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(Circulation. 2006;114:790-797.)
© 2006 American Heart Association, Inc.

Epidemiology

Redefinition of Myocardial Infarction

Prospective Evaluation in the Community

Véronique L. Roger, MD, MPH; Jill M. Killian, BS; Susan A. Weston, MS; Allan S. Jaffe, MD; Jan Kors, PhD; Paula J. Santrach, MD; Hugh Tunstall-Pedoe, MD; Steven J. Jacobsen, MD, PhD

From the Division of Cardiovascular Diseases and Internal Medicine (V.L.R., A.S.J.) and the Department of Health Sciences Research (V.L.R., J.M.K., S.A.W.), Mayo Clinic College of Medicine, Rochester, Minn; the Department of Medical Informatics (J.K.), Erasmus University Medical Center, Rotterdam, the Netherlands; the Department of Laboratory Medicine and Pathology (P.J.S.), Division of Clinical Core Laboratory Services, and the Cardiovascular Epidemiology Unit (H.T.-P.), Institute of Cardiovascular Research, University of Dundee, Scotland; and Research and Evaluation (S.J.J.), Southern California Permanente Medical Group, Pasadena, Calif.

Correspondence to Dr Véronique L. Roger, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail roger.veronique{at}mayo.edu

Received November 30, 2005; de novo received March 17, 2006; revision received June 9, 2006; accepted June 12, 2006.

Background— The 2000 European Society of Cardiology/American College of Cardiology definition for myocardial infarction (MI) combines ischemic symptoms, electrocardiographic changes, and troponin rather than creatine kinase levels. The use of troponins will increase the detection of MI by a magnitude to be quantified, and the clinical acceptance of the new definition is unknown.

Method and Results— Subjects presenting to an Olmsted County facility with a troponin T value 0.03 ng/mL between November 2002 and March 2005 were prospectively classified through the use of standardized MI criteria, relying on cardiac pain, Minnesota coding of the ECG, and troponin, creatine kinase, and its MB fraction measured simultaneously. Through the use of dynamic changes in troponin, 538 MIs were identified versus 327 with creatine kinase and 427 with only the MB fraction of creatine kinase. This represents a 74% (95% confidence interval [CI], 69% to 79%) increase above the number of MIs identified with creatine kinase and a 41% (95% CI, 37% to 46%) increase above the number identified with criteria including only its MB fraction. When relying on single values of troponin, increases in the number of MIs were always large but varied widely according to the threshold used for troponin. Cases meeting only troponin-based criteria were less likely to have electrocardiographic ST-segment elevation and had better survival than those identified with previous criteria. Clinician diagnoses mentioned MI in 42% (95% CI, 34% to 49%) of cases meeting only troponin-based criteria versus 74% (95% CI, 69% to 78%) for MIs meeting the previous criteria (P<0.001).

Conclusions— The prospective application of the new criteria in the community results in a large increase in the number of MIs and a change in case mix. The clinical acceptance of the new criteria is incomplete, and studies that rely exclusively on dismissal diagnoses to assess MI rates may underestimate the burden of disease as presently defined.

Key Words: myocardial infarction • criteria • biomarkers • diagnosis

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