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Results: 31 studies (16,111 participants) were included, with most showing moderate-to-severe risk of 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infarction: a systematic review  \nPishoy Gouda  ,1 Shehzeen Lalani,2 Kristin Newby,3 Renato Lopes,4 Schuyler Jones4  \n► Additional supplemental material is published online only. To view, please visit the journal online ([https://doi.org/10.1136/](https://doi.org/10.1136/)[ ](https://doi.org/10.1136/)[openhrt-2025-003867](openhrt-2025-003867)) .  \nTo cite: Gouda P, Lalani S, Newby K, et al. Utility of biomarkers in patients with a type 2 myocardial infarction: a systematic review. Open Heart 2026;13:e003867 . doi:10 . 1136/ openhrt-2025-003867  \nReceived 13 November 2025 Accepted 23 November 2025  \n© Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.  \n1University of Alberta, Edmonton, Alberta, Canada  \n2McGill University, Montreal, Quebec, Canada  \n3Duke University Duke Clinical Research Institute, Durham, North Carolina, USA  \n4Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA  \nCorrespondence to  \nDr Pishoy Gouda; gouda@ [ualberta.ca](ualberta.ca)  \nABSTRACT  \nBackground Differentiating type 1 myocardial infarctions (T1MI) from type 2 myocardial infarctions (T2MI) can be challenging based on clinical variables alone. This review aimed to explore the utility of novel and traditional biomarkers to discriminate between these entities and potentially provide additional prognostic information. Methods A systematic review of observational studies and randomised controlled trials that examined the discriminatory or prognostic roles of either traditional cardiac biomarkers (troponin, creatine kinase or b-type natriuretic peptide) or non-traditional biomarkers. Data sources included PubMed, SCOPUS, Web of Science, EMBASE and clinicaltrials.gov and were last searched on 15 November 2024. The diagnostic accuracy of biomarkers and prognostic utility of identified biomarkers are narratively reported.  \nResults 31 studies with 16 111 individuals with a  \nT2MI were included. Most studies (97%) demonstrated moderate or severe risk of bias. Of studies that examined traditional cardiac biomarkers (n=13), the ability to discriminate between T2MI and T1MI ranged from an area under the curve (AUC) of 0 .61–0.71. Studies that added traditional cardiac biomarkers to clinical variables (n=4) demonstrated a diagnostic accuracy AUC 0.71–0.82. Studies exploring non-traditional biomarkers, metabolic and proteomic profiles (n=14) demonstrated a wide range of diagnostic accuracy (AUC 0 .50–0.77) . Traditional cardiac biomarkers inconsistently demonstrated a correlation with subsequent cardiovascular events. The prognostic utility of non-traditional biomarkers was infrequently assessed. Conclusion The role of biomarkers, metabolic and proteomic profiles in the diagnosis and prognostication of T2MI remains unclear. Higher quality studies and refining the classification of T2MI may improve this further. PROSPERO registration number CRD42023418095 .  \nINTRODUCTION  \nMyocardial infarction (MI) occurs when cardiac myocytes lack sufficient oxygen, leading to a cascade of intracellular changes that result in cell necrosis and death. While cardiac cell death is the common end result of all types of MIs, the underlying mechanism that leads to myocardial injury differs. As defined in the 4th Universal Definition of MI,  \n\n| WHAT IS ALREADY KNOWN ON THIS TOPIC |\n| --- |\n| ⇒ Type 2 myocardial infarction (T2MI) is common, prognostically important and challenging to distinguish from type 1 myocardial infarction (T1MI) using clinical features alone.\u003Cbr>⇒ Cardiac troponins are essential for diagnosing myocardial infarction, but have limited discriminatory ability between T1MI and T2MI.\u003Cbr>⇒ Numerous traditional and non-traditional biomarkers have been proposed, yet their diagnostic and prognostic roles in T2MI remain unclear and incons","cbCaibxEKZJd2bAJ","https://ap.wps.com/l/cbCaibxEKZJd2bAJ","pdf",1864060,"English","# Abstract\n# Introduction\n# What is already known on this topic\n# What this study adds\n# How this study might affect research, practice or policy","[{\"question\":\"What challenge does the review address about myocardial infarction classification?\",\"answer\":\"It targets the difficulty of distinguishing type 1 myocardial infarction (T1MI) from type 2 myocardial infarction (T2MI) using clinical variables alone.\"},{\"question\":\"Which biomarkers were evaluated in the systematic review?\",\"answer\":\"The review assessed both traditional cardiac biomarkers (such as troponin, creatine kinase, and B-type natriuretic peptide) and non-traditional biomarkers including metabolic and proteomic profiles.\"},{\"question\":\"What did the review find about diagnostic performance and bias across studies?\",\"answer\":\"Most studies showed moderate or severe risk of bias, and traditional biomarkers demonstrated only poor-to-moderate discrimination with inconsistent associations with subsequent cardiovascular events.\"}]","Utility of biomarkers in patients with a type 2 myocardial infarction - a systematic review | PDF",1790730855,23]