Myocardial Ischemic Syndromes: A New Nomenclature to Harmonize Evolving International Clinical Practice Guidelines
William E Boden1, Raffaele De Caterina1, Juan Carlos Kaski2
1VA Boston Healthcare System, Boston University School of Medicine, Boston, MA (W.E.B.).
Insights
New terminology for myocardial ischemia syndromes is proposed to unify classifications and improve patient care. This aims to encompass both obstructive and non-obstructive causes, enhancing diagnostic and therapeutic strategies for angina and infarction.
Area of Science:
- Cardiology
- Medical Terminology
- Ischemic Heart Disease
Background:
- Current classifications for myocardial ischemia lack consistency, using terms like "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS).
- Conflicting guidelines (European vs. American) and restrictive terminology perpetuate a narrow view of CAD, often overlooking non-obstructive mechanisms.
- Existing classifications fail to inclusively address diverse causes of angina and myocardial ischemia, hindering conceptual clarity and unified management.
Purpose of the Study:
- To propose a new, inclusive binary classification for myocardial ischemic syndromes.
- To advance terminology that encompasses both obstructive and non-obstructive causes of ischemia, including microvascular dysfunction and vasospastic disorders.
- To harmonize dyssynchronous nomenclatures across international guidelines for improved diagnostic and therapeutic approaches.
Main Methods:
- Review and analysis of existing classification systems for acute myocardial infarction (MI) and chronic stable manifestations of myocardial ischemia.
- Development of a novel binary classification: "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes."
- Integration of established categories (e.g., ACS, STEMI, NSTEMI) and emerging concepts (e.g., MI with non-obstructive coronary arteries) into the proposed framework.
Main Results:
- A proposed binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes."
- The new classification incorporates obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes.
- Retains established MI categories while accommodating new terms for ischemia and MI with non-obstructive coronary arteries.
Conclusions:
- The proposed nomenclature offers a more encompassing framework for understanding myocardial ischemia.
- This unified terminology aims to refine diagnostic and therapeutic strategies by addressing multiple pathophysiologic causes of angina, ischemia, and infarction.
- Adoption of this inclusive classification should lead to more targeted patient management and improved outcomes in ischemic heart disease.
Abstract:
Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischemia, various classifications have emerged over time, often with conflicting terminology-eg, "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with "acute coronary syndromes" (ACS), the 2023 American guidelines endorsed the alternative term "chronic coronary disease." An unintended consequence of these competing classifications is perpetuation of the restrictive terms "coronary" and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes," which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischemia, and infarction.
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