Elsevier

The Lancet

Volume 389, Issue 10065, 14–20 January 2017, Pages 197-210
The Lancet

Seminar
Acute myocardial infarction

https://doi.org/10.1016/S0140-6736(16)30677-8Get rights and content

Summary

Acute myocardial infarction has traditionally been divided into ST elevation or non-ST elevation myocardial infarction; however, therapies are similar between the two, and the overall management of acute myocardial infarction can be reviewed for simplicity. Acute myocardial infarction remains a leading cause of morbidity and mortality worldwide, despite substantial improvements in prognosis over the past decade. The progress is a result of several major trends, including improvements in risk stratification, more widespread use of an invasive strategy, implementation of care delivery systems prioritising immediate revascularisation through percutaneous coronary intervention (or fibrinolysis), advances in antiplatelet agents and anticoagulants, and greater use of secondary prevention strategies such as statins. This seminar discusses the important topics of the pathophysiology, epidemiological trends, and modern management of acute myocardial infarction, focusing on the recent advances in reperfusion strategies and pharmacological treatment approaches.

Section snippets

Epidemiology

Acute myocardial infarction is the most severe manifestation of coronary artery disease, which causes more than 2·4 million deaths in the USA, more than 4 million deaths in Europe and northern Asia,1 and more than a third of deaths in developed nations annually.2 Increased use of evidence-based therapies and lifestyle changes have spurred considerable reductions in mortality from coronary heart disease in recent decades.1 However, myocardial infarction retains a substantial footprint on global

Pathophysiology

Acute myocardial infarction is divided into STEMI and NSTEMI.5 Unstable angina is also considered an acute coronary syndrome (ACS), because it is an imminent precursor to myocardial infarction. Unstable angina has a similar pathophysiology to NSTEMI, and they are together referred to as non-ST-segment elevation ACS (NSTE-ACS). They have traditionally been grouped together for management decisions. In most cases, myocardial infarction is due to disruption of a vulnerable atherosclerotic plaque

Diagnosis

A combined task force of major professional societies revised the definition of myocardial infarction in 2012 to reflect any event leading to myocardial ischaemia causing cardiac myocyte cell death, and suggested myocardial infarction be classified by its pathological cause into five types (appendix p 5).5 In each case, the diagnosis of myocardial infarction relies on biomarker evidence of myocyte necrosis, and either electrocardiographic (ECG) criteria of ischaemia or infarction, or ischaemic

Risk assessment

Early risk stratification of patients with myocardial infarction allows for prognostication and triage via initiation of one of several vital treatment pathways. Several clinical prediction scores estimate short-term and long-term risks of recurrent ischaemic events and death after myocardial infarction. The TIMI risk score is easiest to use, whereas GRACE is more accurate, comprehensive, and applicable to both NSTEMI and STEMI (appendix p 2).11 Dedicated STEMI risk scores also exist, but they

General principles

In NSTEMI, antithrombotic therapy is thought to stabilise the vulnerable plaque and allow endogenous fibrinolysis to restore patency.12 Percutaneous coronary intervention (PCI) is usually pursued to improve blood flow and prevent recurrent ischaemia. PCI should be done within 24 h of NSTEMI if possible, but some studies suggest that PCI could be done in low-risk patients up to 48–72 h without clinical consequence.13 However, doing PCI after 24 h has been associated with longer hospitalisation,14

Aspirin

Randomised trials have shown a reduction in death or myocardial infarction of greater than 50% with aspirin compared with placebo in patients with ACS.68, 69 Guidelines recommend a loading dose of aspirin (162–325 mg) as soon as possible following myocardial infarction, whereas indefinite low-dose aspirin (75–100 mg) is advised for secondary prevention, because it is as effective as higher doses at preventing ischaemic events but causes less bleeding.4, 15, 17

P2Y12 inhibitors

Clopidogrel is a second generation

Complications from acute myocardial infarction

Knowledge of the cardinal features and timing of the complications of myocardial infarction is essential to recognise and properly treat these potentially fatal events (figure 3).

New antithrombotic therapies

When added to DAPT, both rivaroxaban and vorapaxar improve the secondary prevention of cardiovascular events, at the expense of increased bleeding.130, 131 Either therapy could be useful in high-risk patients following myocardial infarction or with established coronary artery disease and low bleeding risk (appendix p 10).

Lipid-lowering therapy

Aggressive control of LDL cholesterol with high-intensity statin therapy (eg, atorvastatin 80 mg) is advised in all patients after myocardial infarction on the basis of results

Future directions

Continued progress in improving outcomes following acute myocardial infarction will be made only with a commitment to research targeted at improving the systems in which care is delivered. The largest gains might be from research into increasing adherence to guideline-directed medical therapies and spreading established systems-based advances to developing countries. Additionally, it is hopeful that emerging technologies and translational science (including novel applications of gene and

Search strategy and selection criteria

We searched MEDLINE between Jan 1, 2002, and Dec 31, 2015, with the following search terms: “ST segment elevation myocardial infarction”, “non-ST segment myocardial infarction”, “acute coronary syndrome”, “myocardial infarction”, “fibrinolysis”, “thrombolysis”, “angioplasty”, “stent”, “cardiogenic shock”, “anti-platelet therapy”, “anti-thrombotic therapy”, “clinical guidelines”, “quality of care”, and “survival”. Additionally, we reviewed the reference lists of manuscripts identified by this

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