348 (14):1309-21. Levi F, Lucchini F, Negri E, La Vecchia C. Trends in mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world. Patients with refractory angina, clinical evidence of heart failure, or hemodynamic or electrical instability who do not have serious comorbidities or contraindications to angiography/PCI should undergo an early invasive strategy. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Terkelsen CJ, Sorensen JT, Maeng M, et al. James SK, Lindahl B, Siegbahn A, et al. Operative management of postinfarction ventricular septal defect. L-carnitine in the secondary prevention of cardiovascular disease: systematic review and meta-analysis. 2007 Jul. Lancet. Ventricular septal rupture (acute ventricular septal defect) is a rare but critical complication of MI. Soares AAS, Tavoni TM, de Faria EC, Remalay AT, Maranhao RC, Sposito AC, et al. 364 (9438):937-52. Medscape Medical News. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. 2013 Dec 31. DiNicolantonio JJ, Lavie CJ, Fares H, Menezes AR, O'Keefe JH. Viable myocardium is at the left, and neutrophils with apoptosis (karyorrhexis) are seen infiltrating the necrotic muscle. [2, 4]  and low molecular weight heparin (LMWH) (eg, enoxaparin The incidence increases with ST-elevation MI STEMI and decreases with non-STEMI (NSTEMI). Rencuzogullari I, Cagdas M, Karabag Y, et al. Becker L, Larsen MP, Eisenberg MS. The Platelet Inhibition and Patient Outcomes (PLATO) trial compared clopidogrel to ticagrelor in patients with NSTE-ACS and concluded that patients receiving ticagrelor had lower events of MI, stroke, and overall mortality. Isolated LMI, similar to other acute MI, is caused by acute atherosclerotic plaque rupture with subsequent thrombus formation in LCx or one of its branches. Extrapolated results from the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial demonstrated that clopidogrel can be used in patients with NSTE-ACS who are intolerant to aspirin. Thus, their use in NSTE-ACS is limited currently. [85]. [121, 122]. Available at https://www.medscape.com/viewarticle/886075. [2]. 2012 Dec 18, Anderson JL,Karagounis LA,Califf RM, Metaanalysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction. [Medline]. 2013 Feb. 32 (2):157-87. Fast Five Quiz: Myocardial Infarction Clinical Keys, Colchicine a Case Study for What's Wrong With US Drug Pricing, Dec 4, 2020 This Week in Cardiology Podcast, Many Patients With Type 2 MI Don't Get Cardiologist Evaluation, Keys to Diagnosing Broken Heart Syndrome (Takotsubo Cardiomyopathy), Chili Pepper Consumption Linked to Better Midlife Survival, Pesco-Mediterranean Diet, Fasting 'Ideal' to Reduce CVD, SAMSON Pins Most Muscle Pain Experienced With Statins on the Nocebo Effect, Proinflammatory Dietary Pattern Linked to Higher CV Risk, Heart Failure With Preserved Ejection Fraction Management: 5 Things to Know, Young Women Have Worse MI Outcomes Than Men of Same Age, Diabetes Confers Greater Excess Risk of Myocardial Infarction in Women Than Men, Postinfarction Ventricular Septal Rupture, Aspirin Reduces Ischaemic Events in Patients With Pneumonia. [Medline]. Interventions such as smoking cessation, weight reduction, medication adherence, and dietary modification have all been well established in improving overall cardiovascular mortality. 2000 Sep. 36 (3):693-8. Acute myocardial infarction, reperfusion type. Therefore, systems must be placed and implemented to prevent delay in management of patients who develop STEMI. [Guideline] Eckel RH, Jakicic JM, Ard JD, et al. [97, 98]. [Medline]. Risk stratification using TIMI scores can help identify patients with increased in-hospital mortality. Narrowing of the coronary artery, leading to a myocardial infarction, usually develops over several years. Am Heart J. Earliest activation is recorded in red; late activation shows as blue to magenta. Bonaca MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Jensen EC, et al. The patient becomes volume dependent to maintain adequate left and right ventricular filling. An initial loading dose of 60 IU/kg (maximum 4,000 IU) with an initial infusion of 12 IU/kg per hour (maximum 1,000 IU/h) adjusted per activated partial thromboplastin time (PTT) is recommended to maintain therapeutic anticoagulation according to the specific hospital protocol. Lipids, lipoproteins, and metabolites and risk of myocardial infarction and stroke. Clin Biochem. Circulation. Mahmoud H Abdou, MD Fellow, Division of Cardiology, Emory University School of Medicine [99]. Widimsky P, Budesínsky T, Vorac D, et al, for the 'PRAGUE' Study Group Investigators. [Medline]. [Medline]. J Cardiovasc Nurs. However, aggressively monitor and treat arrhythmias that result in hypotension, increase myocardial oxygen requirements, and/or predispose the patient to malignant ventricular arrhythmias. The PURSUIT Trial Investigators. Eur Heart J. 2013 Jun, Coons JC,Fera T, Multidisciplinary team for enhancing care for patients with acute myocardial infarction or heart failure. 73 (4):387-96. Cardiol J. [Medline]. [Full Text]. See Complications of Myocardial Infarction. Wendling P. AHA/ACC issue new performance, quality measures for MI. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of a lack of net benefit. Lancet. 2011 Jan, Hreybe H,Saba S, Location of acute myocardial infarction and associated arrhythmias and outcome. 2011 Aug 20. Am J Cardiol. Surgery. [Medline]. Clin Chem. 2012 Oct 16. Lateral wall myocardial infarction patients were further subdivided into those with anterior-lateral and anterior-inferior-lateral MI. An echocardiogram may be helpful in confirming the diagnosis. Available at http://www.astrazeneca.com/Media/Press-releases/Article/20150903. After an MI, all patients should be maintained on a beta blocker. Cremer PC, Khalaf S, Agarwal S, et al. Healed myocardial infarct. Specific prehospital care includes the following: Intravenous access, supplemental oxygen if the oxygen saturation (SaO2) is less than 90%, pulse oximetry, Immediate administration of nonenteric-coated chewable aspirin en route, Nitroglycerin for active chest pain, given sublingually or by spray, Telemetry and prehospital electrocardiography (ECG), if available. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Patients suspected of having acute LMI should have a prompt evaluation with an electrocardiogram (ECG) and measurements of serial cardiac troponins. 2014 Aug 5. 60 (16):1581-98. 7 Feb 2018. Anticoagulant agents are recommended to be given to all patients with NSTE-ACS, regardless of the initial treatment strategy, in addition to antiplatelet therapy. The use of oxygen in patients with acute MI who don’t fall into one of the three above-mentioned categories remains uncertain, with some studies suggesting possible harm in such patients. Heart. [Medline]. Commentary: the role of percutaneous coronary intervention in ST-segment-elevation myocardial infarction. White HD, Kleiman NS, Mahaffey KW, et al. Available at http://www.medscape.com/viewarticle/782488. 345 (14):1014-21. Morrow DA, Rifai N, Antman EM, et al. Clin Cardiol. Lancet. Introducing ticagrelor after myocardial infarction in patients with previous ischemic stroke is associated with lower rates of recurrent ischemic stroke, without an increase in intracranial bleeding. Mizuno S, Kunisawa S, Sasaki N, Fushimi K, Imanaka Y. 2012 Oct. 33 (20):2569-619. 2014 Dec 23, McManus DD,Gore J,Yarzebski J,Spencer F,Lessard D,Goldberg RJ, Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. American College of Cardiology/American Heart Association/European Society of Cardiology/World Heart Federation Universal definition of myocardial infarction classification system and the risk of cardiovascular death: observations from the TRITON-TIMI 38 Trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis in Myocardial Infarction 38). Posterior wall MI is most commonly associated with an inferior or lateral STEMI (occurring 15-20% percent of the time). Risk factors for these aneurysms after acute MI include the following: Total occlusion of the left anterior descending (LAD) coronary artery, Single-vessel coronary artery disease (CAD). [Medline]. [Medline]. Circulation 1999:100(suppl I):I-433 . On physical examination, signs of right-sided heart failure may be present, such as elevated jugular venous pulsation, right-sided S3, Kussmaul sign, or hypotension, but the patient may have clear lung fields. Coronary artery spatial distribution of acute myocardial infarction occlusions. Acute myocardial infarction after laboratory-confirmed influenza infection. Early reperfusion has shown benefits with improved clinical outcomes. People with a history of previous MI can relate current symptoms to previous episodes and tend to seek care sooner. [Medline]. Elevation of the maxillary sinus floor can take place through the lateral sinus wall or through the residual bone crest. Am Heart J. The first goal for healthcare professionals in management of acute myocardial infarction (MI) is to diagnose the condition in a very rapid manner. [2, 4]. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care: endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. The treatment is fluids, fluids, fluids, with isotonic saline to increase preload. Eur Heart J. Most deaths caused by MI occur early and are attributable to primary ventricular fibrillation (VF). [117] demonstrated a reduction in mortality rates in patients who received high-potency statins after acute MI as compared to placebo. [Full Text]. This method of reperfusion entails performing emergent coronary angiography, after establishing arterial access, which can be achieved via the radial or femoral artery. Posterior myocardial infarction represents the end result of myocardial ischemia and coronary insufficiency due to acute obstruction of either right or circumflex coronary arteries. The use of other P2Y12 receptor inhibitor agents in patients treated with fibrinolysis has not been prospectively studied. [Medline]. Lancet. They also play an important role in reduction of reinfarction and complex ventricular arrhythmias. Accessed: March 12, 2014. Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. [Medline]. A 12-lead electrocardiogram (ECG) interpreted by an experienced physician should be completed within 10 minutes of arrival, in addition to establishing intravenous (IV) access. Clin Biochem. Coron Artery Dis. Daggett WM, Buckley MJ, Akins CW, Leinbach RC, Gold HK, Block PC, et al. [Full Text]. 378 (4):345-53. [86]. Lateral myocardial infarction information including symptoms, causes, diseases, symptoms, treatments, and other medical and health issues. 2013 Jun 3. JAMA. Circulation. The recommended frequency of regular exercise training is three or more times a week, for at least 30 minutes per session. Reduce LDL-C levels by ≥30%; for optimal ASCVD risk reduction, particularly in high-risk patients (≥20% 10-year ASCVD risk), reduce LDL-C levels by ≥50%. 2018 Mar. [Full Text]. A two year experience with 250 patients. Clinical cardiology. At 3 days, there is a zone of yellow necrosis surrounded by darker hyperemic borders. The American College of Cardiology (ACC) and the American Heart Association (AHA) published recommendations on the primary prevention of cardiovascular disease (CVD) in March 2019. Use coupon code EXTENDEDHOLIDAY2020 at checkout for 20% off. 1995 Aug 1. 9(1):e85805. (Open Table in a new window), Streptokinase (no longer marketed in the US), 1.5 million units IV given over 30–60 min. Nov 21 2014. Refractory or severe pain should be treated symptomatically with IV morphine. In a STEMI an artery is blocked and treatment centers on opening this up as quick as possible. N Engl J Med. J Am Coll Cardiol. All patients being transported for chest pain should be managed as if the pain is ischemic in origin, unless clear evidence to the contrary is established. 478:51-6. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Heartwire. Healing myocardial infarction, lateral left ventricle. As shown in the figure, the most important risk factors for myocardial infarction are: JAMA. 2014. [Medline]. Patti G, Barczi G, Orlic D, et al. [14] Patients presenting with cardiogenic shock or mitral valve rupture post-MI may need a mechanical supportive device such as an intra-aortic balloon pump (IABP) after PCI. Participation in regional or national acute myocardial infarction registry to help track and assess the outcomes, complications, and quality of care for patients with AMI. Concomitant coronary artery bypass grafting (CABG) may be required. The three major mechanical complications of MI, each of which can cause cardiogenic shock, are as follows: Papillary muscle rupture with severe mitral regurgitation. 1998 Jul. [Guideline] Rihal CS, Naidu SS, Givertz MM, et al. J Heart Lung Transplant. 1995 Mar 15. Mueller C. Biomarkers and acute coronary syndromes: an update. August 26, 2013. Pathological ventricular remodeling: mechanisms: part 1 of 2. Table 2. Postinfarction ventricular septal defect: an argument for early operation. [Medline]. Supplemental oxygen by a mask or nasal cannula is indicated only for patients who are breathless, hypoxic (oxygen saturation < 90% or PaO2< 60 mm Hg 48 (4-5):254-9. Sabatine MS, Giugliano RP, Keech AC, et al, for the FOURIER Steering Committee and Investigators. 295 (13):1519-30. FDA. [7] Physical findings such as diaphoresis, extra heart sounds, heart murmurs, and elevated jugular venous pressure can guide toward the diagnosis of LMI. For more information, see Right Ventricular Infarction. [3], Glycoprotein (GP) IIb/IIIa receptor inhibitors. [Medline]. 127 (4):e362-425. 364 (9438):912-4. [11] Percutaneous intervention (PCI) has demonstrated superior results when compared to fibrinolytic therapy. Modified 2-dimensional (top) echocardiogram and color flow Doppler image (bottom). [96]  The ESC guidelines, however, recommend the use of prasugrel upfront in patients treated for NSTE-ACS—provided there is no contraindication to its use. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. Diagnosis of type I MI focuses on the detection of a rise and/or fall of cardiac Troponin (cTn) with at least one value above the 99th percentile and with the presence of at least one of the following factors: MI can further be classified based on presenting EKG findings and the location of ischemia. Available at http://www.medscape.com/viewarticle/823754. CAPRIE Steering Committee. [124] Investigators in the Reinfusion of Enriched Progenitor Cells And Infarct Remodeling in Acute Myocardial Infarction (REPAIR-AMI) study examined 204 patients with acute ST-elevation MI (STEMI) and reported greater improvement in left ventricular ejection fraction (LVEF) among patients who received intracoronary progenitor cell infusion than among those given placebo. Other antiplatelet agents used for dual antiplatelet therapy are the P2Y12 receptor inhibitors (eg, clopidogrel, ticagrelor, prasugrel); a loading dose of these agents is given before or at the time of reperfusion and an extended duration maintenance dose is administered thereafter, depending on the method of reperfusion. 358 (9282):605-13. Use of aldosterone antagonists at discharge after myocardial infarction: Results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get with the Guidelines (GWTG). [Guideline] Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. Eric H Yang, MD is a member of the following medical societies: Alpha Omega AlphaDisclosure: Nothing to disclose. [Medline]. [Full Text]. Note that fondarparinux is contraindicated in patients with impaired kidney function. [Full Text]. Anticoagulant agents are an important adjunctive therapy for reperfusion therapy regardless of the strategy chosen (ie, whether it is primary PCI or fibrinolysis therapy). [Full Text]. Statin therapy is first-line treatment for the primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol (LDL-C) levels (≥190 mg/dL), those with diabetes mellitus who are aged 40-75 years, and those determined to be at sufficient ASCVD risk after a clinician-patient risk discussion. [Medline]. At every healthcare visit, assess all adults for tobacco use. 116 (7):e148-304. At 3 months, there is dense scar, which is blue on this Masson trichrome stain. Table 1. Gaudiani VA, Miller DG, Stinson EB, Oyer PE, Reitz BA, Moreno-Cabral RJ, et al. Lateral and posterior walls together form the left ventricular free wall which is a common site for free-wall rupture (FWR) post-MI. 109 (10):1223-5. In this case, the infarct is diffusely hemorrhagic. Heart. Left ventricular mural thrombus Is a well-known complication of acute anterior MI and frequently develops after left anterior wall infarction. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. 134 (10):e123-55. Improved results of surgical management of postinfarction ventricular septal rupture. 129 (25 Suppl 2):S76-99. 14 (5):e0216404. In addition, it is reasonable to consider an early reperfusion strategy for patients presenting after more than 12 hours, provided there is clinical and/or ECG evidence of ongoing ischemia, with primary PCI being the preferred method in this population. [2], Table modified from 2013 ACCF/AHA guidelines for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Prehospital notification by emergency medical services (EMS) personnel should alert emergency department staff to the possibility of a patient with myocardial infarction (MI). Medical management of acute ST elevation myocardial infarction. Intravenous thrombolysis in acute myocardial infarction. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 1996 Nov 16. C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: a TIMI 11A substudy. 2010 Sep 2. [Full Text]. [93, 94, 95] Therefore, major contraindication to the use of prasugrel are a previous history of stroke or transient ischemic attack (TIA), age over 75 years, and low body weight (< 60 kg). 6 (6):580-9. 2017 May 4. 343 (8893):311-22. Thygesen K, Mair J, Mueller C, et al, for the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. [Medline]. Beta blockers work by reduction of oxygen consumption of the myocardium by lowering the heart rate, blood pressure, and myocardial contractility. Acute myocardial infarction (AMI), commonly known as a heart attack , is the interruption of blood supply to a part of the heart, causing heart cells to die. Boggs W. Worse Prognosis for Myocardial Infarction Patients With ST-Deviation in AVR. [Medline]. The initial dose of morphine of 2 to 4 mg as an IV bolus can be given, with increments of 2 to 4 mg repeated every 5 to 10 minutes until the pain is relieved or intolerance is manifested by hypotension, vomiting, or depressed respiration. Reddy KS. [Medline]. The FDA also issued a black box warning on this.). Boggs W. Stress Echo Rules out Myocardial Ischemia in the ED. Medscape Medical News. 2009 Sep 10. [4] ) are the available options. Therefore, initial objectives are immediate ECG monitoring; electric cardioversion in cases of VF; and rapid transfer of the patient to facilitate prompt coronary assessment. Table modified from 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. MedPage Today. 2014 Nov. 7 (6):912-9. A loading dose of ticagrelor 180 mg is recommended, followed by a maintenance dose of 90 mg twice daily. 1991 Feb. 83 (2):681-8. JACC Cardiovasc Interv. anterolateral STEMI. Incidence of cardiac arrest during self-transport for chest pain. April 26, 2019; Accessed: April 30,2019. Giraldez RR, Nicolau JC, Corbalan R, et al. 357 (20):2001-15. The role of reperfusion therapy in paced patients with acute myocardial infarction. [Medline]. Dr. Robert Kwok answered. [17] Hreybe et al. 2007 Sep 13. 54 (5):468-76. Cardiac arrhythmias are not uncommon during and immediately after an acute MI. [Medline]. For patients receiving bivalirudin as the primary anticoagulant, routine adjunctive use of GP IIb/IIIa inhibitors is not recommended but may be considered in selected cases. 2018 Jan 7. Charlot M, Grove EL, Hansen PR, et al. Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Vaidya SR, Qamar A, Arora S, Devarapally SR, Kondur A, Kaul P. Culprit versus multivessel coronary intervention in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. [Medline]. Anterior MI is associated with more myocardial damage than inferior infarction; this damage affects LV function, a major determinant in prognostic outcome after acute MI. Absolute and Relative Contraindications to Fibrinolytic Therapy in Patients with STEMI. Enoxaparin is given at a dose of 1 mg/kg subcutaneously (SC) every 12 hours. 284(7):835-42. Prognostic usefulness of white blood cell count and temperature in acute myocardial infarction (from the CARDINAL Trial). https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTU1OTE5LXRyZWF0bWVudA==, Restoration of the balance between oxygen supply and demand to prevent further ischemia, Prevention and treatment of complications, Prehospital electrocardiography (ECG) to diagnose STEMI to activate the percutaneous coronary intervention (PCI) team while the patient is en route to the hospital, Emergency department physicians activate the PCI team, A single call to a central page operator who activates the PCI team, The goal is set for the PCI team to arrive in the catheterization laboratory within 20 minutes after being paged, Timely data feedback and analysis are provided to members of the STEMI care team, Known structural cerebral vascular lesion, Known intracranial neoplasm (primary or metastatic), Ischemic stroke within the past 3 months (except for acute stroke within 4.5 hours), Active bleeding or bleeding diathesis (excluding menses), Significant closed-head or facial trauma within 3 months, Intracranial or intraspinal surgery within 2 months, Severe uncontrolled hypertension (unresponsive to emergency therapy), For streptokinase (no longer marketed in the US): Prior treatment within previous 6 months, History of chronic, severe, poorly controlled hypertension, Systolic pressure >180 mm Hg or diastolic pressure >110 mm Hg, History of prior ischemic stroke >3 months, Known intracranial pathology not covered in absolute contraindications, Recent (within 2-4 weeks) internal bleeding, Current use of anticoagulants: The higher the INR, the higher the risk of bleeding, For streptokinase (no longer marketed in the US): Prior exposure (>5 days previously) or prior allergic reaction to these agents. 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