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Anterior Myocardial Infarction

Myocardial Infarction (anterior Wall)

Anterior myocardial infarction is a term denoting ischemia and necrosis of the anterior myocardial wall due to occlusion of the left anterior descending artery. A sudden onset of chest pain that often radiates to the arm and neck accompanied by dyspnea, nausea, vomiting, weakness, and diaphoresis are some of the most common symptoms. Laboratory workup, electrocardiography (the V1-V4 precordial leads are specific for the anterior wall), and sometimes coronary angiography are essential steps to confirm myocardial infarction, but clinical suspicion is critical for an early diagnosis.


Presentation

Despite the fact that myocardial infarction possesses a different pathogenesis in terms of its location and vessel involved, the clinical presentation is similar. In the case of anterior myocardial infarction, signs and symptoms stem from occlusion of the left anterior descending artery, the blood vessel responsible for supplying this part of the heart [1]. Across many studies, chest pain is identified as the most frequent finding, typically described as a burning or squeezing sensation [2]. It is seen in > 90% of patients [2] [3] [4]. Pain may be mild or quite severe and is further described as retrosternal, precordial, or radiating to various anatomical sites, such as the jaw, the neck, the shoulder, and arms, as well as posteriorly toward the interscapular region of the back [2] [3] [4]. Radiation of pain is usually unilateral but individuals in whom bilateral spread occurred are also reported [2] [3 [4]. In the vast majority of cases, chest pain persists for more than 20 minutes [2]. In addition to pain, other common complaints include nausea, vomiting, dyspnea, shortness of breath, diaphoresis, abdominal pain, fatigue, dizziness, and palpitations [2] [3] [4]. Interestingly, some studies highlight that multiple features are more commonly encountered among women compared to men, without an obvious explanation [4].

Coronary Artery Disease
  • His father had a history of coronary artery disease and AMI after the age of 45 years. There were no other major coronary risk factors. His electrocardiogram showed ST-segment elevation in the precordial leads V1 to V5.[ncbi.nlm.nih.gov]
  • MATERIALS AND METHODS: We analyzed the digital ECG data from 1138 subjects with suspected coronary artery disease in whom the presence or absence of prior IMI or AMI was documented by coronary angiography and left ventriculography.[ncbi.nlm.nih.gov]
  • The timing of CABG after restoration of antegrade flow in the culprit artery with primary PCI in patients with left main or severe multivessel coronary artery disease disease remains undefined. Conflict of Interest: None[drdeepaknatarajan.com]
  • Effects of amiodarone on cardiac and coronary hemodynamics and on myocardial metabolism in patients with coronary artery disease. Circulation 1979;59:1165–1172. Google Scholar 5. DeBoar, LWV, Nosta, JJ, Koner, RA, et al.[link.springer.com]
  • 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]
Chest Pain
  • A 50-year-old male with known dextrocardia and situs inversus presented with acute chest pain radiating to the right arm.[ncbi.nlm.nih.gov]
  • Across many studies, chest pain is identified as the most frequent finding, typically described as a burning or squeezing sensation. It is seen in 90% of patients.[symptoma.com]
  • LESSONS: SCAD should be suspected in young to middle-aged women with chest pain symptoms, particularly during the perinatal period or for subjects who use oral contraceptives.[ncbi.nlm.nih.gov]
  • Abstract A patient presented with chest pain and S-T segment elevation in the anterior chest leads diagnostic of acute anterior myocardial infarction (MI).[ncbi.nlm.nih.gov]
  • Abstract The diagnosis of acute coronary syndrome in patients presenting to the emergency department with chest pain is still challenging.[ncbi.nlm.nih.gov]
Heart Disease
  • Because the patient had no significant risk factors for coronary heart disease, the infarction was likely caused by the chemotherapy regimen.[ncbi.nlm.nih.gov]
  • disease, valvular heart disease, e) patients who died in the early phase of acute anterior myocardial infarction before echocardiographic examination, and f) patients with relative or absolute contraindication to thrombolytic therapy.[medical-dictionary.thefreedictionary.com]
  • diseases Use Additional code to identify presence of hypertension ( I10-I16 ) Ischemic heart diseases I21 ICD-10-CM Diagnosis Code I21 Acute myocardial infarction 2016 2017 2018 - Revised Code 2019 Non-Billable/Non-Specific Code Includes cardiac infarction[icd10data.com]
  • Myocardial Infarction: A Companion to Braunwald’s Heart Disease , by David A. Morrow, MD, is a comprehensive, hands-on resource that provides practical guidance from a name you trust.[books.google.com]
  • Case report A 68-year-old man with hypertension, dyslipidemia and ischemic heart disease, with a previous infarction in 2001 when he underwent percutaneous angioplasty of the anterior descending coronary artery, presented at our emergency room with shock[elsevier.pt]
Neglect
  • For a long time, the importance of right ventricle (RV) function has been neglected. Recently, RV dysfunction has also been associated with poor outcomes in the setting of heart failure.[ncbi.nlm.nih.gov]

Workup

The diagnosis of a myocardial infarction must be made as soon as possible. For this reason, the physician must promptly obtain a detailed history and assess the signs that are present. To confirm the exact location of the infarction and its severity, it is necessary to perform specific laboratory studies that focus on "cardiac markers" and electrocardiography [5] [6] [7] [8] [9]. Troponins T and I, very specific markers of myocardial injury, become elevated within several hours after myocardial infarction and their highest values are estimated to be around 24 hours after the initial event [6]. Creatine kinase myocardial band (CK-MB), initially used an equally important biomarker of cardiac injury [6], is now regarded as an unnecessary test due to its little value and accuracy [10]. For this reason, troponin remains the key biochemical exam [6] [7] [8] [9]. Electrocardiography is, perhaps, the crucial component of the workup in people in whom myocardial infarction is suspected. The diagnosis is made when the elevation of the ST segment at the J-point, ST depression, or inversion of the T wave is seen in 2 contiguous leads (with slightly different cutoff values for men and women) [5] [11] [12]. Anterior myocardial infarction is confirmed when these findings are shown on the precordial leads V1-V4 [1]. In some patients, coronary angiography or other imaging studies of the heart can be used to further elucidate the severity of infarction [3].

Right Axis Deviation
  • Right-axis deviation was present in 4.3% of patients with RBBB at randomization and 6% of patients with new RBBB at 60 minutes.[circ.ahajournals.org]
  • axis deviation) Left anterior fascicular block (may see small q-waves in anterior chest leads) Acute pericarditis (the ST segment elevation may mimic acute transmural injury) Central nervous system disease (may mimic non-Q wave MI by causing diffuse[ecg.utah.edu]
Poor R Wave Progression
  • Copyleft image obtained courtesy of, Shown below is an EKG showing ST elevation in the anterior precordial leads , low voltages in all the leads, poor R wave progression in the precordial leads.[wikidoc.org]
  • This is a cause of poor R wave progression , or PRWP.[healio.com]
  • Poor R wave progression (R wave height 3mm in V3). Abnormal Q waves and T-wave inversion in I and aVL. The pattern indicates prior infarction of the anteroseptal and lateral walls.[lifeinthefastlane.com]
  • WPW preexcitation ( negative delta wave may mimic pathologic Q waves) IHSS (septal hypertrophy may make normal septal Q waves "fatter" thereby mimicking pathologic Q waves) LVH (may have QS pattern or poor R wave progression in leads V1-3) RVH (tall R[ecg.utah.edu]
  • Hyperacute T waves are often “fat and wide” with poor R wave progression and blunt peaks, while hyperkalemic T waves are more often sharp with narrow base.[emdocs.net]
Short PR Interval
  • At the fourth day, while ST elevations returned to baseline, short PR interval and delta waves were observed on the ECG. Myocardial infarction was excluded by biochemical tests, echocardiography, and coronary angiography.[ncbi.nlm.nih.gov]
ST Elevation
  • ECG was recorded in acute phase ( RESULTS: Anterior-STEMI patients had ST-elevation in lead V1 more frequently than apical (70% vs 15%, p CONCLUSIONS: In patients with anterior ST-elevation and acute chest pain, lack of ST-elevation in lead V1 and ST-elevation[ncbi.nlm.nih.gov]
  • His electrocardiogram showed ST elevation in the precordial leads (V1-V6). This condition was erroneously interpreted as an acute myocardial infarction.[ncbi.nlm.nih.gov]
  • Patients were divided into the following 3 groups according to admission ST segment changes in inferior derivations: ST depression (group 1), no ST change (group 2), and ST elevation (group 3).[ncbi.nlm.nih.gov]
  • An anterior MI is characterized by the presence of ST elevation in the anterior leads V3 and V4 . ST elevation in V1 and V2 corresponds to septal infraction whereas ST elevation in leads V5 and V6 corresponds to apical infarction.[wikidoc.org]
  • ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.1 ST elevation (STEMI) myocardial infarction of inferior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST[icd10data.com]
ST Elevation in Anterior Leads
  • For example, ST elevation in anterior leads should produce depression in inferior leads, and elevation in lateral leads should produce depression in septal leads. However, do not rely on reciprocal changes to diagnose STEMI.[emdocs.net]
T Wave Inversion
  • Evolved anterior wall myocardial infarction ECG shows sinus rhythm at a rate of around 100/min, with QS complexes in anterior leads along with a coved ST segment elevation and T wave inversion, suggesting evolved anterior wall myocardial infarction (AWMI[cardiophile.org]
  • Abnormal Q waves and T-wave inversion in I and aVL. The pattern indicates prior infarction of the anteroseptal and lateral walls.[lifeinthefastlane.com]
  • V1 ST segment elevation Gaitonde (2003) Am J Cardiol 92:846-8 [PubMed] Biphasic or deep T Wave Inversion in V2, V3 ( Wellen's Syndrome ) High risk for left anterior descending artery ischemia and Anterior Wall Myocardial Infarction VIII.[fpnotebook.com]
  • There is also a loss of general R wave progression across the precordial leads and there may be symmetric T wave inversion as well.[meds.queensu.ca]
  • Two-thirds of MI's presenting to emergency rooms evolve to non-Q wave MI's, most having ST segment depression or T wave inversion. Most MI's are located in the left ventricle.[ecg.utah.edu]
Electrocardiogram Change
  • Findings: Septal MI Anatomic Distribution Electrocardiogram Changes Lead V1 to lead V2 Distribution Left Coronary Artery : LAD-Septal Branch Complications Infranodal and Bundle Branch Block X.[fpnotebook.com]

Treatment

  • INTERVENTIONS: There is no guiding suggestion for the treatment of SCAD. The main treatment methods are 3 aspects: conservative internal medical treatment, stent implantation, coronary artery bypass grafting.[ncbi.nlm.nih.gov]
  • Diagnosis and treatment of this rare condition is a challenge, but prompt recognition and appropriate early choice of angioplasty or surgery can lead to a good outcome.[ncbi.nlm.nih.gov]
  • Treatment with intralesional abciximab, thrombus aspiration, or both therapies compared with no active therapy before stent implantation resulted in lower 1-year rates of death (4.5% versus 10.4%; P 0.03), severe heart failure (4.2% versus 10.3%; P 0.02[ncbi.nlm.nih.gov]
  • Combination chemotherapy with cisplatin, etoposide, and bleomycin remains the mainstay of treatment. We present a 27-year-old man who presented with an acute anterior myocardial infarction during the second course of chemotherapy for seminoma.[ncbi.nlm.nih.gov]

Prognosis

  • Anterior myocardial infarction carries the worst prognosis of all infarct locations, mostly due to larger infarct size.[lifeinthefastlane.com]
  • Abstract A study was carried out in metropolitan Baltimore in which the short- and long-term prognosis of 655 patients with anterior myocardial infarction (MI) was compared with that of 520 patients with inferior/posterior MI.[ncbi.nlm.nih.gov]
  • […] increased by 25% in the control group but 41% in the treated group with an anti-remodeling effect in the latter: LVEDV increased by 12% in the control vs 2% in the treated group (P Conclusions- The improvement of left-ventricular systolic function and prognosis[bloodjournal.org]
  • BACKGROUND: ST segment elevation of chest lead V4 R is associated with worse prognosis in acute inferior ST-elevation myocardial infarction (STEMI).[ncbi.nlm.nih.gov]
  • […] requires i.v. catecholamines or mechanical hemodynamic support (aortic balloon pump) Significant regional wall motion abnormality in LV angiogram at the time of acute PCI in the LAD territory Age 18 - 80 Years (primary angioplasty confers an adverse prognosis[clinicaltrials.gov]

Etiology

  • KEYWORDS: Aneurysm, dissecting/complications/diagnosis/etiology/radiography; myocardial infarction/etiology; risk factors; treatment outcome; weight lifting/injuries[ncbi.nlm.nih.gov]
  • But there are other suspicious etiologic reasons that lead to coronary embolism, such as intracardiac prosthesis, infective endocarditis, mural thrombus or a cardiac tumor [1-8].[austinpublishinggroup.com]
  • But there are other suspicious etiologic reasons that lead to coronary embolism such as intracardiac prosthesis, infective endocarditis, mural thrombus or a cardiac tumor [ 1 - 7 ].[omicsonline.org]
  • CAUSE (ETIOLOGY) OF MYOCARDIAL INFARCTION The most common cause of myocardial infarction is related to the formation of a blood clot (thrombosis) in a coronary artery.[calshipleymd.com]
  • Ischemic stroke etiologies vary, and may be from causes other than cardioembolism, such as large artery atherosclerosis or small-vessel lacunar disease.[journals.plos.org]

Epidemiology

  • All patients were epidemiologically and clinically similar. There were 6 bleeding episodes that required blood transfusion and 11 episodes of minor bleeding.[ncbi.nlm.nih.gov]
  • EPIDEMIOLOGY OF MYOCARDIAL INFARCTION Estimates are that approximately 1.2 million people in the United Stated experience a fatal or non-fatal acute MI each year. Approximately every minute, an American dies of an acute myocardial infarction.[calshipleymd.com]
  • EPIDEMIOLOGY Myocardial infarction is a common presentation of ischemic heart disease , the leading cause of death in developed countries , and third to AIDS and lower respiratory infections in developing countries .[sites.google.com]
  • Epidemiology [ 5 ] Coronary heart disease (CHD) is the most common cause of death in the UK. CHD is responsible for the deaths of approximately one in five men and one in ten women.[patient.info]
  • "Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance".[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • Early recognition of the underlying pathophysiological mechanism might have major therapeutic implications and could decrease the risk of myocardial rupture.[ncbi.nlm.nih.gov]
  • The clinical implications and pathophysiology of this dangerous association are discussed.[ncbi.nlm.nih.gov]
  • OBJECTIVE: The combination of electrical phenomena and remote myocardial ischemia is the pathophysiological mechanism of ST segment changes in inferior leads in acute anterior myocardial infarction (MI).[ncbi.nlm.nih.gov]
  • Abstract To elucidate the pathophysiological role of diabetes mellitus in determining the left ventricular regional function of the noninfarcted area, 55 patients with acute Q wave anterior myocardial infarction (MI) were studied.[care.diabetesjournals.org]
  • Remember that the underlying pathophysiology of ACS is plaque rupture (usually in plaques less than 50%) with thrombus formation and platelet aggregation.[emdocs.net]

Prevention

  • CONCLUSIONS: The available studies of LVT/SE prevention after MI lacked statistical power and are heterogeneous in terms of treatments, revascularization methods, background medical therapy, and study design.[ncbi.nlm.nih.gov]
  • Abstract Although detecting left ventricular thrombus in anterior myocardial infarction is important for the prevention of embolic events, imaging of apical thrombus is often difficult using conventional echocardiography.[ncbi.nlm.nih.gov]
  • No prospective randomized controlled trial using warfarin has been conducted to study its efficacy after anterior STEMI in preventing left ventricular thrombus for prevention of stroke.[journals.plos.org]
  • METHODS: Cohort of 88 patients after anterior MI ( 6 months) consisted of 43 patients without VT/VF (33 males; 59 12 years; LVEF: 41 7%; NoVT/VF), and 45 patients with VT/VF history- ICD implanted as secondary prevention (40 males; 64 10 years; LVEF:[ncbi.nlm.nih.gov]
  • Pain relief and prevention of complications are also important in management.[healthguideinfo.com]

References

Article

  1. Morris F, Brady WJ. Acute myocardial infarction—Part I. BMJ. 2002;324(7341):831-834.
  2. Malik MA, Alam Khan S, Safdar S, Taseer I-U-H. Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI). Pakistan Journal of Medical Sciences. 2013;29(2):565-568.
  3. Lu L, Liu M, Sun R, Zheng Y, Zhang P. Myocardial Infarction: Symptoms and Treatments. Cell Biochem Biophys. 2015;72(3):865-867.
  4. Berg J, Björck L, Dudas K, Lappas G, Rosengren A. Symptoms of a first acute myocardial infarction in women and men. Gend Med. 2009;6(3):454-462 .
  5. Fleischmann KE, Zègre-Hemsey J, Drew BJ. The New Universal Definition of Myocardial Infarction Criteria Improves Electrocardiographic Diagnosis of Acute Coronary Syndrome. J Electrocardiol. 2011;44(1):69-73.
  6. Stillman AE, Oudkerk M, Bluemke D, et al. Assessment of acute myocardial infarction: current status and recommendations from the North American society for cardiovascular imaging and the European society of cardiac radiology. Int J Cardiovasc Imaging. 2011;27(1):7-24.
  7. McCann CJ, Glover BM, Menown IB, et al. Novel biomarkers in early diagnosis of acute myocardial infarction compared with cardiac troponin T. Eur Heart J. 2008;29:2843–2850.
  8. Jaffe AS, Babuin L, Apple FS. Biomarkers in acute cardiac disease: the present and the future. J Am Coll Cardiol. 2006;48:1–11.
  9. Morrow DA, Cannon CP, Rifai N, et al. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial. JAMA. 2001;286:2405–2412.
  10. Alvin MD, Jaffe AS, Ziegelstein RC, Trost JC. Eliminating Creatine Kinase-Myocardial Band Testing in Suspected Acute Coronary Syndrome: A Value-Based Quality Improvement. JAMA Intern Med. 2017 Aug 14.
  11. Thygesen K, Alpert JS, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. J Am Coll Cardiol. 2007;50 (22):2173–2195.
  12. Ben-Gal T, Herz I, Solodky A, Birnbaum Y, Sclarovsky S, Sagie A. Acute anterior wall myocardial infarction entailing ST-segment elevation in lead V1: electrocardiographic and angiographic correlations. Clin Cardiol.1998;21(6):399-404.

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Last updated: 2018-06-21 19:11