Myocardial Infarction Heart attacks

Camille Borland Medical Physiology Dr. Tolunimi Adedeji Central American Health Science University 10/20/2011

The Heart Next to the brain, the heart is the most important organ in the human body for life. It is simply a muscular pump which single-handedly generates the driving force that allows the blood to circulate throughout the body. The heart pumps blood for many important reasons. The following are a list of these reasons: Distribution of substrates and oxygen to the body cells of the tissues, muscles, etc. Collection of carbon dioxide and waste products from the tissues and carries it to their sites of excretion. Distribution of hormones Aids in the bodys immune response mechanism by delivering antibodies, platelets, and leukocytes. All four of these processes are preformed with one main purpose, maintaining homeostasis. Homeostasis is kept constant in order to achieve a physical and chemical balance in the body with its external environment. In simpler terms, the heart pumps blood through the body, the blood aids in maintaining homeostasis, homeostasis intentions are to sustain a balance throughout the body, and this balance will preserve the bodys physiology. Regardless of how important the heart is, many people develop heart diseases and the most common of these diseases is one called, Myocardial infarction. What is myocardial infarction? Myocardial infarction or MI is the medical term for a type of cardiovascular disease more commonly known as a Heart Attack. A heart attack occurs when there is damage or death to a part of the heart, causing it to cease its work (beating/pumping blood). A heart attack or cardiac arrest or myocardial infarction (MI) happens mainly because of two activities: Myocardial Ischemia Cardiac Hypoxia

In order for these activities to cause a cardiac arrest they must be prolonged.

 Myocardial Ischemia is caused by a clot formation or plaque buildup which occludes the blood vessel (coronary artery) which supplies the heart with blood. This will result in coronary vasospasm. Cardiac Hypoxia occurs by the blockage of oxygen supply to the heart. Without sufficient oxygen the cell tissues of the heart with die. Plaque is a hard substance made up of crystallized cholesterol and other cells. When plaque builds up it will crack or tear the blood vessel. Platelets in the blood with adhere to the ripped fibers and for a blood clot. This clot can form big enough to completely blood oxygen-rich blood from flowing to the heart. If the plaque does not cause a crack of tear in the blood vessel, it will instead just increase in bulk and still end up blocking the coronary artery, leading to not enough oxygen getting to the heart. In the two instances, cells in the portions of the heart which has insufficient oxygen supply will die out and a heart attack can and will arise.

Types of Myocardial Infarctions There are 5 different classifications of myocardial infarctions, type1, type2, type3, type4 (a & b) and type5. The following table will further explain each type and what it consists of.

Types Type 1

Description

Image

Plaque erosion, rupture, fissuring or dissection causing ischemia and produces a spontaneous myocardial infarction.

Type 2 There is an increase in oxygen demand or decreased supply causing Myocardial infarction secondary to ischemia. (coronary artery spasm, coronary embolism, anaemia, arrhythmias, hypertension, or hypotension) Type 3 Myocardial ischemia causing sudden and unexpected cardiac death with cardiac arrest. Usually seen with new ST elevation of indication of thrombus in the coronary artery by angioplasty or autopsy.

Type 4

Interrelated with coronary angioplasty or stents.

-Type 4a

Percutaneous Coronary Intervention (PCI) causing a Myocardial Infarction.

-Type 4b A Myocardial Infarction caused by an angioplasty with a stent thrombosis Type 5

Coronary Artery Bypass Grafting (CABGCABBAGE) producing a Heart Attack.

Almost all cases of MIs are caused by some underlying condition of Coronary Heart Disease, more specifically (atherosclerosis and angina). Atherosclerosis is the hardening and narrowing of the blood vessels, in this case, the coronary artery. This will lead to myocardial ischemia and cardiac hypoxia causing damage of the myocardial tissues. This will result in a lost of contractility of the cardiac muscle i.e. systolic and diastolic dysfunction. A heart attack can either be gradually, within minutes but never suddenly. Some symptoms include:

Chest pain (angina). The pain may radiate into the jaw/teeth, shoulders, arm or back. Bad indigestion Shortness of breath (dypsnea) Fainting (syncope) Tightness or squeezing sensation in the center of the chest. Anxiety, nervousness, cold sweaty skin (diaphoresis), paleness. Fatigue and weakness

Recent clinical research has concluded that signs and symptoms differ in males and females. It is less common for women to experience angina but more likely to have weakness, fatigue and dyspnea (PhD. Klabunde R.E, 2007). Others who have not experienced chest pain would be non-caucasians, older than 75 and those who have diabetes or suffered from a stroke. Furthermore, about 50% of patients have warning symptoms but an MI usually occurs in the early mornings or upon strenuous physical activities. Once symptoms have been sighted the following test can be done to diagnose a heart attack. ECG/EKG (Electrocardiogram) this machine monitors and depict the electrical activities of the heart on a special graph paper. Whenever a heart attack is inevitable the ECG will depict abnormally shaped waves patterns. There are two types of MIs when interpreting the ECG. o STEMI ST elevated myocardial infarction. Where the ST segment of the ECG wave is prominently high. (see image below)

o NSTEMI non-ST elevated myocardial infarction. Since it cannot be identified by an elevated ST segment then a blood test should be done to further clarify heart attack suspicions. (see image below)

Blood test this test is done by testing for cardiac enzyme proteins or biomakers (creatine phosphokinase and tropin) which are secreted into the blood by dying heart muscles. These enzymes will be in high levels in the blood several hours after the onset of a heart attack. (see graph below)

Depending on the classified type of MIs, treatment can be administered. Pain medications: Nitroglycerin is given either in IV (intravenous line) of under the tongue to relieve the pain. Also, Morphine can also be administered for pain and anxiety. These will relax the

individual and allows the heart to work less, possibly dilating the arteries of the heart and causes reduced workload. Anti-clotting agents: At the first sight of a heart attack a simple over the counter medication such as aspirin can be given to the patient. This will help prevent further blood clot from forming and has a great reduction effect on the mortality of the heart attack. Other anti-clot medications include intravenous herapin or warfarin (blood thinners). Person who may be allergic to aspirin can take other anti-clot agents such as colpidogrel or ticlopidine. These can also be taken after having a heart attack, so as to prevent another incident. Medical Procedures: Early catheterization - This is a blood vessel procedure, preformed within the first hours of being hospitalized, where a cardiac catheterization (a small plastic tube) is threaded through an artery (usually in the groin region) leading to the coronary artery. When or if a blockage is found then another procedure called percutaneous coronary intervention (angioplasty or stenting) is done. Next a tiny catheter with an inflatable balloon at the end will progress into the blocked/narrowed coronary artery. The balloon is then inflated and causes the narrowed artery to open up. To prevent narrowing from reoccurring again, an expandable metal tube (stent) is placed in the artery.

(Balloon Angioplast, 2007)

Coronary artery bypass graft surgery (CABG) - this procedure is done if blockage cannot be opened using the previous procedure (angioplasty or stent). In the operation, a blood vessels, which can either be a vein or artery, is taken from the leg or chest and is used to be detoured around the blocked coronary artery. This procedure will allow blood flow to be completely diverted from its original path through the coronary artery and through a unblocked blood vessel.

(Turner M. 2011)

Clot-bursting agents: These are alternatives whenever the medical procedures cannot be performed on hand. Drugs such as thrombolytic or fibrinolytic agents must be given upon arrival at the hospital, within 30 minutes. Take in consideration that not all patients can be given these types of drug, including those who has a high blood pressure reading, who have active bleeding, recent trauma of history of having strokes. Patients with NSTEMIs are prohibited from taken clot-bursting agents also. Other drugs: Usually taken after having a heart attack. Beta blockers will be taken by the patient in order to slow the heart and its demand for oxygen. Such medications include metoprolol, propranolol or timolol. These also cause the heart to work less and reduce the amount of damaged tissue which can result from ischemia. This will protect the heart. Also oxygen is

administered to the patient through nasal prong or a face mask will also minimize the amount of damaged tissue. Life style: The patients life style should change. This means there should be a close monitoring blood pressure, blood sugar and blood cholesterol levels. If the patient is a smoker, they will need to quit smoking. Their diet should be of more fruits, vegetables and whole grain, a more healthy eating habit, which includes low fat intake. Healthy diet also consist of intake of alcohol, which should be limited to one a day for women and two a day for men. Exercise should be a daily routine, at least 30 minutes a day. Prevention: Once a heart attack has been evident, it is impossible to reverse its damage, regardless of treatment. Sequentially, prevention is better than cure. So if it is desired to thwart the occurrence of a heart attack, measures should be taken in ones health. There are many medications that can be taken to prevent an episode of heart attack, including aspirin, as mentioned before, but in this case it will prevent the happening of blood clots rather than disable existing ones. It was researched that it reduces the risk of having a heart attack or a second episode by 15 to 30 %. Other drugs such as lipid-lowering drugs also reduce the risk of death from a heart attack. This drug would be taken with people at high risk like those who are obese with diabetes. After a heart attack, to help prevent the development of heart failure, angiotensin converting enzyme inhibitors are given to them. This ACE inhibitor can reduce the enlargement of the heart, thus increasing the chance of survival after a MI incident. But the most important factor that can lower the threat and prevent a heart attack all together is an individuals lifestyle, with the right diet (low-fat, whole grains, fruits and vegetables), limit alcohol intake to one or two a day (depending on sex), moderate amounts of exercise ( 30 minutes a day for 5 days a week) and smoking cessation. By quitting smoking a person can

reduce his chances of undergoing another MI by 50%. As a side note, smoking cessation also lowers the risk of many other pathological diseases such as lung failure, and lung diseases. Heart Attack Complications Whenever a person has a heart attack scar tissue will be left behind from in the area of the oxygen deprived heart muscles. Evidently the scar tissue will no longer function and leaves the heart weaker and less able to meet the circulation needs of the body. The other working parts of the heart will need to be over worked to compensate, which leads to intolerance to strenuous exercises and the person will supper from early fatigue and dyspnea on exertion. Also, because the muscles have lost its contractible strength less blood will be supplied to the heart making it electrically irritable and cause ventricular fibrillation, which is when ventricles do not undergo systole and diastole as of normal beating of the heart (abnormal beating-arrhythmias). An electrical shock should be performed on the patient in order to reset the hearts beating rhythm. The weakening can also cause ventricular aneurysms, where a thin bulge forms on the damaged muscle. This thin bulge can burst and in that case large blood clots can be formed in the heart chamber. The aneurysm should be surgically removed before it ruptures. Epidemiology (risk factors) Myocardial infarctions are thought to be one of the leading causes of death worldwide. In 2002, 12.6% of worldwide deaths were from ischemia heart disease, with most cases in developed countries such as the United States of America, with the highest numbers. There are more than 3 million people with STEMIs and about 4 million with NSTEMI a year worldwide. Coronary heart disease is the cause of every 1 in 5 deaths in the United States, approximately 500,000 700,000 deaths each year and about 600 cases per every 100,000 person is specifically linked to Myocardial Infarction. The United Stated ranked number 1 with the most deaths while Belize came in at number 58 with only about 35 deaths per year. This is to say that more industrialized and developed nations with higher populations have more deaths caused by MIs than undeveloped or developing nations. Evidently this is so because in

industrialized nations there are a higher number of people with diabetes, hypertension or high cholesterol (factors contributing to cardiovascular diseases). Epidemiology of Heart Attacks in Belize Diseases of the heart and circulation are the leading causes of death in Belize, with heart attacks being a major cause of morbidity and mortality (Crawford J.I, 2011) Risk factors include: age, sex, hereditary, smoking, diet, ethnicity or previous relaying diseases. Diet and Obesity People who have poor eating habits or eating disabilities such as obesity have a higher rate to experience a myocardial infarction than people who exercise regularly, watch what they what and how much they eat and. Poor eating habits would include a diet high in sugar, cholesterol and fats (animal fat) and not enough whole grain, fruits or vegetables. Sex and Age It was found that males with an age range of 35 to 70 are more likely to have a heart attack episode which for females the age range is higher, 45 to 80. The age for females is higher, the post-menopausal period of their lives, due to some protection from atherosclerosis possible because of the estrogen present in females. Approximately about 85% of patients who have a heart attack have died. Rate of mortality due to acute myocardial infarction by age and sex 1999

Smoking As seen in the pie chart to the left, that in the United States, approximately 126,000 people die from ischemia heart disease which was contributed by cigarette smoking. This number is very close to the amount of people who have died from Lung disease alone. Interesting facts: 46% more men are killed than women. 10% of that amount dies from second hand smoke. So when smoking consideration for others should be taken. Ethnicity According to research done by the California Department of Public Health it was found that for some unknown reason black/African American are the most likely to be hospitalized for cardiac arrest. Hereditary When ever a heart disease such as arteriosclerosis is cause by a genetic fact, there is a more likely chance that the individual will have a higher chance of incident of cardiac arrest.

Bibliography Annual Deaths Attributable to Cigarette Smoking United states, 2000-2004 (2010) Center for Disease Control and Prevention. Retrieved on October 16, 2011 from website : http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdeaths/index.htm Balloon Angioplast.(2007) In Encyclopdia Britannica. Retrieved on October 16, 2011 from website: http://www.britannica.com/EBchecked/media/95218/Balloon-angioplasty-andstent-insertion-In-a-coronary-artery-where Bolooki H.M et.al (2011) Acute Myocardial Infarction. Cleveland Clinic. Retrieved on October 19, 2011 from website: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/acut e-myocardial-infarction/#s0055 Crawford J.I. (2011) Belizeans to benefits from fully-equip cath lab. Amandala online. Retrieved on October 16, 2011 from website: http://www.amandala.com.bz/index.php?id=10741 Heart disease, a disabling yet preventable disease (2000) National Academy on an Aging Society. (pdf) Retrieved on October 19, 2011 from website: http://www.agingsociety.org/agingsociety/pdf/heart.pdf PhD. Klabunde R.E (2007) The Pathophysiology of Myocardial Infarction.Cardiovascular Pharmacology Concepts retrieved on October 15, 2011 from website: http://www.cvpharmacology.com/clinical%20topics/myocardial%20infarction.htm Myocardial Infarction (2011). Wikipedia. Retrieved on October 16, 2011 from website: http://en.wikipedia.org/wiki/Myocardial_infarction

Reynen D.J. et.al (2009) Heart Attack: Who is at risk? California department of Public Health. Retrieved on October 19, 2011 from website: http://www.ehib.org/page.jsp?page_key=40#MI_genderdisparities Turner .M (2011) Cardiology: Bypass surgery (CABG). MD Notes. Free Medical Revision Notes for Medical Students. Retreieved on October 16, 2011 from website: http://medicalnotesonline.blogspot.com/2011/01/cardiology-bypass-surgery-cabg.html M.D. Warnica J.W. (2008) Acute Coronary Syndromes (Heart attack; Myocardial Infarction; Unstable Angina). The Merck Manual Home Health Handbook. Retrieved on October 15,2011 from website : http://www.merckmanuals.com/home/heart_and_blood_vessel_disorders/coronary_artery _disease/acute_coronary_syndromes_heart_attack_myocardial_infarction_unstable_angin a.html?qt=&sc=&alt=

Table of contents Topic page #

Introduction (The heart and its importance) ................................................................. 1 What is Myocardial Infarction ...................................................................................... 1 Types of MIs ................................................................................................................ 3 Sign and symptoms ....................................................................................................... 5 Diagnostic test .............................................................................................................. 5 Treatment ...................................................................................................................... 6 Prevention ..................................................................................................................... 9 Complication................................................................................................................. 10 Epidemiology ................................................................................................................ 10 Risk Factor .................................................................................................................... 11 Bibliography ................................................................................................................. 13