email protected]/. 1582 Thygesen et al. JACC Vol. 60, No. 16, 2012 Expert Consensus Document October 16, 2012:1581–98 ESC Jeroen J. Bax (CPG Chairperson) Philippe Kolh (Belgium) Committee (The Netherlands) Theresa McDonagh (UK) for Practice Guidelines Helmut Baumgartner (Germany) Cyril Moulin (France) (CPG) Claudio Ceconi (Italy) Bogdan A. Popescu (Romania) Veronica Dean (France) Zeljko Reiner (Croatia) Christi Deaton (UK) Udo Sechtem (Germany) Robert Fagard (Belgium) Per Anton Sirnes (Norway) Christian Funck-Brentano (France) Michal Tendera (Poland) David Hasdai (Israel) Adam Torbicki (Poland) Arno Hoes (The Netherlands) Alec Vahanian (France) Paulus Kirchhof (Germany/UK) Stephan Windecker (Switzerland) Juhani Knuuti (Finland) Document Joao Morais (CPG Review Coordinator) Mark Hlatky (USA) Reviewers (Portugal) Stefan James (Sweden) Carlos Aguiar (Portugal) Karl B. Kern (USA) Wael Almahmeed (United Arab Emirates) David J. Moliterno (USA) David O. Arnar (Iceland) Christian Mueller (Switzerland) Fabio Barili (Italy) Aleksandar N. Neskovic (Serbia) Kenneth D. Bloch (USA) Burkert Mathias Pieske (Austria) Ann F. Bolger (USA) Steven P. Schulman (USA) Hans Erik Botker (Denmark) Robert F. Storey (UK) Biykem Bozkurt (USA) Kathryn A. Taubert (Switzerland) Raffaele Bugiardini (Italy) Pascal Vranckx (Belgium) Christopher Cannon (USA) Daniel R. Wagner (Luxembourg) James de Lemos (USA) Franz R. Eberli (Switzerland) The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines. Edgardo Escobar (Chile) Myocardial infarction secondary to an ischaemic TABLE OF CONTENTS imbalance (MI type 2) ...................................1587 Cardiac death due to myocardial infarction Abbreviations and acronyms .............................1583 (MI type 3)................................................1587 Myocardial infarction associated with revascularization procedures (MI types 4 and 5) Definition of myocardial infarction .....................1584 ....1587 Electrocardiographic detection of Criteria for acute myocardial infarction...............1584 myocardial infarction......................................1588 Criteria for prior myocardial infarction ................1584 Introduction .................................................1584 Prior myocardial infarction ...............................1589 Pathological characteristics of myocardial ischemia Silent myocardial infarction..............................1589 and infarction ...............................................1585 Biomarker detection of myocardial injury Conditions that confound the ECG diagnosis of myocardial infarction......................................1589 with necrosis ...............................................1585 Clinical features of myocardial ischemia Imaging techniques ........................................1589 and infarction ...............................................1586 Echocardiography ........................................1590 Radionuclide imaging....................................1590 Clinical classification of myocardial infarction .......1586 Magnetic resonance imaging ...........................1590 Computed tomography ..................................1590 Spontaneous myocardial infarction (MI type 1) ......1587 Applying imaging in acute myocardial infarction.....1590 JACC Vol. 60, No. 16, 2012 Thygesen et al. 1583 October 16, 2012:1581–98 Expert Consensus Document Applying imaging in late presentation of CAD ϭ coronary artery disease myocardial infarction ....................................1591 CABG ϭ coronary artery bypass grafting Diagnostic criteria for myocardial infarction CKMB ϭ creatine kinase MB isoform with PCI (MI type 4) .......................................1591 cTn ϭ cardiac troponin Diagnostic criteria for myocardial infarction CT ϭ computed tomography with CABG (MI type 5).....................................1592 CV ϭ coefficient of variation ECG ϭ electrocardiogram Assessment of MI in patients undergoing ϭ other cardiac procedures .................................1592 ESC European Society of Cardiology FDG ϭ fluorodeoxyglucose Myocardial infarction associated with h ϭ hour(s) non-cardiac procedures ...................................1592 HF ϭ heart failure LBBB ϭ left bundle branch block Myocardial infarction in the intensive care unit .....1593 LV ϭ left ventricle Recurrent myocardial infarction.........................1593 LVH ϭ left ventricular hypertrophy MI ϭ myocardial infarction Reinfarction .................................................1593 mlBG ϭ meta-iodo-benzylguanidine ϭ Myocardial injury or infarction associated min minute(s) with heart failure ..........................................1593 MONICA ϭ Multinational MONItoring of trends and determinants in CArdiovascular disease Application of MI in clinical trials and quality MPS ϭ myocardial perfusion scintigraphy assurance programmes ...................................1594 MRI ϭ magnetic resonance imaging ϭ Public policy implications of the adjustment mV millivolt(s) of the MI definition ........................................1594 ng/L ϭ nanogram(s) per liter Non-Q Ml ϭ non-Q wave myocardial infarction Global perspectives of the definition of NSTEMI ϭ non-ST-elevation myocardial infarction myocardial infarction......................................1595 PCI ϭ percutaneous coronary intervention ϭ Conflicts of interest .......................................1595 PET positron emission tomography pg/mL ϭ pictogram(s) per milliliter Acknowledgements ........................................1595 Q wave Ml ϭ Q wave myocardial infarction RBBB ϭ right bundle branch block References ..................................................1595 sec ϭ second(s) SPECT ϭ single photon emission computed tomography Abbreviations and acronyms STEMI ϭ ST elevation myocardial infarction ST-T ϭ ST-segment -T wave ACCF ϭ American College of Cardiology Foundation URL ϭ upper reference limit ACS ϭ acute coronary syndrome WHF ϭ World Heart Federation AHA ϭ American Heart Association WHO ϭ World Health Organization 1584 Thygesen et al. JACC Vol. 60, No. 16, 2012 Expert Consensus Document October 16, 2012:1581–98 Definition of Myocardial Infarction Criteria for acute myocardial infarction The term acute myocardial infarction (MI) should be used when there is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischemia. Under these conditions any one of the following criteria meets the diagnosis for MI: ● Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin (cTn)] with at least one value above
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