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Inferior Wall Myocardial Infarction

Myocardial Infarction (inferior Wall)

Inferior wall myocardial infarction stems from ischemia and necrosis due to occlusion of the right coronary and/or distal circumflex arteries that supply this area of the heart. The clinical presentation most commonly encompasses chest pain that often spreads to other parts of the body (the extremities, the back, or the head and neck), whereas an array of additional symptoms can be present - nausea, vomiting, diaphoresis, palpitations, weakness, etc. The diagnosis rests on a prompt clinical assessment followed by a laboratory investigation with electrocardiography.


Presentation

The clinical presentation of an inferior wall myocardial infarction is no different from other types of infarctions. Occlusion of the arterial vessel (the right coronary and the distal circumflex arteries supply the inferior myocardial wall) leads to ischemia and subsequent necrosis of local tissue, resulting in the appearance of signs [1]. Chest pain is widely described as the predominant finding in the setting of a myocardial infarction and is present in virtually all patients [2] [3] [4]. The pain (generally located retrosternally or precordially) is reported as "burning" or as a heavy "squeezing" pressure on the chest, lasting > 20 minutes in more than 90% of cases [3]. An important feature of chest pain seen in myocardial infarction is its frequent radiation to other parts of the body - the head and neck area (particularly the jaw), the shoulders, arms and forearms; and the back and interscapular region, either in a unilateral or less commonly bilateral fashion [3] [4]. The pain may significantly range in terms of severity- some report only mild discomfort, whereas others complain of excruciating pain [3] [4]. Important additional symptoms are vomiting, nausea, weakness, fatigue, shortness of breath, excessive sweating, abdominal pain, or even palpitations [3] [4].

Pharyngitis
  • Coronary arteriography was performed in four patients with pharyngitis and was normal, while multi-vessel disease was the rule in those without pharyngitis.[ncbi.nlm.nih.gov]
Exudative Pharyngitis
  • In patients with preceding exudative pharyngitis the coronary event was the first and only confrontation with the disease.[ncbi.nlm.nih.gov]
Chest Pain
  • ST segment elevation in the right precordial leads was short lived, having disappeared within 10 hours after the onset of chest pain in half of our patients with right ventricular involvement.[ncbi.nlm.nih.gov]
  • Chest pain is widely described as the predominant finding in the setting of a myocardial infarction and is present in virtually all patients.[symptoma.com]
Heart Disease
  • Smoking and diabetes were more prevalent in RVMI group, while hypertension and family history of ischemic heart disease were more common in isolated IWMI. Ninety per cent of patients received thrombolytic therapy.[ncbi.nlm.nih.gov]
  • 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]
  • Usually there is no history of angina or heart attack, and risk factors for ischemic heart disease may not be present [ 2 ]. This is a case of a 59-year old woman with acute ST-elevated myocardial infarction (STEMI) with normal coronary arteries. 2.[pubs.sciepub.com]
  • "Hormone replacement therapy and the association with coronary heart disease and overall mortality: clinical application of the timing hypothesis".[en.wikipedia.org]
Retrosternal Chest Pain
  • A 56-years old female comes with acute onset retrosternal chest pain of 6 hours duration along with palpitation, sweating, giddiness and dyspnoea. She was a known case of diabetes mellitus and hypertension since last 10 years.[praveenkumargupta2002.blogspot.com]
Cesarean Section
  • The patient tolerated the procedure well and underwent a successful cesarean section with delivery of twins.[ncbi.nlm.nih.gov]

Workup

Myocardial infarction is a medical emergency and a prompt diagnosis is potentially life-saving. Through a detailed patient history and a comprehensive clinical examination, the physician plays a key role in raising initial suspicion. The onset of signs, as well as their progression and severity, should be assessed during the initial encounter with the patient. To make a solid diagnosis, however, two important steps of the workup should be covered - cardiac markers and electrocardiography [5] [6] [7] [8] [9]. The calcium-dependent troponins are currently regarded as the most specific test used to identify myocardial changes [6] [7] [8] [9]. Troponins T and I are cardiac-specific markers that are pathologically elevated about 6 hours after myocardial ischemia ensued, while their peak values are seen about 24 hours after the event [6]. Creatine kinase myocardial band (CK-MB), on the other hand, was until recently included in the biochemical panel, but its very low accuracy and value to physicians have led to its elimination from the workup of these individuals [10]. On electrocardiography, inferior myocardial infarction exhibits pathological changes in limb leads II, III, and aVF, in the form of ST elevation or depression, and/or T wave inversion in 2 contiguous leads as diagnostic criteria [1] [5] [11]. Coronary angiography can be further used to assess the severity of the infarction [4].

Left Axis Deviation
  • Note pathologic Q-waves in V1-4, late R wave in V1, wide S waves in lead I, and left axis deviation (-80 degrees).[ecg.utah.edu]
Dyslipidemia
  • Patients included in this study were subjected to the following: History taking: Full history was taken including age, sex, history of risk factors for CAD which are DM, hypertension, dyslipidemia, smoking and family history of CAD.[scialert.net]
Inferior Q Wave
  • Abstract The aim of this study was to determine the incidence and impact of right and left bundle branch block on the in-hospital, 5-year and 10-year mortality of patients with acute inferior Q wave myocardial infarction.[ncbi.nlm.nih.gov]
  • 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) References: 1.[healio.com]
  • Example #2: Old inferior Q-wave MI; note largest Q in lead III, next largest in aVF, and smallest in lead II (indicative of right coronary artery occlusion).[ecg.utah.edu]
Narrow QRS Complex
  • Electrophysiologic study performed in one patient and a narrow QRS complex in the other patient during the alternate Wenckebach periods confirmed the atrioventricular node as the level of block.[ncbi.nlm.nih.gov]
ST Elevation
  • In left circumflex artery (LCX) occlusions, significantly more ST depression was seen in leads V1-3 (most significantly in lead V2) and ST elevation in lead II.[ncbi.nlm.nih.gov]
  • 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]
  • .-) I21.0 ST elevation (STEMI) myocardial infarction of anterior wall Inclusion term(s): Type 1 ST elevation myocardial infarction of anterior wall I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation[icd10coded.com]
  • In our study, ST elevation in lead III II was seen in 91 patients (75.21%) whereas ST elevation in lead II III was seen in 30 patients (24.79%).[omicsonline.org]
Left Anterior Fascicular Block
  • anterior fascicular block (should see LAD in frontal plane) Anterior or anteroseptal MI Emphysema and COPD (look for R/S ratio in V5-6 1) Diffuse infiltrative or myopathic processes WPW preexcitation (look for delta waves, short PR) Prominent Anterior[ecg.utah.edu]
T Wave Inversion
  • Diagnostic T-wave inversion was defined as complete T inversion or biphasic waves with initial, predominantly negative deflection.[ncbi.nlm.nih.gov]
  • On electrocardiography, inferior myocardial infarction exhibits pathological changes in limb leads II, III, and aVF, in the form of ST elevation or depression, and/or T wave inversion in 2 contiguous leads as diagnostic criteria.[symptoma.com]
  • There is marked ST segment depression in lead I, avL along with T wave inversion in lead avL Lead V1,V2,V3 is showing ST segment depression with ST segment flattening along with upright tall T wave (most prominent in lead V2), ratio of R wave / S wave[praveenkumargupta2002.blogspot.com]
  • Within a few hours, you can begin to see negative T waves or T wave inversion as the MI evolves. The T wave inversion can persist for months after the MI.[dummies.com]
  • ST segment depression and T wave inversion 5 components of Pain Assessment P - precipitating Q - quality R - radiation S - severity T - timing 1.[quizlet.com]
Electrocardiogram Change
  • Leads II, III and aVF reflect electrocardiogram changes associated with acute infarction of the inferior aspect of the heart.[meds.queensu.ca]

Treatment

  • The average heart rate decreased from 82 /- 11 to 69 /- 9 beats/min (p less than 0.05) and the mean arterial blood pressure increased from 81 /- 12 mm Hg before metaraminol treatment to 126 /- 8 mm Hg after treatment.[ncbi.nlm.nih.gov]
  • Treatments may include medicines and medical procedures such as coronary angioplasty. After a heart attack, cardiac rehabilitation and lifestyle changes can help you recover.[icdlist.com]

Prognosis

  • CONCLUSIONS: RVI is associated with worse prognosis and increased number of in-hospital complications. Older patients aged 70 years have definitely poorer prognosis. Thrombolytic therapy in a subgroup of older patients with RVI remains ineffective.[ncbi.nlm.nih.gov]
  • We hypothesized that existence of J-wave in inferior leads and/or its reciprocal wave in leads V1–3 is associated with poor prognosis in patients with inferior wall MI.[jstage.jst.go.jp]

Etiology

  • Electrocardiographic signs of LAH in the presence of IWMI are outlined, and the behavior and etiology of the T-wave changes are analyzed.[ncbi.nlm.nih.gov]
  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • ., high-fat diet Etiology occlusion of a coronary artery can be caused by atheromatous plaque rupture with subsequent thrombi expansion vasospasm emboli, which can be secondary to atrial fibrillation, sending an embolus from the left atrium to the coronary[medbullets.com]
  • ETIOLOGY 7. CLINICAL FEATURES 8. DIAGNOSIS 9. TREATMENT 10. COMPLICATIONS 11. CONCLUSION 12. TAKE HOME MESSAGE THE PIONEERS HAROLD ENSIGN BENNET PARDEE EINTHOVEN PAUL DUDLEY WHITE 13. 2D ECHO 14.[slideshare.net]

Epidemiology

  • EPIDEMIOLOGY-India In India, cardiovascular disease (CVD) is the leading cause of death. 32% of all deaths in 2007. Relatively new epidemic in India.[slideshare.net]
  • Epidemiology It is difficult to be sure of the percentage of myocardial infarctions that are posterior because it seems likely that many are missed. [ 3 ] The risk factors are the same for any cardiovascular disease, such as smoking, hypertension, diabetes[patient.info]
  • […] necrosis are present Non-STEMI (NSTEMI) an ACS without ST-segment elevations found on ECG biomarkers of myocardial necrosis are present unstable angina an ACS without ST-segment elevations found on ECG and no elevation biomarkers of myocardial necrosis Epidemiology[medbullets.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

  • These findings, together with earlier ones, may contribute to our understanding of the pathophysiology of the presence of ST-segment depression in the precordial leads in inferior wall acute MI.[ncbi.nlm.nih.gov]
  • Right ventricular myocardial infarction: From pathophysiology to prognosis. Exp. Clin. Cardiol., 18: 27-30. Direct Link Rudski, L.G., W.W. Lai, J. Afilalo, L. Hua and M.D. Handschumacher et al ., 2010.[scialert.net]
  • […] subsequent thrombi expansion vasospasm emboli, which can be secondary to atrial fibrillation, sending an embolus from the left atrium to the coronary arteries vegetations from infective endocarditis material from an intracardiac prosthetic paradoxical emboli Pathophysiology[medbullets.com]
  • Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty. Lippincott Williams & Wilkins. p. 172. ISBN 9781469816685. Archived from the original on 2017-07-28.[en.wikipedia.org]

Prevention

  • But if you do get quick treatment, you may be able to prevent or limit damage to the heart muscle. That's why it's important to know the symptoms of a heart attack and call 9-1-1 if you or someone else is having them.[icdlist.com]
  • Through this case report, we emphasise the importance of intracoronary fibrinolysis for LMCA thrombosis to prevent the risk of distal embolisation with thrombectomy.[healthcare-bulletin.com]
  • Delay in diagnosis may also contribute. [ 7 ] Prevention See the separate Prevention of Cardiovascular Disease article.[patient.info]
  • "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]
  • Reperfusion therapy usually prevents extensive myocardial necrosis thus decreasing the incidence of VSR. Without reperfusion, myocardial necrosis develops within 3–5 days[ 3 ].[bmcresnotes.biomedcentral.com]

References

Article

  1. Morris F, Brady WJ. Acute myocardial infarction—Part I. BMJ. 2002;324(7341):831-834.
  2. 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.
  3. 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.
  4. Lu L, Liu M, Sun R, Zheng Y, Zhang P. Myocardial Infarction: Symptoms and Treatments. Cell Biochem Biophys. 2015;72(3):865-867.
  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 JC3. 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):2173–95

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Last updated: 2019-06-28 09:27