The clinical diagnosis of myocardial infarction (MI) relies on symptoms, electrocardiographic findings, and biochemical markers (troponin, serum creatine kinase, creatine kinase-MB).^1,2 Acute ischaemic syndromes are now classified as unstable angina/non-ST-elevation MI (UA/NSTEMI) and acute ischaemic syndromes with ST-elevation MI (STEMI).^1,2 The new diagnostic criteria and markers are leading to increased proportions³ of acute ischaemic syndromes being recognised as acute MI. Obviously, elevated troponin concentrations are not, by themselves, synonymous with acute MI and can occur in a variety of cardiac and non-cardiac disorders (for example, sepsis or septic shock, pulmonary embolism, acute exacerbation of chronic obstructive pulmonary disease).⁴ Therefore, the diagnosis of acute MI relies on the combination of all clinical and biochemical tools, each providing its own diagnostic contribution.

The pathological hallmark of acute MI is coagulative necrosis of the myocardium. All recent advances in the definition, diagnostic work-up and treatment of MI are essential to perform an informative pathological investigation. In fatal MI, the pathological study must be performed at the appropriate technical and interpretative level to confirm, extend and improve information useful for the clinical understanding of the event (why one infarction proves fatal while other clinically similar MIs are not) and, eventually, contribute towards improving knowledge that may help future research in the MI setting.

PATHOLOGY

The pathological diagnosis of MI relies on the identification of coagulative necrosis in the myocardium, or of repairing features according to the “age” of the MI,⁵ or, if death occurred before the time necessary for coagulative necrosis to become visible at routine histopathology, on the detection of occlusive coronary thrombosis of an epicardial coronary artery (International classification of diseases, 9th revision (ICD-9) classification 410, 411). When coronary thrombosis is not detected at autopsy in individuals with MI who did not receive reperfusion, plaque …