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Treatments for Myocardial Injury and Type 2 Myocardial Infarction. Still, more unknowns than knowns, but hypothesis generating. Key points and takeaways. Great discussion with @XavierPrida
Full article found here: https://www.ahajournals.org/doi/full/10.1161/JAHA.120.019796
Full article found here: https://www.ahajournals.org/doi/full/10.1161/JAHA.120.019796
Background:
- Fourth Universal Definition of Myocardial Infarction: includes importance of myocardial injury, elevation of cardiac troponin (cTn) > 99th percentile of normal with clinical ischemia (symptoms, EKG changes, imaging evidence)
- Fourth Universal Definition of Myocardial Infarction: includes importance of myocardial injury, elevation of cardiac troponin (cTn) > 99th percentile of normal with clinical ischemia (symptoms, EKG changes, imaging evidence)
Background continued:
- Type 1 myocardial infarction (T1MI): Plaque rupture + thrombus
- Type 2 myocardial infarction (T2MI): Supply / demand imbalance with insult of ischemia
- Chronic troponin elevation definition: <20% change in cTn from prior 48 hours
- Type 1 myocardial infarction (T1MI): Plaque rupture + thrombus
- Type 2 myocardial infarction (T2MI): Supply / demand imbalance with insult of ischemia
- Chronic troponin elevation definition: <20% change in cTn from prior 48 hours
T2MI:
- ~25% of MI
- More common in older patients, women
- Higher association with DM, PE, HTN, HF, atrial fibrillation, heart or renal failure
- May be global ischemic phenomenon with regional myocardial wall dysfunction
- Lower cTn elevation compared to T1MI
- ~25% of MI
- More common in older patients, women
- Higher association with DM, PE, HTN, HF, atrial fibrillation, heart or renal failure
- May be global ischemic phenomenon with regional myocardial wall dysfunction
- Lower cTn elevation compared to T1MI
Management:
- Invasive coronary angiography and CT coronary angiography in T2MI not well-defined
- Management varies across institutions
- T1MI: 5 evidence-based medications (EBM): ASA, P2Y12, B-blockers, ACE/ARB, statins +/- revascularization
- Invasive coronary angiography and CT coronary angiography in T2MI not well-defined
- Management varies across institutions
- T1MI: 5 evidence-based medications (EBM): ASA, P2Y12, B-blockers, ACE/ARB, statins +/- revascularization
Kadesjo et. al
- Single-center cohort study
- 22,589 patients w/ chest pain. cTn > 14 ng/L (99th percentile) or cTn <12 ng/dL w/ change in cTn +/- > 3 ng/L from baseline
- Patients w/ T2MI with 2-3 and 4 EBM: 50% and 56% lower mortality respectively
- Association, no causation
- Single-center cohort study
- 22,589 patients w/ chest pain. cTn > 14 ng/L (99th percentile) or cTn <12 ng/dL w/ change in cTn +/- > 3 ng/L from baseline
- Patients w/ T2MI with 2-3 and 4 EBM: 50% and 56% lower mortality respectively
- Association, no causation
Conclusions:
- Key for T2MI is reversing triggering factor (HTN, arrhythmia, hypoxemia, bleeding, anemia)
- DAPT not beneficial, may worsen symptoms
- ACE/B-blockers may reduce LV remodeling
- More studies needed with EBM and outcomes for T2MI
- Key for T2MI is reversing triggering factor (HTN, arrhythmia, hypoxemia, bleeding, anemia)
- DAPT not beneficial, may worsen symptoms
- ACE/B-blockers may reduce LV remodeling
- More studies needed with EBM and outcomes for T2MI
