Myocardial Infarction

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Introduction 3 Classification 4 Etiology 5 Pathology 6 Genetics 7 Clinical-manifestations 8 Diagnostic-criteria 9 Laboratory 10 Diagnostic-procedures 11 Radiology 12 Complications 13 Differential-diagnosis 14 Management 15 More General Terms 16 Additional Terms 17 Internet Database 18 References

More Specific Terms

• non ST segment elevated myocardial infarction (nonSTEMI, NSTEMI)
• non-Q-wave myocardial infarction
• reperfusion-eligible acute myocardial infarction
• right ventricular myocardial infarction (RV-MI)
• ST segment elevated myocardial infarction (STEMI)

Introduction

• Also see STEMI, NSTEMI & acute coronary syndrome.

Classification

• Killip classification
• class 1: no pulmonary congestion
• class 2: mild pulmonary congestion or isolated S3
• class 3: pulmonary edema
• class 4: hypotension & evidence of shock

Etiology

• occlusion of one or more of the coronary arteries

• if not reversed within 30 minutes, myocardial ischemia generally results in myocardial infarction
• without collaterals 90% of the supplied myocardium is infarcted within 3 hours of occlusion

• thrombus overlying or adjacent to ruptured atherosclerotic plaque
• advanced lesions > 85% stenosis are unlikely to be sites of occlusion giving rise to MI because of collateral circulation which develops in slowly progressive lesions
• lesions with about 50% stenosis are most likely sites for occlusive thrombi because of:

• significant risk for plaque rupture
• lack of significant collateral circulation

• increased sympathetic tone increases risk

• circadian pattern
• early morning & early evening peaks
• emotional stress of bereavement stimulates sympathetic activity & increases risk of MI [37]
• sympathomimetics including cocaine use stimulate sympathetic activity & increase risk of MI

• acute respiratory tract infections transiently increase risk [23]
• also see etiology of MI without coronary artery disease
• also see cardiac risk factors

Pathology

• mortality from MI is greatest within the 1st 2 hours
• earliest histologic evidence of myocardial infarction occurs after 8-12 hours

Genetics

• ALOX5AP haplotypes hapA & hapB are associated with susceptibility to myocardial infarction
• other implicated genes: PALLD

Clinical-manifestations

• chest pain, resembling angina pectoris*

• more severe & longer in duration than angina

• typically > 20 minutes to several hours in duration
• angina is typically < 10 minutes in duration
• a dull pain may persist for days after severe pain subsides

• radiation to one or both arms*
• not relieved by rest or nitroglycerin
• chest pain may be absent:

• post-operative
• elderly
• diabetes
• hypertension

• dyspnea
• nausea/vomiting
• diaphoresis
• palpitations
• exacerbation of CHF/ cardiogenic pulmonary edema
• confusion
• hypotension* may indicate cardiogenic shock

• cardiogenic shock with JVD, but without pulmonary congestion suggests RCA occlusion (inferior wall & right heart)

• jugular venous distention ( JVD) indicates right ventricular failure; clear lungs, bradycardia, hypotension suggests right ventricular infarction
• S3* suggests heart failure
• S4 indicates decreased left ventricular compliance
• new systolic murmur

• mitral regurgitation
• ventricular septal defect

• pericardial friction rub in 15% of cases
• signs/symptoms may be different in women
  *chest pain with radiation to both arms, S3 & hypotension are the most predictive features of myocardial infarction
  

Diagnostic-criteria

• (2 of 3 criteria):
• history of prolonged chest discomfort
• ECG changes consistent with ischemia or infarction
• elevation of serum markers of myocardial infarction

Laboratory

• markers of myocardial infarction

• creatine kinase MB fraction

• serum CK-MB increases 4-6 hours after MI
• peak levels 12-20 hours
• returns to baseline in 36-48 hours
• serum CK MB index > 5% indicates MI (max value is 20%)

• serum troponin-I
• serum lactate dehydrogenase (LDH) isozymes

• elevations in serum LDH become detectable in 12 hours
• peak levels in 24-48 hours
• remain elevated for 10-14 days
• LDH1/LDH2 ratio > 1.0 indicates myocardial infarction
• most useful in patients presenting 24 hours after onset of symptoms

• serum aspartate transaminase ( serum AST, SGOT)
• serum myoglobin

• non-specific marker
• elevation in serum within 1-3 hours of MI

• routine labs

• complete blood count

• leukocytosis may accompany myocardial necrosis
• hemoglobin <10 g/ dL may be indication for transfusion

• serum electrolytes
• serum glucose
• serum creatinine

Diagnostic-procedures

• electrocardiogram:

• the majority of patients with MI have ECG changes
• ST segment elevation, > 1 mm in 2 contiguous leads

• convex
• peaked or inverted T waves

• prolongation of QTc preceeds ST segment elevation [29]
• ST segment depression

• reciprocal depression
• non Q wave MI

• new Q waves > 40 msec may occur with:

• MI
• prolonged ischemia
• myocarditis

• new or presumed new left bundle branch block

Radiology

• chest X-ray to assess for congestive heart failure, pneumothorax

Complications

• mortality from MI is greatest within the 1st 2 hours
• myocardial pump failure

• occurs 2-7 days after MI
• congestive heart failure
• cardiogenic shock
• pulmonary edema
• hepatic congestion from right heart failure
• myocardial rupture

• generally occurs after 3-7 days, but may occur later
• interventricular septum - ventricular septal defect (10%)
• left ventricular free wall (85%)

• sudden death, pulseless electrical activity

• left ventricular aneurysm
• rupture of papillary muscle (5%)

• mitral regurgitation

• loud holosystolic murmur, thrill

• pulmonary edema

• evaluate with emergent echocardiography

• cardiac arrhythmias

• ventricular arrhythmias most lethal

• premature ventricular depolarizations
• ventricular tachycardia ( VT)
• ventricular fibrillation ( VF)
• accelerated idioventricular rhythm ( AIVR)

• supraventricular arrhythmias

• sinus tachycardia
• paroxysmal supraventricular tachycardia ( PSVT)
• atrial fibrillation ( AF)

• excess risk of death is highest for AF developing > 30 days after MI [36]

• atrial flutter

• bradyarrhythmias

• sinus bradycardia
• AV block

• pericarditis

• acute pericarditis

• results from transmural infarction & irritation of the pericardium

• Dressler's syndrome
• non- acetylated salicylate is treatment of choice; avoid NSAIDs (with anti-platelet activity)

• thromboembolism

• intracardiac thrombus occurs in 40% of patients with anterior wall MI
• systemic thromboembolism occurs in 50% of patients with anterior wall MI

• right ventricular infarction occurs in 40% of patients with inferior wall MI
• recurrent myocardial infarction [6]

• risk about 10% in the 1st year
• peak incidence within 1st 6 weeks
• 4-6 weeks necessary for myocardium & ruptured coronary plaque to heal
• life time risk of 2nd MI is 50% [11]

• renal disease associated higher risk of death after MI [12]

• small increase in serum creatinine during hospitalization for MI associated with increased risk of ESRD & death [31,38]

• depression increases risk of adverse outcomes [28]
• women treated with fibrinolytic therapy, antiplatelet agents, or anticoagulation have a higher risk of bleeding complicaions than men [6]

Differential-diagnosis

• (see chest pain)

Management

• goals of management

• relieve pain
• recognize & treat complications of MI
• minimize the size of the infarction

• serial ECGs, upon presentation & QD during hospitalization
• initial medical therapy

• aspirin, clopidogrel, avoid NSAIDs [35]
• oxygen
• beta blocker
• nitrates vs IV fluids (see below), morphine
• heparin

• aspirin 160-325 mg PO immediately (chewed, not EC) & QD

• clopidrogrel may be of benefit (see COMMIT trial)

• oxygen:

• 2-4 liters/min by nasal cannula
• do not continue for more than 3 hours unless hypoxia is present [7]

• IV fluids

• right ventricular MI (avoid nitrates)
• posterior wall MI with hypotension

• analgesia

• nitrates

• nitroglycerin

• relieves angina
• may reduce infarct size

• decrease in wall tension
• affects remodelling

• may diminish susceptibility to ventricular fibrillation
• contraindications to IV nitroglycerin

• hypotension
• right ventricular infarction

• may reduce mortality in patients with large anterior wall myocardial infarction & congestive heart failure

• isosorbide 10-30 mg TID

• do not give every 8 hours
• need relatively drug free period each day with TID schedule (8 AM, 12 noon, 5 PM)
• reduces need for SL NTG

• morphine for anxiety & discomfort

• beta-blockers

• decrease myocardial oxygen consumption

• decreased heart rate
• decreased LV contractility
• decreased BP

• IV beta blockers

• decrease infarct size & mortality
• decrease incidence of ventricular fibrillation
• indicated in patients who present within 4-6 hours after onset of symptoms

• chronic oral cardioselective beta blockers

• atenolol, metoprolol
• used within 3-21 days [6]

• contraindications

• heart rate < 55/min
• systolic blood pressure < 95 torr
• AV block
• obstructive lung disease

• history
• wheezing on examination

• evidence of significant heart failure
• inferior wall MI with high vagal tone

• specific agents

• metoprolol (cardioselective)

• up to 15 mg IV, given in 5 mg doses 5 min to 2 hours apart
• 50 mg PO every 12 hours

• atenolol (cardioselective)

• 5-10 mg IV
• 100 mg PO QD

• labetalol

• 20-80 mg IV every 10 minutes, up to 300 mg
• useful in patients in state of adrenergic excess, circumvents unopposed alpha activity with beta adrenergic antagonists

• cocaine
• alcoholism
• hyperthyroidism
• pheochromocytoma

• timolol

• 1 mg IV repeated after 10 minutes, 0.6 mg/kg infusion for 24 hours, followed by
• 10 mg PO every 12 hours

• esmolol drip

• 250-500 ug/kg bolus
• infusion of 50 ug/kg/min
• useful for patients at risk for complications from beta blockers because of short 1/2 life

• ACE inhibitor or angiotensin receptor antagonist ( ARB) [17]

• early treatment is beneficial

• initiate therapy when hemodynamically safe (2-3 days post MI; within 24 hours [6]) & continue for at least 6 weeks
• increased long term (42 month) survival
• prevents remodeling of infarcted myocardium
• ramipril, perindopril may be better than lisinopril enalapril, fosinopril, captopril, or quinapril [20,21]

• long term management of LV dysfunction following MI

• calcium channel blockers without benefit & potential for harm
• use of diuretics after acute MI may be associated with increased mortality
• amiodarone is agent of choice for arrhythmias not controlled by beta blockers
• anticoagulation

• heparin

• appears to reduce mortality in patients with MI
• risk of bleeding complications probably outweighs benefit in patients at low risk for complications

• warfarin: documented thrombus
• enoxaparin ( Levonox, low molecular weight heparin)

• avoid in obesity, renal failure [6]

• PCI ( PTCA) more effective than thrombolytic therapy [15,27]

• perform within 90 minutes of 1st medical contact [6]
• survival benefit for up to 12 hours after symptom onset (see PCI)
• thrombolysis -> angiography -> coronary stenting [22]
• PCI improves outcomes with cardiogenic shock [26] (see SHOCK trial)
• transfer to PCI-capable hospital should routinely follow thrombolysis [32]
• atrial natriuretic peptide ( ANP) 0.025 ug/kg/min for 3 days post reperfusion may improve outcomes [30]
• also see PCI & STEMI

• intra-aortic balloon pump: [3]

• cardiogenic shock
• acute mitral regurgitation or ventricular septal defect
• intractable ventricular tachycardia
• refractory angina

• recovery

• HMG CoA reductase inhibitor in hospital [24]

• see PROVE-IT & REVERSAL studies
• continue or begin within 24-96 hours [6]

• prolonged bedrest not recommended
• prevention of coronary thrombosis

• aspirin
• clopidogrel ( Plavix) plus aspirin 81 mg [11] appears to be treatment of choice [6]

• esomeprazole more effective than famotidine in preventing GI bleed [40]

• warfarin

• superior to aspirin in reducing subsequent cardiac events & death [10]
• target INR of 2.5-3.5 [11] (without aspirin)

• combination of warfarin + 81 mg aspirin ( INR 2.0-3.0) better than aspirin or warfarin alone [11,13,19]

• eplerenone ( Inspra) for LV dysfunction [6]
• omega-3 fatty acid 1 g/day reduces mortality 45% [16]
• treat depression (see depression & heart disease)
• bone marrow stem cell infusion (see BOOST trial)
• implantable cardioverter-defibrillators ( ICDs)

• confers no survival advantage in high-risk patients early after myocardial infarction
• recurrent MI & cardiac rupture (non-arrhythmic) account for 50% of mortality after MI [33]

• prognosis

• renal insufficiency portends poor prognosis [18]

• 3.7 fold increase in mortality with serum creatinine > 2.0 mg/dL

• hypokalemia or hyperkalemia associated with increased risk of ventricular fibrillation & mortality

• serum potassium < 3.0 meq/L or > 5.0 meq/L
• mortality unaffected by potassium supplementation [39]

• diabetes mellitus associated with poorer prognosis (see VALIANT study)

• follow-up

• screen for depression: associated with increased morbidity & mortality [6]
• rehabilitation treadmill testing 8-10 days post MI
• echocardiogram

• if LVEF < 30%, perform coronary angiography, place AICD

• coronary angiography

• if indicated by rehabilitation treadmill testing
• post infarction angina
• unable to exercise
• within 48 hours ( TACTICS-TIMI trial) [9]

• PneumoVax [8]

• post-MI non- cardiac surgery: delay (if possible) 4-6 weeks (uncomplicated MI)

More General Terms

• heart disease (cardiac disease)
• infarction

Additional Terms

• clinical trials for myocardial infarction
• coronary angiography
• coronary artery disease (CAD)
• depression & heart disease
• Dressler's syndrome (post MI syndrome)
• etiology of myocardial infarction (MI) without coronary atherosclerosis
• markers of myocardial injury/infarction
• myocardial ischemia
• Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial
• stable angina pectoris (chronic stable angina)
• thrombolysis for acute myocardial infarction
• unstable angina (acute coronary syndrome, ACS)

Internet Database

OMIM: 608557

References

1. Cotran et al Robbins Pathologic Basis of Disease, 5th ed. W.B. Saunders Co, Philadelphia, PA 1994 pg 15
2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 94-113
3. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 237-239
4. Ryan TJ et al ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation 94:2341-50 1996 PMID: [1]
5. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 231-234
6. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
7. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 91-91
8. Journal Watch 21(3):24, 2001 Naghavi M et al Association of influenza vaccination and reduced risk of recurrent myocardial infarction. Circulation 102:3039, 2000 PMID: &dopt=Abstract
9. Journal Watch 22(2):13, 2002 Morrow DA et al Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial. JAMA 286:2405, 2001 PMID: [2]
   - Quinn MJ & Moliterna DJ Troponins in acute coronary syndromes: More TACTICS for an early invasive strategy. JAMA 286:2461, 2001 PMID: [3]
10. Journal Watch 22(18):146, 2002 van Es RF et al Aspirin and coumadin after acute coronary syndromes (the ASPECT-2 study): a randomised controlled trial. Lancet 360:109, 2002 PMID: [4]
11. Prescriber's Letter 9(12):68 2002 (subscription needed) [5]
12. Journal Watch 22(23):173, 2002 Shlipack MG et al Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients. Ann Intern Med 137:555, 2002 PMID: [6]
    - Wright RS et al Acute myocardial infarction and renal dysfunction: a high-risk combination. Ann Intern Med 137:563, 2002 PMID: [7]
    - Townsend RR Cardiac mortality in chronic kidney disease: a clearer perspective. Ann Intern Imed 137:615, 2002 PMID: [8]
13. Journal Watch 22(22):164, 2002 Hurlen M et al Warfarin, aspirin, or both after myocardial infarction. N Engl J Med 347:969, 2002 PMID: [9]
    - Becker RC Antithrombotic therapy after myocardial infarction. N Engl J Med 347:1019, 2002 PMID: [10]
14. Journal Watch 22(22):174, 2002 Dickstein K et al Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan. Lancet 360:752, 2002 PMID: [11]
15. Journal Watch 23(5):42, 2003 Keeley EC et al Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 361:13, 2003 PMID: [12]
16. Prescriber's Letter 10(7):38 2003 (subscription needed) [13]
17. Journal Watch 22(1):1, 2004 Pfeffer MA et al Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 349:1893, 2003 PMID: [14]
    - Mann DL & Deswal A Angiotensin-receptor blockade in acute myocardial infarction - a matter of dose. N Engl J Med 349:1963, 2003 PMID: [15]
18. Journal Watch 24(2):16, 2004 Gibson CM et al Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality. J Am Coll Cardiol 42:1535, 2003 PMID: &dopt=Abstract
    - French WJ & Wright RS Renal insufficiency and worsened prognosis with STEMI: a call for action. J Am Coll Cardiol, 42:1544, 2003 PMID: [16]
19. Anand SS and Yusuf S Oral anticoagulants in patients with coronary artery disease. J Am Coll Cardiol 41:62S, 2003 PMID: [17]
20. Prescriber's Letter 11(9): 2004 Detail-Document#: [18] (subscription needed) [19]
21. Journal Watch 24(17):133, 2004 Pilote L, Abrahamowicz M, Rodrigues E, Eisenberg MJ, Rahme E. Mortality rates in elderly patients who take different angiotensin-converting enzyme inhibitors after acute myocardial infarction: a class effect? Ann Intern Med. 2004 Jul 20;141(2):102-12. PMID: [20]
22. Journal Watch 24(22):166, 2004 Fernandez-Aviles F, Alonso JJ, Castro-Beiras A, Vazquez N, Blanco J, Alonso-Briales J, Lopez-Mesa J, Fernandez-Vazquez F, Calvo I, Martinez-Elbal L, San Roman JA, Ramos B; GRACIA (Grupo de Analisis de la Cardiopatia Isquemica Aguda) Group. Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial. Lancet. 2004 Sep 18;364(9439):1045-53. PMID: [21]
23. Journal Watch 25(4):29, 2005 Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med. 2004 Dec 16;351(25):2611-8. PMID: [22]
24. Prescriber's Letter 12(9): 2005 How Soon After a Heart Attack Should Statins be Initiated? Detail-Document#: [23] (subscription needed) [24]
25. Eagle KA, Montoye CK, Riba AL, DeFranco AC, Parrish R, Skorcz S, Baker PL, Faul J, Jani SM, Chen B, Roychoudhury C, Elma MA, Mitchell KR, Mehta RH; American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan; American College of Cardiology Foundation (Bethesda, Maryland) Guidelines Applied in Practice Steering committee. Guideline-based standardized care is associated with substantially lower mortality in medicare patients with acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan. J Am Coll Cardiol. 2005 Oct 4;46(7):1242-8. PMID: [25]
26. Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS; NRMI Investigators. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA. 2005 Jul 27;294(4):448-54. PMID: [26]
27. van 't Hof AW, Rasoul S, van de Wetering H, Ernst N, Suryapranata H, Hoorntje JC, Dambrink JH, Gosselink M, Zijlstra F, Ottervanger JP, de Boer MJ; On-TIME study group. Feasibility and benefit of prehospital diagnosis, triage, and therapy by paramedics only in patients who are candidates for primary angioplasty for acute myocardial infarction. Am Heart J. 2006 Jun;151(6):1255.e1-5. <PubMed> PMID: [27] <Internet> [28]
28. Parashar S et al, for Premier Registry Investigators Time Course of depression and outcome of myocardial infarction. Arch Intern Med 2006, 166:2035 PMID: [29]
29. Kenigsberg DN et al, Prolongation of the QTc interval is seen uniformly during early transmural ischemia. J Am Coll Cardiol 2007, 49:1299 PMID: [30]
30. Kitakaze M et al, Human atrial natriuretic peptide and nicorandil as adjuncts to reperfusion treatment for acute myodardial infarction (J-WIND): Two randomised trials Lancet 2007, 370:1483 PMID: [31]
31. Newsome BB, Warnock DG, McClellan WM, Herzog CA et al Long-term Risk of Mortality and End-Stage Renal Disease Among the Elderly After Small Increases in Serum Creatinine Level During Hospitalization for Acute Myocardial Infarction. Arch Intern Med. 2008 Mar 24;168(6):609-16. PMID: [32]
32. Cantor WJ et al Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction N Engl J Med 2009, 360:2705-2718 <PubMed> PMID: &dopt=Abstract <Internet> [33]
33. Steinbeck G et al. Defibrillator implantation early after myocardial infarction. N Engl J Med 2009 Oct 8; 361:1427 <PubMed> PMID: [34] <Internet> [35]
    - Pouleur A-C et al. Pathogenesis of sudden unexpected death in a clinical trial of patients with myocardial infarction and left ventricular dysfunction, heart failure, or both. Circulation 2010 Aug; 122:597. PMID: [36]
34. Bartolo I et al. Rapid clinical progression to AIDS and death in a persistently seronegative HIV-1 infected heterosexual young man. AIDS 2009 Nov 13; 23:2359. PMID: [37]
35. Schjerning Olsen AM et al Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction <PubMed> PMID: [38] <Internet> [39]
36. Jabre P et al. Atrial fibrillation and death after myocardial infarction: A community study. Circulation 2011 May 17; 123:2094. PMID: [40]
37. Mostofsky E et al Risk of Acute Myocardial Infarction after Death of a Significant Person in One's Life: The Determinants of MI Onset Study Circulation Published online January 9, 2012 <PubMed> PMID: [41] <Internet> [42]
38. Fox CS et al. Short-term outcomes of acute myocardial infarction in patients with acute kidney injury: A report from the National Cardiovascular Data Registry. Circulation 2012 Jan 24; 125:497 PMID: [43]
39. Goyal A et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA 2012 Jan 11; 307:157. PMID: [44]
    - Scirica BM and Morrow DA. Potassium concentration and repletion in patients with acute myocardial infarction. JAMA 2012 Jan 11; 307:195. PMID: [45]
40. Ng F-H et al. Esomeprazole compared with famotidine in the prevention of upper gastrointestinal bleeding in patients with acute coronary syndrome or myocardial infarction. Am J Gastroenterol 2012 Mar; 107:389. PMID: [46]
41. Heart Attack: NIH Institute and Center Resources [47]
42. National Guideline Clearinghouse
    - Acute coronary syndrome and myocardial infarction. (Finnish Medical Society Duodecim) ngc-guideline: [48]
    - Management of cocaine-associated chest pain and myocardial infarction. A scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. ngc-guideline: [49]
    - Post myocardial infarction: secondary prevention in primary and secondary care for patients following a myocardial infarction. National Collaborating Centre for Primary Care. ngc-guideline: [50]
    - AAFP guideline for the detection and management of post-myocardial infarction depression. American Academy of Family Physicians ngc-guideline: [51]

myocardial infarction (MI); heart attack