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Ischaemic heart disease
Defining myocardial infarction: a work in progress
  1. Paul W Armstrong
  1. Professor Paul W Armstrong, Division of Cardiology, University of Alberta, 2–51 Medical Sciences Building, Edmonton, Alberta T6G 2H7, Canada; paul.armstrong{at}

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Few disorders have as broad implications for public health and cardiovascular medicine as myocardial infarction. Herrick’s first description in living man in 1912 was populated by a combination of clinical symptoms and electrocardiographic changes.1 In this prescient description of six cases, the diagnosis was confirmed at autopsy in one who died 3 days after his clinical diagnosis. Interestingly, a period of relative quiescence ensued after Herrick’s original description. In 1959, the World Health Organization contributed to the definition of myocardial infarction with the admonition that it consist of a combination of two of the following three characteristics2:

  • Typical symptoms.

  • A rise in cardiac enzymes

  • An evolutionary ECG pattern which involved Q wave development.

Subsequently, major interest and animated debate emerged concerning the frequency, causes, preferred treatment, and prognosis of acute myocardial infarction. A convergence of factors, including those listed in box 1, helped to galvanise interest in better defining myocardial infarction with a view to both greater sensitivity and specificity.

Box 1 Factors stimulating better definition of myocardial infarction

  • Coronary bypass surgery

  • Percutaneous coronary revascularisation

  • Advances in reperfusion therapy

  • Novel therapeutic strategies aimed at reducing the frequency and size of myocardial infarction

  • Novel biomarkers with enhanced sensitivity and specificity

  • New cardiac imaging techniques with enhanced detection capacity

Given this global significance of myocardial infarction and these multifactorial factors, it was decided that the European Society of Cardiology and American College of Cardiology should convene a consensus conference in July 1999 to examine potential new definitions of myocardial infarction.3 The International Task Force set upon its work recognising that any change in the definition of such an important diagnostic entity might have profound and different implications depending on a particular interest of the individual or group. Figure 1 summarises some of the stakeholders and constituencies so affected.

Figure 1 Summary of key stakeholders interested in the definition of myocardial infarction.

The key elements of the 2000 consensus document emerging …

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  • Competing interests: In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. Research grants: Hoffmann LaRoche, Boehringer Ingelheim, sanofi aventis, Portola. Consulting/Advising: Hoffmann LaRoche, sanofi Aventis, TargeGen.