Classification of Myocardial Infarction: Frequency and Features of Type 2 Myocardial Infarction

doi:10.1016/j.amjmed.2013.02.029

The American Journal of Medicine

Volume 126, Issue 9, September 2013, Pages 789-797

https://doi.org/10.1016/j.amjmed.2013.02.029 Get rights and content

Abstract

Background

The classification of myocardial infarction into 5 types was introduced in 2007 as an important component of the universal definition. In contrast to the plaque rupture–related type 1 myocardial infarction, type 2 myocardial infarction is considered to be caused by an imbalance between demand and supply of oxygen in the myocardium. However, no specific criteria for type 2 myocardial infarction have been established.

Methods

We prospectively studied unselected hospital patients who had cardiac troponin I measured on clinical indication. The diagnosis and classification of myocardial infarction were established, and the frequency and features of type 2 myocardial infarction were investigated by use of novel developed criteria.

Results

From January 2010 to January 2011, a total of 7230 consecutive patients who had cardiac troponin I measured were evaluated, and 4499 patients qualified for inclusion. The diagnosis of myocardial infarction was established in 553 patients, of whom 386 (72%) had a type 1 myocardial infarction and 144 (26%) had a type 2 myocardial infarction. Patients in the group with type 2 myocardial infarction were older and more likely to be female, and had more comorbidities. The proportion of patients without significant coronary artery disease was higher in those with type 2 myocardial infarction (45%) than in those with type 1 myocardial infarction (12%) (P < .001). Tachyarrhythmias, anemia, and respiratory failure were the most prevalent mechanisms causing type 2 myocardial infarction.

Conclusions

In a cohort of patients with myocardial infarction who were admitted consecutively through 1 year, the category of type 2 myocardial infarction comprised one fourth when diagnosed by the use of newly developed criteria. Approximately half of patients with type 2 myocardial infarction had no significant coronary artery disease.

Section snippets

Study Design and Population

The study comprises patients consecutively admitted to a 1000-bed university hospital, which serves as a tertiary referral center for a region with 1.2 million inhabitants and as a local hospital for a catchment area of 300,000 residents. The data is a part of the DEF-AMI Study (Consequences of the universal 2007 DEFinition of Acute Myocardial Infarction studied in a Danish consecutive hospital population). All admitted patients who had cardiac troponin I (cTnI) measured were traced through

Results

cTnI was measured in 7230 hospitalized patients admitted between January 6, 2010, and January 5, 2011. Approximately one third of patients did not meet the inclusion criteria. Thus, 4499 patients were enrolled, and of these 1961 had cTnI elevation above the 99th percentile upper reference limit. Figure 1 shows that 553 patients (12.3%) had myocardial infarction.

Discussion

In this study, 4499 consecutive hospitalized patients with a suspected acute myocardial infarction were evaluated according to the principles of the universal definition and with particular emphasis on novel clinical standard criteria for the classification of type 2 myocardial infarction. Thus, 553 patients had acute myocardial infarction, of whom 26% were classified as having type 2 myocardial infarction. Approximately half of patients with type 2 myocardial infarction did not have

Conclusions

This prospective study on the classification and features of patients with myocardial infarction defined according to the universal definition demonstrates that 26% of these patients had type 2 myocardial infarction when novel developed clinical criteria were used. Patients with type 2 myocardial infarction generally had more severe clinical characteristics than patients with type 1 myocardial infarction. Approximately half of patients with type 2 myocardial infarction had no significant

Acknowledgments

The authors thank Jens Lauritsen, MD, PhD, for taking care of the database.

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Although kidney insufficiency has been shown to be associated with increased risk of myocardial injury, benefit of coronary angiography (CAG) and revascularization remains uncertain, with implications on management strategies and outcomes. We aimed to compare rates of CAG and revascularization and subsequent risk of cardiovascular and kidney outcomes in hospitalized patients with myocardial injury and kidney dysfunction.
Retrospective cohort study encompassing hospitalized patients with myocardial injury i.e. elevated troponin I or T and an eGFR ≤60 ml/min/1.73 m² identified between 2011 and 2021 in Danish national registers. 30-day odds for CAG were computed across granular eGFR-categories based on multiple logistic regression. Standardized one-year risks of cardiovascular and kidney outcomes including mortality were determined based on hazards obtained in multiple Cox regression.
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Probability of CAG following myocardial injury declined with progressive kidney dysfunction. Overall, CAG was associated with lower mortality irrespective of kidney function and subsequent revascularization.
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Among the 4,573 patients included in our study, 3,710 patients (81.1%) were initially diagnosed with T1M1 and 863 (18.9%) with T2MI. After reclassification, 96 T2MI patients were moved into the T1MI category. Out of the remaining 767 patients with T2MI, 567 underwent coronary angiography, and were adjudicated as type 2A MI (68.6%) with obstructive CAD, and type 2B MI (31.4%) without obstructive CAD.
When compared with T1MI and T2BMI, T2AMI patients had worse in-hospital outcomes, including severe heart failure (P < .001), atrial fibrillation or flutter (P < .001) and severe bleeding (P < .001). Kaplan-Meier 1-year survival curves showed higher all-cause and CV causes mortality in T2AMI patients compared to T1MI and T2BMI (P < .001). In multivariate Cox regression analysis, type of MI was independent predictor of death.
Our large observational multicenter study shows major disparities in mortality according to type of MI and support the relevance of the new MI classification to improve risk classification, taking into account CAD in T2MI. Our findings may help identifying specific phenotypes and considering personalized diagnostic and management strategies.
Coronary Computed Tomographic Angiography With Fractional Flow Reserve in Patients With Type 2 Myocardial Infarction
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The goal of this study was to evaluate the presence and characteristics of CAD among patients with T2MI.
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Among individuals with adjudicated T2MI, CAD was prevalent, but the majority of patients had nonobstructive CAD. Mediators of ischemia are likely multifactorial in this population. (Defining the Prevalence and Characteristics of Coronary Artery Disease Among Patients with Type 2 Myocardial Infarction using CT-FFR [DEFINE TYPE 2 MI]; NCT04864119)
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People with human immunodeficiency virus (HIV) infection (PWH) are at higher risk of myocardial infarction (MI) than those without HIV. About half of MIs in PWH are type 2 (T2MI), resulting from mismatch between myocardial oxygen supply and demand, in contrast to type 1 MI (T1MI), which is due to primary plaque rupture or coronary thrombosis. Despite worse survival and rising incidence in the general population, evidence-based treatment recommendations for T2MI are lacking. We used polygenic risk scores (PRS) to explore genetic mechanisms of T2MI compared to T1MI in PWH.
We derived 115 PRS for MI-related traits in 9541 PWH enrolled in the Centers for AIDS Research Network of Integrated Clinical Systems cohort with adjudicated T1MI and T2MI. We applied multivariate logistic regression analyses to determine the association with T1MI and T2MI. Based on initial findings, we performed gene set enrichment analysis of the top variants composing PRS associated with T2MI.
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Type 2 myocardial infarction
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L'infarctus du myocarde (IDM) type 2 est une catégorie des infarctus du myocarde selon la définition universelle de l'infarctus du myocarde (UDMI), fréquemment rencontré dans la pratique courante mais reste encore méconnu en termes de prévalence, démarche diagnostique et thérapeutique. Il touche une population hétérogène, présentant un risque élevé d'événements cardiovasculaires majeurs et de décès non cardiaques.
L'IDM type 2 est secondaire à une inadéquation entre les apports et les besoins en oxygène en l'absence d'un évènement coronarien primaire, par Exemple : spasme des artères coronaires, embolie coronaire, anémie, arythmies, hypertension ou hypotension. Le diagnostic nécessite traditionnellement une évaluation des antécédents, avec certaines preuves indirectes de la nécrose myocardique (biochimiques, électrocardiographiques, imageries). La différenciation entre l'IDM type 1 et type 2 est plus compliquée qu'il n'y paraît, et le traitement de la pathologie sous-jacente est l'objectif principal du traitement.
Type 2 MI is a category of myocardial infarction according to the UDMI, frequently encountered in routine practice but still poorly understood in terms of prevalence, diagnostic and therapeutic approach, it affects a heterogeneous population at high risk of major cardiovascular events and non-cardiac death. It is due to an inadequacy between oxygen supply and demand in the absence of a primary coronary event, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension or hypotension. Diagnosis has traditionally required an integrated history assessment, with some combination of indirect evidence of myocardial necrosis based on biochemical, electrocardiographic, and imaging modalities. Differentiation between type 1 and type 2 MI is more complicated than it appears. Treatment of the underlying pathology is the primary goal of treatment.

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: Funding: This study has been financially supported by the Danish Heart Association, Odense University Hospital, Denmark and by the University of Southern Denmark, Odense, Faculty of Health Sciences.

: Conflict of Interest: None.

: Authorship: All authors had access to the data and played a role in writing this manuscript.

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Clinical research studyClassification of Myocardial Infarction: Frequency and Features of Type 2 Myocardial Infarction

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study Design and Population

Results

Discussion

Conclusions

Acknowledgments

Am J Cardiol

Int J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol Img

Universal definition of myocardial infarction

Eur Heart J

Existing data sources for clinical epidemiology: The Western Denmark Heart Registry

Clin Epidemiol

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008

Crit Care Med

Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper

Eur Respir J

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart

Eur Heart J

Definition and epidemiology of acute heart failure syndromes

Am J Cardiol

Recommendations for the use of cardiac troponin measurement in acute cardiac care

Eur Heart J

Clinical research study
Classification of Myocardial Infarction: Frequency and Features of Type 2 Myocardial Infarction