MYOCARDIAL INFARCTION

CASE STUDY

Heart attack
A heart attack is when blood vessels that supply blood to the heart are blocked, preventing enough oxygen from getting to the heart. The heart muscle dies or becomes permanently damaged.

Causes
Most heart attacks are caused by a blood clot that blocks one of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. If the blood flow is blocked, the heart starves for oxygen and heart cells die. In atherosclerosis, plaque builds up in the walls of your coronary arteries. This plaque is made up of cholesterol and other cells. A heart attack can occur as a result of the following:
The slow buildup of plaque may almost block one of your coronary arteries. A heart attack may occur if not enough oxygen-containing blood can flow through this blockage. This is more likely to happen when you are exercising. The plaque itself develops cracks (fissures) or tears. Blood platelets stick to these tears and form a blood clot (thrombus). A heart attack can occur if this blood clot completely blocks the passage of oxygen-rich blood to the heart. This is the most common cause.

Sudden, significant emotional or physical stress, including an illness, can trigger a heart attack.

Risk Factors
Increasing age (over age 65) Male gender Diabetes Family history of coronary artery disease (genetic or hereditary factors) High blood pressure Smoking Too much fat in your diet Unhealthy cholesterol levels, especially high LDL ("bad") cholesterol and low HDL ("good") cholesterol Chronic kidney disease

ANATOMY OF THE HEART

 The heart is located under the ribcage in the center of the chest between the right and left lungs. Its muscular walls beat, or contract, pumping blood continuously to all parts of the body. The size of the heart can vary depending on the age, size, and the condition of your heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger.

 The heart has four chambers. The right and left atria (AY-tree-uh) and the right and left ventricles (VENtrih-kuls). The ventricle on the right side of the heart pumps blood from your heart to your lungs. When you breathe air in, oxygen passes from the lungs through the blood vessels and into your blood. Carbon dioxide, a waste product, is passed from the blood through blood vessels to the lungs and is removed from the body when you breathe out. The left atrium receives oxygen-rich blood from the lungs. The pumping action of the left ventricle sends this oxygen-rich blood through the aorta (a main artery) to the rest of the body.

Right side of the heart

The superior and inferior vena cavae are the largest veins in your body. After the body's organs and tissues have used the oxygen in the blood, the vena cavae carry the oxygen-poor blood back to the right atrium of your heart. The superior vena cava carries oxygen-poor blood from the upper parts of the body, including the head, chest, arms, and neck. The inferior vena cava carries oxygenpoor blood from the lower parts of the body.

 The oxygen-poor blood from the vena cavae flows into the heart's right atrium and then on to the right ventricle. From the right ventricle, the blood is pumped through the pulmonary (PULL-mun-ary) arteries to the lungs. There, through many small, thin blood vessels called capillaries, the blood picks up more oxygen. The oxygen-rich blood passes from the lungs back to the heart through the pulmonary veins.

Left Side of Your Heart

Oxygen-rich blood from the lungs passes through the pulmonary veins. It enters the left atrium and is pumped into the left ventricle. From the left ventricle, the oxygen-rich blood is pumped to the rest of the body through the aorta. Like all organs, the heart needs blood rich with oxygen. This oxygen is supplied through the coronary arteries as blood is pumped out of the heart's left ventricle. The coronary arteries are located on the heart's surface at the beginning of the aorta. The coronary arteries carry oxygen-rich blood to all parts of the heart.

The Septum
The right and left sides of the heart are divided by an internal wall of tissue called the septum. The area of the septum that divides the atria (the two upper chambers of the heart) is called the atrial or interatrial septum. The area of the septum that divides the ventricles (the two lower chambers of the heart) is called the ventricular or interventricular septum.

Heart Chambers
The two upper chambers of the heart are called atria. The atria receive and collect blood. The two lower chambers of the heart are called ventricles. The ventricles pump blood out of the heart into the circulatory system to other parts of the body.

Heart Valves
The heart has four valves. The valves include the aortic (ay-OR-tik) valve, the tricuspid (tri-CUSSpid) valve, the pulmonary valve, and the mitral (MI-trul) valve.

Blood Flow
The blood enters the right atrium of the heart from the superior and inferior vena cavae. From the right atrium, blood is pumped into the right ventricle. From the right ventricle, blood is pumped to the lungs through the pulmonary arteries. The oxygen-rich blood coming in from the lungs through the pulmonary veins into the heart's left atrium. From the left atrium, the blood is pumped into the left ventricle. The left ventricle pumps the blood to the rest of the body through the aorta.

 For the heart to work properly, the blood must flow in only one direction. The heart's valves make this possible. Both of the heart's ventricles have an "in" (inlet) valve from the atria and an "out" (outlet) valve leading to the arteries. Healthy valves open and close in very exact coordination with the pumping action of the heart's atria and ventricles. Each valve has a set of flaps called leaflets or cusps that seal or open the valves. This allows pumped blood to pass through the chambers and into the arteries without backing up or flowing backward.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY OF MYOCARDIAL INFARCTION

Predisposing factors
y y y y

Precipitating Factors:
y y y

Age- 64 y/o Hypertension High HDL; Low LDL Diabetes Mellitus

Coronary atherosclerotic heart disease Coronary thrombosis/ embolism Decreased blood flow

Myocardial ischemia

Myocardial Oxygen supply

Cellular Hypoxia

Cardiac output

Myocardial Contractility

Altered Cell Membrane Function

Arterial Pressure

Stimulation of Baroreceptors

Stimulation of Sympathetic Receptors

Peripheral vasoconstriction

Afterload

Myocardial Contractility

Heart rate

Diastolic Filling

Decreased Myocardial Tissue Perfusion Increased myocardial oxygen demand

S/Sx:- chest pain, oliguria, ECG changes, Elevated CK-M, Troponin T, LDH, AST

Mechanisms of Occlusion
Most MIs are caused by a disruption in the vascular endothelium associated with an unstable atherosclerotic plaque that stimulates the formation of an intracoronary thrombus, which results in coronary artery blood flow occlusion. If such an occlusion persists long enough (20 to 40 min), irreversible myocardial cell damage and cell death will occur.

 The development of atherosclerotic plaque occurs over a period of years to decades. The initial vascular lesion leading to the development of atherosclerotic plaque is not known with certainty. The two primary characteristics of the clinically symptomatic atherosclerotic plaque are a fibromuscular cap and an underlying lipid-rich core. Plaque erosion may occur due to the actions of metalloproteases and the release of other collagenases and proteases in the plaque, which result in thinning of the overlying fibromuscular cap. The action of proteases, in addition to hemodynamic forces applied to the arterial segment, can lead to a disruption of the endothelium and fissuring or rupture of the fibromuscular cap. The degree of disruption of the overlying endothelium can range from minor erosion to extensive fissuring that results in an ulceration of the plaque. The loss of structural stability of a plaque often occurs at the juncture of the fibromuscular cap and the vessel walla site otherwise known as the plaque's "shoulder region." Any amount of disruption of the endothelial surface can cause the formation of thrombus via platelet-mediated activation of the coagulation cascade. If a thrombus is large enough to completely occlude coronary blood flow for a sufficient time period, MI can result.

Mechanisms of Myocardial Damage

The severity of an MI is dependent on three factors: the level of the occlusion in the coronary artery, the length of time of the occlusion, and the presence or absence of collateral circulation. Generally speaking, the more proximal the coronary occlusion, the more extensive is the amount of myocardium at risk of necrosis. The larger the MI, the greater is the chance of death due to a mechanical complication or pump failure. The longer the time period of vessel occlusion, the greater the chances of irreversible myocardial damage distal to the occlusion.

 The death of myocardial cells first occurs in the area of myocardium that most distal to the arterial blood supplythat is, the endocardium. As the duration of the occlusion increases, the area of myocardial cell death enlarges, extending from the endocardium to the myocardium and ultimately to the epicardium. The area of myocardial cell death then spreads laterally to areas of watershed or collateral perfusion. Generally, after a 6- to 8-hour period of coronary occlusion, most of the distal myocardium has died. The extent of myocardial cell death defines the magnitude of the MI. If blood flow can be restored to at-risk myocardium, more heart muscle can be saved from irreversible damage or death.

Symptoms
Chest pain is a major symptom of heart attack. The pain can be felt in only one part of the body, or it may move from the chest to the arms, shoulder, neck, teeth, jaw, belly area, or back. The pain can be severe or mild. It can feel like:
A tight band around the chest Bad indigestion Something heavy sitting on your chest Squeezing or heavy pressure

The pain usually lasts longer than 20 minutes. Rest and a medicine called nitroglycerin may not completely relieve the pain of a heart attack. Symptoms may also go away and come back.

 Other symptoms of a heart attack include:

Anxiety Cough Fainting Light-headedness, dizziness Nausea or vomiting Palpitations (feeling like your heart is beating too fast or irregularly) Shortness of breath Sweating, which may be extreme

Some people (the elderly, people with diabetes, and women) may have little or no chest pain. Or, they may experience unusual symptoms (shortness of breath, fatigue, weakness). A "silent heart attack" is a heart attack with no symptoms.

Exams and Tests

A heart attack is a medical emergency. If you have symptoms of a heart attack, seek immediate medical help. Call 911 or your local emergency number immediately. DO NOT try to drive yourself to the hospital. DO NOT DELAY, because you are at greatest risk of sudden cardiac death in the early hours of a heart attack. The health care provider will perform a physical exam and listen to the chest using a stethoscope. The doctor may hear abnormal sounds in the lungs (called crackles), a heart murmur, or other abnormal sounds. You may have a rapid pulse. Your blood pressure may be normal, high, or low.

 Tests to look at your heart include:

Coronary angiography CT scan Echocardiography Electrocardiogram (ECG) -- once or repeated over several hours MRI Nuclear ventriculography

 Blood tests can help show if you have heart tissue damage or a high risk for heart attack. These tests include:
Troponin I and troponin T CPK and CPK-MB Serum myoglobin

Treatment
ANGIOPLASTY AND STENT PLACEMENT
Angioplasty, also called percutaneous coronary intervention (PCI), is the preferred emergency procedure for opening the arteries for some types of heart attacks. It should preferably be performed within 90 minutes of arriving at the hospital and no later than 12 hours after a heart attack. Angioplasty is a procedure to open narrowed or blocked blood vessels that supply blood to the heart. A coronary artery stent is a small, metal mesh tube that opens up (expands) inside a coronary artery. A stent is often placed after angioplasty. It helps prevent the artery from closing up again. A drug eluting stent has medicine in it that helps prevent the artery from closing.

 THROMBOLYTIC THERAPY (CLOT-BUSTING DRUGS)

Depending on the results of the ECG, certain patients may be given drugs to break up the clot. It is best if these drugs are given within 3 hours of when the patient first felt the chest pain. This is called thrombolytic therapy. The medicine is first given through an IV. Blood thinners taken by mouth may be prescribed later to prevent clots from forming. Thrombolytic therapy is not appropriate for people who have: Bleeding inside their head (intracranial hemorrhage) Brain abnormalities such as tumors or blood vessel malformations Stroke within the past 3 months (or possibly longer) Head injury within the past 3 months Thrombolytic therapy is extremely dangerous in women who are pregnant or in people who have: A history of using blood thinners such as coumadin Had major surgery or a major injury within the past 3 weeks Had internal bleeding within the past 2-4 weeks Peptic ulcer disease Severe high blood pressure

 CORONARY ARTERY BYPASS SURGERY

Coronary angiography may reveal severe coronary artery disease in many vessels, or a narrowing of the left main coronary artery (the vessel supplying most of the blood to the heart). In these circumstances, the cardiologist may recommend emergency coronary artery bypass surgery (CABG). This procedure is also called "open heart surgery." The surgeon takes either a vein or artery from another location in your body and uses it to bypass the blocked coronary artery.

Prevention
To prevent a heart attack:
Keep your blood pressure, blood sugar, and cholesterol under control. Don't smoke. Consider drinking 1 to 2 glasses of alcohol or wine each day. Moderate amounts of alcohol may reduce your risk of cardiovascular problems. However, drinking larger amounts does more harm than good. Eat a low-fat diet rich in fruits and vegetables and low in animal fat. Eat fish twice a week. Baked or grilled fish is better than fried fish. Frying can destroy some of the health benefits. Exercise daily or several times a week. Walking is a good form of exercise. Talk to your doctor before starting an exercise routine. Lose weight if you are overweight.