The clinical approach to diagnosing peri-procedural myocardial infarction after percutaneous coronary interventions according to the fourth universal definition of myocardial infarction – from the study group on biomarkers of the European Society of Cardiology (ESC) Association for Acute CardioVascular Care (ACVC)

This review intends to illustrate basic principles on how to apply the Fourth Universal Definition of Myocardial Infarction (UDMI) for the diagnosis of peri-procedural myocardial infarction (MI) after percutaneous coronary interventions (PCI) in clinical practice. Review of routine case-based events. Increases in cardiac troponin (cTn) concentrations are common after elective PCI in patients with chronic coronary syndrome (CCS). Peri-procedural PCI-related MI (type 4a MI) in CCS patients should be diagnosed in cases of major peri-procedural acute myocardial injury indicated by an increase in cTn concentrations of >5-times the 99th percentile upper reference limit (URL) together with evidence of new peri-procedural myocardial ischaemia as demonstrated by electrocardiography (ECG), imaging, or flow-limiting peri-procedural complications in coronary angiography. Measurement of cTn baseline concentrations before elective PCI is useful. In patients presenting with acute MI undergoing PCI, peri-procedural increases in cTn concentrations are usually due to their index presentation and not PCI-related, apart from obvious major peri-procedural complications, such as persistent occlusion of a large side branch or no-reflow after stent implantation. The distinction between type 4a MI, PCI-related acute myocardial injury, and chronic myocardial injury can be challenging in individuals undergoing PCI. Careful integration of all available clinical data is essential for correct classification.

本综述旨在阐明临床实践中应用第四次心肌梗死全球统一定义（Fourth Universal Definition of Myocardial Infarction, UDMI）诊断经皮冠状动脉介入治疗（percutaneous coronary interventions, PCI）后围手术期心肌梗死（peri-procedural myocardial infarction, MI）的基本原则。本文回顾了常规的基于病例的临床事件。慢性冠状动脉综合征（chronic coronary syndrome, CCS）患者行择期PCI后，心肌肌钙蛋白（cardiac troponin, cTn）浓度升高较为常见。对于CCS患者，若需诊断围手术期PCI相关4a型心肌梗死（type 4a MI），应满足以下诊断标准：心肌肌钙蛋白浓度升高超过99百分位参考上限（99th percentile upper reference limit, URL）的5倍，且存在新的围手术期心肌缺血证据——该证据可通过心电图（electrocardiography, ECG）、影像学检查或冠状动脉造影（coronary angiography）显示的限血流性围手术期并发症予以证实。择期PCI前检测心肌肌钙蛋白基线浓度具有临床指导价值。对于因急性心肌梗死就诊并接受PCI的患者，其围手术期心肌肌钙蛋白浓度升高通常源于患者首次就诊时的急性心肌梗死发作，而非PCI相关因素，除非存在明确的严重围手术期并发症，如大的侧支血管持续闭塞或支架植入后无复流现象。对于接受PCI的患者，区分4a型心肌梗死、PCI相关急性心肌损伤与慢性心肌损伤颇具挑战。正确的分类需仔细整合所有可获得的临床资料，这一点至关重要。