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Apical Myocardial Infarction

The apical myocardial infarction is a subtype of the acute coronary syndrome, caused by myocardial ischemia. This particular type of infarction is subject to debate, given that its electrocardiography description does not always correlate with echocardiography findings. V1 to V4 abnormalities were considered to denote anteroseptal suffering, but other studies showed that the involvement of anteroapical and apical segments manifests with ECG changes in the same territory.


Presentation

The presentation of an apical myocardial infarction patient depends on whether the disease is acute or chronic. Acute patients have the usual complaints of cardiac ischemia patients. A strictly apical location implies that the mass of the affected myocardial tissue is relatively small, therefore the patient is unlikely to present in cardiogenic shock, but rather be a Killip class I case, with no evidence of heart failure. Pulmonary edema presentation is also unlikely. In return, the patient complains of chest pain that often radiates to the epigastrium or malaise. The pain is severe and lasts for 30 to 60 minutes. The character of the disease is different in different individuals, being described as a squeezing, burning, pressure, aching or sharp sensation. In other cases, myocardial ischemia can go unrecognized, as the patient believes he or she is suffering from indigestion or has no complaints whatsoever. This latter situation is more frequently seen in diabetes, dementia or elderly patients. Symptoms are more frequent during the early morning hours [1].

Patients with a previous apical myocardial infarction may have heart failure signs if the acute event was not strictly apical, but involved significant parts of neighboring walls and was complicated by aneurysm formation that occupies a significant ventricular territory. The anterior wall is more frequently implicated than the inferior and posterior ones.

Coronary Artery Disease
  • One hundred twenty-four (98 M, 26 F) out of 1500 patients with suspected coronary artery disease, showed apical perfusion defect not reversible at rest and after reinjection at tomographic SPECT analysis during thallium-201 scintigraphy.[ncbi.nlm.nih.gov]
  • Abstract A teenage boy of 19 years without traditional risk factors for coronary artery disease, presented with typical anginal pain with ST-T changes in anterior leads and elevated cardiac troponin T.[banglajol.info]
  • There was no cardiac biomarker rise and coronary angiography did not reveal evidence of significant coronary arterial disease.[readbyqxmd.com]
  • McCrohon JA, Moon JC, Prasad SK et al (2003) Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance.[link.springer.com]
  • The investigators aimed to determine what proportion of patients were diagnosed with Takotsubo cardiomyopathy as opposed to myocardial infarction with non-obstructive coronary artery disease (MINOCA).[thecardiologyadvisor.com]
Chest Pain
  • Case Presentation: A 29 year old African American male presented with non-radiating, mid-sternal chest pain, which was relieved by sitting up. His vital signs and physical examination were unremarkable.[shmabstracts.com]
  • A 51-year-old Japanese woman consulted the emergency room complaining of the sudden onset of anterior chest pain while shopping.[ncbi.nlm.nih.gov]
  • A 67-year-old Sudanese male without cardiac risk factors presented to hospital with chest pain and electrocardiographic findings of septal ST-segment elevation, ST-segment depression in V4-V6, and diffuse T-wave inversion.[readbyqxmd.com]
  • In return, the patient complains of chest pain that often radiates to the epigastrium or malaise. The pain is severe and lasts for 30 to 60 minutes.[symptoma.com]
  • Patients commonly present with ST-segment elevation in the precordial leads, chest pain, relatively minor elevation of cardiac enzyme and biomarker levels, and transient apical systolic left ventricular dysfunction despite the absence of obstructive epicardial[annals.org]
Heart Disease
  • 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]
  • Coronary: · failure · insufficiency I24.9 Acute ischaemic heart disease, unspecified Excludes: ischaemic heart disease (chronic) NOS ( I25.9 ) I25 Chronic ischaemic heart disease Excludes: cardiovascular disease NOS ( I51.6 ) I25.0 Atherosclerotic cardiovascular[apps.who.int]
  • Diagnosis Ischemic heart disease is typically associated with an underlying specific heart disease. In “stable” angina, chest pain with typical features occurs at predictable levels of exertion.[courses.lumenlearning.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]
  • He was an ex-smoker, hypercholestrolaemic and had a family history of ischaemic heart disease. During stress electrocardiography, he developed chest pain at nine minutes of a standard Bruce protocol, but no significant ST changes.[bjcardio.co.uk]

Workup

The first step in addressing a non-critical myocardial infarction patient should be obtaining the history of the disease and assessing risk factors [2] [3]. Clinical examination should assess the skin (color and presence of diaphoresis), blood pressure, pulse (frequency, rhythm and equality in similar territories), heart and breathing sounds, the presence of gastrointestinal symptoms such as nausea and vomiting, neck vein aspect, temperature (fever is present during the first two days of evolution [4]) and urinary output.

Once the suspicion of an acute myocardial infarction is raised, electrocardiography is usually the first investigation performed. As discussed above, the apical localization is rather difficult to define by this method, but modifications do appear in contiguous leads.

The electrocardiogram also detects newly installed branch blocks, also an indicator of ischemia, and potentially life-threatening arrhythmias [5] [6].

The protocol states that cardiac enzymes (troponin, myoglobin and creatine kinase) should be measured in a serial manner [7] [8]. Recent guidelines advise that high-sensitive troponin I or troponin T assays should be used [9] [2]. Brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide is only useful in chronic myocardial infarction patients for risk stratification and heart failure prognosis [10] [11].

The exact localization of the infarction area is stated by imaging methods. Echocardiography is a useful, readily available and reliable method that helps to evaluate wall motion abnormalities. Multidetector computed tomography and single-photon emission CT (SPECT) or positron emission tomography (PET) scanning, although viable methods, are not routinely used in triage settings, but are useful in detecting ventricular aneurysms [12]. Classic coronary catheterization has the advantage of offering clear diagnosis and being a therapeutic procedure, as well.

Inferior Q Wave
  • Q Waves - not Old Inferior Wall Myocardial Infarction (MI) ECG Old Inferior Wall Myocardial Infarction (MI) ECG (Example 1) Old Inferior Wall Myocardial Infarction (MI) ECG (Example 2) Posterior Wall Myocardial Infarctions Inferior-Posterior Wall Myocardial[healio.com]
ST Elevation
  • In the acute period (6 9 h; range, 1 to 48 h), ST elevation was observed in 79 (90%) of the patients, including four patients with solitary ST elevation of limb-lead and 13 patients without right precordial (V 1 , V 2 ) ST elevation.[onlinejacc.org]
  • He was treated as an acute ST-elevation myocardial infarction with thrombolytics. There was no cardiac biomarker rise and coronary angiography did not reveal evidence of significant coronary arterial disease.[readbyqxmd.com]
  • The aim of the work was to assess apical rotation in acute ST-elevation MI.[mmj.eg.net]
  • Overnight, his subsequent EKG showed diffuse ST elevation and PR segment depression suggestive of pericarditis, and he was started on colchicine and NSAIDs. However, his chest pain did not resolve. His CRP was 0.2 mg/dL and ESR was 2 mm/hr.[shmabstracts.com]
  • 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]

Treatment

  • Features an extensive treatment section that covers the latest drugs and most recent clinical trials of antiplatelet therapy, coronary revascularization, gene therapy, and approaches to reperfusion injury and ventricular remodeling.[books.google.com]
  • Detailed discussions of hot topics, full-color illustrations, and a DVD of procedural video clips, animations, and downloadable image libraries help you provide fast, appropriate treatment for each challenging case you face.[books.google.com]
  • A high incidence of aborted infarction in a population of AMI patients is certainly a marker of treatment success.[ecrjournal.com]
  • Treatment requires emergency surgery for mitral valve repair and revascularization. Medical treatment, without surgery, is associated with poor long-term survival [ 5 ].[ceemjournal.org]

Prognosis

  • Brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide is only useful in chronic myocardial infarction patients for risk stratification and heart failure prognosis.[symptoma.com]
  • Time to treatment influences the impact of STsegment resolution on one-year prognosis, Circulation, 2001;104:2653–9.[ecrjournal.com]
  • Mitral regurgitation following myocardial infarction predicts a poor prognosis but is often transient and asymptomatic.[patient.info]
  • […] is dependent on the adequacy of the residual left ventricular function, patients with severe left ventricular dysfunction having higher mortality rates. 25 In this case the early prognosis was favorable, but on the long term, the prognosis still remains[tmj.ro]
  • By definition, patients in quadrant 4 are in "cardiogenic shock" and have a poor prognosis, unless they have a correctable mechanical complication, or unless they are early into the course of their MI, and some of the ischemic myocardium is recovered[brown.edu]

Etiology

  • Therefore, the precise clinical features and the etiologic basis of this syndrome remain unclear.[onlinejacc.org]
  • Although this mechanism is only one hypothesis about the cause of LVBS, as is also presented in several previous reports, we think this case is very rare and has implications for investigating the etiology of LVBS in the future.[jmedicalcasereports.biomedcentral.com]
  • We performed tridimensional (3D) transthoracic echocardiography to study the etiology of MR.[tmj.ro]
  • Non-ischemic CM has a variable etiology, i.e. genetic, toxic, metabolic, infectious and idiopathic.[radiologyassistant.nl]
  • The simplest classification is based on etiology: either infective or non-infective, depending on whether a microorganism is the source of the inflammation or not.[courses.lumenlearning.com]

Epidemiology

  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • […] left ventricular apical ballooning suggested a possible genetic predisposition to this disease. 21 Curiously, men have higher levels of basal sympathetic activity and produce higher levels of plasma catecholamines; however, one of the more noteworthy epidemiological[invasivecardiology.com]
  • "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

  • We think this case may promote discussion regarding the pathophysiology of left ventricular apical ballooning syndrome.[ncbi.nlm.nih.gov]
  • Conclusion We think this case may promote discussion regarding the pathophysiology of left ventricular apical ballooning syndrome.[jmedicalcasereports.biomedcentral.com]
  • Her interests are in the pathophysiology of heart failure.[books.google.com]
  • Triggering factors such as emotional exposure, physical stress and preceding disorders are more important clinical information as the pathophysiologic basis of this heart syndrome.[onlinejacc.org]
  • Thus, cardiac MRI allows an accurate and comprehensive insight into the pathophysiology of ischemic myocardial damage and the post-infarction remodeling.[cdt.amegroups.com]

Prevention

  • Prevention The same lifestyle habits that can help treat myocardial ischemia can also help prevent it from developing in the first place.[mayoclinic.org]
  • The main aim of treatment strategies for LV thrombus is to prevent systemic embolisation. Oral anticoagulation with vitamin K antagonists is the mainstay of treatment for LV thrombus to prevent systemic embolisation [1, 2].[smw.ch]
  • "Vitamin and mineral supplements in the primary prevention of cardiovascular disease and cancer: An updated systematic evidence review for the U.S. Preventive Services Task Force".[en.wikipedia.org]
  • 2019 together with World Congress of Cardiology Bringing the world of cardiology together Abstract submission: December 2018 - 14 February 2019 Saturday, August 31st 2019 Late registration deadline ESC Congress Wednesday, July 31st 2019 at 11:59 PM Preventive[semsearch.escardio.org]
  • This calls for a randomised trial to be conducted to determine whether anticoagulation treatment prevents embolic complications in AMI patients treated with primary PCI.[heart.bmj.com]

References

Article

  1. Wijnbergen I, Van't Veer M, Pijls NH, et al. Circadian and weekly variation and the influence of environmental variables in acute myocardial infarction. Neth Heart J. 2012; 20 (9):354-9.
  2. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130 (25):e344-426.
  3. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37 (3):267-315.
  4. Kacprzak M, Kidawa M, Zielińska M. Fever in myocardial infarction: is it still common, is it still predictive?. Cardiol J. 2012;19 (4):369-73.
  5. O'Gara PT, Kushner FG, Ascheim DD, et al. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127 (4):e362-425.
  6. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC); Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33 (20):2569-619.
  7. Storrow AB, Nowak RM, Diercks DB, et al. Absolute and relative changes (delta) in troponin I for early diagnosis of myocardial infarction: Results of a prospective multicenter trial. Clin Biochem. 2015;48 (4-5):260-7.
  8. Storrow AB, Christenson RH, Nowak RM, et al. Diagnostic performance of cardiac troponin I for early rule-in and rule-out of acute myocardial infarction: Results of a prospective multicenter trial. Clin Biochem. 2015;48 (4-5):254-9.
  9. Reichlin T, Irfan A, Twerenbold R, et al. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation. 2011; 12. 124(2):136-45.
  10. 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;124 (5):444-52.
  11. Thygesen K, Mair J, Mueller C, et al. Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J. 2012; 33 (16):2001-6.
  12. Cremer PC, Khalaf S, Agarwal S, et al. Myocardial perfusion imaging in emergency department patients with negative cardiac biomarkers: yield for detecting ischemia, short-term events, and impact of downstream revascularization on mortality. Circ Cardiovasc Imaging. 2014; 7 (6):912-9.

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Last updated: 2018-06-21 20:11