Review
Diagnostic and Therapeutic Implications of Type 2 Myocardial Infarction: Review and Commentary

https://doi.org/10.1016/j.amjmed.2013.09.031Get rights and content

Abstract

The Task Force for the Universal Definition of Myocardial Infarction recently published updated guidelines for the clinical and research diagnosis of myocardial infarction under a variety of circumstances and in a variety of categories. A type 1 myocardial infarction (MI) is usually the result of atherosclerotic coronary artery disease with thrombotic coronary arterial obstruction secondary to atherosclerotic plaque rupture, ulceration, fissuring, or dissection, causing coronary arterial obstruction with resultant myocardial ischemia and necrosis. Patients with a type 2 MI do not have atherosclerotic plaque rupture. In this latter group of patients, myocardial necrosis occurs because of an increase in myocardial oxygen demand or a decrease in myocardial blood flow. Type 2 MI has been the subject of considerable clinical discussion and confusion. This review by knowledgeable members of the Task Force seeks to help clinicians resolve the confusion surrounding type 2 MI.

Section snippets

Type 1 vs Type 2 MI

Distinguishing patients with type 2 MI from those with type 1 MI often is not difficult. This distinction can be straightforward in many patients but challenging at other times. Patients with type 1 MI usually present with spontaneous symptoms with or without associated ischemic electrocardiographic (ECG) changes and in the absence of a cause for increased myocardial oxygen demand, for example, tachycardia with heart rates in excess of 120 beats per minute or decreased myocardial blood flow,

The Essence of a Type 2 MI

In the most recent publications from the task force, type 2 MI was categorized as a myocardial infarction secondary to an ischemic imbalance between blood supply and myocardial oxygen demand.4, 5 Patients may or may not have atherosclerotic coronary artery disease. Instances of ischemic myocardial injury with necrosis where an imbalance between myocardial oxygen supply or demand occur include coronary endothelial dysfunction, coronary artery spasm, coronary embolism, tachy-/bradyarrhythmias,

Type 2 MI vs Nonischemic Myocardial Injury with Necrosis

Distinguishing type 2 MI from nonischemic myocardial injury with necrosis represents another challenging problem for the clinician. Nonischemic myocardial injuries are common in patients with severe illness, for example, bacteremia secondary to pneumonia. Problems with the diagnosis of type 2 MI usually do not arise in relatively straightforward patients, but rather in complex medical and surgical patients with multiple comorbidities (Table). An example of such a complex patient would be a

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Conflict of Interest: None.

Authorship: All authors had access to the manuscript and contributed to the manuscript.

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