Authors/Task Force Members/Chairpersons Kristian Thygesen∗ (Denmark) Joseph S. Alpert∗ (USA) Allan S. Jaffe (USA) Bernard R. Chaitman (USA) Jeroen J. Bax (the Netherlands) David A. Morrow (USA) ...Harvey D. White∗ (New Zealand) Hans Mickley (Denmark) Filippo Crea (Italy) Frans Van de Werf (Belgium) Chiara Bucciarelli-Ducci (UK) Hugo A. Katus (Germany) Fausto J. Pinto (Portugal) Elliott M. Antman (USA) Christian W. Hamm (Germany) Raffaele De Caterina (Italy) James L. Januzzi Jr (USA) Fred S. Apple (USA) Maria Angeles Alonso Garcia (Spain) S. Richard Underwood (UK) John M. Canty Jr (USA) Alexander R. Lyon (UK) P.J. Devereaux (Canada) Jose Luis Zamorano (Spain) Bertil Lindahl (Sweden) William S. Weintraub (USA) L. Kristin Newby (USA) Renu Virmani (USA) Pascal Vranckx (Belgium) Don Cutlip (USA) Raymond J. Gibbons (USA) Sidney C. Smith (USA) Dan Atar (Norway) Russell V. Luepker (USA) Rose Marie Robertson (USA) Robert O. Bonow (USA) P. Gabriel Steg (France) Patrick T. O'Gara (USA) Keith A. A. Fox (UK)Document Reviewers David Hasdai (CPG Review Coordinator) (Israel) Victor Aboyans (France) Stephan Achenbach (Germany) Stefan Agewall (Norway) Thomas Alexander (India) Alvaro Avezum (Brazil) Emanuele Barbato (Italy) Jean-Pierre Bassand (France) Eric Bates (USA) John A. Bittl (USA) Güenter Breithardt (Germany) Héctor Bueno (Spain) Raffaele Bugiardini (Italy) Mauricio G. Cohen (USA) George Dangas (USA) James A. de Lemos (USA) Victoria Delgado (the Netherlands) Gerasimos Filippatos (Greece) Edward Fry (USA) Christopher B. Granger (USA) Sigrun Halvorsen (Norway) Mark A. Hlatky (USA) Borja Ibanez (Spain) Stefan James (Sweden) Adnan Kastrati (Germany) Christophe Leclercq (France) Kenneth W. Mahaffey (USA) Laxmi Mehta (USA) Christian Müller (Switzerland) Carlo Patrono (Italy) Massimo Francesco Piepoli (Italy) Daniel Piñeiro (Argentina) Marco Roffi (Switzerland) Andrea Rubboli (Italy) Marc Ruel (Canada) Samin Sharma (USA) Iain A. Simpson (UK) Michael Tendera (Poland) Marco Valgimigli (Switzerland) Allard C. van der Wal (the Netherlands) Stephan Windecker (Switzerland)Table of Contents Abbreviations and acronyms2234 What is new in the Universal Definition of Myocardial Infarction? 2234 Universal definitions of myocardial injury and myocardial infarction: summary2235 Introduction2235 Pathological characteristics of myocardial ischaemia and infarction2236 Biomarker detection of myocardial injury and infarction2236 Clinical presentations of myocardial infarction2238 Clinical classification of myocardial infarction2238 7.1.Myocardial infarction type 12238 7.2.Myocardial infarction type 22239 7.3.Myocardial infarction type 2 and myocardial injury2241 7.4.Myocardial Infarction type 32242 8. References2260 Abbreviations and Acronyms ACS Acute coronary syndrome AHA American Heart Association ARC-2 Academic Research Consortium-2 AUC Area under the curve CAD Coronary artery disease CABG Coronary artery bypass grafting CKD Chronic kidney disease CK-MB Creatine kinase MB isoform CMR Cardiac magnetic resonance CTCA Computed tomographic coronary angiography cTn Cardiac troponin cTnI Cardiac troponin I cTnT Cardiac troponin T CT Computed tomography CV Coefficient of variation EF Ejection fraction ECG Electrocardiogram or electrocardiographic HF Heart failure hs-cTn High-sensitivity cardiac troponin IFCC International Federation of Clinical Chemistry and Laboratory Medicine ISFC International Society and Federation of Cardiology LAD Left anterior descending artery LBBB Left bundle branch block; LoD Limit of detection LGE Late gadolinium enhancement LGE-CMR Late gadolinium enhancement cardiac magnetic resonance LV Left ventricular LVH Left ventricular hypertrophy MI Myocardial infarction MINOCA Myocardial infarction with non-obstructive coronary arteries MONICA MONItoring of trends and determinants in CArdiovascular disease MPS Myocardial perfusion scintigraphy NHLBI National Heart, Lung, and Blood Institute NSTEMI Non-ST-elevation myocardial infarction PET Positron emission tomography PCI Percutaneous coronary intervention POC Point of care RBBB Right bundle branch block SPECT Single photon emission computed tomography STEMI ST-elevation myocardial infarction ST-T ST-segment–T wave TIMI Thrombolysis In Myocardial Infarction TTS Takotsubo syndrome UDMI Universal Definition of Myocardial Infarction URL Upper reference limit WHF World Heart Federation WHO World Health Organization 1 What is New in the Universal Definition of Myocardial Infarction? Silent or unrecognized myocardial infarction.ECG = electrocardiogram; MINOCA = myocardial infarction with non-obstructive coronary arteries; STEMI = ST-elevation myocardial infarction. 2 Universal Definitions of Myocardial Injury and Myocardial Infarction: Summary Universal definitions of myocardial injury and myocardial infarctionCriteria for myocardial injuryThe term myocardial injury should be used when there is evidence of elevated cardiac troponin values (cTn) with at least one value above the 99th percentile upper reference limit (URL).
Medical Aphorisms Redux Alpert, Joseph S.
The American journal of medicine,
08/2024
Journal Article
Recenzirano
1.Medicine heals doubt as well as disease (Karl Marx). I estimate that at least half of my outpatient visits and many of my inpatient consults involve relieving patients of anxiety caused by their ...illness or fear of illness. So, even though Karl Marx was not a physician, he must have had experiences where his own doctor relieved illness anxiety.2.At the end of the day, feel happy that you helped someone. For me, my day ends happily when there have been positive interactions with patients in clinic or in the hospital. In a similar vein: The best way to find yourself is to lose yourself in the service of others (Mahatma Gandhi). Helping another human being is perhaps the most satisfying thing that one can do. The Dalai Lama has also said this on many occasions.3.Save one life and you're a hero; save a hundred lives and you're a doctor. This anonymous quote suggests that physicians are constantly saving hundreds of lives. That is indeed an exaggeration, but it is true that improving patients’ lifestyle habits and designing evidence-based medical programs often result in positive clinical outcomes.4.Behind every fine doctor there is a nurse. Every physician knows this or should know this. We see an inpatient for a short time each day. The nursing staff sees that patient throughout the day. Every physician knows that nursing ministrations play a big role in positive patient outcomes.5.“Half of what you'll learn in medical school will be shown to be either wrong or out of date within five years of graduation; the trouble is that nobody can tell you which half, so the important thing to learn is how to learn on your own.” David L. Sackett, OC, MD1 During my long career, I have seen this quote turn out to be correct many times. It has been said that if a doctor were stranded on a desert island for 7 years and then rescued, he or she would have to go back and repeat medical school because everything they knew before being stranded had changed.6.The enemy of good is perfect (alpert). This is particularly true when treating elderly patients. I have seen many geriatric patients with heart failure who developed symptomatic hypotension because of overly enthusiastic dosing of vasodilators, diuretics, and beta blockers. I am constantly telling myself the geriatric maxim: “Start low and go slow”.7.Walking is a man's best medicine (Hippocrates). For most of human history, we have had to exert ourselves vigorously every day to eat and often to avoid being eaten. It is my belief that the need to exercise is imbedded in our DNA. The medical literature is filled with studies documenting the positive health effects of regular exercise. Two similar maxims are: “Only exercise on the days that you eat” (Alpert) and “Exercise is the key not only to physical health but to peace of mind” (Nelson Mandela).8.If you listen to patients carefully enough, they will tell you the diagnosis (Osler). Too often these days, the medical interview is short and performed behind a hand-held computer. This kind of patient/physician interaction can only result in poor outcomes through lack of patient adherence to medical advice. I never hurry my patient encounters, a lesson learned decades ago from outstanding mentors at the Peter Bent Brigham Hospital.9.No matter how old you are, no matter how much you weigh, you can still control the health of your body (Harvey Cushing). Physicians have recognized this maxim since the time of Hippocrates and probably even before that. Patients who follow physician recommendations for lifestyle and therapy have far better outcomes compared with individuals who ignore medical advice.10.Don't get old, Joseph, you won't like it (JSA's mother). Of course, my mother was being sarcastic when in her mid-90’s she told me this. My response was “What choice do I have?” Another clever aphorism reflecting the same truth is “Nobody gets out of this life alive.” What can we do to age gracefully? The answer is stay active by continuing to use muscles and brain, stay connected with loved ones, friends, and colleagues, follow a healthy lifestyle, and work with a physician to control health risks and current disease.11.The only substitute for brilliance is experience (Judah Folkman). Folkman was one of my teachers at Harvard. He was a brilliant surgeon, teacher, investigator and administrator. He died much too young and was often said to be on a short list for the Nobel Prize when he succumbed. He often quoted this aphorism during his weekly research lab meetings.12.Common sense is not so common (Voltaire); “Three fifths of the practice of medicine depends on common sense, knowledge of people and of human relations” (Harvey Cushing). I have many times seen brilliant physicians pursue a diagnostic or therapeutic pathway that makes no sense. For example, offering a coronary angiogram to a bed-ridden patient with chest discomfort and advanced dementia2-4.13.The less a procedure is indicated, the more likely that its and use will be accompanied by complications (Alpert and others). Only consider procedures that have a reasonable chance of improving the patient's prognosis or quality of life. Avoid interventions that offer no benefit to the patient. When complications occur because of an unnecessary test, everyone is unhappy including the physician, the patient, and the patient's family2.14.If you are going through Hell, keep going (Winston Churchill). The Prime minister spoke this axiom to a war weary London undergoing nightly bombing by the Germans during World War II. It can also apply to clinical situations involving critically ill patients. Often, but not always, a satisfactory outcome can be achieved by hard work and “staying the course”.15.Physician, heal thyself (Jesus); every human being is the author of his own health (Buddha). It goes without saying that physicians need to practice what they preach. A doctor who smokes cigarettes will have no success getting his/her patients to stop smoking.16.Physician error is often the result of overconfidence. Better the doctor that says I do not know than the doctor who has an answer to everything (MB Reid, MD). There is no perfection in clinical medicine. Shared decision-making involves pointing out the possible “potholes in the road ahead” rather than glibly telling the patient and their family that nothing can go wrong 2,5.17.Guidelines are guides and not inviolate laws. Guideline directed diagnosis and therapy may not apply to all patients. Individualization of clinical care is the pathway to success.18.The bed sucks strength from the sick (MB Reid, MD). I constantly exhort my hospitalized patients to get out of bed and start walking. If they are unstable on their feet, I ask the nurses to help them get mobilized2.19.To the love of the profession, the physician should add a love of humanity (Hippocrates). The best doctors are those who love people and show it. I cannot imagine a successful clinician who disliked other humans.20.Health is the greatest of human blessings (Hippocrates). “It is health that is the real wealth and not pieces of gold or silver.” (Ghandi). Nothing more need be said about this. It is a universal truth.
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