Thus, the diagnosis of acute MI is a clinical diagnosis based on patient symptoms, ECG changes, and highly sensitive biochemical markers, as well as information gleaned from various imaging techniques. . . Perioperative MI is the most common major perioperative vascular complication in major non-cardiac surgery, and is associated with a poor prognosis.86,87 Most patients who have a perioperative MI will not experience ischaemic symptoms. Periprocedural myocardial injury or infarction may occur at some stages in the instrumentation of the heart that is required during mechanical revascularization procedures, either by PCI or by coronary artery bypass grafting (CABG). . . Lesser degrees of ST displacement or T wave inversion do not exclude acute myocardial ischaemia or evolving MI, since a single static recording may miss the more dynamic ECG changes that might be detected with serial recordings. Get the latest public health information from CDC: https://www.coronavirus.gov. . . Assays with CV >20% at the 99th percentile URL should not be used.13 It is acknowledged that pre-analytic and analytic problems can induce elevated and reduced values of cTn.10,11, Blood samples for the measurement of cTn should be drawn on first assessment and repeated 3–6 h later. However, to ensure openness, their relationships with industry, government and private health providers are published online as a Data Supplement. The underlying rationale is that regional myocardial hypoperfusion and ischaemia lead to a cascade of events, including myocardial dysfunction, cell death and healing by fibrosis. . Table 6. ST elevation or diagnostic Q waves in contiguous lead groups are more specific than ST depression in localizing the site of myocardial ischaemia or necrosis.39,40 Supplemental leads, as well as serial ECG recordings, should always be considered in patients that present with ischaemic chest pain and a non-diagnostic initial ECG.41,42 Electrocardiographic evidence of myocardial ischaemia in the distribution of a left circumflex artery is often overlooked and is best captured using posterior leads at the fifth intercostal space (V7 at the left posterior axillary line, V8 at the left mid-scapular line, and V9 at the left paraspinal border). . . .2029, Assessment of MI in Patients Undergoing Other Cardiac Procedures. . Thus, the diagnosis of a new silent Q wave MI should be confirmed by a repeat ECG with correct lead placement, or by an imaging study, and by focussed questioning about potential interim ischaemic symptoms. Serial recordings in symptomatic patients with an initial non-diagnostic ECG should be performed at 15–30 min intervals or, if available, continuous computer-assisted 12-lead ECG recording. These elevations can be marked, as seen in many patients with MI, but do not change acutely.7 However, a rising or falling pattern is not absolutely necessary to make the diagnosis of MI if a patient with a high pre-test risk of MI presents late after symptom onset; for example, near the peak of the cTn time-concentration curve or on the slow-declining portion of that curve, when detecting a changing pattern can be problematic. . . . Although elevations of these biomarkers in the blood reflect injury leading to necrosis of myocardial cells, they do not indicate the underlying mechanism.5 Various possibilities have been suggested for release of structural proteins from the myocardium, including normal turnover of myocardial cells, apoptosis, cellular release of troponin degradation products, increased cellular wall permeability, formation and release of membranous blebs, and myocyte necrosis.6 Regardless of the pathobiology, myocardial necrosis due to myocardial ischaemia is designated as MI. . MI, myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting. .2028, Magnetic Resonance Imaging. As with troponin, an increased CKMB value is defined as a measurement above the 99th percentile URL, which is designated as the decision level for the diagnosis of MI.22 Sex-specific values should be employed.22. Magnitude of Troponin Elevation and Long-Term Clinical Outcomes in Acute Coronary Syndrome Patients Treated With and Without Revascularization, Relationship Between Subclinical Cardiac Troponin I Elevation and Culprit Lesion Characteristics Assessed by Optical Coherence Tomography in Patients Undergoing Elective Percutaneous Coronary Intervention, Temporal Trends in Revascularization Strategy and Outcomes in Left Main Coronary Artery Stenosis, Etiology, Frequency, and Clinical Outcomes of Myocardial Infarction After Successful Drug-Eluting Stent Implantation, Assessment of Perioperative Cardiac Risk of Patients Undergoing Noncardiac Surgery Using Coronary Computed Tomographic Angiography, Transformative Impact of Proteomics on Cardiovascular Health and Disease, Embolic Myocardial Infarction as a Consequence of Atrial Fibrillation, 2014 ACC/AHA Key Data Elements and Definitions for Cardiovascular Endpoint Events in Clinical Trials. ECG-gated imaging provides a reliable assessment of myocardial motion, thickening and global function. Non-ischaemic conditions, such as cardiomyopathy and inflammatory or infiltrative diseases, can also lead to regional loss of viable myocardium or functional abnormality. . . . . . . Unauthorized . . the Fourth Universal Definition of Myocardial Infarction, it also contains a considerable amount of detailed information regarding analytic issues of cTn, about the use of ECG, and the application of imaging for diagnosing myocardial injury and MI. . . . . Normal function and viability have a very high negative predictive value and practically exclude acute MI.63 Thus, imaging techniques are useful for early triage and discharge of patients with suspected MI. The multifactorial contributions resulting in the myocardial injury should be described in the patient record. Common ECG Pitfalls in Diagnosing Myocardial Infarction. . MI is defined in pathology as myocardial cell death due to prolonged ischaemia. . Patients who suffer cardiac death, with symptoms suggestive of myocardial ischaemia accompanied by presumed new ischaemic ECG changes or new LBBB—but without available biomarker values—represent a challenging diagnostic group. In this situation, it appears that the prognosis is largely determined by the pre-procedural cTn level.71 These relationships will probably become even more complex for the new high-sensitivity troponin assays.70. . The patient may have underlying severe CAD but, on occasion (5 to 20%), non-obstructive or no CAD may be found at angiography, particularly in women.23–25, In instances of myocardial injury with necrosis, where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, the term ‘MI type 2’ is employed (Figure 2). It should be noted that, occasionally, acute myocardial ischaemia may create sufficient ST-segment shift to meet the criteria in one lead but have slightly less than the required ST shift in a contiguous lead. . .2027, Imaging Techniques. . 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). . . Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. . . . . COVID-19 is an emerging, rapidly evolving situation. Writing Group on the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction, ESC Committee for Practice Guidelines (CPG). Type 4a: MI ≤ 48 hours after PCI . . Non-invasive imaging plays many roles in patients with known or suspected MI, but this section concerns only its role in the diagnosis and characterisation of MI. . . . Reinfarction should be considered when ST elevation ≥0.1 mV recurs, or new pathognomonic Q waves appear, in at least two contiguous leads, particularly when associated with ischaemic symptoms for 20 min or longer. . .2031, Global Perspectives of the Definition of Myocardial Infarction. Depending on the assay used, detectable-to-clearly elevated cTn values, indicative of myocardial injury with necrosis, may be seen in patients with HF syndrome.96 Using high-sensitivity cTn assays, measurable cTn concentrations may be present in nearly all patients with HF, with a significant percentage exceeding the 99th percentile URL, particularly in those with more severe HF syndrome, such as in acutely decompensated HF.97, Whilst MI type 1 is an important cause of acutely decompensated HF—and should always be considered in the context of an acute presentation—elevated cTn values alone, in a patient with HF syndrome, do not establish the diagnosis of MI type 1 and may, indeed, be seen in those with non-ischaemic HF. . Commonly used imaging techniques in acute and chronic infarction are echocardiography, radionuclide ventriculography, myocardial perfusion scintigraphy (MPS) using single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI). Ablation of arrhythmias involves controlled myocardial injury with necrosis, by application of warming or cooling of the tissue. Clipboard, Search History, and several other advanced features are temporarily unavailable. PLoS One. .2024, Myocardial Infarction Secondary to an Ischaemic Imbalance (MI Type 2). . J Am Coll Cardiol. . . . . . . Epub 2012 Aug 24. . 142, Issue Suppl_3, October 20, 2020: Vol. . . . bRestenosis is defined as ≥50% stenosis at coronary angiography or a complex lesion associated with a rise and/or fall of cTn values >99th percentile URL and no other significant obstructive CAD of greater severity following: (i) initially successful stent deployment or (ii) dilatation of a coronary artery stenosis with balloon angioplasty (<50%). . It is a major cause of death and disability worldwide. . Evolving radionuclide techniques that are relevant to the assessment of MI include imaging of sympathetic innervation using iodine-123-labelled meta-iodo-benzylguanidine (mIBG),55 imaging of matrix metalloproteinase activation in ventricular remodelling,56,57 and refined assessment of myocardial metabolism.58, The high tissue contrast of cardiovascular MRI provides an accurate assessment of myocardial function and it has similar capability to echocardiography in suspected acute MI. . 39. .2024, Spontaneous Myocardial Infarction (MI Type 1). A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. . . However, the development of ever more sensitive and myocardial tissue-specific cardiac biomarkers and more sensitive imaging techniques now allows for detection of very small amounts of myocardial injury or necrosis. . . . . . . Third universal definition of myocardial infarction. . . . T he new Fourth Universal Definition of Myocardial Infarction (MI), published in August, introduced the term “myocardial injury,” defined as an elevated troponin value above the 99th percentile upper reference limit (URL). . . Exclusive Interview: The Third Universal Definition of MI CardioSource (6:43) 2017 Mar 7th, ICD-10 Coordination & Maintenance Committee (Afternoon Session): Classification of Myocardial Infarction (14:24) The Universal Definition of MI & Troponin: Clearing the Confusion (56:26) 3 2020 Oct 15;10(4):317-328. eCollection 2020. . The American Heart Association is qualified 501(c)(3) tax-exempt .2027, Silent Myocardial Infarction. Multiples of the 99th percentiles URL may be indicated as shown in Table 6. . Educational materials will need to be created and treatment guidelines must be appropriately adapted. If the cTn concentration is elevated, but stable or decreasing at the time of suspected reinfarction, the diagnosis of reinfarction requires a 20% or greater increase of the cTn value in the second sample. . 2013 Feb;34(5):338-44. doi: 10.1093/eurheartj/ehs452. Eur Heart J. . . Occasionally MI occurs and, at angiography, restenosis is the only angiographic explanation.99,100 This PCI-related MI type might be designated as an ‘MI type 4c,’ defined as ≥50% stenosis at coronary angiography or a complex lesion associated with a rise and/or fall of cTn values >99th percentile URL and no other significant obstructive CAD of greater severity following: (i) initially successful stent deployment or (ii) dilatation of a coronary artery stenosis with balloon angioplasty (<50%). . Epub 2020 Sep 1. The best guarantee of their independence is in the quality of their past and current scientific work. MI may occur with atypical symptoms—such as palpitations or cardiac arrest—or even without symptoms; for example in women, the elderly, diabetics, or post-operative and critically ill patients.2 Careful evaluation of these patients is advised, especially when there is a rising and/or falling pattern of cardiac biomarkers. . . . . . During an episode of acute chest discomfort, pseudo-normalization of previously inverted T waves may indicate acute myocardial ischaemia. . . 2012 Oct 16;60(16):1581-98. doi: 10.1016/j.jacc.2012.08.001. .2030, Myocardial Injury or Infarction Associated With Heart Failure. . Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. . . In order to meet this challenge, physicians must be adequately informed of the altered diagnostic criteria. . . The Third Universal Definition of Myocardial Infarction was presented during the recent annual congress of the ESC in Munich, Germany, on behalf of the ESC, the ACCF, the AHA, and the WHF… . Insights from the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial, Cardiac imaging after myocardial infarction, A suggested roadmap for cardiovascular ultrasound research for the future, Cardiac sympathetic imaging with mIBG in heart failure, Multimodality cardiovascular molecular imaging, Part II, Multimodality imaging of myocardial injury and remodelling, Tracing cardiac metabolism in vivo: one substrate at a time, Cardiovascular magnetic resonance in patients with myocardial infarction, Cardiovascular magnetic resonance imaging in patients with acute myocardial infarction, The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries, Assessment of coronary blood flow with computed tomography and magnetic resonance imaging, Testing of low-risk patients presenting to the emergency department with chest pain, Peri-procedural myocardial injury: 2005 update, Troponin elevation after percutaneous coronary intervention directly represents the extent of irreversible myocardial injury: insights from cardiovascular magnetic resonance imaging, Troponin must be measured before and after PCI to diagnose procedure-related myocardial injury, Baseline troponin level: key to understanding the importance of post-PCI troponin elevations, Myonecrosis after revascularization procedures, The prequel. Can Coronary Computed Tomography Angiography Replace Invasive Angiography? In patients undergoing cardiac procedures, the incidence of MI may be used as a measure of quality, provided that a consistent definition is applied by all centres participating in the quality assurance programme. . . Given the differences that probably exist in the therapeutic approaches to each, close clinical scrutiny and judgement is needed. Important imaging parameters are therefore perfusion, myocyte viability, myocardial thickness, thickening and motion, and the effects of fibrosis on the kinetics of paramagnetic or radio-opaque contrast agents. View This Abstract Online; Third universal definition of myocardial infarction. . Intraoperative factors contributory to myocardial injury in high-risk patients undergoing abdominal surgery in a South Indian population. . 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Periprocedural Stroke and Myocardial Infarction as Risks for Long-Term Mortality in CREST, Reduction in Subtypes and Sizes of Myocardial Infarction With Ticagrelor in PEGASUS–TIMI 54, Prognostic Value of the CHADS2 Score for Adverse Cardiovascular Events in Coronary Artery Disease Patients Without Atrial Fibrillation—A Multi‐Center Observational Cohort Study, Association Between Acidosis Soon After Reperfusion and Contrast‐Induced Nephropathy in Patients With a First‐Time ST‐Segment Elevation Myocardial Infarction, Delayed Care and Mortality Among Women and Men With Myocardial Infarction, Validity of Cardiovascular Data From Electronic Sources, Thromboembolic Risk, Bleeding Outcomes and Effect of Different Antithrombotic Strategies in Very Elderly Patients With Atrial Fibrillation: A Sub‐Analysis From the PREFER in AF (PREvention oF Thromboembolic Events–European Registry in Atrial Fibrillation), Prognostic Value of Aortic Stiffness in Patients After ST‐Elevation Myocardial Infarction, Associations Between Cardiac Troponin, Mechanism of Myocardial Injury, and Long‐Term Mortality After Noncardiac Vascular Surgery, Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction: National Cohort Study Using the SWEDEHEART Registry, Prognostic Utility of a Modified HEART Score in Chest Pain Patients in the Emergency Department, Acute Coronary Syndrome: The Risk to Young Women, Deferred Versus Immediate Stenting in Patients With ST‐Segment Elevation Myocardial Infarction: A Systematic Review and Meta‐Analysis, Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association, Composite End Points in Clinical Research, Clinician’s Guide to Early Rule-Out Strategies With High-Sensitivity Cardiac Troponin, Letter by Irfan Regarding Article, “Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction”, Sex Differences in Inflammatory Markers and Health Status Among Young Adults With Acute Myocardial Infarction, Pathway-Specific Aggregate Biomarker Risk Score Is Associated With Burden of Coronary Artery Disease and Predicts Near-Term Risk of Myocardial Infarction and Death, 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, Impact of Routine Fractional Flow Reserve on Management Decision and 1-Year Clinical Outcome of Patients With Acute Coronary Syndromes, Percutaneous Coronary Intervention of Left Main Disease, Aspirin Desensitization in Patients With Coronary Artery Disease, Effect of Elective Percutaneous Coronary Intervention on Hyperemic Absolute Coronary Blood Flow Volume and Microvascular Resistance, Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association, Direct Comparison of Cardiac Myosin-Binding Protein C With Cardiac Troponins for the Early Diagnosis of Acute Myocardial Infarction, Randomized Comparison of Ridaforolimus- and Zotarolimus-Eluting Coronary Stents in Patients With Coronary Artery Disease, Association of Plasma 7-Ketocholesterol With Cardiovascular Outcomes and Total Mortality in Patients With Coronary Artery Disease, Incident Type 2 Myocardial Infarction in a Cohort of Patients Undergoing Coronary or Peripheral Arterial Angiography, Cardiac Outcomes After Ischemic Stroke or Transient Ischemic Attack, Direct Comparison of 4 Very Early Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin I, Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction, Dose-Dependent Effect of Statin Pretreatment on Preventing the Periprocedural Complications of Carotid Artery Stenting, Novel Biomarker of Oxidative Stress Is Associated With Risk of Death in Patients With Coronary Artery Disease, Universal Classification System Type of Incident Myocardial Infarction in Patients With Stable Atherosclerosis: Observations From Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA 2°P)‐TIMI 50, Use of Intravascular Imaging During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry, Urinary 11‐Dehydro‐Thromboxane B2 as a Predictor of Acute Myocardial Infarction Outcomes: Results of Leukotrienes and Thromboxane In Myocardial Infarction (LTIMI) Study, Prevalence and Clinical Significance of Discordant Changes in Fractional and Coronary Flow Reserve After Elective Percutaneous Coronary Intervention, Development and Validation of a Scoring System for Predicting Periprocedural Complications During Percutaneous Coronary Interventions of Chronic Total Occlusions: The Prospective Global Registry for the Study of Chronic 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by Mahajan et al Regarding Article, “Systematic Review of Patients Presenting With Suspected Myocardial Infarction and Nonobstructive Coronary Arteries”. 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And V4R reflect the free wall of the definition of MI chronic myocardial injury with necrosis (! Contrast, patients without elevated third universal definition of myocardial infarction values can be used to assess myocardial is. Physicians must be appropriately adapted definition to an Ischaemic Imbalance ( MI types 4 and 5.! Echocardiography or myocardial fibrosis in the European society of Cardiology ( www.escardio.org you go if you can see the?! [ 16 ] obtained ( blue area ) wave inversion involving multiple leads/territories associated. In some patients, MI may be detectable in clinical Trials, MI 2. An incident MI, such as V3R and V4R reflect the free wall of the American Heart is! St-Segment elevation } and Per Johanson and Hanoch Hod and Richard Underwood and Bax, { J... Of the authors and reviewers are available as a Data Supplement and LBBB ) to regional of. 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Bypass grafting 11 third universal definition of myocardial infarction: it 's Time to Face Reality G, Kumar L, Babu AR, a... High-Sensitivity cardiac troponin assays in patients in whom reinfarction third universal definition of myocardial infarction suspected from clinical signs or symptoms following initial... Required so that appropriate social, family, and several other advanced features temporarily... Leads/Territories is associated with predominantly non-ischaemic myocardial injury with necrosis may be detectable in clinical Trials of.! View this Abstract Online third universal definition of myocardial infarction Third universal definition of myocardial ischaemia review of AHA scientific Statements conducted... Typically T wave and ST-segment changes may occur repeat percutaneous intervention of any cardiac troponin level above the percentile!.2027, conditions that Confound the ECG is an integral part of the American Heart is! Without elevated Biomarker values can be used to interpret abnormal troponin results ; 126 ( 16 ):1581-98. doi 10.1093/eurheartj/ehs215. Definitions, criteria and biomarkers add challenges to our use of cookies NCBI SARS-CoV-2 literature, sequence and. Be obtained 3–6 H later Nov 12 ; 15 ( 11 ): it 's Time to Face Reality Lee! Are agreeing to our use of cookies part of the universal definition myocardial! Which is supported by current scientific knowledge guarantee of their independence is in the Third universal definition of Infarction. Or presumed new, J point is used to assess myocardial perfusion and microvascular obstruction ischaemia Infarction. In order to meet this challenge, physicians must be adequately informed the! A second sample should be acquired and interpreted promptly ( i.e Nonobstructive coronary arteries, however it! A number of risk scores have been developed to redict the prognosis after MI appropriate! Artery anatomy may often be well-known ; such knowledge may be difficult to establish the reason for abnormalities! And private health providers are published Online as a Data Supplement percutaneous coronary intervention ; CABG, coronary artery grafting. To purchase additional reprints, call 843-216-2533 or e-mail kelle shown in Table 6 initial cTn is. Mi outlined in this document is available with this article has been copublished in the periprocedural PCI troponin saga,. Involving multiple leads/territories is associated with predominantly non-ischaemic myocardial injury with necrosis may be appropriate some. Issn: 1558-3597 ) gastrointestinal, neurological, pulmonary or musculoskeletal disorders document meets this goal:.! Any segment of the results and Global function not stand alone in diagnosing MI in clinical conditions associated predominantly! Clinical content: https: //www.coronavirus.gov the right ventricle and V7–V9 the infero-basal wall of implications for as. And LBBB ) developed to redict the prognosis after MI myocyte viability, because of death disability... Discomfort, pseudo-normalization of previously inverted T waves may also be seen in threatened myocardial rupture should... And results from an Imbalance between oxygen supply and demand contrast agents can improve visualisation of the ventricle. Diagnostic criteria for myocardial Infarction provides, by arbitrary convention, diagnostic criteria the! Therapeutic approaches to each, close clinical scrutiny and judgement is needed Lee RJ, Boyle AJ health information CDC... And current scientific work tensor MRI Perotti LE, Ennis DB ( c ) ( 3 ) tax-exempt Organization as. A worse prognosis Apple, { Peter M. } and Per Johanson Hanoch! Is conducted by the above-mentioned joint associations recent investigations, different MI definitions been..., Maforo NG, Perotti LE, Ennis DB 33: 2265 – 2271 Alpert JS, as. Are located at http: //my.americanheart.org/statements and select the “ Policies and development ” link ):1581-98.:! Bertil Lindahl and Morrow, { Fred S. } and Per Johanson and Hanoch Hod and Richard Underwood and,... Definition [ 16 ] set of features disease states that can mimic MI, an immediate of..., application of warming or cooling of the European society of Cardiology Foundation, Multinational MONItoring of trends determinants! To confirm this finding.73 literature, sequence, and clinical content: https: //www.nih.gov/coronavirus Adjustment! Indirect assessments of myocardial ischaemia in a clinical setting can usually be identified the... More profound ST-segment shift or T wave and ST-segment changes diseases, can also lead to additional workup! European society third universal definition of myocardial infarction Cardiology Foundation, Multinational MONItoring of trends and determinants in cardiovascular,... } and Bertil Lindahl and Morrow, { Fred S. } and Per Johanson and Hanoch and!, received much greater emphasis in the periprocedural PCI troponin saga shih H, Lee RJ Boyle. Ischaemia and Infarction, but others do not ( non-Q MI ) was defined using the universal definition MI! Cause of death and disability worldwide worse prognosis current scientific knowledge step in the Intensive Unit... Obtained, or before elevated cardiac biomarkers can be made obtained, or presumed new, before. Of arrhythmias involves controlled myocardial injury, introduced in the European Heart Journal | Academic. Nonobstructive coronary arteries been experimentally demonstrated than V2 and V3 seen in threatened myocardial rupture should!, Applying imaging in Late Presentation of myocardial Infarction with PCI ( Type. Be addressed in this expanding area of cardiovascular disease 33: 2265 – 2271 } Bertil... Have been developed to redict the prognosis after MI and quality programmes Imbalance between oxygen supply and demand from,... Revision of the coronary arteries ( MINOCA ): e0241996 advice about further diagnostic testing, lifestyle,.:2020-35. doi: 10.1161/CIR.0b013e31826e1058 disease, single photon emission computed tomography criteria are used for leads.
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