Prakriti Gaba, MD Cardiovascular Medicine Fellow Brigham and Women's Hospital

Updated Classification of Acute MI Based on Stages of Tissue Injury Severity Interview with:

Prakriti Gaba, MDCardiovascular Medicine Fellow Brigham and Women's Hospital

Dr. Gaba

Prakriti Gaba, MD
Cardiovascular Medicine Fellow
Brigham and Women’s Hospital

Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, FESC Executive Director of Interventional Cardiovascular Programs, Brigham and Women’s Hospital Heart & Vascular Center Professor of Medicine, Harvard Medical School Boston, MA 02115

Dr. Deepak  Bhatt

Deepak L. Bhatt MD MPH
Director of Mount Sinai Fuster Heart Hospital
Dr. Valentin Fuster Professor of Cardiovascular Medicine
Icahn School of Medicine at Mount Sinai What is the background for this study? 

Response: Accurate classification of acute myocardial infarction is instrumental for the appropriate diagnosis and effective management of patients suffering from this widely prevalent cardiovascular condition.

In the past, there have been a variety of clinical scores published to advise clinicians on the best classifications schemes for patients with acute MI. These have included the Thrombolysis in Myocardial Infarction (TIMI) risk score, the HEART score, and the Killip classification. The strength of these traditional scores includes their practicality, as they can be implemented at the bedside to rapidly assist with prognostication. Nonetheless, as technologic advancements have made imaging and tissue identification more accessible, national and international committees are looking to revise traditional classification schemes of acute MI with novel ones leveraging multimodal approaches. What are the main classifications?

Response: In this issue of the Canadian Journal of Cardiology, Kumar et al. present the Canadian Cardiovascular Society (CCS) Classification of Acute Myocardial Infarction, a new expert consensus classification of atherothrombotic MI. Utilizing data on acute MI and reperfusion therapy over the last five decades, this classification scheme highlights four key stages of progressively worsening myocardial tissue injury including:

  • 1) Aborted MI (no/minimal myocardial necrosis)
  • 2) MI with significant cardiomyocyte necrosis but without microvascular injury
  • 3) Cardiomyocyte necrosis and microvascular dysfunction leading to microvascular obstruction (i.e., “no-reflow”), and
  • 4) Cardiomyocyte and microvascular necrosis leading to reperfusion hemorrhage. Injury at each stage builds upon that of the previous stage, escalating in severity and deteriorating prognosis. How can patients and providers utilize this tool?

Response:  In research, the benefits of such a nuanced classification system are evident. The new classification system would allow for the assessment of experimental diagnostic and therapeutic strategies in a more detailed manner. Investigators would be able to understand how tissue changes associated with the various stages of acute MI are impacted by new study treatments.

At the bedside, implementation of the proposed pathology-based classification system would be, at present, more challenging as it relies on pathology-based characteristics obtained using cardiac magnetic resonance (CMR) imaging. Greater access to CMR would be needed to implement this new clinical approach broadly, though for research on emerging diagnostic and therapeutic strategies, it could be implemented immediately. What recommendations do you have for future research as a results of this study?

Response: Moving forward, understanding whether there are ways in which to increase access to CMR will be important for the implementation of this new clinical approach broadly.

Any disclosures?

Response: Prakriti Gaba has no disclosures. Dr. Bhatt discloses the following relationships – Advisory Board: Angiowave, Bayer, Boehringer Ingelheim, Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, Regado Biosciences, Stasys; Board of Directors: Angiowave (stock options), Boston VA Research Institute, Bristol Myers Squibb (stock), DRS.LINQ (stock options), High Enroll (stock), Society of Cardiovascular Patient Care, TobeSoft; Chair: Inaugural Chair, American Heart Association Quality Oversight Committee; Consultant: Broadview Ventures, Hims; Data Monitoring Committees: Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Boston Scientific (Chair, PEITHO trial), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical), Novartis, Population Health Research Institute; Rutgers University (for the NIH-funded MINT Trial); Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News,; Chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol-Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (Course Director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees), Wiley (steering committee); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Patent: Sotagliflozin (named on a patent for sotagliflozin assigned to Brigham and Women’s Hospital who assigned to Lexicon; neither I nor Brigham and Women’s Hospital receive any income from this patent); Research Funding: Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CinCor, Cleerly, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, Youngene, 89Bio; Royalties: Elsevier (Editor, Braunwald’s Heart Disease); Site Co-Investigator: Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St. Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte, Vascular Solutions; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Takeda.


1) Kumar A, Connelly K, Vora K, Bainey KR, Howarth A, Leipsic J, Betteridge-LeBlanc S, Prato FS, Leong-Poi H, Main A, Atoui R, Saw J, Larose E, Graham MM, Ruel M, Dharmakumar R. The Canadian Cardiovascular Society Classification of Acute Atherothrombotic Myocardial Infarction Based on Stages of Tissue Injury Severity: An Expert Consensus Statement. Can J Cardiol. 2023 Oct 26:S0828-282X(23)01735-X. doi: 10.1016/j.cjca.2023.09.020. Epub ahead of print. PMID: 37906238.

2)Promise of a Novel Classification System for Acute Myocardial Infarction
Prakriti Gaba, M.D. Deepak L. Bhatt, M.D., M.P.H.
Published:October 27, 2023

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Last Updated on November 6, 2023 by Marie Benz