Acute myocardial infarction caused by coronary embolism complicated by left ventricular free wall rupture.

Acute myocardial infarction with normal coronary arteries is a relatively infrequent finding. This report describes a rare combination of an embolic event to a normal coronary artery, presumably originating from a left atrial thrombus. An anomalous origin of the infarct-related coronary artery presumably enabled preferential penetration of the clot into the artery. The infarction was further complicated by rupture of the left ventricular free wall.     

Acute myocardial infarction and multiple traumas: a dilemma of protocol

Treatment of myocardial infarction is today governed by specific protocols. Angioplasty involves a therapeutical anticoagulation to prevent the risk of acute thrombosis. Acute myocardial infarction after a blunt trauma has been described, but there is no specific treatment recommendations extant, particularly weighing the risk of hemorrhage. In this report, we describe an adolescent boy who suffered from an acute myocardial infarction by dissection of the left anterior descending coronary after a car crash. He also presented with a subdural hemorrhage and a lung contusion, injuries, which both present a substantial risk of hemorrhage. After diagnosing the therapeutical problem, we describe our decisions regarding how we approached this case. We provide an algorithm of treatment coming from our experience of these cases with the hope it can help physicians in their future decisions.     

Association of serum immunoglobulin G (IgG) levels against two periodontal pathogens and prothrombotic state: a clinical pilot study

Normal pregnancy corresponds to a procoagulant state. Acute myocardial infarction during pregnancy is rare, yet considering the low non-pregnant risk score of childbearing women it is still surprisingly frequent. We report a case of postpartum recurrent non-ST elevation myocardial infarction in a 40-year-old caucasian woman with essential thrombocythaemia in the presence of a positive JAK-2 mutation and an elevated anti-cardiolipin IgM antibody titer. In the majority of cases of myocardial infarction in pregnancy or in the peripartal period, atherosclerosis, a thrombus or coronary artery dissection is observed. The combination of essential thrombocythaemia and elevated anti-cardiolipin IgM antibody titer in the presence of several cardiovascular risk factors seems to be causative in our case. In conclusion, with the continuing trend of childbearing at older ages, rare or unlikely conditions leading to severe events such as myocardial infarction must be considered in pregnant women.     

Probably myocardial infarction in a 14-year-old boy

After vigorous physical activity a 14-year-old boy from a family with a strong history of cardiac disease developed symptoms consistent with a myocardial infarction, a relatively rare event in this age group. Isoenzyme patterns of creatine kinase and lactate dehydrogenase were consistent with the occurrence of an infarction.     

Peripartum acute myocardial infarction: management perspective

Acute myocardial infarction in pregnancy and puerperium is an uncommon event with substantial morbidity and mortality rates. Atherosclerosis may be the cause, but often the coronary arteries are healthy at angiography. In such cases, the suggested mechanism is a decreased coronary perfusion related to coronary spasm or in situ thrombosis. Most pregnant women who died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Therefore, there should be efforts to limit myocardial oxygen demand throughout pregnancy, and particularly during parturition. It is important for diagnosis to have increased awareness of its possible occurrence. Although principles of management can be generalized, it is necessary to provide individualized care for these high-risk patients by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.     

Cocaine-induced acute myocardial infarction

Acute myocardial infarction may occur following cocaine use. Cocaine-induced infarction is particularly common in younger patients aged 18 to 45 years old. Patients may or may not have angiographic evidence of coronary artery disease at the time of their acute event. Previous studies have shown that coronary artery spasm occurs with cocaine use, and perhaps platelet activation, both contributing to a process that may culminate in coronary artery occlusion. Primary coronary intervention should be the preferred revascularization modality by an experienced team. Thrombolytic therapy needs to be instituted if this intervention is unavailable. Beta blockers should be utilized with caution since they may increase coronary spasm or cause a paradoxical rise in blood pressure. They should be avoided in the early hours of the infarction, but be instituted prior to patient discharge. Interruption of cocaine abuse is the cornerstone of secondary prevention in cocaine-related myocardial infarction.     

Counter-Terrorism for Emergency Responders,Second Edition

Abstract

Acute coronary syndrome and myocardial infarction have been described to present with atypical symptoms in certain subsets of patients. However, these subsets commonly do not include middle-aged males with a paucity of underlying medical conditions. We present a very unique case of acute coronary syndrome in a 53-year-old male, with no previously identified medical conditions other than chronic back pain. The patient was encountered by rural emergency medical service providers presenting with syncope followed by intermittent episodes of lightheadedness. Further, electrocardiographic changes consistent with acute ischemia could only be demonstrated with the patient in a standing position, prior to the development of an occurrence of ventricular tachycardia, which degenerated into ventricular fibrillation. To our knowledge, this is a very rare case of electrocardiographic changes consistent with occult, acute cardiac ischemia with a proven coronary artery lesion seen initially only with the patient in a standing position.     

Assessing the clinical and economic burden of coronary artery disease: 1986-1998

BACKGROUND: The acute phase of coronary artery disease (CAD) is dramatic and receives much attention because of its high mortality and associated treatment cost. However, the acute phase typically resolves within 30 days whereas CAD is a chronic disease, which most patients will live with for more than a decade. We compared the clinical and economic burden of CAD during the acute phase (first 30 days) with that in the postacute phase (31st day through 10 years). METHODS: We included acute coronary syndrome (ACS) patients with significant CAD receiving an initial cardiac catheterization at Duke University Medical Center between 1986 and 1997 with follow-up continuing through 1998. Inpatient medical costs were estimated from ACS clinical trial and economic study data. Costs were adjusted to 1997 values and discounted at 3% per annum. RESULTS: Our study included 9,876 ACS patients (5,557 with an acute myocardial infarction [MI] and 4,319 with unstable angina [UA]). Acute MI patients had higher 30-day mortality than UA patients (5.6% vs. 2.3%, P <0.001). In addition, acute MI and UA patients had significant 10-year unadjusted and adjusted survival differences (both P <0.001). For patients who survived to 30 days, there was no difference in 10-year survival between acute MI and UA patients before adjustment (P = 0.472). After adjustment, however, unstable angina patients who survived to 30 days had greater survival than myocardial infarction patients (P = 0.011). Mean 10-year discounted ACS inpatient medical costs were $45,253 ($23,510 acute phase and $21,819 postacute phase, P = 0.002). Ten year costs for unstable angina patients were $46,423 ($21,824 acute phase and $24,599 postacute phase, P = 0.003); ten year costs for myocardial infarction patients were $44,663 ($24,823 acute phase and $19,840 postacute phase, P <0.001). CONCLUSIONS: We found that the clinical and economic burden of CAD continues long after a patient's acute event has resolved and that postacute CAD cardiac event rates and inpatient medical costs may be higher than previously estimated. With much of all medical costs occurring in the postacute phase, the potential for effective secondary prevention therapies is substantial.     

Effective Myocardial Salvage with Percutaneous Coronary Intervention in Late Diagnosed Acute Post-Traumatic ST-Elevation Myocardial Infarction

Background: Acute post-traumatic ST-elevation myocardial infarction (STEMI) is rare but potentially disastrous in patients with blunt cardiac injury. Sometimes the diagnosis is delayed. Failed myocardial salvage by percutaneous coronary intervention (PCI) within 9 h after the onset of post-traumatic STEMI has been described. Objective: We present a case report of a patient in whom effective myocardial salvage with PCI was obtained in a late diagnosed acute post-traumatic STEMI. Case Report: We report the case of a young man who was involved in a motorcycle crash, who had a delayed diagnosis of post-traumatic STEMI. Diagnostic coronary angiography was performed to guide treatment strategy. An occluded left anterior descending artery due to a dissection, and an intimal flap at the first diagonal branch were found. A PCI was done 18 h after the onset of the event with striking and immediate improvement of the regional left ventricular wall motion and ejection fraction. Conclusion: After blunt thoracic injury, there is the possibility of an acute post-traumatic STEMI being present when facing a patient with clues of blunt cardiac injury. If the diagnosis of acute post-traumatic STEMI is clinically strong, the patient should be managed individually according to the clinical scenario. Early recognition and prompt management are vital when dealing with patients suffering post-traumatic STEMI.     

急性下壁心肌梗死胸前导联ST段压低的临床意义

目的分析急性下壁心肌梗死伴胸前导联ST段压低的临床意义。方法选择84例急性下壁心肌梗死患者常规心电图及24h动态心电图进行对照分析。结果急性下壁心肌梗死伴胸前导联ST段压低多于不伴胸前导联ST段压低（P〈0．01）;下壁伴正后壁心肌梗死伴胸前导联ST段压低多于不伴胸前导联ST段压低（P〈0．01）;下壁伴右心室心肌梗死与胸前导联ST段压低无明显关联（P〈0．01）;急性下壁心肌梗死伴胸前导联ST段压低者严重室性心律失常与房室传导阻滞的发生率较不伴胸前导联ST段压低者高（P〈0．01）。结论急性下壁心肌梗死伴胸前导联ST段压低往往提示梗死范围大或同时存在心肌缺血、冠脉病变广泛、心功能损害较严重,并且严重室性心律失常与房室传导阻滞的发生率明显增高,心肌酶峰值明显增高临床预后较差。     

Spontaneous dissecting aneurysm of the coronary artery. A rare cause of myocardial infarction and sudden death

Spontaneous dissecting aneurysm of the coronary artery (SDACA) not associated with aortic aneurysm or trauma is a very rare cause of myocardial ischemia. It has a higher prevalence in otherwise healthy women, especially in the peri- and postpartum period. In 80-90% of cases the diagnosis of SDACA is confirmed at autopsy, as the majority of patients present with acute myocardial infarction or sudden death. We describe the case of a 47-year-old Caucasian woman who died suddenly without any previous sign of cardiac disease. She had no clinical signs of Marfan's syndrome or arterial hypertension, she used no oral contraceptives and she was not in the peri- or postpartum period. At autopsy we found a recent dissecting aneurysm of the right coronary artery. Histology showed a hematoma between the media and adventitia of the coronary artery, flattening and occluding the lumen. Acute myocardial infarction was present in the posterior wall of the left cardiac ventricle. SDACA is an unpredictable condition and prompt diagnosis and life-saving procedures--either surgical or conservative--are rarely successful. We report a very rare disease documented in only 108 cases according to the English-language literature accessible to us.     

急性下壁心肌梗死胸前导联ST段改变的临床意义

目的分析急性下壁心肌梗死伴胸前导联ST段压低的临床意义。方法选择38例急性下壁心肌梗死患者常规心电图及24h动态心电图进行对照分析。结果急性下壁心肌梗死伴胸前导联ST段压低多于不伴胸前导联ST段压低(P<0.01);下壁伴正后壁心肌梗死伴胸前导联ST段压低多于不伴胸前导联ST段压低(P<0.01);下壁伴右心室心肌梗死与胸前导联ST段压低无明显关联(P<0.01);急性下壁心肌梗死伴胸前导联ST段压低者严重室性心律失常与房室传导阻滞的发生率较不伴胸前导联ST段压低者高(P<0.01)。结论急性下壁心肌梗死伴胸前导联ST段压低往往提示梗死范围大或同时存在心肌缺血、冠脉病变广泛、心功能损害较严重,并且严重室性心律失常与房室传导阻滞的发生率明显增高,心肌酶峰值明显增高临床预后较差。     

Experimental myocardial infarction: II. Acute depression and subsequent recovery of left ventricular function: serial measurements in intact conscious dogs

Acute myocardial infarction causes depression of left ventricular function, but the capacity of the ventricle to recover from such an injury remains unknown. This problem was explored by measuring left ventricular function in eight intact conscious dogs before, 1 hr after, and again 6-8 days after myocardial infarction. Acute myocardial infarction was produced using a technique which entails gradual inflation over an average period of 1 hr of a balloon cuff previously implanted around the left anterior descending coronary artery. Occurrence of anterior wall infarction was detected electrocardiographically and later confirmed by postmortem examination. Left ventricular function was evaluated from the relationship between left ventricular developed pressure (left ventricular peak systolic pressure minus left ventricular end-diastolic pressure) and left ventricular end-diastolic pressure during transient aortic occlusion with a balloon catheter. Left ventricular function curves were obtained by plotting left ventricular-developed pressure at increasing left ventricular end-diastolic pressures up to 50 mm Hg. Acute myocardial infarction caused marked depression of left ventricular function measured 1 hr after onset of infarction, but 1 wk later all eight animals showed improvement with return of function toward the control levels. A small but significant descending limb was noted at left ventricular end-diastolic pressures above 35 mm Hg. Quantitatively, the descending limb was similar before, 1 hr after, and 1 wk after myocardial infarction. Hemodynamic data revealed evidence of left ventricular failure in all animals, but variability in individual hemodynamic parameters was noted. The data indicate that the marked depression of left ventricular function observed immediately after experimental acute myocardial infarction undergoes considerable resolution within 1 wk, but that functional recovery remains incomplete.     

Surgical repair of acute postinfarction cardiac rupture

Acute myocardial infarction is complicated by cardiac rupture in 4% to 24% of all infarction deaths, and approximately 10% of hospital infarction deaths. There are no reliable indices to determine which patients run an increased risk of cardiac rupture. This report describes the surgical treatment and outcome of a patient who sustained a rupture of the left ventricular free wall, nine days after extensive anterior myocardial infarction.     

老年急性心肌梗死患者的基础护理体会

目的探讨老年急性心肌梗死患者基础护理实施及临床满意度调查。方法选择2011年12月～2012年12月在我院心脏科住院治疗的43例老年急性心肌梗死患者为研究对象，分析老年急性心肌梗死基础护理实施和患者家属对护理服务满意度调查。结果全组43例患者临床总有效率为93．02％，基础护理合格率为93．02％，患者对护理服务的满意率达到95．35％（41／43），实现了护理零投诉。结论注重基础护理，有利于提高老年急性心肌梗死护理的质量，改善医患关系，促进护理事业的快速发展。     

The case for echocardiography in acute myocardial infarction

Acute myocardial infarction occurs after a period of profound myocardial ischemia. Ischemia of this degree immediately produces a regional contraction abnormality, which is readily detectable by echocardiography before the onset of necrosis. Echocardiography has been used both experimentally and clinically as a guide to the functional extent of myocardial involvement in evolving infarction and hence provides an objective anatomic basis for electing therapeutic interventions and assessing a prognosis.     

A CUTE C ORONARY S YNDROME : P HARMACOTHERAPY

Acute coronary syndrome (ACS) refers to the spectrum of cardiac disease, from unstable angina to ST-segment-elevation myocardial infarction. In the emergency medical services (EMS) setting, ACS may be more broadly thought to include patients with chest pain or other symptoms believed to have a cardiac origin who have evidence of ischemia or acute myocardial infarction on a 12-lead electrocardiogram, or symptomatic patients with a previous cardiac event or known cardiac disease. Pharmacologic management of these patients is based on the use of three primary classes of drugs: those that affect clotting, those that establish and maintain hemodynamic control, and those that relieve pain. Many of these agents have been evaluated in large clinical trials for in-hospital use, and a number of ongoing studies are assessing their efficacy in the prehospital setting. The appropriateness of prehospital use of specific agents within each class depends on proper patient selection, the necessity of immediate intervention, ease of use in the field, expertise of EMS personnel, and cost-effectiveness of therapy. This consensus group reviewed agents from all three classes (including aspirin, GPIIb/IIIa inhibitors, unfractionated and low-molecular-weight heparins, fibrinolytics, beta-adrenergic blockers, calcium antagonists, nitrates, and morphine) for their overall indication, applicability to the prehospital setting, and current prehospital use.     

老年急性心肌梗死患者基础护理探讨

目的探讨老年急性心肌梗死患者基础护理方法及临床满意度调查。方法选择2010年1月～2012年1月在我科住院治疗的37例老年急性心肌梗死患者为研究对象，观察老年急性心肌梗死基础护理合格率和患者家属对护理服务满意度，基础护理合格率由科室护士长和责任护士按照护理部下发的基础护理质量评价标准进行测评，患者家属满意度由患者家属在病人转出重症医学科时对护理部下发的护理工作满意度调查表进行填写。结果护理合格率为91．89％（34／37），患者对护理服务的满意率达到94．59％（35／37），实现了护理零投诉。结论注重基础护理，有利于提高老年急性心肌梗死护理的质量，改善医患关系，促进护理事业的快速发展。     

Manageability, vulnerability and interaction: a qualitative analysis of acute myocardial infarction patients' conceptions of the event.

BACKGROUND: Delay in seeking care remains a problem for many patients with myocardial infarction. There is a great deal of knowledge available about clinical factors contributing to this delay, while studies focusing on the patients' own experiences are few. AIM: Describe variations in how individuals perceived suffering symptoms of an acute myocardial infarction. DESIGN: A qualitative method using phenomenographic design was applied. Interviews were conducted with 15 strategically selected patients with myocardial infarction. FINDINGS: Eight sub-categories in the pre-hospital phase were summarised into three categories: manageability, vulnerability, and interaction. To manage their situation, patients expressed a need to understand it and to have a similar situation to compare with. They also described coping with the arising threat to their lives by self-medication or denying their symptoms. Patients expressed vulnerability, with feelings of anxiety, both as triggers and barriers to seeking medical care. In interaction with others, psychosocial support and guidance from the environment, was fundamental in helping the patients to manage the situation. CONCLUSIONS: There were large variations in myocardial infarction patients' conceptions of the event. To improve disease management in the pre-hospital phase, the awareness of this large variation in conceptions about suffering symptoms of an myocardial infarction could be used in the dialogue between patients and health care professionals, in cardiac prevention programmes, as well as in health care education.     

不同特征的社区人群对急性心肌梗死认知的调查分析

目的了解不同特征的社区人群对急性心肌梗死认知及健康教育的需求，为社区干预提供依据，从而保证健康教育的质量。方法选择杭州市小营街道社区常住居民300例，采用自行设计的调查问卷，按性别、年龄、文化程度、月收入、费用类别不同等对其进行AMI知晓情况，胸痛首次发作时选择30min内就医的情况，就医时选择的交通工具，健康教育的需求的调查。结果188例（65．28%）的社区居民不知道AMI是严重的疾病，在性别、文化层次的比较差异有显著意义（P〈0．05），如若胸痛首次发作，66例（22．92％）社区居民选择30min内决定上医院，在性别、年龄、月收入、文化层次的比较上有显著意义，在胸痛不适时45例（15．63％）的居民选择呼叫120救护车上医院，这在年龄、费用类别、月收入的比较差异有显著意义，281例（97．57％）的社区居民表示非常需要了解AMI的相关知识，在获取AMI知识的方式在年龄及文化层次上有不同。结论社区人群对AMI肌梗死的认知水平不高，不同特征人群间存在差异，可以根据不同特征社区人群采取不同的健康教育方式，以达到更好的健康教育的效果。