Elsevier

The Lancet

Volume 361, Issue 9360, 8 March 2003, Pages 847-858
The Lancet

Seminar
Acute myocardial infarction

https://doi.org/10.1016/S0140-6736(03)12712-2Get rights and content

Summary

Acute myocardial infarction is a common disease with serious consequences in mortality, morbidity, and cost to the society. Coronary atherosclerosis plays a pivotal part as the underlying substrate in many patients. In addition, a new definition of myocardial infarction has recently been introduced that has major implications from the epidemiological, societal, and patient points of view. The advent of coronary-care units and the results of randomised clinical trials on reperfusion therapy, lytic or percutaneous coronary intervention, and chronic medical treatment with various pharmacological agents have substantially changed the therapeutic approach, decreased in-hospital mortality, and improved the long-term outlook in survivors of the acute phase. New treatments will continue to emerge, but the greatest challenge will be to effectively implement preventive actions in all high-risk individuals and to expand delivery of acute treatment in a timely fashion for all eligible patients.

Introduction

During the past decades, major improvements have been achieved in management of patients with acute myocardial infarction. The introduction of coronary care units in the 1960s, pharmacological reperfusion therapy in the 1980s, and the widespread application of catheter-based interventions in the 1990s have contributed to a striking fall in in-hospital mortality rates.1, 2, 3, 4, 5, 6 Additionally, chronic treatment with aspirin, β blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins have contributed to improved long-term prognosis in survivors of the acute phase of this disorder.7, 8, 9, 10 Despite these developments, myocardial infarction remains a major event, from a clinical, psychological, and social point of view. First, a large number of asymptomatic individuals are at serious risk of developing a first heart attack because of their genetic predisposition, smoking behaviour, unhealthy dietary habits, or physical inactivity. Second, evidence is emerging that medical practice does not adequately implement preventive actions in asymptomatic high-risk individuals and patients with established coronary disease,11 and thus they remain at substantial risk of (recurrent) disease and death. Third, about a third of patients with evolving myocardial infarction die before they reach hospital to receive any effective treatment.12 Finally, the improved survival of acute coronary syndromes has resulted in a growing population of patients with chronic conditions,13 which is amplified by the ageing of the general population. Thus, myocardial infarction remains an important health problem, and merits continued attention from basic and clinical researchers, epidemiologists, and practising physicians. We review the current knowledge about acute myocardial infarction and discuss issues about the pathophysiology, diagnosis, epidemiology, treatment, and prevention of this disorder. We concentrate on the most prominent recent developments.

Section snippets

Pathophysiology

The term myocardial infarction is thought to reflect death of cardiac myocytes due to prolonged ischaemia.14 As such, myocardial infarction is an acute coronary syndrome that can occur during the natural course of coronary atherosclerosis (figure 1).15, 16 Progression of atherosclerosis is triggered and enhanced by several factors, which can cause mediating diseases or directly affect the arterial wall. In advanced stages of the disease process, atherosclerotic plaques develop. Initially,

Definitions, diagnosis, and epidemiology

According to WHO's definition, a myocardial infarction occurs if at least two of three criteria are fulfilled: typical ischaemic chest pain; raised concentrations of creatine kinase-MB in serum; and typical electrocardiographic findings, including development of pathological Q-waves.38 Creatine kinase-MB, however, is not a sensitive marker of myocardial necrosis. Therefore, application of the WHO definition in clinical practice results in several patients erroneously diagnosed with

In-hospital treatment

Since myocardial infarction was shown to be caused by an acute intracoronary thrombotic occlusion, treatment strategies have been introduced that aim at rapid, complete, and lasting restoration of coronary blood circulation. Physicians can now choose from different pharmacological reperfusion regimens based on thrombolytic, antiplatelet, and anticoagulant agents. In some hospitals, catheter-based interventions are also available.

Prevention and long-term treatment

It is important to stratify patients according to the risk of further coronary events after acute myocardial infarction, and to take measures to prevent them. In high-risk patients, coronary interventions should be considered.106 In general, however, effort should be devoted to actions that aim to change unhealthy life-styles, and provide individualised advice on smoking, diet, weight control, and exercise.22 For long-term medical management, the value of aspirin, β blockers, and ACE inhibitors

Future directions

With the understanding on development of coronary atherosclerosis as an inflammatory disease, future research should concentrate on development and wide implementation of new approaches that will allow screening for serum markers of chronic low-grade vascular wall inflammation, and clinical imaging of the vulnerable plaque that will discriminate among patients who are at an increased risk for plaque rupture and infarction. However, front-line research towards new risk markers of coronary

Search strategy and selection criteria

We identified 20 047 reports by a computerised search of Medline that were published in the English language between Jan 1, 1990, and Jan 18, 2003, with myocardial infarction as major topic, and aetiology, pathophysiology, epidemiology, diagnosis, therapy, or prevention as secondary topics. Of these, we reviewed the abstracts of 5231 reports labelled as clinical trials, meta-analysis, review, or practice guidelines. Relevant papers (n=592) were selected, and the content examined. The

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