II. Evaluation

  1. Echocardiogram
    1. Ejection Fraction is best predictor of prognosis
  2. Stress Test
    1. Indicated for Myocardial Infarction if angiography was not performed
      1. Class I evidence - standard of care (most recurrent cardiovascular events occur in the first month after Myocardial Infarction)
    2. Precautions
      1. Do not perform if revascularization was performed
      2. Must be stable for 48-72 hours prior to testing
    3. Protocols
      1. Submaximal test 3-6 days post-Myocardial Infarction (prior to discharge) or
      2. Symptom limited, maximal stress test at 2-3 weeks if not performed prior to discharge
  3. Coronary Angiogram Indications
    1. Check Re-perfusion after:
      1. Large or Anterior Myocardial Infarction
      2. Thrombolytic use

III. Management: Formal, consistent hospital education process

  1. Review lifestyle interventions below
  2. Primary care and cardiology follow-up
  3. Review of hospital diagnoses
  4. Emergent symptoms and signs
    1. Unstable Angina
      1. Review Nitroglycerin home protocol
    2. Congestive Heart Failure
      1. Review weight monitoring
      2. Significant weight gain is 2 pounds in one day or 5 pounds overall over baseline
    3. Cerebrovascular Accident
      1. Risk increased 44 fold in first 30 days post-MI
      2. Witt (2005) Ann Intern Med 143:785-92 [PubMed]
  5. Medication Compliance is critical (review their importance and risk of stopping)
    1. Antiplatelet agents (Aspirin, Clopidogrel)
    2. Beta Blockers
    3. Statins
    4. ACE Inhibitor (or ARB Agents)
    5. Nitroglycerin as needed
  6. Identify and manage barriers to compliance
    1. Transportation to appointments
    2. Medication cost (e.g. limit number of medications and stick to generics)
    3. Use medication Pillbox, alarms

IV. Management: Lifestyle recommendations and education

  1. Mediterranean Diet
  2. Tobacco Cessation
    1. Strongly consider Nicotine Replacement on discharge
  3. Activity
    1. Cardiac Rehabilitation
    2. Brisk walking or similar moderate intensity Exercise for 150 minutes per week
  4. Treat Comorbid Major Depression (present in 15-22%)
    1. See Depression Management in Cardiovascular Disease
    2. Risk of MI related death increased 3.5 fold

V. Management: Restrictions following ST Elevation Myocardial Infarction

  1. Walking
    1. Initiate soon after discharge
  2. Sexual activity
    1. May begin at one week following discharge
    2. Stress test predicts safety and risk of ischemia
      1. Drory (1995) Am J Cardiol 75:835-7 [PubMed]
  3. Driving
    1. May begin at 3 weeks following discharge
  4. Air travel
    1. May begin flying at 2 weeks
    2. Exception for flight earlier than 2 weeks:
      1. Symptom free AND
      2. Has Nitroglycerin AND
      3. Has a traveling partner AND
      4. Avoids increased physical exertion

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Ontology: Myocardial Infarction (C0027051)

Definition (MEDLINEPLUS)

Each year over a million people in the U.S. have a heart attack. About half of them die. Many people have permanent heart damage or die because they don't get help immediately. It's important to know the symptoms of a heart attack and call 9-1-1 if someone is having them. Those symptoms include

  • Chest discomfort - pressure, squeezing, or pain
  • Shortness of breath
  • Discomfort in the upper body - arms, shoulder, neck, back
  • Nausea, vomiting, dizziness, lightheadedness, sweating

These symptoms can sometimes be different in women.

What exactly is a heart attack? Most heart attacks happen when a clot in the coronary artery blocks the supply of blood and oxygen to the heart. Often this leads to an irregular heartbeat - called an arrhythmia - that causes a severe decrease in the pumping function of the heart. A blockage that is not treated within a few hours causes the affected heart muscle to die.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI_FDA) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (NCI_CTCAE) A disorder characterized by gross necrosis of the myocardium; this is due to an interruption of blood supply to the area.
Definition (NCI) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (CSP) gross necrosis of the myocardium, as a result of interruption of the blood supply to the area.
Definition (MSH) NECROSIS of the MYOCARDIUM caused by an obstruction of the blood supply to the heart (CORONARY CIRCULATION).
Concepts Disease or Syndrome (T047)
MSH D009203
ICD10 I22 , I21
SnomedCT 66514008, 266288001, 155304006, 194796000, 233824008, 22298006
LNC LP98884-7, MTHU035551, LA14274-7, LA10558-7
English Myocardial Infarct, Infarctions, Myocardial, Myocardial Infarction, Myocardial Infarctions, Infarcts, Myocardial, Myocardial Infarcts, HEART ATTACK, Infarct, Myocardial, Infarction, Myocardial, MI, Myocardial infarction (MI), Attack heart (NOS), Infarct myocardial, cardiac infarction, Myocardial Infarction [Disease/Finding], attacking heart, heart attacks, attack hearts, infarctions myocardial, infarcts myocardial, myocardial infarctions, Infarction;heart, myocardial infarcts, Infarction;myocardial, AMI, attacks coronary, attacks hearts, coronary attack, disorder infarction myocardial, myocardial necrosis, syndrome myocardial infarction, heart attack, mies, Heart Attack, Attack - heart, Cardiac infarct, myocardial infarction, myocardial infarction (diagnosis), MI, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, (MI), INFARCTION (MI), MYOCARDIAL, -- Heart Attack, Cardiovascular Stroke, Cardiovascular Strokes, Stroke, Cardiovascular, Strokes, Cardiovascular, Myocardial infarct, Myocardial infarction, Heart attack, MI - Myocardial infarction, Cardiac infarction, Infarction of heart, Myocardial infarction (disorder), cardiac; infarction, infarction; myocardial, Cardiac infarction, NOS, Heart attack, NOS, Infarction of heart, NOS, Myocardial infarction, NOS, Heart Attacks, Infarctions (Myocardial), Myocardial infarction NOS, Attack coronary, heart infarction
German MYOKARDINFARKT, Koronarattacke, Herzanfall, MI, Herzanfall (NNB), HERZANFALL, Herzinfarkt, Myokardinfarkt
Dutch hartaanval, hartinfarct, hartaanval (NAO), MI, cardiaal; infarct, infarct; myocard, myocardinfarct, Hartinfarct, Infarct, myocard-, Myocardinfarct
French Crise coronaire, IM, Crise cardiaque SAI, Crise cardiaque, CRISE CARDIAQUE, INFARCTUS DU MYOCARDE, IDM (Infarctus Du Myocarde), Infarctus du myocarde, Infarctus myocardique
Italian MI, Attacco cardiaco, Attacco coronarico, Attacco cardiaco (NAS), Infarto del miocardio, Infarto miocardico
Portuguese Ataque coronário, Ataque do coração, Ataque cardíaco NE, EM, ATAQUE CARDIACO, ENFARTO DO MIOCARDIO, Enfarte do miocárdio, Infarto do Miocárdio
Spanish IM, Crisis coronaria, Ataque al corazón, Ataque al corazón (NEOM), Infarto miocárdico, ATAQUE CARDIACO, INFARTO DE MIOCARDIO, Infarto al Miocardio, ataque al corazón, infarto cardíaco, infarto de corazón, infarto de miocardio (trastorno), infarto de miocardio, Infarto de miocardio, Infarto del Miocardio
Japanese 心臓発作(NOS), 冠発作, 心臓発作, カンホッサ, シンゾウホッサNOS, シンゾウホッサ, シンキンコウソク, 冠状動脈梗塞, 心筋梗塞, 冠動脈梗塞, 心筋梗塞症
Swedish Hjärtinfarkt
Czech infarkt myokardu, Srdeční záchvat, Srdeční záchvat (NOS), IM, Koronární záchvat, Infarkt myokardu
Finnish Sydäninfarkti
Russian INFARKT MIOKARDA, ИНФАРКТ МИОКАРДА
Croatian SRČANI INFARKT
Polish Świeży zawał serca, Zawał serca świeży, Zawał mięśnia sercowego, Zawał serca
Hungarian Coronaria roham, Szívroham (k.m.n.), Szívroham, Infarctus myocardii, Szívizom infarctus, MI
Norwegian Hjerteinfarkt, Hjerteattakk, Myokardinfarkt