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Vol. 72. Issue 8.
Pages 696 (August 2019)
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Vol. 72. Issue 8.
Pages 696 (August 2019)
Editor letter
DOI: 10.1016/j.rec.2019.02.020
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Definition of Myocardial Infarction Type 4a: Can We Define Its Diagnosis and Systematize Clinical Practice? Response
Definición de infarto tipo 4a: ¿podemos definir mejor su diagnóstico y sistematizar la práctica clínica? Respuesta
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Antonia Sambolaa,b,
Corresponding author
asambola@vhebron.net

Corresponding author:
, Ana Viana Tejedorc, Pilar Jiménez-Quevedoc, Fernando Alfonsod
a Departamento de Cardiología, Hospital Universitari Vall d’Hebron, Barcelona, Spain
b Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
c Departamento de Cardiología, Hospital Clínico Universitario San Carlos, Madrid, Spain
d Departamento de Cardiología, Hospital Universitario de La Princesa, Madrid, Spain
Related content
Rev Esp Cardiol. 2019;72:695-610.1016/j.rec.2019.01.012
Iñigo Lozano, Juan Rondán, José M. Vegas, Eduardo Segovia
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To the Editor,

We thank Lozano et al. for their interest in our article.1

It is true that scientific societies differ in the criteria they use to define myocardial infarction (MI). Type 4a MI is that occurring after percutaneous coronary intervention and is defined by the European Society of Cardiology as an elevation in high-sensitivity cardiac troponin (hs-cTn) ≥ 5 times the 99th percentile upper reference limit (URL) if this is accompanied by electrocardiogram changes, the appearance of new Q waves, and imaging or angiographic evidence of myocardial ischemia.1 In contrast, the Society for Cardiovascular Angiography and Interventions (SCAI) defines “clinically relevant” postrevascularization MI as an hs-cTn increase ≥ 70 times the 99th percentile URL in the presence of new pathological Q waves or new persistent left bundle branch block.2 These divergent definitions are based on different scientific evidence. The European Society of Cardiology definition of type 4a MI is based on optimal hs-cTn thresholds that have been validated for the prediction of cardiovascular events in recent studies.3 The SCAI definition is based on the assumption that the optimal biomarker for defining clinically relevant MI after percutaneous coronary intervention is the serum creatine kinase MB fraction (CK-MB)3; the proposed hs-cTn threshold of ≥ 70 times the 99th percentile URL is calculated from the 7:1 ratio between troponin and CK-MB and was shown in a previous study to be a reliable proxy for elevated CK-MB.4

Clinical practice guideline recommendations should be the servants, not the masters, of clinical judgment. Adherence to this guiding principal will help us to improve the quality of care for our patients and balance the costs and benefits of the techniques used.

References
[1]
SEC Working Group for the 2018 ESC Fourth Universal Definition of Myocardial Infarction; Expert Reviewers for the 2018 ESC Fourth Universal Definition of Myocardial Infarction; SEC Guidelines Committee. Comments on the 2018 ESC Fourth Universal Definition of Myocardial. Rev Esp Cardiol. 2019;72:10-15.
[2]
I.D. Moussa, L.W. Klein, B. Shah, et al.
Consideration of a new definition of clinically relevant myocardial infarction after coronary revascularization: an expert consensus document from the Society for Cardiovascular Angiography and Interventions (SCAI).
Catheter Cardiovasc Interv., 83 (2014), pp. 27-36
[3]
M. Zeitouni, J. Silvain, P. Guedeney, et al.
Periprocedural myocardial infarction and injury in elective coronary stenting.
Eur Heart J., 39 (2018), pp. 1100-1109
[4]
V. Novack, M. Pencina, D.J. Cohen, et al.
Troponin criteria for myocardial infarction after percutaneous coronary intervention.
Arch Intern Med., 172 (2012), pp. 502-508
Copyright © 2019. Sociedad Española de Cardiología
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