What are the types of myocardial infarction

(MI, heart attack), and how is each defined?

Updated: May 07, 2019 
 Author: A Maziar Zafari, MD, PhD, FACC, FAHA; Chief Editor: Eric H Yang,
MD  more...
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The Joint ESC/ACCF/AHA/WHF Task Force further classified MI into 5 types

on the basis of the underlying cause [7] :
 Type 1 (spontaneous MI): Related to atherosclerotic plaque rupture,
ulceration, fissuring, erosion, or dissection with intraluminal thrombus in
one or more of the coronary arteries, leading to decreased myocardial
blood flow or distal platelet emboli and thereby resulting in myocyte
necrosis. The patient may or may not have underlying obstructive
coronary artery disease (CAD).
 Type 2 (MI secondary to an ischemic imbalance): MI consequent to
increased oxygen demand or a decreased supply (eg, coronary
endothelial dysfunction, coronary artery spasm, coronary artery
embolus, tachyarryhthmias/bradyarrhythmias, anemia, respiratory failure,
hypertension, or hypotension).
 Type 3 (MI resulting in death when biomarker values are
unavailable): Sudden, unexpected cardiac death before blood samples
for biomarkers could be drawn or before their appearance in the
circulation.
 Type 4a (MI related to percutaneous coronary intervention
[PCI]): Elevation of biomarker values (cTn is preferred) to more than 5
times the 99 th percentile of the URL in patients with normal baseline
values (<99^th percentile URL) or a rise of values over 20% if
the baseline values are elevated but stable or falling. In addition, any of
the following are required: (1) symptoms suggestive of myocardial
ischemia; (2) new ischemic ECG changes or new BBB; (3) angiographic
loss of patency of a major coronary artery or a side branch or persistent
slow flow or no flow or embolization; or (4) demonstration of  the new loss
 of viable myocardium or new regional wall motion abnormality by cardiac
imaging.
 Type 4b (MI related to stent thrombosis): MI associated with stent
thrombosis as detected by coronary angiography or autopsy in the setting
of myocardial ischemia in combination with a rise and/or fall of cardiac
biomarkers with at least one value above the 99 th percentile URL.
 Type 5 (MI related to coronary artery bypass grafting
[CABG]): Elevation of cardiac biomarker values more than 10 times the
99 th percentile URL in patients with normal baseline cTn values. In
addition, either (1) new pathologic Q waves or new BBB, (2)
angiographic-documented new graft or native coronary artery occlusion,
or (3) evidence of new loss of viable myocardium or new regional wall
motion abnormality by cardiac imaging is required.

A Simplified Proposal to Redefine Acute

Myocardial Infarction Versus Acute
Myocardial Injury
Peter Nagele, MD, MS
DISCLOSURES 
Circulation. 2020;141(18):1431-1433. 

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The first consensus definition of myocardial infarction (MI) was published almost 20
years ago and was widely recognized as a landmark achievement. [1] The latest iteration,
the 2018 "Fourth Universal Definition of Myocardial Infarction," [2] is the result of
hundreds of hours of work by a cadre of international experts and differentiates MI into
multiple subtypes on the basis of clinical context and pathophysiological mechanism.
The "Fourth Universal Definition of Myocardial Infarction" is very complex. It defines 7
distinct subtypes of MI (type 1, type 2, type 3, type 4a, type 4b, type 4c, and type 5),
and the related category of myocardial injury (cardiac biomarker release without
evidence for myocardial ischemia). Because of the complexity, clinicians and experts
alike—both in the community and academia—struggle to consistently and correctly
apply the Universal Definition of MI in everyday clinical practice. The biggest challenge
relates to appropriately diagnosing type 2 MI and distinguishing type 2 MI from acute
myocardial injury.[3–5] Confusion abounds and, personally, I am afraid that the universal
definition of MI has become too complicated for everyday clinical practice.
But could the diagnosis of MI be simplified without sacrificing the underlying biological
concepts? I argue yes. I believe that we only need a single definition of acute MI that is,
both conceptually and mechanistically, distinctly different from acute myocardial injury
(Table).
Under the proposed concept, acute MI would include all conditions where an acute
coronary artery occlusion results in myocardial necrosis regardless of the underlying
cause. Coronary occlusion may be the result of an acute coronary plaque rupture,
coronary embolism, vasospasm, or acute coronary artery dissection. Central to the
definition is the acute interruption of coronary blood flow, and its diagnosis and therapy
are directed at restoring coronary blood flow. On the other hand, acute myocardial injury
would denote a condition where there is evidence of acute myocardial necrosis as a
result of noncoronary causes. Examples are atrial fibrillation with rapid ventricular
response, pulmonary embolism, sepsis, strenuous exercise, or exposure to potent
vasoactive drugs, causing an acute elevation of cardiac troponin. Central to the
diagnosis of acute myocardial injury is that the primary underlying cause of myocardial
necrosis is external to the coronary arteries. Thus, diagnosis and treatment of acute
myocardial injury would be directed at identifying and treating the underlying,
noncoronary cause.
The astute reader might point out that some cases may meet both criteria and
myocardial necrosis may be due to a combination of coronary and extracoronary
pathophysiology. For example is a patient with a stable but high-grade coronary
stenosis who develops atrial fibrillation, acute anemia, or sepsis, triggering acute
myocardial ischemia. In these cases, where coronary and extracoronary pathology
overlap, it would be at the discretion of the clinician to classify the event as either acute
MI or acute myocardial injury. We must accept that there are circumstances that may fit
both criteria and that we will need to allow clinicians to exercise discretion in choosing
the appropriate diagnosis.
Of note, the proposed simplified definition into only 2 conditions, myocardial infarction or
myocardial injury, does not predicate specific diagnostic criteria or treatment. Rather,
the definition focuses solely on the taxonomy, what we understand as MI versus
myocardial injury, and not how we delineate diagnostic criteria or recommended
treatment. ECG presentation (ST-elevation or non-ST-elevation) or the exact level of
cardiac troponin elevation or change values of high-sensitivity cardiac troponin, are
fundamentally important for the diagnosis of MI (and myocardial injury) but immaterial
for the definition of MI. Of note, the proposed definition does also not specify the
severity of the condition.
Similarly, the proposed simplified definition of acute MI does not predicate any
treatment modality. Because the criterion for MI involves the clinical suspicion of a
coronary event, most patients who meet the proposed definition of acute MI will likely
undergo coronary angiography or imaging. It is not automatic, however, that those
patients will require a coronary intervention. Conversely, patients with suspected acute
myocardial injury may require a coronary intervention when an acute extracoronary
 event, such as atrial fibrillation, causes acute myocardial ischemia in the setting of
stable obstructive coronary artery disease. Naturally, differentiated treatment guidelines
will need to be developed for both acute MI and acute myocardial injury. Acute MI
caused by acute coronary thrombosis as a result of a plaque rupture event will require
different guidelines than coronary vasospasm or coronary artery dissection. Similarly—
and reminiscent of the 5 Hs and 5 Ts in the nonshockable cardiac arrest algorithm—
treatment recommendations for acute myocardial injury will need to focus on the
underlying cause. Treatment guidelines for acute myocardial injury in the setting of atrial
fibrillation with a rapid ventricular response rate will obviously differ from myocardial
injury as a result of sepsis or anemia.
The proposed simplified definition would have several advantages. First, it would align
the underlying mechanism of myocardial damage, coronary versus extracoronary, with
the definition, myocardial infarction versus injury. Second, it would also help our patients
who wonder whether they actually had had a heart attack. Aligning the colloquial term
"heart attack" with acute MI will provide clarity to both clinician and patient and avoid
much of the confusion that exists now. Third, by refocusing the definition of MI on the
actual taxonomy ("what is an acute MI") rather than combining it with diagnostic criteria
(eg, rise or fall pattern of cardiac troponin, specific ECG changes, clinical symptoms),
we will provide more clarity for clinicians to correctly apply the definition.
Simplifying the diagnosis of acute MI may also have several disadvantages. First,
further revisions to the universal definition will, at least initially, cause more confusion
among clinicians, not less. Second, the proposal would potentially require coronary
imaging in most patients to make the diagnosis of myocardial infarction, which is not
feasible in many parts of the world. This requirement would make adjudication for
clinical trials more challenging and would potentially have implications for drug
development. Also, some diagnostic stratification would still be required to guide
therapy (eg, spontaneous coronary dissection, coronary vasospasm). Third, there is a
potential risk of this approach that patients with acute myocardial injury would be even
less likely to undergo thorough investigation and treatment as those currently classified
as having type 2 MI, despite having a high rate of cardiovascular morbidity and
mortality. It is important to highlight that regardless of how these patients are classified,
they require careful clinical evaluation to understand the mechanism of myocardial
injury in order to provide the best treatment and care.
The proposed simplified definition of acute MI is not meant as a critique of the work of
the committee developing the "Fourth Universal Definition of Myocardial Infarction," for
whom I have deep respect. I fully recognize the immense challenge they have taken on
and the amount of work that went into developing the universal definition. Rather, it
offers a suggestion to simplify and resolve the confusion now present among clinicians
trying to correctly diagnose acute MI.
 References
Circulation. 2020;141(18):1431-1433. © 2020 American Heart Association, Inc.