心肌梗死全球统一定义与影像学诊断,何作祥 中国医学科学院阜外心血管病医院,Thygesen, K. et al. Circulation 2007;116:2634-2653,Criteria for Acute MI,Criteria for Acute MI,Criteria for Acute MI,Criteria for Acute MI,Criteria for Acute MI,Criteria for Acute MI,Criteria for Prior MI,Thygesen, K. et al. Circulation 2007;116:2634-2653,Biomarker Evaluation,The preferred biomarker for myocardial necrosis is cardiac troponin (I or T), which has nearly absolute myocardial tissue specificity as well as high clinical sensitivity, thereby reflecting even microscopic zones of myocardial necrosis. If troponin assays are not available, the best alternative is CKMB (measured by mass assay).,Electrocardiographic Detection of Myocardial Infarction,The ECG is an integral part of the diagnostic work-up of patients with suspected myocardial infarction. The acute or evolving changes in the ST-T waveforms and the Q-waves when present potentially allow the clinician to date the event, to suggest the infarct-related artery, and to estimate the amount of myocardium at risk.,Electrocardiographic Detection of Myocardial Infarction,Coronary artery dominance, size and distribution of arterial segments, collateral vessels, and location, extent, and severity of coronary stenoses can also impact ECG manifestations of myocardial ischemia.,Electrocardiographic Detection of Myocardial Infarction,The ECG by itself is often insufficient to diagnose acute myocardial ischemia or infarction since ST deviation may be observed in other conditions such as acute pericarditis, LV hypertrophy, LBBB, Brugada syndrome, and early repolarization patterns. Also Q-waves may occur due to myocardial fibrosis in the absence of coronary artery disease, as in, for example, cardiomyopathy.,Imaging Techniques,The underlying rationale is that regional myocardial hypoperfusion and ischemia lead to a cascade of events including myocardial dysfunction, cell death, and healing by fibrosis. Important imaging parameters are therefore perfusion, myocyte viability, myocardial thickness, thickening, and motion, and the effects of fibrosis on the kinetics of radiolabeled and paramagnetic contrast agents.,Echocardiography,Echocardiography is an excellent real-time imaging technique with moderate spatial and temporal resolution. Its strength is the assessment of myocardial thickness, thickening, and motion at rest. This can be aided by tissue Doppler imaging. Echocardiographic contrast agents can improve endocardial visualization, but contrast studies are not yet fully validated for the detection of myocardial necrosis, although early work is encouraging.,Radionuclide Imaging,Several radionuclide tracers allow viable myocytes to be imaged directly, including thallium-201, technetium-99m MIBI, tetrofosmin, and 18F2-fluorodeoxyglucose (FDG). The strength of the techniques are that they are the only commonly available direct methods of assessing viability, although the relatively low resolution of the images disadvantages them for detecting small areas of infarction.,Radionuclide Imaging,The common single photon-emitting radio-pharmaceuticals are also tracers of myocardial perfusion and so the techniques readily detect areas of infarction and inducible perfusion abnormalities. ECG-gated imaging provides a reliable assessment of myocardial motion, thickening, and global function.,Magnetic Resonance Imaging,Cardiovascular MRI has high spatial resolution and moderate temporal resolution. It is a well-validated standard for the assessment of myocardial function and has, in theory, similar capability to echocardiography in suspected acute infarction. It is, however, more cumbersome in an acute setting and is not commonly used.,Magnetic Resonance Imaging,Paramagnetic contrast agents can be used to assess myocardial perfusion and the increase in extracellular space associated with the fibrosis of chronic infarction. The former is not yet fully validated in clinical practice, but the latter is well validated and can play an important role in the detection of infarction.,X-Ray Computed Tomography,Infarcted myocardium is initially visible to CT as a focal area of decreased LV enhancement, but later imaging shows hyperenhancement as with late gadolinium imaging by MRI. This finding is clinically relevant because contrast enhanced CT may be performed for suspected embolism and aortic dissection, conditions with clinical features that overlap with those of acute myocardial infarction.,关键要点,心电图着重急性心肌缺血和先前（陈旧性）心肌梗死标准 生物标志物明确强调首推肌钙蛋白，CK-MB是次选，不被推荐 影像技术的发展使其在心肌梗死的诊断和分型中有一席之地,