Clinicopathological complexity in the application of the universal definition of myocardial infarction

A universal definition of myocardial infarction (UDMI) has been established, periodically updated, and refined over the past twenty years. The primary purpose of the UDMI is to bring uniformity and accuracy to clinical diagnosis. Herein, a review and analysis of the UDMI is presented with emphasis on clinicopathological correlation. Determination of the presence of myocardial injury is based on the detection of abnormal serum cardiac biomarkers, particularly cardiac troponin (cTn), and in the current fourth iteration of the UDMI, high sensitivity (hs)-cTn. Differentiation of myocardial infarction from other causes of myocardial injury requires the documentation of clinical evidence of myocardial ischemia. In this review, difficulties in applying the UDMI in actual practice are discussed, based on the experience and perspective of those of us who face these problems as part of our own practice of pathology. The complexity in application of the UDMI is highlighted by the presentation of five illustrative cases involving the differential diagnosis of myocardial injury and myocardial infarction due to atherothrombotic and nonatherothrombotic coronary artery disease. The cases include myocardial infarction due to severe coronary atherosclerosis, supply-demand mismatch, coronary artery dissection associated with an eosinophilic coronary periarteritis, and coronary thromboembolism, and a case with a differential diagnosis of myocarditis and myocardial infarction. These cases illustrate how pathological findings can contribute to more accurate application of the UDMI and how, when critically applied, the UDMI can be used to better characterize myocardial infarcts in clinical practice.