第三版心肌梗死定义英文版.docx
- 文档编号:26323721
- 上传时间:2023-06-17
- 格式:DOCX
- 页数:19
- 大小:24.21KB
第三版心肌梗死定义英文版.docx
《第三版心肌梗死定义英文版.docx》由会员分享,可在线阅读,更多相关《第三版心肌梗死定义英文版.docx(19页珍藏版)》请在冰豆网上搜索。
第三版心肌梗死定义英文版
ClinicalBiochemistry
Volume46,Issues1–2,January2013,Pages1–4
ThirdUniversalDefinitionofMyocardialInfarction
∙AllanS.Jaffe,
Introduction
TheThirdUniversalDefinitionofMyocardialInfarction(MI)wasrecentlypublishedconjointlybythemajorcardiologyorganizationsthroughouttheworldandinthejournalsoftheWorldHealthOrganization(WHO).Thisdefinitionbuildsontwoprevioustwoiterationswhichweredevelopedtomakethediagnosisofmyocardialinfarction(MI)moreconsistent.
Theeffortsstartedoriginallyin1999intheconferenceinNicestimulatedbytheinnovationofDr.KristianThygesenandDr.JosephAlbertwhohadrecognizedthisproblemandwhodevelopedataskforcejointlysponsoredbytheACC(AmericanCollegeofCardiology)andtheESC(EuropeanSocietyofCardiology)toattempttostandardizethedefinitionofMI[1].ThismajorstepledtothefirstdocumentwhichmovedthefieldfromtheepidemiologicallyorienteddefinitionofMIwhichhadbeendevelopedbytheWHOtotracktheincidenceofcoronarydiseaseandthereforewasorientedtowardsspecificitytoamoreclinicallyorienteddefinitionwhichreliedonbiomarkersasakeyfeatureofthediagnosis.Thisresultedinaparadigmshiftwherethediagnosisrequireddocumentationofmyocardialnecrosiswithbiomarkersandespeciallycardiactroponin(cTn)whichwasemergingatthetimeintheproperclinicalsituation.Aseconditerationin2007[2]updatedtheguidelinesandthe2012definitionrefinesthedefinitionstillfurtherparticularlyasitrelatestobiomarkers[3]whichhaveinthepastdecadebecomeprogressivelymoreandmoresensitive.Intrinsically,increasesinsensitivityofthissorttendtoresultinadiminutionofspecificitysinceincreasinglysensitivemeasurementsoftenunmasknewetiologiesforinthisinstance,elevationsofthesesensitivecTnbiomarkers.
Areasofthe2012definitionthatremainsimportantbutunchanged
ThedefinitionofMIfromthepathologiccircumstanceobviouslyisnotgoingtochange.Thedefinitionmandatesthefindingofcardiomyocytenecrosisdefinedpathologicallyduetomyocardialischemia.However,theclinicaldefinitionsincepathologyisnotreadilyavailabletoguideclinicalcarereliesonasurrogatemarkerforcardiacinjury;i.e.,cardiacbiomarkersandparticularly,cTn.Asinpreviousiterations,cTnisthebiomarkerofchoiceandstronglypreferredfortheoverallguidelinesaswellasforeachspecificguideline.ThedefinitionofMIfromtheclinicalperspectivehasnotchangedsubstantively.Itrequiresdetectionofariseand/orafallofacardiacbiomarker,preferablycTn,withatleastonevalueabovethe99thpercentilereferencelimitintheappropriateclinicalsetting(seeTable 1forcriteria).ThereareadditionaltypesofMIwhichwillbecoveredsubsequentlybuttheguidelinesrelyheavilyonclinicalsignsorsymptoms,aclinicalsituationwhereischemiaissuspectedevenifsignsandsymptomsareabsentorimaginginformationsuggestiveofischemiainthepresenceofachangingpatternofelevatedbiomarkers.
Table 1.
Criteriaforacutemyocardialinfarction(ThirdUniversalDefinitionofMyocardialInfarction).
➢Detectionofariseand/orafallofcardiacbiomarkervalues(preferablycardiactroponin(cTn))withatleastonevalueabovethe99thpercentileupperreferencelimit(URL)andatleastoneofthefollowing:
➢Ischemicsymptoms
➢ECGchangesofnewischemia(newST–TchangesornewLBBB)
➢DevelopmentofpathologicQwavesintheECG
➢Imagingevidenceofnewlossofviablemyocardiumornewregionalwallmotionabnormality
➢Identificationofanintracoronarythrombusbyangiographyorautopsy
Full-sizetable
Tableoptions
Themetricsfortheuseofthesebiomarkersremainthesame.Oneneedsavalueabovethe99thpercentileoftheupperreferencelimitwitharisingand/orafallingpatternofvalues.However,ascTnassaysensitivityhasimproved,theabilitytoconsistentlyoperationalizethesecriteriahasbecomemoreproblematicaswillbediscussedbelow.Thedocumentalsorecognizesavarietyofspecialclinicalcircumstanceswhichrequireuniquehandling.Someofthesearerelatedtocardiacproceduressuchaspercutaneousinterventions(PCI)orcoronaryarterybypassgraft(CABG)surgerybutotherstonovelproceduresthatarebeingdevelopedsuchastranscutaneousaorticvalveinterventions(TAVI).Thedocumentdiscussesaswellsubsetsofpatientswhoarecriticallyill,thosewithheartfailure,andthoseundergoingnon-cardiacsurgeryaswell.Theseclassificationsarenotnewfromthe2007documentbutareconsideredingreaterdetail.
Issuesrelatedtobiomarkers
Asinthepast,cTnisthemarkerofchoiceandariseand/orafallinvaluesisnecessarytodefineanacuteeventsuchasMI.Itisrecognizedthatthereissometensionabouthowonedefinesthe99thpercentile.Itisassaydependentandisoftendefinedbasedonconveniencesamples.Therefore,thereisconcernthatperhapstheyarenotasreliableasifthesamplepopulationsweremoreintensivelystudied[4].Thevaluesfortheseassaysshouldbeexpressedinng/Lsothattheyarewholenumbersbecauseasassaysbecomemorecomplicatedandmoresensitive,thenumberofzeroscouldleadtoclinicaldysfunction.TheassaysshouldbepreciseandthedocumentprefersassaysthathaveexcellentprecisionwithaCVof10%orlessofthe99thpercentiletoallowdetectionofchangingvalues.However,thedocumentallowsforassayswithCVsupto20%tobeused[5].Italsoisnotedthatanalyticandpre-analyticproblemscanbeproblematicandleadtofalse-positiveandfalse-negativevaluesespeciallywithmoresensitiveassays.Itisalsorecommendedthatsexdependentvaluesmaybeusedwithhighsensitivityassays.
Samplingshouldbedoneat0,3,and6 handlaterifadditionalepisodesoccurorifthetimingoftheinitialsymptomsisunclear.Thediagnosisrequiresarisingandafallingpatternwhichisessentialtodifferentiateelevationsthatareacutefromthosethatarechronicandassociatedwithstructuralheartdiseasesuchaspatientswithrenalfailure,heartfailure,leftventricularhypertrophy,andthelike.Itisrecognizedthatoneneedstobecarefulbecauseattimesonecouldpresentsufficientlylateastomissanelevatedvalueorcouldbenearthetimeofpeakvaluesatwhichpointintimeonecouldbelievethatachangehadnotoccurredwhensimplythevaluesweresimilaronbothsidesofthepeak.
ItisrecognizedandallowedthattheremaybecircumstancesinwhichcardiacinjurycouldbepresentbutnotmeetthediagnosisofMIbecauseitisnotintheappropriatesettingordoesnotmanifestariseandafallandtherearealargenumberofsuchsituationsinwhichadiagnosisofcardiacinjurymaybemoreappropriatethanthediagnosisofacuteMI(seeTable 2).
Table 2.
Elevationsofcardiactroponinvaluesbecauseofmyocardialinjury(ThirdUniversalDefinitionofMyocardialInfarction).
➢Injuryrelatedtoprimarymyocardialischemia(MItype1;i.e.,plaguerupture,intraluminalcoronaryarterythrombusformation)
➢Injuryrelatedtosupply/demandimbalanceofmyocardialischemia(MItype2;i.e.,tachy-/brady-arrhythmias,aorticdissection,orsevereaorticvalvedisease,hypertrophiccardiomyopathy,cardiogenicorsepticshock,severerespiratoryfailure,severeanemia,hypertensionwithorwithoutLVH,coronaryspasm,coronaryembolismorvasculitis,coronaryendothelialdysfunctionwithoutsignificantCAD)
➢Injurynotrelatedtomyocardialischemia(i.e.,cardiaccontusion,surgery,ablation,pacing,defibrillatorshocks,rhabdomyolysiswithcardiacinvolvement,myocarditis,cardiotoxicagents)
➢Multifactorialorindeterminatemyocardialinjury(i.e.,heartfailure,stress(takotsubo)cardiomyopathy,severepulmonaryembolismorpulmonaryhypertension,sepsisandcriticallyillpatients,renalfailure,severeacuteneurological(e.g.,stroke)infiltrativediseases(e.g.,amyloidosis),strenuousexercise)
OperationalizingchangeincTnvaluesiscomplexandassaydependent.Itshouldbeclearthatgivenpreviouswaysofdiagnosinginfarctionhaveoftennotrequiredchangesovertimethatasonestartstoimplementthesechanges,onewillhavedifferencesinbothsensitivityandspecificity[6].Infact,mostofthedatainthisareasuggeststhattheuseofdeltachangecriteriaimprovesspecificitybutatthecostofsensitivity.Therearemultiplereasonswhythiscouldbethecase.Thefirstisthatitmaybethattherearepatientsbeingdiagnosedwithacuteinfarctionwhodonothavearisingandafallingpatternbasedonclinicaljudgmentsinceonecanhaveacutelookingplaqueseveninpatientswithstablecoronaryarterydisease[7].Asecondpotentialissuerelatestothesituationwherethereisvariationincoronaryarteryperfusion.Biomarkerreleaseisflowdependentandtheconsequenceofthatisthattheremaywellbecircumstanceswithclosedvesselswhereittakesmuchlongerfortheegressofmarkertoreachthecirculationthaninothers.Thus,theideaofshortperiodsofoneortwohoursamplingtimeslookingforchangemaybeinadequate.Therealsoareissuesrelatedtothespontaneouschangethatcanoccur.Thishasbeentermedbiologicalvariationandclearlyismuchmoresubstantialthanjustthevariabilityassociatedwiththeimprecisionoftheassays[8].Nonetheless,itisclearthereissomeoverlapbetweenthevaluesthatonebelievesareassociatedwithpatientswithMIandthevaluesthatareconsideredpartofthespontaneousbiologicalvariation[9].Inaddition,theoptimalvaluestousewitheachassayarenotclear.OnecouldcalculateanROCcurvewhichmanylaboratoriansareenamoredofdoingandpickthevalue
- 配套讲稿:
如PPT文件的首页显示word图标,表示该PPT已包含配套word讲稿。双击word图标可打开word文档。
- 特殊限制:
部分文档作品中含有的国旗、国徽等图片,仅作为作品整体效果示例展示,禁止商用。设计者仅对作品中独创性部分享有著作权。
- 关 键 词:
- 第三 版心 梗死 定义 英文
![提示](https://static.bdocx.com/images/bang_tan.gif)