Department of Cardiovascular Diseases, Mayo Clinic, Rochester, USA.
Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, USA.
Eur Heart J Acute Cardiovasc Care. 2020 Feb;9(1):62-69. doi: 10.1177/2048872618787796. Epub 2018 Jul 6.
First, describe how acute myocardial infarction criteria are used to diagnose type 1 (T1MI) and 2 (T2MI) myocardial infarction. Second, determine whether subjective or objective criteria are used for T2MI. Third, examine outcomes for T2MI based on the presence or absence of objective evidence of myocardial ischemia compared with myocardial injury.
Post-hoc analysis of UTROPIA (NCT02060760), a prospective, observational, cohort study involving 1640 consecutive emergency department patients with serial high-sensitivity cardiac troponin I among whom 74 (4.5%) had T1MI, 103 (6.3%) T2MI, and 245 (15%) myocardial injury. Compared with T1MI, patients with T2MI were less likely to have ischemic symptoms (97% . 83%), Q waves (24% . 1%), new ST-T wave changes (74% . 51%), new regional wall motion abnormality (64% . 11%), and a culprit lesion on coronary angiography (59% . 0%) (all <0.05). T2MIs were more likely to be diagnosed using subjective criteria (symptoms alone) than T1MI (42% . 12%, <0.0001). Patients with objective T2MI, but not subjective T2MI, had a two-fold increase in early mortality compared with myocardial injury, with 30- and 60-day hazard ratios (95% confidence interval) of 2.3 (0.9, 6.2) and 2.0 (0.9, 4.7) respectively.
Among patients with T2MI, many cases are diagnosed using subjective criteria. The presence of objective evidence of myocardial ischemia may identify a higher-risk group of T2MI patients in whom early outcomes are worse than myocardial injury. Emphasis on using objective evidence of myocardial ischemia to diagnose T2MI may result in a more precise and specific disease definition.
首先，描述如何使用急性心肌梗死标准来诊断 1 型（T1MI）和 2 型（T2MI）心肌梗死。其次，确定是否使用主观或客观标准来诊断 T2MI。第三，根据是否存在心肌缺血的客观证据与心肌损伤相比，检查 T2MI 的结局。
对 UTROPIA（NCT02060760）的事后分析，这是一项前瞻性、观察性队列研究，涉及 1640 例连续急诊高敏肌钙蛋白 I 升高的患者，其中 74 例（4.5%）患有 T1MI，103 例（6.3%）患有 T2MI，245 例（15%）患有心肌损伤。与 T1MI 相比，T2MI 患者发生缺血症状的可能性较低（97%比 83%），Q 波（24%比 1%），新的 ST-T 波改变（74%比 51%），新的区域性壁运动异常（64%比 11%）和冠状动脉造影上的罪犯病变（59%比 0%）（均<0.05）。T2MI 更可能通过主观标准（仅症状）而不是 T1MI 进行诊断（42%比 12%，<0.0001）。与心肌损伤相比，有客观 T2MI 但无主观 T2MI 的患者早期死亡率增加了一倍，30 天和 60 天的危险比（95%置信区间）分别为 2.3（0.9，6.2）和 2.0（0.9，4.7）。
在 T2MI 患者中，许多病例是通过主观标准诊断的。存在心肌缺血的客观证据可能会识别出一个风险较高的 T2MI 患者群体，其早期结局比心肌损伤更差。强调使用心肌缺血的客观证据来诊断 T2MI 可能会导致更精确和具体的疾病定义。
