A cute M y o c ard i al

I n f a rc t i o n
Akram W. Ibrahim, MD, Thomas C. Riddell, MD, Chandan M. Devireddy, MD*

KEYWORDS

Myocardial infarction
Coronary artery disease
Unstable angina

Fibrinolytic therapy
Primary percutaneous coronary intervention

KEY POINTS

Cases of acute coronary syndrome demand rapid treatment which varies depending on
the underlying type.

In the intensive care unit setting, chest pain demands immediate evaluation.

The differential diagnoses to consider with chest pain are many, some of which are
benign; but morbid consequences can ensue if high-risk features are not recognized.

Many causes may be stratified by a focused history alone; but most presentations of chest
pain will still require additional testing, such as electrocardiograms, imaging, and labora-
tory data for a reliable diagnosis.

APPROACH TO PATIENTS WITH ACUTE CHEST PAIN IN THE INTENSIVE CARE UNIT

In the intensive care unit (ICU) setting, chest pain demands immediate evaluation. The
differential diagnoses to consider with chest pain are many, some of which are benign;
but morbid consequences can ensue if high-risk features are not recognized. Many
causes may be stratified by a focused history alone; but most presentations of chest
pain will still require additional testing, such as electrocardiograms (ECG), imaging,
and laboratory data for a reliable diagnosis.
Acute myocardial infarction (AMI) is the most feared cause of chest pain, but a wide
range of cardiac and noncardiac pathophysiology may explain new-onset chest
discomfort. It is important to review the common causes of chest pain in the ICU
setting not related to AMI.
Common causes of chest pain in ICU setting

Pericarditis

Aortic dissection

Disclosure statement: Chandan M. Devireddy, advisory board (2013), Medtronic. The authors
have no financial conflicts related to the content of this article.
Division of Cardiology, Department of Medicine, Emory University School of Medicine, Emory
University Hospital Midtown, Medical Office Tower, 550 Peachtree Street, Atlanta, GA 30308, USA
* Corresponding author. Emory University School of Medicine, Emory University Hospital
Midtown, Medical Office Tower, 6th floor, 550 Peachtree Street, Atlanta, GA 30308.
E-mail address: [email protected]

Crit Care Clin 30 (2014) 341–364

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342 Ibrahim et al

Pulmonary embolism

Pneumothorax

Musculoskeletal pain

Acute myocarditis

Recommendation for initial assessment
 A focused history and physical
 Vital signs (including invasive hemodynamic monitoring if necessary)
 ECG
 Chest radiograph or further imaging modality
 Cardiac biomarkers

Pericarditis
Acute pericarditis refers to inflammation of the pericardial sac, which consists of 2 tis-
sue layers encasing the heart and great vessels in the mediastinum. The potential
causes of pericarditis are many and may present as an isolated disorder or part of a
systemic process. Although most episodes of pericarditis can be effectively managed
with medications, certain high-risk features should be noted in the ICU setting1:
High-risk features of acute pericarditis

Fever and leukocytosis

Large pericardial effusion or evidence of cardiac tamponade

Acute trauma

Recent thoracic surgical procedure or instrumentation

Anticoagulant therapy

Immunosuppressed state
Certain specific auscultatory phenomena may occur in acute pericarditis. The peri-
cardial friction rub is the most common finding and is caused by friction between the 2
inflamed pericardial layers.2 The murmur is generally loudest along the left sternal
border and consists of scratching or scraping sounds between S1 and S2.3
ECG findings of pericarditis are varied and change with the acuity of the inflamma-
tory process. Typical ECG findings are listed next4:
Stage 1 is seen in the first few hours to days and is characterized by diffuse ST
elevation (typically concave up) with reciprocal ST depression in leads aVR and
V1. There is also an atrial current of injury, reflected by the elevation of the PR
segment in lead aVR and depression of the PR segment in other limb leads and
in the left chest leads, primarily V5 and V6 (Fig. 1).
Stage 2, typically seen in the first week, is characterized by normalization of the ST
and PR segments.
Stage 3 is characterized by the development of diffuse T-wave inversions, generally
after the ST segments have become isoelectric. However, this stage is not seen in
some patients.
Stage 4 is represented by the normalization of the ECG or indefinite persistence of
T-wave inversions.
Important distinctions must be made in this setting between ECG features of acute
pericarditis and ST-elevation MI (STEMI). The first is that ST elevation in acute peri-
carditis usually begins at the J point (at the end of the QRS complex and the begin-
ning of the ST segment) and remains concave (see ECG discussed earlier). In STEMI,
the ST segments are generally more convex (dome shaped). The ST elevation in peri-
carditis tends to be widespread, whereas in STEMI the ST-elevation pattern will
follow the distribution of a blocked coronary artery. Lastly, the classic PR depression
 Acute Myocardial Infarction 343

Fig. 1. Acute pericarditis. Note the diffuse ST elevation with concave ST segments. (From
LeWinter MM, Tischler MD. Pericardial diseases. In: Bonow RO, Mann DL, Zipes DP, et al,
editors. Braunwald’s heart disease: a textbook of cardiovascular medicine. 9th edition.
Philadelphia: Saunders Publishing; 2011; with permission.)

in acute pericarditis is not generally seen in STEMI because of the lack of atrial injury
in AMI (Fig. 2).
Additional diagnostic modalities to consider in the evaluation of pericarditis include
echocardiography to evaluate for effusion, chest radiograph, and laboratory data with
comprehensive evaluation of pericardial disease in the proper setting. Although the
treatment of pericarditis depends of the cause, the mainstay of therapy is antiinflam-
matory medications (nonsteroidal antiinflammatory drugs, aspirin, and colchicine).
Patients refractory to standard medication or with contraindications may benefit
from glucocorticoid therapy. In the case of large pericardial effusion or cardiac tampo-
nade, a timely pericardiocentesis should be considered for diagnosis and therapy (See
Fig. 2).

Fig. 2. STEMI. This image demonstrates acute ST elevation of anterior wall MI. You can see
the ST changes across the precordium as well as into the lateral leads. Reciprocal changes
are also seen in the inferior leads. (From Mirvis DM, Goldberger AL. Electrocardiography.
In: Bonow RO, Mann DL, Zipes DP, et al, editors. Braunwald’s heart disease: a textbook of car-
diovascular medicine. 9th edition. Philadelphia: Saunders Publishing; 2011; with permission.)
344 Ibrahim et al

Venous Thromboembolism
Deep vein thrombosis and pulmonary embolism (PE) constitute the entity of venous
thromboembolism (VTE). VTE accounts for hundreds of thousands of hospital admis-
sions annually.5 Despite advances in medical and catheter-based therapy, mortality
remains high for these patients up to 72 hours after admission.6
The diagnosis of PE relies heavily on clinical suspicion. The classic triad of tachycardia,
hypoxia, and tachypnea may lead a clinician to investigate further. Although the gold
standard of diagnosis is the pulmonary angiogram, computed tomography (CT) with
contrast is the preferred modality for the diagnosis of PE. The mainstay of treatment of
PE is anticoagulation, with heparin or tissue plasminogen activator (tPa). In certain in-
stances, more invasive methods, such as catheter-directed thrombolysis and surgical
embolectomy, may be indicated. For more information on PE, please see the article on
“Submassive Pulmonary Embolism” by Drs Laurence W. Busse and Jason S. Vourlekis.
Gastrointestinal Conditions
There any many gastrointestinal disorders that may mimic chest pain. Gastroesopha-
geal reflux disease, esophageal spasm, esophageal rupture, or sliding hiatal hernia
may all present as acute chest pain in the ICU setting. Although an uncommon compli-
cation of transesophageal echocardiogram, esophageal rupture may be catastrophic
and lead to complications, such as mediastinitis. In the largest inpatient and surgical
setting review, the incidence of esophageal perforation was found to be 0.01%.7
Chest radiograph is typically abnormal in this group of patients. This complication
can be confirmed using water-soluble contrast before the patients’ chest radiography.
Musculoskeletal and Other Causes
In the hospital setting, anywhere from 10% to 30% of acute chest pain may be muscu-
loskeletal in origin.8 Clinical syndromes, such as costochondritis, lower rib pain syn-
dromes, fibromyalgia, or simply muscle spasm, may all be considered and can
typically be elicited through physical maneuvers.

AMI
Introduction
Coronary artery disease (CAD) is the leading cause of death worldwide.9 The term
acute coronary syndrome (ACS) is applied to patients with suspected ongoing
myocardial ischemia. There are 3 types of ACS: STEMI, non–ST-elevation MI
(NSTEMI), and unstable angina (UA). Two multicenter, international surveys studied
the relative frequency of these disorders: the Global Registry of Acute Coronary
Events (GRACE) and the Euro Heart Survey.10 These registries demonstrated that,
in 22,000 patients admitted with ACS, STEMI occurred in approximately 30%,
NSTEMI in 25%, and UA in 40%.
Definition of AMI
The diagnosis of AMI is made when there is a typical increase and decrease in cardiac
biomarkers indicating myocardial necrosis, plus one of the following to signify injury to
myocardium:

Symptoms of myocardial ischemia

Ischemic ECG changes (ST segments elevated or depressed)

Development of pathologic Q waves

Imaging evidence of new loss of viable myocardium or new regional wall motion
abnormalities1
 Acute Myocardial Infarction 345

The definition was revised in 2012 from the European Society of Cardiology, the
American College of Cardiology Foundation, the American Heart Association, and
the World Health Federation (ESC/ACCF/AHA/WHF). In addition to the aforemen-
tioned definition, any one of the following meets the diagnosis of AMI:

Cardiac death with symptoms suggestive of myocardial ischemia

Percutaneous coronary intervention (PCI)–related MI as defined by the elevation
of cardiac biomarkers to more than 3 times the upper limit of normal or a 20%
increase from baseline with symptoms of ischemia

Occlusive stent thrombosis when detected by coronary angiogram or autopsy in
the setting of acute ischemia

Coronary artery bypass graft surgery (CABG)–related MI as defined by the eleva-
tion of cardiac biomarkers such as cardiac troponin to more than 5 times the
upper limit of normal
Classification of MI
The ESC/ACCF/AHA/WHF joint task force further revised the classification of MI ac-
cording to the cause11; this has led to more specific definitions of AMI and addresses
different causes of troponin leak commonly seen in the ICU setting.

Type 1 (spontaneous MI): MI consequent to coronary arterial pathologic condi-
tions (eg, plaque erosion/rupture, fissuring, or dissection), resulting in intraluminal
thrombus

Type 2 (MI secondary to an ischemic imbalance or commonly referred to as
demand ischemia): MI consequent to increased oxygen demand or decreased
supply (eg, coronary endothelial dysfunction, coronary artery spasm, coronary
artery embolus, anemia, tachyarrhythmias/bradyarrhythmias, anemia, respira-
tory failure, hypertension, or hypotension)

Type 3 (MI resulting in death when biomarker values are unavailable): Sudden un-
expected cardiac death before blood samples for biomarkers could be drawn or
before their appearance in the blood

Type 4a (MI related to PCI)

Type 4b (MI related to stent thrombosis)

Type 5 (MI related to CABG)
Pathology
Coronary atherosclerosis
Almost all MIs are caused by underlying coronary atherosclerosis, generally superim-
posed with coronary thrombosis.2 It has been surmised that chronic, fibrous, athero-
sclerotic lesions of epicardial arteries are not the cause of AMI. In AMI, it is plaque
rupture, often of nonobstructive lesions, that exposes thrombogenic material promoting
platelet aggregation and thrombus formation. This acute interruption of blood flow cre-
ates an acute supply-demand mismatch of oxygen, leading to myocardial necrosis.2
Plaque composition and rupture
Plaques identified at autopsy, from patients with MI, are generally composed of
fibrous tissue with superimposed thrombus.2 Platelet-rich thrombi are commonly
found on the surface of these complicated lesions. It is thought that impaired endothe-
lial function may contribute to atherogenesis through the release of certain growth fac-
tors.2 Subsequent luminal narrowing further enhances platelet activation through
augmentation of shear forces.
In atherosclerotic plaques that are prone to rupture, there is an increased formation
of metalloproteinases that degrade the surrounding extracellular matrix.12 These
346 Ibrahim et al

proteinases are augmented by activated macrophages and mast cells that are found
in increased numbers at sites of plaque formation and rupture.13 Once plaque rupture
has occurred, platelets begin to adhere and are subsequently activated. This process
results in a cascade of activation of thrombogenic mediators, including thromboxane
A2, serotonin, adenosine diphosphate, platelet-activating factor, thrombin, tissue
factor, and oxygen-derived free radicals (Fig. 3).

Release of cardiac biomarkers

A variety of cardiac biomarkers are used to evaluate patients with suspected AMI. The
most common biomarkers are cardiac troponin I and T as well as the MB isoenzyme
of creatine kinase (CK-MB). Although absolute values differ between individual labora-
tories, reference values greater than the upper level limit should be considered abnormal.
Cardiac troponins (troponin I or troponin T) are the preferred marker for the diag-
nosis of myocardial injury given the increased specificity and sensitivity compared
with CK-MB.14 Cardiac troponins used in laboratory analysis are regulatory proteins
used in the calcium-mediated control of actin and myosin. Cardiac troponin I is unique
to adult cardiac myocytes, whereas cardiac troponin T can be found in small amounts
in skeletal muscle (Fig. 4, graph release biomarkers).15
However, it is crucial to examine the context in which elevations of cardiac troponin
are interpreted. The new AMI guidelines support the notion that not all elevations in
troponin are caused by ACS. Common causes in the hospital setting for elevated
troponin not associated with ACS are heart failure, rapid atrial fibrillation, myocarditis,
sepsis, and chronic kidney disease.16 The underlying process elevating troponin in
these settings is myocardial strain and necrosis. This process may be caused by direct
myocardial injury, such as seen in myocarditis or implantable cardioverter-defibrillator
defibrillation, or by elevated pressures in the heart (caused by increased preload or
afterload). In the case of elevated troponin levels and sepsis, a small study conducted
by Ammann and colleagues17 demonstrated a significant increase in mortality in pa-
tients with systemic inflammatory response syndrome and sepsis. Fifty-five percent

Fig. 3. Atherosclerosis. Progression of arterial plaque. The so-called vulnerable plaque consists
of a relatively large lipid core and a thin (<100 mm) fibrous cap. Thrombotic complications can
occur as a result of cap rupture, superficial endothelial erosion, intraplaque hemorrhage, or
erosion of a calcified nodule in which circulating blood elements come in contact with the
thrombogenic lipid core. (From Owens CD. Atherosclerosis. In: Cronenwett JL, Johnston KW,
editors. Rutherford’s vascular surgery. London: Elsevier Saunders; 2014; with permission.)
 Acute Myocardial Infarction 347

Fig. 4. Release of cardiac biomarkers. Timing of release of cardiac biomarkers following MI.
Peak A, early release of myoglobin or CK-MB isoforms after AMI; peak B, cardiac troponin
after AMI; peak C, CK-MB after AMI; peak D, cardiac troponin after unstable angina.
Data are plotted on a relative scale, whereby 1.0 is set at the AMI cutoff concentration.
(From Apple FS, Gibler WB. National Academy of Clinical Biochemistry Standards of Labora-
tory Practice: recommendations for the use of cardiac markers in coronary artery disease.
Clin Chem 1999;45:1104; with permission.)

of the patients with sepsis had elevated troponin and had a mortality of 22%,
compared with 5% in those without elevated cardiac troponin. Although, there is no
specific guideline for determining acceptable troponin elevations in this context, the
authors think that the clinical circumstances (eg, patient’s medical history and absolute
peak level and trend of cardiac biomarkers) should guide whether patients with
elevated troponins require further cardiac investigation once stabilized. If a patient’s
rise in troponin is believed to reflect true cardiac pathology, initiating ASA, unless
contraindicated, may prove beneficial because of its low incidence of complications.

Clinical manifestations of myocardial ischemia

An understanding of the cascade of events that occur during ACS will help direct patient
care. After acute occlusion of the coronary vessel, myocardial blood flow ceases, lead-
ing to initial diastolic and then systolic dysfunction. Myocardial wall motion abnormality
and diastolic impairment can be detected with echocardiography. As intracardiac pres-
sures continue to increase, the pulmonary-capillary wedge pressure increases. Electro-
cardiographic changes will subsequently occur, including ST segment changes;
subsequently, patients may present with angina (Fig. 5, manifestations).

STEMI
Introduction
STEMI includes a subset of patients with ACS presenting with a typical evolution of
ECG changes (described later). The underlying lesions cause transmural infarcts in
which myocardial necrosis involves the full thickness of the ventricular wall.2
In a retrospective study with hospitalized patients with AMI, the peak time for the
onset of symptoms was found to be between 6 AM and 12 PM.18 This pattern of circa-
dian periodicity corresponds to early morning increases in cortisol, catecholamines,
and platelet aggregability.19
Recently published observational data describe the mortality of in-hospital STEMI
versus outpatient STEMI. Patients who are hospitalized for noncardiac issues and
develop STEMI have significantly reduced survival to discharge versus outpatient
STEMI (60% vs 96%).20 This surprising result was primarily driven by a delay to
348 Ibrahim et al

Fig. 5. Manifestations of myocardial ischemia. The relative development of the manifesta-

tions of myocardial ischemia as the rate-pressure product is increased. Regional myocardial
dysfunction, which can be detected as regional wall motion abnormalities on echocardiog-
raphy, occurs before ECG changes or anginal chest pain. PCW, pulmonary capillary wedge.
(Adapted from Beller GA. Myocardial perfusion imaging for detection of silent myocardial
ischemia. Am J Cardiol 1988;61:22.)

ECG time, which was 36 minutes longer in the inpatient setting. Although counterintu-
itive, critical care providers need to be extra vigilant in activating emergency cardiac
STEMI protocols for in-hospital patients with STEMI to avoid delays beyond what is
experienced for patients presenting in the emergency department or in transfer from
another institution. This may be caused by hospitals not having as streamlined a pro-
cess for STEMI recognition and care activation for in-hospital patients.

Clinical Features
Physical examination
Despite severe symptoms and extensive myocardial damage, physical examination
findings during AMI may be unremarkable. Nonspecific findings of cardiac dysfunction
may include muffled heart sounds, an S3 or S4, transient systolic murmurs, and peri-
cardial friction rubs.

Electrocardiographic findings

Although not frequently seen, hyperacute (or peaked) T waves develop initially
reflective of localized hyperkalemia.

Next there is J-point elevation, and the ST segment retains its normal concave
configuration.

Over time, the ST-segment elevation becomes more pronounced, becoming
more convex or rounded upward.

Lastly, the ST segment may become contiguous with the T wave.

Electrocardiographic diagnosis
The joint ESC/ACCF/AHA/WHF developed the following criteria for the diagnosis of
STEMI11:

New ST segment elevation at the J point in 2 contiguous leads, with greater than
0.1 mV in all leads other than V2-V3

For leads V2-V3, greater than 0.2 mV for men older than 40 years or greater than
0.15 mV elevation for women

New left bundle branch block with consistent changes and only in the setting of a
high degree of clinical suspicion
 Acute Myocardial Infarction 349

Serum markers of cardiac damage

The diagnosis of AMI necessitates certain clinical findings along with the increase or
decrease of cardiac biomarkers. Commonly used biomarkers include the CK isoen-
zymes (MB) and cardiac-specific troponins. Because of the prevalence of discordant
values between cardiac troponins and CK-MB, cardiac troponins are the preferred
marker for the diagnosis of AMI.21
Recommendations for the evaluation of cardiac biomarkers are constantly changing
because of newer technology and availability. It is generally recommended to check
Troponin I (TnI) and Troponin T (TnT) at the initial presentation and every 6 to 8 hours
if the initial value was negative. It is common in practice, however, to check a second
troponin earlier because 80% of patients presenting with AMI have a positive marker
within 2 to 3 hours.22 CK-MB is currently used when cardiac troponin markers are un-
available or to assess for reinfarction as elevated troponins take longer to return to
baseline after an initial injury.

Acute Management
Assessment of reperfusion options for STEMI
Rapid reperfusion with early PCI remains the standard of care for patients presenting
with STEMI. In a PCI-capable hospital, focus should be made on timely activation of
the cardiac catheterization laboratory according to hospital protocols. In non–PCI-
capable hospitals, focus should shift to reperfusion therapies with thrombolytics
(tPA), emergent transfer to a PCI-capable facility, or both. Guidelines have shifted to
pursuing coronary reperfusion within 90 minutes of the first medical contact.

General treatment measures

Aspirin Aspirin is the cornerstone of the initial treatment of ACS. Pharmacologic ac-
tion relies on blocking the formation of thromboxane A2 in platelets. Aspirin should
be chewed in order to facilitate rapid absorption.

b-blockers b-blockers decrease heart rate and systemic arterial pressure, thus,
decreasing myocardial oxygen demand. These drugs have been shown to reduce
angina and decrease infarct size and should be used in all patients with STEMI unless
contraindicated.23
Nitrates Nitrates enhance coronary blood flow and decrease ventricular preload. Sub-
lingual nitroglycerin is indicated for almost all patients with STEMI except those in
shock or those who have ingested recent phosphodiesterase (type 5) inhibitors,
such as sildenafil.

Statins Intensive statin therapy is recommended as early as possible in all patients

with STEMI. Clinical trials, such as PROVE IT-TIMI 22 and MIRACL, have demon-
strated the efficacy of early statin admisintration.24

Anticoagulant and antiplatelet therapy

Antiplatelet therapy P2Y12 receptor inhibitors are a central component of antiplatelet
therapy in patients with acute coronary syndromes (NSTEMI, STEMI, and UA) (Fig. 6).
Thienopyridines (clopidogrel, ticagrelor, prasugrel) work by furthering platelet inhibi-
tion at the level of the ADP receptor and are indicated in the acute management of
ACS. Trials, such as CURE and CLARITY-TIMI 28, have demonstrated improved out-
comes in patients with ACS receiving these agents.25,26
The latest version of the ACCF/AHA’s guidelines on antiplatelet therapies in UA/
NSTEMI highlighted the pivotal role of these antiplatelet agents.27 The use of prasugrel
and ticagrelor were approved by the Food and Drug Administration (FDA) following
350 Ibrahim et al

Fig. 6. Anticoagulants and antiplatelets. (From Michelson A. Antiplatelet therapies for the
treatment of cardiovascular disease. Nat Rev Drug Discov 2010;9:156; with permission.)

head-to-head comparison trials with clopidogrel, in which prasugrel, and ticagrelor were
found to be superior to clopidogrel in reducing clinical events at the expense of
increased risk of bleeding. The major trial for prasugrel, TRITON-TIMI 38, focused on pa-
tients with ACS who were referred for PCI.28 The loading dose of prasugrel was 60 mg
followed by 10 mg daily maintenance dose. There was a significant 2.2% absolute
reduction and a 19% relative reduction in the composite event rate of death from car-
diovascular causes. However, there was a significant increase in the rate of bleeding,
reaching 2.4% of patients taking prasugrel versus 1.8% of patients taking clopidogrel.28
The pivotal trial for ticagrelor, Platelet Inhibition and Patient Outcomes (PLATO),29
was a multicenter randomized controlled trial comparing ticagrelor with clopidogrel.
At 12 months, ticagrelor was associated with a 1.9% absolute reduction and 16% rela-
tive reduction in the primary composite outcome (time to first occurrence of the com-
posite of vascular death, MI, or stroke). Ticagrelor exhibits a reversible inhibition of the
P2Y12 receptor and is associated with a more rapid functional recovery of circulating
platelets.29 The FDA approved ticagrelor on July 20, 2011, with a boxed warning indi-
cating that an aspirin daily maintenance dose of greater than 100 mg decreases the
effectiveness of ticagrelor.
 Acute Myocardial Infarction 351

The ACCF/AHA’s guidelines27 on the choice of P2Y12 receptor inhibitors along with
aspirin in patients with ACS are based solely on the TRITON-TIMI 38 and PLATO trial,
and their clinical use should be determined with this perspective. For instance, prasu-
grel was administered only in the setting of PCI, whereas ticagrelor was studied in all-
comer patients with UA/NSTEMI. Therefore, it is not recommended that prasugrel be
administered routinely to patients with UA/NSTEMI before angiography. Additionally,
the increased bleeding risks associated with prasugrel and ticagrelor have to be taken
into consideration as well as the potential excess risk in the elderly. There is no head-
to-head comparison between prasugrel and ticagrelor.
Glycoprotein (GP) IIb/IIIa receptor antagonists’ efficacy in patients with ACS has been
well established during PCI procedures and in patients with UA/NSTEMI, particularly
high-risk patients, such as patients with elevated troponin biomarkers, those with dia-
betes, and those undergoing revascularization.27 Most of the evidence on the use of
glycoprotein IIb/IIIA receptor antagonists predated the trials that established the benefits
of clopidogrel.27 More recent trials focused on determining the optimal timing of the initi-
ation of GP IIb/IIIa receptor antagonist in patients with UA/NSTEMI. These studies sup-
ported the upstream use of a GP IIb/IIIa receptor antagonist as a second agent in
combination with aspirin for dual antiplatelet therapy in patients with UA/NSTEMI, espe-
cially in high-risk subsets, such as those with elevated cardiac biomarkers, diabetes, and
undergoing PCI. The EARLY ACS30 and ACUITY31 trials highlighted the potential bleeding
risks of the upstream use of GP IIb/IIIa receptor antagonist as part of triple antiplatelet
therapy with aspirin and clopidogrel. The trial revealed that the routine use of GP IIb/
IIIa receptor antagonists as part of triple antiplatelet therapy is associated with bleeding
risks and its use in non–high-risk patients, such as those without diabetes, with normal
baseline troponin levels, and patients older than 75 years, should not be adopted.27
Timing of discontinuation of P2Y12 receptor inhibitor therapy before CABG The
ACCF/AHA’s 2012 guidelines on the management of patients with UA/NSTEMI sug-
gest discontinuation of clopidogrel therapy for at least 5 days before CABG, a period
of at least 7 days in patients receiving prasugrel, and a period of at least 5 days in pa-
tients receiving ticagrelor before their planned CABG. In urgent situations demanding
more timely operative revascularization, consultation with the cardiothoracic surgeon
is warranted.27

Anticoagulant therapy Heparin, low-molecular-weight heparin, bivalirudin, and fonda-

parinux are the major anticoagulants that have been extensively studied in ACS. The
current recommendations confer the use of at least one of these anticoagulants regard-
less of where an invasive or conservative approach is taken. In the group of patients with
UA/NSTEMI in whom an initial conservative strategy is selected with no subsequent fea-
tures that would necessitate diagnostic angiography (recurrent symptoms, heart failure,
or serious arrhythmias), it is recommended to start unfractionated heparin (level of
evidence [LOE] A) for 48 hours or to administer enoxaparin (LOE A) or fondaparinux
(LOE B) over bivalirudin for the duration of hospitalization up to 8 days and then dis-
continue anticoagulant therapy. For patients with UA/NSTEMI in whom PCI has been
selected as a postangiography management strategy, it is recommended to start
unfractionated heparin or bivalirudin as opposed to low-molecular-weight heparin and
to discontinue anticoagulant therapy after PCI for uncomplicated cases (LOE A).

Fibrinolytic therapy versus invasive strategy

Before the advent of PCI, fibrinolytic therapy was the mainstay of reperfusion therapy in
STEMI. Patients receiving fibrinolytics earlier in their course demonstrated the most
favorable outcomes, coining the concept that time is muscle.32 However, thrombolytics
352 Ibrahim et al

have limitations. Infarct vessel patency was restored in only 60% to 85% of patients.
Reocclusion and/or reinfarction occurred in 30% of patients by 3 months, which led
to increased mortality. Increased rates of intracranial hemorrhage and other significant
bleeding were also demonstrated.
Coronary angiography in a PCI-capable hospital is the current gold standard of
treatment in STEMI if this therapy can be delivered within 120 minutes of the first med-
ical contact. Current guidelines support immediate angiography in all patients pre-
senting within 12 hours of symptoms. However, in patients with severe heart failure
or cardiogenic shock, PCI should be attempted regardless of the time of presentation.
PCI should also be considered early if evidence of failed fibrinolysis is present.33
A large 2009 meta-analysis of randomized controlled trials (RCT) and observational
studies (OS) was conducted. It compared primary PCI (with balloon angioplasty or
stenting) with fibrinolysis. The study found that primary PCI was associated with sig-
nificant reductions in short-term (6 weeks) mortality of 34% in the RCT. It was also
associated with significant reductions in long-term (>1 year) mortality of 24% and rein-
farction of 51% in the RCT. This finding was not noted in the OS being analyzed.34
In summary for most patients, there is a plethora of evidence from clinical trials that
demonstrate superiority of primary PCI regardless of whether balloon angioplasty or
stenting is performed.
Guidelines for the Management of Patients with STEMI
Stents
The advent of the bare-metal stent (BMS) drastically altered reperfusion strategy since
the 1990s (Fig. 7). Although dramatically improving procedural success over balloon
angioplasty, there still remained a high incidence (10%–20%) of target vessel revas-
cularization. Drug-eluting stents (DES) advanced this mode of interventional therapy
and, on the whole, demonstrate a 50% to 70% decrease in repeat revascularization
seen with BMS.35 DES possess antiproliferative drugs that elute from polymers on
the metal scaffolding. These drugs decrease the rate of neointimal hyperplasia, the un-
derlying pathophysiologic process behind restenosis.
These antiproliferative coatings delay normal endothelial healing within the stent.
During this phase, in the absence of antiplatelet therapy, patients are at increased
risk of stent thrombosis. The current guidelines recommend a dual antiplatelet
regimen (aspirin plus thienopyridine) for at least 1 month following revascularization
with a BMS and 12 months after DES. DES are generally preferred over BMS, given
the reduced rates of restenosis, with more pronounced benefit in left main coronary
artery PCI, small-caliber vessels, diffuse CAD, diabetes, and saphenous vein grafts.
BMS should strongly be considered in patients that have upcoming surgery within
1 year, a history of medical noncompliance, and patients considered to be at high
risk for bleeding. Special consideration should be made for patients who will require
outpatient systemic anticoagulation with agents such as warfarin.

UA AND NSTEMI

UA is defined as angina pectoris (or an equivalent type of ischemic discomfort) with at

least one of 3 features:

Occurring at rest (or minimal exertion) and usually lasting greater than 20 minutes
(if not interrupted by the administration of a nitrate or an analgesic)

Being severe and usually described as frank pain

Occurring with a crescendo pattern (ie, pain that awakens patients from sleep or
that is more severe, prolonged, or frequent than previously)36
 Acute Myocardial Infarction 353

Fig. 7. STEMI algorithm. Reperfusion therapy for patients with STEMI. The bold arrows and
boxes are the preferred strategies. CABG, coronary artery bypass graft; DIDO, door-in–door-
out; FMC, first medical contact; LOE, Level of Evidence; MI, myocardial infarction; PCI, percu-
taneous coronary intervention; STEMI, ST-elevation myocardial infarction. *Patients with
cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should
be transferred for cardiac catheterization and revascularization as soon as possible, irrespec-
tive of time delay from MI onset. yAngiography and revascularization should not be per-
formed within the first 2 to 3 hours after administration of fibrinolytic therapy. (From
O’Gara, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of
ST-elevation myocardial infarction: executive summary. Circulation 2013;127:529–55; with
permission.)

Approximately two-thirds of patients with UA have evidence of myocardial necrosis

from elevated cardiac serum markers, such as cardiac-specific TnT, TnI, and CK-MB,
and, thus, have a diagnosis of NSTEMI.36 With the introduction of more sensitive
troponin assays, a higher percentage of patients with UA/NSTEMI will exhibit some
release of cardiac biomarkers. This circumstance has led to an increase in the proportion
of cases designated as NSTEMI, with a concomitant reduction in the fraction with UA.

Pathophysiology
Five main pathophysiologic processes serve as underlying mechanisms for UA/
NSTEMI (Fig. 8)37:

Plaque rupture or erosion with superimposed nonocclusive thrombus is the most
common.

Dynamic intracoronary obstruction has a variety of causes, such as epicardial ar-
tery spasm or the enhanced action of local platelet-released vasoconstrictors,
such as thromboxane A2. Other factors include a disruption in coronary intramu-
ral muscular regulatory function; endothelial dysfunction; and adrenergic stimuli,
such as cold exposure or cocaine.

In secondary UA, myocardial oxygen demand outstrips oxygen supply (eg, fever,
sepsis, hypotension, anemia).
354 Ibrahim et al

Fig. 8. Pathophysiology of unstable angina: 5 main processes contributing to the development

of unstable angina. MVO2, myocardial oxygen consumption. (Adapted from Braunwald EG.
Unstable angina: An etiologic approach to management. Circulation 1998;98 2219–22; with
permission.)

Progressive chronic coronary luminal narrowing resulting in downstream

myocardial ischemia is also an underlying mechanism.37

Electrocardiography and Serum Biomarkers

Electrocardiography
All patients with UA/NSTEMI should be placed on continuous electrocardiographic
monitoring to identify ischemia-related arrhythmias and recurrent ST segment
changes indicating ongoing ischemia. A repeat ECG should follow the initial ECG ob-
tained in 6 to 12 hours. It has been reported that up to 50% of patients with UA/
NSTEMI38 present with ECG abnormalities, namely, ST depression (transient ST
elevation) and T wave changes. Novel ECG changes noted on admission are a reliable
measure of ischemia and prognosis. Approximately 10% of patients with UA/NSTEMI
exhibit transient (<20 minutes) ST elevation. ST elevation portends a high risk of future
cardiac events. It is hypothesized that ST depressions (>0.1 mV) and marked T-wave
inversions (>0.3 mV) are sensitive but not specific markers of acute ischemia.
Dynamic ECG changes manifesting as recurrent ST depressions are an indepen-
dent marker of an adverse outcome.39

Serum cardiac biomarkers

It is essential to measure serum cardiac biomarkers in all patients with ACS as these
aid in identifying patients with UA or NSTEMI. A cardiac-specific troponin is the
preferred marker. In patients with negative cardiac markers within 6 hours of the onset
of pain, another sample should be drawn in the 6- to 12-hour time frame. Persistent
elevation of troponin after an acute event is associated with worsened outcomes.40

Clinical Classification
Patients presenting with UA/NSTEMI compose a heterogeneous population.41 A clin-
ical classification of patients with UA/NSTEMI provides a useful means to stratify risk.
Patients fall into 3 groups depending on the underlying pathophysiology.
 Acute Myocardial Infarction 355

Group A from secondary UA

Group B suffers from primary UA

Group C from postinfarction angina41
Simultaneously, patients are classified according to the severity of ischemia. This
classification (Table 1) provides valuable prognostic information. It has the added util-
ity of identifying high-risk patients, mainly those with ongoing or recurrent chest pain
and primary/secondary UA (see Table 1).41

Risk Assessment Scores

Integrating variables from the ECG, serum biomarkers, and clinical variables, multiple
risk assessment scores have been derived.
The TIMI risk score assigns one point to each of the following 7 independent risk
factors:

Age greater than 65 years

Greater than 3 risk factors of CAD

ST deviation greater than 0.5 mm

Greater than 2 episodes of angina in the last 24 hours

Documented CAD at catheterization

Aspirin use within the prior week

Elevated cardiac biomarkers
Using the TIMI risk score, patients can be risk stratified across an almost 10-fold
gradient of risk of death, urgent revascularization, or MI at 14 days from 4.7% (TIMI
0/1) to 40.9% (TIMI 6/7) (P<.001).36
It is noted that patients with higher TIMI risk scores have significant reductions in
cardiac events when treated with an invasive versus conservative management
strategy.42

Table 1
Classification of UA

Clinical circumstances
Severity A. Develops in B. Develops in C. Develops within
presence of absence of 2 wk after MI
extracardiac extracardiac (postinfarction UA)
condition that condition
intensifies (primary UA)
myocardial
ischemia
(secondary UA)
I. New onset of severe angina IA IB IC
or accelerated angina, no
rest pain
II. Angina at rest within past IIA IIB IIC
month but not within
preceding 48 h (angina at
rest, subacute)
III. Angina at rest within 48 h IIIA IIIB IIIC
(angina at rest, acute)

Adapted from Braunwald E. Unstable angina: a classification. Circulation 1989;80:410; with

permission.
356 Ibrahim et al

Another helpful risk assessment score is the GRACE score. This score has also
identified factors associated independently with increased mortality:

Age

Killip classification (Table 2)

Increased heart rate

ST-segment depression

Signs of heart failure

Lower systolic blood pressure

Cardiac arrest at presentation

Elevated serum creatinine or cardiac biomarkers43

Treatment strategies and interventions

There are 2 main approaches to the management of patients with UA/NSTEMI:

The early invasive approach (Fig. 9) is a strategy that involves early cardiac cath-
eterization followed by PCI, CABG, or more intensive medical therapy.36

The conservative approach (Fig. 10) is a treatment arm that focuses on medical
management with cardiac catheterization reserved for patients with recurrent
ischemia either at rest or on a noninvasive stress test with subsequent revascu-
larization if deemed appropriate.36
To date, the aforementioned approaches were studied in 10 large randomized trials,
6 of which demonstrated a significant benefit of an early invasive strategy.44–46 A
recent meta-analysis of the more recent trials has concluded that managing NSTEMI
by an early invasive strategy results in an overall significant reduction in death, MI, or
rehospitalization and of mortality during a mean follow-up of 2 years whereby the inci-
dence of all-cause mortality was 4.9% in the early invasive group compared with 6.5%
in the conservative group (risk ratio 5 0.75, 95% confidence interval 0.63 to 0.90, P 5
.001). It also demonstrated a benefit of an early invasive strategy in all men and high-
risk women but not in low-risk women.46
Indications for Invasive Versus Conservative Management Strategies
Based on the results of several recent randomized trials and meta-analyses, an early
invasive strategy is the recommended strategy in patients with UA/NSTEMI with the
following:

ECG changes, namely, ST depressions

Positive troponins

Other high-risk features, including recurrent ischemia and evidence of conges-
tive heart failure36

Table 2
Killip classification

Killip Subgroup Clinical Characteristics Hospital Mortality (%)

I No congestion signs <6
II S3, basal rales <17
III Acute pulmonary edema 38
IV Cardiogenic shock 81

Data from Killip T, Kimball J. Treatment of myocardial infarction in a coronary care unit: a two year
experience with 250 patients. Am J Cardiol 1967;20:457–65.
 Acute Myocardial Infarction 357

Fig. 9. Algorithm for patients with UA/NSTEMI managed by an initial invasive strategy. ASA,
aspirin; IV, intravenous; UFH, unfractionated heparin. (From Anderson JL, Adams CD, Antman
EM, et al, 2011 Writing Group Members, ACCF/AHATask Force Members. 2011 ACCF/AHA focused
update incorporated into the ACC/AHA 2007 guidelines for the management of patients with
unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Car-
diology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation
2011;123(18):e426–579. http://dx.doi.org/10.1161/CIR.0b013e318212bb8b; with permission.)

The following two trials have provided evidence to a very early invasive strategy,
especially in high-risk patients:

In the Intracoronary Stenting with Antithrombotic Regimen Cooling-Off (ISAR-
COOL) trial,47 immediate invasive strategies were beneficial with an average
time from randomization to catheterization of 2 hours compared with 4 days
with a delayed invasive strategy.

In the TIMACS trial,48 the primary end point was death, stroke, and MI. It
compared early (median 5 14 hours after randomization) with later (median 5
50 hours) angiography. A trend in reduction of the primary end point (death,
MI, and stroke) was noted in the overall group but a significant reduction in the
primary end point was achieved in patients with a high GRACE risk score. There
was also a significant 28% reduction of the secondary end point of death, MI,
and refractory ischemia with earlier angiography.
358 Ibrahim et al

Fig. 10. Algorithm for patients with UA/NSTEMI managed by an initial conservative strategy.
ASA, aspirin; EF, ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction;
UFH, unfractionated heparin. (From Anderson JL, Adams CD, Antman EM, et al, 2011 Writing
Group Members, ACCF/AHA Task Force Members. 2011 ACCF/AHA focused update incorpo-
rated into the ACC/AHA 2007 guidelines for the management of patients with unstable
angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiol-
ogy Foundation/American Heart Association Task Force on Practice Guidelines. Circulation
2011;123(18):e426–579. http://dx.doi.org/10.1161/CIR.0b013e318212bb8b; with permission.)

ACUTE COMPLICATIONS OF MI

Free wall rupture
The incidence of this complication seems to be decreasing with significant
improvement in time to reperfusion. It is noted that rupture of the free wall
of the infarcted ventricle occurs in up to 10% of patients dying in the hospital
of STEMI.36
This condition occurs more commonly in the elderly, women, and usually in-
volves the anterior or lateral walls of the left ventricle in the area of terminal dis-
tribution of the left anterior descending artery. It also occurs more frequently
in patients with STEMI who were subjected to fibrinolytic therapy as opposed
to PCI.49 Rupture of the free wall is commonly associated with hemopericar-
dium and death from cardiac tamponade. Incomplete rupture may occur
 Acute Myocardial Infarction 359

when organizing thrombus and hematoma seal a left ventricular rupture and
prevent the development of hemopericardium. The tenous patch of thrombus
results in the formation of pseudoaneurysm that communicates with the left
ventricular cavity.

Rupture of the interventricular septum
The risk of a rupture causing ventricular septal defect increases with increasing
age, the lack of development of a collateral network, and anterior infarc-
tion.50 Clinically, this condition appears by the presence of a new harsh,
loud holosystolic murmur that is heard best at the lower left sternal border
and accompanied by a thrill.51 Diagnosis is usually made by echocardiogra-
phy with color flow.

Rupture of a papillary muscle
This complication is a rare yet fatal complication of a transmural MI. Anterolat-
eral wall MI can lead to the rupture of the anterolateral papillary muscle, yet
inferior wall infarction can lead to the rupture of the posteromedial papillary
muscle, which occurs more commonly. The sudden onset of severe mitral
regurgitation is a catastrophic result of a complete transection of a papillary
muscle and is not compatible with life. The rupture of a partial portion of the
papillary muscle will present less dramatically.36 Patients with this condition
develop a new holosystolic murmur that may attenuate as the systemic arte-
rial pressure decreases. The diagnosis of this condition can be promptly
made by echocardiography. Color flow Doppler can differentiate acute
mitral regurgitation from a ventricular septal defect.
Surgical treatment remains the most definitive treatment modality for patients with a
mechanical complication caused by MI. Often, however, surgery is not an option either
because of hemodynamic instability or from a lack of suitable tissue in which to oper-
ate on. Percutaneous options for closure of post-MI ventricular septal defects exist but
are made difficult by the friability of infarct scar and the serpiginous track of infarcted
tissue. Any post-MI mechanical complication demands urgent cardiovascular consul-
tation to determine if any treatment options exist and to evaluate the potential benefits
of ventricular assist options in the setting of clinical instability.

POST-MI CARE

The following is according to the 2013 guidelines from the ACCF/AHA and the ESC for
the management of AMI in patients presenting with STEMI52,53:
All hospitals participating in the care of patients with STEMI should have a coronary
care unit (CCU) equipped to provide all aspects of care for patients with STEMI,
including treatment of ischemia, severe heart failure, arrhythmias, and common
comorbidities (class I, LOE C).53
All patients should have an echocardiography for the assessment of infarct size and
resting left ventricular function (class I, LOE C52; class I, LOE B53). Patients undergoing
uncomplicated successful reperfusion therapy should be kept in the CCU for a mini-
mum of 24 hours, after which they may be moved to a step-down monitored bed
for another 24 to 48 hours (class I, LOE C).53 The Primary Angioplasty in Myocardial
Infarction II (PAMI-II) trial showed that low-risk patients with successful primary PCI
could be safely discharged from the hospital at day 3 without noninvasive testing.54
To identify these low-risk patients, schemes such as the PAMI-II criteria designate
low-risk patients as
1. Less than 70 years of age
360 Ibrahim et al

2. Left ventricular ejection fraction greater than 45%

3. One- or 2-vessel disease, successful PCI, and no persistent arrhythmias
In general, the decision to transfer patients out of the CCU involves the physician
and nursing staff and is usually favored in the following:
1. Absence of recurrent chest pain
2. Presence of hemodynamic stability
3. Down trending cardiac biomarkers
4. Successful uncomplicated revascularization
5. The absence of unstable arrhythmias or dynamic ECG changes
Long-term antithrombotic and antiplatelet therapy at hospital discharge should be
continued depending on the adopted ACS management strategy (conservative vs
invasive in UA/NSTEMI) and depending on whether a bare-metal or drug-eluting intra-
coronary stent was deployed (Fig. 11).
Secondary prevention and long-term management strategies should also be initi-
ated, with benefits that are seen even with early initiation in the ICU setting. These stra-
tegies include counseling on smoking cessation, a target blood pressure goal less
than 140/90 mm Hg (or <130/90 if diabetes or chronic kidney disease is present),
and intensive lipid management therapy with high-intensity statins.55 The goal of treat-
ment with statin therapy is to achieve a low-density-lipoprotein cholesterol (LDL-C) of
100 mg/dL. For very-high-risk patients, namely, those with established CAD plus (1)

Fig. 11. The ACC/AHA’s guideline for long-term antithrombotic therapy at hospital discharge
after UA/NSTEMI. INR, international normalized ratio. (From Cannon CP, Braunwald EG,
editors. Unstable angina and non–ST elevation myocardial infarction. In: Bonow RO, Mann DL,
Zipes DP, et al, editors. Braunwald’s heart disease: a textbook of cardiovascular medicine. 9th
edition. Saunders Publishing; 2011; with permission.)
 Acute Myocardial Infarction 361

multiple major risk factors (especially diabetes), (2) severe and poorly controlled risk
factors (especially continued cigarette smoking), (3) multiple risk factors of the meta-
bolic syndrome (especially high triglycerides >200 mg/dL plus non–high-density-lipo-
protein cholesterol [HDL-C] >130 mg/dL with low HDL-C <40 mg/dL), and (4) patients
with acute coronary syndrome, an LDL-C target of 70 mg/dL is reasonable.55 In addi-
tion, cardiac rehabilitation and secondary prevention programs are recommended for
patients with STEMI.54 Finally, patients should be on optimal medical therapy,
including antiplatelet therapy, as per the ACC/AHA’s guidelines listed in Fig. 11.

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