Fourth Universal Definition of Myocardial Infarction (2018)

Thygesen, Kristian; Alpert, Joseph S.; Jaffe, Allan S.; Chaitman, Bernard R.; Bax, Jeroen J.; Morrow, David A.; White, Harvey D.

doi:10.1016/j.jacc.2018.08.1038

Cited by 3,018 publications

(2,720 citation statements)

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“…Previous evidence for using “negative” hs-cTnI levels to “rule out” acute myocardial infarction is clear cut and robust 14151632. The Fourth Universal Definition3 recommends a diagnosis of acute myocardial infarction when there is clinical evidence of acute myocardial ischaemia and when an increase or decrease in cardiac troponin levels is detected. However, using the recommended ULN as a “rule in” test for acute myocardial infarction might not be appropriate in patients presenting with atypical symptoms and other comorbidities, such as in the emergency department or on acute medical and surgical wards.…”

Section: Discussionmentioning

confidence: 99%

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True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

Mariathas

Allan

Ramamoorthy

et al. 2019

BMJ

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ObjectiveTo determine the distribution, and specifically the true 99th centile, of high sensitivity cardiac troponin I (hs-cTnI) for a whole hospital population by applying the hs-cTnI assay currently used routinely at a large teaching hospital.DesignProspective, observational cohort study.SettingUniversity Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, between 29 June 2017 and 24 August 2017.Participants20 000 consecutive inpatients and outpatients undergoing blood tests for any clinical reason. Hs-cTnI concentrations were measured in all study participants and nested for analysis except when the supervising doctor had requested hs-cTnI for clinical reasons.Main outcome measuresDistribution of hs-cTnI concentrations of all study participants and specifically the 99th centile.ResultsThe 99th centile of hs-cTnI for the whole population was 296 ng/L compared with the manufacturer’s quoted level of 40 ng/L (currently used clinically as the upper limit of normal; ULN). Hs-cTnI concentrations were greater than 40 ng/L in one in 20 (5.4%, n=1080) of the total population. After excluding participants diagnosed as having acute myocardial infarction (n=122) and those in whom hs-cTnI was requested for clinical reasons (n=1707), the 99th centile was 189 ng/L for the remainder (n=18 171). The 99th centile was 563 ng/L for inpatients (n=4759) and 65 ng/L for outpatients (n=9280). Patients from the emergency department (n=3706) had a 99th centile of 215 ng/L, with 6.07% (n=225) greater than the recommended ULN. 39.02% (n=48) of all patients from the critical care units (n=123) and 14.16% (n=67) of all medical inpatients had an hs-cTnI concentration greater than the recommended ULN.ConclusionsOf 20 000 consecutive patients undergoing a blood test for any clinical reason at our hospital, one in 20 had an hs-cTnI greater than the recommended ULN. These data highlight the need for clinical staff to interpret hs-cTnI concentrations carefully, particularly when applying the recommended ULN to diagnose acute myocardial infarction, in order to avoid misdiagnosis in the absence of an appropriate clinical presentation.Trial registrationClinicaltrials.govNCT03047785.

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Section: Discussionmentioning

confidence: 99%

“…A diagnosis of acute myocardial infarction is defined, in the context of an appropriate clinical presentation, by a rise or fall in cardiac troponin concentration, now the gold standard biomarker,12 with at least one value greater than the 99th centile derived from a reference population of healthy individuals 345…”

Section: Introductionmentioning

confidence: 99%

True 99th centile of high sensitivity cardiac troponin for hospital patients: prospective, observational cohort study

Mariathas

Allan

Ramamoorthy

et al. 2019

BMJ

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“…Several studies indicated that acute myocardial injury was observed in patients who required oxygen supports, including invasive ventilation and/or ECMO [7][8][9]. Those patients may have hypoxemia or hypotension along with intense systemic inflammation, which may cause an oxygen supply and demand imbalance in the heart [20,42,62], especially when underlying CAD exists. Two recent clinical studies clarified the characteristics of patients having acute myocardial injury.…”

Section: Myocardial Injurymentioning

confidence: 99%

Impact of COVID-19 on the Cardiovascular System: A Review

Matsushita

Marchandot

Jesel

et al. 2020

JCM

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The recent outbreak of coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 has been declared a public health emergency of international concern. COVID-19 may present as acute respiratory distress syndrome in severe cases, and patients with pre-existing cardiovascular comorbidities are reported to be the most vulnerable. Notably, acute myocardial injury, determined by elevated high-sensitivity troponin levels, is commonly observed in severe cases, and is strongly associated with mortality. Therefore, understanding the effects of COVID-19 on the cardiovascular system is essential for providing comprehensive medical care for critically ill patients. In this review, we summarize the rapidly evolving data and highlight the cardiovascular considerations related to COVID-19.

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“…Acute myocardial injury is defi ned as a rise in cardiac troponins above a patient's baseline and the assay's 99th percentile upper reference level. 8 The main pathophysiological processes include myocarditis, takotsubo cardiomyopathy, microvascular obstruction, capillaritis, primary coronary event of a type 1 myocardial infarction, supply-demand imbalance injury of type 2 myocardial infarction, or right ventricular strain due to right heart failure, acute respiratory distress syndrome (ARDS) or pulmonary embolism. 8 Limited TTE or cPOCUS focusing on left and right ventricular dysfunction and the pattern of wall motion abnormalities may provide insight regarding the etiology and severity of acute myocardial injury, and can dictate clinical management in most circumstances.…”

Section: ■ Acute Myocardial Injurymentioning

confidence: 99%