1 Gardagar

Rule Out Myocardial Infarction Case Study

  • [Guideline] Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 23. 130 (25):e344-426. [Medline]. [Full Text].

  • [Guideline] O'Gara PT, Kushner FG, Ascheim DD, et al. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29. 127 (4):e362-425. [Medline]. [Full Text].

  • [Guideline] Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016 Jan 14. 37 (3):267-315. [Medline]. [Full Text].

  • [Guideline] Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC); Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012 Oct. 33 (20):2569-619. [Medline]. [Full Text].

  • Costa e Silva R, Pellanda L, Portal V, Maciel P, Furquim A, Schaan B. Transdisciplinary approach to the follow-up of patients after myocardial infarction. Clinics (Sao Paulo). 2008 Aug. 63 (4):489-96. [Medline].

  • Rathore SS, Gersh BJ, Weinfurt KP, Oetgen WJ, Schulman KA, Solomon AJ. The role of reperfusion therapy in paced patients with acute myocardial infarction. Am Heart J. 2001 Sep. 142(3):516-9. [Medline].

  • Jaffe AS. Third universal definition of myocardial infarction. Clin Biochem. 2013 Jan. 46 (1-2):1-4. [Medline].

  • Bonaca MP, Wiviott SD, Braunwald E, et al. American College of Cardiology/American Heart Association/European Society of Cardiology/World Heart Federation Universal definition of myocardial infarction classification system and the risk of cardiovascular death: observations from the TRITON-TIMI 38 Trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis in Myocardial Infarction 38). Circulation. 2012 Jan 31. 125(4):577-83. [Medline].

  • Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012 Oct 16. 60 (16):1581-98. [Medline].

  • Fujita M, Nakae I, Kihara Y, et al. Determinants of collateral development in patients with acute myocardial infarction. Clin Cardiol. 1999 Sep. 22 (9):595-9. [Medline].

  • Burchfield JS, Xie M, Hill JA. Pathological ventricular remodeling: mechanisms: part 1 of 2. Circulation. 2013 Jul 23. 128 (4):388-400. [Medline].

  • Yellon DM, Hausenloy DJ. Myocardial reperfusion injury. N Engl J Med. 2007 Sep 13. 357 (11):1121-35. [Medline].

  • Marban E. Myocardial stunning and hibernation. The physiology behind the colloquialisms. Circulation. 1991 Feb. 83 (2):681-8. [Medline].

  • McGill HC Jr, McMahan CA, Zieske AW, et al. Associations of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler Thromb Vasc Biol. 2000 Aug. 20 (8):1998-2004. [Medline].

  • Kolodgie FD, Virmani R, Burke AP, et al. Pathologic assessment of the vulnerable human coronary plaque. Heart. 2004 Dec. 90 (12):1385-91. [Medline].

  • Chatzizisis YS, Coskun AU, Jonas M, Edelman ER, Feldman CL, Stone PH. Role of endothelial shear stress in the natural history of coronary atherosclerosis and vascular remodeling: molecular, cellular, and vascular behavior. J Am Coll Cardiol. 2007 Jun 26. 49(25):2379-93. [Medline].

  • Wang JC, Normand SL, Mauri L, Kuntz RE. Coronary artery spatial distribution of acute myocardial infarction occlusions. Circulation. 2004 Jul 20. 110(3):278-84. [Medline].

  • Falk E, Shah PK, Fuster V. Coronary plaque disruption. Circulation. 1995 Aug 1. 92(3):657-71. [Medline].

  • McDaniel MC, Willis P, Walker B, et al. Plaque necrotic core content is greater immediately distal to bifurcations compared to bifurcations in the proximal lad of patients with CAD. Am J Cardiol. 2008. 102(8):242i.

  • Yusuf S, Hawken S, Ounpuu S, et al, for the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 Sep 11-17. 364 (9438):937-52. [Medline].

  • Concheiro-Guisan A, Sousa-Rouco C, Fernandez-Santamarina I, Gonzalez-Carrero J. Intrauterine myocardial infarction: unsuspected diagnosis in the delivery room. Fetal Pediatr Pathol. 2006 Jul-Aug. 25(4):179-84. [Medline].

  • Rogers WJ, Frederick PD, Stoehr E, et al. Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J. 2008 Dec. 156 (6):1026-34. [Medline].

  • Lloyd-Jones D, Adams RJ, Brown TM, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23. 121 (7):948-54. [Medline].

  • Levi F, Lucchini F, Negri E, La Vecchia C. Trends in mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world. Heart. 2002 Aug. 88 (2):119-24. [Medline].

  • Critchley J, Liu J, Zhao D, Wei W, Capewell S. Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999. Circulation. 2004 Sep 7. 110 (10):1236-44. [Medline].

  • Reddy KS. Cardiovascular disease in non-Western countries. N Engl J Med. 2004 Jun 10. 350 (24):2438-40. [Medline].

  • Okrainec K, Banerjee DK, Eisenberg MJ. Coronary artery disease in the developing world. Am Heart J. 2004 Jul. 148 (1):7-15. [Medline].

  • Ezzati M. How can cross-country research on health risks strengthen interventions? Lessons from INTERHEART. Lancet. 2004 Sep 11-17. 364 (9438):912-4. [Medline].

  • Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16. 284(7):835-42. [Medline].

  • Jaber WA, Prior DL, Marso SP, Houghtaling PL, Menon V, Harrington RA. CHF on presentation is associated with markedly worse outcomes among patients with acute coronary syndromes: PURSUIT trial findings. Circulation 1999:100(suppl I):I-433 .

  • Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol. 1967 Oct. 20(4):457-64. [Medline].

  • James SK, Lindahl B, Siegbahn A, et al. N-terminal pro-brain natriuretic peptide and other risk markers for the separate prediction of mortality and subsequent myocardial infarction in patients with unstable coronary artery disease: a Global Utilization of Strategies To Open occluded arteries (GUSTO)-IV substudy. Circulation. 2003 Jul 22. 108 (3):275-81. [Medline].

  • de Lemos JA, Morrow DA, Bentley JH, et al. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes. N Engl J Med. 2001 Oct 4. 345 (14):1014-21. [Medline].

  • Haaf P, Reichlin T, Corson N, et al. B-type natriuretic peptide in the early diagnosis and risk stratification of acute chest pain. Am J Med. 2011 May. 124 (5):444-52. [Medline].

  • Morrow DA, Rifai N, Antman EM, et al. C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: a TIMI 11A substudy. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol. 1998 Jun. 31 (7):1460-5. [Medline].

  • Boggs W. Worse Prognosis for Myocardial Infarction Patients With ST-Deviation in AVR. Medscape. Jul 11 2013. [Full Text].

  • Alherbish A, Westerhout CM, Fu Y, et al. The forgotten lead: does aVR ST-deviation add insight into the outcomes of ST-elevation myocardial infarction patients?. Am Heart J. Jul 3 2013. [Full Text].

  • Lee KL, Woodlief LH, Topol EJ, et al, for the GUSTO-I investigators. Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Results from an international trial of 41,021 patients. GUSTO-I Investigators. Circulation. 1995 Mar 15. 91 (6):1659-68. [Medline].

  • [Guideline] Smith SC Jr, Allen J, Blair SN, et al,. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006 May 16. 113 (19):2363-72. [Medline]. [Full Text].

  • Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Saunders; 2015.

  • Wijnbergen I, Van't Veer M, Pijls NH, Tijssen J. Circadian and weekly variation and the influence of environmental variables in acute myocardial infarction. Neth Heart J. 2012 Sep. 20 (9):354-9. [Medline].

  • Kacprzak M, Kidawa M, Zielińska M. Fever in myocardial infarction: is it still common, is it still predictive?. Cardiol J. 2012. 19 (4):369-73. [Medline].

  • Risøe C, Kirkeby OJ, Grøttum P, Sederholm M, Kjekshus JK. Fever after acute myocardial infarction in patients treated with intravenous timolol or placebo. Br Heart J. 1987 Jan. 57 (1):28-31. [Medline].

  • Patel MR, Mahaffey KW, Armstrong PW, Weaver WD, Tasissa G, Hochman JS, et al. Prognostic usefulness of white blood cell count and temperature in acute myocardial infarction (from the CARDINAL Trial). Am J Cardiol. 2005 Mar 1. 95 (5):614-8. [Medline].

  • Lee-Lewandrowski E, Januzzi JL Jr, Grisson R, Mohammed AA, Lewandrowski G, Lewandrowski K. Evaluation of first-draw whole blood, point-of-care cardiac markers in the context of the universal definition of myocardial infarction: a comparison of a multimarker panel to troponin alone and to testing in the central laboratory. Arch Pathol Lab Med. 2011 Apr. 135 (4):459-63. [Medline].

  • Apple FS. A new season for cardiac troponin assays: it's time to keep a scorecard. Clin Chem. 2009 Jul. 55 (7):1303-6. [Medline].

  • Diercks DB, Peacock WF 4th, Hollander JE, et al. Diagnostic accuracy of a point-of-care troponin I assay for acute myocardial infarction within 3 hours after presentation in early presenters to the emergency department with chest pain. Am Heart J. 2012 Jan. 163 (1):74-80.e4. [Medline].

  • Takakuwa KM, Ou FS, Peterson ED, et al. The usage patterns of cardiac bedside markers employing point-of-care testing for troponin in non-ST-segment elevation acute coronary syndrome: results from CRUSADE. Clin Cardiol. 2009 Sep. 32 (9):498-505. [Medline].

  • Mueller C. Biomarkers and acute coronary syndromes: an update. Eur Heart J. 2014 Mar. 35 (9):552-6. [Medline].

  • Anderson JL, Adams CD, Antman EM, et al, for the ACC, AHA Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the management of patients with unstable angina/NSTEMI, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interv... Circulation. 2007 Aug 14. 116 (7):e148-304. [Medline].

  • Reichlin T, Irfan A, Twerenbold R, et al. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation. 2011 Jul 12. 124(2):136-45. [Medline].

  • Storrow AB, Nowak RM, Diercks DB, et al. Absolute and relative changes (delta) in troponin I for early diagnosis of myocardial infarction: Results of a prospective multicenter trial. Clin Biochem. 2015 Mar. 48 (4-5):260-7. [Medline].

  • Storrow AB, Christenson RH, Nowak RM, et al. Diagnostic performance of cardiac troponin I for early rule-in and rule-out of acute myocardial infarction: Results of a prospective multicenter trial. Clin Biochem. 2015 Mar. 48 (4-5):254-9. [Medline].

  • Cullen L, Parsonage WA, Greenslade J, et al. Delta troponin for the early diagnosis of AMI in emergency patients with chest pain. Int J Cardiol. 2013 Oct 3. 168 (3):2602-8. [Medline].

  • Thygesen K, Mair J, Mueller C, et al, for the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J. 2012 Aug. 33 (16):2001-6. [Medline].

  • Goldstein JA, Chinnaiyan KM, Abidov A, et al, for the CT-STAT Investigators. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011 Sep 27. 58 (14):1414-22. [Medline].

  • Samad Z, Hakeem A, Mahmood SS, et al. A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department. J Nucl Cardiol. 2012 Apr. 19 (2):364-76. [Medline].

  • Cremer PC, Khalaf S, Agarwal S, et al. Myocardial perfusion imaging in emergency department patients with negative cardiac biomarkers: yield for detecting ischemia, short-term events, and impact of downstream revascularization on mortality. Circ Cardiovasc Imaging. 2014 Nov. 7 (6):912-9. [Medline].

  • Becker L, Larsen MP, Eisenberg MS. Incidence of cardiac arrest during self-transport for chest pain. Ann Emerg Med. 1996 Dec. 28 (6):612-6. [Medline].

  • Mathews R, Peterson ED, Li S, et al. Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines. Circulation. 2011 Jul 12. 124 (2):154-63. [Medline].

  • Cabello JB, Burls A, Emparanza JI, Bayliss S, Quinn T. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev. 2013 Aug 21. 8:CD007160. [Medline].

  • Gislason GH, Jacobsen S, Rasmussen JN, et al. Risk of death or reinfarction associated with the use of selective cyclooxygenase-2 inhibitors and nonselective nonsteroidal antiinflammatory drugs after acute myocardial infarction. Circulation. 2006 Jun 27. 113 (25):2906-13. [Medline].

  • Luepker RV, Raczynski JM, Osganian S, et al. Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial. JAMA. 2000 Jul 5. 284 (1):60-7. [Medline].

  • De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004 Mar 16. 109 (10):1223-5. [Medline].

  • Armstrong PW, Westerhout CM, Welsh RC. Duration of symptoms is the key modulator of the choice of reperfusion for ST-elevation myocardial infarction. Circulation. 2009 Mar 10. 119 (9):1293-303. [Medline].

  • Bates ER, Nallamothu BK. Commentary: the role of percutaneous coronary intervention in ST-segment-elevation myocardial infarction. Circulation. 2008 Jul 29. 118 (5):567-73. [Medline].

  • Ellis SG, Armstrong P, Betriu A, et al, for the Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events Investigators. Facilitated percutaneous coronary intervention versus primary percutaneous coronary intervention: design and rationale of the Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events (FINESSE) trial. Am Heart J. 2004 Apr. 147 (4):E16. [Medline].

  • Andersen HR, Nielsen TT, Rasmussen K, et al, for the DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003 Aug 21. 349 (8):733-42. [Medline].

  • Widimsky P, Budesínsky T, Vorac D, et al, for the 'PRAGUE' Study Group Investigators. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial--PRAGUE-2. Eur Heart J. 2003 Jan. 24 (1):94-104. [Medline].

  • Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. 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. 1994 Feb 5. 343 (8893):311-22. [Medline].

  • White HD. Thrombolytic therapy in the elderly. Lancet. 2000 Dec 16. 356 (9247):2028-30. [Medline].

  • Van de Werf F, Barron HV, Armstrong PW, et al, for the ASSENT-2 Investigators. Assessment of the Safety and Efficacy of a New Thrombolytic. Incidence and predictors of bleeding events after fibrinolytic therapy with fibrin-specific agents: a comparison of TNK-tPA and rt-PA. Eur Heart J. 2001 Dec. 22 (24):2253-61. [Medline].

  • Yusuf S, Mehta SR, Chrolavicius S, et al, for the OASIS-6 Trial Group. Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA. 2006 Apr 5. 295 (13):1519-30. [Medline].

  • Giraldez RR, Nicolau JC, Corbalan R, et al. Enoxaparin is superior to unfractionated heparin in patients with ST elevation myocardial infarction undergoing fibrinolysis regardless of the choice of lytic: an ExTRACT-TIMI 25 analysis. Eur Heart J. 2007 Jul. 28 (13):1566-73. [Medline].

  • Wallentin L, Goldstein P, Armstrong PW, et al. Efficacy and safety of tenecteplase in combination with the low-molecular-weight heparin enoxaparin or unfractionated heparin in the prehospital setting: the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 PLUS randomized trial in acute myocardial infarction. Circulation. 2003 Jul 15. 108 (2):135-42. [Medline].

  • Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 Investigators. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet. 2001 Aug 25. 358 (9282):605-13. [Medline].

  • White H, Hirulog and Early Reperfusion or Occlusion (HERO)-2 Trial Investigators. Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: the HERO-2 randomised trial. Lancet. 2001 Dec 1. 358 (9296):1855-63. [Medline].

  • Wiviott SD, Braunwald E, McCabe CH, et al, for the TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15. 357 (20):2001-15. [Medline].

  • Tcheng JE, Mackay SM. Prasugrel versus clopidogrel antiplatelet therapy after acute coronary syndrome: matching treatments with patients. Am J Cardiovasc Drugs. 2012 Apr 1. 12 (2):83-91. [Medline].

  • Schnapf AJ. Prasugrel versus clopidogrel: new management strategies for acute coronary syndrome. J Cardiovasc Nurs. 2013 Sep-Oct. 28 (5):483-94. [Medline].

  • Ryan TJ. Percutaneous coronary intervention in st-elevation myocardial infarction. Curr Cardiol Rep. 2001 Jul. 3(4):273-9. [Medline].

  • Berger JS, Sallum RH, Katona B, et al. Is there an association between aspirin dosing and cardiac and bleeding events after treatment of acute coronary syndrome? A systematic review of the literature. Am Heart J. 2012 Aug. 164 (2):153-162.e5. [Medline].

  • CURRENT-OASIS 7 Investigators, Mehta SR, Bassand JP, Chrolavicius S, et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med. 2010 Sep 2. 363 (10):930-42. [Medline].

  • CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet. 1996 Nov 16. 348 (9038):1329-39. [Medline].

  • Wallentin L, Becker RC, Budaj A,et al, for the PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009 Sep 10. 361 (11):1045-57. [Medline].

  • Storey RF, Becker RC, Harrington RA, et al. Characterization of dyspnoea in PLATO study patients treated with ticagrelor or clopidogrel and its association with clinical outcomes. Eur Heart J. 2011 Dec. 32 (23):2945-53. [Medline].

  • The PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998 Aug 13. 339 (7):436-43. [Medline].

  • Gibson CM, Goel M, Cohen DJ, et al. Six-month angiographic and clinical follow-up of patients prospectively randomized to receive either tirofiban or placebo during angioplasty in the RESTORE trial. Randomized Efficacy Study of Tirofiban for Outcomes and Restenosis. J Am Coll Cardiol. 1998 Jul. 32 (1):28-34. [Medline].

  • Goodman SG, Cohen M, Bigonzi F, et al. Randomized trial of low molecular weight heparin (enoxaparin) versus unfractionated heparin for unstable coronary artery disease: one-year results of the ESSENCE Study. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events. J Am Coll Cardiol. 2000 Sep. 36 (3):693-8. [Medline].

  • Petersen JL, Mahaffey KW, Hasselblad V, et al. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-Segment elevation acute coronary syndromes: a systematic overview. JAMA. 2004 Jul 7. 292 (1):89-96. [Medline].

  • White HD, Kleiman NS, Mahaffey KW, et al. Efficacy and safety of enoxaparin compared with unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention in the Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial. Am Heart J. 2006 Dec. 152 (6):1042-50. [Medline].

  • Stone GW, McLaurin BT, Cox DA, et al, for the ACUITY Investigators. Bivalirudin for patients with acute coronary syndromes. N Engl J Med. 2006 Nov 23. 355 (21):2203-16. [Medline].

  • Goto K, Lansky AJ, Fahy M, et al. Predictors of outcomes in medically treated patients with acute coronary syndromes after angiographic triage: an Acute Catheterization And Urgent Intervention Triage Strategy (ACUITY) substudy. Circulation. 2010 Feb 23. 121 (7):853-62. [Medline].

  • FUTURA/OASIS-8 Trial Group, Steg PG, Jolly SS, Mehta SR, et al. Low-dose vs standard-dose unfractionated heparin for percutaneous coronary intervention in acute coronary syndromes treated with fondaparinux: the FUTURA/OASIS-8 randomized trial. JAMA. 2010 Sep 22. 304 (12):1339-49. [Medline].

  • Jolly SS, Faxon DP, Fox KA, et al. Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes treated with glycoprotein IIb/IIIa inhibitors or thienopyridines: results from the OASIS 5 (Fifth Organization to Assess Strategies in Ischemic Syndromes) trial. J Am Coll Cardiol. 2009 Jul 28. 54 (5):468-76. [Medline].

  • Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA. 1995 May 10. 273 (18):1450-6. [Medline].

  • Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20. 342 (3):145-53. [Medline].

  • ONTARGET Investigators, Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008 Apr 10. 358 (15):1547-59. [Medline].

  • Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003 Apr 3. 348 (14):1309-21. [Medline].

  • Lopez-Jimenez F, Simha V, Thomas RJ, et al. A summary and critical assessment of the 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: filling the gaps. Mayo Clin Proc. 2014 Sep. 89 (9):1257-78. [Medline].

  • Schwartz GG, Olsson AG, Ezekowitz MD, Ganz P, Oliver MF, Waters D, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA. 2001 Apr 4. 285(13):1711-8. [Medline].

  • Patti G, Barczi G, Orlic D, et al. Outcome comparison of 600- and 300-mg loading doses of clopidogrel in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: results from the ARMYDA-6 MI (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty-Myocardial Infarction) randomized study. J Am Coll Cardiol. 2011 Oct 4. 58 (15):1592-9. [Medline].

  • [Guideline] Eckel RH, Jakicic JM, Ard JD, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 24. 129 (25 Suppl 2):S76-99. [Medline]. [Full Text].

  • David TE. Operative management of postinfarction ventricular septal defect. Semin Thorac Cardiovasc Surg. 1995 Oct. 7(4):208-13. [Medline].

  • Gaudiani VA, Miller DG, Stinson EB, Oyer PE, Reitz BA, Moreno-Cabral RJ, et al. Postinfarction ventricular septal defect: an argument for early operation. Surgery. 1981 Jan. 89(1):48-55. [Medline].

  • Daggett WM, Buckley MJ, Akins CW, Leinbach RC, Gold HK, Block PC, et al. Improved results of surgical management of postinfarction ventricular septal rupture. Ann Surg. 1982 Sep. 196(3):269-77. [Medline]. [Full Text].

  • Schachinger V, Erbs S, Elsasser A, et al, for the REPAIR-AMI Investigators. Intracoronary bone marrow-derived progenitor cells in acute myocardial infarction. N Engl J Med. 2006 Sep 21. 355 (12):1210-21. [Medline].

  • Traverse JH, Henry TD, Ellis SG, et al. Effect of intracoronary delivery of autologous bone marrow mononuclear cells 2 to 3 weeks following acute myocardial infarction on left ventricular function: the LateTIME randomized trial. JAMA. 2011 Nov 16. 306(19):2110-9. [Medline].

  • [Guideline] Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014 Oct 1. 35 (37):2541-619. [Medline]. [Full Text].

  • [Guideline] Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2016 Mar 15. 133 (11):1135-47. [Medline]. [Full Text].

  • [Guideline] Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011 Dec 6. 124 (23):e574-651. [Medline]. [Full Text].

  • [Guideline] Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 Dec 6. 124 (23):e652-735. [Medline]. [Full Text].

  • [Guideline] Kulik A, Ruel M, Jneid H, et al, for the American Heart Association Council on Cardiovascular Surgery and Anesthesia. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015 Mar 10. 131 (10):927-64. [Medline]. [Full Text].

  • [Guideline] Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care: endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. J Am Coll Cardiol. 2015 May 19. 65 (19):e7-e26. [Medline]. [Full Text].

  • [Guideline] Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013 Feb. 32 (2):157-87. [Medline]. [Full Text].

  • [Guideline] Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable isc... Circulation. 2016 Sep 6. 134 (10):e123-55. [Medline]. [Full Text].

  • Modi KA, Nylk TM, Sheridan FM. Medical management of acute ST elevation myocardial infarction. J La State Med Soc. 2001 Jun. 153(6):284-90. [Medline].

  • Ohman EM, Harrington RA, Cannon CP, Agnelli G, Cairns JA, Kennedy JW. Intravenous thrombolysis in acute myocardial infarction. Chest. 2001 Jan. 119(1 Suppl):253S-277S. [Medline].

  • Chou R, for the High Value Care Task Force of the American College of Physicians. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015 Mar 17. 162 (6):438-47. [Medline].

  • Ferencik M. High-risk coronary plaque predicts acute coronary syndrome independently of >50% coronary stenosis and cardiovascular risk factors in patients with acute chest pain: results from ROMICAT II trial (abstract 109). Presented at: Society of Cardiovascular Computed Tomography 2014 Annual Scientific Meeting; July 11, 2014; San Diego, California.

  • Busko M. High-risk plaque predicts ACS in ER patients with chest pain. Heartwire. July 18, 2014. [Full Text].

  • Diaz-Zamudio M. Quantitative plaque burden from coronary CT angiography noninvasively predict lesion-specific ischemia in intermediate coronary lesions (abstract 231). Presented at: Society of Cardiovascular Computed Tomography 2014 Annual Scientific Meeting; July 12, 2014; San Diego, California.

  • Than M, Cullen L, Reid CM, Lim SH, et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet. 2011 Mar 26. 377 (9771):1077-84. [Medline].

  • Innocenti F, Lazzeretti D, Conti A, Zanobetti M, Vicidomini S, Pini R. Stress echocardiography in the ED: diagnostic performance in high-risk subgroups. Am J Emerg Med. 2013 Jul 1. [Medline].

  • Boggs W. Stress Echo Rules out Myocardial Ischemia in the ED. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/808919. Accessed: August 12, 2013.

  • Terkelsen CJ, Sorensen JT, Maeng M, et al. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010 Aug 18. 304 (7):763-71. [Medline].

  • Jeffrey S. AVOID Oxygen? Evidence of Harm in MI. Medscape. Nov 21 2014. [Full Text].

  • Nainggolan L. New US STEMI Guidelines Are More User Friendly. Medscape News Dec 18, 2012. Available at http://www.medscape.com/viewarticle/776325. Accessed: February 6, 2013.

  • Niccoli G, Rigattieri S, De Vita MR, et al. Open-label, randomized, placebo-controlled evaluation of intracoronary adenosine or nitroprusside after thrombus aspiration during primary percutaneous coronary intervention for the prevention of microvascular obstruction in acute myocardial infarction: the REOPEN-AMI study (Intracoronary Nitroprusside Versus Adenosine in Acute Myocardial Infarction). JACC Cardiovasc Interv. 2013 Jun. 6 (6):580-9. [Medline].

  • Montalescot G, Zeymer U, Silvain J, et al. Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial. Lancet. 2011 Aug 20. 378(9792):693-703. [Medline].

  • Stone GW, Witzenbichler B, Guagliumi G, et al. Heparin plus a glycoprotein IIb/IIIa inhibitor versus bivalirudin monotherapy and paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction (HORIZONS-AMI): final 3-year results from a multicentre, randomised controlled trial. Lancet. 2011 Jun 25. 377(9784):2193-204. [Medline].

  • Charlot M, Grove EL, Hansen PR, et al. Proton pump inhibitor use and risk of adverse cardiovascular events in aspirin treated patients with first time myocardial infarction: nationwide propensity score matched study. BMJ. 2011 May 11. 342:d2690. [Medline]. [Full Text].

  • AstraZeneca. US FDA approves expanded indication for BRILINTA to include long-term use in patients with a history of heart attack [news release]. Available at http://www.astrazeneca.com/Media/Press-releases/Article/20150903. September 3, 2015; Accessed: September 15, 2015.

  • Bonaca MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Jensen EC, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015 May 7. 372 (19):1791-800. [Medline].

  • Cuzick J, Thorat MA, Bosetti C, et al. Estimates of benefits and harms of prophylactic use of aspirin in the general population. Ann Oncol. 2014 Aug 5. [Medline].

  • Bankhead C. Benefits add up for regular aspirin use. MedPage Today. August 5, 2014. [Full Text].

  • Stiles S. L-Carnitine Retakes Spotlight, Hints at Survival Benefit in Acute MI: Meta-analysis. Medscape Medical News. Available at http://www.medscape.com/viewarticle/782488. Accessed: May 2, 2013.

  • DiNicolantonio JJ, Lavie CJ, Fares H, Menezes AR, O'Keefe JH. L-carnitine in the secondary prevention of cardiovascular disease: systematic review and meta-analysis. Mayo Clin Proc. 2013 Jun. 88 (6):544-51. [Medline].

  • Reuters Health Information. Prophylactic Lidocaine for Out-of-Hospital Cardiac Arrest Seen Helpful. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/805805. Accessed: June 30, 2013.

  • Kudenchuk PJ, Newell C, White L, Fahrenbruch C, Rea T, Eisenberg M. Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital ventricular fibrillation cardiac arrest. Resuscitation. 2013 Jun 3. [Medline].

  • Boggs W. Aspiration thrombectomy may improve angioplasty after acute MI. Medscape Medical News. May 13, 2013. [Full Text].

  • Kumbhani DJ, Bavry AA, Desai MY, Bangalore S, Bhatt DL. Role of aspiration and mechanical thrombectomy in patients with acute myocardial infarction undergoing primary angioplasty: An updated meta-analysis of randomized trials. J Am Coll Cardiol. 2013 May 8. [Medline].

  • Zaman S, Narayan A, Thiagalingam A, et al. Long-term arrhythmia-free survival in patients with severe left ventricular dysfunction and no inducible ventricular tachycardia post myocardial infarction. Circulation. 2013 Dec 31. [Medline].

  • O'Riordan M. Positive EP test helps ID post-MI patients for ICDs. Heartwire. January 2, 2014. [Full Text].

  • Wood S. FDA Review Finds No Increased Risk of MI With Dabigatran (Pradaxa). Medscape Medical News. Available at http://www.medscape.com/viewarticle/825080. Accessed: May 27, 2014.

  • FDA. FDA study of Medicare patients finds risks lower for stroke and death but higher for gastrointestinal bleeding with Pradaxa (dabigatran) compared to warfarin. Available at http://www.fda.gov/Drugs/DrugSafety/ucm396470.htm. Accessed: May 27, 2014.

  • O'Riordan M. A shot in arm, a boost for the heart: flu vaccination reduces AMI risk. Medscape Medical News. August 26, 2013. [Full Text].

  • Macintyre CR, Heywood AE, Kovoor P, et al. Ischaemic heart disease, influenza and influenza vaccination: a prospective case control study. Heart. 2013 Dec. 99 (24):1843-8. [Medline].

  • Rao KK, Enriquez JR, de Lemos JA, Alexander KP, Chen AY, McGuire DK, et al. Use of aldosterone antagonists at discharge after myocardial infarction: Results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get with the Guidelines (GWTG). Am Heart J. 2013 Oct. 166(4):709-715. [Medline].

  • Stiles, S. Even With CKD, Warfarin Safely Cuts Events in AF After MI, Study Finds. Medscape Medical News. Available at http://www.medscape.com/viewarticle/821444. Accessed: March 12, 2014.

  • Carrero JJ, Evans M, Szummer K, Spaak J, Lindhagen L, Edfors R, et al. Warfarin, kidney dysfunction, and outcomes following acute myocardial infarction in patients with atrial fibrillation. JAMA. 2014 Mar 5. 311(9):919-28. [Medline].

  • FDA approves Zontivity to reduce the risk of heart attacks and stroke in high-risk patients. US Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm396585.htm. Accessed: May 12, 2014.

  • Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS One. 2014. 9(1):e85805. [Medline]

  • A 66-year-old man sought medical care at the hospital due to severe chest pain lasting for 24 hours. The patient was aware of being hypertensive and was a smoker. Without any prior symptom, he started to have severe chest pain and sought emergency medical care after about 24 hours, due to pain persistence.

    At physical examination (August 13, 2005, 10 PM) he had a heart rate of 90 bpm and blood pressure of 110/70 mmHg. Lung examination showed no alterations. Heart assessment showed a systolic murmur in the lower left sternal border and mitral area.

    The initial electrocardiogram (August 13, 2005, 22 h) showed HR of 100 bpm, sinus rhythm, 1st-degree atrioventricular block (PR 240 ms), low-voltage QRS complexes in the frontal plane, QRS complex electrical alternans and extensive ongoing anterior wall infarction (QS V1 to V6, ST elevation in the same leads and QS in the inferior wall, II, III and aVF) (Figure 1).

    Figure 1

    ECG: low QRS voltage in the frontal plane, electrical alternans of QRS complexes, electrically inactive lower wall area and extensive ongoing myocardial infarction.

    Acetylsalicylic acid by oral route and 5 mg of intravenous metoprolol were administered. The patient had bradycardia and cardiorespiratory arrest in pulseless electrical activity, reversed after five minutes. He developed hypotension and peripheral hypoperfusion and was transferred to InCor (The Heart Institute).

    On admission he had received heparin and continuous intravenous norepinephrine. BP was 60/30 mmHg.

    The ECG (August 13, 2005, 11:36 PM) disclosed heart rate of 116 bpm, junctional escape rhythm with sinus arrest and atrial extrasystoles); low-voltage QRS complex in the frontal plane, extensive ongoing anterior acute myocardial infarction, inactive area in the inferior wall; presence of ST elevation at V1 to V5 and ST depression in leads I, II and aVF; ST elevation in aVR (Figure 2).

    Figure 2

    ECG: low QRS voltage in the frontal plane, electrically inactive lower wall area and anterior myocardial infarction with increased ST elevation, still with positive T waves, "hyperacute phase of myocardial infaction".

    Coronary angiography was indicated, which disclosed anterior interventricular branch occlusion and images suggestive of intracoronary thrombus, lesion of 70% in the circumflex artery, 50% in the right coronary artery and 70% in the ostium of the right posterior descending branch. Angioplasty was performed with stent implant in the anterior interventricular artery, but distal flow was not restored. This was followed by cardiac arrest in asystole, which did not respond to treatment and the patient died.

    Clinical Aspects

    This clinical case reports on a 66-year-old hypertensive patient, long-term smoker, who sought medical care due to acute chest pain. The main diagnostic hypothesis for this clinical case is of acute coronary syndrome.

    Chest pain is one of the most common reasons for seeking emergency care and remains a challenge for the clinician, due to the difficulty in differentiating between non-emergency diagnoses and those of high morbidity and mortality, such as acute coronary syndrome (ACS), aortic dissection and pulmonary thromboembolism.

    In the assessment of acute chest pain, there are three basic parameters for its management: clinical examination (clinical history and physical examination), electrocardiogram (ECG) and myocardial necrosis markers. They should be analyzed together to provide a safer approach to the patient, especially when it is necessary ruling out ACS. Chest radiography, chest Computed Tomography Angiography (CTA), echocardiography and other tests may be useful in the differential diagnosis.

    Approximately 15-25% of patients presenting in the ER with chest pain are diagnosed with acute coronary syndrome, and this represents its more frequent clinical manifestation1. Therefore, in the first step of the evaluation, which is the clinical examination, the greater determinant of an ischemic etiology is the characteristic presence of angina.

    Angina is often described as a burning or compression sensation or difficulty breathing, located in the precordial region or any other region of the chest, radiating to the neck, shoulder and left arm. It usually increases in intensity within minutes and may be accompanied by symptoms such as nausea and sweating. It can be triggered by physical or emotional stress and relieved by rest or use of nitrates. It should also be remembered that ACS can occur without obvious precipitating factors and be asymptomatic or present as ischemic equivalent, especially in the elderly and diabetic patients with autonomic dysfunction (dyspnea, syncope and pre-syncope).

    On the other hand, there are characteristics of pain that make the diagnosis of ACS unlikely, such as pleuritic pain (reproduced by respiratory movements) located with the fingertip, pain in meso/hypogastrium region and reproduction of pain with local palpation or movement. These features raise the suspicion of other differential diagnoses such as pericarditis, pleuritis, gastrointestinal or musculoskeletal diseases.

    In the present case report, the patient presented with prolonged chest pain, which does not rule out acute coronary syndrome (ACS), but raises the possibility of some condition associated with this coronary picture, such as pericarditis or mechanical complications.

    Among the most important risk factors for atherosclerotic disease risk are dyslipidemia, diabetes mellitus, hypertension, male gender, older age, obesity/metabolic syndrome, smoking, sedentary lifestyle, chronic kidney disease, depression and stress. This patient had some risk factors that contributed to the development of coronary artery disease: age, male gender, hypertension and smoking.

    Patients with chest pain and ACS often have a nonspecific physical examination, with less than 20% of them showing significant alterations in the initial evaluation2. This becomes important by helping in the detection of differential diagnoses (e.g., pericardial friction rub in pericarditis) or by inferring the presence of risk factors for coronary artery disease (abdominal or carotid murmur, among others).

    However, when findings resulting from an ACS are present, they indicate a worse prognosis due to mechanical complications or due to a large area of myocardium at risk and ventricular dysfunction (hypotension, tachycardia, pulmonary edema and mitral regurgitation murmur secondary to ischemia).

    The electrocardiogram is important in the diagnostic, prognostic and therapeutic approach and must be obtained within 10 minutes after the presentation of patients with ongoing chest pain2. A normal electrocardiographic tracing does not exclude the possibility of ACS and a serial ECG is indicated, which increases its sensitivity and helps differentiating between acute and chronic alterations.

    The patient reported in this clinical case had, at the admission ECG performed at another service, ST-segment elevation in the anterior wall, suggesting the hypothesis of acute coronary syndrome with ST-segment elevation. However, this ECG also showed low voltage and electrical alternans of the QRS complex, which suggests large pericardial effusion or even cardiac tamponade.

    The main hypothesis for this pericardial effusion is a mechanical complication of myocardial infarction: left ventricular free wall rupture. It occurs within 24 hours after infarction or between the third and fifth day, has an incidence of 0.8 to 6.2% and is more common in an extensive myocardial infarction, in the elderly, women and hypertensive patients. Its clinical course is variable3 and may be acute and severe, leading to sudden death or subacute, with nonspecific clinical manifestations.

    Other mechanical complications that may be present in myocardial infarction are papillary muscle and interventricular septum rupture. These complications do not present with significant pericardial effusion and normal pulmonary auscultation in this patient also makes the diagnosis of papillary muscle rupture less likely. This clinical condition presents with pulmonary congestion due to volume overload secondary to acute mitral regurgitation.

    Another diagnostic hypothesis for this patient presenting with chest pain and pericardial effusion would be aortic dissection. Pain, in these cases, is usually of sudden onset and strong intensity since the beginning (unlike angina pain, which often increasingly escalates). It is often described as excruciating and its location reflects the site and progression of the dissection. Autonomic signs (pallor, profuse sweating) are greatly associated.

    In aortic dissection, physical examination may disclose hypertensive crisis, differences between limb pulses, signs of pleural and pericardial effusion, diastolic murmur of aortic regurgitation, different from the systolic murmur detected in this clinical case. The extension of the dissection to other vessels can lead to other symptoms corresponding to ischemia of the organs irrigated by them: cerebrovascular accident, acute myocardial infarction, mesenteric ischemia, etc.

    Another diagnostic hypothesis for the clinical case is pulmonary embolism. The absence of pulmonary symptoms, mainly dyspnea, makes this hypothesis less likely. It is the most common symptom of this disease, occurring in over 78% of the patients4. Sudden chest pain of sudden onset and very often pleuritic, affects up to 44% of patients4. Cough and hemoptysis may also occur. Additionally, there was no mention is made on admission at the other service, of right ventricular dysfunction manifestations, such as jugular stasis and hypotension.

    The patient, an hour and 36 minutes after his admission at the Heart Institute, was submitted to coronary angiography with left anterior descending artery angioplasty. However, he developed asystole and cardiac arrest.

    The main diagnoses for the final clinical picture are cardiogenic shock and/or distributive shock due to cardiac tamponade, discussed below.

    The hypothesis of cardiogenic shock should be considered, as the patient had an extensive acute myocardial infarction without culprit artery reperfusion even after percutaneous revascularization attempt. However, this diagnosis cannot fully explain the patient's clinical condition, such as the absence of pulmonary congestion, which usually follows an acute myocardial failure.

    Considering the patient's history, late cardiac tamponade seems to have been the main precipitating factor of the final clinical picture in this case. The electrocardiographic findings commonly observed in cardiac tamponade are low voltage and electrical alternans of the QRS complex, observed in the case. Although physical examination made no reference to clinical findings suggestive of tamponade, such as jugular stasis or muffled heart sounds, we cannot exclude this diagnostic hypothesis.

    An echocardiography could have been performed to confirm this diagnosis, which is the most widely used noninvasive method for diagnostic investigation of this pathology. The ventriculography in this context would not be informative, as it was a free wall rupture with cardiac tamponade and thus, it would not allow the visualization of contrast leakage into the pericardial cavity.

    This is a patient with myocardial infarction that came at the emergency room more than 24 hours after the onset of the event and who probably had a mechanical complication of myocardial infarction: ventricular free wall rupture.

    Most deaths from myocardial infarction occur in the first hours of disease onset, with 40-65% occurring within the first hour and approximately 80% in the first 24 hours5,6. The recently implemented therapies for MI treatment have been proven to modify patient evolution and prognosis. However, the effectiveness of most of these measures is time-dependent and delay in seeking medical care may have been the factor that likely contributed to the clinical outcome of the patient in this case report. (Dr. Wilma Noia Ribeiro, Dr. Alice Tatsuko Yamada)

    Diagnostic hypotheses: Acute myocardial infarction with mixed shock (cardiogenic - distributive) by mechanical complication - free wall rupture with tamponade (Dr. Wilma Noia Ribeiro, Dr. Alice Tatsuko Yamada)


    The heart weighed 414 g. The myocardium of the left ventricular anterosseptal wall and right ventricular anterior wall was softened, slightly yellowish in color, characterizing extensive transmural acute myocardial infarction. There was an obvious narrowing of the affected anterosseptal wall, with ventricular septum rupture in the anterior region of its mid portion, with a ventricular septal defect measuring 10 mm in its longest axis. The other left ventricular walls showed to be slightly hypertrophic and there was a small area of fibrosis in the postero-inferior region of the ventricular septum. There was also moderate right ventricular dilation (Figure 3).

    Figure 3

    Cross-section of the ventricles showing left ventricular transmural infarction of the anterosseptal wall (asterisks) and of the right ventricular anterior wall (arrows). The explorer shows the VSD secondary to septal rupture. Observe the ventricular wall...

    Histological analysis confirmed the presence of myocardial infarction, with marked neutrophil infiltration, confirming histological dating of 24-48 hours of onset. Another small ongoing microinfarction was observed in the posterior region of the ventricular septum, in addition to the previously described small area of fibrosis (healed infarction), compatible with approximately 7-10 days of evolution.

    There was superficial fibrin deposition in the epicardium, with the presence of reactive inflammatory infiltrate. Examination of the initial segment of the left anterior descending artery showed fatty atherosclerotic plaques with areas of marked thinning of the fibrous cap that covered the lipid core and 80% of obstruction.

    There were also areas of plaque rupture and hemorrhage, with acute thrombosis in the first and second centimeters of that artery (Figs. 4 and ​5).

    Figure 4

    Histological section of the first centimeter of the left anterior descending artery showing large lipid-core atherosclerotic plaque, with internal area of fibrin deposition and hemorrhage (asterisk). Observe the area with marked thinning of the fibrous...

    Figure 5

    Histological section of the second centimeter of the anterior interventricular artery showing large lipid-core atherosclerotic plaque with ruptured area (arrows) and occlusive luminal thrombosis (asterisk). Hematoxylin-eosin, 2.5×.

    The lungs weighed 1,208 g together and showed alveolar edema. The kidneys showed irregular surface and retention cysts, with hyaline arteriolosclerosis on histological examination. The aorta showed mild / moderate degree of atherosclerosis. (Dr. Luiz Alberto Benvenuti)

    Anatomopathological diagnoses. Coronary atherosclerosis; acute myocardial infarction involving the left ventricular anterosseptal wall and the right ventricular anterior wall; rupture of the ventricular septum, with VSD; acute pulmonary edema (cause of death) (Dr. Luiz Alberto Benvenuti).


    This is the case report of a 66-year-old man with systemic hypertension and a chronic smoker that presented with acute severe chest pain. After medical assessment, he was diagnosed with acute myocardial infarction and the patient underwent coronary angiography, which disclosed proximal occlusion of the left anterior descending artery with images suggesting the presence of thrombi. He was submitted to balloon-angioplasty in the affected segment without restoration of distal coronary flow (unsuccessful procedure) and the patient developed irreversible cardiac arrest and died.

    The autopsy confirmed acute myocardial infarction, which was very extensive, affecting the left ventricular anterosseptal wall and the right ventricular anterior wall. Histological dating was 24-48 hours of onset, consistent with the clinical history. It is noteworthy the fact that the detailed examination of the ventricular septum showed the presence of two previous microinfarctions, an old (healed) one and an ongoing one.

    The presence of atherosclerosis of the coronary arteries was identified, with massive plaques in the proximal segment of the left anterior descending artery, which resulted in chronic obstruction of 80% of the lumen. The fatty plaques had extensive lipid cores and there were areas of marked thinning of the fibrous cap that covered the cores, as well as areas of rupture associated with acute thrombosis of the remaining lumen in the first two centimeters of the left anterior descending artery. It is known that acute coronary occlusions with luminal thrombosis are usually associated with large lipid-core plaques, which undergo rupture due to the instability of their thin fibrous cap7, as observed in this case.

    Aside from the great extent of the infarcted area, the patient developed an important mechanical complication of acute myocardial infarction, the occurrence of ventricular septal rupture with the establishment of VSD8 - which certainly aggravated his hemodynamic condition, progressing to cardiogenic shock -, acute pulmonary edema and death. It should be emphasized that the patient had two classic risk factors for atherosclerosis and myocardial infarction: systemic hypertension and chronic smoking9. (Dr. Luiz Alberto Benvenuti)

    Section Editor: Alfredo José Mansur (rb.psu.rocni@rusnamja)

    Associated Editors: Desidério Favarato (rb.psu.rocni@otaravaflcd)

    Vera Demarchi Aiello (rb.psu.rocni@arevpna)


    1. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163–1170.[PubMed]

    2. Piegas LS, Feitosa G, Mattos LA, Nicolau JC, Rossi Neto JM, Timerman A, et al. Sociedade Brasileira de Cardiologia. Diretriz da Sociedade Brasileira de Cardiologia sobre tratamento do infarto agudo do miocárdio com supradesnível do segmento ST. Arq Bras Cardiol. 2009;93(6) supl.2:e179–e264.[PubMed]

    3. Becker RC, Gore JM, Lambrew C, Weaver WD, Rubison RM, French WJ, et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol. 1996;27(6):1321–1326.[PubMed]

    4. Miniat M, Prediletto R, Formichi B, Marini C, Di Ricco G, Tornelli L, et al. Accuracy of clinical assesment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. 1999;159(3):864–871.[PubMed]

    5. Kannel WB, Cupples LA, D'Agostino RB. Sudden death risk in overt coronary heart disease: the Framingham Study. Am Heart J. 1987;113(3):799–804.[PubMed]

    6. Tunstall-Pedoe H, Kuulasmaa K, Amouyel P, Arveiler D, Rajakangas AM, Pajak A. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation. 1994;90(1):583–612.[PubMed]

    7. Fleg JL, Stone GW, Fayad ZA, Granada JF, Hatsukami TS, Kolodgie FD, et al. Detection of high-risk atherosclerotic plaque: report of the NHLBI Working Group on current status and future directions. JACC Cardiovasc Imaging. 2012;5(9):941–955.[PMC free article][PubMed]

    8. Birnbaum Y, Fishbein MC, Blanche C, Siegel RJ. Ventricular septal rupture after acute myocardial infarction. N Engl J Med. 2002;347(18):1426–1432.[PubMed]

    9. Landini L, Leone A. Smoking and hypertension: effects on clinical, biochemical and pathological variables due to isolated or combined action on cardiovascular system. Curr Pharm Des. 2011;17(28):2987–3001.[PubMed]

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