This ESC/ACC/AHA/WHF consensus document proposes a revised clinical classification of myocardial infarction (MI), replacing the prior numerical type 1–5 system with three categories—primary, secondary, and procedure-related MI—supported by objective diagnostic criteria, updated ICD-11 coding, and guidance on cardiac biomarkers, imaging, and special populations.
The Fifth UDMI replaces the previous numerical MI types with three clinical categories: (1) primary MI (spontaneous acute coronary pathology, including atherothrombosis, SCAD, vasospasm, embolism); (2) secondary MI (oxygen supply–demand imbalance from another acute condition, confirmed by obstructive CAD or new wall motion abnormality/loss of viability); and (3) procedure-related MI (cardiac procedure complication within 30 days, confirmed by coronary complication plus new wall motion abnormality or loss of viability—both required if the complication occurs during the index procedure). Sex-specific 99th percentile troponin thresholds define myocardial injury, and diagnosis of procedure-related MI no longer relies on arbitrary biomarker multiples.
This is a consensus/expert statement, not a systematic review or clinical trial, so recommendations reflect task force opinion and available observational evidence rather than randomized data. Many key diagnostic criteria (e.g., troponin thresholds of >5× URL post-PCI and >35× URL post-surgery to trigger imaging) remain arbitrary and unvalidated. Applicability is constrained in low-resource settings where high-sensitivity troponin, coronary angiography, and cardiac imaging are unavailable.
Clinicians should apply the new three-category MI classification (primary, secondary, procedure-related) and use sex-specific 99th percentile troponin thresholds to define myocardial injury, avoiding the old type 1–5 labels. Imaging—coronary angiography and/or CMR—is required to confirm secondary and procedure-related MI rather than relying on troponin levels alone.
Explore related topics
