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Clinical Practice/Controversy: Selection of Reperfusion Therapy and Transfer Strategies for Patients with ST-Elevation Myocardial Infarction

Case Presentation A 57-year-old man presents to a community hospital without capability for primary percutaneous coronary intervention (PPCI) in the early morning (4 am ) with a 1.5-hour history of severe chest pain. His medical history is significant for hypertension. His wife called 911, and at the time of first medical contact by paramedics, he was hemodynamically stable. On cardiac examination, his jugular venous pressure is…

Management Principles in Myocardial Infarction

Introduction The key principles that underlie management of myocardial infarction (MI) are based on the pathophysiology of the condition and the time course of irreversible myocardial injury. The fundamental goals of managing acute MI include (1) minimizing the duration of exposure of myocardium to ischemia, (2) rapidly establishing effective reperfusion, (3) preventing recurrent ischemia and re-occlusion, (4) managing arrhythmic and mechanical complications, and (5) modifying underlying…

Clinical Practice/Controversy: Emergency Department Evaluation of the Lower-Risk Patient: Whom Can You Send Home?

Introduction Of the more than 8 million visits to emergency departments (EDs) in the United States for chest pain or other potential ischemic symptoms, only a small minority will yield a diagnosis of an acute coronary syndrome (ACS). Less than 5% of patients so affected will prove to have ST-elevation myocardial infarction (MI), and only approximately one fourth will receive the final diagnosis of non–ST-elevation ACS…

Risk Stratification in Acute Myocardial Infarction

Introduction Acute myocardial infarction (MI) is a leading cause of morbidity and mortality worldwide (see Chapter 2 ). Although an estimated 157,000 patients will die each year in the United States as a result of an MI, this statistic belies the wide variability in the rate of mortality and recurrent ischemic events across the spectrum of patients with MI. Although patients presenting with ST-elevation MI (STEMI)…

Optical Coherence Tomography and Other Emerging Diagnostic Procedures for Vulnerable Plaque

Introduction Outcomes after percutaneous coronary intervention (PCI) have improved significantly over the past few decades, in large part because of newer stent platforms, better implantation techniques, and improved adjunctive medical therapy. However, the risk of recurrent cardiac events after successful PCI remains high, and the culprit site for these events often differs from that of the index procedure. Traditional clinical risk models, such as the Framingham…

Cardiac Imaging for Patients with Acute Chest Pain in the Emergency Department

Introduction Previous chapters have detailed the important roles of clinical presentation (see Chapter 6 ), cardiovascular risk factors, electrocardiography (ECG), and biomarkers (see Chapter 7 and Chapter 8 ) in the initial assessment of patients who present with acute chest pain to the emergency department (ED). However, even all of this information does not allow accurate exclusion or diagnosis of acute myocardial infarction (MI) in a…

Other Biomarkers and the Evaluation of Patients with Suspected Myocardial Ischemia

Introduction Cardiac troponin (cTn) is the preferred biomarker for the evaluation of patients with suspected acute myocardial infarction (MI) (see Chapter 7 ). In addition, it makes sense that other biomarkers that reflect the varied causes and consequences of MI, such as inflammation, activation of coagulation, endothelial dysfunction, and hemodynamic stress, might contribute information that is complementary to the detection of myocyte injury with cTn. Hence,…

Optimal Use of Cardiac Troponin in Patients with Chest Discomfort

Introduction Cardiac troponin (cTn) is the biomarker of choice for the evaluation of patients with symptoms suggestive of acute myocardial ischemia. Increases in cTn are necessary for the diagnosis of acute myocardial infarction (MI). Some even have opined that with the advent of high-sensitivity assays that the diagnosis of acute unstable coronary disease will eventually require an increasing pattern of cTn values, assuming timing permits such…

Clinical Practice/Controversy: Clinical Approach to Suspected Acute Myocardial Infarction

Introduction Chest symptoms suspicious for acute myocardial infarction (MI) are among the most common reasons for emergency evaluation, accounting for six to seven million emergency department (ED) visits each year in the United States. The initial assessment of nontraumatic chest discomfort is challenging because of the broad range of possible causes ( Figure 6-1 ). The primary aim of the ED assessment is to rapidly identify…

Prehospital Assessment and Systems of Care

Case Vignette A 56-year-old riverboat captain experienced sudden onset of shortness of breath and diaphoresis at 1:30 am while on his boat near Red Wing, Minnesota ( Figure 5-e1 ). Emergency Medical Services (EMS) were activated from the boat, and at 2:26 am , the first responders from the Red Wing Fire Department arrived on scene. At 2:38 am , a 12-lead electrocardiogram (ECG) ( Figure…

Mechanisms of Myocardial Ischemic Injury, Healing, and Remodeling

Evolution of Concepts Regarding Mechanisms of Myocardial Infarction Historical Perspective The scientific study of the mechanisms of myocardial infarction (MI) occurred surprisingly recently. Heberden published his strikingly contemporary description of angina pectoris in 1772. The very first article in the predecessor of the New England Journal of Medicine , published in 1812, described a North American case of angina pectoris that came to autopsy. The author,…

New and Emerging Insights into the Pathobiology of Acute Myocardial Infarction

Introduction Atherosclerosis is a lipoprotein-driven chronic inflammatory disease of arteries that leads to the accumulation of fibrotic, necrotic, and calcified tissue in the arterial intima, which is described as an atherosclerotic lesion or plaque. These plaques cause clinical disease by luminal narrowing or sudden precipitation of arterial thrombi that obstruct blood flow to the heart (coronary heart disease [CHD]), brain (ischemic stroke), or legs (peripheral artery…

Global Evolving Epidemiology, Natural History, and Treatment Trends of Myocardial Infarction

Introduction Cardiovascular disease (CVD) was the single most important cause of death worldwide in 2013, when it was responsible for 17 million deaths and the loss of 329 million disability-adjusted life-years (DALYs). Of all causes of CVD, ischemic heart disease (IHD) remains the major contributor, accounting for half of all CVD-associated morbidity and mortality. IHD as measured by the Global Burden of Disease project is driven…

Classification and Diagnosis of Acute Coronary Syndromes

Introduction Until the beginning of 20th century, it was believed that coronary thrombosis was always immediately fatal. In 1910, two Ukrainian physicians described five patients with acute myocardial infarction (MI), in whom three were found to have coronary thrombosis at autopsy. In 1912, James Herrick articulated the first clear description in English of the clinical syndrome of acute MI in his landmark article, “Certain Clinical Features…

Fetal echocardiography in cardiac tumors

Key points Fetal cardiac tumors are extremely rare and most are benign. They tend to appear between 20 and 30 weeks of pregnancy. The most common types of fetal cardiac tumors are rhabdomyomas, teratomas, and fibromas respectively. Fetal cardiac tumors may cause important complications, including arrhythmias, ventricular outflow or inflow obstruction, atrioventricular valve insufficiency, heart failure, and hydrops fetalis. Cardiac tumors are generally easy to diagnose…

Minimally invasive surgery in cardiac masses

Key points Today minimally invasive cardiac surgery (MICS) is a good alternative for standard midsternotomy for many cardiac surgeries. Indications, technical issues, and the number of centers for MICS are improving. Less tissue damage and systemic inflammatory response syndrome (SIRS), less postoperative bleeding and pain, less need for transfusion, shorter hospital stay and early patient return to daily work and also the patients’ satisfaction on small…

Introduction to interventional radiology in cardiac mass

Key points Surgical removal is the mainstay of cardiac mass diagnosis and treatment. When complete tumor removal of the tumor is not possible or patient intention or condition does not allow proceeding toward the surgery, interventional radiology (IR) is a good option for the cardio-oncology team to consider. Interventional oncology (IO) is a rapidly developing branch of IR that encompass procedures to yield tissue sample for…

Fossa ovalis, patent foramen ovale, and cardiac masses

Key points Fossa ovalis is a depression on the right atrial side of interatrial septum. It is an embryonic remnant of a once patent channel between the right and left atria of the fetal heart, serving fetal circulatory system. In adults, this landmark is often used surgically for accessing the left atrium from right atrium for various surgical procedures. In about a quarter of the population,…