The impact of the 2007 ESC–ACC–AHA–WHF Universal definition on the incidence and classification of acute myocardial infarction: A retrospective cohort study

doi:10.1016/j.ijcard.2008.10.021

International Journal of Cardiology

Volume 139, Issue 3, 18 March 2010, Pages 228-233

https://doi.org/10.1016/j.ijcard.2008.10.021 Get rights and content

Abstract

Objective

To investigate the impact on the apparent incidence and classification of acute myocardial infarction (AMI) after employing the ESC–ACC–AHA–WHF 2007 Universal definition of myocardial infarction (the 2007 definition).

Setting

Retrospective cohort study in a single hospital serving a geographically well-defined population.

Methods and results

Retrospectively, the medical records for all patients hospitalized with suspected AMI during 2004 were reviewed (915 with AMI discharge diagnosis, 1037 with elevated troponin T > 0.03 µg/L without AMI diagnosis, 948 undergoing revascularisation and 34 with sudden death possible due to AMI). After correcting for misclassification (49 overdiagnosed and 236 underdiagnosed AMI) the number of AMI according to the 2000 definition was 1102 (20.5% overall underdiagnosed).

After reclassification to the 2007 definition the total number of AMI cases decreased with 9 patients mainly due to increase of the troponin decision limit for PCI related AMI (reducing the number of PCI related AMI from 111 to 69). The percentages of patients of each type according to the 2007 subclassification were spontaneous AMI (type 1) 88.5%; AMI due to myocardial oxygen deficit (type 2) 1.6%; sudden death without troponin elevation (type 3) 2.6%; PCI related AMI (type 4) 6.8%; and AMI after coronary artery bypass (type 5) 0.5%.

Conclusions

Employing the 2007 revision of the Universal definition of AMI did not substantially alter the apparent incidence of acute AMI substantially in our population. The level of misclassification of acute coronary syndromes after introduction of the 2007 definition may depend on the clinical acceptance of AMI subgrouping.

Introduction

Accurate diagnosis and classification of acute myocardial infarction (AMI) is essential as this has important implications both for the individual patient, epidemiological research and the health care system [1]. Recent changes in the presentations of acute coronary syndromes (ACS) [2], [3], and major advances in both the detection and treatment of AMI have resulted in revisions of the definition of AMI. The 2000 ESC/ACC AMI definition [4] was introduced to better reflect the pathophysiologic mechanisms underlying ACS, but has been criticized as not being applicable in many clinical situations [5], [6], [7], [8], [9], [10]. Therefore, after reevaluating the previous definition [11], the ESC–ACC–AHA–WHF Joint Force recently published the criteria for the 2007 Universal definition of myocardial infarction [12]. However, the impact of this new classification on the number and subtypes of AMI in clinical practice has not yet been investigated. After reviewing the hospital information systems (HIS) and the electronic patient records for the year 2004 in a large hospital serving a geographically well defined population, we retrospectively estimated how introduction of the 2007 definition affects the incidence and classification of acute myocardial infarction compared to the 2000 AMI definition.

Section snippets

Methods

The 2000 AMI definition stated that there should be a typical rise or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper limit of normal (ULN: the 99 percentile of a normal population with an analytic variance coefficient < 10%). Norway approved the 2000 ESC/ACC AMI definition in 2001. As local reference measurements of troponin was not available in many hospitals in Norway in 2001, the lower limit of decision for serum cardiac

Discussion

We have retrospectively evaluated the effects on the incidence and classification of AMI after applying the new 2007 ESC/ACC/AHA/WHF definition [12] on a well defined hospital cohort. The great majority of AMI cases belonged to the spontaneous type 1 subclass, and the adjusted number of AMI cases was largely dependent on misclassification level and on the troponin cutoff value used. The revised criteriae for AMI in relation to myocardial oxygen mismatch, sudden death, and post-revascularisation

Implications of the 2007 definition

The new 2007 AMI definition clarifies several important issues regarding classification of patients admitted with biomarker elevation with or without clinical ACS, and may reduce the level of misclassification in clinical practice. This may have important social and medical consequences for the patients. Patients belonging to different AMI subclasses may require different treatment [21]. For example, whereas patients with type 1 AMI needs antithrombotic medication and early invasive

Acknowledgements

Competing interest statement

Kenneth Dickstein is a member of the European Society Cardiology Committee for practice guidelines. This does not imply any financial consequences in relation to the current study.

Details of contributors

Tor Melberg (TM) initiated the study. The study protocol was written by TM and Robert Burman (RB). RB and TM analyzed and entered all data into the database, which was thereafter validated by Kenneth Dickstein (KD). TM designed the study database and performed the

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Citation Excerpt :
T2MI is defined as the presence of cardiac biomarker elevation with one or more symptoms or signs of ischemia, without evidence of atherosclerotic thrombotic occlusion.2 The proportion of patients with T2MI amongst patients presenting with AMI has varied between 2-58% in various studies.3,11 and prognosis is known be worse in T2MI compared with T1MI.4,5
Little is known about the association between acute prevalent conditions in patients with type 2 Myocardial Infarction (T2MI) and clinical outcomes, particularly between genders. Using the Nationwide Inpatient Sample (2017), we examined outcomes of T2MI in patients stratified by prevalent associated conditions (renal failure, decompensated heart failure, infection, acute respiratory failure, cardiac arrhythmias, bleeding) and gender. Multivariable logistic regression was performed to assess the odds ratios (OR) of in-hospital all-cause mortality in each of the study groups. A total of 38,715 T2MI patients were included in the analysis, of which 47.9% (n = 18,540) were females. Renal failure was the most common prevalent condition in both genders (males: 60%; females: 52.6%). Acute respiratory failure was associated with the greatest odds of mortality (OR 5.46, 95% confidence interval (CI) 5.02 to 5.94) when compared with other conditions: renal failure (OR 2.20 95% CI 2.01 to 2.40), infections (OR 2.96 95% CI 2.72 to 3.21), major bleeding (OR 1.71 95% CI 1.52 to 1.93), arrhythmias (OR 1.30 95% CI 1.19 to 1.43) and decompensated heart failure (OR 0.71, 95% CI 0.65 to 0.77). However, there was no difference in mortality between genders for all acute conditions except renal failure (females OR: 1.02, 95% CI 1.02 to 1.02, p = 0.011). In conclusion, in-hospital mortality after T2MI differs according to the underlying acute condition, with acute respiratory failure being associated with the highest rate of mortality. No significant differences in mortality were observed between genders amongst all prevalent acute conditions, with the exception of renal failure which was marginally higher in females.
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Type 2 myocardial infarction (MI) patients may have different characteristics and outcomes when compared with type 1 MI.
The purpose of this study was to compare patients with type 1 MI to those with type 2 MI in the United States.
Using the Nationwide Readmissions Database, MI patients were categorized over the 3 months following the introduction of an International Classification of Diseases-10th Revision code specific for type 2 MI. Baseline characteristics and inpatient and post-discharge outcomes among both cohorts were compared.
There were 216,657 patients with type 1 MI, 37,765 patients with type 2 MI, and 1,525 patients with both type 1 and 2 MI. Patients with type 2 MI were older (71 years vs. 69 years; p < 0.001), were more likely to be women (47.3% vs. 40%; p < 0.001), and had higher prevalence of heart failure (27.9% vs. 10.9%; p < 0.001), kidney disease (35.7% vs. 25.7%; p < 0.001), and atrial fibrillation (31% vs. 21%; p < 0.001). Rates of coronary angiography (10.9% vs. 57.3%; p < 0.001), percutaneous coronary intervention (1.7% vs. 38.5%; p < 0.001), and coronary artery bypass grafting (0.4% vs. 7.8%; p < 0.001) were lower among type 2 MI patients. Patients with type 2 MI had lower risk of in-hospital mortality (adjusted odds ratio: 0.57 [95% confidence interval: 0.54 to 0.60]) and 30-day MI readmission (adjusted odds ratio: 0.46 [95% confidence interval: 0.35 to 0.59]). There was no difference in risk of 30-day all-cause or heart failure readmission.
Patients with type 2 MI have a unique cardiovascular phenotype when compared with type 1 MI, and are managed in a heterogenous manner. Validated management strategies for type 2 MI are needed.
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Acute myocardial infarction (MI) can occur from increased myocardial oxygen demand and/or reduced supply in the absence of acute atherothrombotic plaque disruption; a condition called type 2 myocardial infarction (T2MI). As with any MI subtype, there must be clinical evidence of myocardial ischemia to make the diagnosis. This condition is increasingly diagnosed due to the increasing sensitivity of cardiac troponin assays and is associated with adverse short-term and long-term prognoses. Limited data exist defining optimal management strategies because T2MI is a heterogeneous entity with varying etiologies and triggers. Thus, these patients require individualized care. A major barrier is the absence of a uniform definition that can be operationalized with high reproducibility. This document provides a synthesis of the data about T2MI to assist clinicians’ understanding of its pathobiology, when to deploy the diagnosis, and its associated treatments. It also clarifies prognosis, identifies gaps in knowledge, and provides recommendations for moving forward.
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Despite adverse prognoses of type 2 myocardial infarction and myocardial injury, an effective, practical risk stratification method remains an unmet clinical need. We sought to develop an efficient clinical bedside tool for estimating the risk of major adverse cardiovascular events at 180 days for this patient population.
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The TARRACO Score included cardiac troponin (cTn) concentrations and 5 independent clinical predictors of adverse cardiovascular events: age, hypertension, absence of chest pain, dyspnea, and anemia. The score exhibited good discriminative accuracy (area under the curve = 0.74; 95% CI, 0.70-0.79). Patients were classified into low-risk (score 0-6) and high-risk (score ≥7) categories. Major adverse cardiovascular events rates were 5 times more likely in high-risk patients compared with those at low risk (78.9 vs 15.4 events/100 patient-years, respectively; logrank P < .001). The external validation showed equivalent prognostic capacity (area under the curve=0.71, 0.65-0.78).
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During a 1-year period from January 2010 to January 2011, all hospitalized patients who had cardiac troponin I measured on clinical indication were prospectively studied. Patients with at least one cardiac troponin I value >30 ng/L underwent case ascertainment and individual evaluation by an experienced adjudication committee. Patients were classified as having type 1 myocardial infarction, type 2 myocardial infarction, or myocardial injury according to the criteria of the universal definition of myocardial infarction. Follow-up was ensured until December 31, 2014. Data on mortality and causes of death were obtained from the Danish Civil Registration System and the Danish Register of Causes of Death.
Overall, 3762 consecutive patients were followed for a mean of 3.2 years (interquartile range 1.3-3.6 years). All-cause mortality differed significantly among categories: Type 1 myocardial infarction 31.7%, type 2 myocardial infarction 62.2%, myocardial injury 58.7%, and 22.2% in patients with nonelevated troponin values (log-rank test; P < .0001). In patients with type 1 myocardial infarction, 61.3% died from cardiovascular causes, vs 42.6% in patients with type 2 myocardial infarction (P = .015) and 41.2% in those with myocardial injury (P < .0001). The overall mortality and the causes of death did not differ substantially between patients with type 2 myocardial infarction and those with myocardial injury.
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View full text

The impact of the 2007 ESC–ACC–AHA–WHF Universal definition on the incidence and classification of acute myocardial infarction: A retrospective cohort study

Abstract

Objective

Setting

Methods and results

Conclusions

Introduction

Section snippets

Methods

Discussion

Implications of the 2007 definition

Acknowledgements

Lancet

Am J Cardiol

Cardiovasc Pathol

J Am Coll Cardiol

Int J Cardiol

Invited commentary: will heart attacks be “gone with the century”?

Am J Epidemiol

Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota Heart Survey

Circulation

Longitudinal trends in the severity of acute myocardial infarction: a population study in Olmsted County, Minnesota

Am J Epidemiol

Myocardial infarction redefined — a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction

Eur Heart J

J Am Coll Cardiol

Circulation

Clinical implications of the new definition of myocardial infarction

Heart

A new definition for myocardial infarction: what difference does it make?

Eur Heart J

Redefinition of myocardial infarction: prospective evaluation in the community

Circulation

A call for universal definitions in cardiovascular disease

Circulation