The Frequency of Type 2 Myocardial Infarction in the Structure of Hospital Mortality According to 7-Years Data of a State University Clinic

Aim      To evaluate the proportion of type 2 myocardial infarction (MI) in the structure of mortality at a multidisciplinary hospital; to describe major causes for MI development, and characteristics of patients with a verified diagnosis of type 2 MI by data of postmortem examination.

Material and methods  1574 protocols of the autopsies performed at the Central Pathology Department of the I.I. Mechnikov North-West State Medical University from 01.01.10 through 31.12.16 were studied retrospectively by the continuous sampling method. A group with verified diagnosis of type 2 MI was isolated from the total sample of autopsies. Major causes for and the proportion of type 2 MI among the causes of death were studied. Also, major demographic parameters, hospitalization profile, and condition of coronary arteries (CA) were compared in patients with fatal type 2 MI and those who died from atherothrombotic type 1 MI.

Results Analysis of 1574 fatal cases among patients of the multidisciplinary hospital showed that in 360 cases (22.87 %), the cause of death was MI, including 137 cases of fatal type 2 MI. Proportions of men and women among the patients with postmortem verification of type 2 MI were comparable. Analysis of the age structure showed the highest incidence of type 2 MI in elderly (48.2 %) and senile (34.3 %) age. Mean age of patients with type 2 MI was 71.7 years (68.2 years for men and 75.3 years for women), which was comparable with the age range of patients with fatal type 1 MI. In both groups, men with fatal MI were significantly younger than women. Analysis of causes for type 2 MI demonstrated that the most frequent ones were tachysystolic arrhythmias (59.12 %) and severe hypoxia of different origin (35.04 %). Analysis of the type of CA lesions showed that significant lesions were significantly more frequently absent in type 2 MI (32.85 %) while in type 1 MI, the proportion of patients with unchanged CA was 1.84 %. In the group of patients with fatal type 1 MI, 67.29 % had multivascular lesions, and one in two patients had an occlusive lesion. In the group with type 2 MI, multivascular lesions were half as frequent (31.38 %), and only 4.38 % of patients had a complete occlusion of a coronary vessel. Comparison of death rate in different departments of the multidisciplinary hospital showed that only 29.2 % of patients with type 2 MI originally were managed at a specialized cardiological department; 45.3 % of patients were admitted to an internal medicine department for different conditions often not related with ischemic heart disease. Furthermore, 25.5 % of patients with subsequently developed type 2 MI originally even received scheduled or emergency medical care for a leading surgical condition.

Conclusion      Cardiovascular diseases predominate among causes of mortality in a multidisciplinary hospital. This study showed that almost one in four patients dies from MI, and type 2 MI accounts for more than one third of fatal MIs. Among major causes for type 2 MI, tachysystolic arrhythmias (59.12 %) and pronounced hypoxia associated with anemia and severe respiratory failure (35.04 %) should be noted. Gender and age characteristics of patients with type 2 MI were comparable with those of patients with fatal type 1 MI. Furthermore, surgical patients accounted for 25.5 % of fatal cases of type 2 MI.

1. Samorodskaya I.V., Barbarash O.L., Kashtalap V.V., Starinskaya M.A. Mortality from myocardial infarction in Russia in the years 2006 and 2015. Russian Journal of Cardiology. 2017;11(151):22-6. https://doi.org/10.15829/1560-4071-2017-11-22-26

2. Sandoval Y, Thygesen K. Myocardial Infarction Type 2 and Myocardial Injury. Clinical Chemistry. 2017;63(1):101-7. https://doi.org/10.1373/clinchem.2016.255521

3. Thygesen K, Alpert JS, White HD, Biomarker Group, Jaffe AS, Apple FS et al. Universal definition of myocardial infarction: Kristian Thygesen, Joseph S. Alpert and Harvey D. White on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. European Heart Journal. 2007;28(20):2525-38. https://doi.org/10.1093/eurheartj/ehm355

4. Kuznetsova O.Yu., Dubikaitis T.A., Frolova E.V., Moiseeva I.E., Zobenko I.A. The classification of acute myocardial infarction types and the preconditions for its development. Type II myocardial infarction. Russian Family Doctor. 2017;21(3):5-15. https://doi.org/10.17816/RFD201735-15

5. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA et al. Fourth Universal Definition of Myocardial Infarction (2018). Global Heart. 2018;13(4):305-38. https://doi.org/10.1016/j.gheart.2018.08.004

6. Zhelnov V.V., Dyatlov N.V., Dvoretsky L.I. Myocardial infarction type 2: myth or reality? Archive of internal medicine. 2016;6(2):34-41. https://doi.org/10.20514/2226-6704-2016-6-2-34-41

7. Greenslade JH, Adikari T, Mueller C, Sandoval Y, Nestelberger T, Parsonage W et al. Characteristics and occurrence of type 2 myocardial infarction in emergency department patients: a prospective study. Emergency Medicine Journal. 2018;35(3):169-75. https://doi.org/10.1136/emermed-2017-206869

8. Szymański FM, Karpiński G, Płatek AE, Majstrak F, HrynkiewiczSzymańska A, Kotkowski M et al. Clinical characteristics, aetiology and occurrence of type 2 acute myocardial infarction. Kardiologia Polska. 2014;72(4):339-44. https://doi.org/10.5603/KP.a2013.0284

9. Melberg T, Burman R, Dickstein K. The impact of the 2007 ESCACC-AHA- WHF Universal definition on the incidence and classification of acute myocardial infarction: a retrospective cohort study. International Journal of Cardiology. 2010;139(3):228-33. https://doi.org/10.1016/j.ijcard.2008.10.021

10. McCarthy CP, Vaduganathan M, Januzzi JL. Type 2 Myocardial Infarction - Diagnosis, Prognosis, and Treatment. JAMA. 2018;320(5):433-4. https://doi.org/10.1001/jama.2018.7125

11. Radovanovic D, Pilgrim T, Seifert B, Urban P, Pedrazzini G, Erne P. Type 2 myocardial infarction: incidence, presentation, treatment and outcome in routine clinical practice. Journal of Cardiovascular Medicine. 2017;18(5):341-7. https://doi.org/10.2459/JCM.0000000000000504

12. Smilowitz NR, Subramanyam P, Gianos E, Reynolds HR, Shah B, Sedlis SP. Treatment and outcomes of type 2 myocardial infarction and myocardial injury compared with type 1 myocardial infarction. Coronary Artery Disease. 2018;29(1):46-52. https://doi.org/10.1097/MCA.0000000000000545

13. Saaby L, Poulsen TS, Diederichsen ACP, Hosbond S, Larsen TB, Schmidt H et al. Mortality Rate in Type 2 Myocardial Infarction: Observations from an Unselected Hospital Cohort. The American Journal of Medicine. 2014;127(4):295-302. https://doi.org/10.1016/j.amjmed.2013.12.020

14. Cediel G, Gonzalez-del-Hoyo M, Carrasquer A, Sanchez R, Boqué C, Bardají A. Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury. Heart. 2017;103(8):616-22. https://doi.org/10.1136/heartjnl-2016-310243

15. Lambrecht S, Sarkisian L, Saaby L, Poulsen TS, Gerke O, Hosbond S et al. Different Causes of Death in Patients with Myocardial Infarction Type 1, Type 2, and Myocardial Injury. The American Journal of Medicine. 2018;131(5):548-54. https://doi.org/10.1016/j.amjmed.2017.11.043

16. Brinkmann C, Schofer J. 4th universal definition of myocardial infarction 2018 : What is new? Herz. 2018;43(8):681-8. https://doi.org/10.1007/s00059-018-4763-6

17. Meier T, Gräfe K, Senn F, Sur P, Stangl GI, Dawczynski C et al. Cardiovascular mortality attributable to dietary risk factors in 51 countries in the WHO European Region from 1990 to 2016: a systematic analysis of the Global Burden of Disease Study. European Journal of Epidemiology. 2019;34(1):37-55. https://doi.org/10.1007/s10654-018-0473-x

18. Zhuravlev Yu.I., Ataev O.G., Krasnovsky A.A., Tkhorikova V.N. Analysis of the hospital letality structure of patients with polymorbide pathology. Scientific reports of Belgorod State University. Series: Medicine. Pharmacy. 2017;26(275):114-22.

19. Saaby L, Poulsen TS, Hosbond S, Larsen TB, Pyndt Diederichsen AC, Hallas J et al. Classification of myocardial infarction: frequency and features of type 2 myocardial infarction. The American Journal of Medicine. 2013;126(9):789-97. https://doi.org/10.1016/j.amjmed.2013.02.029

20. Javed U, Aftab W, Ambrose JA, Wessel RJ, Mouanoutoua M, Huang G et al. Frequency of elevated troponin I and diagnosis of acute myocardial infarction. The American Journal of Cardiology. 2009;104(1):9-13. https://doi.org/10.1016/j.amjcard.2009.03.003

21. Collinson P, Lindahl B. Type 2 myocardial infarction: the chimaera of cardiology? Heart. 2015;101(21):1697-703. https://doi.org/10.1136/heartjnl-2014-307122

22. Putot A, Jeanmichel M, Chagué F, Avondo A, Ray P, Manckoundia P et al. Type 1 or Type 2 Myocardial Infarction in Patients with a History of Coronary Artery Disease: Data from the Emergency Department. Journal of Clinical Medicine. 2019;8(12):2100. https://doi.org/10.3390/jcm8122100