Acute Myocardial Infarction

Acute myocardial infarction is the medical name for a heart attack. A heart attack is a
life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off,
causing tissue damage. This is usually the result of a blockage in one or more of the coronary
arteries. A blockage can develop due to a buildup of plaque, a substance mostly made of
fat, cholesterol, and cellular waste products.

Etiology

 Ventricular fibrillation
 Coronary arteries: occlusion (atherosclerosis, thrombosis, embolus), structural abnormalities
of the epicardial arteries, coronary artery dissection or aneurysm
 Hypertensive heart disease
 Cardiomyopathies: hypertrophic cardiomyopathy, dilated cardiomyopathy (genetic,
myocarditis, toxic, peripartum, idiopathic), restrictive cardiomyopathy (idiopathic,
amyloidosis, sarcoidosis, radiation fibrosis, metastasis, deposition disease/inborn errors of
metabolism)
 Other cardiomyopathies: arrhythmogenic right ventricular dysplasia, arrhythmogenic left
ventricular dysplasia, left ventricular non-compaction, restrictive conditions (endomyocardial
fibrosis, Loeffler endomyocarditis, and endocardial fibroelastosis)
 Inflammatory: myocarditis, pericarditis (bacterial, viral, Dressler syndrome)
 Valvular: congenital abnormalities (bicuspid valve), rheumatic heart disease
 Functional abnormalities: long QT syndrome (LQTS), short QT syndrome (SQTS),
catecholaminergic polymorphic ventricular tachycardia (CPVT), Brugada syndrome, Asian
sudden unexplained nocturnal death syndrome (SUNDS)
 Acute myocardial infarction, cardiac tamponade, cardiac outflow obstruction (aortic stenosis,
valvular prosthesis thrombosis, atrial myxoma), and congenital heart disease are also heart
conditions that can lead to instantaneous / sudden death
Effects of Acute Myocardial Infarction

Cardiopulmonary
 sytolic/diastolic dysfunction
 decreased cardiac output
(↓ stroke volume)
 tachycardia
 arrhythmias
 dyspnea
 pulmonary congestion/edema
Systemic Vasculature
 ↑ sytemic vascular resistance
 ↑ blood volume
 ↑ systemic edema
Neurohumoral
 sympathetic activation
 ↑ circulating catecholamines
 ↑ angiotensin II and ↑ aldosterone
 ↑ natriuretic peptides
 ↑ arginine vasopressin (ADH)

Signs and symptoms

Chest pain is the most common symptom of acute myocardial infarction and is often
described as a sensation of tightness, pressure, or squeezing. Pain radiates most often to the left
arm, but may also radiate to the lower jaw, neck, right arm, back, and upper abdomen. The pain
most suggestive of an acute MI, with the highest likelihood ratio, is pain radiating to the right
arm and shoulder. Similarly, chest pain similar to a previous heart attack is also suggestive.
Levine's sign, in which a person localizes the chest pain by clenching one or both fists over
their sternum, has classically been thought to be predictive of cardiac chest pain, although a
prospective observational study showed it had a poor positive predictive value. Pain that
responds to nitroglycerin does not indicate the presence or absence of a myocardial infarction.
Chest pain may be accompanied by sweating, nausea or vomiting, and fainting, and these
symptoms may also occur without any pain at all. In women, the most common symptoms of
myocardial infarction include shortness of breath, weakness, and fatigue. Shortness of breath is a
common, and sometimes the only symptom, occurring when damage to the heart limits
the output of the left ventricle, with breathlessness arising either from low oxygen in the blood,
or pulmonary edema. Other less common symptoms include weakness, light-
headedness, palpitations, and abnormalities in heart rate or blood pressure. These symptoms are
likely induced by a massive surge of catecholamines from the sympathetic nervous system,
which occurs in response to pain and, where present, low blood pressure. Loss of
consciousness due to inadequate blood flow to the brain and cardiogenic shock, and sudden
death, frequently due to the development of ventricular fibrillation, can occur in myocardial
infarctions. Cardiac arrest, and atypical symptoms such as palpitations, occur more frequently in
women, the elderly, those with diabetes, in people who have just had surgery, and in critically ill
patients.
"Silent" myocardial infarctions can happen without any symptoms at all. These cases can
be discovered later on electrocardiograms, using blood enzyme tests, or at autopsy after a person
has died. Such silent myocardial infarctions represent between 22 and 64% of all infarctions, and
are more common in the elderly, in those with diabetes mellitus and after heart transplantation.
In people with diabetes, differences in pain threshold, autonomic neuropathy,
and psychological factors have been cited as possible explanations for the lack of symptoms.In
heart transplantation, the donor heart is not fully innervated by the nervous system of the
recipient.

Causes

Your heart is the main organ in your cardiovascular system, which also includes different
types of blood vessels. Some of the most important vessels are the arteries. They take oxygen-
rich blood to your body and all of your organs. The coronary arteries take oxygen rich blood
specifically to your heart muscle. When these arteries become blocked or narrowed due to a
buildup of plaque, the blood flow to your heart can decrease significantly or stop completely.
This can cause a heart attack. Several factors may lead to a blockage in the coronary arteries.

Bad cholesterol
Bad cholesterol, also called low-density lipoprotein (LDL), is one of the leading causes of a
blockage in the arteries. Cholesterol is a colorless substance that’s found in the food you eat.
Your body also makes it naturally. Not all cholesterol is bad, but LDL cholesterol can stick to the
walls of your arteries and produce plaque. Plaque is a hard substance that blocks blood flow in
the arteries. Blood platelets, which help the blood to clot, may stick to the plaque and build up
over time.

Saturated fats
Saturated fats may also contribute to the buildup of plaque in the coronary arteries. Saturated fats
are found mostly in meat and dairy products, including beef, butter, and cheese. These fats may
lead to an arterial blockage by increasing the amount of bad cholesterol in your blood system and
reducing the amount of good cholesterol.

Trans fat
Another type of fat that contributes to clogged arteries is trans fat, or hydrogenated fat. Trans
fat is usually artificially produced and can be found in a variety of processed foods. Trans fat is
typically listed on food labels as hydrogenated oil or partially hydrogenated oil.
 Risk for Acute Myocardial Infarction

High blood pressure

You’re at greater risk for heart attack if you have high blood pressure. Normal blood
pressure is below 120/80 mm Hg (millimeters of mercury) depending on your age. As the
numbers increase, so does your risk of developing heart problems. Having high blood pressure
damages your arteries and accelerates the buildup of plaque.

High cholesterol levels

Having high levels of cholesterol in your blood puts you at risk for acute myocardial
infarction. You may be able to lower your cholesterol by making changes to your diet or by
taking certain medications called statins.

High triglyceride levels

High triglyceride levels also increase your risk for having a heart attack. Triglycerides are
a type of fat that clog up your arteries. Triglycerides from the food you eat travel through your
blood until they’re stored in your body, typically in your fat cells. However, some triglycerides
may remain in your arteries and contribute to the buildup of plaque.

Diabetes and high blood sugar levels

Diabetes is a condition that causes blood sugar, or glucose, levels to rise. High blood
sugar levels can damage blood vessels and eventually lead to coronary artery disease. This is a
serious health condition that can trigger heart attacks in some people.

Obesity
Your chances of having a heart attack are higher if you’re very overweight. Obesity is
associated with various conditions that increase the risk of heart attack, including:
 diabetes
 high blood pressure
 high cholesterol levels
 high triglyceride levels
Smoking
Smoking tobacco products increases your risk for heart attack. It may also lead to other
cardiovascular conditions and diseases.

Age
The risk of having a heart attack increases with age. Men are at a higher risk of a heart
attack after age 45, and women are at a higher risk of a heart attack after age 55.

Family history
You’re more likely to have a heart attack if you have a family history of early heart
disease. Your risk is especially high if you have male family members who developed heart
disease before age 55 or if you have female family members who developed heart disease before
age 65.
Other factors that can increase your risk for heart attack include:
 stress
 lack of exercise
 the use of certain illegal drugs, including cocaine and amphetamines
 a history of preeclampsia, or high blood pressure during pregnancy

Heart Anatomy

Your heart is located between your lungs in the middle of your chest, behind and slightly
to the left of your breastbone (sternum). A
double-layered membrane called the pericardium
surrounds your heart like a sac. The outer layer of
the pericardium surrounds the roots of your
heart's major blood vessels and is attached by
ligaments to your spinal column, diaphragm, and
other parts of your body.

The heart weighs between 7 and 15

ounces (200 to 425 grams) and is a little larger
than the size of your fist. By the end of a long life, a person’s heart may have beat (expanded and
contracted) more than 3.5 billion times. In fact, each day, the average heart beats 100,000 times,
pumping about 2,000 gallons (7,571 liters) of blood.

Your heart is located between your lungs in the middle of your chest, behind and slightly
to the left of your breastbone (sternum). A double-layered membrane called the pericardium
surrounds your heart like a sac. The outer layer of the pericardium surrounds the roots of your
heart’s major blood vessels and is attached by ligaments to your spinal column, diaphragm, and
other parts of your body. The inner layer of the pericardium is attached to the heart muscle. A
coating of fluid separates the two layers of membrane, letting the heart move as it beats.

Your heart has 4 chambers. The upper chambers are called the left and right atria, and the
lower chambers are called the left and right ventricles. A wall of muscle called the septum
separates the left and right atria and the left and right ventricles. The left ventricle is the largest
and strongest chamber in your heart. The left ventricle’s chamber walls are only about a half-
inch thick, but they have enough force to push blood through the aortic valve and into your body.

The Heart Valves

Four valves regulate blood flow through your heart:

 The tricuspid valve regulates blood flow

between the right atrium and right ventricle.
 The pulmonary valve controls blood flow
from the right ventricle into the pulmonary
arteries, which carry blood to your lungs to
pick up oxygen.
 The mitral valve lets oxygen-rich blood
from your lungs pass from the left atrium
into the left ventricle.
 The aortic valve opens the way for oxygen-rich blood to pass from the left ventricle into
the aorta, your body’s largest artery.
 The Conduction System

Electrical impulses from your heart muscle (the myocardium) cause your heart to
contract. This electrical signal begins in the sinoatrial (SA) node, located at the top of the right
atrium. The SA node is sometimes called the heart’s “natural pacemaker.” An electrical impulse
from this natural pacemaker travels through the muscle fibers of the atria and ventricles, causing
them to contract. Although the SA node sends electrical impulses at a certain rate, your heart rate
may still change depending on physical demands, stress, or hormonal factors.

The Circulatory System

The heart and circulatory system make up your cardiovascular system. Your heart works
as a pump that pushes blood to the organs, tissues, and cells of your body. Blood delivers oxygen
and nutrients to every cell and removes the carbon dioxide and waste products made by those
cells. Blood is carried from your heart to the rest of your body through a complex network of
arteries, arterioles, and capillaries. Blood is returned to your heart through venules and veins. If
all the vessels of this network in your body were laid end-to-end, they would extend for about
60,000 miles (more than 96,500 kilometers)

The heart consists of four chambers:

 Atria: the two upper chambers (they receive blood).

 Ventricles: the two lower chambers (they discharge blood).

The left atria and left ventricle are separated
from the right atria and right ventricle by a
wall of muscle called the septum.

The wall of the heart consists of three layers of

tissue:

 Epicardium — protective layer mostly made

of connective tissue.
 Myocardium — the muscles of the heart.

 Endocardium — lines the inside of the heart and protects the valves and chambers.
These layers are covered in a thin protective coating called the pericardium.

Blood vessels

There are three types of blood vessels:

Arteries: carry oxygenated blood from the heart to the rest of the body. Arteries are strong and
stretchy, which helps push blood through the circulatory system. Their elastic walls help
keep blood pressure consistent. Arteries branch into smaller arterioles.

Veins: these carry deoxygenated blood back to the heart and increase in size as they get closer to
the heart. Veins have thinner walls than arteries.

Capillaries: they connect the smallest arteries to the smallest veins. They have very thin walls,
which allow them to exchange compounds with surrounding tissues, such as carbon dioxide,
water, oxygen, waste, and nutrients.

Pathophysiology of Myocardial Infarction

The pathophysiology of acute myocardial infarction is complex. Loss of viable

myocardium impairs global cardiac function, which can lead to reduced cardiac output, and if
damage is severe, to cardiogenic shock. Systolic and diastolic dysfunction are associated with
ischemic myocardium. If left ventricular function is significantly impaired, pulmonary
congestion and edema can occur. Ischemia can also precipitate abnormal cardiac rhythms and
conduction blocks that can further impair function and become life-threatening in some cases.
Reduced cardiac output and arterial pressure can elicit baroreceptor reflexes that lead to
activation of neurohumoral compensatory mechanisms (e.g., activation of sympathetic nerves
and the renin-angiotensin-aldosterone system) similar to what occurs during heart failure. The
pain and anxiety associated with myocardial infarction further activates the sympathetic nervous
system, which causes systemic vasoconstriction and cardiac stimulation (this explains why some
patients become hypertensive and have tachycardia). While sympathetic activation helps to
maintain arterial pressure, it also leads to a large increase in myocardial oxygen demand that can
lead to greater myocardial hypoxia, enlarge the infarcted region, precipitate arrhythmias, and
further impair cardiac function. Sympathetic activation is responsible for the diaphoresis
(sweating) experienced by the patient. Renal hypoperfusion and sympathetic activation stimulate
renin release, which leads to increased plasma levels of angiotensin II and aldosterone that
enhance renal retention of sodium and water.