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New Concepts in Cardiac Rehabilitation and Secondary Prevention After Myocardial Infarction

Introduction Evidence-based treatments for patients with myocardial infarction (MI) have improved outcomes, with substantive reductions in mortality rates ( Chapter 2 ). Nevertheless, patients who survive an acute MI remain at increased risk for recurrent MI and death and also suffer from clinical symptoms and loss of physical, psychological, or social functioning after discharge that can lead to impaired health-related quality of life. The effectiveness and…

Cardiac Magnetic Resonance Imaging After Myocardial Infarction

Introduction The use of sensitive biomarkers has significantly improved the diagnosis of myocardial infarction (MI), and has been incorporated into the “Universal Definition” of MI (see Chapter 1 ). However, the diagnosis of MI can still be difficult. There is significant overlap with other disorders that result in myocardial injury (see Chapter 6 ). For instance, disorders such as Takotsubo cardiomyopathy and myocarditis are associated with…

Nuclear Cardiology Techniques After Myocardial Infarction

Introduction Cardiovascular nuclear medicine imaging techniques are part of the ever-growing clinical noninvasive imaging armamentarium for the evaluation of suspected or known coronary artery disease (CAD). These techniques provide valuable information regarding diagnosis and clinical risk, and consequently have established a role in the management of this disease. In this chapter, we will provide a concise summary of contemporary nuclear cardiology techniques, and then use a…

Echocardiography in Patients with Myocardial Infarction

Acknowledgments The authors are grateful to Celine Pitre, chief sonographer at the Montreal Heart Institute, for her contribution to the figures and videos, and to Dr François Marcotte for kindly providing the dobutamine stress echocardiography videos. Introduction Echocardiography is a rapid, noninvasive, portable, and inexpensive imaging modality, making it the preferred technique for the assessment of patients with myocardial infarction (MI). The echocardiographic evaluation focuses on…

Clinical Practice/Controversy: Approach to Noninvasive Testing After Presentation with Acute Myocardial Infarction

Introduction Noninvasive testing after presentation with acute myocardial infarction (MI) plays an essential role in patient management. Noninvasive testing complements clinical assessment of risk stratification and can be used to aid management decisions. The major purposes of testing are measurement of left ventricular (LV) function in nearly all patients and assessment of ischemic burden, primarily among low-risk patients who are initially treated conservatively, to identify potential…

Epidemiology and Management of Bleeding in Acute Myocardial Infarction

Introduction Clinical outcomes after acute coronary syndrome (ACS) have significantly improved over time. A significant proportion of the reduction in mortality has been the result of development and adoption of potent anticoagulant and antiplatelet therapies coupled with invasive risk stratification in high-risk patients (see Chapter 13 ). In addition, the use of secondary prevention strategies to control risk factors has further improved long-term outcomes (see Chapter…

Arrhythmias and Sudden Cardiac Death After Myocardial Infarction

Introduction Despite significant advances in the diagnosis and treatment of malignant cardiac arrhythmias, sudden cardiac death (SCD) occurs in 180,000 to 250,000 people annually, mostly in patients with coronary artery disease. Myocardial infarction (MI) remains a vulnerable cardiac pathology that contributes to SCD, and identifying patients with MI who are at heightened risk for SCD continues to be a challenge. Although professional guidelines suggest that patients…

Clinical Practice/Controversy: Mechanical Circulatory Support for Complications of Myocardial Infarction: Role of Currently Available Devices

Introduction Mortality for patients with myocardial infarction (MI) remains unacceptably high despite improvements in medical therapy and revascularization. Death, when it occurs, is often caused by cardiac dysfunction, which leads to low cardiac output, hypotension, and end-organ failure ( Figure 27-1 ). This syndrome is broadly referred to as cardiogenic shock, and can be considered a continuum of severity from pre-shock to refractory shock (see Chapter…

Mechanical Complications of Myocardial Infarction

Introduction Myocardial infarction (MI) caused by coronary artery disease remains the leading cause of death in the United States (see Chapter 2 ). Although the advent of coronary care units and early reperfusion therapy has decreased in-hospital mortality rates for acute MI by one-third, acute MI remains an important cause of death. Along with cardiogenic shock (see Chapter 25 ), complications from severe myocardial injury are…

Heart Failure and Cardiogenic Shock After Myocardial Infarction

Introduction Myocardial infarction (MI) is defined by myocyte necrosis. If large in its territory or critical in its location, this injury can lead to loss of contractile function or other structural complications (see Chapter 26 ) that result in insufficient cardiac output and consequent heart failure or cardiogenic shock. Despite significant advancements in the acute management of MI, incident heart failure still occurs in 10% to…

Reperfusion Injury: Prevention and Management

Introduction The term “reperfusion injury” refers to cellular damage that occurs during the reperfusion phase after an episode of ischemia. If reperfusion occurs after a short period of ischemia, all cells are salvaged ( Figure 24-1A ). However, as the duration of ischemia increases, cells become irreversibly injured, and the territory of cell death increases in size over time ( Figure 24-1B ). Sorting out damage…

Recurrent Ischemia and Recurrent Myocardial Infarction: Detection, Diagnosis, and Outcomes

Introduction There has been a major decline in the incidence of myocardial infarction (MI) in the developed world, with the proportion of ST-elevation MI (STEMI) decreasing and the proportion of non–ST-elevation MI (NSTEMI) increasing (see Chapter 2 ). As survival following MI improves, more survivors are candidates for recurrent events, including recurrent MI. However, the incidence of recurrent MI in the community has fallen, with a…

Stem Cell Therapy in Patients with Myocardial Infarction

Acknowledgments This work was supported in part by NIH grants P01 HL-78825 and UM1 HL-113530 (CCTRN). Introduction Cell-based therapy is an exciting new treatment modality that has the potential to revolutionize cardiovascular (CV) medicine. Research on the application of cell therapy for ischemic heart disease emerged in the late 1990s, when conventional wisdom regarded the heart as an organ devoid of capacity for endogenous repair. The…

Old and New Oral Anticoagulant Therapy After Myocardial Infarction

Introduction Despite improvements in secondary preventive care and risk factor modification, there is a persistently elevated risk of recurrent cardiovascular (CV) events after experiencing a myocardial infarction (MI), with more than 10% of patients developing recurrent MI, refractory angina, hospitalization, or death within the subsequent 6 months. Therapies to minimize atherothrombotic complications in patients with MI have evolved over the past several decades. The current standard…

Clinical Practice/Controversy: Individualization of Antiplatelet Therapy for Patients with Acute Coronary Syndromes

Introduction The combination of aspirin with P2Y 12 inhibitors, which is also known as dual antiplatelet therapy, is the standard of care for oral antiplatelet treatment in patients presenting with an acute coronary syndrome (ACS) and/or who are undergoing percutaneous coronary intervention (PCI). The widely variable pharmacological effects of clopidogrel and the heterogeneous relationship between the extreme value of adenosine diphosphate (ADP)–induced platelet aggregation and the…

Overview of Antiplatelet Therapy for Myocardial Infarction

Introduction Atherosclerotic plaque rupture followed by arterial thrombosis is the major determinant that leads to an acute coronary syndrome (ACS). Platelet adhesion, activation, and aggregation have a pivotal role in the cascade of events that lead to arterial thrombosis, and therefore, antiplatelet therapy is essential in the treatment of patients with ACS. Multiple platelet signaling pathways are involved in thrombus formation, which represent potential targets for…

Clinical Practice/Controversy: Selection of Initial Anticoagulant Therapy

Introduction Myocardial infarction (MI) includes patients presenting with ST-elevation MI (STEMI) and those without ST-segment MI (NSTEMI), and although these types of MI share a common physiopathology and principles of treatment (see Chapter 13 ), the approaches to management of anticoagulant therapy for these conditions differ by MI type and overall management strategy (invasive vs. conservative). Rationale for Anticoagulant Therapy in Acute Coronary Syndrome The rationale…

Approach to Percutaneous Coronary Intervention in Myocardial Infarction

Introduction Percutaneous coronary intervention (PCI) is the dominant strategy used for coronary revascularization in acute myocardial infarction (MI). In the United States, approximately 600,000 patients are discharged from the hospital with a principal diagnosis of acute MI (see Chapter 2 ), which includes a substantial percentage of the primary indications for PCI of the estimated 954,000 PCIs performed annually. This chapter reviews the evidence and practical…

Revascularization in Non–ST-Elevation Acute Coronary Syndrome: For Whom, When, and How?

Introduction A non–ST-elevation acute coronary syndrome (NSTE-ACS) is caused by a severe flow-limiting stenosis or acute thrombotic obstruction of a coronary artery (see Chapter 13 ). In the absolute majority of cases,levels of myocardial markers also are elevated, indicating myocardial damage related to thrombotic obstruction at the site of the culprit coronary lesion, as well as to downstream embolization of thrombotic material from the lesion. The…

Fibrinolytic Therapy for Patients with ST-Elevation Myocardial Infarction

Introduction A ST-segment myocardial infarction (STEMI) is caused by the occlusion of a major epicardial coronary artery and is generally triggered by rupture of a vulnerable plaque, with subsequent formation of an occlusive thrombus. Rapid restoration of coronary blood flow is essential in preventing myocardial necrosis, and early reperfusion of the infarct-related artery limits infarct size and improves outcome (see also Chapter 13 ). Therefore, achieving…