Question 1 of 10

    Acute Myocardial Infarction (Myocardium Infarction Acute)

    AMI scheme[1]

    Acute myocardial infarction (AMI) ,colloquially referred to as a heart attack, is an irreversible death of a myocardial segment sequel to persistent occlusion and inadequacy of coronary blood flow to the heart. AMI typically presents with central chest pain which may radiate to the neck, left arm, jaw, and shoulders. Accompanying these symptoms are diaphoresis, dyspnea and presyncope.

    Acute Myocardial Infarction emerges due to the following process: vascular.

    Presentation

    Presentation of acute MI may range from asymptomatic to sudden cardiac death. Asymptomatic AMIs occur most commonly in diabetics. Typical symptoms of acute MI include;

    • Chest pain, which could be experienced as pressure or a squeezing/choking sensation at the center of the chest which radiates to the jaw, shoulder, left arm and, occasionally, to the back.
    • Chest pain may, typically, be associated with the following; dyspnea, epigastric pain, palpitations, diaphoresis, syncope or presyncope and disorientation. AMIs occur most likely in the early hours of the morning and with exertion.

    Jaw & Teeth
    Jaw Pain
    • However, women are more likely than men to have: shortness of breath jaw pain upper back pain lightheadedness nausea vomiting In fact, some women who have had a heart attack report that their symptoms felt like the symptoms of the flu.[healthline.com]
    • Atypical symptoms include abdominal discomfort or jaw pain; elderly patients may present with altered mental state.[patient.info]
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  • Entire body system
    Arm Pain
    • Differential diagnosis of acute myocardial infarction Arm pain Myocardial ischemia, cervical/thoracic vertebral pain, thoracic outlet syndrome Epigastric pain Myocardial ischemia, GI tract–esophagus, peptic ulcers, pancreas, liver disease–cholecystitis[medical-dictionary.thefreedictionary.com]
    Congestive Heart Failure
    • The reduced left ventricular ejection fraction may lead to congestive heart failure and predispose to ventricular arrhythmias.[brown.edu]
    • The recommended duration of supplemental oxygen administration in a MI is 2 to 6 hours, longer if congestive heart failure occurs or arterial oxygen saturation is less than 90%.[clevelandclinicmeded.com]
    • There may be signs of congestive heart failure, including pulmonary rales, peripheral oedema, elevated jugular venous pressure.[patient.info]
    • Complications can include: Arrhythmias and conduction defects, with possible "sudden death" Extension of infarction, or re-infarction Congestive heart failure (pulmonary edema) Cardiogenic shock Pericarditis Mural thrombosis, with possible embolization[library.med.utah.edu]
    • PubMed Google Scholar Jougasaki M, Wei CM, McKinley LJ, Burnett JC: Elevation of circulating and ventricular adrenomedullin in human congestive heart failure.[bmcmedicine.biomedcentral.com]
    Coronary Artery Disease
    • While the step-by-step process leading to a heart attack is not fully understood, major risk factors for coronary artery disease are well-known.[webmd.com]
    • "Triple rule-out” coronary CT angiography Some institutions are using this protocol that examines for not only coronary artery disease, but also aortic dissection, pulmonary embolism, and other chest diseases.[radiopaedia.org]
    • It showed calcium score of 0 Agatston units and no evidence of coronary artery disease.[hindawi.com]
    • The diagnosis of people who are less likely to have coronary artery disease and who are at lower risk of having heart problems in the future.[patient.info]
    • The patient may or may not have underlying obstructive coronary artery disease (CAD).[emedicine.medscape.com]
    Fatigue
    • Patients with typical acute MI usually present with chest pain and may have prodromal symptoms of fatigue, chest discomfort, or malaise in the days preceding the event; alternatively, typical ST-elevation MI (STEMI) may occur suddenly without warning.[emedicine.medscape.com]
    • […] common heart attack symptom in women is chest pain, women often experience heart attack symptoms that are different from men, including: Pain in the jaw or shoulder; Sweating; Nausea; Shortness of breath; Indigestion or heartburn; and Weakness or unusual fatigue[atlantic-cardiology.net]
    • Although most patients present with typical chest pain, including women, women are more often reporting atypical chest pain and/or associated symptoms (dyspnea, fatigue, weakness) compared to men.[acc.org]
    • Chest pain may be associated with sweating, nausea, vomiting, dyspnoea, fatigue and/or palpitations.[patient.info]
    • There are many different causes of fatigue, and myocardial infarction is not a common cause.[en.wikipedia.org]
    Fever
    • Nausea and/or vomiting, hypotension, and fever have also been reported.[tnkase.com]
    • Pericarditis pain is distinguishable from infarct pain because of its pleuritic nature, radiation to the left trapezius ridge, and the associated low-grade fever and pericardial friction rub.[brown.edu]
    • Signs Cardiovascular examination findings can vary enormously: Low-grade fever, pale and cool, clammy skin.[patient.info]
    • […] sepsis Coronary trauma Primary coronary vasospasm (variant angina) Drug use (eg, cocaine, amphetamines, ephedrine) Arteritis Coronary anomalies, including aneurysms of coronary arteries Factors that increase oxygen requirement, such as heavy exertion, fever[emedicine.medscape.com]
    • A myocardial infarction may result from a heart with a limited blood supply subject to increased oxygen demands, such as in fever, a fast heart rate, hyperthyroidism, too few red blood cells in the bloodstream, or low blood pressure.[en.wikipedia.org]
    Pallor
    • Gross morphologic changes evolve over time as follows: Time from Onset Gross Morphologic Finding 18 - 24 Hours Pallor of myocardium 24 - 72 Hours Pallor with some hyperemia 3 - 7 Days Hyperemic border with central yellowing 10 - 21 Days Maximally yellow[library.med.utah.edu]
    • Gross Findings The earliest change that can be grossly discerned in the evolution of acute myocardial infarction (MI) is pallor of the myocardium, which is visible 12 hours or later after the onset of irreversible ischemia.[emedicine.medscape.com]
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  • neurologic
    Altered Mental Status
    • In addition, some patients may have an altered mental status caused by medications or impaired cerebral perfusion.[emedicine.medscape.com]
    Confusion
    • Patterns of Anterior Infarction The nomenclature of anterior infarction can be confusing, with multiple different terms used for the various infarction patterns.[lifeinthefastlane.com]
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  • Skin
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  • respiratoric
    Dyspnea
    • Although most patients present with typical chest pain, including women, women are more often reporting atypical chest pain and/or associated symptoms (dyspnea, fatigue, weakness) compared to men.[acc.org]
    • Chest pain described as a pressure sensation, fullness, or squeezing in the midportion of the thorax Radiation of chest pain into the jaw or teeth, shoulder, arm, and/or back Associated dyspnea or shortness of breath Associated epigastric discomfort with[clevelandclinicmeded.com]
    Rales
    • There may be signs of congestive heart failure, including pulmonary rales, peripheral oedema, elevated jugular venous pressure.[patient.info]
    • Killip classification is widely used in patients presenting with acute MI for the purpose of risk stratification, as follows [ 38 ] : Killip class I includes individuals with no clinical signs of heart failure Killip class II includes individuals with rales[emedicine.medscape.com]
    Respiratory Distress
    • Therefore, oxygen is currently only recommended if oxygen levels are found to be low or if someone is in respiratory distress.[en.wikipedia.org]
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  • gastrointestinal
    Abdominal Pain
    Epigastric Pain
    • Differential diagnosis of acute myocardial infarction Arm pain Myocardial ischemia, cervical/thoracic vertebral pain, thoracic outlet syndrome Epigastric pain Myocardial ischemia, GI tract–esophagus, peptic ulcers, pancreas, liver disease–cholecystitis[medical-dictionary.thefreedictionary.com]
    Nausea
    • Anxiety, commonly described as a sense of impending doom Pain or discomfort in areas of the body, including the arms, left shoulder, back, neck, jaw, or stomach Lightheadedness, with or without syncope Cough Nausea, with or without vomiting Profuse sweating[emedicine.medscape.com]
    • However, women are more likely than men to have: shortness of breath jaw pain upper back pain lightheadedness nausea vomiting In fact, some women who have had a heart attack report that their symptoms felt like the symptoms of the flu.[healthline.com]
    • Although the most common heart attack symptom in women is chest pain, women often experience heart attack symptoms that are different from men, including: Pain in the jaw or shoulder; Sweating; Nausea; Shortness of breath; Indigestion or heartburn; and[atlantic-cardiology.net]
    • Other signs of a heart attack include shortness of breath, dizziness , faintness, or nausea .[webmd.com]
    • Nausea and/or vomiting, hypotension, and fever have also been reported.[tnkase.com]
    Vomiting
    • Anxiety, commonly described as a sense of impending doom Pain or discomfort in areas of the body, including the arms, left shoulder, back, neck, jaw, or stomach Lightheadedness, with or without syncope Cough Nausea, with or without vomiting Profuse sweating[emedicine.medscape.com]
    • However, women are more likely than men to have: shortness of breath jaw pain upper back pain lightheadedness nausea vomiting In fact, some women who have had a heart attack report that their symptoms felt like the symptoms of the flu.[healthline.com]
    • […] common symptoms include: Chest discomfort that may start out feeling mild and build in intensity; Discomfort in other areas of the upper body; Shortness of breath; Breaking out in a cold sweat; Feeling dizzy, light-headed or nauseated; or Belching or vomiting[atlantic-cardiology.net]
    • Nausea and/or vomiting, hypotension, and fever have also been reported.[tnkase.com]
    • Chest pain may be associated with sweating, nausea, vomiting, dyspnoea, fatigue and/or palpitations.[patient.info]
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  • musculoskeletal
    Shoulder Pain
    • […] ischemia, GI tract–esophagus, peptic ulcers, pancreas, liver disease–cholecystitis, hepatic distension, pericardial pain, pneumonia Retrosternal pain Myocardial ischemia, aortic dissection, esophageal pain, mediastinal lesions, pericardial pain, PTE Shoulder[medical-dictionary.thefreedictionary.com]
    Upper Back Pain
    • However, women are more likely than men to have: shortness of breath jaw pain upper back pain lightheadedness nausea vomiting In fact, some women who have had a heart attack report that their symptoms felt like the symptoms of the flu.[healthline.com]
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  • cardiovascular
    Chest Pain
    • The typical chest pain of acute MI usually is intense and unremitting for 30-60 minutes.[emedicine.medscape.com]
    • Plain radiograph Useful in excluding other causes of chest pain, e.g. pneumonia.[radiopaedia.org]
    • The chest pain in an MI may mimic heartburn.[en.wikipedia.org]
    • Although most patients present with typical chest pain, including women, women are more often reporting atypical chest pain and/or associated symptoms (dyspnea, fatigue, weakness) compared to men.[acc.org]
    Heart Disease
    • Other risks factors that contribute to the development of coronary heart disease (CHD) include: Smoking; Family history of heart disease; Diabetes mellitus; High cholesterol levels or lipid disorders; Hypertension, or high blood pressure; Eating a diet[atlantic-cardiology.net]
    • Of these deaths 7.3 million were due to coronary heart disease and 6.2 million from stroke.[cescatherapeutics.com]
    • Smoke-free policies have been found to prompt some smokers to quit smoking ( 1 ); because active smoking is a major risk factor for heart disease and AMI, this effect also would be expected to reduce heart disease and AMI rates at a population level.[cdc.gov]
    • Given the recent increase in coronary heart disease events among women 45-65 years of age, these trends are concerning.[acc.org]
    Pericardial Friction Rub
    • Pericarditis pain is distinguishable from infarct pain because of its pleuritic nature, radiation to the left trapezius ridge, and the associated low-grade fever and pericardial friction rub.[brown.edu]
    Retrosternal Chest Pain
    • chest pain accompanied by tightness, discomfort, & SOB; cardiac pain often radiates to the arm & neck, and less commonly to the jaw; the pain of AMI generally is. not relieved with nitroglycerin, in contrast to esophageal pain, which is often identical[medical-dictionary.thefreedictionary.com]
    Systolic Murmur
    • Diagnosis is made by detection of a new systolic murmur, and by the documentation of giant "V-waves" on the pulmonary capillary wedge tracing.[brown.edu]
    • Third and fourth heart sound, systolic murmur if mitral regurgitation or ventricular septal defect develops, pericardial rub.[patient.info]
    Tachycardia
    • These data show the following: ( a ) LVEDP is usually elevated in acute myocardial infarction, even in absence of clinical heart failure; ( b ) cardiac output apparently is supported by increased LVEDP and compensatory tachycardia; ( c ) in patients with[jci.org]
    • Figure 1: Sinus tachycardia and diffuse ST segment elevation suggestive of early repolarization.[hindawi.com]
    • Despite the possible limitations regarding the diagnosis of ventricular tachycardia, it remained associated with a high chance of in-hospital death on multivariate analysis.[scielo.br]
    • Any type of infarct can lead to an abnormal conduction interface (where normal tissue is adjacent to injured tissue), which may lead to re-entry rhythms including ventricular tachycardia and atrial flutter.[brown.edu]
    • Developing complications Arrhythmia complications During their stay in the CICU, a small number of the younger patients presented with malignant ventricular arrhythmias: 9.1% presented with ventricular tachycardia (VT) and 8.8% with ventricular fibrillation[revespcardiol.org]
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  • urogenital
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  • Workup

    The ECG is the diagnostic test of choice and should be done within 10 minutes of presentation. Therapeutic interventions are guided by ECG results. Diagnosis is confirmed with serial ECG tracings done every 8 hours within the first 24 hours of presentation, then once daily. Gradual return to normal ECG findings or development of abnormal Q waves confirm the diagnosis.

    An elevation of the ST segment by at least 1 mm on the adjacent leads opposite the diseased area on the ECG is diagnostic of an ST segment elevation myocardial infarction (STEMI). ST segment elevation has a 90% specificity and 45% sensitivity in diagnosing AMI. In STEMI, ECG shows ST-segment elevation ≥ 1 mm in at least 2 adjacent leads opposite the damaged area, which is diagnostic as supposed to its absence in non-ST segment elevation myocardial infarction (NSTEMI).

    AMI often has similar ECG tracings as left bundle branch block, therefore, it is recommended that patients with symptoms in keeping with AMI and a provisional diagnosis of left bundle branch block should be treated for STEMI.

    Assay of cardiac markers helps in the diagnosis of AMI. Cardiac markers include CK-MB, myoglobin, troponin I, and troponin T. These cardiac markers have varying sensitivities and specificities for AMI. However, the troponins are most sensitive and specific and are the cardiac markers of choice in the diagnosis of AMI.

    Coronary angiography serves for both diagnostic evaluation and therautic intervention in the management of AMI. In emergency settings, coronary angiography is recommended. It is also recommended as a therapeutic modality in patients unresponsive to medical therapy and those which severe cardiac sequalae such as cardiogenic shock and unstable arrhythmias. In unstable angina or uncomplicated NSTEMI, diagnostic angiography is necessary posttreatment for detection of untreated lesions.

    Adjunct investigations include erythrocyte sedimentation rate and complete blood count. A high ESR supports, but is a non-specific index in the diagnosis of AMI. Additionally, same day lipid profile should be done in all patients treated for AMI.

    Test Results

    Other Test Results
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  • Laboratory

    Serum
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  • Urine
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  • ECG

    PR Interval
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  • QRS Wave
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  • QT, RR, ST Intervals
    ST Elevation
    • elevation (NSTEMI) myocardial infarction I220Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I221Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I222Subsequent non-ST elevation (NSTEMI) myocardial infarction[cms.gov]
    • Occlusion proximal to S1 Signs of basal septal involvement: ST elevation in aVR ST elevation in V1 2.5 mm Complete RBBB ST depression in V5 Occlusion proximal to D1 Signs of high lateral involvement: ST elevation / Q-wave formation in aVL ST depression[lifeinthefastlane.com]
    • An ECG, which is a recording of the heart's electrical activity, may confirm an ST elevation MI (STEMI) if ST elevation is present.[en.wikipedia.org]
    • We are focused on developing a cellular therapeutic for the LVEF High Rate risk ST-Elevated Myocardial Infarction patient using the patient’s own bone marrow derived stem cells.[cescatherapeutics.com]
    • ACS is divided into two main categories, non–ST elevation (NSTE) ACS and ST-elevation MI (STEMI) NSTE ACS NSTE ACS is further divided into unstable angina (UA) and non–ST-elevation myocardial infraction (NSTEMI). [emedicine.medscape.com]
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  • T Wave
    T Wave Inversion
    • Abnormal Q waves and T-wave inversion in I and aVL.[lifeinthefastlane.com]
    • Features may initially be normal but abnormalities include new ST-segment elevation; initially peaked T waves and then T-wave inversion; new Q waves; new conduction defects.[patient.info]
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  • Blocks
    Complete Left Bundle Branch Block
    • ., complete left bundle branch block, paced rhythm, accessory pathway, left ventricular hypertrophy, digitalis use, and resting ST-segment abnormalities).4 From a prognostic standpoint, an inability to exercise and exercise-induced ST-segment depression[clevelandclinicmeded.com]
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  • Rhythm
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  • Other ECG Findings
    Ischemic Changes
    • Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic changes or injury or new BBB on ECG, but death occurred before cardiac biomarker levles were obtained, or before cardiac biomarker values would be increased.[emedicine.medscape.com]
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  • Imaging

    X-ray
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  • Ultrasound
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  • Angiography
    Mural Thrombus
    • This is a low-power photomicrograph of a mural thrombus (1) adherent to the endocardial surface (arrows).[peir.path.uab.edu]
    • Left ventricular aneurysm containing mural thrombus, gross.[library.med.utah.edu]
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  • Treatment

    Both STEMI and NSTEMI have different courses of treatment, therefore, the importance of an early ECG cannot be overemphasized. Nonetheless, the first step of treating all cases of MI is an urgent revascularizaton and reperfusion. Thereafter, relief of pain and prevention or treatment of complications are initiated.

    En route the emergency room, the patient should have an intravenous line in place and concurrent administration of supplemental oxygen, aspirin, and nitroglycerin. If available, a prehospital ECG should be obtained.

    At the emergency department, medical reperfusion strategies should be commenced immediately. These reperfusion treatments include: thrombolytic therapy, anticoagulation, and antlatelet therapy. Thrombolytic treatment should be administered within 30 minutes of the patient's presentation. Beyond 2 hours of presentation, use of thrombolytics show little effectiveness. Thrombolytic therapy has not proven to be of benefit in the treatment of STEMI.

    Antiplatelet therapy is also vital in management of AMI. It is associated with high success if administered early even before arriving at the hospital. Clopidogrel is used in cases of aspirin allergy. As recommended in the Antiplatelet Therapy for Reduction of Myocardial Damage During Angioplasty-Myocardial Infarction (ARMYDA-6 MI) multicenter study, a stat dose of 600 mg clopidogrel, compared to a 300 mg stat dose, prior to primary PCI was associated with a smaller infarct size [15].

    Anticoagulation is the most critical aspect of treatment of ACS. It should be instituted together with anti platelet therapy in all suspected or diagnosed cases of unstable angina or NSTEMI. Unfractionated heparin, enoxaparin, and bivalirudin are examples of potent anticoagulants for use in these cases, especially those for whom invasive interventions may be necessarily.

    Other aspects of treatment in the management of AMI include pain relief, correction of complications, and cardioprotective treatment plans. Pain relief is best achieved with morphine sulphate in STEMI [16].

    ACE inhibitors and beta-blockers also significantly reduce morbidity and mortality in AMI. However, these should be used only after excluding all contraindications to their use. Angiotensin-receptor blockers are alternatives to ACE inhibitors if there are any contraindications to the use of ACE inhibitors. Nondihydropyridine calcium channel blockers ( verapamil and diltiazem) are indicated if there are contraindications to the use of beta-blockers upon exclusion of left ventricular failure, pulmonary edema and AV block [17] [18].

    Failure of the above medical intervention and percutaneous interventions are indications for coronary artery bypass surgery (CABG). CABG is also indicated if there are concomitant cardiac complications or defects.

    Prognosis

    AMI causes death in 30% of cases, over half of which occur before the patient arrives at the hospital. Generally, most of the deaths caused by AMI occur within the first 24 hours of onset of symptoms. Up to 10% of patients who get treatment for AMI die within the same year of treatment, and in up to 50% of cases, there is a recurrence of AMI.

    Most of the deaths from AMI are due to ventricular arrhythmias. Deaths within a year of successful treatment of AMI results from ventricular arrhythmias, ventricular failure, or a recurrent AMI. Consequently, a stress ECG is recommended for all patients successfully treated for AMI. Poor stress ECG results strongly predicts imminent mortality.

    By and large, prognosis of AMI depends largely on the extent of myocardial necrosis, the timing of initiating reperfusion measures, and the degree of ventricular dysfunction. Early reperfusion and revascularization ( initiation of thrombolytic therapy within 30 minutes of presentation or of percutaneous intervention within 90 minutes of presentation) with preserved ventricular function is associated with a better prognosis.

    A high thrombolysis in Myocardial infarction score (TIMI) is strongly associated with a high mortality rate in AMI. Several indices are taken into account in calculating this score. The more indices present in the individual, the higher the score. These indices include [7]:

    1. At least 65 years of age.

    2. Presence of at least 3 risk factors for artherosclerotic cardiovascular disease.

    3. Positive history of coronary artery disease.

    4. Elevated cardiac enzymes.

    5. Aspirin use within the last one week.

    6. ST segment elevation by at least 0.5mm.

    Presence of risk factors of atheroscleotic vascular diseases, late or unsuccessful reperfusion, severe ventricular failure, congestive cardiac failure, pulmonary edema all contribute to high mortality and bad outcome [8] [9]. Laboratory findings of elevated B-natiuretic peptide, C-reactive proteins levels and high secretory-associated  phospholipase A2 activity are also associated with high mortality in AMI [10] [11] [12] [13] [14].

    Complications

    Acidosis
    • Causes of sudden-onset breathlessness generally involve the lungs or heart - including pulmonary edema, pneumonia, allergic reactions and asthma, and pulmonary embolus, acute respiratory distress syndrome and metabolic acidosis.[en.wikipedia.org]
    Acute Gastritis
    • Gastrointestinal: oesophageal spasm , gastro-oesophageal reflux disease , acute gastritis, cholecystitis , acute pancreatitis .[patient.info]
    Acute Pancreatitis
    • Copeptin is a predictive biomarker of severity in acute pancreatitis .[nature.com]
    • Gastrointestinal: oesophageal spasm , gastro-oesophageal reflux disease , acute gastritis, cholecystitis , acute pancreatitis .[patient.info]
    Acute Pericarditis
    • pericarditis; subacute bacterial endocarditis; hemostatic defects including those secondary to severe hepatic or renal disease; significant hepatic dysfunction; pregnancy; diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions; septic[activase.com]
    • pericarditis, subacute bacterial endocarditis, hemostatic defects, severe hepatic dysfunction, pregnancy, diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions, septic thrombophlebitis or occluded AV cannula at seriously infected[tnkase.com]
    • Cardiovascular: stable angina , another form of ACS (unstable angina or NSTEMI), acute pericarditis , myocarditis , aortic stenosis , aortic dissection , pulmonary embolism .[patient.info]
    Angina Pectoris
    • Recently, he had begun to experience occasional angina Angina pectoris is chest pain produced by myocardial ischemia, it worsens upon exertion. .[peir.path.uab.edu]
    • Approximately 50% of patients have some warning symptoms (angina pectoris or an anginal equivalent) before the infarct.[clevelandclinicmeded.com]
    • Pectoris , Cholesterol-Lowering Medications , and Statins for Cholesterol .[emedicine.medscape.com]
    Atrial Arrhythmia
    • Likewise, any infarct can lead to impaired LV filling, leading to acute atrial enlargement, leading to atrial arrhythmias including atrial fibrillation.[brown.edu]
    Atrial Fibrillation
    • The final diagnosis of atrial fibrillation and non-ST segment elevation myocardial infarction likely secondary to amphetamine-induced vasospasm was made.[hindawi.com]
    • Likewise, any infarct can lead to impaired LV filling, leading to acute atrial enlargement, leading to atrial arrhythmias including atrial fibrillation.[brown.edu]
    • The latest guidelines recommend the use of warfarin for at least 3 months in patients with left ventricular aneurysm or thrombus, a left ventricular ejection fraction less than 30%, or chronic atrial fibrillation.[clevelandclinicmeded.com]
    • Conversely, atrial fibrillation and 3rd degree AV block occurred more frequently in the patients in group B (Table 5).[revespcardiol.org]
    • fibrillation or flutter, or other supraventricular arrhythmias; bradyarrhythmias may be present In general, the patient's blood pressure is initially elevated because of peripheral arterial vasoconstriction resulting from an adrenergic response to pain[emedicine.medscape.com]
    Atrial Flutter
    • Any type of infarct can lead to an abnormal conduction interface (where normal tissue is adjacent to injured tissue), which may lead to re-entry rhythms including ventricular tachycardia and atrial flutter.[brown.edu]
    Cardiac Arrest
    • An MI may cause heart failure, an irregular heartbeat, cardiogenic shock, or cardiac arrest.[en.wikipedia.org]
    • 4.Emergency care 4.1 Initial diagnosis 4.2 Relief of pain, breathlessness, and anxiety 4.3 Cardiac arrest 4.4 Prehospital logistics of care 5.Reperfusion therapy 5.1 Selection of reperfusion strategies 5.2 Primary percutaneous coronary intervention and[escardio.org]
    • Depending on the severity of a heart attack, a person may experience: Heart failure , where the heart doesn't pump well enough to meet the body's needs Arrhythmias or abnormal heart rhythms Cardiac arrest or sudden cardiac death, where the heart stops[webmd.com]
    • The following adverse reactions have been reported among patients receiving TNKase in clinical trials: cardiogenic shock, arrhythmias, atrioventricular block, pulmonary edema, heart failure, cardiac arrest, recurrent myocardial ischemia, myocardial reinfarction[tnkase.com]
    • In contrast, concentric subendocardial necrosis may result from global ischemia and reperfusion in cases of prolonged cardiac arrest with resuscitation.[emedicine.medscape.com]
    Cardiac Arrhythmia
    • Notably, heterogeneity has been reported in literature concerning the types of CVE occurring in CAP patients, which include acute myocardial infarction (AMI), acute heart failure and cardiac arrhythmias.[openres.ersjournals.com]
    • With the above anatomical correlates in mind, the various complications of acute MI are easier to explain: Arrhythmias / Heart block : Almost any cardiac arrhythmia may occur in the setting of acute MI.[brown.edu]
    • The potential importance of bradyarrhythmias was further highlighted in the CARISMA (Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction) study (33) , in which post-MI patients with a left ventricular ejection fraction  40% received[content.onlinejacc.org]
    Cardiogenic Shock
    • Most often cardiogenic shock is caused by a severe heart attack and the induced damage to the heart muscle.[cochrane.org]
    • Cardiogenic shock Cardiogenic shock results when there is a marked reduction in forward cardiac output leading to hypotension, decreased organ perfusion, and at the same time elevated left ventricular filling pressures leading to congestive heart failure[brown.edu]
    • Cardiogenic shock is the largest cause of in-hospital mortality.[en.wikipedia.org]
    Costochondritis
    • […] addition to myocardial infarction, other causes include angina, insufficient blood supply (ischemia) to the heart muscles without evidence of cell death, gastroesophageal reflux disease; pulmonary embolism, tumors of the lungs, pneumonia, rib fracture, costochondritis[en.wikipedia.org]
    Deep Vein Thrombosis
    • Reembolization of Deep Venous Thrombi during Treatment for Acute Massive Pulmonary Embolism Activase has not been shown to treat adequately underlying deep vein thrombosis in patients with PE.[activase.com]
    Dressler Syndrome
    • Dressler's syndrome, a reaction following larger infarcts and a cause of pericarditis is also possible.[en.wikipedia.org]
    Esophagitis
    • Clinical Main presenting symptom–retrosternal chest pain accompanied by tightness, discomfort, & SOB; cardiac pain often radiates to the arm & neck, and less commonly to the jaw; the pain of AMI generally is. not relieved with nitroglycerin, in contrast to esophageal[medical-dictionary.thefreedictionary.com]
    • Rarer severe differential diagnoses includes aortic dissection, esophageal rupture, tension pneumothorax, and pericardial effusion causing cardiac tamponade.[en.wikipedia.org]
    Hypertriglyceridemia
    • […] for atherosclerosis include the following: Age Sex Family history of premature coronary heart disease Male-pattern baldness Modifiable risk factors for atherosclerosis include the following [20] : Smoking or other tobacco use Hypercholesterolemia and hypertriglyceridemia[emedicine.medscape.com]
    Hypotension
    • Hypotension : Hypotension may occur in various settings following acute MI.[brown.edu]
    • Nausea and/or vomiting, hypotension, and fever have also been reported.[tnkase.com]
    • , the patient's blood pressure is initially elevated because of peripheral arterial vasoconstriction resulting from an adrenergic response to pain and ventricular dysfunction However, with right ventricular MI or severe left ventricular dysfunction, hypotension[emedicine.medscape.com]
    • Hypotension or hypertension can be observed depending on the extent of the myocardial infarction.[patient.info]
    • Adrenomedullin mediates an increase in cAMP with resultant vasodilatation and hypotension [ 69 ].[bmcmedicine.biomedcentral.com]
    Hypoxia
    • In addition, markers of ischemia include hypoxia-inducible factor-1, complement leaking into myocytes, and cyclooxygenase-2, which can be demonstrated immunohistochemically.[emedicine.medscape.com]
    • […] anomalies, including aneurysms of coronary arteries Factors that increase oxygen requirement, such as heavy exertion, fever, or hyperthyroidism Factors that decrease oxygen delivery, such as hypoxemia of severe anemia In addition, MI can result from hypoxia[emedicine.medscape.com]
    Left Ventricular Aneurysm
    • Left ventricular aneurysm, gross.[library.med.utah.edu]
    • Other complications after MI Left ventricular aneurysm formation: Left ventricular apical aneurysm formation usually occurs following antero-apical myocardial infarction, after LAD occlusion.[brown.edu]
    • Residual ST elevation in V1-3 (“left ventricular aneurysm” morphology).[lifeinthefastlane.com]
    • The latest guidelines recommend the use of warfarin for at least 3 months in patients with left ventricular aneurysm or thrombus, a left ventricular ejection fraction less than 30%, or chronic atrial fibrillation.[clevelandclinicmeded.com]
    Leukocytosis
    • In hospital FBC to rule out anaemia; leukocytosis is common; monitor potassium levels (electrolyte disturbances may cause arrhythmias, especially potassium and magnesium); renal function - estimated glomerular filtration rate (eGFR) - should be measured[patient.info]
    • […] stability A patient was considered to reach clinical stability when the following criteria were met in a single day during hospitalisation: 1) improved clinical signs (cough and shortness of breath); 2) the patient was afebrile for 8 h; 3) improving leukocytosis[openres.ersjournals.com]
    Mural Thrombosis
    • There was extensive mural thrombosis Mural thrombosis is the formation of multiple thrombi along an injured endocardial wall. and reactive pericarditis Pericarditis is inflammation of the pericardium - often with deposition of fibrin. .[peir.path.uab.edu]
    • Emboli - from left sided mural thrombosis, vegetative endocarditis, or paradoxic emboli from the right side of heart through a patent foramen ovale.[library.med.utah.edu]
    • The improvement in prognosis that has occurred in the last decade is due to early treatment with thrombolytic agents and reperfusion. [9] Mural thrombosis over the area of infarction may result in embolization and concomitant stroke but is decreased in[emedicine.medscape.com]
    Peptic Ulcer
    • Hospital Medicine Infectious Diseases Neurology Oncology and Hematology Pediatrics and Adolescent Medicine Psychiatry Women’s Health Topics: Aging / Geriatrics Allergy / Asthma Arthritis/Rheumatic Disease Breast Cancer Depression / Anxiety Diabetes GERD / Peptic[jwatch.org]
    • Differential diagnosis of acute myocardial infarction Arm pain Myocardial ischemia, cervical/thoracic vertebral pain, thoracic outlet syndrome Epigastric pain Myocardial ischemia, GI tract–esophagus, peptic ulcers, pancreas, liver disease–cholecystitis[medical-dictionary.thefreedictionary.com]
    • Other secondary noncardiological diagnoses reported were as follows: chronic obstructive pulmonary disease (22 patients), gastritis (9), chronic renal failure (8), peripheral vascular disease (4), and peptic ulcer (3).[scielo.br]
    Pericardial Effusion
    • effusion, mitral regurgitation, thrombosis, embolism, and electromechanical dissociation.[tnkase.com]
    • Echocardiography can define the extent of the infarction and assess overall ventricular function and can identify complications, such as acute mitral regurgitation, left ventricular rupture or pericardial effusion.[patient.info]
    • Rarer severe differential diagnoses includes aortic dissection, esophageal rupture, tension pneumothorax, and pericardial effusion causing cardiac tamponade.[en.wikipedia.org]
    Pulmonary Embolism
    • "Triple rule-out” coronary CT angiography Some institutions are using this protocol that examines for not only coronary artery disease, but also aortic dissection, pulmonary embolism, and other chest diseases.[radiopaedia.org]
    • Reembolization of Deep Venous Thrombi during Treatment for Acute Massive Pulmonary Embolism Activase has not been shown to treat adequately underlying deep vein thrombosis in patients with PE.[activase.com]
    • Cardiovascular: stable angina , another form of ACS (unstable angina or NSTEMI), acute pericarditis , myocarditis , aortic stenosis , aortic dissection , pulmonary embolism .[patient.info]
    • In addition, 1 case of pulmonary embolism with no death was reported.[scielo.br]
    Right Bundle Branch Block
    • Right bundle branch block in anterior MI is an independent marker of poor prognosis; this is due to the extensive myocardial damage involved rather than the conduction disorder itself.[lifeinthefastlane.com]
    Shock
    • Most often cardiogenic shock is caused by a severe heart attack and the induced damage to the heart muscle.[cochrane.org]
    • The first derivative of left ventricular pressure was significantly lower in shock than in the nonshock group.[jci.org]
    • Cardiogenic shock Cardiogenic shock results when there is a marked reduction in forward cardiac output leading to hypotension, decreased organ perfusion, and at the same time elevated left ventricular filling pressures leading to congestive heart failure[brown.edu]
    Sinus Bradycardia
    • At the 2-year follow-up, 17% of patients had either high-degree atrioventricular block, significant sinus bradycardia, or sinus arrest.[content.onlinejacc.org]
    Sudden Cardiac Death
    • Black women have a higher prevalence of AMI than other women, including higher rates of sudden cardiac death.[acc.org]
    • Depending on the severity of a heart attack, a person may experience: Heart failure , where the heart doesn't pump well enough to meet the body's needs Arrhythmias or abnormal heart rhythms Cardiac arrest or sudden cardiac death, where the heart stops[webmd.com]
    • ., plaque rupture, thrombotic occlusion) type II : secondary to ischaemia from a supply-and-demand mismatch. type III : MI resulting in sudden cardiac death type IV : type IVa : is an MI associated with percutaneous coronary intervention type IVb : associated[radiopaedia.org]
    • Type 3 is an MI resulting in sudden cardiac death.[clevelandclinicmeded.com]
    • The phrase "heart attack" is often used non-specifically to refer to a myocardial infarction and to sudden cardiac death.[en.wikipedia.org]
    Sudden Death
    • A reduced LVEF is one of the risk factors for both sudden and non-sudden death, with the odds ratio for 1 year mortality after myocardial infarction at 9.48 (High Rate) for patients with an LVEF of 30% compared to patients with LVEF 50%, 2.94% (Moderate[cescatherapeutics.com]
    • Myocardial wall rupture, with possible tamponade Papillary muscle rupture, with possible valvular insufficiency Ventricular aneurysm formation Sudden death occurs within an hour of onset of symptoms.[library.med.utah.edu]
    • Arrhythmias include ventricular tachyarrhythmias, which are the most common cause of sudden death, especially early after infarction, and various degrees of heart block.[emedicine.medscape.com]
    • The predominant mechanisms of the benefit for beta-blocker therapy after MI are reductions in ischemia, reinfarction, and sudden death.[content.onlinejacc.org]
    • Otherwise, collapse and sudden death are likely.[patient.co.uk]
    Syncope
    • Anxiety, commonly described as a sense of impending doom Pain or discomfort in areas of the body, including the arms, left shoulder, back, neck, jaw, or stomach Lightheadedness, with or without syncope Cough Nausea, with or without vomiting Profuse sweating[emedicine.medscape.com]
    • […] or near syncope without other cause Impairment of cognitive function without other cause[clevelandclinicmeded.com]
    • Patients should be instructed to go to the emergency department immediately if the suspected ACS symptoms last longer than 20 minutes at rest or are associated with near syncope/syncope or hemodynamic instability.[emedicine.medscape.com]
    Ventricular Fibrillation
    • Of the 17 cases of ventricular fibrillation, 7 were of the primary type (1.8%).[scielo.br]
    • fibrillation Triggers Heavy exertion in 5% of Pts, which is inversely related to Pt's habitual physical activity Etiology Occlusion of major coronary artery–CA, in a background of ASHD, due primarily to the plugging of the vessel with debris from an[medical-dictionary.thefreedictionary.com]
    • Declining incidence of ventricular fibrillation in myocardial infarction.[revespcardiol.org]
    • There are premature atrial complexes (beat 4 on the rhythm strip) and multifocal ventricular ectopy (PVCs of two different types), indicating an “irritable” myocardium at risk of ventricular fibrillation.[lifeinthefastlane.com]
    • Of particular interest is a report that noted an adjusted odds ratio of 5 for beta-blocker use among out-of-hospital cardiac arrest survivors presenting with pulseless electrical activity versus ventricular fibrillation (32) .[content.onlinejacc.org]
    Ventricular Septal Defect
    • septal defect but occurs in the free wall of the left ventricle, usually resulting in abrupt cardiogenic shock due to "cardiac tamponade" (see chapter 14, pp 233-236).[brown.edu]
    • Third and fourth heart sound, systolic murmur if mitral regurgitation or ventricular septal defect develops, pericardial rub.[patient.info]
    • septal defect, free wall rupture, or acute mitral regurgitation.[clevelandclinicmeded.com]
    Ventricular Septal Rupture
    • Ventricular septal rupture: Acute ventricular septal rupture can occur usually several days following the acute infarction, due to softening of the necrotic portion of the septum.[brown.edu]
    Ventricular Tachycardia
    • Despite the possible limitations regarding the diagnosis of ventricular tachycardia, it remained associated with a high chance of in-hospital death on multivariate analysis.[scielo.br]
    • Any type of infarct can lead to an abnormal conduction interface (where normal tissue is adjacent to injured tissue), which may lead to re-entry rhythms including ventricular tachycardia and atrial flutter.[brown.edu]
    • Anterior infarcts, persistent ventricular tachycardia or fibrillation, development of heart blocks, and left ventricular impairment are all associated with poorer prognosis.[en.wikipedia.org]
    • tachycardia, diabetes, prior PCI, or bypass surgery are recommended to undergo early PCI ( 48 hours).[clevelandclinicmeded.com]
    • Developing complications Arrhythmia complications During their stay in the CICU, a small number of the younger patients presented with malignant ventricular arrhythmias: 9.1% presented with ventricular tachycardia (VT) and 8.8% with ventricular fibrillation[revespcardiol.org]
  • more...
  • Etiology

    The risk factors for AMI consist of diseases and lifestyle habits which predispose one to vascular damage and occlusion. These factors could be categorized as modifiable and nonmodifiable. The modifiable risk factors include diabetes mellitus, hyperlipidemia, hypertension, tobacco use, and substance abuse. The non modifiable risk factors include a male gender and a positive family history of vasculocclusive diseases.

    High levels of total cholesterol, LDL, or triglycerides cause considerable increase in the risk of developing coronary artherosclerosis and AMI. Persistent reduction of HDL levels below 40mg/dl is also associated with a high risk of developing AMI [3]. Dyslipidemia may also be the indirect link between diabetes and coronary artery disease. Diabetes causes coronary artery diseases directly by causing endothelial damage.

    Hypertension involving either or both systolic and diastolic pressures is a strong risk factor for coronary artery disease and AMI [4]. Tobacco use constitutes a significant risk factor of AMI and strokes. Constituents of tobacco impose toxic reactions to the endothelium of blood vessels. This injury, in turn, triggers an inflammatory response which results in atherosclerotic changes in the vessels [5].

    Although, males are said to be at a higher risk of developing coronary artery disease than females, the incidence evens out with increasing age. A family history of atherosclerotic cardiovascular and cerebrovascular diseases are often associated with genetic links to these diseases, predisposing individuals with such family histories to developing coronary artery disease.

    Coronary artery disease and AMI are not exclusively linked to atherosclerosis, other vascular and cardiac defects including vasculitis, valvular heart defects, coronary trauma, and congenital coronary defects may also predispose to AMI.

    Epidemiology

    Cardiovascular disease is the leading cause of death in the United States. As reported in the results of the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey, MI occurs more in men than women and the incidence of the disease significantly increases with age.

    Sex distribution
    Age distribution

    Pathophysiology

    Acute myocardial infarction is the terminal response of the heart to undercompensated and persistent myocardial ischemia. Most cases of AMI result from coronary artery disease involving atherosclerotic occlusion of the vessel [6]. This makes AMI a presentation of acute coronary syndromes.

    An atherosclerotic plaque is made up of a lipid core and a fibromuscular outer layer. This outer layer is eroded with time by the actions of catalytic enzymes which include collagenases, proteases and matrix metalloproteases. This enzymatic breakdown coupled with hemodynamic forces in the blood vessel completely erode the fibromuscular layer and a consequent endothelial damage. The endothelial injury triggers the extrinsic coagulation pathway, eventually leading to thrombus formation. Occlusion of the coronary vessel is caused by the thrombus.

    Persistent occlusion of the coronary vessel shifts changes from compensation to the occurrence of an acute myocardial infarction. Prolonged ischemia first leads to necrosis of the endocardium, then the myocardium before affecting the epicardium. After onset of AMI, failure to restore coronary blood flow within 8 hours leads to a significant myocardial loss. The severity of AMI is determined by the extent of myocardial necrosis, which in turn, is determined by the duration and level of coronary occlusion. The more proximal the coronary occlusion occurs, the greater the severity and complications of AMI.

    Prevention

    The modifiable risk factors for coronary artery disease can be prevented to forestall the occurrence or recurrence of AMI. Smoke cessation is associated with a 50% reduction in the risk of recurrence of AMI within the same year of quitting. This informs the recommendation of counselling and appropriate smoke cessation therapies for all patients with acute coronary syndrome who smoke.

    Mild alcohol consumption has also been shown to reduce the risk of atherosclerotic vascular disease. However, there are no strict guildlines on alcohol use in the prevention of AMI and, therefore, should be based on the doctor's clinical discretion.

    Summary

    Acute myocardial infarction (AMI) refers to irreversible myocardial necrosis resulting from sustained myocardial ischemia [1] [2]. AMI is usually the complication of coronary artery disease in which an atherosclerotic plaque, mostly, occludes coronary blood flow. 

    AMI may present with no symptoms at all. However, typical symptoms of AMI are a central chest pain which often radiates to the jaw, neck, left arms, and shoulders and which may be associated with dyspnea, palpitations and, presyncope.

    Diagnosis of AMI is made by characteristic features on the ECG. However, coronary angiography presents an excellent modality for both diagnostic and therapeutic purposes in the management of AMI.

    Treatment of AMI is achieved with fast institution of antiplatelet and thrombolytic therapy and, most importantly, anticoagulation. Percutaneous intervention and coronary artery bypass surgery may be necessary in cases unresponsive to medical treatment.

    Patient Information

    Overview.

    Myocardial infarction is the medical term for a heart attack. A heart attack occurs when the blood flow to the heart is blocked for a long time. The heart muscle dies after a prolonged period of inadequate blood and oxygen supply. This death and sudden loss of action of the heart muscle is what is referred to as a heart attack. It presents suddenly, that's why its described as acute.

    Etiology.

    The obstruction of the blood supply is initiated by a fatty substance which attaches to the blood vessel wall, building up with time and trigerring the development of a clot which, ultimately, blocks the vessel. This deprivation of blood flow causes the heart muscle to die, becoming fatal in a few hours.The risk of having a heart attack increases with advancing age, tobacco smoking, diabetes and a family history of a heart attack, to name a few.

    Presentation.

    A heart attack , typically, presents with chest pain which radiates to the left arm, jaw, shoulders and neck. There could also be breathlessness, vomiting , and sweating. Patients also feel lightheaded and dizzy.

    Work up.

    An Electrocardiogram (ECG) is the diagnostic method of choice for AMI. Once your symptoms are typical of a heart attack, an urgent ECG would be ordered. Other laboratory tests such as cardiac enzyme levels may also be necessary to support the diagnosis. A coronary angiography is a form of X-ray of the blood vessels of the heart done after a dye is passed through them to make them more visible. This test may be ordered to view the coronary vessels and the site of the blockage and it could also be used to remove the blockage in emergency situations.

    Treatment.

    A heart attack requires an urgent treatment, which involves an urgent call to the paramedics who would initiate treatment to reopen the blood vessel even before reaching the hospital. The longer one stays without restoring the blood flow to the heart, the more likely the individual would die, even en route the hospital. In severe cases, surgery may be needed to repair the affected blood vessel.

    Prognosis.

    More than one-third of patients who develop a heart attack die, half of these people die before getting to the hospital. The key thing to note in AMI is that the longer the patient stays without treatment of the symptoms, the greater the extent of the heart muscle death and the higher the chances of death from this condition.

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    References

    1. Alpert JS, Thygesen K, Antman E, Bassand JP. 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 2000; 36:959.
    2. Thygesen K, Alpert JS, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007; 28:2525.
    3. Adult Treatment Panel III. Detection, evaluation, and treatment of high blood cholesterol in adults. Available at http://www.nhlbi.nih.gov/guidelines/cholesterol (accessed March 2, 2009).
    4. National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Available at http://www.nhlbi.nih.gov/guidelines/hypertension (accessed March 2, 2009).
    5. Hung J, Lam JYT, Lacoste L, Letchacovski G. Cigarette smoking acutely increases platelet thrombus formation in patients with coronary artery disease taking aspirin. Circulation. 1995, 92: 2432-2436.
    6. Cotran RS, Kumar V, Robbins SL (eds): Robbins Pathologic Basis of Disease. 5th ed. Philadelphia: WB Saunders, 1994.
    7. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16. 284(7):835-42.
    8. aber WA, Prior DL, Marso SP, Houghtaling PL, Menon V, Harrington RA. CHF on presentation is associated with markedly worse outcomes among patients with acute coronary syndromes: PURSUIT trial findings. Circulation 1999:100(suppl I):I-433.
    9. Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol. 1967 Oct. 20(4):457-64.
    10. James SK, Lindahl B, Siegbahn A, Stridsberg M, Venge P, Armstrong P, et al. N-terminal pro-brain natriuretic peptide and other risk markers for the separate prediction of mortality and subsequent myocardial infarction in patients with unstable coronary artery disease: a Global Utilization of Strategies To Open occluded arteries (GUSTO)-IV substudy. Circulation. 2003 Jul 22. 108(3):275-81.
    11. de Lemos JA, Morrow DA, Bentley JH, Omland T, Sabatine MS, McCabe CH, et al. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes. N Engl J Med. 2001 Oct 4. 345(14):1014-21.
    12. Haaf P, Reichlin T, Corson N, et al. B-type Natriuretic Peptide in the Early Diagnosis and Risk Stratification of Acute Chest Pain. Am J Med. 2011 May. 124(5):444-52.
    13. Morrow DA, Rifai N, Antman EM, Weiner DL, McCabe CH, Cannon CP, et al. C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: a TIMI 11A substudy. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol. 1998 Jun. 31(7):1460-5.
    14. Lind L, Simon T, Johansson L, Kotti S, Hansen T, Machecourt J, et al. Circulating levels of secretory- and lipoprotein-associated phospholipase A2 activities: relation to atherosclerotic plaques and future all-cause mortality. Eur Heart J. 2012 Jun 17.
    15. Antman EM, Hand M, Armstrong PW, Bates ER, et al. 2007 Focused Update of the ACC/AHA 2004 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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial I... Circulation. 2008 Jan 15. 117(2):296-329
    16. Patti G, Barczi G, Orlic D, et al. Outcome Comparison of 600- and 300-mg Loading Doses of Clopidogrel in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction Results From the ARMYDA-6 MI (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty-Myocardial Infarction) Randomized Study. J Am Coll Cardiol. 2011 Oct 4. 58(15):1592-9.
    17. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interve... J Am Coll Cardiol. 2007 Aug 14. 50(7):e1-e157.
    18. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004 Aug 3. 110(5):588-636..

    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • Alterations in acute myocardial infarction. I. Cardiac output, mean arterial pressure, total peripheral resistance,“central” and total blood volumes, venous pressure and - ED Freis, HW Schnaper, RL Johnson - Journal of Clinical , 1952 - ncbi.nlm.nih.gov
    • Acute myocardial infarction in young adults: causes and management - S Osula, GM Bell, RS Hornung - Postgraduate medical journal, 2002 - pmj.bmj.com
    • 2001 sccm/esicm/accp/ats/sis international sepsis definitions conference - MM Levy, MP Fink, JC Marshall, E Abraham - Intensive care , 2003 - Springer
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • Acute pericarditis of benign type - RB Logue, MH Wendkos - American Heart Journal, 1948 - Elsevier
    • Chest x-ray findings in the acute phase of Kawasaki disease - T Umezawa, T Saji, N Matsuo, K Odagiri - Pediatric radiology, 1989 - Springer
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Width level predicts worse postinterventional thrombolysis in myocardial infarction flow reflecting abnormal reperfusion in acute myocardial infarction treated with a - A Karabulut, H Uyarel, B Uzunlar - Coronary Artery , 2012 - journals.lww.com
    • Abnormal glucose tolerance–a common risk factor in patients with acute myocardial infarction in comparison with population‐based controls - M Bartnik, K Malmberg, A Hamsten - Journal of internal , 2004 - Wiley Online Library
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • Myocardial infarction with isolated ST-segment elevation in posterior chest leads V7–9:“hidden” ST-segment elevations revealing acute posterior infarction - S Matetzky, D Freimark, MS Feinberg - Journal of the , 1999 - Am Coll Cardio Found
    • Of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction: The Joint European - E Antman, JP Bassand, W Klein - Journal of the , 2000 - Am Coll Cardio Found
    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • Acute Myocardial Infarction and Complete Bundle Branch Block at Hospital Admission: Clinical Characteristics and Outcome in the Thrombolytic Era fn1 - EB Sgarbossa, SL Pinski, EJ Topol - Journal of the , 1998 - Am Coll Cardio Found
    • Cross-sectional echocardiographic analysis of the extent of left ventricular asynergy in acute myocardial infarction - JJ Heger, AE Weyman, LS Wann, EW Rogers - Circulation, 1980 - Am Heart Assoc
    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • A critique of several epidemiological studies of physical activity and its relationship to aging, health, and mortality - KS Brown, P Milvy - Annals of the New York Academy of , 1977 - Wiley Online Library
    • ACC/AHA guidelines for the clinical application of echocardiography: executive summary - MD Cheitlin, JS Alpert, WF Armstrong - Journal of the , 1997 - Am Coll Cardio Found
    • Efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction - M Seyfarth, D Sibbing, I Bauer - Journal of the , 2008 - Am Coll Cardio Found
    • Value of serum creatine kinase isoenzyme MB mass, cardiac troponin T and myosin light chain levels in suspected acute myocardial infarction: analysis of 28 months - J Ravkilde, H Nissen, M Hørder, K Thygesen - Journal of the American , 1995 - Elsevier
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Of heart rate variability index and left ventricular ejection fraction for all-cause mortality, arrhythmic events and sudden death after acute myocardial infarction - O Odemuyiwa, M Malik, T Farrell, Y Bashir - The American journal of , 1991 - Elsevier
    • Decreased heart rate variability and its association with increased mortality after acute myocardial infarction - RE Kleiger, JP Miller, JT Bigger, AJ Moss - The American journal of , 1987 - Elsevier
    • A Randomized, Controlled Trialof Aspirin in Persons Recovered From Myocardial Infarction - MD Schoenberger - JAMA, 1980 - Am Med Assoc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, JL Anderson, EM Antman, BA Braniff - Circulation, 1996 - Am Heart Assoc
    • Alterations of long-chain free fatty acid and magnesium concentrations in acute myocardial infarction - EB Flink, JE Brick, SR Shane - Archives of internal medicine, 1981 - Am Med Assoc
    • Fibrillation induced by myocardial ischemia during exercise in dogs with healed myocardial infarction. An experimental preparation for sudden cardiac death - PJ Schwartz, GE Billman, HL Stone - Circulation, 1984 - Am Heart Assoc
    • Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction - A Prasad, A Lerman, CS Rihal - American heart journal, 2008 - intranet.santa.lt
    • Antiarrhythmic effect of carvedilol after acute myocardial infarction: results of the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction ( - J McMurray, L Køber, M Robertson - Journal of the , 2005 - Am Coll Cardio Found
    • C-reactive protein as a predictor of infarct expansion and cardiac rupture after a first Q-wave acute myocardial infarction - T Anzai, T Yoshikawa, H Shiraki, Y Asakura, M Akaishi - Circulation, 1997 - Am Heart Assoc
    • A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction - CL Grines, KF Browne, J Marco - England Journal of , 1993 - Mass Medical Soc
    • Constriction of the fetal ductus arteriosus. A possible mechanism for persistent pulmonary hypertension and transient tricuspid insufficiency in the newborn infant - DL Levin, LJ Mills, AG Weinberg - Circulation, 1979 - Am Heart Assoc
    • Acute cardiac tamponade - DH Spodick - New England Journal of Medicine, 2003 - Mass Medical Soc
    • Future risk of coronary heart disease in initially healthy middle-aged men: results from the MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) - W Koenig, M Sund, M Fröhlich, HG Fischer, H Löwel - Circulation, 1999 - Am Heart Assoc
    • A cost-effectiveness strategy for transtelephonic arrhythmia monitoring - J Wu, DK Kessler, S Chakko, KM Kessler - The American journal of , 1995 - Elsevier
    • Bundle branch block in acute myocardial infarction - RM Norris, MS Croxson - American heart journal, 1970 - Elsevier
    • A POST-MYOCARDIAL-INFARCTION SYNDROME PRELIMINARY REPORT OF A COMPLICATION RESEMBLING IDIOPATHIC, RECURRENT, BENIGN - W Dressler - Journal of the American Medical Association, 1956 - Am Med Assoc
    • Patients presenting with congestive heart failure complicating acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction - AH Wu, L Parsons, NR Every - Journal of the American , 2002 - Am Coll Cardio Found
    • Tachycardia As Studied by Electrical Stimulation of the Heart Chronic Recurrent Ventricular Tachycardia and Ventricular Tachycardia During Acute Myocardial - HJJ WELLENS, KI Lie, D DURRER - Circulation, 1974 - Am Heart Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Fibrillation induced at programmed stimulation and delayed potentials detected on the signal-averaged electrocardiograms of survivors of acute myocardial infarction. - AR Denniss, DA Richards, DV Cody, PA Russell - Circulation, 1986 - Am Heart Assoc
    • Comparison of angioplasty with infusion of tirofiban or abciximab and with implantation of sirolimus-eluting or uncoated stents for acute myocardial infarction - M Valgimigli, G Campo, G Percoco - JAMA: the journal of , 2008 - Am Med Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Of heart rate variability index and left ventricular ejection fraction for all-cause mortality, arrhythmic events and sudden death after acute myocardial infarction - O Odemuyiwa, M Malik, T Farrell, Y Bashir - The American journal of , 1991 - Elsevier
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Acute metabolic complications in diabetes - H Fishbein, PJ Palumbo - Diabetes in America, 1995 - books.google.com
    • Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. - K Chadda, S Goldstein, R Byington, JD Curb - Circulation, 1986 - Am Heart Assoc
    • A simplified method to predict occurrence of complete heart block during acute myocardial infarction - GA Lamas, JE Muller, ZG Turi, PH Stone - The American journal of , 1986 - Elsevier
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, JL Anderson, EM Antman, BA Braniff - Circulation, 1996 - Am Heart Assoc
    • Fatal outcome: dynamic coronary thrombosis leading to infarction and/or sudden death. Autopsy evidence of recurrent mural thrombosis with peripheral embolization - E Falk - Circulation, 1985 - Am Heart Assoc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • A comparison of omeprazole and placebo for bleeding peptic ulcer - MS Khuroo, GN Yattoo, G Javid, BA Khan - England Journal of , 1997 - Mass Medical Soc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, JL Anderson, EM Antman, BA Braniff - Circulation, 1996 - Am Heart Assoc
    • Early dilation of the infarcted segment in acute transmural myocardial infarction: role of infarct expansion in acute left ventricular enlargement - JA Erlebacher, JL Weiss, ML Weisfeldt - Journal of the American , 1984 - Elsevier
    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction: The Joint European - E Antman, JP Bassand, W Klein - Journal of the , 2000 - Am Coll Cardio Found
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • In conjunction with tissue-type plasminogen activator and aspirin for acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) 5 trial - CP Cannon, CH McCabe, TD Henry - Journal of the American , 1994 - Elsevier
    • Implantable cardioverter defibrillator as antiarrhythmic treatment modality of choice for survivors of cardiac arrest unrelated to acute myocardial infarction. - MH Lehmann, RT Steinman, CD Schuger - The American journal , 1988 - ukpmc.ac.uk
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era - RH Mehta, PT O'Gara, E Bossone - Journal of the , 2002 - Am Coll Cardio Found
    • Acute myocardial infarction in pregnancy - AH James, MG Jamison, MS Biswas, LR Brancazio - Circulation, 2006 - Am Heart Assoc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • 2001 sccm/esicm/accp/ats/sis international sepsis definitions conference - MM Levy, MP Fink, JC Marshall, E Abraham - Intensive care , 2003 - Springer
    • Investigation of 100 Cases of Massive Embolism of the Pulmonary Artery; Diagnosis by Physical Signs and Differentiation From Acute Myocardial Infarction - LW Gorham - Archives of internal medicine, 1961 - Am Med Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Blood transfusion in elderly patients with acute myocardial infarction - WC Wu, SS Rathore, Y Wang, MJ Radford - England Journal of , 2001 - Mass Medical Soc
    • Myocardial infarction with isolated ST-segment elevation in posterior chest leads V7–9:“hidden” ST-segment elevations revealing acute posterior infarction - S Matetzky, D Freimark, MS Feinberg - Journal of the , 1999 - Am Coll Cardio Found
    • Acupuncture therapy rapidly terminates intractable hiccups complicating acute myocardial infarction - FC Liu, CA Chen, SS Yang, SH Lin - Southern medical journal, 2005 - journals.lww.com
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • A community-wide assessment of the use of pulmonary artery catheters in patients with acute myocardial infarction. - JM Gore, RJ Goldberg, DH Spodick - CHEST , 1987 - journal.publications.chestnet.org
    • A randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity - HS Trivedi, H Moore, S Nasr, K Aggarwal - Nephron Clinical , 2003 - content.karger.com
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Blood transfusion in elderly patients with acute myocardial infarction - WC Wu, SS Rathore, Y Wang, MJ Radford - England Journal of , 2001 - Mass Medical Soc
    • Doppler contrast echocardiography differentiates stunning from necrosis and predicts recovery of left ventricular function after acute myocardial infarction - ML Main, A Magalski, NK Chee - Journal of the , 2001 - Am Coll Cardio Found
    • Cardiovascular complications of thrombolytic therapy in patients with a mistaken diagnosis of acute myocardial infarction - JC Blankenship, AK Almquist - Journal of the American College of , 1989 - Elsevier
    • -aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2 - HV Barron, NR Every, LS Parsons - American heart , 2001 - works.bepress.com
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Angiotherapy with mallory-weiss tear - RG Fisher, JT Schwartz - American Journal of , 1980 - Am Roentgen Ray Soc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Cardiovascular complications of thrombolytic therapy in patients with a mistaken diagnosis of acute myocardial infarction - JC Blankenship, AK Almquist - Journal of the American College of , 1989 - Elsevier
    • Fibrillation induced at programmed stimulation and delayed potentials detected on the signal-averaged electrocardiograms of survivors of acute myocardial infarction. - AR Denniss, DA Richards, DV Cody, PA Russell - Circulation, 1986 - Am Heart Assoc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • C-reactive protein in predicting long-term risk of death or acute myocardial infarction in patients with unstable or stable angina pectoris or acute myocardial infarction. - JS Zebrack, JL Anderson, CA Maycock - The American journal , 2002 - ukpmc.ac.uk
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • Treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction - K Malmberg, A Norhammar, H Wedel, L Rydén - Circulation, 1999 - Am Heart Assoc
    • Before primary percutaneous transluminal coronary angioplasty reduces catheterization laboratory events in high-risk patients with acute myocardial infarction - BR Brodie, TD Stuckey, C Hansen, D Muncy - The American journal of , 1999 - Elsevier
    • A new method for radionuclide imaging of acute myocardial infarction in humans - RW PARKEY, FJ BONTE, SL MEYER, JM ATKINS - Circulation, 1974 - Am Heart Assoc
    • Autonomic disturbance at onset of acute myocardial infarction - SW Webb, AAJ Adgey, JF Pantridge - British medical journal, 1972 - ncbi.nlm.nih.gov
    • A decision tree for the early diagnosis of acute myocardial infarction in nontraumatic chest pain patients at hospital admission - J Mair, J Smidt, P Lechleitner - CHEST , 1995 - journal.publications.chestnet.org
    • Two-dimensional echocardiographic measurements are major predictors of adverse cardiovascular events after acute myocardial infarction. The protective effects of - MSJ Sutton, MA Pfeffer, T Plappert, JL Rouleau - Circulation, 1994 - Am Heart Assoc
    • Antibodies to cardiolipin in young survivors of myocardial infarction: an association with recurrent cardiovascular events - A Hamsten, M Björkholm, R Norberg, U De Faire - The Lancet, 1986 - Elsevier
    • Fatal outcome: dynamic coronary thrombosis leading to infarction and/or sudden death. Autopsy evidence of recurrent mural thrombosis with peripheral embolization - E Falk - Circulation, 1985 - Am Heart Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Arrhythmic and nonarrhythmic death after acute myocardial infarction based on heart rate variability, signal-averaged electrocardiogram, ventricular arrhythmias and - JEK Hartikainen, M Malik, A Staunton - Journal of the American , 1996 - Elsevier
    • Acute and chronic thrombosis of the mesenteric arteries associated with malabsorption - RS Shaw, EP Maynard III - New England Journal of Medicine, 1958 - Mass Medical Soc
    • Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm - V Fuster, LE Rydén, DS Cannom, HJ Crijns - , 2006 - Eur Heart Rhythm Assoc
    • ANGINA PECTORIS, CORONARY FAILURE AND ACUTE MYOCARDIAL INFARCTION THE ROLE OF CORONARY OCCLUSIONS AND COLLATERAL - HL Blumgart, MJ Schlesinger, PM Zoll - Journal of the American , 1941 - Am Med Assoc
    • Autologous intramyocardial injection of cultured skeletal muscle-derived stem cells in patients with non-acute myocardial infarction - J Herreros, F Prósper, A Perez, JJ Gavira - European heart , 2003 - Eur Soc Cardiology
    • Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus - K CHATTERJEE, WW PARMLEY, HJC Swan - Circulation, 1973 - Am Heart Assoc
    • Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction - M Marzilli, E Orsini, P Marraccini, R Testa - Circulation, 2000 - Am Heart Assoc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus - K CHATTERJEE, WW PARMLEY, HJC Swan - Circulation, 1973 - Am Heart Assoc
    • 99mTc-hexakis-2-methoxy-2-methylpropyl-isonitrile imaging for the assessment of myocardial area at risk and the effect of treatment in acute myocardial infarction - RJ Gibbons, MS Verani, T Behrenbeck, PA Pellikka - Circulation, 1989 - Am Heart Assoc
    • Cardiogenic brain embolism - CET Force - Archives of Neurology, 1986 - Am Med Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Acute anterior wall myocardial infarction secondary to blunt chest trauma - MJ Anto, SG Cokinos, E Jonas - Angiology, 1984 - ang.sagepub.com
    • Acute myocardial infarction following cocaine abuse in a young woman with normal coronary arteries - RE Howard, DC Hueter, GJ Davis - JAMA: the journal of the , 1985 - Am Med Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, JL Anderson, EM Antman, BA Braniff - Circulation, 1996 - Am Heart Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Angina and oesophageal pain - E Rapaport - European heart journal, 1986 - Eur Soc Cardiology
    • Acute myocardial infarction following wasp sting: report of two cases and critical survey of the literature - HD Levine - American heart journal, 1976 - Elsevier
    • A single‐centre double‐blind trial of Trasylol therapy in primary acute pancreatitis - CW Imrie, IS Benjamin, JC Ferguson - British Journal of , 1978 - Wiley Online Library
    • -aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2 - HV Barron, NR Every, LS Parsons - American heart , 2001 - works.bepress.com
    • Fibrillation induced at programmed stimulation and delayed potentials detected on the signal-averaged electrocardiograms of survivors of acute myocardial infarction. - AR Denniss, DA Richards, DV Cody, PA Russell - Circulation, 1986 - Am Heart Assoc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Investigation of 100 Cases of Massive Embolism of the Pulmonary Artery; Diagnosis by Physical Signs and Differentiation From Acute Myocardial Infarction - LW Gorham - Archives of internal medicine, 1961 - Am Med Assoc
    • Angina pectoris, myocardial infarction and sudden cardiac death with normal coronary arteries: a clinicopathologic study of 9 patients with progressive systemic - BH Bulkley, PG Klacsmann, GM Hutchins - American heart journal, 1978 - Elsevier
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, JL Anderson, EM Antman, BA Braniff - Circulation, 1996 - Am Heart Assoc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, EM Antman, NH Brooks, RM Califf, LD Hillis - Circulation, 1999 - Am Heart Assoc
    • A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction - RC Becker, JM Gore, C Lambrew - Journal of the American , 1996 - Elsevier
    • Investigation of 100 Cases of Massive Embolism of the Pulmonary Artery; Diagnosis by Physical Signs and Differentiation From Acute Myocardial Infarction - LW Gorham - Archives of internal medicine, 1961 - Am Med Assoc
    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Investigation of 100 Cases of Massive Embolism of the Pulmonary Artery; Diagnosis by Physical Signs and Differentiation From Acute Myocardial Infarction - LW Gorham - Archives of internal medicine, 1961 - Am Med Assoc
    • Acute myocardial infarction caused by coronary embolism from infective endocarditis - CJ Roxas, AJ Weekes - The Journal of Emergency Medicine, 2011 - Elsevier
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Affective disorders and survival after acute myocardial infarction Results from the post-infarction late potential study - KH Ladwig, M Kieser, J König, G Breithardt - European heart , 1991 - Eur Soc Cardiology
    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • " Inadvertent" Thrombolytic Administration in Patients Without Myocardial Infarction: Clinical Features and Outcome - NE Khoury, S Borzak, A Gokli, SL Havstad - Annals of emergency , 1996 - Elsevier
    • A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction - CL Grines, KF Browne, J Marco - England Journal of , 1993 - Mass Medical Soc
    • Acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial - F Van de Werf, J Bax, A Betriu - European heart , 2008 - Eur Soc Cardiology
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, JL Anderson, EM Antman, BA Braniff - Circulation, 1996 - Am Heart Assoc
    • Characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain - GW Rouan, TH Lee, EF Cook, DA Brand - The American journal of , 1989 - Elsevier
    • A double-blind trial of low doses of subcutaneous heparin in the prevention of deep-vein thrombosis after myocardial infarction - C Warlow, G Terry, ACF Kenmure, AG Beattie - The Lancet, 1973 - Elsevier
    • Investigation of 100 Cases of Massive Embolism of the Pulmonary Artery; Diagnosis by Physical Signs and Differentiation From Acute Myocardial Infarction - LW Gorham - Archives of internal medicine, 1961 - Am Med Assoc
    • Investigation of 100 Cases of Massive Embolism of the Pulmonary Artery; Diagnosis by Physical Signs and Differentiation From Acute Myocardial Infarction - LW Gorham - Archives of internal medicine, 1961 - Am Med Assoc
    • A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction - CL Grines, KF Browne, J Marco - England Journal of , 1993 - Mass Medical Soc
    • Levels circulating in plasma and deposited in the tissues: Comparison between Helicobacter pylori-associated gastritis and acute myocardial infarction - S Kayo, M Ohsawa, S Ehara, T Naruko, Y Ikura - American heart , 2004 - Elsevier
    • Blood transfusion in elderly patients with acute myocardial infarction - WC Wu, SS Rathore, Y Wang, MJ Radford - England Journal of , 2001 - Mass Medical Soc
    • Of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) - TJ Ryan, JL Anderson, EM Antman, BA Braniff - Circulation, 1996 - Am Heart Assoc
    • Acute myocardial infarction in women: influence of gender on mortality and prognostic variables - H Dittrich, E Gilpin, P Nicod, G Cali, H Henning - The American journal of , 1988 - Elsevier
    • Adams-Stokes syndrome caused by paroxysmal third-degree atrioventricular block. - G Jensen, B Sigurd, J Meibom, E Sandoe - British heart journal, 1973 - ncbi.nlm.nih.gov
    • , risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: Prospective Registry of Acute Ischaemic Syndromes in the - J Collinson, MD Flather, KAA Fox, I Findlay - European heart , 2000 - Eur Soc Cardiology

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