VA Boston Healthcare System, Boston University School of Medicine, Boston, MA (W.E.B.).
Molecular and Clinical Sciences Research Institute, St. George's University of London, UK (J.C.K.).
Circulation. 2024 Nov 12;150(20):1631-1637. doi: 10.1161/CIRCULATIONAHA.123.065656. Epub 2024 Aug 30.
Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischemia, various classifications have emerged over time, often with conflicting terminology-eg, "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with "acute coronary syndromes" (ACS), the 2023 American guidelines endorsed the alternative term "chronic coronary disease." An unintended consequence of these competing classifications is perpetuation of the restrictive terms "coronary" and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes," which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischemia, and infarction.
自 20 世纪 60 年代以来，心脏病专家采用了几种用于急性心肌梗死 (MI) 的二分法分类系统，这有助于改善患者管理。相反，对于心肌缺血的慢性稳定表现，随着时间的推移出现了各种分类，术语常常相互矛盾——例如，“稳定型冠状动脉疾病”(CAD)、“稳定型缺血性心脏病”和“慢性冠状动脉综合征”(CCS)。虽然 2019 年欧洲指南引入 CCS 以与“急性冠状动脉综合征”(ACS)保持对称，但 2023 年美国指南支持替代术语“慢性冠状动脉疾病”。这些竞争性分类的一个意外后果是延续了限制性术语“冠状动脉”和 'disease'，通常仅暗示单一的阻塞性 CAD 机制。现在重要的是为心绞痛和心肌缺血的阻塞性和非阻塞性原因推进更广泛的包容性术语，以促进概念的清晰性并统一指南之间不同步的命名法。因此，我们提出了一种新的二分法“急性心肌缺血综合征”和“非急性心肌缺血综合征”，它包含了阻塞性心外膜和非阻塞性发病机制，包括微血管功能障碍、血管痉挛障碍和非冠状动脉原因。在此，我们保留了公认的 ACS、ST 段抬高型心肌梗死和非 ST 段抬高型心肌梗死的类别，因为这些是经证实具有临床益处的重要亚组，以及新的术语，如非阻塞性冠状动脉的缺血和心肌梗死。总体而言，这种更全面的命名法更好地协调、统一和协调了心肌缺血的不同病理生理原因，应该导致针对心绞痛、缺血和梗死的多种病理生物诱因的更精细的诊断和治疗方法。
