Myocardial Infarction

A. Introduction to the Disease

1. Nature of the Disease
Inadequate supply of blood and oxygen to a portion of the myocardium; it typically occurs when there is
an imbalance between myocardial oxygen supply and demand
2. Cause of the Disease
The most common cause of myocardial ischemia is atherosclerotic disease of an epicardial coronary
artery (or arteries) sufficient to cause a regional reduction in myocardial blood flow and inadequate
perfusion of the myocardium supplied by the involved coronary artery.
3. Prevalence of the Disease
IHD is the most common, serious, chronic, life-threatening illness in the United States, where 15.5
million persons have IHD, and 3.4 million people aged ≥40 years have angina pectoris. Although there is
regional variation, about 4% of the population has sustained a myocardial infarction.
4. Range of the Disease
Population subgroups that appear to be particularly affected are men in South Asian countries, especially
India and the Middle East. In light of the projection of large increases in IHD throughout the world, IHD
is likely to become the most common cause of death worldwide by 2020.
5. Severity of the Disease
The abrupt development of severe ischemia, as occurs with total or subtotal coronary occlusion, is
associated with almost instantaneous failure of normal muscle relaxation and then contraction. The
relatively poor perfusion of the subendocardium causes more intense ischemia of this portion of the wall.
Ischemia of large portions of the ventricle causes transient left ventricular failure, and if the papillary
muscle apparatus is involved, mitral regurgitation can occur. When ischemia is transient, it may be
associated with angina pectoris; when it is prolonged, it can lead to myocardial necrosis and scarring with
or without the clinical picture of acute myocardial infarction.
6. Transmission of the Disease
An increased blood concentration of apolipoprotein B (apo B)–containing lipoproteins, of which low-
density lipoproteins (LDLs) is usually the most prevalent form, is necessary for atherosclerosis to
develop, but many other factors can facilitate the development of atherosclerosis and MI. The central
disease mechanisms discussed are assumed to be the same, irrespective of the set of causal factors in a
particular patient, but the presence of individual risk factors influences the course of the disease and the
mode of presentation. For example, cigarette smoking predisposes to thrombotic complications and
increases the risk more for MI than for stable angina, hypertension is an exceptionally powerful risk
factor for stroke, and smoking and diabetes.
7. Other Interesting Facts about the Disease
●Most heart attacks happen on Monday mornings. In the early morning hours, blood platelets are stickier,
a person is partially dehydrated, and stress hormones (such as cortisol) are at their peak.
●Women have different heart attack symptoms (nausea, indigestion, and shoulder aches) compared to
classic chest pain that men might experience. 25% of all heart attacks (especially those in women) go
unrecognized.
●Laughter is good for the heart! It relaxes and expands blood vessels increasing blood flow up to 20%!
●CT Scans of Egyptian mummies show that many had heart attacks debunking the myth that coronary
heart disease is caused solely by modern day lifestyles.
●A daily dose of aspirin may help prevent a second heart attack.
●People who live alone are twice as likely to have a heart attack compared to those who live with a
partner or roommates.
●Heart attacks are 27% more likely to happen around your birthday. They are also most likely on
Christmas Day, December 26th, and New Year’s Day.
●Coronary heart disease alone costs the United States $108.9 billion each year. This total includes the
cost of health care services, medications, and lost productivity.
●Drinking a diet soda a day increase your chance of getting a heart attack. Read more about the CUMC
study here. Fruit-infused seltzer water is a good alternative to cool off and satisfy your sweet tooth.
●Most importantly, hospital admissions of elderly Americans for heart attacks are on the decline mostly
due to the accomplishment of preventive medicine, such as smoking cessation programs.
●Every 20 seconds a heart attack occurs and a heart attack fatality occurs about every minute.
●Almost 14 million Americans have a history of heart attack or angina.
●Heart attacks do not always have recognizable symptoms.
-This is referred to as a silent heart attack and is most common in diabetic patients and those over the
age of 75.
●Men and women do not always experience the same heart attack symptoms.
●Women under the age of 50 are twice as likely to die of a heart attack than men of the same age.
●Costs related to heart exceed 60 billion dollars per year, which includes charges for hospitalization,
doctors and prescription drugs.
●At the first sign of chest discomfort, chewing an uncoated aspirin can help reduce the amount of damage
to the heart muscles during a heart attack.
●Around half of heart attack deaths occur within one hour of the heart attack outside a hospital.
●Heart attacks can occur in young people.
-While over 80% of people who die of coronary heart disease are at least 65 years old, heart attacks can
also happen much earlier in life. No matter what your age, do not neglect the warning signs of heart
attack.
B. Diagnosis and Treatment
1. Signs and Symptoms
The classic manifestation of ischemia is angina, which is usually described as a heavy chest pressure or
squeezing, a burning feeling, or difficulty breathing. The discomfort often radiates to the left shoulder,
neck, or arm. It typically builds in intensity over a few minutes. The pain may begin with exercise or
psychological stress, but ACS most frequently occurs without obvious precipitating factors.
Atypical descriptions of chest pain

 Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory movements or coughing)
 Primary or sole location of the discomfort in the middle or lower abdominal region
 Pain that may be localized by the tip of one finger, particularly over the left ventricular apex
 Pain reproduced with movement or palpation of the chest wall or arms
 Constant pain that persists for many hours
 Very brief episodes of pain that last a few seconds or less
 Pain that radiates into the lower extremities
Clinicians should be mindful of “angina equivalents” such as jaw or shoulder pain in the absence of chest
pain; nausea or vomiting; and diaphoresis. In particular, women, older persons, and individuals with
diabetes may be more likely to report atypical symptoms of myocardial ischemia or MI.
 2. Prevention
2.a. Healthy diet
2.b. Exercise
2.c. Diet low in fat and cholesterol
2.d. Maintenance of ideal body weight
2.e. Stop smoking
3. Medical Treatment
Treatment of risk factors
• Obesity
• Cigarette smoking
• Hypertension
• Diabetes mellitus
• Dyslipidemia
Drug treatment
• Nitrates
• Beta blockers
• Calcium channel blockers
• Anti-platelets
• ACE inhibitors
• Ranolazine
• Nicorandil
• Ivabradine
Coronary revascularization
• Percutaneous coronary intervention
• Coronary artery bypass graft
4. Cutting Edge Research
A. Clinical case of successful management of acute myocardial infarction during pregnancy.
-The importance of minimizing the time to hospitalization of a pregnant woman with a MI to a
specialized center for timely and complete diagnostic measures, which, in turn, allow to properly choose
the tactics of patient management. Timely revascularization and properly selected anticoagulation are the
key factors of the successful management in this category of patients.
B. PET-Based Imaging of Ischemic Heart Disease.
-PET-based cardiac nuclear imaging plays a large role in the management of ischemic heart disease.
Compared with conventional single-photon emission CT myocardial perfusion imaging, PET provides
superior accuracy in diagnosis of coronary artery disease and, with the incorporation of myocardial blood
flow and coronary flow reserve, adds value in assessing prognosis for established coronary and
microvascular disease.
References:
1. Jameson, J., Kasper, D. L., Longo, D. L., Fauci, A. S., Hauser, S. L., & Loscalzo, J. (n.d.). Harrison's
Principles of Internal Medicine (20th ed., Vol. 1). McGraw-Hill Education.
2. Zipes, D. P., Libby, P., Bonow, R. O., Mann, D. L., & Tomaselli, G. F. (n.d.). Braunwald's Heart Disease. A
Textbook of Cardiovascular Medicine (11th ed.). Philadelphia, Pennysylvania: Elsevier.

3. Morrow, D. A. (2017). Myocardial Infarction. A Companion to Braunwald's Heart Disease. St. Louis,
Missouri: Elsevier.

4. 10 Facts You May Not Have Known About Heart Attacks. (n.d.). Retrieved from
http://columbiasurgery.org/news/2014/07/28/10-facts-you-may-not-have-known-about-heart-attacks

5. UnityPoint Health. (2014, September 10). 10 Surprising Facts About Heart Attacks (Infographic).
Retrieved from https://www.unitypoint.org/waterloo/article.aspx?id=12039594-19a6-4fa2-8e58-
cd1647daa647

6. Loskutov, O. A., Zhezher, A. O., & Sulimenko, Y. M. (2019). Clinical case of successful management of
acute myocardial infarction during pregnancy. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/30903792

7. Chen, K., Miller, E. J., & Sadeghi, M. M. (2019, April). PET-Based Imaging of Ischemic Heart Disease.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30826019