Great debate: the universal definition of myocardial infarction is flawed and should be put to rest

Myocardial infarction (MI) is defined pathologically as myocardial cell death resulting from prolonged ischaemia. The clinical definition of this pathological process relies on clinical evidence of myocardial ischaemia and biomarker evidence of myocardial cell death. Cardiac troponins are the standard clinical biomarker for assessing cardiac cell death. Within the framework of the universal definition of myocardial infarction (UDMI), the definition of acute MI aims to guide clinicians to accurately diagnose and classify acute MI, and distinguish acute MI from other forms of myocardial injury in daily practice. In the latest (Fourth) UDMI, a major effort has been made to providing: (i) a stratified pathophysiology-informed framework for the classification of different MI types and (ii) an overview of the factors that should be considered for distinguishing MI from non-ischaemic myocardial injury. The development and implementation of the UDMI in its various iterations has intended to comprehensively define MI and not to provide an MI management guideline. It has resulted in major achievements. However, significant reservations have emerged among different stakeholders (Graphical Abstract) which form the basis of this ‘Great Debate’ manuscript.