Modern Management of Acute Myocardial Infarction
Section snippets
Epidemiology
Cardiovascular disease is the leading cause of morbidity and mortality in both men and women. It is estimated that 1.7 million Americans per year suffer from a myocardial infarction. Seventy percent of these events are due to NSTEMI and 30% to STEMI (which includes those with the new onset of left bundle branch in the setting of AMI).1 This distribution of AMI patients reflects a shift over the past 10 to 20 years. Data from the Minnesota Heart Survey during 1985 to 1990 showed that the 28-day
Pathophysiology
AMI occurs when profound and prolonged ischemia leads to irreversible myocardial cell damage and necrosis. In most cases, this is the result of a completely (STEMI4) or partially (UA/NSTEMI5) obstructive intracoronary thrombus. In a landmark study, DeWood and colleagues performed early coronary angiography in 322 patients with AMI.4 At 4 hours from symptom onset, total coronary occlusion was present in 87% and decreased to 65% at 12 to 24 hours. In addition, they retrieved thrombus from 52 of
Clinical Presentations
The classic symptom of AMI is discomfort in the central area of the chest that may radiate to the neck, back, or arms; is persistent (unrelieved by nitrates); and is frequently associated with diaphoresis, nausea, weakness, and fear of impending death. The discomfort usually achieves maximum intensity over several minutes.
At least one-fifth of MIs are clinically unrecognized because of atypical symptoms or absence of chest discomfort. Painless myocardial infarction is known to occur in the
Risk Stratification
Risk stratification of patients with STEMI can be based on physical exam findings at the time of presentation. The Killip classification (Table 1) is easy to use and provides a rapid method of risk-stratifying patients in the emergency department.15
Therapy
The therapeutic management strategy for STEMI patients can be divided into the following four major categories: (1) initial management; (2) reperfusion strategy; (3) additional antiplatelet therapy; and (4) management in the coronary care unit.
Risk Stratification
Risk stratification is pivotal in NSTEMI patients, because they represent a more heterogeneous group in terms of clinical outcomes. Specifically, risk stratification helps determine which patients benefit from the use of glycoprotein IIb/IIIa inhibitors and an early-invasive strategy. Risk stratification can be easily and quickly performed with use of the TIMI Risk Score or by assessing the initial ECG and cardiac biomarkers.
Complications of Myocardial Infarction
The potential complications of AMI can be divided into two main categories: mechanical complications and electrical complications.
Summary
Despite the numerous improvements in the management of AMI, it remains one of the leading causes of morbidity and mortality worldwide. The key steps in the management of these patients include rapid diagnosis, prompt delivery of initial therapeutic agents, immediate reperfusion of STEMI patients, and diligent in-hospital management. Future improvements in each of these categories need to be made if any significant reductions in the morbidity and mortality are to be obtained.
Elliott M. Antmann:
References (139)
- et al.
Prediction of acute left main coronary artery obstruction by 12-lead electrocardiographyST segment elevation in lead aVR with less ST segment elevation in lead V(1)
J Am Coll Cardiol
(2001) - et al.
Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II Investigators. Fast Revascularisation during InStability in Coronary artery disease
Lancet
(2000) - et al.
Treatment of myocardial infarction in a coronary care unitA two year experience with 250 patients
Am J Cardiol
(1967) Beta-blocker therapy and primary angioplasty: what is the controversy?
J Am Coll Cardiol
(2004)- et al.
Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials
Lancet
(2003) - et al.
Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything?
Am J Cardiol
(2003) - et al.
Combined Angioplasty and Pharmacological Intervention Versus Thrombolysis Alone in Acute Myocardial Infarction (CAPITAL AMI Study)
J Am Coll Cardiol
(2005) - et al.
Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study
Lancet
(2001) - et al.
New antithrombotics
Chest
(1995) - et al.
Combination reperfusion therapy with eptifibatide and reduced-dose tenecteplase for ST-elevation myocardial infarction: results of the integrilin and tenecteplase in acute myocardial infarction (INTEGRITI) Phase II Angiographic trial
J Am Coll Cardiol
(2003)
Effects of abciximab pretreatment in patients with acute myocardial infarction undergoing primary angioplasty
Am J Cardiol
Effect of tirofiban before primary angioplasty on initial coronary flow and early ST-segment resolution in patients with acute myocardial infarction
Am J Cardiol
Emergency room administration of eptifibatide before primary angioplasty for ST elevation acute myocardial infarction and its effect on baseline coronary flow and procedure outcomes
Am J Cardiol
Clinical and angiographic correlates and outcomes of suboptimal coronary flow inpatients with acute myocardial infarction undergoing primary percutaneous coronary intervention
J Am Coll Cardiol
Ability of the no-reflow phenomenon during an acute myocardial infarction to predict left ventricular dysfunction at one-month follow-up
Am J Cardiol
ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina)
J Am Coll Cardiol
The potential relevance of the multiple lipid-independent (pleiotropic) effects of statins in the management of acute coronary syndromes
J Am Coll Cardiol
Randomized trial of low molecular weight heparin (enoxaparin) versus unfractionated heparin for unstable coronary artery disease: one-year results of the ESSENCE StudyEfficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events
J Am Coll Cardiol
The effect of clopidogrel in combination with aspirin when given before coronary artery bypass grafting
J Am Coll Cardiol
A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapyResults of the medicine versus angiography in thrombolytic exclusion (MATE) trial
J Am Coll Cardiol
Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trialRandomized Intervention Trial of unstable Angina
Lancet
Papillary muscle rupture complicating acute myocardial infarction: analysis of 17 patients
Am J Cardiol
Cardiac rupture, mortality and the timing of thrombolytic therapy: a meta-analysis
J Am Coll Cardiol
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction)
J Am Coll Cardiol
Recent trends in acute coronary heart disease—mortality, morbidity, medical care, and risk factorsThe Minnesota Heart Survey Investigators
N Engl J Med
Trends in the incidence and survival of patients with hospitalized myocardial infarction, Olmsted County, Minnesota, 1979 to 1994
Ann Intern Med
Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction
N Engl J Med
Coronary arteriographic findings soon after non-Q-wave myocardial infarction
N Engl J Med
Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction
J Am Coll Cardiol
Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I
N Engl J Med
Prognostic influence of elevated values of cardiac troponin I in patients with unstable angina
Circulation
Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromesThe GUSTO-IIa Investigators
Circulation
Cardiac troponin T levels for risk stratification in acute myocardial ischemiaGUSTO IIA Investigators
N Engl J Med
The prognostic value of serum troponin T in unstable angina
N Engl J Med
National Academy of Clinical Biochemistry Standards of Laboratory Practice: recommendations for the use of cardiac markers in coronary artery diseases
Clin Chem
Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2
Lancet
Cumulative meta-analysis of therapeutic trials for myocardial infarction
N Engl J Med
Beta blockade after myocardial infarction: systematic review and meta regression analysis
BMJ
Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarctionResults of the Thrombolysis in Myocardial Infarction (TIMI) II-B Study
Circulation
COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative groupEarly intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial
Lancet
Intravenous nitroglycerin therapy to limit myocardial infarct size, expansion, and complicationsEffect of timing, dosage, and infarct location
Circulation
Effect of intravenous nitroglycerin on collateral blood flow and infarct size in the conscious dog
Circulation
Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarctiondoi;10.1056/NEJMoa060898
N Engl J Med
Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction
Lancet
Reperfusion for ST-segment elevation myocardial infarction: an overview of current treatment options
Circulation
Acute myocardial infarction: reperfusion treatment
Heart
Pharmacological facilitation of primary percutaneous coronary intervention for acute myocardial infarction: is the slope of the curve the shape of the future?
JAMA
A comparison of reteplase with alteplase for acute myocardial infarction
N Engl J Med
Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trialAssessment of the Safety and Efficacy of a New Thrombolytic Investigators
Lancet
Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts
Circulation
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2024, Clinica Chimica ActaNicorandil alleviates cardiac remodeling and dysfunction post -infarction by up-regulating the nucleolin/autophagy axis
2022, Cellular SignallingCitation Excerpt :Myocardial infarction (MI) is the most serious form of coronary artery disease (CAD), and it is also the main cause of human death [1,2]. Although reperfusion measures, such as thrombolysis and rapid percutaneous coronary intervention, greatly improve the symptoms of MI patients and enhance the short-term survival rate of MI patients [3,4], MI survivors are often at a high risk of subsequent heart failure [5]. Pathological myocardial remodeling is responsible for heart failure and accounts for cardiovascular events after MI [6].
Modern Management of Acute Myocardial Infarction
2012, Current Problems in CardiologyHyperglycemia and insulin in myocardial infarction: The controversy continues
2008, Medicina Clinica
The authors have no conflicts of interest to disclose.