Clinicopathological complexity in the application of the universal definition of myocardial infarction

• Published in: Cardiovascular pathology 2020-01, Vol.44, p.107153-107153, Article 107153
• Main Authors: Buja, Louis Maximilian, Zehr, Bradley, Lelenwa, Laura, Ogechukwu, Eze, Zhao, Bihong, Dasgupta, Amitava, Barth, Rolf F.
• Format: Article
• Language: English
• Subjects: Acute coronary syndromes; Adult; Aged; Autopsy; Biomarkers - blood; Consensus; Coronary artery dissection; Eosinophilic periarteritis; Female; Humans; Male; Middle Aged; Myocardial infarction; Myocardial Infarction - blood; Myocardial Infarction - classification; Myocardial Infarction - diagnosis; Myocardial Infarction - pathology; Myocardial injury; Myocarditis; Myocardium - pathology; Pathology; Predictive Value of Tests; Prognosis; Risk Factors; Terminology as Topic; Troponin; Troponin - blood; Universal definition
• ISSN: 1054-8807; 1879-1336
• DOI: 10.1016/j.carpath.2019.107153

A universal definition of myocardial infarction (UDMI) has been established, periodically updated, and refined over the past twenty years. The primary purpose of the UDMI is to bring uniformity and accuracy to clinical diagnosis. Herein, a review and analysis of the UDMI is presented with emphasis on clinicopathological correlation. Determination of the presence of myocardial injury is based on the detection of abnormal serum cardiac biomarkers, particularly cardiac troponin (cTn), and in the current fourth iteration of the UDMI, high sensitivity (hs)-cTn. Differentiation of myocardial infarction from other causes of myocardial injury requires the documentation of clinical evidence of myocardial ischemia. In this review, difficulties in applying the UDMI in actual practice are discussed, based on the experience and perspective of those of us who face these problems as part of our own practice of pathology. The complexity in application of the UDMI is highlighted by the presentation of five illustrative cases involving the differential diagnosis of myocardial injury and myocardial infarction due to atherothrombotic and nonatherothrombotic coronary artery disease. The cases include myocardial infarction due to severe coronary atherosclerosis, supply-demand mismatch, coronary artery dissection associated with an eosinophilic coronary periarteritis, and coronary thromboembolism, and a case with a differential diagnosis of myocarditis and myocardial infarction. These cases illustrate how pathological findings can contribute to more accurate application of the UDMI and how, when critically applied, the UDMI can be used to better characterize myocardial infarcts in clinical practice. •The universal definition of myocardial infarction (UDMI) provides a structure fro rapid diagnosis of AMI.•In the UDMI, the diagnosis of AMI is based on elevated (hs)-cTn and evidence of myocardial ischemia.•In this review, complexities in the application of the UDMI are discussed.•Five illustrative cases are presented.