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
SeminarAcute myocardial infarction
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
References (123)
- et al.
Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials
Lancet
(2003) - et al.
Clinical effects of early angiotensin-converting enzyme inhibitor treatment for acute myocardial infarction are similar in the presence and absence of aspirin: systematic overview of individual data from 96 712 randomized patients
J Am Coll Cardiol
(2000) - et al.
Effect of thrombolytic treatment delay on myocardial infarct size
Lancet
(1992) - et al.
Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention
Atherosclerosis
(1998) - et al.
Chronic infections and coronary heart disease: is there a link?
Lancet
(1997) - et al.
Acute coronary syndrome without ST elevation: implementation of new guidelines
Lancet
(2001) - et al.
Effect of prehospital thrombolysis on aborting acute myocardial infarction
Am J Cardiol
(1999) - et al.
Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations
Lancet
(1999) - et al.
Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations
Lancet
(2000) - et al.
Risk of intracranial haemorrhage with bolus versus infusion thrombolytic therapy: a meta-analysis
Lancet
(2000)
Primary stent implantation compared with primary balloon angioplasty for acute myocardial infarction: a meta-analysis of randomized clinical trials
Am J Cardiol
Effect of glycoprotein IIb/IIIa receptor blockade with abciximab on clinical and angiographic restenosis rate after the placement of coronary stents following acute myocardial infarction
J Am Coll Cardiol
The clinical implications of no reflow demonstrated with intravenous perfluorocarbon containing microbubbles following restoration of Thrombolysis In Myocardial Infarction (TIMI) 3 flow in patients with acute myocardial infarction
Am J Cardiol
Prognostic implications of TIMI flow grade in the infarct related artery compared with continuous 12-lead ST-segment resolution analysis: reexamining the “gold standard” for myocardial reperfusion assessment
J Am Coll Cardiol
1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction)
J Am Coll Cardiol
A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: the Air Primary Angioplasty in Myocardial Infarction study
J Am Coll Cardiol
Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour
Lancet
Influence of early prehospital thrombolysis on mortality and event-free survival: the Myocardial Infarction Triage and Intervention Randomized Trial
Am J Cardiol
The evolution of the coronary care unit
Cardiovasc Res
Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients
Lancet
Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review
JAMA
Shattuck lecture: cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities
N Engl J Med
A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin
Eur Heart J
Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients
BMJ
Beta blockade after myocardial infarction: systematic review and meta regression analysis
BMJ
Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial
JAMA
Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries
Lancet
Sudden death due to cardiac arrhythmias
N Engl J Med
Cardiovascular disease in the Netherlands, 1975 to 1995: decline in mortality, but increasing numbers of patients with chronic conditions
Heart
Myocardial infarction redefined: a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction
Eur Heart J
The pathogenesis of coronary artery disease and the acute coronary syndromes (1)
N Engl J Med
The pathogenesis of coronary artery disease and the acute coronary syndromes (2)
N Engl J Med
Compensatory enlargement of human atherosclerotic coronary arteries
N Engl J Med
Thrombus formation on atherosclerotic plaques: pathogenesis and clinical consequences
Ann Intern Med
The pathogenesis of atherosclerosis: a perspective for the 1990s
Nature
Atherosclerosis: an inflammatory disease
N Engl J Med
Novel clinical markers of vascular wall inflammation
Circ Res
Plasma homocysteine levels and mortality in patients with coronary artery disease
N Engl J Med
C-Reactive protein, a sensitive marker of inflammation, predicts future risk of coronary heart disease in initially healthy middle-aged men: results from the MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Augsburg Cohort Study, 1984 to 1992
Circulation
Lipoprotein(a) and coronary heart disease. Meta-analysis of prospective studies
Circulation
C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women
N Engl J Med
Pregnancy-associated plasma protein A as a marker of acute coronary syndromes
N Engl J Med
Risk factors for coronary heart disease and infection with Helicobacter pylori: meta-analysis of 18 studies
BMJ
Chronic infection in the etiology of atherosclerosis: the case for Chlamydia pneumoniae
Clin Cardiol
Chlamydia pneumoniae IgA titres and coronary heart disease; prospective study and meta-analysis
Eur Heart J
Inflammatory gene polymorphisms and ischaemic heart disease: review of population association studies
Heart
Increasing burden of cardiovascular disease: current knowledge and future directions for research on risk factors
Circulation
Identification of atherosclerotic plaque components with intravascular ultrasound elastography in vivo: a Yucatan pig study
Circulation
Thermal heterogeneity within human atherosclerotic coronary arteries detected in vivo: A new method of detection by application of a special thermography catheter
Circulation
Clinical imaging of the high-risk or vulnerable atherosclerotic plaque
Circ Res
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