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Myocardial injury
• Depending on the assay used, detectable to clearly elevated cTn

or infarction values being indicative of myocardial injury may be seen in
patients with heart failure (HF), both with reduced ejection
associated with fraction (EF) and with preserved EF.
heart failure
• The diagnosis of TTS should be suspected when the clinical

Takotsubo manifestations and ECG abnormalities are out of proportion to
the degree of elevation of cTn values, and when the distribution
syndrome of the LV wall motion abnormalities does not correlate with a
single coronary artery distribution.
Myocardial
• The diagnosis of MINOCA, like the diagnosis of MI, indicates
infarction with that there is an ischaemic mechanism responsible for the
myocyte injury (i.e. non-ischaemic causes such as myocarditis
non-obstructive have been excluded).
coronary arteries
Myocardial injury • The mechanisms include increased ventricular
and/or infarction pressure, small-vessel coronary obstruction,
anaemia, hypotension, and possibly direct toxic
associated with effects on the myocardium associated with the
kidney disease uraemic state.
Myocardial injury • Elevations of cTn values are common in patients in

and/or the intensive care unit and are associated with
infarction in adverse prognosis regardless of the underlying
disease state.
critically ill patients
• The analytical sensitivity [limit of detection (LoD)] of

Analytical issues of cTnI and cTnT assays varies 10-fold. Because assays
cardiac are not standardized, values from one assay cannot
be directly compared with those from another
troponins assay.
Biochemical approach for
diagnosing myocardial injury and
infarction
The 99th • The 99th percentile URL is designated as the decision level for
the presence of myocardial injury and must be determined for
percentile upper each specific assay with quality control materials used at the
reference limit URL to validate appropriate assay imprecision
Operationalizing
• To establish the diagnosis of an acute MI, a rise and/or fall in
criteria for cTn values with at least one value above the 99th percentile URL
myocardial injury is required, coupled with a high clinical and/or ECG likelihood of
myocardial ischaemia. hs-cTn assays shorten the time to
and infarction diagnosis in many patients towithin 3 h ofonset of symptoms
Application of
supplemental • Supplemental leads, as well as serial ECG recordings, should be
deployed with a very low threshold in patients who present
electrocardiogram with ischaemic chest pain and a non-diagnostic initial ECG.
leads
Electrocardiographic detection
of myocardial infarction
Electrocardiographic • It is not possible to initially distinguish ECG manifestations of
detection acute or chronic myocardial injury from acute myocardial
ischaemia.
of myocardial injury
Conditions that • A QS complex in lead V1 is normal. A Q wave < 0.03 s and < 0.25
confound the of the R wave amplitude in lead III is normal if the frontal QRS
axis is between -30 and 0. A Q wave may also be normal in aVL
electrocardiographic if the frontal QRS axis is between 60–90. Septal Q waves are
diagnosis of small, nonpathological Q waves < 0.03 s and < 0.25 of the R-
wave amplitude in leads I, aVL, aVF, and V4–V6.
myocardial infarction
• In patients with LBBB, ST-segment elevation >_ 1 mm

Conduction concordant with theQRS complex in any lead may be an
disturbances and indicator of acute myocardial ischaemia. Similar findings can be
useful in detecting ECG evidence for acute myocardial ischaemia
pacemakers in patients with right ventricular paced rhythms.
Prior or silent/unrecognized
myocardial infarction
• In some patients, the tachycardia may result in an
insufficient increase in coronary flow to match
Atrial fibrillation myocardial oxygen demand, resulting in cellular
hypoxia and abnormal repolarization.
Applying imaging in • the presence of a regional abnormality of

myocardial motion, thickening, thinning, or scar in
acute myocardial the absence of a non-ischaemic cause provides
infarction supportive evidence of pastMI
Applying imaging in • Imaging techniques can be useful in the diagnosis of

late presentation of acute MI because of the ability to detect wall
motion abnormalities or loss of viable myocardium
myocardial in the presence of elevated cardiac biomarker
infarction values.
Imaging techniques
• Echocardiography
• Radionuclide imaging
• Cardiac magnetic resonance imaging
Regulatory perspective • Multiples of the 99th percentile URL should be
on myocardial indicated and reported, both for those with cardiac
infarction in clinical procedural myocardial injury and those diagnosed with
trials types 4a and 5 MI.
Silent/unrecognized
myocardial infarction in • An annual ECG is reasonable in clinical trials to monitor
for silent Q wave MI events if the study population is
epidemiological studies expected to have an accelerated rate of atherosclerotic
and quality events.
programmes
• A tentative or final diagnosis is the basis for advice

Individual and public about further diagnostic testing, lifestyle changes,
implications of the treatment, and prognosis for the patient. The aggregate
myocardial of patients with a particular diagnosis is the basis for
infarction definition healthcare planning, and policy and resource
allocation.
Global perspectives of the
definition of myocardial infarction
Using the Universal Definition
of Myocardial Infarction in the
healthcare system
• clinical findings,
• patterns on the ECG,
• laboratory data,
• observations from imaging procedures,
• and on occasion pathological findings,
• all viewed in the context of the time horizon over
which the suspected event unfolds.

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Myocardial injury

• Depending on the assay used, detectable to clearly elevated cTn

• The diagnosis of TTS should be suspected when the clinical

Myocardial injury • Elevations of cTn values are common in patients in

• The analytical sensitivity [limit of detection (LoD)] of

• In patients with LBBB, ST-segment elevation >_ 1 mm

Applying imaging in • the presence of a regional abnormality of

Applying imaging in • Imaging techniques can be useful in the diagnosis of

• A tentative or final diagnosis is the basis for advice

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