Acute Myocardial Infarction in Pregnancy

Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction has been rising over the past 2 decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of acute myocardial infarction in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to acute myocardial infarction in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex condition. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with acute myocardial infarction in pregnancy.     

Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence,Predictors, Management,and Outcomes

BackgroundClinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding.MethodsPatients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment.ResultsA total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01).ConclusionIn the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.     

Thrombolytics and myocardial infarction

Coronary artery disease is the single leading cause of death in the United States. Occlusion of the coronary artery was identified to be the cause of myocardial infarction almost a century ago. Following a series of investigations, streptokinase was discovered and demonstrated to be beneficial for the treatment of patients with acute myocardial infarction in terms of reducing short- and long-term mortality. Newer agents including tissue plasminogen activators such as alteplase, reteplase, tenecteplase were developed subsequently. In the present era, thrombolytic therapy and primary percutaneous coronary intervention has revolutionized the way patients with acute myocardial infarction are managed resulting in significant reduction in cardiovascular death. This article provides an overview of the various thrombolytic agents utilized in the management of patients with acute myocardial infarction.     

非心脏病患者住院发生急性心肌梗死的现状综述

急性心肌梗死(acute myocardial infarction, AMI)是严重威胁人类生命健康的心血管不良事件，然而非心脏病患者住院期间发生AMI是一种独特的心脏疾病，其临床特征、治疗和预后均不同于院外AMI。这种疾病仅在10年内才开始受到越来越多的关注和研究，本文就住院患者发生AMI的相关研究及进展进行综述。     

Acute myocardial infarction in hemoglobin SC disease

Although there are reports of myocardial infarction (MI) in patients with sickle cell diseases, an antemortem diagnosis of acute MI in a patient with compound heterozygous hemoglobin SC disease has not been reported. Herein, we present a patient with hemoglobin SC who suffered an acute MI. She had typical chest pain for myocardial ischemia, associated with ST elevations on the electrocardiogram (EKG) and elevations of cardiac injury markers diagnostic of infarction. The patient was treated with conventional therapies for acute coronary syndrome and also emergent red blood cell exchange. Interestingly, coronary angiography was completely normal in this patient. Potential mechanisms and management for acute MI in patients with sickle cell disease are discussed.     

Modern approach to myocardial infarction: Determination of prognosis and therapy

During the past decade, coronary artery disease has been recognized as one of the major health issues in the adult population, and as a result, intense interest was devoted to the investigation and management of patients with acute myocardial infarction. Major developments in noninvasive and invasive technologies to monitor the electrical and mechanical disturbances of the heart have been achieved.^1–3 As the result of these investigations and techniques, the patient with acute infarction can be characterized by physiologic measurements of rhythm and mechanical function in the absence as well as in the presence of heart failure and cardiogenic shock. With such objective information available on cardiac performance in the individual patient, a variety of therapeutic strategies has become available.^4–6 Thus management of acute myocardial infarction can range from home care or early hospital discharge to intervention with agents to salvage ischemic myocardium and reduce infarction size.This review will describe physiologic measurements in patients with acute myocardial infarction and will include information during the acute phase and several weeks after convalescence. The therapeutic options available in the acute and early convalescent phase will also be discussed.     

A national Survey of Acute Myocardial Infarction and Ischaemia (SAMII) in the U.K.: characteristics, management and in-hospital outcome in women compared to men in patients under 70 years.

AIMS: To assess the clinical characteristics, management and outcome of women compared to men with acute myocardial infarction or ischaemia. DESIGN: A prospective clinical survey was made in a random sample of 94 District General Hospitals in the U.K. 1064 patients, <70 years of age, comprising six consecutive females and six consecutive males from each hospital, diagnosed on admission as acute coronary syndromes (myocardial infarction or myocardial ischaemia) were studied. Outcome measures included: admission and final diagnosis, time to delivery of care, inpatient management, complications and clinical outcome. RESULTS: Five hundred and three women and 561 men were admitted with a diagnosis of acute myocardial infarction or myocardial ischaemia. Women were older, waited longer between seeking and receiving advice, and much less likely to have infarction than men. After adjustment for age, diagnosis and past medical history there were no gender differences in initial and subsequent hospital management, in complications (recurrent ischaemia, arrhythmias, temporary pacing, heart failure), any routine procedure or outcome. Of all patients, 3.4% died in a District General Hospital, 12.2% were transferred to Specialist Cardiac Centres and 84.4% discharged home. Prophylactic medication on discharge was similar for men and women. CONCLUSION: After adjustment for age, diagnosis and past medical history, although women waited longer between seeking and receiving medical advice, in hospital their assessment, management, complications, outcome and follow-up arrangements were the same as for men. In hospital, management and outcomes were mainly influenced by age, diagnosis (infarction or ischaemia), a past history of coronary disease, but not by gender. This large, nationally representative, survey has found no evidence of important gender difference in the hospital management of acute ischaemic syndromes.     

Lack of myocardial necrosis despite clinical and electrocardiographic criteria of acute transmural infarction

The development of "pathologic" Q waves with ST segment elevation is considered diagnostic of transmural myocardial infarction. Previous reports have suggested that myocardial ischemia without infarction can result in electrocardiographic abnormalities simulating those of acute infarction. However, lack of infarction has been poorly documented in these reports. If real, this phenomenon could have an impact on the management of patients with apparent acute infarction. This study describes a patient with documented severe myocardial ischemia and electrocardiographic evidence of acute transmural myocardial infarction, in whom significant myocardial necrosis has been excluded definitively.     

Clinical perspectives and therapeutics of thrombolysis

Reperfusion therapy with thrombolytic agents has been a significant advancement in the management of patients with acute ST elevation myocardial infarction. The outcome of acute myocardial infarction has significantly improved by early application of thrombolytic therapy. Intracoronary streptokinase has been used for >30 years, but reawakening interest occurred in the early 1980s in the use of thrombolytic therapy to establish rapid reperfusion during an acute myocardial infarction. Initial studies aimed at direct intracoronary thrombolysis, but owing to its cumbersome process and requirement of an active round the clock cardiac catheterization laboratory, it has been replaced by regimens of intravenous thrombolytic therapy which is as efficacious as intracoronary administration. Consideration of thrombolytic therapy has become a standard treatment for patients presenting with acute ST elevation myocardial infarction and various well-controlled trials have demonstrated the importance of both early and full reperfusion in improving clinical outcome in the setting of acute myocardial infarction. The subject of intravenous thrombolysis is perhaps the most rapidly evolving area in the management of acute myocardial infarction patients in the past decade. The current review focuses on the thrombolysis in the treatment of myocardial infarction and other conditions.     

The prehospital phase in patients with acute myocardial infarct in Slovakia. A challenge

Better management of patients with acute myocardial infarction during the prehospital phase is at present a challenge not only for health workers but for society as a whole. The authors pay attention to knowledge of the complex problem of the prehospital phase in patients with acute myocardial infarction which is a prerequisite for finding possible solutions for a favourable effect on their management. The authors analyzed 3,040 patients who were admitted to hospital alive within 96 hours after the development of complaints with suspicion of a first or repeated acute myocardial infarction. They focused attention in particular on prehospital time delay. They found that within a satisfactory time interval (within 2 hours) 29.8% patients were delivered and within a yet acceptable interval of 4 hours 51.6% patients (with respect to effectiveness of thrombolytic treatment). Similarly undesirable are also data on the patient time delay. Within the optimal first hour after development of complaints following the decision of the patient (subjects present) to ask for or seek medical assistance was the decision of 34% patients, during the first two hours 47.5% and within 4 hours 61.2% patients with acute myocardial infarction. The ratio of time delay of the patient in the total prehospital delay is 45.5% even in patients who were admitted during the first hour after development of acute myocardial infarction. In patients who were admitted 4 hours after development of complaints it is 79.5%. The patient is admitted to hospital most quickly if he calls the medical emergency service and latest when he decides to see a doctor. Physicians and other health workers contributed only in 16.4-20.9% patients with acute myocardial infarction to their early decision to seek medical assistance. Patients with an early decision (within one hour) call most frequently the medical emergency service and are taken to hospital by this service. The time delay due to transport is shortest in these patients. The late hospital admission of patients with acute myocardial infarction in Slovakia calls for reduction of the time interval from the development of complaints to hospital admission (total prehospital delay), in particular the time taken by the patient to make up his mind (patient time delay). Early calling of the emergency medical service and transport of the maximum possible number of patients with acute myocardial infarction to hospital by the emergency medical service will greatly improve the management of patients with acute myocardial infarction. Comprehensive implementation of the survival chain (24), the most comprehensive implementation of recommendations of the European Society of Cardiology and the European Resuscitation Council for in the management of patients with acute heart attacks during the prehospital phase (21) and early effective treatment which begins already in the prehospital phase has a favourable impact on the condition of patients with acute myocardial infarction and on their prognosis. Along with early and effective treatment of patients with acute myocardial infarction in hospital and their stratification these are the most important approaches to the development and control of sudden cardiac death. Knowledge of the complex problem of the prehospital phase in patients with acute myocardial infarction is the prerequisite for the elaboration of high standard prehospital management of patients with acute myocardial infarction.     

Microcirculatory dysfunction in ST-elevation myocardial infarction: cause, consequence, or both?

AIMS: Despite advancements over the past years, normal reperfusion at the myocardial level is not achieved in approximately every other patient with ST-elevation myocardial infarction. In the current work, we aimed at reviewing the role of the coronary microcirculation in the development and outcome of this acute coronary syndrome entity. METHODS AND RESULTS: A PubMed/Medline search was performed with the key words acute coronary syndrome, acute myocardial infarction, coronary artery disease, endothelial dysfunction, microcirculation, and reperfusion. The synthesis of the information points to myocardial microcirculatory dysfunction as a consequence of a primary epicardial event, based on the vulnerable plaque concept. As an alternative theory, microcirculatory dysfunction may contribute to the clinical course of the acute coronary event, based on the vulnerable patient concept. The pros and cons of these two viewpoints are to be discussed and their influence on patient management is to be considered. CONCLUSION: Microcirculatory dysfunction in ST-elevation myocardial infarction can be cause, consequence or both according to non-traditional and traditional concepts.     

Submaximal exercise testing early after myocardial infarction. Difficulty of predicting coronary anatomy and left ventricular performance

Impaired left ventricular function and extensive coronary artery disease are important determinants of prognosis after acute myocardial infarction. The ability of clinical and predischarge submaximal exercise test variables to predict multivessel coronary artery disease and impaired left ventricular function was assessed in 62 survivors of acute myocardial infarction. Abnormal exercise blood pressure response and short exercise performance were predictors of multivessel disease, but exercise induced ST segment changes and clinical variables were not. Q wave infarction, high grade Killip classification, and exercise induced ST segment elevation predicted statistically significant impairment of resting left ventricular function, whereas other clinical and exercise test variables did not. Exercise induced ST segment changes were therefore of little value in detecting extensive coronary disease, although exercise induced ST elevation was an indicator of poor resting left ventricular function. Although abnormal exercise haemodynamics may detect extensive coronary artery disease, other physiological markers of reversible myocardial ischaemia are probably necessary to plan optimal management in these patients.     

早发冠心病心肌梗死型与非心肌梗死型危险因素差异分析

目的探讨早发冠心病中心肌梗死型与非心肌梗死型的危险因素差异。方法回顾性分析2004年1月至2009年12月在沈阳医学院附属奉天医院心血管内科住院并确诊的45岁及以下冠心病患者165例,分为急性心肌梗死(AMI)组和非AMI组。对两组患者的相关临床资料及危险因素进行统计分析。结果 AMI组吸烟史比例、男性比率、血浆纤维蛋白原及D-二聚体均高于非AMI组,差异有统计学意义(P<0.05),两组的血脂异常率、血小板计数(PLT)、血小板压积、凝血酶原时间(PT)、国际标准化比值(INR)和活化部分凝血活酶时间(APTT)的差异无统计学意义。结论吸烟、男性性别、血脂水平异常是早发冠心病重要危险因素;血浆纤维蛋白原水平增高对于预测早发冠心病心肌梗死可能具有一定的临床意义。     

Submaximal exercise testing early after myocardial infarction. Difficulty of predicting coronary anatomy and left ventricular performance.

Impaired left ventricular function and extensive coronary artery disease are important determinants of prognosis after acute myocardial infarction. The ability of clinical and predischarge submaximal exercise test variables to predict multivessel coronary artery disease and impaired left ventricular function was assessed in 62 survivors of acute myocardial infarction. Abnormal exercise blood pressure response and short exercise performance were predictors of multivessel disease, but exercise induced ST segment changes and clinical variables were not. Q wave infarction, high grade Killip classification, and exercise induced ST segment elevation predicted statistically significant impairment of resting left ventricular function, whereas other clinical and exercise test variables did not. Exercise induced ST segment changes were therefore of little value in detecting extensive coronary disease, although exercise induced ST elevation was an indicator of poor resting left ventricular function. Although abnormal exercise haemodynamics may detect extensive coronary artery disease, other physiological markers of reversible myocardial ischaemia are probably necessary to plan optimal management in these patients.     

Indications for coronary arteriography after myocardial infarction

The prognosis of patients after an acute myocardial infarction depends on the extent of the myocardial damage, its resulting left ventricular dysfunction and on the number and degree of narrowing of diseased coronary arteries. Patients with a severe multivessel disease constitute a high-risk group with an important morbidity and mortality during the first few months after hospitalization for a myocardial infarction. They could benefit from early revascularization therapy, whether by coronary artery bypass surgery, whether by percutaneous transluminal coronary angioplasty. Although early coronary revascularization is still controversial, management of patients after a myocardial infarction certainly will improve from a more accurate risk profiling by a careful diagnostic evaluation--including coronary arteriography in some subsets of patients--during the in-hospital period.     

青年急性心肌梗死诊治(附26例报告)

目的 探讨青年（年龄≤40岁）急性心肌梗死的病因、临床特点及治疗方法.方法 对26例青年急性心肌梗死患者临床资料进行回顾性分析.结果 26例青年急性心肌梗死首发症状多样化,经积极治疗,痊愈或好转24例,死亡2例.结论 多种因素可诱发青年心肌梗死.临床医师应重视青年急性心肌梗死的诊治及健康教育,做到防治结合,从而达到降低青年急性心肌梗死死亡率的目的.     

Ecstasy induced acute myocardial infarction

A 23 year old man presented with a clinical history and ECG compatible with acute myocardial infarction, having taken a single tablet of ecstasy (3,4-methylenedioxymetamphetamine) 18 hours previously. He was treated with aspirin and thrombolytic therapy; however, cardiac catheterisation showed angiographically normal coronary arteries and left ventricular function. Sympathomimetic drugs are freely available and widely abused in Britain, but there is little evidence of the mechanisms or management of cardiac complications. In such cases the use of standard treatment for acute myocardial infarction is recommended with agents such as glyceryl trinitrate and phentolamine to reduce coronary artery spasm. Early coronary angiography may help to determine the relative contribution of spasm, thrombus, and underlying atherosclerotic disease.


Keywords: ecstasy; 3,4-methylenedioxymetamphetamine; acute myocardial infarction     

Comparison of the circadian variation of the time of onset of acute myocardial infarction and of attack of vasospastic angina without significant stenosis

OBJECTIVES: To study the involvement of vasospasm as the trigger of acute myocardial infarction without significant stenosis, the circadian variation of the time of onset of acute myocardial infarction was compared with that of vasospastic angina without significant stenosis. METHODS: The subjects consisted of 3 groups, 64 patients with acute myocardial infarction without significant stenosis, 101 patients with acute myocardial infarction with one vessel disease and 98 patients with vasospastic angina without significant stenosis. The times of onset of acute myocardial infarction and spontaneous attack of vasospastic angina were recorded and classified according to the 4 periods (0:00-6:00, 6:00-12:00, 12:00-18:00, 18:00-24:00) and the pattern of distribution was compared between the 3 groups. RESULTS: The time distribution of acute myocardial infarction without significant stenosis showed a double peaked pattern at 6:00-12:00 and 18:00-24:00 and was similar to the pattern of acute myocardial infarction with one vessel disease(p = 0.93). Only a single peak in 0:00-6:00 was found in the pattern of distribution of vasospastic angina without significant stenosis and differed significantly from acute myocardial infarction(p < 0.01). CONCLUSIONS: The circadian variation of the time of onset of acute myocardial infarction was similar in patients with or without significant stenosis, and differed significantly from that in patients with vasospastic angina.     

糖尿病对急性心肌梗死患者近期预后的影响分析

目的探讨糖尿病对急性心肌梗死患者近期预后的影响。方法选择连续住院的急性心肌梗死患者3572例,按照有无糖尿病将其分为糖尿病组(1008例)和非糖尿病组(2564例),然后进行回顾性分析。结果与非糖尿病组比较,糖尿病组患者年龄、女性、高血压、陈旧性脑梗死、3支或左主干病变、冠状动脉旁路移植术、住院病死率明显增高,而广泛前壁或前壁心肌梗死、非ST段抬高心肌梗死、单支病变、PCI比例明显降低(P<0.05,P<0.01)。logistic回归分析,糖尿病增加急性心肌梗死患者住院死亡,且独立于年龄、广泛前壁或前壁心肌梗死、前间壁心肌梗死、陈旧性脑梗死、冠状动脉造影、PCI等因素存在。结论糖尿病增加急性心肌梗死患者住院死亡风险。