DEFINITION

Myocardial infarction, commonly known as a heart attack, is

the irreversible necrosis of heart muscle secondary to prolonged
ischemia. This usually results from an imbalance in oxygen supply
and demand, which is most often caused by plaque rupture with
thrombus formation in a coronary vessel, resulting in an acute
reduction of blood supply to a portion of the myocardium.1
Myocardial infarction (MI) death of the cells of an area of
the heart muscle (myocardium) as a result of oxygen deprivation,
which in turn is caused by obstruction of the blood supply.
The myocardium receives its blood supply from the two large
coronary arteries and their branches. Occlusion of one or more of
these blood vessels (coronary occlusion) is one of the major
causes of myocardial infarction. The occlusion may result from
the formation of a clot that develops suddenly when an
atheromatous plaque ruptures through the sublayers of a blood
vessel, or when the narrow, roughened inner lining of a sclerosed
artery leads to complete thrombosis.2

ETIOLOGY
Atherosclerosis is the disease primarily responsible for most
acute coronary syndrome (ACS) cases. Approximately 90% of
myocardial infarctions result from an acute thrombus that
obstructs an atherosclerotic coronary artery. Plaque rupture and
erosion are considered to be the major triggers for coronary
thrombosis. Following plaque erosion or rupture, platelet
activation and aggregation, coagulation pathway activation, and
endothelial vasoconstriction occur, leading to coronary
thrombosis and occlusion.3
Nonmodifiable risk factors for atherosclerosis include the
following:
Age
Sex
Family history of premature coronary heart disease
Male-pattern baldness
Modifiable risk factors for atherosclerosis include the
following:
Smoking or other tobacco use
Diabetes mellitus
1 http://emedicine.medscape.com/article/155919-overview#a2
2 http://medical-dictionary.thefreedictionary.com/myocardial+infarction
3 http://emedicine.medscape.com/article/155919-overview#a5

Hypertension
Hypercholesterolemia and hypertriglyceridemia, including
inherited lipoprotein disorders
Dyslipidemia
Obesity
Sedentary lifestyle and/or lack of exercise
Psychosocial stress
Poor oral hygiene
Type A personality

Nonatherosclerotic causes of myocardial infarction include

the following:

Coronary occlusion secondary to vasculitis

Ventricular hypertrophy (eg, left ventricular
hypertrophy, idiopathic hypertrophic subaortic stenosis
[IHSS], underlying valve disease)
Coronary artery emboli, secondary to cholesterol, air,
or the products of sepsis
Congenital coronary anomalies
Coronary trauma
Primary coronary vasospasm (variant angina)
Drug use (eg, cocaine, amphetamines, ephedrine)
Arteritis
Coronary anomalies, including aneurysms of coronary
arteries
Factors that increase oxygen requirement, such as heavy
exertion, fever, or hyperthyroidism
Factors that decrease oxygen delivery, such as
hypoxemia of severe anemia
Aortic dissection, with retrograde involvement of the
coronary arteries
Infected cardiac valve through a patent foramen ovale
(PFO)
Significant gastrointestinal bleed

In addition, myocardial infarction can result from hypoxia

due to carbon monoxide poisoning or acute pulmonary disorders.
Infarcts due to pulmonary disease usually occur when demand on
the myocardium dramatically increases relative to the available
blood supply.

EPIDEMIOLOGY
United States statistics Incidence and mortality rate
Cardiovascular disease is the leading cause of death in the
United States; approximately 500,000-700,000 deaths related to
the coronary artery occur each year.

Approximately 1.5 million cases of myocardial infarction

occur annually in the United States; the yearly incidence rate is
approximately 600 cases per 100,000 people. The proportion of
patients diagnosed with NSTEMI compared with STEMI has
progressively increased. Despite an impressive decline in ageadjusted death rates attributable to acute myocardial infarction
since the mid-1970s, the total number of myocardial infarctionrelated deaths in the United States has not declined. This may in
part be the result of population growth.
Cardiovascular disease is the leading cause of morbidity and
mortality among black, Hispanic, and white populations in the
United States.

Sex predilection in cardiovascular disease

A male predominance in the incidence of cardiovascular
disease exists up to approximately age 70 years, when the sexes
converge to equal incidence. Premenopausal women appear to be
somewhat protected from atherosclerosis, possibly owing to the
effects of estrogen.

Age predilection in cardiovascular disease

The incidence of cardiovascular disease increases with age,
with acute myocardial infarction being rare in childhood and
adolescence. Most patients who develop an acute myocardial
infarction are older than 60 years. Elderly people also tend to
have higher rates of morbidity and mortality from their infarcts.
Age (75 y) is the strongest predictor of 90-day mortality in
patients with STEMI undergoing percutaneous coronary
intervention. A continued focus on improving outcomes for these
high-risk patients is needed.

CLINICAL MANIFESTATIONS

Elderly patients and those with diabetes may have

particularly subtle presentations and may complain of
fatigue, syncope, or weakness.
The typical chest pain of acute myocardial infarction
is intense and unremitting for 30-60 minutes. It is
retrosternal and often radiates up to the neck,
shoulder, and jaw and down to the ulnar aspect of the
left arm. Chest pain is usually described as a
substernal pressure sensation that also may be
described as squeezing, aching, burning, or even sharp.
Hypotension may indicate ventricular dysfunction due to
ischemia. Hypotension in the setting of myocardial

infarction usually indicates a large infarct secondary

to either decreased global cardiac contractility or a
right ventricular infarct.
In general, the patient's blood pressure is initially
elevated because of peripheral arterial
vasoconstriction resulting from an adrenergic response
to pain and ventricular dysfunction. However, with
right ventricular myocardial infarction or severe left
ventricular dysfunction, hypotension is seen.
The respiratory rate may be increased in response to
pulmonary congestion or anxiety.
Arterial pulsations may exhibit pulsus alternans, which
reflects impaired left ventricular function and is
characterized by strong and weak alternating pulse
waves.
Peripheral cyanosis, pallor, diminished pulse volume,
delayed rise, and delayed capillary refill may indicate
vasoconstriction, diminished cardiac output, and right
ventricular dysfunction or failure.4

4
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/
acute-myocardial-infarction/