Fifth Universal Definition of Myocardial Infarction (2026)

1. Executive summary 4 2. Context 4 3. Objective 5 4. What is new 5 5. Definition of myocardial infarction 5 6. Acute and chronic myocardial injury 7 6.1. Acute myocardial injury 8 6.2. Chronic myocardial injury 8 7. Classification of myocardial infarction 9 7.1. Approaches to the classification of myocardial infarction 9 7.1.1. Classification based on aetiology 9 7.1.2. Classification based on the electrocardiogram 10 7.2. Clinical classification of myocardial infarction 10 7.2.1. Primary myocardial infarction 10 7.2.2. Secondary myocardial infarction 13 7.2.3. Procedure-related myocardial infarction 16 8. Diagnosis of myocardial infarction following sudden death 19 9. Silent or unrecognized myocardial infarction 20 10. Unstable angina 20 11. Myocardial injury with non-obstructive coronary arteries 21 12. Symptoms of myocardial infarction 21 13. The electrocardiogram 21 14. Cardiac biomarkers 23 14.1. Cardiac troponin 24 14.1.1. Defining the 99th percentile upper reference limit 24 14.1.2. Analytical considerations 25 14.1.3. Serial measurements 25 14.1.4. Defining a significant rise and fall 26 14.1.5. Accelerated diagnostic pathways 27 14.1.6. Interpretation of cardiac troponin for diagnosis 27 14.2. Alternative biomarkers of myocardial injury 27 15. Coronary and cardiac imaging 28 15.1. Invasive imaging 28 15.1.1. Invasive coronary angiography 28 15.1.2. Intravascular imaging 28 15.1.3. Invasive functional testing 28 15.2. Non-invasive imaging 28 15.2.1. Echocardiography 29 15.2.2. Cardiac magnetic resonance imaging 29 15.2.3. Coronary computed tomography angiography 29 15.2.4. Nuclear medicine 29 16. Special situations 30 16.1. Recurrent myocardial infarction 30 16.2. Heart failure 31 16.3. Chronic kidney disease 32 16.4. Critical illness 32 16.5. Non-cardiac surgery 33 16.6. Structural cardiac intervention 33 16.7. Cardio-oncology 34 17. Implications for patients, secondary prevention, and cardiac rehabilitation 34 18. Implications for public health and classification of disease 34 19. Implications and adaptions for low-resource settings 35 20. Implications of the definition on research 35 21. Evidence tables 37 22. Data availability 37 23. Author information 37 24. Appendix 37 25. References 38 Box 1: Criteria for acute myocardial injury 8 Box 2: Criteria for chronic myocardial injury 8 Box 3: Diagnostic criteria for primary myocardial infarction 10 Box 4: Diagnostic criteria for secondary myocardial infarction 13 Box 5: Diagnostic criteria for procedure-related myocardial infarction 16 Box 6: Interpretation of cardiac troponin for diagnosis of myocardial infarction 27 Box 7: Diagnostic criteria for myocardial infarction in low-resource settings where biomarker testing and cardiac imaging are not available 35 Box 8: Recommendations for further research 36 Table 1 Comparison of the Fourth and Fifth Universal Definitions of Myocardial Infarction 7 Table 2 Mechanisms of acute myocardial injury 8 Table 3 Mechanisms of chronic myocardial injury 9 Table 4 ICD-11 codes for the classification of myocardial infarction 13 Table 5 Electrocardiographic findings of myocardial ischaemia or infarction 23 Figure 1 Central illustration. Fifth Universal Definition of Myocardial Infarction 6 Figure 2 Diagnostic pathway for possible primary myocardial infarction 11 Figure 3 Primary myocardial infarction due to acute coronary pathology 12 Figure 4 Diagnostic pathway for possible secondary myocardial infarction 14 Figure 5 Secondary myocardial infarction due to supply–demand imbalance 15 Figure 6 Diagnostic pathway for possible procedure-related myocardial infarction 17 Figure 7 Procedure-related myocardial infarction due to a complication of cardiac surgery or intervention 18 Figure 8 Diagnostic pathway for possible primary myocardial infarction following sudden death 19 Figure 9 Electrocardiographic features of acute coronary occlusion 22 Figure 10 Rise and fall in cardiac troponin over time from symptom onset 26 Figure 11 Stages of primary myocardial infarction by cardiac magnetic resonance imaging 30 Figure 12 Role of cardiac magnetic resonance imaging in possible or confirmed primary myocardial infarction 31 American College of Cardiology Acute coronary syndrome American Heart Association Artificial intelligence Coronary artery disease Coronary artery bypass graft(ing) Coronary computed tomography angiography Creatine kinase-muscle/brain isoenzyme Chronic kidney disease Cardiac magnetic resonance Cardiac myosin-binding protein C Computed tomography Electrocardiogram Estimated glomerular filtration rate European Society of Cardiology Fractional flow reserve International Classification of Diseases Instantaneous wave-free ratio Intravascular ultrasound Left bundle branch block Late gadolinium enhancement Low- and middle-income countries Myocardial injury with non-obstructive coronary arteries Myocardial injury after non-cardiac surgery Non-ST-segment elevation myocardial infarction Optical coherence tomography Percutaneous coronary intervention Positron emission tomography Peri-operative myocardial injury Resting full-cycle ratio Spontaneous coronary artery dissection Single photon emission computed tomography ST-segment elevation myocardial infarction Transcatheter aortic valve implantation Universal definition of myocardial infarction Upper reference limit World Heart Federation The Fifth Universal Definition of Myocardial Infarction (UDMI) updates the classification to better reflect underlying pathophysiology, align with clinical evaluation of patients, and incorporate diagnostic classification myocardial infarction in clinical myocardial infarction due to acute coronary pathology myocardial are due to coronary coronary imaging and functional myocardial infarction from acute supply–demand imbalance myocardial criteria are to the of cardiac and or coronary diagnosis and myocardial infarction a complication of or cardiac myocardial The diagnosis of procedure-related myocardial infarction not on cardiac biomarker and is for and of is on the of and of myocardial cardiac and of the classification of myocardial infarction with International Classification from myocardial and for patients, public and research are is of the classification in and research the diagnosis of myocardial infarction is for and with for The Fifth is a from the European Society of Cardiology the American College of Cardiology the American Heart Association and the World Heart Federation is a and in with and clinical The by a of a of with from 12 countries 5 by a 18 by the by a of and from the European Association for the Society of Clinical and Cardiac of the and the for The of on the of the of the diagnosis of myocardial infarction The to the diagnosis of myocardial infarction by the World in the diagnosis based on and cardiac coronary in the by the and to the with the of cardiac troponin testing and of coronary angiography in and in and the and by the of cardiac troponin and further in cardiac the to the underlying of myocardial infarction and myocardial and the of diagnostic to new the diagnosis of myocardial infarction and is Myocardial infarction a on and of in is the of myocardial 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of in of the are in the Evidence The classification of myocardial infarction in the and the in the Fourth to in is myocardial infarction from acute illness or a coronary or following coronary intervention or cardiac surgery new clinical classification of myocardial infarction is based on pathophysiology, with clinical evaluation of and by diagnostic updates from the Fourth are in Table 1. Central illustration. 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are and is for the of in the of cardiac troponin is is for the diagnosis of myocardial infarction in low-resource settings International Classification of codes for in and public health are align with the classification of myocardial infarction to and further research Myocardial infarction is myocardial death due to of ischaemia by or coronary flow and diagnosis a clinical diagnosis of myocardial infarction confirmed the evaluation of clinical and coronary or cardiac clinical diagnosis of death and death by myocardial the diagnosis of acute myocardial criteria are the myocardial infarction The clinical diagnosis of myocardial infarction of acute myocardial injury and or of the or of acute myocardial ischaemia new or on the electrocardiogram imaging of acute coronary or new of or a new in a with criteria are to the clinical is acute onset of in the of and the evaluation clinical The diagnosis is the is with and or by ST-segment elevation on the not and the is or not diagnostic of 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the or of myocardial a diagnosis of 2 myocardial infarction for The of and 5 myocardial infarction following coronary intervention and cardiac surgery to in myocardial injury is in settings and the not following 5 and 10 the 99th percentile of the cardiac troponin and with criteria for the diagnosis of and 5 myocardial for 5 myocardial a of cardiac surgery cardiac troponin 10 the of the and the to to of coronary artery bypass surgery criteria cardiac troponin to the or and kinase-muscle/brain isoenzyme to of the diagnosis of myocardial infarction following coronary intervention and on the of myocardial injury after coronary surgery and coronary are not a for clinical diagnosis and the are not the of of the to the diagnosis is in the diagnostic criteria to myocardial infarction in clinical and to on the and of a classification not information the underlying of myocardial of with and with The classification in myocardial infarction based on the to the or of ST-segment elevation The ICD-11 the of classification by codes for ST-segment elevation myocardial infarction and elevation myocardial infarction ST-segment elevation acute coronary occlusion of flow to not with acute coronary occlusion ST-segment elevation on the and bundle branch of the classification is and to to from coronary intervention or The in the underlying of myocardial and are the acute on the clinical definition and of myocardial of the in a new clinical classification of myocardial infarction is is with the pathway for evaluation of with myocardial the underlying pathophysiology, and diagnostic criteria to in and clinical clinical classification myocardial infarction in due to a primary acute coronary pathology myocardial secondary to acute in myocardial supply–demand imbalance myocardial or a complication following a cardiac myocardial classification to and in Central Figure Primary myocardial infarction is in a with onset of or of acute myocardial ischaemia and acute myocardial injury where acute or cardiac the the are due to primary acute coronary The diagnostic criteria for primary myocardial infarction to acute coronary pathology and coronary angiography to the diagnosis and the underlying Diagnostic criteria for primary myocardial infarction The diagnosis is in with acute myocardial injury the of cardiac troponin or clinical or features are Symptoms with acute myocardial ischaemia or new on the electrocardiogram of The diagnosis is confirmed with or features on of acute coronary pathology coronary artery or or or bypass failure 30 from of a new or new of in a with The diagnostic pathway for with possible primary myocardial infarction is in Figure 2. The diagnosis is in with acute myocardial injury with the onset of of myocardial ischaemia or on the with acute myocardial ischaemia clinical features are the of myocardial infarction is Coronary angiography cardiac imaging are to the and with angiography or imaging is to the underlying acute coronary pathology for further classification where coronary angiography and cardiac imaging are not available or are not a diagnosis of primary myocardial infarction based on evaluation and clinical criteria Diagnostic pathway for possible primary myocardial elevation myocardial ST-segment elevation myocardial of possible acute coronary occlusion with a diagnosis of acute myocardial injury is to the fall of cardiac troponin or and with the 99th percentile upper reference limit on coronary angiography and cardiac imaging are not available or are not a diagnosis of primary myocardial infarction based on evaluation and clinical criteria features and the codes or the aetiology is with a diagnosis of myocardial injury with non-obstructive coronary arteries Primary myocardial infarction due to acute coronary the primary myocardial infarction is in classification to from secondary and procedure-related myocardial is with myocardial diagnosis is to the diagnosis myocardial primary myocardial infarction acute coronary pathology a or coronary artery with or ST-segment with or is the acute coronary pathology in primary myocardial to acute coronary The of and in the and are of myocardial acute coronary in primary myocardial with or ST-segment coronary artery dissection or or from a or failure 30 from a for 30 in of and in or the Coronary angiography not the underlying acute coronary pathology is the of the primary myocardial coherence tomography and ultrasound coronary and cardiac imaging are to or the diagnosis of primary myocardial is in with non-obstructive coronary arteries patients, cardiac magnetic resonance imaging is the of to the diagnosis of myocardial of acute myocardial injury or coronary angiography is not the diagnosis of or with primary myocardial infarction of aetiology coronary angiography is and the underlying acute coronary pathology the diagnosis reflect information of coronary and ICD-11 codes for the classification of myocardial infarction of the International Classification of findings of acute coronary occlusion Figure 8. The diagnosis of secondary myocardial infarction is in with acute myocardial injury secondary to acute a myocardial and in or of myocardial The diagnosis of secondary myocardial infarction is confirmed the myocardial ischaemia from supply–demand is a of of acute coronary or the myocardial injury is to a new or of myocardial The diagnostic criteria and coronary angiography and cardiac imaging to the the diagnosis for the imaging of acute coronary pathology a diagnosis of primary myocardial infarction Diagnostic criteria for secondary myocardial infarction The diagnosis is in with acute myocardial injury the of cardiac troponin with acute in myocardial supply–demand or clinical or features are Symptoms with acute myocardial ischaemia or new on the electrocardiogram of The diagnosis is with or coronary artery disease clinical due to the of myocardial ischaemia on the electrocardiogram or cardiac troponin in coronary cardiac imaging is and the diagnosis is confirmed or of the following features are coronary artery in by angiography in is on acute coronary pathology of a new or new or of in a with The pathway for in the diagnosis of secondary myocardial infarction is is in Figure 4. Myocardial supply–demand imbalance a of or or or acute myocardial ischaemia secondary to supply–demand imbalance in acute the The and of the for supply–demand imbalance and the underlying or cardiac disease the and of or is not possible to for of the of supply–demand imbalance to Diagnostic pathway for possible secondary myocardial supply–demand imbalance a of or or fall of cardiac troponin and with the 99th percentile upper reference limit on primary myocardial infarction is computed tomography coronary angiography following from acute illness coronary artery disease is in by angiography or is on Secondary myocardial infarction due to supply–demand of myocardial ischaemia are to are to and are to due to the underlying acute myocardial ischaemia secondary to supply–demand imbalance ST-segment or are Acute myocardial injury is in in supply–demand cardiac troponin from the diagnosis of myocardial infarction in or of myocardial ischaemia and cardiac troponin clinical and cardiac imaging are is and based on the clinical to or the diagnosis of secondary myocardial in not or imaging of new of and the diagnosis of secondary myocardial infarction is to acute or primary myocardial infarction is myocardial infarction is the underlying aetiology of acute myocardial injury possible is or myocardial ischaemia and primary myocardial infarction is a coronary angiography is imaging is after the acute and the of coronary computed tomography angiography with or due to the underlying acute cardiac imaging is not not possible to the diagnosis of secondary myocardial infarction and clinical is Secondary myocardial infarction is or significant myocardial injury cardiac with coronary disease are to myocardial ischaemia on the features a clinical diagnosis imaging is not or of diagnostic criteria for secondary myocardial infarction the of the diagnosis of myocardial infarction in acute illness and diagnosis of secondary myocardial infarction confirmed by coronary cardiac imaging for with The of criteria to the diagnosis of secondary myocardial infarction cardiac imaging in the of non-obstructive or unrecognized cardiac or The diagnosis of procedure-related myocardial infarction is myocardial infarction a complication of a cardiac 30 of the 30 is is with of cardiac is coronary angiography with or cardiac or and or cardiac valve or for The of procedure-related myocardial infarction is following or is following cardiac The new diagnostic criteria for procedure-related myocardial infarction are the the complication from a or Diagnostic criteria for procedure-related myocardial infarction The diagnosis is in with a coronary complication 30 of a cardiac and acute myocardial injury the of cardiac troponin or clinical or features are Symptoms with acute myocardial ischaemia or new on the electrocardiogram of sudden clinical following a the diagnosis is with cardiac biomarker from and to rise 6 for and 24 for The diagnosis is confirmed with or the complication the or the is in the of acute myocardial are of a coronary complication of intervention branch or or or surgery bypass of a coronary or occlusion of coronary valve Cardiac imaging a new or new or of in a with aetiology the by the coronary artery in the complication The pathway for in the diagnosis of procedure-related myocardial infarction is is in Figure 6. 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