Neonatal myocardial infarction due to thrombotic occlusion.

Neonatal myocardial infarction is rare and its prognosis is poor. We describe the clinical course and autopsy findings of a newborn female with myocardial infarction. Her clinical course was rapidly progressive, becoming fatal before we could detect the cause. Autopsy demonstrated significant occlusion of the left coronary artery as well as evidence of new infarction, suggesting that the event occurred at birth. This case illustrates myocardial infarction as a possible cause of early neonatal death.     

Pregnancy-associated spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction that occurs particularly in women during the pregnancy and in the postpartum period. We describe a dramatic case of pregnancy-related spontaneous left main coronary artery dissection that resulted in acute myocardial infarction with severe left ventricular dysfunction and was complicated by acute heart failure and cardiogenic shock. Urgent revascularization and restoration of myocardial perfusion that were performed in this case resulted in marked left ventricular function recovery and clinical improvement.     

Myocardial infarction in the 34th week of gestation: case report

Acute myocardial infarction during pregnancy is a rare event that is often associated with a very high maternal mortality, estimated to be from 19 to 37%. During the last decades the incidence of myocardial infarction during pregnancy has increased . The main contributing factor could be a higher prevalence of the metabolic syndrome. The strongest predictors correlated with a myocardial infarction are hypertension, diabetes mellitus and advanced maternal age. In addition, improved diagnostic tools could explain the elevated incidence of myocardial infarction during pregnancy. In general gestation is not considered a risk factor for myocardial infarction but gravidity is accompanied by an increase in oestrogen and progesterone levels. It is generally accepted that oral contraceptives increase the risk of coronary heart disease. We present a case where a 37-year-old gravida was admitted to hospital with diffuse thoracic pain. In the patient's history, we found several putative reasons for the thoracic pain that pointed to a musculoskeletal cause. Based on an elevation of ischaemic heart markers and continuous non-specific thoracic pain we performed a primary Cesarean section. In the coronary angiography procedure that followed, a thrombotic occlusion of the ramus diagonalis was diagnosed. We here describe the differential diagnosis as well as the problems associated with diagnosing myocardial infarction in the third trimester of pregnancy.     

Chronic diffuse intravascular coagulation (DIC) in nonmetastatic ovarian cancer: Report of a case and review of the literature

A patient with a dramatic clinical picture of cerebral artery occlusion, peripheral artery occlusion, and pulmonary embolism was diagnosed as suffering from disseminated intravascular coagulation (DIC) according to the typical laboratory findings of hypofibrinogenemia, hypoprothrombinemia, relative thrombocytopenia, and reduction of other clotting factors. Increased fibrinogen split products (FSP) were found on several occasions later in the disease. Heparin was effective in controlling the syndrome which recurred when treatment was stopped. The cause of the syndrome was an ovarian tumor. The patient died of acute myocardial infarction. The postmortem examination confirmed the diagnosis of DIC, the primary disease being a mucinous cystadenocarcinoma of the right ovary, and revealed that the terminal myocardial infarction was also the result of DIC. The surprise was that the tumor was solitary and without metastases. The literature dealing with chronic DIC in cancer is reviewed, and its diagnosis, frequency, and association with metastases is assessed.     

Arteriosclerosis in popliteal artery trifurcation as a predictor for myocardial infarction after arterial reconstructive operation

The frequency of myocardial infarction and mortality within 30 days after lower limb vascular reconstruction, in relation to the extent of atherosclerotic lesions in the trifurcation of the popliteal artery, have been retrospectively analyzed in 158 consecutive patients reconstructed in the aortoiliac region and 239 consecutive patients undergoing femorodistal bypass. Among the patients without trifurcational disease (TFD) none had myocardial infarction develop postoperatively, as compared with four of the 50 patients with TFD in the aortoiliac series (p less than 0.05) and 18 of the 174 patients with TFD in the femorodistal series (p less than 0.05). In nine instances, the cause of death was myocardial infarction. The strong correlation between postoperative myocardial infarction and the presence of TFD, may be due to a direct correlation between coronary artery disease and TFD. The finding is of practical importance in the selection of treatment for patients with circulatory disorders of the lower limbs. The finding facilitates the preoperative identification of patients liable to have myocardial infarction develop. Indications for operation can be made more stringent and optimal intraoperative and postoperative monitoring can be instituted.     

Who was caring for Mary? 1993.

An academic physician gives a personal account of his wife's progressive deterioration during her hospitalization at a university medical center. He encounters physicians who are too distracted by other academic pursuits to care adequately for his wife. Her hospital course is complicated by bilateral pulmonary emboli which occur during inadequate heparin therapy and are followed by myocardial infarction, shock, and the adult respiratory distress syndrome. His experience exemplifies the importance of closely supervised care. He calls on the leaders of academic medical centers to make excellence in patient care a top priority and recommends that clinical as well as research skills be rewarded.     

The use of hormone replacement therapy in women with acute myocardial infarction: an audit of current practice

We undertook criterion-based audit of the current practice of prescribing hormone replacement therapy for women with acute myocardial infarction; the audit included 181 consecutive women admitted to one hospital with this diagnosis in one calendar year. The set standard was that, barring any contraindication, all postmenopausal women with acute myocardial infarction should be prescribed hormone replacement therapy before discharge from hospital. The evidence base of this standard derives from more than 30 epidemiological and clinical studies and a large body of biological data. Only 4.7% of the women were current users of hormone replacement therapy and the set standard was met in only 3% of eligible nonusers. Professionals caring for women who have had a myocardial infarction need to consider hormone replacement therapy as a secondary prophylaxis of myocardial infarction. Gynaecologists should liaise with colleagues in other specialties and general practice to ensure that information on the nongynaecological benefits of hormone replacement therapy is widely disseminated.     

Survival after intrauterine myocardial infarction: noninvasive assessment of myocardial perfusion with 99mTc-Sestamibi scintigraphy

Survival after severe intrauterine myocardial infarction has not been reported previously. We describe the course of a neonate with a structurally normal heart, who presented with cardiogenic shock at birth due to intrauterine myocardial infarction with a huge ventricular aneurysm. Myocardial perfusion was assessed noninvasively by means of 99mTc-Sestamibi, a radiopharmaceutical agent recently introduced in nuclear cardiology to avoid repeated coronary angiography. The patient survived with improved cardiac function and normal neurodevelopmental outcome.     

Myocardial Infarction in a Young Indian Grandmultipara

EDITORIAL COMMENT": We accepted this case report for publication to remind readers that myocardial infarction or ischaemia can occur in women in the reproductive age group. In the 1988–1990 triennium in Australia there were 33 indirect maternal deaths, in 3 of which myocardial infarction or ischaemia was the primary cause.     

Risk of myocardial infarction, angina and stroke in users of oral contraceptives: an updated analysis of a cohort study

Objectives To investigate risk of myocardial infarction, angina and stroke in users of contraceptive pills compared with users of other methods of contraception.
Design Prospective cohort study, with recruitment between 1968 and 1974 and annual follow up until the age of 45 years. After this age, only women who had never used oral contraception or those who had used it for eight or more years continued to be followed up annually until July 1994.
Setting Seventeen family planning clinics in England and Scotland.
Population 17,032 women aged between 25 and 39 years at entry to the study.
Main outcome measures Occurrence of angina, myocardial infarction or stroke that was associated with either hospital admission or outpatient referral to hospital or death.
Results Increased risk of myocardial infarction in oral contraceptive users was observed only in women who were heavy smokers at entry to the study. In this subgroup the relative risk of a myocardial infarction was 4.2 (95% CI 1.4–16.6) in ever users of oral contraception compared with non-users, 4–9 (1.2–23.6) in current users, and 4–0 (1.3–16.2) in ex-users. In all current users the relative risk of angina was 0.5 (0.1–1.4), and the relative risk of ischaemic stroke was 2.9 (1.3–6.7). The increased risk of ischaemic stroke did not persist in ex-users.
Conclusions Use of oral contraception is associated with increased risk of ischaemic stroke and increased risk of myocardial infarction (only in heavy smokers), but no increased risk of angina. These increased risks need to be considered within the context of the very low absolute risks of cardiovascular disease in this population. 5880 women need to take oral contraception for one year to cause one extra stroke, and 1060 women who are heavy smokers need to take it for one year to cause one extra myocardial infarction.     

Outcome of primary percutaneous coronary intervention in octogenarians with acute myocardial infarction.

BACKGROUND/PURPOSE: Acute myocardial infarction (AMI) results in more complications and increased mortality in octogenarians compared to patients in younger age groups. This study investigated the short- and long-term outcomes in octogenarians after primary percutaneous coronary intervention (PCI). METHODS: During the study period from May 1997 to August 2004, 54 patients > or = 80 years old with ST-elevation myocardial infarction (STEMI) were eligible for primary PCI. Data collected included baseline clinical characteristics and usage of cardiovascular medications. Diagnostic coronary angiography and revascularization procedures were performed using standard practices. During hospitalization, the clinical course including serial changes in cardiac enzymes, adverse events associated with myocardial infarction or treatment, and inhospital or long-term mortality of patients were recorded. RESULTS: The mean age of the 54 patients (35 men, 19 women) was 82.8 +/- 2.5 years (range, 80-89 years). Among them, 27 (50%) had anterior infarction, six (11%) had anterolateral infarction, and 21 (39%) had inferior infarction, inclusive of three patients with accompanying right ventricular infarction. Among them, 20 (37%) patients were in Killip class I, nine (17%) were in class II, two (4%) in class III, and 23 (43%) in class IV. The mean delay from onset of symptoms to arrival in hospital was 220 +/- 167 minutes, and 189 +/- 169 minutes from hospital arrival to reperfusion. Diagnostic coronary angiography revealed that 48 (89%) patients had multivessel disease. Inhospital death occurred in 23 (43%) patients, with the leading causes of death being profound cardiogenic shock (61%), and free wall rupture (26%). CONCLUSION: Octogenarian patients who developed STEMI tended to have multivessel disease. These patients had a high inhospital mortality rate that was most likely to be due to cardiogenic shock.     

Diagnostic efficacy of a monoclonal antibody-based immunoenzymetric technique for quantitation of creatine kinase MB isoenzyme in serum

The clinical usefulness of the Tandem-E CK-MB method (A) using two monoclonal antibodies to measure the intact cardiac specific creatine kinase isoenzyme (CK-MB) was evaluated against results obtained by Corning's electrophoretic fluorescence scanning method (B) and the DuPont aca mechanized column chromatographic method (C). In 95 patients suspected to have myocardial infarction, a total of 127 CK's with MB's were simultaneously determined by methods "A", "B", and "C". "C" produced a total of 16.5% (21 out of 127) false-negative or false-positive results. In contrast, CK-MB results obtained by "A" correlated very well with those determined by "B" (r = 0.97; N = 64). In addition, the clinical course of myocardial infarction as monitored by the measurement of CK-MB at various time intervals by both methods showed excellent parallelism. Furthermore, "A" was shown to be free of interference from the presence of macro CK type I and II. Also, the presence of increasing concentrations of CK-BB (up to 29 IU/L) did not alter the assay response of CK-MB in these serum samples. In conclusion, we found the Tandem-E CK-MB method to be sensitive (sensitivity = 94%) and specific (specificity = 96%).     

Correcting misconceptions about oral contraceptives

Although the majority of American women believe that oral contraceptives can cause serious health problems such as cancer or heart disease, the scientific literature does not support these beliefs. Oral contraceptives actually protect against endometrial and ovarian cancer. The increased incidence of cardiovascular disease in oral contraceptive users, including myocardial infarction, appears to be caused by thrombosis and not atherosclerosis. The studies suggesting an increased risk of cardiovascular disease in oral contraceptive users were published in the late 1970s and therefore used a data base of women ingesting formulations containing 50 micrograms of estrogen or more. More recently published data involving healthy women taking mainly lower estrogen dose preparations suggest that there is no increased incidence of myocardial infarction or stroke. Nearly all published studies indicate that there is no increased risk of myocardial infarction in former users of oral contraceptives. Animal data actually suggest that oral contraceptives may have a protective effect against atherosclerosis, even in the presence of lowered high-density lipoprotein levels. The low-dose triphasic and monophasic formulations are effective, safe methods of contraception that can be used by most healthy women of reproductive age.     

Intrauterine left chamber myocardial infarction of the heart and hydrops fetalis in the recipient fetus due to twin-to-twin transfusion syndrome

A rare complication of twin-to-twin transfusion syndrome (TTTS) is described: myocardial infarction of the recipient fetus. Myocardial infarction and hydrops are considered to be consequences of hypertension in the recipient. No other organs were affected. Pathological signs of intrauterine hypertension were estimated by the thickness of vessel walls and signs of hypertrophied myocardial cells. In the heart of the recipient fetus there was a chronic myocardial infarction near the apex cordis on the anterior wall with an aneurysm 4x5 mm in diameter. Diagnosis was based on light microscopic examination. The poor myocardial systolic function resulted in hydrops. Since the mother was administered beta sympathomimetics in therapeutic doses the contribution of the drug to the myocardial infarction is uncertain, but we would like to suggest this as a possible adverse effect in TTTS. The present case is the first reported myocardial infarction in connection with the syndrome.     

Acute myocardial infarction in the puerperium in patients receiving bromocriptine

Although described in the literature as a powerful vasodilator, bromocriptine has been noted to cause vasospasm and hypertension. Two cases are presented where administration of bromocriptine in the puerperium was associated with massive myocardial infarction. These incidents suggest the possibility that bromocriptine occasionally displays the vasoconstrictor effects of other (nonhydrogenated) ergot alkaloids.     

Pneumomediastinum as a cause of acute chest pain postpartum.

Pneumomediastinum can easily be mistaken for a pulmonary embolus or myocardial infarction. We describe herein a case of pneumomediastinum postpartum. A primigravida complained five-hours postpartum of acute chest pain and mild dyspnea. The initial (working) diagnosis was pulmonary embolus and the patient was treated with antithrombotic therapy. A CT scan revealed the real cause of the chest pain: pneumomediastinum. The patient was given adequate analgesia and two days later was able to leave the hospital in good clinical condition. We suggest that in the case of acute chest pain during or shortly following labor, pneumomediastinum should be considered.     

Fetal and neonatal cardiovascular complications from beta-sympathomimetic therapy for tocolysis

beta-Sympathomimetic drugs cross the placenta freely. Just as these agents cause serious cardiovascular changes in the mother, they may cause severe cardiovascular complications in the fetus. beta-Sympathomimetic agents for tocolysis have been associated with fetal heart rate and rhythm disturbances, hydrops, stillbirth, neonatal cardiac failure, myocardial ischemia and infarction, and neonatal death. Prospective studies have documented changes in interventricular septa of babies exposed to these drugs. Histologic changes have been reproduced in animal models and in vitro similar to those seen in infants with myocardial disease caused by beta-mimetic therapy. The mechanism of beta-mimetic toxicity appears to be increased myocardial intracellular calcium leading to overexcitation and cell necrosis. Since serious fetal cardiovascular effects may occur with beta-mimetic use, benefits should clearly outweigh risks before these drugs are administered.     

Human mesenchymal stem cells improve myocardial performance in a splenectomized rat model of chronic myocardial infarction.

BACKGROUND/PURPOSE: Cellular therapy has been applied to animal studies and clinical trials for acute or subacute myocardial infarction. Little is known about the effect of cell therapy on chronic myocardial infarction. The goal of this study was to investigate myocardial performance after human bone marrow-derived mesenchymal stem cell (hMSCs) transplantation in rats with chronic myocardial infarction. METHODS: The hMSCs were obtained from adult human bone marrow and expanded in vitro. The purity and characteristics of hMSCs were identified by flow cytometry and immunophenotyping. Splenectomy in male rats was performed to prevent immune reaction. One week after splenectomy, ligation of the left anterior descending coronary artery was performed to induce myocardial infarction. Four weeks after ligation of the coronary artery, culture-expanded hMSCs were injected intramyocardially at the left anterior free wall. Left ventricular function measured by echocardiography, infarct size and immunohistochemical stain were performed to evaluate the effect of the therapy. RESULTS: The engrafted hMSCs were positive for the cardiac marker troponin T. Infarct size (35.4 +/- 3.4% vs. 53.3 +/- 3.0%, p < 0.001) and fibrotic area (2.6 +/- 0.1% vs. 5.9 +/- 0.2%, p < 0.001) were significantly smaller in the hMSC-treated group than in the control group at 28 days after therapy. hMSC transplantation resulted in smaller left ventricular end-diastolic dimension (6.5 +/- 0.1 mm vs. 7.9 +/- 0.7 mm, p < 0.001) and better left ventricular ejection fraction (88.7 +/- 1.2% vs. 65.8 +/- 2.5%, p < 0.001) than in the control group. Capillary density was markedly increased after hMSC transplantation compared with the control group. CONCLUSION: This study demonstrates that intramyocardial transplantation of hMSCs improves cardiac function after chronic myocardial infarction through enhancement of angiogenesis and myogenesis in the ischemic myocardium. Transplantation of hMSCs for myocardial regeneration may become the future therapy for chronic myocardial infarction.     

Myocardial infarction during pregnancy: a review

In the present review the world literature on pregnancy complicated by myocardial infarction is summarized, and two additional cases are presented. It is apparent that the majority of pregnant women who have died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Moreover, delivery within two weeks of infarction was associated with increased mortality as was reinfarction during labor. These results suggest that the increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Efforts should therefore be made to limit myocardial oxygen demand/consumption throughout pregnancy, and particularly during parturition. Although principles of management can be generalized, these high risk patients require individualization of care by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.     

Postpartum acute myocardial infarction

We report a postpartum acute myocardial infarction that occurred during the first week after cesarean section delivery. We also calculated the rate of postpartum myocardial infarction as related to all women with myocardial infarctions seen in our hospital.(Am J Obstet Gynecol 1997;177:1553-5.)