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Cardiac
Diagnosis
Coronary Artery Disease
Acute Myocardial Infarction
Acute Myocardial Infarction
Stephan Achenbach, MD, FESC, FACC, FSCCT; Suhny Abbara, MD, FACR, FSCCT; Arzu Canan, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Acute myocardial infarction (MI)
              • Rise &/or fall of cardiac biomarker values (preferably cardiac troponin) and ≥ 1 of following
                • Symptoms of ischaemia
                • New or presumed new significant ST-segment T wave changes or new left bundle branch block
                • Development of pathological Q waves on ECG
                • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
                • Identification of intracoronary thrombus by angiography or autopsy
              • MI is acute coronary syndrome
                • ST-segment elevation MI (STEMI)
                • Non-ST-segment elevation MI (NSTEMI)
                • Unstable angina pectoris
            • Right ventricular myocardial infarction (RVMI): Myocardial infarction of portions or all of right ventricular (RV) free walls and inferior septum
              • Subgroup of patients with left ventricular (LV) inferior wall infarction have concomitant RV infarction
            • Nontransmural myocardial infarction: Infarct affecting subendocardial surface of myocardium with < 100% transmural extension
            • Type II myocardial Infarction: Acute ischemic injury of myocardium unrelated to typical mechanism of plaque rupture and coronary thrombosis, but to other causes such as coronary artery dissection, spasm, or embolism
            • Myocardial infarction with normal coronary arteries (MINOCA) MI in absence or any coronary flow abnormality or obstruction, e.g., due to embolism or transient thrombus.

          IMAGING

          • General Features

            • Radiographic Findings

              • CT Findings

                • MR Findings

                  • Echocardiographic Findings

                    • Angiographic Findings

                      • Nuclear Medicine Findings

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • General Features

                              • Gross Pathologic & Surgical Features

                                CLINICAL ISSUES

                                • Presentation

                                  • Demographics

                                    • Natural History & Prognosis

                                      • Treatment

                                        DIAGNOSTIC CHECKLIST

                                        • Consider

                                          • Image Interpretation Pearls

                                            Selected References

                                            1. Moore A et al: Acute myocardial infarct. Radiol Clin North Am. 57(1):45-55, 2019
                                            2. Thygesen K et al: Fourth universal definition of myocardial infarction (2018). Eur Heart J. 40(3):237-69, 2019
                                            3. Albulushi A et al: Acute right ventricular myocardial infarction. Expert Rev Cardiovasc Ther. 16(7):455-464, 2018
                                            4. Bulluck H et al: Cardiovascular magnetic resonance in acute ST-segment-elevation myocardial infarction: Recent advances, controversies, and future directions. Circulation. 137(18):1949-64, 2018
                                            5. Thygesen K et al: Fourth Universal Definition of Myocardial Infarction (2018). Glob Heart. 13(4):305-338, 2018
                                            6. O'Gara PT et al: 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 127(4):e362-425, 2013
                                            7. Rajiah P et al: MR imaging of myocardial infarction. Radiographics. 33(5):1383-412, 2013
                                            8. Carbone I et al: Myocardial edema imaging by cardiovascular magnetic resonance: current status and future potential. Curr Cardiol Rep. 14(1):1-6, 2012
                                            9. Goldstein JA: Acute right ventricular infarction: insights for the interventional era. Curr Probl Cardiol. 37(12):533-57, 2012
                                            10. Salavati A et al: Dual-source computed tomography angiography for diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. J Cardiovasc Comput Tomogr. 6(2):78-90, 2012
                                            11. So A et al: Prospectively ECG-triggered rapid kV-switching dual-energy CT for quantitative imaging of myocardial perfusion. JACC Cardiovasc Imaging. 5(8):829-36, 2012
                                            12. So A et al: Dual-energy CT and its potential use for quantitative myocardial CT perfusion. J Cardiovasc Comput Tomogr. 6(5):308-17, 2012
                                            13. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC) et al: ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 33(20):2569-619, 2012
                                            14. Thygesen K et al: Third universal definition of myocardial infarction. J Am Coll Cardiol. 60(16):1581-98, 2012
                                            15. Anderson JL et al: ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction. J Am Coll Cardiol. 50(7):e1-e157, 2007. Erratum in: J Am Coll Cardiol. 51(9):974, 2008
                                            16. Florian A et al: Cardiac magnetic resonance imaging in ischemic heart disease: a clinical review. J Med Life. 4(4):330-45, 2011
                                            17. Notghi A et al: Myocardial perfusion scintigraphy: past, present and future. Br J Radiol. 84 Spec No 3:S229-36, 2011
                                            18. Ordovas KG et al: Delayed contrast enhancement on MR images of myocardium: past, present, future. Radiology. 261(2):358-74, 2011
                                            19. Pakkal M et al: Non-invasive imaging in coronary artery disease including anatomical and functional evaluation of ischaemia and viability assessment. Br J Radiol. 84 Spec No 3:S280-95, 2011
                                            20. Kakouros N et al: Right ventricular myocardial infarction: pathophysiology, diagnosis, and management. Postgrad Med J. 86(1022):719-28, 2010
                                            21. Mendoza DD et al: Viability imaging by cardiac computed tomography. J Cardiovasc Comput Tomogr. 4(2):83-91, 2010
                                            22. Dilsizian V et al: PET myocardial perfusion and metabolism clinical imaging. J Nucl Cardiol. 16:651, 2009
                                            23. Kim HW et al: Cardiovascular magnetic resonance in patients with myocardial infarction: current and emerging applications. J Am Coll Cardiol. 55(1):1-16, 2009
                                            24. Friedrich MG: Tissue characterization of acute myocardial infarction and myocarditis by cardiac magnetic resonance. JACC Cardiovasc Imaging. 1(5):652-62, 2008
                                            25. Ibrahim T et al: Diagnostic value of contrast-enhanced magnetic resonance imaging and single-photon emission computed tomography for detection of myocardial necrosis early after acute myocardial infarction. J Am Coll Cardiol. 49(2):208-16, 2007
                                            26. Larose E et al: Right ventricular dysfunction assessed by cardiovascular magnetic resonance imaging predicts poor prognosis late after myocardial infarction. J Am Coll Cardiol. 49(8):855-62, 2007
                                            27. Stork A et al: Value of T2-weighted, first-pass and delayed enhancement, and cine CMR to differentiate between acute and chronic myocardial infarction. Eur Radiol. 17(3):610-7, 2007
                                            28. Cury RC et al: Diagnostic performance of stress perfusion and delayed-enhancement MR imaging in patients with coronary artery disease. Radiology. 240(1):39-45, 2006
                                            29. Kumar A et al: Contrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction. J Am Coll Cardiol. 48(10):1969-76, 2006
                                            30. Nieman K et al: Differentiation of recent and chronic myocardial infarction by cardiac computed tomography. Am J Cardiol. 98(3):303-8, 2006
                                            31. Antman EM et al: Acute myocardial infarction. In Braunwald E: Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia: W. B. Saunders, 2001
                                            32. Ibrahim T et al: Quantitative measurement of infarct size by contrast-enhanced magnetic resonance imaging early after acute myocardial infarction: comparison with single-photon emission tomography using Tc99m-sestamibi. J Am Coll Cardiol. 45(4):544-52, 2005
                                            33. Abdel-Aty H et al: Delayed enhancement and T2-weighted cardiovascular magnetic resonance imaging differentiate acute from chronic myocardial infarction. Circulation. 109(20):2411-6, 2004
                                            34. Mahrholdt H et al: Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation. 109(10):1250-8, 2004
                                            35. Wagner A et al: Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet. 361(9355):374-9, 2003
                                            36. Choi KM et al: Transmural extent of acute myocardial infarction predicts long-term improvement in contractile function. Circulation. 104(10):1101-7, 2001
                                            37. Mehta SR et al: Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiology 37:37-43, 2001
                                            38. Kim RJ et al: Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function. Circulation. 100(19):1992-2002, 1999
                                            39. Wu KC et al: Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation. 97(8):765-72, 1998
                                            40. Zehender M et al: Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med. 328(14):981-8, 1993
                                            41. Reimer KA et al: The wavefront phenomenon of myocardial cell death: transmural progression of necrosis within the framework of ischemic bed size (myocardium at risk) and collateral flow. Lab Invest. 40:633, 1979
                                            42. Weissman HF et al: Effect of extent of transmurality on infarct expansion. Clin Res. 32:477A, 1984
                                            Related Anatomy
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                                            Related Differential Diagnoses
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                                            References
                                            Tables

                                            Tables

                                            KEY FACTS

                                            • Terminology

                                              • Imaging

                                                • Top Differential Diagnoses

                                                  • Clinical Issues

                                                    TERMINOLOGY

                                                    • Definitions

                                                      • Acute myocardial infarction (MI)
                                                        • Rise &/or fall of cardiac biomarker values (preferably cardiac troponin) and ≥ 1 of following
                                                          • Symptoms of ischaemia
                                                          • New or presumed new significant ST-segment T wave changes or new left bundle branch block
                                                          • Development of pathological Q waves on ECG
                                                          • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
                                                          • Identification of intracoronary thrombus by angiography or autopsy
                                                        • MI is acute coronary syndrome
                                                          • ST-segment elevation MI (STEMI)
                                                          • Non-ST-segment elevation MI (NSTEMI)
                                                          • Unstable angina pectoris
                                                      • Right ventricular myocardial infarction (RVMI): Myocardial infarction of portions or all of right ventricular (RV) free walls and inferior septum
                                                        • Subgroup of patients with left ventricular (LV) inferior wall infarction have concomitant RV infarction
                                                      • Nontransmural myocardial infarction: Infarct affecting subendocardial surface of myocardium with < 100% transmural extension
                                                      • Type II myocardial Infarction: Acute ischemic injury of myocardium unrelated to typical mechanism of plaque rupture and coronary thrombosis, but to other causes such as coronary artery dissection, spasm, or embolism
                                                      • Myocardial infarction with normal coronary arteries (MINOCA) MI in absence or any coronary flow abnormality or obstruction, e.g., due to embolism or transient thrombus.

                                                    IMAGING

                                                    • General Features

                                                      • Radiographic Findings

                                                        • CT Findings

                                                          • MR Findings

                                                            • Echocardiographic Findings

                                                              • Angiographic Findings

                                                                • Nuclear Medicine Findings

                                                                  • Imaging Recommendations

                                                                    DIFFERENTIAL DIAGNOSIS

                                                                      PATHOLOGY

                                                                      • General Features

                                                                        • Gross Pathologic & Surgical Features

                                                                          CLINICAL ISSUES

                                                                          • Presentation

                                                                            • Demographics

                                                                              • Natural History & Prognosis

                                                                                • Treatment

                                                                                  DIAGNOSTIC CHECKLIST

                                                                                  • Consider

                                                                                    • Image Interpretation Pearls

                                                                                      Selected References

                                                                                      1. Moore A et al: Acute myocardial infarct. Radiol Clin North Am. 57(1):45-55, 2019
                                                                                      2. Thygesen K et al: Fourth universal definition of myocardial infarction (2018). Eur Heart J. 40(3):237-69, 2019
                                                                                      3. Albulushi A et al: Acute right ventricular myocardial infarction. Expert Rev Cardiovasc Ther. 16(7):455-464, 2018
                                                                                      4. Bulluck H et al: Cardiovascular magnetic resonance in acute ST-segment-elevation myocardial infarction: Recent advances, controversies, and future directions. Circulation. 137(18):1949-64, 2018
                                                                                      5. Thygesen K et al: Fourth Universal Definition of Myocardial Infarction (2018). Glob Heart. 13(4):305-338, 2018
                                                                                      6. O'Gara PT et al: 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 127(4):e362-425, 2013
                                                                                      7. Rajiah P et al: MR imaging of myocardial infarction. Radiographics. 33(5):1383-412, 2013
                                                                                      8. Carbone I et al: Myocardial edema imaging by cardiovascular magnetic resonance: current status and future potential. Curr Cardiol Rep. 14(1):1-6, 2012
                                                                                      9. Goldstein JA: Acute right ventricular infarction: insights for the interventional era. Curr Probl Cardiol. 37(12):533-57, 2012
                                                                                      10. Salavati A et al: Dual-source computed tomography angiography for diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. J Cardiovasc Comput Tomogr. 6(2):78-90, 2012
                                                                                      11. So A et al: Prospectively ECG-triggered rapid kV-switching dual-energy CT for quantitative imaging of myocardial perfusion. JACC Cardiovasc Imaging. 5(8):829-36, 2012
                                                                                      12. So A et al: Dual-energy CT and its potential use for quantitative myocardial CT perfusion. J Cardiovasc Comput Tomogr. 6(5):308-17, 2012
                                                                                      13. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC) et al: ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 33(20):2569-619, 2012
                                                                                      14. Thygesen K et al: Third universal definition of myocardial infarction. J Am Coll Cardiol. 60(16):1581-98, 2012
                                                                                      15. Anderson JL et al: ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction. J Am Coll Cardiol. 50(7):e1-e157, 2007. Erratum in: J Am Coll Cardiol. 51(9):974, 2008
                                                                                      16. Florian A et al: Cardiac magnetic resonance imaging in ischemic heart disease: a clinical review. J Med Life. 4(4):330-45, 2011
                                                                                      17. Notghi A et al: Myocardial perfusion scintigraphy: past, present and future. Br J Radiol. 84 Spec No 3:S229-36, 2011
                                                                                      18. Ordovas KG et al: Delayed contrast enhancement on MR images of myocardium: past, present, future. Radiology. 261(2):358-74, 2011
                                                                                      19. Pakkal M et al: Non-invasive imaging in coronary artery disease including anatomical and functional evaluation of ischaemia and viability assessment. Br J Radiol. 84 Spec No 3:S280-95, 2011
                                                                                      20. Kakouros N et al: Right ventricular myocardial infarction: pathophysiology, diagnosis, and management. Postgrad Med J. 86(1022):719-28, 2010
                                                                                      21. Mendoza DD et al: Viability imaging by cardiac computed tomography. J Cardiovasc Comput Tomogr. 4(2):83-91, 2010
                                                                                      22. Dilsizian V et al: PET myocardial perfusion and metabolism clinical imaging. J Nucl Cardiol. 16:651, 2009
                                                                                      23. Kim HW et al: Cardiovascular magnetic resonance in patients with myocardial infarction: current and emerging applications. J Am Coll Cardiol. 55(1):1-16, 2009
                                                                                      24. Friedrich MG: Tissue characterization of acute myocardial infarction and myocarditis by cardiac magnetic resonance. JACC Cardiovasc Imaging. 1(5):652-62, 2008
                                                                                      25. Ibrahim T et al: Diagnostic value of contrast-enhanced magnetic resonance imaging and single-photon emission computed tomography for detection of myocardial necrosis early after acute myocardial infarction. J Am Coll Cardiol. 49(2):208-16, 2007
                                                                                      26. Larose E et al: Right ventricular dysfunction assessed by cardiovascular magnetic resonance imaging predicts poor prognosis late after myocardial infarction. J Am Coll Cardiol. 49(8):855-62, 2007
                                                                                      27. Stork A et al: Value of T2-weighted, first-pass and delayed enhancement, and cine CMR to differentiate between acute and chronic myocardial infarction. Eur Radiol. 17(3):610-7, 2007
                                                                                      28. Cury RC et al: Diagnostic performance of stress perfusion and delayed-enhancement MR imaging in patients with coronary artery disease. Radiology. 240(1):39-45, 2006
                                                                                      29. Kumar A et al: Contrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction. J Am Coll Cardiol. 48(10):1969-76, 2006
                                                                                      30. Nieman K et al: Differentiation of recent and chronic myocardial infarction by cardiac computed tomography. Am J Cardiol. 98(3):303-8, 2006
                                                                                      31. Antman EM et al: Acute myocardial infarction. In Braunwald E: Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia: W. B. Saunders, 2001
                                                                                      32. Ibrahim T et al: Quantitative measurement of infarct size by contrast-enhanced magnetic resonance imaging early after acute myocardial infarction: comparison with single-photon emission tomography using Tc99m-sestamibi. J Am Coll Cardiol. 45(4):544-52, 2005
                                                                                      33. Abdel-Aty H et al: Delayed enhancement and T2-weighted cardiovascular magnetic resonance imaging differentiate acute from chronic myocardial infarction. Circulation. 109(20):2411-6, 2004
                                                                                      34. Mahrholdt H et al: Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation. 109(10):1250-8, 2004
                                                                                      35. Wagner A et al: Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet. 361(9355):374-9, 2003
                                                                                      36. Choi KM et al: Transmural extent of acute myocardial infarction predicts long-term improvement in contractile function. Circulation. 104(10):1101-7, 2001
                                                                                      37. Mehta SR et al: Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiology 37:37-43, 2001
                                                                                      38. Kim RJ et al: Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function. Circulation. 100(19):1992-2002, 1999
                                                                                      39. Wu KC et al: Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation. 97(8):765-72, 1998
                                                                                      40. Zehender M et al: Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med. 328(14):981-8, 1993
                                                                                      41. Reimer KA et al: The wavefront phenomenon of myocardial cell death: transmural progression of necrosis within the framework of ischemic bed size (myocardium at risk) and collateral flow. Lab Invest. 40:633, 1979
                                                                                      42. Weissman HF et al: Effect of extent of transmurality on infarct expansion. Clin Res. 32:477A, 1984