• Search Menu
  • Volume 2024, Issue 2, February 2024 (In Progress)
  • Volume 2024, Issue 1, January 2024
  • Case of the Year
  • MSF Case Reports
  • Audiovestibular medicine
  • Cardiology and cardiovascular systems
  • Critical care medicine
  • Dermatology
  • Emergency medicine
  • Endocrinology and metabolism
  • Gastroenterology and hepatology
  • Geriatrics and gerontology
  • Haematology
  • Infectious diseases and tropical medicine
  • Medical ophthalmology
  • Medical disorders in pregnancy
  • Paediatrics
  • Palliative medicine
  • Pharmacology and pharmacy
  • Radiology, nuclear medicine, and medical imaging
  • Respiratory disorders
  • Rheumatology
  • Sexual and reproductive health
  • Sports medicine
  • Substance abuse
  • Author Guidelines
  • Submission Site
  • Open Access
  • Editorial Board
  • Advertising and Corporate Services
  • Journals Career Network
  • Self-Archiving Policy
  • Journals on Oxford Academic
  • Books on Oxford Academic

Article Contents

Answer to part 1, answer to part 2, answer to part 3, answer to part 4, answer to part 5.

  • < Previous

Educational Case: A 57-year-old man with chest pain

Contributed equally.

  • Article contents
  • Figures & tables
  • Supplementary Data

Nikhil Aggarwal, Subothini Selvendran, Vassilios Vassiliou, Educational Case: A 57-year-old man with chest pain, Oxford Medical Case Reports , Volume 2016, Issue 4, April 2016, Pages 62–65, https://doi.org/10.1093/omcr/omw008

  • Permissions Icon Permissions

This is an educational case report including multiple choice questions and their answers. For the best educational experience we recommend the interactive web version of the exercise which is available via the following link: http://www.oxfordjournals.org/our_journals/omcr/ec01p1.html

A 57 year-old male lorry driver, presented to his local emergency department with a 20-minute episode of diaphoresis and chest pain. The chest pain was central, radiating to the left arm and crushing in nature. The pain settled promptly following 300 mg aspirin orally and 800 mcg glyceryl trinitrate (GTN) spray sublingually administered by paramedics in the community. He smoked 20 cigarettes daily (38 pack years) but was not aware of any other cardiovascular risk factors. On examination he appeared comfortable and was able to complete sentences fully. There were no heart murmurs present on cardiac auscultation. Blood pressure was 180/105 mmHg, heart rate was 83 bpm and regular, oxygen saturation was 97%.

What is the most likely diagnosis?

An ECG was requested and is shown in figure 1.

How would you manage the patient? (The patient has already received 300 mg aspirin).

30 minutes later the patient's chest pain returned with greater intensity whilst waiting in the emergency department. Now, he described the pain as though “an elephant is sitting on his chest”. The nurse has already done an ECG by the time you were called to see him. This is shown in figure 2.

ECG on admission.

ECG on admission.

ECG 30 minutes after admission.

ECG 30 minutes after admission.

What would be the optimal management for this patient?

He was taken to the catheterization lab where the left anterior descending coronary artery (LAD) was shown to be completely occluded. Following successful percutaneous intervention and one drug eluding stent implantation in the LAD normal flow is restored (Thrombosis in myocardial infarction, TIMI = 3). 72 hours later, he is ready to be discharged home. The patient is keen to return to work and asks when he could do so.

When would you advise him that he could return to work?

One week later, he receives a letter informing him that he is required to attend cardiac rehabilitation. The patient is confused as to what cardiac rehabilitation entails, although he does remember a nurse discussing this with him briefly before he was discharged. He phones the hospital in order to get some more information.

Which of the following can be addressed during cardiac rehabilitation?

A - Acute coronary syndrome

Although the presentation could be attributable to any of the above differential diagnoses, the most likely etiology given the clinical picture and risk factors is one of cardiac ischemia. Risk factors include gender, smoking status and age making the diagnosis of acute coronary syndrome the most likely one. The broad differential diagnosis in patients presenting with chest pain has been discussed extensively in the medical literature. An old but relevant review can be found freely available 1 as well as more recent reviews. 2 , 3

C - Atorvastatin 80 mg, Clopidogrel 300 mcg, GTN 500 mcg, Ramipril 2.5 mg,

In patients with ACS, medications can be tailored to the individual patient. Some medications have symptomatic benefit but some also have prognostic benefit. Aspirin 4 , Clopidogrel 5 , Atenolol 6 and Atorvastatin 7 have been found to improve prognosis significantly. ACE inhibitors have also been found to improve left ventricular modeling and function after an MI. 8 , 9 Furthermore, GTN 10 and morphine 11 have been found to be of only significant symptomatic benefit.

Oxygen should only to be used when saturations <95% and at the lowest concentration required to keep saturations >95%. 12

There is no evidence that diltiazem, a calcium channel blocker, is of benefit. 13

His ECG in figure 1 does not fulfil ST elevation myocardial infarction (STEMI) criteria and he should therefore be managed as a Non-STEMI. He would benefit prognostically from beta-blockade however his heart rate is only 42 bpm and therefore this is contraindicated. He should receive a loading dose of clopidogrel (300 mg) followed by daily maintenance dose (75 mg). 14 , 15 He might not require GTN if he is pain-free but out of the available answers 3 is the most correct.

D - Proceed to coronary angiography

The ECG shows ST elevation in leads V2-V6 and confirms an anterolateral STEMI, which suggests a completely occluded LAD. This ECG fulfils the criteria to initiate reperfusion therapy which traditionally require one of the three to be present: According to guidance, if the patient can undergo coronary angiography within 120 minutes from the onset of chest pain, then this represents the optimal management. If it is not possible to undergo coronary angiography and potentially percutaneous intervention within 2 hours, then thrombolysis is considered an acceptable alternative. 12 , 16

≥ 1 mm of ST change in at least two contiguous limb leads (II, III, AVF, I, AVL).

≥ 2 mm of ST change in at least two contiguous chest leads (V1-V6).

New left bundle branch block.

GTN and morphine administration can be considered in parallel but they do not have a prognostic benefit.

E - Not before an exercise test

This patient is a lorry driver and therefore has a professional heavy vehicle driving license. The regulation for driving initiation in a lorry driver following a NSTEMI/ STEMI may be different in various countries and therefore the local regulations should be followed.

In the UK, a lorry driver holds a category 2 driving license. He should therefore refrain from driving a lorry for at least 6 weeks and can only return to driving if he completes successfully an exercise evaluation. An exercise evaluation is performed on a bicycle or treadmill. Drivers should be able to complete 3 stages of the standard Bruce protocol 17 or equivalent (e.g. Myocardial perfusion scan) safely, having refrained from taking anti-anginal medication for 48 hours and should remain free from signs of cardiovascular dysfunction during the test, notably: angina pectoris, syncope, hypotension, sustained ventricular tachycardia, and/or electrocardiographic ST segment shift which is considered as being indicative of myocardial ischemia (usually >2 mm horizontal or down-sloping) during exercise or the recovery period. 18

For a standard car driving license (category 1), driving can resume one week after successful intervention providing that no other revascularization is planned within 4 weeks; left ventricular ejection fraction (LVEF) is at least 40% prior to hospital discharge and there is no other disqualifying condition.

Therefore if this patent was in the UK, he could restart driving a normal car one week later assuming an echocardiogram confirmed an EF > 40%. However, he could only continue lorry driving once he has passed the required tests. 18

E - All of the above

Cardiac rehabilitation bridges the gap between hospitals and patients' homes. The cardiac rehabilitation team consists of various healthcare professions and the programme is started during hospital admission or after diagnosis. Its aim is to educate patients about their cardiac condition in order to help them adopt a healthier lifestyle. This includes educating patients' about their diet, exercise, risk factors associated with their condition such as smoking and alcohol intake and finally, about the medication recommended. There is good evidence that adherence to cardiac rehabilitation programmes improves survival and leads to a reduction in future cardiovascular events.​ 19 , 20

Oille JA . Differential diagnosis of pain in the chest . Can Med Assoc J . 1937 ; 37 (3) : 209 – 216 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC536075/ .

Google Scholar

Lee TH , Goldman L . Evaluation of the patient with acute chest pain . N Engl J Med . 2000 ; 342 (16) : 1187 – 1195 . http://www.nejm.org/doi/full/10.1056/NEJM200004203421607 .

Douglas PS , Ginsburg GS . The evaluation of chest pain in women . N Engl J Med . 1996 ; 334 (20) : 1311 – 1315 . http://www.nejm.org/doi/full/10.1056/NEJM199605163342007 .

Baigent C , Collins R , Appleby P , Parish S , Sleight P , Peto R . ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither. the ISIS-2 (second international study of infarct survival) collaborative group . BMJ . 1998 ; 316 (7141) : 1337 – 1343 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28530/ .

Yusuf S , Zhao F , Mehta S , Chrolavicius S , Tognoni G , Fox K . Clopidogrel in unstable angina to prevent recurrent events trail investigators . effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation . N Engl J Med . 2001 ; 345 (7) : 494 – 502 . http://www.nejm.org/doi/full/10.1056/NEJMoa010746#t=articleTop .

Yusuf S , Peto R , Lewis J , Collins R , Sleight P . Beta blockade during and after myocardial infarction: An overview of the randomized trials . Prog Cardiovasc Dis . 1985 ; 27 (5) : 335 – 371 . http://www.sciencedirect.com/science/article/pii/S0033062085800037 .

Schwartz GG , Olsson AG , Ezekowitz MD et al.  . Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: The MIRACL study: A randomized controlled trial . JAMA . 2001 ; 285 (13) : 1711 – 1718 . http://jama.jamanetwork.com/article.aspx?articleid=193709 .

Pfeffer MA , Lamas GA , Vaughan DE , Parisi AF , Braunwald E . Effect of captopril on progressive ventricular dilatation after anterior myocardial infarction . N Engl J Med . 1988 ; 319 (2) : 80 – 86 . http://content.onlinejacc.org/article.aspx?articleid=1118054 .

Sharpe N , Smith H , Murphy J , Hannan S . Treatment of patients with symptomless left ventricular dysfunction after myocardial infarction . The Lancet . 1988 ; 331 (8580) : 255 – 259 . http://www.sciencedirect.com/science/article/pii/S0140673688903479 .

Ferreira JC , Mochly-Rosen D . Nitroglycerin use in myocardial infarction patients . Circ J . 2012 ; 76 (1) : 15 – 21 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527093/ .

Herlitz J , Hjalmarson A , Waagstein F . Treatment of pain in acute myocardial infarction . Br Heart J . 1989 ; 61 (1) : 9 – 13 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1216614/ .

Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, et al . ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation . Eur Heart J . 2012 ; 33 (20) : 2569 – 2619 . http://eurheartj.oxfordjournals.org/content/33/20/2569 .

The effect of diltiazem on mortality and reinfarction after myocardial infarction . the multicenter diltiazem postinfarction trial research group . N Engl J Med . 1988 ; 319 (7) : 385 – 392 . http://www.nejm.org/doi/full/10.1056/NEJM198808183190701 .

Jneid H , Anderson JL , Wright RS et al.  . 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update) A report of the american college of cardiology foundation/american heart association task force on practice guidelines . J Am Coll Cardiol . 2012 ; 60 (7) : 645 – 681 . http://circ.ahajournals.org/content/123/18/2022.full .

Hamm CW , Bassand JP , Agewall S et al.  . ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the european society of cardiology (ESC) . Eur Heart J . 2011 ; 32 (23) : 2999 – 3054 . http://eurheartj.oxfordjournals.org/content/32/23/2999.long .

O'Gara PT , Kushner FG , Ascheim DD et al.  . 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary: A report of the american college of cardiology foundation/american heart association task force on practice guidelines . J Am Coll Cardiol . 2013 ; 61 (4) : 485 – 510 . http://content.onlinejacc.org/article.aspx?articleid=1486115 .

BRUCE RA , LOVEJOY FW Jr . Normal respiratory and circulatory pathways of adaptation in exercise . J Clin Invest . 1949 ; 28 (6 Pt 2) : 1423 – 1430 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC439698/ .

DVLA . Https://Www.gov.uk/current-medical-guidelines-dvla-guidance-for-professionals-cardiovascular-chapter-appendix .

British Heart Foundation . Http://Www.bhf.org.uk/heart-health/living-with-heart-disease/cardiac-rehabilitation.aspx .

Kwan G , Balady GJ . Cardiac rehabilitation 2012: Advancing the field through emerging science . Circulation . 2012 ; 125 (7) : e369–73. http://circ.ahajournals.org/content/125/7/e369.full .

Author notes

  • knowledge acquisition

Email alerts

Citing articles via, affiliations.

  • Online ISSN 2053-8855
  • Copyright © 2024 Oxford University Press
  • About Oxford Academic
  • Publish journals with us
  • University press partners
  • What we publish
  • New features  
  • Open access
  • Institutional account management
  • Rights and permissions
  • Get help with access
  • Accessibility
  • Advertising
  • Media enquiries
  • Oxford University Press
  • Oxford Languages
  • University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

  • Copyright © 2024 Oxford University Press
  • Cookie settings
  • Cookie policy
  • Privacy policy
  • Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

  • Introduction
  • Conclusions
  • Article Information

The start of the early coronavirus disease 2019 (COVID-19) period (February 23, 2020) and later COVID-19 period (March 29, 2020), as defined by segmented regression analysis, are indicated by vertical lines. Dotted lines indicate the best-fit regression lines for the 3 periods (including the before COVID-19 period). Projected volumes with 95% CIs are displayed in gray. STEMI indicates ST-segment elevation myocardial infarction.

eTable 1. ICD-10 Codes

eTable 2. MS-DRG Codes Used in Treatment Approaches Analysis

eTable 3. Weekly Case Volumes in 2020

eFigure 1. Weekly Volumes by State

eFigure 2. Treatment Approaches

See More About

Select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

  • Academic Medicine
  • Acid Base, Electrolytes, Fluids
  • Allergy and Clinical Immunology
  • American Indian or Alaska Natives
  • Anesthesiology
  • Anticoagulation
  • Art and Images in Psychiatry
  • Artificial Intelligence
  • Assisted Reproduction
  • Bleeding and Transfusion
  • Caring for the Critically Ill Patient
  • Challenges in Clinical Electrocardiography
  • Climate and Health
  • Climate Change
  • Clinical Challenge
  • Clinical Decision Support
  • Clinical Implications of Basic Neuroscience
  • Clinical Pharmacy and Pharmacology
  • Complementary and Alternative Medicine
  • Consensus Statements
  • Coronavirus (COVID-19)
  • Critical Care Medicine
  • Cultural Competency
  • Dental Medicine
  • Dermatology
  • Diabetes and Endocrinology
  • Diagnostic Test Interpretation
  • Drug Development
  • Electronic Health Records
  • Emergency Medicine
  • End of Life, Hospice, Palliative Care
  • Environmental Health
  • Equity, Diversity, and Inclusion
  • Facial Plastic Surgery
  • Gastroenterology and Hepatology
  • Genetics and Genomics
  • Genomics and Precision Health
  • Global Health
  • Guide to Statistics and Methods
  • Hair Disorders
  • Health Care Delivery Models
  • Health Care Economics, Insurance, Payment
  • Health Care Quality
  • Health Care Reform
  • Health Care Safety
  • Health Care Workforce
  • Health Disparities
  • Health Inequities
  • Health Policy
  • Health Systems Science
  • History of Medicine
  • Hypertension
  • Images in Neurology
  • Implementation Science
  • Infectious Diseases
  • Innovations in Health Care Delivery
  • JAMA Infographic
  • Law and Medicine
  • Leading Change
  • Less is More
  • LGBTQIA Medicine
  • Lifestyle Behaviors
  • Medical Coding
  • Medical Devices and Equipment
  • Medical Education
  • Medical Education and Training
  • Medical Journals and Publishing
  • Mobile Health and Telemedicine
  • Narrative Medicine
  • Neuroscience and Psychiatry
  • Notable Notes
  • Nutrition, Obesity, Exercise
  • Obstetrics and Gynecology
  • Occupational Health
  • Ophthalmology
  • Orthopedics
  • Otolaryngology
  • Pain Medicine
  • Palliative Care
  • Pathology and Laboratory Medicine
  • Patient Care
  • Patient Information
  • Performance Improvement
  • Performance Measures
  • Perioperative Care and Consultation
  • Pharmacoeconomics
  • Pharmacoepidemiology
  • Pharmacogenetics
  • Pharmacy and Clinical Pharmacology
  • Physical Medicine and Rehabilitation
  • Physical Therapy
  • Physician Leadership
  • Population Health
  • Primary Care
  • Professional Well-being
  • Professionalism
  • Psychiatry and Behavioral Health
  • Public Health
  • Pulmonary Medicine
  • Regulatory Agencies
  • Reproductive Health
  • Research, Methods, Statistics
  • Resuscitation
  • Rheumatology
  • Risk Management
  • Scientific Discovery and the Future of Medicine
  • Shared Decision Making and Communication
  • Sleep Medicine
  • Sports Medicine
  • Stem Cell Transplantation
  • Substance Use and Addiction Medicine
  • Surgical Innovation
  • Surgical Pearls
  • Teachable Moment
  • Technology and Finance
  • The Art of JAMA
  • The Arts and Medicine
  • The Rational Clinical Examination
  • Tobacco and e-Cigarettes
  • Translational Medicine
  • Trauma and Injury
  • Treatment Adherence
  • Ultrasonography
  • Users' Guide to the Medical Literature
  • Vaccination
  • Venous Thromboembolism
  • Veterans Health
  • Women's Health
  • Workflow and Process
  • Wound Care, Infection, Healing

Others Also Liked

  • Download PDF
  • X Facebook More LinkedIn

Gluckman TJ , Wilson MA , Chiu S, et al. Case Rates, Treatment Approaches, and Outcomes in Acute Myocardial Infarction During the Coronavirus Disease 2019 Pandemic. JAMA Cardiol. 2020;5(12):1419–1424. doi:10.1001/jamacardio.2020.3629

Manage citations:

© 2024

  • Permissions

Case Rates, Treatment Approaches, and Outcomes in Acute Myocardial Infarction During the Coronavirus Disease 2019 Pandemic

  • 1 Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St Joseph Health, Portland, Oregon
  • 2 Clinical Analytics, Providence St Joseph Health, Renton, Washington
  • 3 Heart and Vascular Institute, Providence Regional Medical Center Everett, Everett, Washington
  • 4 Providence Heart Institute, Providence St Peter Hospital, Olympia, Washington

Question   How have case rates, treatment approaches, and in-hospital outcomes changed for patients with acute myocardial infarction (AMI) during the coronavirus disease 2019 (COVID-19) pandemic?

Findings   In this cross-sectional study of 15 244 hospitalizations involving 14 724 patients with AMI, case rates began to decrease on February 23, 2020, followed by a modest recovery after 5 weeks. Although no statistically significant difference in treatment approaches was found, the risk-adjusted mortality rate among patients with ST-segment elevation myocardial infarction increased substantially.

Meaning   The findings of this study show that changes in AMI hospitalizations and in-hospital outcomes occurred during the COVID-19 pandemic periods analyzed; additional research is warranted to explain the higher mortality rate among patients with ST-segment elevation myocardial infarction.

Importance   The coronavirus disease 2019 (COVID-19) pandemic has changed health care delivery worldwide. Although decreases in hospitalization for acute myocardial infarction (AMI) have been reported during the pandemic, the implication for in-hospital outcomes is not well understood.

Objective   To define changes in AMI case rates, patient demographics, cardiovascular comorbidities, treatment approaches, and in-hospital outcomes during the pandemic.

Design, Setting, and Participants   This cross-sectional study retrospectively analyzed AMI hospitalizations that occurred between December 30, 2018, and May 16, 2020, in 1 of the 49 hospitals in the Providence St Joseph Health system located in 6 states (Alaska, Washington, Montana, Oregon, California, and Texas). The cohort included patients aged 18 years or older who had a principal discharge diagnosis of AMI (ST-segment elevation myocardial infarction [STEMI] or non–ST-segment elevation myocardial infarction [NSTEMI]). Segmented regression analysis was performed to assess changes in weekly case volumes. Cases were grouped into 1 of 3 periods: before COVID-19 (December 30, 2018, to February 22, 2020), early COVID-19 (February 23, 2020, to March 28, 2020), and later COVID-19 (March 29, 2020, to May 16, 2020). In-hospital mortality was risk-adjusted using an observed to expected (O/E) ratio and covariate-adjusted multivariable model.

Exposure   Date of hospitalization.

Main Outcomes and Measures   The primary outcome was the weekly rate of AMI (STEMI or NSTEMI) hospitalizations. The secondary outcomes were patient characteristics, treatment approaches, and in-hospital outcomes of this patient population.

Results   The cohort included 15 244 AMI hospitalizations (of which 4955 were for STEMI [33%] and 10 289 for NSTEMI [67%]) involving 14 724 patients (mean [SD] age of 68 [13] years and 10 019 men [66%]). Beginning February 23, 2020, AMI-associated hospitalizations decreased at a rate of –19.0 (95% CI, –29.0 to –9.0) cases per week for 5 weeks (early COVID-19 period). Thereafter, AMI-associated hospitalizations increased at a rate of +10.5 (95% CI, +4.6 to +16.5) cases per week (later COVID-19 period). No appreciable differences in patient demographics, cardiovascular comorbidities, and treatment approaches were observed across periods. The O/E mortality ratio for AMI increased during the early period (1.27; 95% CI, 1.07-1.48), which was disproportionately associated with patients with STEMI (1.96; 95% CI, 1.22-2.70). Although the O/E mortality ratio for AMI was not statistically different during the later period (1.23; 95% CI, 0.98-1.47), increases in the O/E mortality ratio were noted for patients with STEMI (2.40; 95% CI, 1.65-3.16) and after risk adjustment (odds ratio, 1.52; 95% CI, 1.02-2.26).

Conclusions and Relevance   This cross-sectional study found important changes in AMI hospitalization rates and worse outcomes during the early and later COVID-19 periods. Future studies are needed to identify contributors to the increased mortality rate among patients with STEMI.

The coronavirus disease 2019 (COVID-19) pandemic has profoundly changed health care delivery worldwide. Although early attention to COVID-19 was disproportionately focused on efforts to flatten the (pandemic) curve, recent studies have revealed a substantial decrease in hospitalization rates for acute myocardial infarction (AMI). Reports from Austria, 1 Italy, 2 and the US (California) 3 have noted lower admission rates for both ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation myocardial infarction (NSTEMI). This decreased hospitalization rate likely reflects multiple factors. Most worrisome among these factors has been the reluctance of patients with AMI to seek medical attention out of fear that they may become infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 4

We performed a retrospective, cross-sectional study of all AMI hospitalizations in a large multistate health care system. We sought to define changes in AMI case rates, patient demographics, cardiovascular comorbidities, treatment approaches, and in-hospital outcomes during the pandemic.

This study included patients aged 18 years or older with a principal discharge diagnosis of AMI who were admitted between December 30, 2018, and May 16, 2020, into 1 of 49 hospitals in the Providence St Joseph Health (PSJH) system located in 6 states (Alaska, Washington, Montana, Oregon, California, and Texas). We used International Statistical Classification of Diseases and Related Health Problems, Tenth Revision , codes to define the population (eTable 1 in the Supplement ). Individuals who were admitted as an outpatient were excluded. This study was approved by the PSJH Institutional Review Board, which waived the informed consent requirement because of the retrospective nature of the study.

The primary outcome was the weekly rate of AMI (STEMI or NSTEMI) hospitalizations before and after the pandemic onset. The secondary outcomes were patient characteristics, treatment approaches, and in-hospital outcomes (mortality, length of stay, and discharge disposition) of patients with STEMI or NSTEMI. Treatment approaches were defined by Medicare Severity-Diagnosis Related Groups (MS-DRGs) for percutaneous coronary intervention, coronary artery bypass graft surgery, and medical management of AMI (eTable 2 in the Supplement ).

Weekly volumes of AMI hospitalizations (categorized as STEMI or NSTEMI) are presented in the Figure as line graphs. Segmented regression analysis was used to ascertain volume changes over time. Using 2 identified break points (February 23, 2020 and March 29, 2020), we grouped cases into 1 of 3 periods for analysis: before COVID-19 (December 30, 2018, to February 22, 2020), early COVID-19 (February 23, 2020, to March 28, 2020), and later COVID-19 (March 29, 2020, to May 16, 2020). Segmented regression analysis was also used to identify the slope change in weekly hospitalizations during the 3 periods, with consideration of time dependence in the model.

Risk-adjusted in-hospital mortality was examined with 2 models. The first was the PSJH mortality risk model, which was a lookup table consisting of more than 5430 expected mortality rates. Such data were derived from the 3M All Patient Refined DRG, risk of mortality, and severity-of-illness grouper algorithm applied to a large inpatient database in the western US (eMethods in the Supplement ). The second was a multivariable logistic model, which considered all demographic variables listed in Table 1 . Results of the multivariable model were presented as adjusted odds ratio (OR) with 95% CI.

Patient demographics, cardiovascular comorbidities, treatment approaches, and in-hospital outcomes were summarized as descriptive statistics. Categorical data were presented as frequency (percentage). Numeric data were tested for normality and presented as mean (SD) or median (interquartile range [IQR]), as appropriate. Trends among the 3 COVID-19 periods were compared using univariate χ 2 , Fisher exact, or Kruskal-Wallis tests, as appropriate, for each variable. The level of statistical significance varied from P  < .05 to P  < .008, depending on Bonferroni adjustment for multiple comparisons (eMethods in the Supplement ).

The study cohort comprised 15 244 hospitalizations for AMI (4955 for STEMI [33%] and 10 289 for NSTEMI [67%]) involving 14 724 patients. Of those hospitalized, 5225 were women (34%) and 10 019 were men (66%), with a mean (SD) age of 68 (13) years ( Table 1 ). Before the COVID-19 period, the mean (SD) weekly case rate was 222 (17) patients for AMI, 72 (9) patients for STEMI, and 150 (13) patients for NSTEMI ( Figure and eTable 3 in the Supplement ). Beginning February 23, 2020, AMI hospitalizations decreased at a rate of –19.0 (95% CI, –29.0 to –9.0) cases per week for 5 weeks, marking the early COVID-19 period ( Figure ). Thereafter, AMI hospitalizations increased at a rate of +10.5 (95% CI, +4.6 to +16.5) cases per week, marking the later COVID-19 period. Weekly AMI hospitalization rates had not returned to baseline, however, by the last week evaluated (May 10, 2020; eTable 3 in the Supplement ). Similar trends in hospitalization for AMI, STEMI, and NSTEMI were observed in the PSJH system in all 6 states (eFigure 1 in the Supplement ).

Patients hospitalized for AMI in the early and later COVID-19 periods vs the before period were slightly younger (mean [SD] age, 67 [13] years vs 68 [13] years; P  < .001) and more likely to be Asian (50 [6%] and 62 [6%] vs 667 [5%]; P  = .01) or Native American individuals (20 [2%] and 21 [2%] vs 151 [1%]; P  = .01) ( Table 1 ). Treatment approaches for patients with STEMI or NSTEMI were not statistically different across periods (eFigure 2 in the Supplement ). Median (IQR) length of stay for patients with AMI was shorter in the early COVID-19 period by 7 hours and in the later COVID-19 period by 6 hours compared with the before period (56 [41-115] hours and 57 [41-116] hours vs 63 [43-122] hours, respectively; P  < .001) ( Table 2 ). Similar trends were observed for both types of AMI. A greater number of patients with AMI were discharged to home in the early and later COVID-19 periods vs the before COVID-19 period, with consistent findings among those with STEMI (235 [83%] and 284 [81%] vs 3402 [79%]; P  = .02) and NSTEMI (465 [81%] and 587 [83%] vs 6976 [77%]; P  = .006).

The observed (crude) in-hospital mortality rate was similar between periods for all groups ( Table 2 ). Compared with the before COVID-19 period, however, patients with STEMI had a statistically greater risk of mortality during the later COVID-19 period after adjusting for patient demographic characteristics and comorbidities (OR, 1.52; 95% CI, 1.02-2.26). Using the PSJH model, the observed to expected (O/E) hospital mortality ratio for patients with AMI was statistically increased in the early COVID-19 period (O/E ratio, 1.27; 95% CI, 1.07-1.48), with consistent findings in the later period as well (O/E ratio, 1.23; 95% CI, 0.98-1.47). These findings, however, were different for patients with STEMI vs those with NSTEMI. For patients with STEMI, the O/E mortality ratio was substantially higher in all 3 COVID-19 periods. These patients had a stepwise increase in the O/E mortality ratio from the before period (O/E ratio, 1.48; 95% CI, 1.34-1.62) to the early (O/E ratio, 1.96; 95% CI, 1.22-2.70) and later (O/E ratio, 2.40; 95% CI, 1.65-3.16) periods. The O/E mortality ratio for STEMI in the later period was statistically greater than the before period. In contrast, patients with NSTEMI had a consistently lower O/E mortality ratio for all 3 periods (before: O/E ratio, 0.80 [95% CI, 0.71-0.88]; early: O/E ratio, 0.91 [95% CI, 0.46-1.36]; later: O/E ratio, 0.71 [95% CI, 0.49-0.93]).

Consistent with previous reports, this study found a substantial decrease in AMI hospitalization rates in the early COVID-19 period. Beginning March 29, 2020, however, hospitalizations for AMI began to increase, albeit at a slower rate. Among the many factors likely associated with this rebound in cases was encouragement of patients with symptoms or signs of AMI to seek immediate medical attention, even amid the pandemic. 5 , 6

Although patient demographics and treatment approaches were fairly consistent across periods, patients with AMI hospitalized during the COVID-19 period were 1 to 3 years younger, had a shorter length of stay, and were more likely to be discharged to home. Possible explanations for these findings were greater reluctance by older patients to seek medical attention, hospital efforts to maintain bed availability, patient preference for early discharge, and concern about risk of contracting SARS-CoV-2 in post–acute care facilities.

Notable differences in risk-adjusted mortality were observed over the periods analyzed. Patients hospitalized for AMI during the early COVID-19 period had an increased O/E mortality ratio, associated disproportionately with patients with STEMI. In this population, the O/E ratio and risk-adjusted mortality rates were even greater during the later COVID-19 period. Given the time-sensitive nature of STEMI, any delay by patients, emergency medical services, the emergency department, or cardiac catheterization laboratory may have played a role. 7 , 8 Additional complications from delayed reperfusion (eg, conduction disturbances, heart failure, cardiogenic shock, and mechanical complications) 9 may have occurred in some patients. Further research is needed to identify factors associated with the higher mortality rate in patients with STEMI.

In the weeks and months to come, clinicians may see greater numbers of patients with more severe manifestations of AMI. With the uncertainty on timing of a COVID-19 vaccine, this study reinforces the need to address important care processes for patients with AMI to help mitigate further risk.

This study has several limitations. First, because the cohort was defined by coding data, it is possible that the primary reason for hospitalization was misclassified as an AMI. Second, the treatment analysis excluded outpatients and those with other MS-DRG codes. Although this group represented a small percentage of the total patient cohort (8% [1165]), treatment shifts may have been underappreciated. Third, the data set did not allow us to evaluate potential timing-related factors that may have contributed to higher in-hospital mortality (eg, time of symptom onset, first medical contact, and hospital arrival). Fourth, although the PSJH mortality risk model is not AMI-specific, we found consistent results with a multivariable model adjusted for patient demographic characteristics and comorbidities. Fifth, the COVID-19 status of patients included in the analysis was not available. As such, the higher observed rate of AMI mortality during the COVID-19 period could have been associated with concurrent SARS-CoV-2 infection.

Results of this cross-sectional study appear to validate previous concerns that large numbers of patients with AMI initially avoided hospitalization during the COVID-19 pandemic, likely out of fear of contracting SARS-CoV-2. Hospitalization rates for AMI have begun to increase but so has the risk of in-hospital mortality. Further research into factors associated with an increase in the STEMI mortality rate is warranted.

Accepted for Publication: July 10, 2020.

Corresponding Author: Ty J. Gluckman, MD, Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St Joseph Health, 9427 SW Barnes Rd, Ste 594, Portland, OR 97225 ( [email protected] ).

Published Online: August 7, 2020. doi:10.1001/jamacardio.2020.3629

Author Contributions: Drs Gluckman and Chiu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gluckman, Chiu, Penny, Spinelli.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Gluckman, Chiu, Spinelli.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chiu.

Administrative, technical, or material support: Gluckman, Wilson, Penny, Chepuri, Waggoner, Spinelli.

Supervision: Gluckman, Spinelli.

Conflict of Interest Disclosures: None reported.

  • Register for email alerts with links to free full-text articles
  • Access PDFs of free articles
  • Manage your interests
  • Save searches and receive search alerts

What’s new in VA-ECMO for acute myocardial infarction-related cardiogenic shock

  • What's New in Intensive Care
  • Published: 18 March 2024

Cite this article

  • Alain Combes   ORCID: orcid.org/0000-0002-6030-3957 1 , 2 ,
  • Susanna Price 3 , 4 &
  • Bruno Levy 5  

234 Accesses

6 Altmetric

Explore all metrics

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

case study acute myocardial infarction

Mebazaa A, Combes A, van Diepen S et al (2018) Management of cardiogenic shock complicating myocardial infarction. Intensive Care Med 44:760–773

Article   PubMed   Google Scholar  

de Chambrun MP, Donker DW, Combes A (2020) What’s new in cardiogenic shock? Intensive Care Med 46:1016–1019

Abrams D, Garan AR, Abdelbary A et al (2018) Position paper for the organization of ECMO programs for cardiac failure in adults. Intensive Care Med 44:717–729

Combes A, Price S, Slutsky AS et al (2020) Temporary circulatory support for cardiogenic shock. Lancet 396:199–212

Ostadal P, Rokyta R, Karasek J et al (2023) Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation 147:454–464

Article   CAS   PubMed   Google Scholar  

Banning AS, Sabaté M, Orban M et al (2023) Venoarterial extracorporeal membrane oxygenation or standard care in patients with cardiogenic shock complicating acute myocardial infarction: the multicentre, randomised EURO SHOCK trial. EuroIntervention 19:482–492

Thiele H, Zeymer U, Akin I et al (2023) Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med 389:1286–1297

Zeymer U, Freund A, Hochadel M et al (2023) Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials. Lancet 402:1338–1346

Thiele H, Zeymer U, Neumann FJ et al (2012) Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 367:1287–1296

Jentzer JC, van Diepen S, Barsness GW et al (2019) Cardiogenic shock classification to predict mortality in the cardiac intensive care unit. J Am Coll Cardiol 74:2117–2128

Berg DD, Bohula EA, van Diepen S et al (2019) Epidemiology of shock in contemporary cardiac intensive care units. Circ Cardiovasc Qual Outcomes 12:e005618

Jozwiak M, Bougouin W, Geri G et al (2020) Post-resuscitation shock: recent advances in pathophysiology and treatment. Ann Intensive Care 10:170

Article   PubMed   PubMed Central   Google Scholar  

Bréchot N, Hajage D, Kimmoun A et al (2020) Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study. Lancet 396:545–552

Muller G, Flecher E, Lebreton G et al (2016) The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med 42:370–378

Low CJW, Ling RR, Lau M et al (2024) Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies. Intensive Care Med. https://doi.org/10.1007/s00134-023-07278-3

Grandin EW, Nunez JI, Willar B et al (2022) Mechanical left ventricular unloading in patients undergoing venoarterial extracorporeal membrane oxygenation. J Am Coll Cardiol 79:1239–1250

Schrage B, Becher PM, Bernhardt A et al (2020) Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation: results from an international, multicenter cohort study. Circulation 142:2095–2106

Article   CAS   PubMed   PubMed Central   Google Scholar  

Kim MC, Lim Y, Lee SH et al (2023) Early left ventricular unloading or conventional approach after venoarterial extracorporeal membrane oxygenation: the EARLY-UNLOAD randomized clinical trial. Circulation 148:1570–1581

Download references

Author information

Authors and affiliations.

Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France

Alain Combes

Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, Boulevard de L’Hôpital, 75013, Paris, France

Cardiology and Critical Care, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK

Susanna Price

National Heart and Lung Institute, Imperial College, London, UK

Université de Lorraine, CHRU de Nancy, Institut Lorrain du Cœur Et Des Vaisseaux, Service de Médecine Intensive-Réanimation, U1116, FCRIN-INICRCT, Nancy, France

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Alain Combes .

Ethics declarations

Conflicts of interest.

AC reports grants from Getinge, and personal fees from Getinge, Baxter and Xenios outside the submitted work. SP reports reports no disclosures. BL reports grants from Getinge, BD and personal fees from Abiomed, Gettinge, Baxter, Novartis, Sanofi, Amomed, AOP Pharma and Orion.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Combes, A., Price, S. & Levy, B. What’s new in VA-ECMO for acute myocardial infarction-related cardiogenic shock. Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07356-0

Download citation

Received : 12 January 2024

Accepted : 10 February 2024

Published : 18 March 2024

DOI : https://doi.org/10.1007/s00134-024-07356-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Advertisement

  • Find a journal
  • Publish with us
  • Track your research
  • Case Report
  • Open access
  • Published: 19 March 2024

Paclitaxel-induced acute myocardial infarction: a case report and literature review

  • Gi Eun Kim 1 ,
  • Ayman R. Ibrahim 1 ,
  • Duha Shalatouni 1 ,
  • Nadin H. Abouzeid 1 &
  • Fahmi Othman 2  

BMC Cardiovascular Disorders volume  24 , Article number:  167 ( 2024 ) Cite this article

66 Accesses

Metrics details

Paclitaxel is a chemotherapeutic agent commonly used for ovarian, lung, breast carcinoma, and Kaposi’s sarcoma. Its common side effects include hypersensitivity reaction, bone marrow suppression, and peripheral neuropathy. However, a rare and life-threatening side effect is paclitaxel-induced myocardial infarction.

Case presentation

A 71-year-old man with type 2 diabetes mellitus, hypertension, heavy smoking history, previous coronary artery disease with percutaneous coronary intervention (PCI) in left anterior descending artery (LAD), and non-small lung cancer presented with non-ST elevation myocardial infarction during infusion of paclitaxel infusion. Coronary angiogram showed de novo three vessel disease with 70% stenosis in ostial to distal left main artery (LM) and 80% in-stent re-stenosis in proximal to mid left anterior descending artery.

Conclusions

Physicians should be keeping this in mind when dealing with patients on paclitaxel, especially if they have previous risk factors for coronary artery disease.

Peer Review reports

The chronic inflammation in cancer predisposes patients to arterial and venous thromboembolism, including myocardial infarction [ 1 ]. Not only that, but chemotherapy itself is increasingly associated with cardiotoxicity with reported cases of myocardial infarction induced by various chemotherapeutic agents. Potential inducers of coronary vasospasm are 5-fluorouracil, capecitabine, paclitaxel, gemcitabine, rituximab and sorafenib. Other chemotherapeutic drugs are thought to cause direct toxicity on endothelial cells and cause erosion with atherosclerotic plaque rupture, such as cisplatin and vinca alkaloids [ 1 ]. We present a case of a patient with metastatic non-small lung cancer (cT4N2M1) who developed acute coronary syndrome during infusion of paclitaxel infusion.

A 71-year-old man with metastatic non-small cell lung carcinoma and cardiovascular risk factors of type 2 diabetes mellitus, hypertension, heavy smoking history of 80 pack years, and previous coronary artery disease, presented to oncology unit for cycle 8 of pembrolizumab and cycle 5 of paclitaxel and carboplatin. He had coronary angiogram in 2014 which showed distal LM 20–30%, left circumflex artery (LCX) 80%, right coronary artery (RCA) chronic total occlusion, and PCI was done to LAD. He has no family history of coronary artery disease. He was recently diagnosed with poorly differentiated squamous cell carcinoma with staging of cT4N2M1. He had previously progressed on four cycles of pembrolizumab, thus carboplatin and paclitaxel were added two months prior to our event. Patient received a total of 7 doses of pembrolizumab and 4 doses of carboplatin and paclitaxel with no events.

During the eighth session of chemotherapy, pre-medications including diphenhydramine 50 mg, dexamethasone 20 mg, and netupitant were given, and patient completed the pembrolizumab infusion without any complications. However, after starting paclitaxel infusion, the patient developed sudden onset left side chest pain, radiating to left arm associated with shortness of breath. On examination, he was alert and oriented, he was tachypneic (respiratory rate of 25 breathes per minute), tachycardic (heart rate of 109 beats per minute), normotensive (blood pressure of 123/58mmHg), and he was maintaining his oxygen saturation (oxygen saturation 93%) on 4 L of oxygen. Physical examination was remarkable for raised jugular venous pressure with diffuse wheezes and bilateral basal crackles on chest. Paclitaxel was immediately stopped, and the patient received hydrocortisone and diphenhydramine as possible hypersensitivity reaction. Electrocardiogram was showing normal sinus rhythm, ST depression 1 mm in the inferolateral leads and 1 mm ST elevation in aVR (Fig.  1 ). Laboratory results revealed troponin T levels of 32 ng/L, 74 ng/L, then 1439 ng/L. The peak troponin level was 2834 ng/L (normal value 3–15 ng/L). He was diagnosed with non-ST elevation myocardial infarction and shifted to coronary care unit.

He received full anti-ischemic medications including his home medications which were aspirin 100 mg, bisoprolol 2.5 mg, isosorbide dinitrate 20 mg, rosuvastatin 20 mg, and in addition, he was loaded with 300 mg clopidogrel and started on therapeutic enoxaparin.

CT pulmonary angiogram showed no evidence of pulmonary embolism. Transthoracic echocardiography showed left ventricular ejection fraction (LVEF) of 30% (compared to LVEF 49% in previous echocardiogram), with regional wall motion abnormalities in inferior and anterolateral walls (additional file 1 ).

Coronary angiogram was done (additional file 2 ) which showed 70% stenosis in ostial and distal LM, 80% stenosis in-stent restenosis in proximal to mid LAD, 80% stenosis in distal left circumflex artery, 100% chronic total obstruction in proximal right coronary artery. A drug-eluting stent (Xience Sierra 3.5 × 33 mm) was placed in the ostial LM to proximal LAD.

Unfortunately, two days after the coronary angiogram, patient developed melena with 4 gram drop in hemoglobin, for which he required two units of packed red blood cells. Upper and lower endoscopy showed only two small, flat angiodysplasia lesions oozing blood in cecum which were clipped, which stopped the oozing. Even after gastrointestinal bleeding, he was kept on dual antiplatelet, and his recovery afterwards was unremarkable, with no more drops in hemoglobin.

After several days of observation, he was discharged home with education regarding smoking cessation and lifestyle modification, in addition to dual anti-platelet therapy with aspirin and ticagrelor for one year, then with ticagrelor monotherapy lifelong. In a follow up with cardiology clinic 2 weeks after discharge, patient was well and compliant to medications.

figure 1

Initial electrocardiogram

Discussion and conclusions

Paclitaxel is a chemotherapeutic agent in class called taxane approved by Food and Drug Administration (FDA) for ovarian, lung, breast carcinoma, and Kaposi’s sarcoma [ 2 ]. It causes cell cycle inhibition by stabilizing microtubule and activates cell apoptosis pathway. Its most common side effects include hypersensitivity reaction, bone marrow suppression, and peripheral neuropathy. Cardiovascular abnormalities are rare (< 1%) however includes bradycardia, atrial and ventricular arrhythmias, negative inotropic effect, and congestive heart failure [ 2 ]. A concerning cardiovascular side effect is life-threatening myocardial infarction, which has been reported in literature in 10 case reports [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ].

There are various proposed mechanisms for how paclitaxel induces myocardial infarction [ 12 ]. The most proposed mechanism is acute myocardial infarction due to prolonged coronary artery vasospasm, whether it is histamine induced from castor oil used in suspension, increased intracellular calcium concentration, or allergy to paclitaxel [ 12 ].

We searched on Pubmed and Google scolar database for paclitaxel-induced myocardial infarction published till 2 October 2023 using keywords “paclitaxel”, “myocardial infarction”, “acute coronary syndrome”. There were 10 cases which are summarized in Table  1 . Most of the acute myocardial infarctions occurred during or right after paclitaxel infusion (Table  1 ),

In addition, most cases showed ST elevation in electrocardiogram. Coronary angiogram was done in only 5 cases, one of which showed normal coronaries suggesting only vasospasm, while 4 cases showed coronary artery stenosis, suggesting the possibility of paclitaxel not only inducing vasospasm, but also coronary artery stenosis. The compounding factor in determining that paclitaxel is causing the stenosis itself is that malignancy itself is a risk factor for CAD, and although 8 out of 10 case reports did not have any other cardiovascular risk factors (Table  1 ), our patient has multiple cardiovascular risk factors including type 2 diabetes mellitus, hypertension, previous CAD and stent, heavy smoking history, as well as malignancy itself.

Carboplatin is an alkylating agent that interacts with purine bases in DNA interfering with normal transcription and DNA replication and causes cancer cell apoptosis [ 13 ]. Cisplatin, which is in the same class, is known to increase risk of thromboembolism, with several case reports on cisplatin-induced myocardial infarction [ 14 , 15 , 16 ]. There was one retrospective cohort study that showed that there is no significant difference between cisplatin and carboplatin in risk of thromboembolism, and 15.2% of thromboembolic events from carboplatin group were arterial compared to 0% in cisplatin group, which included pulmonary embolism, cerebrovascular accidents, and myocardial infarction [ 13 ]. Thus, as our patient was on regimen including carboplatin, although he did not receive it on the day of event, it is likely an additional risk factor for thrombosis.

On the day of the event, the patient received pembrolizumab as well, which completed before MI occurred. There are no reports that linked pembrolizumab to myocardial infarction so far. Thus, we thought it most likely that paclitaxel was the culprit.

A seemingly contradictory aspect of this paclitaxel-induced adverse effect is that paclitaxel-coated balloons and stents are commonly used for coronary revascularization [ 17 ]. One possible explanation is that the adverse effect is due to coronary vasospasm from suspension medium, rather than drug itself [ 12 ]. Paclitaxel is highly lipophilic, and it requires a suspension medium when given intravenously for chemotherapy, most commonly co-solvent of ethanol and Cremophor EL™ (a polyoxyethylated castor oil) [ 18 ]. This is not necessary in drug eluting stents or balloon as they are directly applied to walls of coronary arteries. However, further studies are required to delineate the exact mechanism of paclitaxel-induced myocardial infarction.

The strength of this case report includes the high probability of adverse reaction being caused by paclitaxel, due to timing of the adverse effect right after the paclitaxel infusion, supported by other case reports describing a similar timeline. A weakness is that our patient had multiple other cardiovascular risk factors, which is a compounding factor, however other case reports also reported the presence of other cardiovascular risk factors.

Although most of the cases occurred after first or second dose of paclitaxel, one case report had the adverse effect after the fifth dose (Table  1 ). Therefore, it seems the adverse effect occurs more commonly after the first two doses, but it can still occur in subsequent doses.

Paclitaxel-induced myocardial infarction is a rare but fatal complication, especially in patients with previous risk factors for coronary artery disease. Physicians should be more aware of this side effect for prompt diagnosis and treatment, to prevent significant morbidity and mortality.

Data availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Abbreviations

Left anterior descending artery

Left main artery

Left circumflex artery

Right coronary artery

Left ventricular ejection fraction

Percutaneous coronary intervention

Costa IBS, da Andrade S, de Carter FT, Seleme D, Costa VB, Campos MS et al. CM,. Challenges and Management of Acute Coronary Syndrome in Cancer Patients. Frontiers in Cardiovascular Medicine [Internet]. 2021;8:590016. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219848/ .

Farrar MC, Jacobs TF. Paclitaxel [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536917/ .

Hekmat E. Fatal myocardial infarction potentially Induced by Paclitaxel. Ann Pharmacother. 1996;30(10):1110–2.

Article   CAS   PubMed   Google Scholar  

Laher S, Karp SJ. Acute myocardial infarction following paclitaxel administration for ovarian carcinoma. Clin Oncol. 1997;9(2):124–6.

Article   CAS   Google Scholar  

Schrader C, Keussen C, Bewig B, Freier A, Lins M. Symptoms and signs of an acute myocardial ischemia caused by chemotherapy with Paclitaxel (Taxol) in a patient with metastatic ovarian carcinoma. PubMed. 2005;10(11):498–501.

Google Scholar  

Gemici G, ÇinçinA, DeǧertekinM, Oktay A. Paclitaxel-induced ST-Segment elevations. Clin Cardiol. 2009;32(6):E94–6.

Article   PubMed   PubMed Central   Google Scholar  

Londhey V, Parikh F. Paclitaxel-induced myocardial infarction in a case of carcinoma ovary. J Association Physicians India. 2009;57:342–3.

Park SH, Byon JS, Lee SW, Lee SJ, Jin DK, Shin WY. Coronary artery thrombosis Associated with Paclitaxel in Advanced Ovarian Cancer. Korean Circulation J. 2009;39(3):124.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Shah K, Gupta S, Ghosh J, Bajpai J, Maheshwari A. Acute non-ST elevation myocardial infarction following paclitaxel administration for ovarian carcinoma: a case report and review of literature. J Cancer Res Ther. 2012;8(3):442–2.

Article   PubMed   Google Scholar  

Esber. Acute myocardial infarction in patient with Triple negative breast Cancer after Paclitaxel infusion: a Case Report. Cardiol Res. 2014.

Rawal G. Paclitaxel Induced Acute ST Elevation myocardial infarction: a rare case report. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH; 2016.

Higami S, Tanaka Y, Deguchi T, Shiraishi M, Shiki Y. Acute ST-segment elevations following paclitaxel administration for uterine cervical cancer: a case report and literature review. Cardio-Oncology. 2022;8(1).

Kim ES, Baran AM, Mondo EL, Rodgers TD, Nielsen GC, Dougherty DW et al. Risk of thromboembolism in cisplatin versus carboplatin-treated patients with lung cancer. Kirchmair R, editor. PLOS ONE. 2017;12(12):e0189410.

Rao AS, Kumar R, Narayanan GS. A rare case of cisplatin-induced acute myocardial infarction in a patient receiving chemoradiation for lung cancer. J Cancer Res Ther. 2015;11(4):983–3.

Mehta S, Naveed S, Muhammad Abubakar Shakir, Leidig GA, CISPLATIN-INDUCED THROMBOSIS, LEADING TO MYOCARDIAL INFARCTION. J Am Coll Cardiol. 2023;81(8):2718–8.

Article   Google Scholar  

Hanchate LP. Cisplatin Induced Acute myocardial infarction and Dyslipidemia. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH; 2017.

Loh JP, Waksman R. Paclitaxel Drug-Coated balloons. JACC: Cardiovasc Interventions. 2012;5(10):1001–12.

Haddad R, Alrabadi N, Altaani B, Li T. Paclitaxel Drug Delivery Systems: Focus on Nanocrystals’ Surface Modifications. Polymers. 2022;14(4):658.

Download references

Acknowledgements

Open access fee for this article was funded by Qatar National library.

There was no financial support for this case report.

Open Access funding provided by the Qatar National Library.

Author information

Authors and affiliations.

Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar

Gi Eun Kim, Ayman R. Ibrahim, Duha Shalatouni & Nadin H. Abouzeid

Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar

Fahmi Othman

You can also search for this author in PubMed   Google Scholar

Contributions

GK and DS contributed to writing of the manuscript. NA contributed to literature search. AI contributed to imaging provided. FO contributed to revising and editing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Gi Eun Kim .

Ethics declarations

Ethics approval and consent to participate.

Ethics committee approval was waived. Informed consent was taken from the patient.

Consent for publication

Informed consent was taken from the patient.

Competing interests

The authors declare no competing interests.

Author’s information

GK, AI, DS, NA are medical residents in internal medicine residency program at Hamad Medical Corporation. FO is consultant in cardiology at Hamad Medical Corporation.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, supplementary material 3, supplementary material 4, supplementary material 5, supplementary material 6, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Kim, G.E., Ibrahim, A.R., Shalatouni, D. et al. Paclitaxel-induced acute myocardial infarction: a case report and literature review. BMC Cardiovasc Disord 24 , 167 (2024). https://doi.org/10.1186/s12872-024-03814-1

Download citation

Received : 30 November 2023

Accepted : 24 February 2024

Published : 19 March 2024

DOI : https://doi.org/10.1186/s12872-024-03814-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Acute myocardial infarction
  • Chemotherapy
  • Case report

BMC Cardiovascular Disorders

ISSN: 1471-2261

case study acute myocardial infarction

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Mr. Bob Carlson is a 59 year old male who came to Ventura County Medical Center (VCMC) with nausea, upper back pain he rated 7/10, and diaphoretic. His vital signs were BP 156/92, HR 90, RR 22 SpO2 90%, and temperature 99.5. Physical examination revealed clear lung sounds, mild tachypnea, S1 S2 present, and several ulcerations to the right foot. Ordes were  given to obtain a 12-lead ECG and labs (CBC, CMP, Coagulations, Cardiac Enzymes, and Lipid Profile). In addition orders were given to start Mr. Carlson on 2L oxygen via nasal cannula and obtain venous access. A 20 gauge IV was started in his left AC.

Mr. Carlson’s medical history revealed that he is a type II diabetic, has hypertension, hyperlipidemia, and smokes 1/2 pack of cigarettes a day for the past 40 years. His diabetes is poorly managed and Mr.Carlson had a left below the knee amputation 2 years ago due to diabetic ulcers that were gangrenous. In addition, Mr. Carlson has a history of IV drug use but now receives a daily dose (90 mg) of Methadone at a local clinic. He is divorced, no children and is currently living with his 85 year old mother.

Mr. Carlson’s ECG results showed ST-segment elevation in leads II, III, and aVf and in V4, V5 and V6 with ST-segment depression V1, V2, and V3. The provider identified this to be an MI occurring in the inferior portion of the heart, likely affecting his right coronary artery (RCA). Lab results confirmed a ST-segment elevation MI (Troponin-I 12.9, CK 520, and CKMB 25.2). A code STEMI was called and Mr. Carlson was immediately prepared for a Percutaneous coronary intervention (PCI). While waiting for transfer to the Catheterization Lab at Community Memorial Hospital (CMH) Mr. Carlson was given 325 mg of Aspirin, 2 mg Morphine, and was started on a 5000 unit bolus of Heparin. Nitroglycerin was not given due to the profound hypotension associated with nitroglycerin and patients experiencing an inferior myocardial infarction.

Mr. Carlson was transferred to the CMH catheterization lab. His vitals were stable and he was able to give informed consent. The cardiac angiography showed a 95% occlusion to the RCA. A stent was placed, the patient tolerated the procedure well. The patient’s right femoral artery was closed successfully with manual pressure.

Mr. Carlson returned to the cardiac care unit where upon assessment his groin was found to be soft and without hepatoma and with minimal drainage from incision site. His peripheral pulses were present, and distal to the incision his skin was warm with capillary refill less than 2 seconds. Mr. Carlson was transferred back to VCMC the following day were he recovered without further incident.

Before discharge Mr. Carlson’s was educated on his new prescriptions and was educated on the importance of taking his daily aspirin. He met with the diabetes educator, dietician, and social worker before discharge. Mr. Carlson was informed of smoking cessation programs in the area but declined to enroll. Case Management found placement in a skilled nursing facility for 20 days, the amount of days 100% covered by Medi-Cal, where he could start a cardiac rehabilitation program. A home health organization was organized to help provide care for Mr. Carlson when he returned to his home.

  • What medications do you anticipate Mr. Carlson being prescribed upon discharge?  Aspirin, ACE-I or ARB, beta blocker, and a statin
  • What nursing interventions are critical prior to the patient being taken to the cath lab?  -Assess the client’s and family’s knowledge and understanding of the procedure. – Provide routine preoperative care as ordered. Signed consent is required and maintain patient NPO. -Assess for hypersensitivity to iodine, radiologic contrast media, or seafood. An iodine-based radiologic contrast dye is typically used for angiogram. Iodine or seafood allergy increases the risk for anaphylaxis and requires an alternative dye or special precautions. -Record baseline assessment data, including vital signs, height, and weight. Mark the locations of peripheral pulses; document their equality and amplitude. 
  • Which risk factors may have contributed to Mr. Carlson’s myocardial infarction?  Hyperlipidemia, uncontrolled diabetes, smoking, inactivity, drug use, and diet. 

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

Share This Book

Myocardial Infarction (MI) Case Study (45 min)

Watch More! Unlock the full videos with a FREE trial

Included In This Lesson

Study tools.

Access More! View the full outline and transcript with a FREE trial

Definition of Myocardial Infarction (MI)

Myocardial infarction, commonly known as a heart attack, is a critical medical event that occurs when the blood supply to the heart muscle is severely reduced or completely blocked. It is a leading cause of death worldwide and a significant public health concern.

Introduction to Myocardial Infarction (MI)

This nursing case study aims to provide a comprehensive understanding of myocardial infarction by delving into its various aspects, including its pathophysiology, risk factors, clinical presentation, diagnostic methods, and management strategies. Through the exploration of a fictional patient’s journey, we will shed light on the intricate nature of this life-threatening condition and highlight the importance of early recognition and intervention.

Background and Significance of Myocardial Infarction

Myocardial infarction is a sudden and often catastrophic event that can have profound consequences on an individual’s health and well-being. Understanding its underlying mechanisms and risk factors is essential for healthcare professionals, as timely intervention can be life-saving. This case study not only serves as a learning tool but also emphasizes the critical role of medical practitioners in identifying and managing myocardial infarctions promptly.

Pathophysiology of Myocardial Infarction

A crucial aspect of comprehending myocardial infarction is exploring its pathophysiology. We will delve into the intricate details of how atherosclerosis, the buildup of plaque in coronary arteries, leads to the formation of blood clots and the subsequent interruption of blood flow to the heart muscle. This disruption in blood supply triggers a cascade of events, ultimately resulting in the death of cardiac cells.

Risk Factors of Myocardial Infarction

Understanding the risk factors associated with myocardial infarction is vital for prevention and early detection. This case study will examine both modifiable and non-modifiable risk factors, including age, gender, family history, smoking, high blood pressure, diabetes, and high cholesterol levels. Recognizing these risk factors is instrumental in developing effective strategies for prevention and risk reduction.

Clinical Presentation Myocardial Infarction

Recognizing the signs and symptoms of myocardial infarction is crucial for timely intervention. We will present a fictional patient’s experience, illustrating the typical clinical presentation, which often includes chest pain or discomfort, shortness of breath, nausea, lightheadedness, and diaphoresis. Through this patient’s journey, we will highlight the importance of accurate symptom assessment and prompt medical attention.

Diagnostic Methods for Myocardial Infarction

Modern medicine offers various diagnostic tools to confirm a myocardial infarction swiftly and accurately. This case study will explore these diagnostic methods, such as electrocardiography (ECG), cardiac biomarkers, and imaging techniques like coronary angiography. By understanding these diagnostic modalities, healthcare professionals can make informed decisions and initiate appropriate treatments promptly.

Management Strategies for Myocardial Infarction

The management of myocardial infarction involves a multidisciplinary approach, including medication, revascularization procedures, and lifestyle modifications. We will discuss the fictional patient’s treatment plan, emphasizing the importance of reestablishing blood flow to the affected heart muscle and preventing further complications.

Nursing Case Study for Myocardial Infarction (MI)

Having established a foundational understanding of myocardial infarction, we will now delve deeper into Mr. Salazar’s case, tracing his journey through diagnosis, treatment, and recovery. This in-depth examination will shed light on the real-world application of the principles discussed in the introduction, providing valuable insights into the clinical management of myocardial infarction and its impact on patient outcomes.

Mr. Salazar, a 57-year-old male, arrives at the Emergency Department (ED) with complaints of chest pain that began approximately one hour after dinner while he was working. He characterizes the discomfort as an intense “crushing pressure” located centrally in his chest, extending down his left arm and towards his back. He rates the pain’s severity as 4/10. Upon examination, Mr. Salazar exhibits diaphoresis and pallor, accompanied by shortness of breath (SOB).

What further nursing assessments need to be performed for Mr. Salazar?

  • Heart Rate (HR): The number of heartbeats per minute.
  • Blood Pressure (BP): The force of blood against the walls of the arteries, typically measured as systolic (during heartbeats) and diastolic (between heartbeats) pressure.
  • Respiratory Rate (RR): The number of breaths a patient takes per minute.
  • Body Temperature (Temp): The measurement of a patient’s internal body heat.
  • Oxygen Saturation (SpO2): The percentage of oxygen in the blood.
  • S1: The first heart sound, often described as “lub,” is caused by the closure of the mitral and tricuspid valves.
  • S2: The second heart sound, known as “dub,” results from the closure of the aortic and pulmonic valves.
  • These sounds provide important diagnostic information about the condition of the heart.
  • Clear: Normal, healthy lung sounds with no added sounds.
  • Crackles (Rales): Discontinuous, often high-pitched sounds are heard with conditions like pneumonia or heart failure.
  • Wheezes: Whistling, musical sounds often associated with conditions like asthma or chronic obstructive pulmonary disease (COPD).
  • Pulses refer to the rhythmic expansion and contraction of arteries with each heartbeat. Common pulse points for assessment include the radial artery (wrist), carotid artery (neck), and femoral artery (groin). Evaluating pulses helps assess the strength, regularity, and rate of blood flow.
  • Edema is the abnormal accumulation of fluid in body tissues, leading to swelling. It can occur in various body parts and may indicate underlying conditions such as heart failure, kidney disease, or localized injury. Edema assessment involves evaluating the degree of swelling and its location.
  • Skin condition (temperature, color, etc.)

What interventions do you anticipate being ordered by the provider?

  • Oxygen therapy involves administering oxygen to a patient to increase the level of oxygen in their blood. It is used to treat conditions such as respiratory distress, and hypoxia (low oxygen levels), and to support patients with breathing difficulties.
  • Nitroglycerin is a medication used to treat angina (chest pain) and to relieve symptoms of heart-related conditions. It works by relaxing and widening blood vessels, which improves blood flow to the heart, reducing chest pain.
  • Aspirin is a common over-the-counter medication and antiplatelet drug. In the context of myocardial infarction (heart attack), it is often administered to reduce blood clot formation, potentially preventing further blockage in coronary arteries.
  • A 12-lead EKG is a diagnostic test that records the electrical activity of the heart from 12 different angles. It provides information about the heart’s rhythm, rate, and any abnormalities, helping diagnose conditions like arrhythmias, heart attacks, and ischemia.
  • Cardiac enzymes are proteins released into the bloodstream when heart muscle cells are damaged or die, typically during a heart attack. Measuring these enzymes, such as troponin and creatine kinase-MB (CK-MB), helps confirm a heart attack diagnosis and assess its severity.
  • A chest X-ray is a diagnostic imaging procedure that creates images of the chest and its internal structures, including the heart and lungs. It is used to identify issues like lung infections, heart enlargement, fluid accumulation, or fractures in the chest area.
  • Possibly an Echocardiogram

Upon conducting a comprehensive assessment, it was observed that the patient exhibited no signs of jugular vein distention (JVD) or edema. Auscultation revealed normal heart sounds with both S1 and S2 present, while the lungs remained clear, albeit with scattered wheezes. The patient’s vital signs were recorded as follows:

  • BP 140/90 mmHg SpO 2 90% on Room Air
  • HR 92 bpm and regular Ht 173 cm
  • RR 32 bpm Wt 104 kg
  • Temp 36.9°C

The 12-lead EKG repor t indicated the presence of “Normal sinus rhythm (NSR) with frequent premature ventricular contractions (PVCs) and three- to four-beat runs of ventricular tachycardia (VT).” Additionally, there was ST-segment elevation in leads I, aVL, and V2 through V6 (3-4mm), accompanied by ST-segment depression in leads III and aVF.

Cardiac enzyme levels were collected but were awaiting results at the time of assessment. A chest x-ray was also ordered to provide further diagnostic insights.

In response to the patient’s condition, the healthcare provider prescribed the following interventions:

  • Aspirin: 324 mg administered orally once.
  • Nitroglycerin: 0.4 mg administered sublingually (SL), with the option of repeating the dose every five minutes for a maximum of three doses.
  • Morphine: 4 mg to be administered intravenously (IVP) as needed for unrelieved chest pain.
  • Oxygen: To maintain oxygen saturation (SpO2) levels above 92%.

These interventions were implemented to address the patient’s myocardial infarction (heart attack) and alleviate associated symptoms, with a focus on relieving chest pain, improving oxygenation, and closely monitoring vital signs pending further diagnostic results.

What intervention should you, as the nurse, perform right away? Why?

  • Apply oxygen – this can be done quickly and easily and can help to prevent further complications from low oxygenation.
  • Oxygen helps to improve oxygenation as well as to decrease myocardial oxygen demands.
  • Often it takes a few minutes or more for medications to be available from the pharmacy, so it makes sense to take care of this intervention first.
  • ABC’s – breathing/O 2 .

What medication should be the first one administered to this patient? Why? How often?

  • Nitroglycerin 0.4mg SL – it is a vasodilator and works on the coronary arteries. The goal is to increase blood flow to the myocardium. If this is effective, the patient merely has angina. However, if it is not effective, the patient may have a myocardial infarction.
  • Aspirin should also be given, but it is to decrease platelet aggregation and reduce mortality. While it can somewhat help prevent the worsening of the blockage, it does little for the current pain experienced by the patient.
  • Morphine should only be given if the nitroglycerin and aspirin do not relieve the patient’s chest pain.

What is the significance of the ST-segment changes on Mr. Salazar's 12-lead EKG?

  • ST-segment changes on a 12-lead EKG indicate ischemia (lack of oxygen/blood flow) or infarction (death of the muscle tissue) of the myocardium (heart muscle). 
  • This indicates an emergent situation. The patient’s coronary arteries are blocked and need to be reopened by pharmacological (thrombolytic) or surgical (PCI) intervention.
  • Time is tissue – the longer the coronary arteries stay blocked, the more of the patient’s myocardium that will die. Dead heart tissue doesn’t beat.

Mr. Salazar’s chest pain was unrelieved after three (3) doses of sublingual nitroglycerin (NTG). Morphine 5 mg intravenous push (IVP) was administered, as well as 324 mg chewable baby aspirin. His pain was still unrelieved at this point

Mr. Salazar’s cardiac enzyme results were as follows:

Troponin I 3.5 ng/mL

Based on the results of Mr. Salazar's labs and his response to medications, what is the next intervention you anticipate? Why?

  • Mr. Salazar needs intervention. He will either receive thrombolytics or a heart catheterization (PCI).
  • Based on the EKG changes, elevated Troponin level, and the fact that his symptoms are not subsiding, it’s possible the patient has a significant blockage in one or more of his coronary arteries. 
  • It seems as though it may be an Anterior-Lateral MI because ST elevation is occurring in I, aVL, and V 2 -V 6 .

Mr. Salazar was taken immediately to the cath lab for a Percutaneous Coronary Intervention (PCI). The cardiologist found a 90% blockage in his left anterior descending (LAD) artery. A stent was inserted to keep the vessel open.

What is the purpose of Percutaneous Coronary Intervention (PCI), also known as a heart catheterization?

  • A PCI serves to open up any coronary arteries that are blocked. First, they use contrast dye to determine where the blockage is, then they use a special balloon catheter to open the blocked vessels. 
  • If that doesn’t work, they will place a cardiac stent in the vessel to keep it open.[ /faq]

[faq lesson="true" blooms="Application" question="What is the expected outcome of a PCI? What do you expect to see in your patient after they receive a heart catheterization?"]

  • Blood flow will be restored to the myocardium with minimal residual damage.
  • The patient should have baseline vital signs, relief of chest pain, normal oxygenation status, and absence of heart failure symptoms (above baseline).
  • The patient should be able to ambulate without significant chest pain or SOB.
  • The patient should be free from bleeding or hematoma at the site of catheterization (often femoral, but can also be radial or (rarely) carotid.

Mr. Salazar tolerated the PCI well and was admitted to the cardiac telemetry unit for observation overnight. Four (4) hours after the procedure, Mr. Salazar reports no chest pain. His vital signs are now as follows:

  • BP 128/82 mmHg SpO 2 96% on 2L NC
  • HR 76 bpm and regular RR 18 bpm
  • Temp 37.1°C

Mr. Salazar will be discharged home 24 hours after his arrival to the ED and will follow up with his cardiologist next week. 

What patient education topics would need to be covered with Mr. Salazar?

  • He should be taught any dietary and lifestyle changes that should be made.
  • Diet – low sodium, low cholesterol, avoid sugar/soda, avoid fried/processed foods.
  • Exercise – 30-45 minutes of moderate activity 5-7 days a week, u nless instructed otherwise by a cardiologist. This will be determined by the patient’s activity tolerance – how much can they do and still be able to breathe and be pain-free?
  • Stop smoking and avoid caffeine and alcohol.
  • Medication Instructions
  • Nitroglycerin – take one SL tab at the onset of chest pain. If the pain does not subside after 5 minutes, call 911 and take a second dose. You can take a 3rd dose 5 minutes after the second if the pain does not subside. Do NOT take if you have taken Viagra in the last 24 hours.
  • Aspirin – take 81 mg of baby aspirin daily
  • Anticoagulant – the patient may be prescribed an anticoagulant if they had a stent placed.  They should be taught about bleeding risks.
  • When to call the provider – CP unrelieved by nitroglycerin after 5 minutes. Syncope. Evidence of bleeding in stool or urine (if on anticoagulant). Palpitations, shortness of breath, or difficulty tolerating activities of daily living.

Linchpins for Myocardial Infarction Nursing Case Study

In summary, Mr. Salazar’s case highlights the urgency of recognizing and responding to myocardial infarction promptly. The application of vital signs, EKG, cardiac enzymes, and medications like aspirin, nitroglycerin, and morphine played a pivotal role in his care. Diagnostic tools like echocardiography and chest X-rays contributed to a comprehensive evaluation.

Nurses must remain vigilant and compassionate in such emergencies. This case study emphasizes the importance of adhering to best practices in the assessment, diagnosis, and management of myocardial infarction, with the ultimate goal of achieving favorable patient outcomes.

View the FULL Outline

When you start a FREE trial you gain access to the full outline as well as:

  • SIMCLEX (NCLEX Simulator)
  • 6,500+ Practice NCLEX Questions
  • 2,000+ HD Videos
  • 300+ Nursing Cheatsheets

“Would suggest to all nursing students . . . Guaranteed to ease the stress!”

Nursing Case Studies

Jon Haws

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

  • 6 Questions
  • 7 Questions
  • 5 Questions
  • 4 Questions

GI/GU Nursing Case Studies

  • 2 Questions
  • 8 Questions

Obstetrics Nursing Case Studies

Respiratory nursing case studies.

  • 10 Questions

Pediatrics Nursing Case Studies

  • 3 Questions
  • 12 Questions

Neuro Nursing Case Studies

Mental health nursing case studies.

  • 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • View all journals
  • My Account Login
  • Explore content
  • About the journal
  • Publish with us
  • Sign up for alerts
  • Open access
  • Published: 15 March 2024

Prognostic impact and predictors of persistent renal dysfunction in acute kidney injury after percutaneous coronary intervention for acute myocardial infarction

  • Takuya Nakamura 1 ,
  • Makoto Watanabe 1 ,
  • Junichi Sugiura 1 ,
  • Atsushi Kyodo 1 ,
  • Saki Nobuta 1 ,
  • Kazutaka Nogi 1 ,
  • Yasuki Nakada 1 ,
  • Satomi Ishihara 1 ,
  • Yukihiro Hashimoto 1 ,
  • Hitoshi Nakagawa 1 ,
  • Tomoya Ueda 1 ,
  • Ayako Seno 1 ,
  • Taku Nishida 1 ,
  • Kenji Onoue 1 &
  • Shungo Hikoso 1  

Scientific Reports volume  14 , Article number:  6299 ( 2024 ) Cite this article

120 Accesses

Metrics details

This study aimed to evaluate the prognostic impact and predictors of persistent renal dysfunction in acute kidney injury (AKI) after an emergency percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). A total of 877 patients who underwent emergency PCI for AMI were examined. AKI was defined as serum creatinine (SCr) ≥ 0.3 mg/dL or ≥ 50% from baseline within 48 h after PCI. Persistent AKI was defined as residual impairment of SCr ≥ 0.3 mg/dL or ≥ 50% from baseline 1 month after the procedure. The primary outcome was the composite endpoints of death, myocardial infarction, hospitalization for heart failure, stroke, and dialysis. AKI and persistent AKI were observed in 82 (9.4%) and 25 (2.9%) patients, respectively. Multivariate Cox proportional hazards analysis demonstrated that persistent AKI, but not transient AKI, was an independent predictor of primary outcome (hazard ratio, 4.99; 95% confidence interval, 2.30–10.8; P < 0.001). Age > 75 years, left ventricular ejection fraction < 40%, a high maximum creatinine phosphokinase MB level, and bleeding after PCI were independently associated with persistent AKI. Persistent AKI was independently associated with worse clinical outcomes in patients who underwent emergency PCI for AMI. Advanced age, poor cardiac function, large myocardial necrosis, and bleeding were predictors of persistent AKI.

Similar content being viewed by others

case study acute myocardial infarction

Acute kidney injury

John A. Kellum, Paola Romagnani, … Hans-Joachim Anders

case study acute myocardial infarction

Acute heart failure

Mattia Arrigo, Mariell Jessup, … Alexandre Mebazaa

case study acute myocardial infarction

The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial

Adriaan A. Voors, Christiane E. Angermann, … Piotr Ponikowski

Introduction

Acute kidney injury (AKI) is a frequent complication in patients with acute myocardial infarction (AMI) undergoing primary percutaneous intervention (PCI) compared to those undergoing elective PCI 1 , 2 and is known to be an independent risk factor for increased long-term mortality and worse clinical outcomes 3 , 4 .

The cause of AKI in patients with AMI is multifactorial because AKI develops not only because of the large amount of contrast medium exposure during PCI but also because of hemodynamic instability, renal hypoperfusion following impaired cardiac output, and systemic inflammatory response due to ischemic injury and myocardial necrosis 5 .

Most AKI cases after PCI are transient and improve within 2 weeks, whereas some patients have persistent renal dysfunction after the development of AKI 6 . However, the impact of persistent or transient renal dysfunction on worse clinical outcomes, including major adverse cardiovascular events (MACEs) and dialysis, and predictors of persistent renal dysfunction remain unclear in patients with AMI undergoing PCI.

This study aimed to investigate the impact of renal function reversibility following AKI on clinical outcomes and predictors of persistent renal dysfunction in patients with AMI undergoing emergency PCI.

Study design and population

This was a single-center, retrospective, observational study. Patients with AMI who underwent emergency PCI at Nara Medical University Hospital between January 2012 and December 2020 were enrolled. The diagnoses of AMI included ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) within 48 h of AMI onset. STEMI was defined as continuous chest pain, ST-segment elevation in two contiguous leads or a new left bundle branch block on 12-lead electrocardiography, and elevated cardiac marker levels (creatine kinase-MB or troponin). NSTEMI was defined as ischemic symptoms in the absence of ST-segment elevation on electrocardiography with elevated cardiac marker levels 7 . Patients on previous chronic dialysis or who underwent hemodialysis after admission, died in hospital, or lacked data on serum creatinine (SCr) levels were excluded from the study. Figure  1 shows the enrollment and exclusion criteria and study flow. Primary PCI was performed using standard techniques and catheters via the femoral or radial approach according to the operator’s usual practice.

figure 1

Study flow. AKI acute kidney injury, AMI acute myocardial infarction, SCr serum creatinine.

Data collection and clinical definition

Baseline data including clinical characteristics, laboratory data, medication upon admission, and procedural data were obtained for all patients.

Baseline laboratory data included hemoglobin (Hb), SCr, HbA1c, and maximum creatine phosphokinase MB (Max CKMB) levels and estimated glomerular filtration rate (eGFR). Anemia was defined as Hb < 12 g/dL in males and < 11 g/dL in females. The eGFR was calculated as follows using the “Japanese Modification of Diet in Renal Disease study equation” published by the Japanese Society of Nephrology: eGFR (men) = 194 × serum creatinine − 1.094 × age − 0.287 and eGFR (women) = eGFR (men) × 0.739 8 . Procedural data included STEMI or NSTEMI, culprit vessel (left anterior descending artery, left circumflex artery, right coronary artery, or left main trunk), diseased vessels (one or multiple vessels), Killip class ≥ 3, approach site for PCI (femoral artery or not), multivessel PCI in hospital (one-time or staged strategy), volume of contrast media, thrombolysis in myocardial infarction flow grade (TIMI) score before and after PCI, use of mechanical circulatory support (intra-aortic balloon pumping or extracorporeal membrane oxygenation) during PCI, use of catecholamine, and perioperative major bleeding complication within 48 h after PCI, defined as Bleeding Academic Research Consortium (BARC) 9 type 3 or greater. Echocardiography was performed to evaluate left ventricular ejection fraction (EF) within 1 week of the procedure. SCr levels were measured before the procedure (baseline), every day for the following 2 days, and 1 month after the procedure to identify patients without AKI (non-AKI), those with persistent AKI, and those with transient AKI. AKI was defined as an increase in SCr ≥ 0.3 mg/dL or ≥ 50% from baseline within 48 h 10 . Patients diagnosed with AKI were divided into those with persistent AKI and those with transient AKI. Persistent AKI was defined as residual impairment of SCr ≥ 0.3 mg/dL or ≥ 50% from baseline 1 month after procedure. Transient AKI was defined as recovery to SCr < 0.3 mg/dL and < 50% from baseline 1 month after the procedure. The Mehran score was calculated based on eight clinical and procedural variables: age > 75 years, hypotension, congestive heart failure, use of an intra-aortic balloon pump, serum creatinine level, diabetes, anemia, and volume of contrast, according to a previous report 11 .

The primary outcome of this study was a composite of MACEs, including death, myocardial infarction, hospitalization for heart failure, stroke, and initiation of maintenance dialysis. The secondary endpoints were MACEs, mortality, and dialysis. Clinical follow-up was conducted through outpatient visits or telephone interviews.

Statistical analysis

The Shapiro–Wilk test was used to evaluate the distribution of continuous data. Normally distributed data are expressed as mean ± standard deviation (SD), and those with skewed distributions are expressed as median with interquartile range, whereas categorical variables are presented as counts and percentages. Categorical data were compared using the Pearson χ 2 test. Continuous variables were compared using parametric one-way analysis of variance or the non-parametric Kruskal–Wallis test, based on the distribution of variables. The cumulative incidence of survival-free periods from clinical events was estimated using the Kaplan–Meier method. In the case of significant differences, pairwise post-hoc tests were performed with Bonferroni correction. A univariate Cox proportional hazards model was used to identify variables associated with the primary outcomes in the present study. Two multivariate Cox proportional hazards models were used to identify independent predictors of the primary outcome, including 12 variables with P < 0.05 in the univariate model. One model included post PCI TIMI score < 3, and the other included mechanical circulatory support. Univariate logistic regression analysis was used to identify the significant clinical factors associated with the development of AKI and persistent AKI. A multivariate logistic regression model was used to identify independent predictors of persistent AKI, which included variables with P < 0.05, in the univariate model. A P < 0.05 was considered statistically significant. All statistical analyses were performed using JMP software version 16 (SAS Institute JAPAN Corporation, Roppongi, Tokyo).

Ethics statement

This study was approved by the Ethics Committee of Nara Medical University (Reference no. 2162) and complied with the Declaration of Helsinki’s Ethical Principles for Medical Research Involving Human Subjects. Informed consent was obtained in the form of an opt-out option on the Department of Cardiovascular Medicine, Nara Medical University website.

Patient characteristics

Of the 1107 consecutive patients, 230 were excluded (41 were on maintenance hemodialysis, 16 were undergoing temporary hemodialysis in the hospital, 72 were in-hospital deaths, and 101 lacked data on SCr). Finally, 877 consecutive patients were included in the study, and AKI was present in 82 (9.4%). Of the AKI cases, persistent and transient AKIs were present in 25 (30.5%) and 57 (69.5%) patients, respectively (Fig.  1 ).

Table 1 shows a comparison of the baseline clinical characteristics among the three groups. The persistent AKI group was older and more frequently had anemia and a lower left ventricular ejection fraction (EF < 40%) than the non-AKI group. The transient AKI group was older; had a higher prevalence of diabetes, lower baseline eGFR levels, and lower EF; and more frequent use of angiotensin II receptor blocker (ARB), angiotensin-converting enzyme inhibitors (ACE-Is), and angiotensin receptor neprilysin inhibitor (ARNI) than the non-AKI group. There were no significant differences in the baseline clinical characteristics between the persistent and transient AKI groups. Table 2 compares the baseline lesion and procedural characteristics among the three groups. Transient AKI group had a higher incidence of severe myocardial infarction with Killip ≥ 3 and a higher contrast volume/eGFR ratio compared with non-AKI group. The incidence of BARC type 3 or greater bleeding complication was significantly higher in the persistent and the transient AKI groups compared to the non-AKI group. The Mehran risk score was significantly higher in the persistent and transient AKI groups than in the non-AKI group. There were no significant differences in baseline lesion and procedural characteristics between the persistent and transient AKI groups.

Long-term clinical outcomes

The median follow-up period was 1593 days (interquartile range, 903–2378 days), and the mean follow-up period was 1689 ± 926 years.

Figure  2 shows the Kaplan–Meier survival curves for clinical outcomes in the three groups. There was a significant difference in primary outcome-free survival (log-rank, P < 0.0001) and all-cause death-free survival (log-rank, P < 0.0001) among the three groups. In the pairwise post hoc tests, the cumulative incidence of the primary outcome was significantly higher in the persistent AKI (log-rank, P < 0.0001) and transient AKI (log-rank, P < 0.0001) groups than in the non-AKI group, and the cumulative incidence of all-cause death was significantly higher in the persistent AKI (log-rank, P < 0.0001) and transient AKI (log-rank, P = 0.0003) groups than in the non-AKI group. However, there was no significant difference between patients with persistent and transient AKIs in terms of the cumulative incidence of the primary outcome and all-cause death. Table 3 shows the incidence of primary and secondary outcomes in the three groups. Kaplan–Meier survival analysis also showed significant differences in MACEs, hospitalization for heart failure, stroke, and initiation of maintenance dialysis among the three groups. We investigated the predictors of primary outcomes using multivariate Cox proportional hazards analysis with two models. In both models, persistent AKI remained a significant predictor for primary outcome compared to non-AKI (model 1: HR, 2.68, 95% CI, 1.41–5.10, P = 0.0026; model 2: HR, 2.62, 95% CI, 1.38–4.99, P = 0.0034; Table 4 ). However, the incidence of transient AKI did not differ significantly from that of AKI in either model. Other predictors of primary outcomes in the multivariate analysis included age > 75 years; previous myocardial infarction, stroke, peripheral arterial disease (PAD); anemia; EF < 40%; and higher maximum CKMB level (Table 4 ).

figure 2

Kaplan–Meier survival curves of 3-year clinical outcomes. ( a ) Primary outcomes (death, myocardial infarction, hospitalization for heart failure, stroke, and initiation of maintenance dialysis); ( b ) All-cause death.

Predictors of AKI and persistent AKI

The predictors of AKI and persistent AKI evaluated using univariate logistic regression analyses are shown in Table 5 . Age > 75 years, diabetes mellitus, anemia, bleeding with BARC type 3 or greater, Killip ≥ 3, low eGFR, EF < 40%, higher maximum CKMB level, femoral artery approach, multivessel PCI with one-time strategy, higher contrast volume/eGFR ratio, mechanical circulatory support use, and higher Mehran risk score were predictors of AKI. Age > 75 years, bleeding with BARC type 3 or greater, lower eGFR, EF < 40%, higher maximum CK-MB level, higher contrast volume/eGFR ratio, and a higher Mehran risk score were also predictors of persistent AKI.

We investigated the predictors of persistent AKI using multivariate logistic regression analysis with four models containing three variables that were strongly relevant as predictors of persistent AKI in univariate analysis. Age > 75 years, EF < 40%, and higher maximum CK-MB level were independent predictors of persistent AKI in Model 1, age > 75 years and EF < 40% were independent predictors of persistent AKI in Models 2 and 3, and age > 75 years, EF < 40%, and bleeding with BARC type 3 or greater were independent predictors of persistent AKI in Model 4 (Table 6 ).

The major findings of this study are that: (1) in patients who underwent emergency PCI for AMI, AKI was present in 82 (9.4%), and of the AKI, persistent AKI was present in 25 (30.5%) and transient AKI in 57 (69.5%); (2) primary outcome and all-cause death occurred more frequently in patients with persistent AKI and transient AKI than in those with non-AKI, and persistent AKI, but not transient AKI, was an independent predictor of primary outcome; (3) age > 75 years, EF < 40%, higher maximum CKMB level, and perioperative bleeding complication with BARC type 3 or greater were independent predictors of persistent AKI.

Contrast-induced nephropathy (CIN) is the main cause of renal dysfunction after PCI and is associated with increased long-term mortality and MACEs 12 . CIN is generally considered transient, with SCr levels typically reaching a peak within a few days and returning to baseline within 2 weeks in most cases 6 . However, some patients with CIN develop persistent increase in SCr levels.

Several studies have reported the incidence and prognostic impact of persistent and transient renal dysfunction after elective 13 , 14 and emergency 15 , 16 , 17 , 18 PCIs. The time interval for assessing persistent or transient renal dysfunction differed among studies. Some studies assessed persistent or transient renal dysfunction at short time intervals (2 weeks 17 or at discharge 16 , 17 , 18 ) from baseline, whereas others assessed long-term interval (1 15 , 3 13 , or 12 months 14 ). Some patients, classified as having early persistent renal dysfunction, may have later improved their renal function. Therefore, we assessed persistent or transient renal dysfunction at long-term interval (1 month) from baseline. Despite the time intervals and definition for assessing persistent renal dysfunction among studies, the incidence of persistent renal dysfunction among patients with AKI was approximately 20–60%, which is similar to our result (30.5%).

In previous studies targeting patients who underwent elective PCI, Maioli et al. 13 reported that both persistent and transient renal dysfunctions were independently associated with long-term mortality and MACEs, whereas Abe et al. 14 reported that only persistent renal dysfunction was independently associated with increased long-term mortality. In previous studies targeting patients with AMI, Choi et al. 16 reported that both persistent and transient renal dysfunction were independently associated with long-term mortality, whereas Kurogi et al. 17 reported that persistent renal dysfunction, but not transient renal dysfunction, was independently associated with both long-term mortality and worse clinical outcomes. In the recent large-scale substudy 18 from the MATRIX-Access (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial, with a study population of 8201 patients who underwent catheter procedure for acute coronary syndrome (ACS), Landi et al. reported that in-hospital persistent but not transient AKI was independently associated with 1-year MACEs and mortality. The present study demonstrated that persistent renal dysfunction, but not transient renal dysfunction, was independently associated with poor long-term clinical outcomes. These studies, including the present one, consistently suggest that persistent renal dysfunction is associated with worse clinical outcomes. However, the effect of transient renal dysfunction on long-term clinical outcomes differs among studies. Nevertheless, the reversibility of renal dysfunction after AKI development has significant implications for the long-term follow-up of patients who undergo PCI.

Although several risk scores are available as predictors of CIN after cardiac catheterization procedures 19 , little is known about the predictors of persistent renal dysfunction. Some studies 20 have investigated the predictors of persistent renal dysfunction and reported that the Mehran risk score 13 , 21 and contrast volume/baseline eGFR ratio 17 are useful for predicting persistent renal dysfunction. A recent study 22 reported that the preprocedural N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is useful for predicting persistent renal dysfunction. NT-proBNP reflects impaired cardiac output and increased inflammation 23 , which plays an important role in the development of persistent renal dysfunction. The present study demonstrated that EF < 40% and higher maximum CK-MB levels were strongly associated with the development of persistent renal dysfunction. Once AMI develops, cardiac function rapidly declines and cardiac damage is sustained. Subsequently, renal hypoperfusion following impaired cardiac output and systemic inflammatory response due to ischemic injury and myocardial necrosis may play important roles in the development of persistent renal dysfunction. Therefore, the assessment of cardiac function and the extent of myocardial necrosis after the onset of AMI might be useful for predicting the development of persistent renal dysfunction.

The present study demonstrated that major perioperative bleeding after PCI (BARC type 3 or greater) was not only associated with the development of AKI but also with the development of persistent renal dysfunction. A bleeding complication, especially one related to vascular access, is well known as a major complication after PCI. A previous study showed that bleeding complications after PCI are associated with the development of CIN 24 , the severity of which is closely correlated with the severity of bleeding. A sudden blood loss due to major bleeding such as BARC type 3 or greater may cause a serious impairment in renal perfusion, subsequently making AKI more severe and resulting in persistent renal dysfunction.

Early clinical follow-up, careful management, and close monitoring of renal function may improve long-term clinical outcomes in patients at high risk of developing persistent renal dysfunction after AKI. Additionally, the risk of bleeding complication is lower in PCI via the radial access than via a femoral access 25 . In high-risk patients of AKI, the choice of radial access may prevent the development of persistent renal dysfunction after PCI.

Limitations

This study had several limitations. First, this was a single-center, retrospective observational study. Second, the high number of patients excluded due to the absence of analytical evaluation in the first month (approximately 9%). Third, the lack of data regarding patients who died during the index hospitalization (6.5%), specifically the time elapsed between PCI and death, as well as the progression of renal function in this subgroup. Forth, pharmacological treatments (diuretics, ACE-Is, ARB, and ARNI) and the examination using contrast media (contrast-enhanced computed tomography) after PCI, which might have influenced the worsening of renal function, were not included in the analysis. Fifth, we included only three variables to investigate the independent predictors of persistent AKI in the multivariate logistic regression analysis because of the small number of patients with persistent AKI. Sixth, the sample size was small and the present findings were considered exploratory in nature. Therefore, a large-scale prospective cohort study is required to verify our results. Seventh, the use of drugs such as ACE-Is, ARB, and ARNI, which improve prognosis after AMI, may be hindered by the presence of AKI and subsequent persistent renal dysfunction. As a result, its insufficient treatment may have worsened the prognosis in patients with persistent AKI. To clarify this causal relationship and identify the best therapeutic strategy in patients at high-risk of AKI, it is necessary to evaluate to what extent limitations in terms of the dosage of drugs potentially harmful to renal function in high-risk patients mitigate the progression to irreversible renal injury and influence the prognosis. A large-scale prospective study may therefore provide useful information for daily clinical practice.

To conclude, in patients who underwent emergency PCI for AMI, persistent AKI was independently associated with worse clinical outcomes, and advanced age, low cardiac function, greater myocardial necrosis, and perioperative major bleeding after PCI were predictors of persistent AKI.

Data availability

The datasets generated or analyzed during the current study are available from the corresponding author on reasonable request.

Tsai, T. T. et al. Contemporary incidence, predictors, and outcomes of acute kidney injury in patients undergoing percutaneous coronary interventions: Insights from the NCDR Cath-PCI registry. JACC Cardiovasc. Interv. 7 , 1–9 (2014).

Article   PubMed   PubMed Central   Google Scholar  

Abe, D. et al. Clinical predictors of contrast-induced acute kidney injury in patients undergoing emergency versus elective percutaneous coronary intervention. Circ. J. 78 , 85–91 (2014).

Article   CAS   PubMed   Google Scholar  

Narula, A. et al. Contrast-induced acute kidney injury after primary percutaneous coronary intervention: Results from the HORIZONS-AMI substudy. Eur. Heart J. 35 , 1533–1540 (2014).

Sun, G. et al. Contrast-induced nephropathy and long-term mortality after percutaneous coronary intervention in patients with acute myocardial infarction. Angiology 70 , 621–626 (2019).

Article   PubMed   Google Scholar  

Shacham, Y., Steinvil, A. & Arbel, Y. Acute kidney injury among ST elevation myocardial infarction patients treated by primary percutaneous coronary intervention: a multifactorial entity. J. Nephrol. 29 , 169–174 (2016).

Brown, J. R. et al. Transient and persistent renal dysfunction are predictors of survival after percutaneous coronary intervention: Insights from the Dartmouth Dynamic Registry. Catheter. Cardiovasc. Interv. 72 , 347–354 (2008).

Thygesen, K. et al. Third universal definition of myocardial infarction. Circulation 126 , 2020–2035 (2012).

Matsuo, S. et al. Revised equations for estimated GFR from serum creatinine in Japan. Am. J. Kidney Dis. 53 , 982–992 (2009).

Mehran, R. et al. Standardized bleeding definitions for cardiovascular clinical trials: A consensus report from the Bleeding Academic Research Consortium. Circulation 123 , 2736–2747 (2011).

Mehta, R. L. et al. Acute Kidney Injury Network: Report of an initiative to improve outcomes in acute kidney injury. Crit. Care 11 , R31 (2007).

Mehran, R. et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: Development and initial validation. J. Am. Coll. Cardiol. 44 , 1393–1399 (2004).

PubMed   Google Scholar  

Rihal, C. S. et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 105 , 2259–2264 (2002).

Maioli, M. et al. Persistent renal damage after contrast-induced acute kidney injury: Incidence, evolution, risk factors, and prognosis. Circulation 125 , 3099–3107 (2012).

Abe, M. et al. Impact of transient or persistent contrast-induced nephropathy on long-term mortality after elective percutaneous coronary intervention. Am. J. Cardiol. 120 , 2146–2153 (2017).

Wi, J. et al. Impact of contrast-induced acute kidney injury with transient or persistent renal dysfunction on long-term outcomes of patients with acute myocardial infarction undergoing percutaneous coronary intervention. Heart 97 , 1753–1757 (2011).

Choi, J. S. et al. Relation between transient or persistent acute kidney injury and long-term mortality in patients with myocardial infarction. Am. J. Cardiol. 112 , 41–45 (2013).

Kurogi, K. et al. Persistent renal dysfunction in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. J. Am. Heart Assoc. 8 , e014096 (2019).

Landi, A. et al. Transient vs in-hospital persistent acute kidney injury in patients with acute coronary syndrome. JACC Cardiovasc. Interv. 16 , 193–205 (2023).

Isaka, Y. et al. Guideline on the use of iodinated contrast media in patients with kidney disease 2018. Circ. J. 83 , 2572–2607 (2019).

Watanabe, M. Prediction of persistent renal dysfunction following contrast-induced nephropathy after cardiac catheterization procedures. Circ. J. 87 , 266–267 (2023).

Wi, J. et al. Prediction of contrast-induced nephropathy with persistent renal dysfunction and adverse long-term outcomes in patients with acute myocardial infarction using the Mehran risk score. Clin. Cardiol. 36 , 46–53 (2013).

Luo, M. et al. Predictive value of N-terminal pro B-type natriuretic peptide for contrast-induced nephropathy non-recovery and poor outcomes among patients undergoing percutaneous coronary intervention. Circ. J. 87 , 258–265 (2023).

Jensen, J. et al. Inflammation increases NT-proBNP and the NT-proBNP/BNP ratio. Clin. Res. Cardiol. 99 , 445–452 (2010).

Ohno, Y. et al. Impact of periprocedural bleeding on incidence of contrast-induced acute kidney injury in patients treated with percutaneous coronary intervention. J. Am. Coll. Cardiol. 62 , 1260–1266 (2013).

Valgimigli, M. et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: A randomised multicentre trial. Lancet 385 , 2465–2476 (2015).

Download references

Acknowledgements

The authors thank the patients, participating cardiologists, and staff who contributed to this study.

Author information

Authors and affiliations.

Department of Cardiovascular Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan

Takuya Nakamura, Makoto Watanabe, Junichi Sugiura, Atsushi Kyodo, Saki Nobuta, Kazutaka Nogi, Yasuki Nakada, Satomi Ishihara, Yukihiro Hashimoto, Hitoshi Nakagawa, Tomoya Ueda, Ayako Seno, Taku Nishida, Kenji Onoue & Shungo Hikoso

You can also search for this author in PubMed   Google Scholar

Contributions

T.N. wrote the main manuscript text and prepared the Figures. All authors, mainly M.W., reviewed the manuscript.

Corresponding author

Correspondence to Makoto Watanabe .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Nakamura, T., Watanabe, M., Sugiura, J. et al. Prognostic impact and predictors of persistent renal dysfunction in acute kidney injury after percutaneous coronary intervention for acute myocardial infarction. Sci Rep 14 , 6299 (2024). https://doi.org/10.1038/s41598-024-56929-y

Download citation

Received : 04 July 2023

Accepted : 12 March 2024

Published : 15 March 2024

DOI : https://doi.org/10.1038/s41598-024-56929-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

  • Explore articles by subject
  • Guide to authors
  • Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

case study acute myocardial infarction

  • Open supplemental data
  • Reference Manager
  • Simple TEXT file

People also looked at

Opinion article, cardiac mri assessment of myocardial viability in chronic myocardial infarction: how should we do it.

case study acute myocardial infarction

  • Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, United States

Introduction

Myocardial infarction (MI) remains a significant global health concern prompting ongoing advancements in diagnostic and therapeutic approaches. Accurate assessment of myocardial viability is crucial in guiding therapeutic decisions and predicting patient outcomes. While the body of literature on cardiac MRI (CMR) provides insights into viability assessment, existing studies lack comprehensive analyses to inform practitioners about the nuances of measurements and their implications for patient selection and outcomes in chronic infarction. This article aims to propose an assessment method and discuss the need for new research.

The current literature recommends assessing viability by calculating the percentage of non-enhanced myocardium across the full myocardial thickness ( 1 ). This approach aids in determining the percentage of the viable myocardium, providing valuable information for risk stratification and surgical candidacy. Although effective in evaluating the transmurality of ischemic/infarct-related changes in cases of acute MI, this method is not suitable for assessing chronic infarction ( Figure 1 ), where the myocardium has already undergone thinning.

www.frontiersin.org

Figure 1 . Cardiac MRI (CMR) with a delayed enhancement sequence, revealing subendocardial delayed enhancement and thinning in the lateral wall, consistent with chronic infarct ( A ). The illustrations highlight fibrosis corresponding to the CMR delayed enhancement ( B , C ).

Assessing myocardial infarct transmurality during the chronic phase requires additional considerations. Following an MI, the affected myocardial region undergoes a complex remodeling process, which includes necrosis of myocardial cells, inflammation, and scar formation, leading to changes in myocardial thickness and function. This remodeling process results in the thinning of the myocardial wall and expansion of the extracellular matrix, indicative of scar tissue formation ( 2 ). The chronic phase is characterized by myocardial remodeling, leading to wall thinning in the infarcted region. Accurate estimation of myocardial viability requires determining the initial myocardial thickness, achieved by referencing the healthy myocardium adjacent to the infarcted region. Hence, the authors propose estimating myocardial viability by determining the percentage of non-enhanced myocardium across the neighboring unaffected myocardial thickness adjacent to the infarcted area. This suggestion is supported by the observations that both the degree of wall thinning and transmurality alone are predictive, but not completely specific, for functional recovery of myocardium after revascularization. The authors propose cardiac reserve may be better evaluated by evaluating both as a single entity ( 3 ). A similar method was mentioned in another article as an indirect measurement technique; however, the authors did not prefer its use over the conventional method ( 4 ).

Illustrative scenario

Initial healthy myocardial thickness: 10 mm

Total thickness of remodeled myocardium: 5 mm

Delayed enhancement in remodeled myocardium: 2 mm

Non-delayed enhancement in remodeled myocardium: 3 mm

According to the existing approach, the calculated viable myocardial percentage is 60% (non-delayed enhancement/total thickness of remodeled myocardium) ( Figure 2 ). However, when compared with the adjoining normal myocardium, the viable myocardium is actually 30% (non-delayed enhancement/initial healthy myocardial thickness). This substantial difference in results raises concerns. Given that a 50% threshold is a critical criterion for determining candidacy for coronary artery bypass grafting (CABG) surgery, the conventional method deems revascularization viable, whereas the proposed approach suggests the tissue may not be viable.

www.frontiersin.org

Figure 2 . Illustration showing the thickness of delayed enhancement/fibrosis ( A ), the full thickness of the remodeled myocardium ( B ), the thickness of the non-enhancing myocardium ( C ), and the full thickness of the adjacent healthy myocardium ( D ). The authors recommend calculating viability as C / D , whereas the traditional method employs C / B .

A case report

A 42-year-old patient underwent CMRI for viability assessment. The conventional assessment method yielded a viable myocardial percentage of 53%. In contrast, applying a proposed assessment method resulted in a recalculated viable myocardial percentage of 40% (as illustrated in Supplementary Image S1 ). Initial diagnostic procedures included an echocardiogram conducted 1 day before the CMRI, which revealed a dilated left ventricle with a significantly reduced ejection fraction of 28%, indicative of impaired systolic function. Following the viability assessment and based on the initial conventional method's findings, the patient underwent CABG. A follow-up echocardiogram post-CABG showed no substantial improvement in the patient's systolic function. The echocardiogram reported a persistently dilated left ventricle with an ejection fraction of 29%.

The rationale of this proposal is akin to the surgeon's knot: are we cutting too long or too short? Is the absolute or the relative viability of myocardial tissue more important to patient prognosis and success in revascularization? As radiologists, are we leaving too many patients on the table—or taking too many—based on imperfect measurements? These questions remain unanswered, and as surgical revascularization remains a mainstay of treatment, there is an opportunity for improved patient selection. Therefore, a more accurate understanding of the extent of myocardial damage during the chronic phase can guide long-term management strategies, including the optimization of medical therapy, timing of interventions, and risk stratification for adverse cardiovascular events. This knowledge will contribute to improving patient outcomes and enhancing the overall quality of care in the post-MI setting.

Future CMR research endeavors should seek to elucidate the optimal method for assessing transmurally/viability in chronic MI. Emerging technologies, such as artificial intelligence, myocardial mapping, and advances in MRI technology, hold promise in enhancing the accuracy of transmurality assessments.

In summary, we propose an innovative approach for evaluating myocardial viability by determining the percentage of non-enhanced myocardium across the neighboring unaffected myocardial thickness adjacent to the infarcted area.

Author contributions

IK: Writing – original draft, Writing – review and editing. JC: Conceptualization, Supervision, Writing – original draft, Writing – review and editing. EM: Writing – original draft, Writing – review and editing.

The authors declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fcvm.2024.1377230/full#supplementary-material

Supplementary Image S1 Cardiac MRI (CMR) showing the thickness of delayed enhancement/fibrosis ( A ), the full thickness of the remodeled myocardium ( B ), the thickness of non-enhancing myocardium ( C ), and the full thickness of adjacent healthy myocardium ( D ). The authors recommend calculating viability as [ C / D ], while the traditional method employs [ C/B ].

1. Al-Sabeq B, Nabi F, Shah DJ. Assessment of myocardial viability by cardiac MRI. Curr Opin Cardiol . (2019) 34(5):502–9. doi: 10.1097/HCO.0000000000000656

PubMed Abstract | Crossref Full Text | Google Scholar

2. Frantz S, Hundertmark MJ, Schulz-Menger J, Bengel FM, Bauersachs J. Left ventricular remodelling post-myocardial infarction: pathophysiology, imaging, and novel therapies. Eur Heart J . (2022) 43(27):2549–61. doi: 10.1093/eurheartj/ehac223

3. Garcia MJ, Kwong RY, Scherrer-Crosbie M, Taub CC, Blankstein R, Lima J, et al. State of the art: imaging for myocardial viability: a scientific statement from the American Heart Association. Circ Cardiovasc Imaging . (2020) 13(7):e000053. doi: 10.1161/HCI.0000000000000053

4. Van Assche LM, Kim HW, Kim RJ. Cardiac MR for the assessment of myocardial viability. Methodist Debakey Cardiovasc J . (2013) 9(3):163–8. doi: 10.14797/mdcj-9-3-163

Keywords: CMR, MI, CABG, viability, DE

Citation: Kabakus IM, Chamberlin JH and Miller EJ (2024) Cardiac MRI assessment of myocardial viability in chronic myocardial infarction: how should we do it?. Front. Cardiovasc. Med. 11:1377230. doi: 10.3389/fcvm.2024.1377230

Received: 27 January 2024; Accepted: 11 March 2024; Published: 20 March 2024.

Reviewed by:

© 2024 Kabakus, Chamberlin and Miller. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ismail M. Kabakus [email protected]

Myocardial Infarction

case study acute myocardial infarction

Learn about the nursing care management of patients with myocardial infarction in this nursing study guide .

Table of Contents

  • What is Myocardial Infarction? 

Pathophysiology

Statistics and epidemiology, clinical manifestations, assessment and diagnostic findings, pharmacologic therapy, emergent percutaneous coronary intervention, nursing assessment, planning & goals, nursing priorities, nursing interventions, discharge and home care guidelines, documentation guidelines, practice quiz: myocardial infarction, what is myocardial infarction.

Myocardial infarction (MI) , is used synonymously with coronary occlusion and heart attack, yet MI is the most preferred term as myocardial ischemia causes acute coronary syndrome (ACS) that can result in myocardial death .

  • In an MI, an area of the myocardium is permanently destroyed because plaque rupture and subsequent thrombus formation result in complete occlusion of the artery.
  • The spectrum of ACS includes unstable angina , non-ST-segment elevation MI , and ST-segment elevation MI .

In each case of MI, a profound imbalance exists between myocardial oxygen supply and demand.

Myocardial Infarction Pathophysiology

  • Unstable angina . There is reduced blood flow in a coronary artery, often due to rupture of an atherosclerotic plaque, but the artery is not completely occluded.
  • Development of infarction. As the cells are deprived of oxygen, ischemia develops, cellular injury occurs, and lack of oxygen leads to infarction or death of the cells.
  • Schematic Diagram of Myocardial Infarction via Scribd

“Time is muscle ”; this is the reflection of the urgency of appropriate treatments to improve patient outcome.

  • Each year in the United States, nearly 1 million people have acute MIs.
  • One fourth of the people with the disease die of MI.
  • Half of the people who die with acute MI never reach the hospital.

The causes of MI primarily stems from the vascular system.

  • Vasospasm. This is the sudden constriction or narrowing of the coronary artery.
  • Decreased oxygen supply. The decrease in oxygen supply occurs from acute blood loss , anemia , or low blood pressure .
  • Increased demand for oxygen. A rapid heart rate, thyrotoxicosis, or ingestion of cocaine causes an increase in the demand for oxygen.

Some of the patients have prodromal symptoms or a previous diagnosis of CAD, but about half report no previous symptoms.

Location of Chest Pain During Myocardial Infarction

  • Chest pain .  This is the cardinal symptom of MI. Persistent and crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. Pain is usually described as heavy, squeezing, or crushing and may persist for 12 hours or more.
  • Shortness of breath. Because of increased oxygen demand and a decrease in the supply of oxygen, shortness of breath occurs.
  • Indigestion. Indigestion is present as a result of the stimulation of the sympathetic nervous system .
  • Tachycardia and tachypnea. To compensate for the decreased oxygen supply, the heart rate and respiratory rate speed up.
  • Catecholamine responses. The patient may experience such as coolness in extremities, perspiration, anxiety , and restlessness.
  • Fever. Unusually occurs at the onset of MI, but a low-grade temperature elevation may develop during the next few days.

A healthy lifestyle could help prevent the development of MI.

  • Exercise. Exercising at least thrice a week could help lower cholesterol levels that cause vasoconstriction of the blood vessels.
  • Balanced diet. Fruits, vegetables, meat and fish should be incorporated in the patient’s daily diet to ensure that he or she gets the right amount of nutrients he or she needs.
  • Smoking cessation. Nicotine causes vasoconstriction which can increase the pressure of the blood and result in MI.

The diagnosis of MI is generally based on the presenting symptoms.

  • Patient history. The patient history includes the description of the presenting symptoms, the history of previous cardiac and other illnesses, and the family history of heart diseases.
  • ECG .  ST elevation signifying ischemia; peaked upright or inverted T wave indicating injury; development of Q waves signifying prolonged ischemia or necrosis.
  • Cardiac enzymes and isoenzymes.  CPK-MB (isoenzyme in cardiac muscle): Elevates within 4–8 hr, peaks in 12–20 hr, returns to normal in 48–72 hr.
  • LDH.  Elevates within 8–24 hr, peaks within 72–144 hr, and may take as long as 14 days to return to normal. An LDH 1  greater than LDH 2  (flipped ratio) helps confirm/diagnose MI if not detected in acute phase.
  • Troponins.  Troponin I (cTnI) and troponin T (cTnT): Levels are elevated at 4–6 hr, peak at 14–18 hr, and return to baseline over 6–7 days. These enzymes have increased specificity for necrosis and are therefore useful in diagnosing postoperative MI when MB-CPK may be elevated related to skeletal trauma .
  • Myoglobin.  A heme protein of small molecular weight that is more rapidly released from damaged muscle tissue with elevation within 2 hr after an acute MI, and peak levels occurring in 3–15 hr.
  • Electrolytes .  Imbalances of sodium and potassium can alter conduction and compromise contractility.
  • WBC.  Leukocytosis (10,000–20,000) usually appears on the second day after MI because of the inflammatory process.
  • ESR.  Rises on second or third day after MI, indicating inflammatory response.
  • Chemistry profiles.  May be abnormal, depending on acute/chronic abnormal organ function/perfusion.
  • ABGs / pulse oximetry .  May indicate hypoxia or acute/chronic lung disease processes.
  • Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides, phospholipids).  Elevations may reflect arteriosclerosis as a cause for coronary narrowing or spasm.
  • Chest x-ray .  May be normal or show an enlarged cardiac shadow suggestive of HF or ventricular aneurysm .
  • Two-dimensional echocardiogram .  May be done to determine dimensions of chambers, septal/ventricular wall motion, ejection fraction (blood flow), and valve configuration/function.
  • Nuclear imaging studies:  Persantine or Thallium.   Evaluates myocardial blood flow and status of myocardial cells, e.g., location/extent of acute/previous MI.
  • Cardiac blood imaging/MUGA.  Evaluates specific and general ventricular performance, regional wall motion, and ejection fraction.
  • Technetium.  Accumulates in ischemic cells, outlining necrotic area(s).
  • Coronary angiography.  Visualizes narrowing/occlusion of coronary arteries and is usually done in conjunction with measurements of chamber pressures and assessment of left ventricular function (ejection fraction). Procedure is not usually done in acute phase of MI unless angioplasty or emergency heart surgery is imminent.
  • Digital subtraction angiography (DSA).  Technique used to visualize status of arterial bypass grafts and to detect peripheral artery disease.
  • Magnetic resonance imaging (MRI).  Allows visualization of blood flow, cardiac chambers or intraventricular septum, valves, vascular lesions, plaque formations, areas of necrosis/infarction, and blood clots.
  • Exercise stress test.  Determines cardiovascular response to activity (often done in conjunction with thallium imaging in the recovery phase).

Medical Management

The goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complications.

case study acute myocardial infarction

  • Morphine administered in IV boluses is used for MI to reduce pain and anxiety.
  • ACE Inhibitors . ACE inhibitors prevent the conversion of angiotensin I to angiotensin II to decrease blood pressure and for the kidneys to secrete sodium and fluid, decreasing the oxygen demand of the heart.
  • Thrombolytics. Thrombolytics dissolve the thrombus in the coronary artery,allowing blood to flow through the coronary artery again, minimizing the size of the infarction and preserving ventricular function.
  • The procedure is used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen.
  • PCI may also be indicated in patients with unstable angina and NSTEMI for patients who are at high risk due to persistent ischemia.

Nursing Management

The nursing management involved in MI is critical and systematic, and efficiency is needed to implement the care for a patient with MI.

One of the most important aspects of care of the patient with MI is the assessment.

  • Assess for chest pain not relieved by rest or medications.
  • Monitor vital signs, especially the blood pressure and pulse rate.
  • Assess for presence of shortness of breath, dyspnea , tachypnea, and crackles.
  • Assess for nausea and vomiting .
  • Assess for decreased urinary output.
  • Assess for the history of illnesses.
  • Perform a precise and complete physical assessment to detect complications and changes in the patient’s status.
  • Assess IV sites frequently.

Based on the clinical manifestations, history, and diagnostic assessment data, major nursing diagnoses may include.

  • Ineffective cardiac tissue perfusion related to reduced coronary blood flow.
  • Risk for ineffective peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction.
  • Deficient knowledge related to post-MI self-care .

Main Article:   7 Myocardial Infarction (Heart Attack) Nursing Care Plans

To establish a plan of care, the focus should be on the following:

  • Relief of pain or ischemic signs and symptoms.
  • Prevention of myocardial damage.
  • Absence of respiratory dysfunction.
  • Maintenance or attainment of adequate tissue perfusion.
  • Reduced anxiety.
  • Absence or early detection of complications.
  • Chest pain absent/controlled.
  • Heart rate/rhythm sufficient to sustain adequate cardiac output/tissue perfusion.
  • Achievement of activity level sufficient for basic self-care.
  • Anxiety reduced/managed.
  • Disease process, treatment plan, and prognosis understood.
  • Plan in place to meet needs after discharge.
  • Relieve pain, anxiety.
  • Reduce myocardial workload.
  • Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications.
  • Promote cardiac health, self-care.

Nursing interventions should be anchored on the goals in the nursing care plan .

  • Administer oxygen along with medication therapy to assist with relief of symptoms.
  • Encourage bed rest with the back rest elevated to help decrease chest discomfort and dyspnea.
  • Encourage changing of positions frequently to help keep fluid from pooling in the bases of the lungs .
  • Check skin temperature and peripheral pulses frequently to monitor tissue perfusion.
  • Provide information in an honest and supportive manner.
  • Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, changes in skin color, and laboratory values.

After the implementation of the interventions within the time specified, the nurse should check if:

  • There is an absence of pain or ischemic signs and symptoms.
  • Myocardial damage is prevented.
  • Adequate tissue perfusion maintained.
  • Anxiety is reduced.

The most effective way to increase the probability that the patient will implement a self-care regimen after discharge is to identify the patient’s priorities.

  • Education. This is one of the priorities that the nurse must teach the patient about heart-healthy living.
  • Home care. The home care nurse assists the patient with scheduling and keeping up with the follow-up appointments and with adhering to the prescribed cardiac rehabilitation management.
  • Follow-up monitoring. The patient may need reminders about follow-up monitoring including periodic laboratory testing and ECGs, as well as general health screening.
  • Adherence. The nurse should also monitor the patient’s adherence to dietary restrictions and prescribed medications.

To ensure that every action documented is an action done, documentation must be secured. The following should be documented:

  • Individual findings.
  • Vital signs, cardiac rhythm , presence of dysrhythmias.
  • Plan of care and those involved in planning.
  • Teaching plan.
  • Response to interventions, teaching, and actions performed.
  • Attainment or progress towards desired outcomes.
  • Modifications to plan of care.

Let’s reinforce what you’ve learned with this 5-item NCLEX practice quiz about Myocardial Infarction. Please visit our nursing test bank for more NCLEX practice questions .

1. Which of the following is the most common symptom of myocardial infarction (MI)?

A. Chest pain B. Dyspnea C. Edema D. Palpitations

2. An intravenous analgesic frequently administered to relieve chest pain associated with MI is:

A. Meperidine hydrochloride B. Hydromorphone hydrochloride C. Morphine sulfate D. Codeine sulfate

3. The classic ECG changes that occur with an MI include all of the following except:

A. An absent P wave B. An abnormal Q wave C. T-wave inversion D. ST segment elevation

4. Which of the following statements about myocardial infarction pain is incorrect?

A. It is relieved by rest and inactivity. B. It is substernal in location. C. It is sudden in onset and prolonged in duration. D. It is viselike and radiates to the shoulders and arms.

5. Myocardial cell damage can be reflected by high levels of cardiac enzymes. The cardiac-specific isoenzyme is:

A. Alkaline phosphatase B. Creatine kinase (CK-MB) C. Myoglobin D. Troponin

1. Answer: A. Chest pain

  • A: The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart.
  • B: Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI.
  • C: Edema is a later sign of heart failure , often seen after an MI.
  • D: Palpitations may result from reduced cardiac output, producing arrhythmias.

2. Answer: C. Morphine sulfate

  • C: Morphine administered in IV boluses is used for MI to reduce pain and anxiety.
  • A: Meperidine hydrochloride is not the analgesic of choice for MI.
  • B: Hydromorphone hydrochloride is not the analgesic of choice for MI.
  • D: Codeine sulfate is not the analgesic of choice for MI.

3. Answer: A. An absent P wave

  • A: An absent P wave is not part of the classic changes seen in an ECG result.
  • B: An abnormal Q wave is an indication of MI.
  • C: T-wave inversion is a classic ECG change in a patient with MI.
  • D: ST segment elevation is an indication of MI.

4. Answer: A. It is relieved by rest and inactivity.

  • A: MI pain continues despite rest and medications.
  • B: The pain occurs substernally or at the chest area.
  • C: MI pain occurs suddenly and is prolonged in duration.
  • D: The pain grips the patient like a vise and radiates towards the arms or the shoulders.

5. Answer: B. Creatine kinase (CK-MB)

  • B: CK-MB is the isoenzyme for the heart muscle and the cardiac-specific enzyme.
  • A: Alkaline phosphatase is not part of the creatine kinase isoenzymes.
  • C: Myoglobin is a heme protein that helps transport oxygen.
  • D: Troponin regulates the myocardial contractile process.

Posts related to Myocardial Infarction:

  • 7 Myocardial Infarction (Heart Attack) Nursing Care Plans
  • Myocardial Infarction and Heart Failure NCLEX Practice Quiz (70 Items)
  • Heart Failure
  • Cardiovascular Care Nursing Mnemonics and Tips

3 thoughts on “Myocardial Infarction”

Good lecture

Very refreshing lecture

Leave a Comment Cancel reply

INTER-HEART: A global study of risk factors for acute myocardial infarction

Affiliation.

  • 1 Canadian Cardiovascular Collaboration, McMaster University, Canada.
  • PMID: 11320357
  • DOI: 10.1067/mhj.2001.114974

Background: Although declines in mortality rates have occurred in most developed countries, increases are being seen in developing countries. Our knowledge of risk factors for acute myocardial infarction (AMI) is largely derived from studies in the former. Applicability of these results to other populations is unknown. The objectives of INTER-HEART are to determine the association between risk factors and AMI within populations defined by ethnicity and/or geographic region and to assess the relative importance of risk factors across these populations.

Methods: INTER-HEART is a study of 14,000 cases of AMI and 16,000 matched control patients from 46 countries, which was conducted with a standardized protocol. Questionnaires were translated into 11 languages; physical measurements were obtained, and 20 mL of blood was drawn and shipped frozen to a central laboratory in Canada. The study will evaluate the importance of conventional and emerging risk factors within each geographic region and whether their impact varies by region.

Results: INTER-HEART is sponsored by the World Health Organization and the World Heart Federation and has received funding from several peer-reviewed agencies and many different pharmaceutical companies. A vanguard phase (February 1999 to 2000) enrolled 4000 subjects from 41 countries. Full data collection started in April 2000 and is expected to be completed by October 2002.

Conclusions: Several years of targeted work have allowed the development of the concepts that were tested in the pilot studies. This has ensured the feasibility of INTER-HEART. This study has the potential to have a major impact in developing a worldwide strategy for cardiovascular disease prevention, especially in developing countries and nonwhite populations.

Publication types

  • Comparative Study
  • Evaluation Study
  • Multicenter Study
  • Research Support, Non-U.S. Gov't
  • Case-Control Studies
  • Global Health
  • Lipids / blood
  • Middle Aged
  • Myocardial Infarction / blood
  • Myocardial Infarction / epidemiology
  • Myocardial Infarction / etiology*
  • Risk Factors
  • Socioeconomic Factors
  • Surveys and Questionnaires
  • Survival Rate
  • Campus Directory
  • Current Students
  • Faculty & Staff

College of Health Professions

Acute Myocardial Infarction Case Study

Myocardial infarction (heart attack) is the leading cause of death in the United States. It is estimated that one in every five deaths in the US is due to a heart attack. Approximately one million patients are admitted to hospitals each year due to heart attacks. 200,000 to 300,000 individuals die from heart attacks before ever receiving medical care. In Case #2 we’ll join 48-year-old Jason Dixon as he experiences a life-threatening heart attack.

Module 7: Acute Myocardial Infarction

case study acute myocardial infarction

48 year old Jason Dixon had not been feeling well all day and around 10:00 p.m he went to bed...

AMI - Page 1

case study acute myocardial infarction

Before we progress further into this relatively complex case, please review module 6 in the...

AMI - Page 2

case study acute myocardial infarction

Case continued: Enroute to the ER, the patient's acute symptoms had been relieved...

AMI - Page 3

case study acute myocardial infarction

This is a critical decision point for the cardiologist. There are several algorithms...

AMI - Page 4

case study acute myocardial infarction

Case Summary

Summary of the Case

AMI - Summary

case study acute myocardial infarction

Answers to Case Questions

AMI - Answers

case study acute myocardial infarction

Professionals

Health Professionals Introduced in Case

AMI - Professionals

case study acute myocardial infarction

Additional Links

Optional Links to Explore Further

AMI - Links

U.S. flag

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

Cover of StatPearls

StatPearls [Internet].

Myocardial infarction.

Niranjan Ojha ; Amit S. Dhamoon .

Affiliations

Last Update: August 8, 2023 .

  • Continuing Education Activity

Myocardial infarction (MI), colloquially known as "heart attack," is caused by decreased or complete cessation of blood flow to a portion of the myocardium. Myocardial infarction may be"silent," and go undetected, or it could be a catastrophic event leading to hemodynamic deterioration and sudden death. Most myocardial infarctions are due to underlying coronary artery disease, the leading cause of death in the United States. With coronary artery occlusion, the myocardium is deprived of oxygen. Prolonged deprivation of oxygen supply to the myocardium can lead to myocardial cell death and necrosis. Patients can present with chest discomfort or pressure that can radiate to the neck, jaw, shoulder, or arm. In addition to the history and physical exam, myocardial ischemia may be associated with ECG changes and elevated biochemical markers such as cardiac troponins. This activity describes the pathophysiology, evaluation, and management of myocardial infarction and highlights the role of the interprofessional team in improving care for affected patients.

  • Review the basic pathophysiology of myocardial infarction.
  • Explain the management protocol when presented with acute myocardial infarction, including all necessary laboratory and other diagnostic testing.
  • Summarize the long-term management and rehabilitation for a patient post-MI.
  • Explain interprofessional team strategies for improving care coordination and communication to advance the prevention and management of myocardial infarction leading to improved outcomes.
  • Introduction

Myocardial infarction (MI), colloquially known as “heart attack,” is caused by decreased or complete cessation of blood flow to a portion of the myocardium. Myocardial infarction may be “silent” and go undetected, or it could be a catastrophic event leading to hemodynamic deterioration and sudden death. [1] Most myocardial infarctions are due to underlying coronary artery disease, the leading cause of death in the United States. With coronary artery occlusion, the myocardium is deprived of oxygen. Prolonged deprivation of oxygen supply to the myocardium can lead to myocardial cell death and necrosis. [2]  Patients can present with chest discomfort or pressure that can radiate to the neck, jaw, shoulder, or arm. In addition to the history and physical exam, myocardial ischemia may be associated with ECG changes and elevated biochemical markers such as cardiac troponins. [3] [4]

As stated above, myocardial infarction is closely associated with coronary artery disease. INTERHEART is an international multi-center case-control study which delineated the following modifiable risk factors for coronary artery disease: [5] [6]

  • Abnormal lipid profile/blood apolipoprotein (raised ApoB/ApoA1)
  • Hypertension
  • Diabetes mellitus
  • Abdominal obesity (waist/hip ratio) (greater than 0.90 for males and greater than 0.85 for females)
  • Psychosocial factors such as depression, loss of the locus of control, global stress, financial stress, and life events including marital separation, job loss, and family conflicts
  • Lack of daily consumption of fruits or vegetables
  • Lack of physical activity
  • Alcohol consumption (weaker association, protective)

The INTERHEART study showed that all the above risk factors were significantly associated with acute myocardial infarction except for alcohol consumption, which showed a weaker association. Smoking and abnormal apolipoprotein ratio showed the strongest association with acute myocardial infarction. The increased risk associated with diabetes and hypertension were found to be higher in women, and the protective effect of exercise and alcohol was also found to be higher in women. [5]

Other risk factors include a moderately high level of plasma homocysteine, which is an independent risk factor of MI. Elevated plasma homocysteine is potentially modifiable and can be treated with folic acid, vitamin B6, and vitamin B12. [7]

Some non-modifiable risk factors for myocardial infarction include advanced age, male gender (males tend to have myocardial infarction earlier in life), genetics (there is an increased risk of MI if a first-degree relative has a history of cardiovascular events before the age of 50). [6] [8]  The role of genetic loci that increase the risk for MI is under active investigation. [9] [10]

  • Epidemiology

The most common cause of death and disability in the western world and worldwide is coronary artery disease. [11]  Based on 2015 mortality data from the National Health Interview Survey (NHIS-CDC), MI mortality was 114,023, and MI any-mention mortality (i.e., MI is mentioned as a contributing factor in the death certificate) was 151,863.

As per the National Health and Nutrition Examination Survey (NHANES)-CDC data from 2011 to 2014, an estimated 16.5 million Americans older than 20 years of age have coronary artery disease, and the prevalence was higher in males than females for all ages. As per the NHANES 2011 through 2014, the overall prevalence of MI is 3.0% in US adults older than 20 years of age.

Prevalence of MI in the US Sub-populations

Non-Hispanic Whites

  • 4.0% (Male)
  • 2.4% (Female)

Non-Hispanic Blacks

  • 3.3% (Male)
  • 2.2% (Female)
  • 2.9% (Male)
  • 2.1% (Female)

Non-Hispanic Asians

  • 2.6% (Male)
  • 0.7% (Female)

Based on the Atherosclerosis Risk in Communities Study (ARIC) performed by National Heart, Lung, and Blood Institute (NHLBI) collected between 2005 and 2014, the estimated annual incidence is 605,000 new MIs and 200,000 recurrent MIs. [12]

The ARIC study also found that the average age at first MI is 65.6 years for males and 72.0 years for females. In the past decades, several studies have shown a declining incidence of MI in the United States. [12]

  • Pathophysiology

The acute occlusion of one or multiple large epicardial coronary arteries for more than 20 to 40 minutes can lead to acute myocardial infarction. The occlusion is usually thrombotic and due to the rupture of a plaque formed in the coronary arteries. The occlusion leads to a lack of oxygen in the myocardium, which results in sarcolemmal disruption and myofibril relaxation. [2]  These changes are one of the first ultrastructural changes in the process of MI, which are followed by mitochondrial alterations. The prolonged ischemia ultimately results in liquefactive necrosis of myocardial tissue. The necrosis spreads from sub-endocardium to sub-epicardium. The subepicardium is believed to have increased collateral circulation, which delays its death. [2]  Depending on the territory affected by the infarction, the cardiac function is compromised. Due to the negligible regeneration capacity of the myocardium, the infarcted area heals by scar formation, and often, the heart is remodeled characterized by dilation, segmental hypertrophy of remaining viable tissue, and cardiac dysfunction. [13]

  • History and Physical

The imbalance between oxygen supply and the demand leads to myocardial ischemia and can sometimes lead to myocardial infarction. The patient’s history, electrocardiographic findings, and elevated serum biomarkers help identify ischemic symptoms. Myocardial ischemia can present as chest pain, upper extremity pain, mandibular, or epigastric discomfort that occurs during exertion or at rest. Myocardial ischemia can also present as dyspnea or fatigue, which are known to be ischemic equivalents. [14]  The chest pain is usually retrosternal and is sometimes described as the sensation of pressure or heaviness. The pain often radiates to the left shoulder, neck, or arms with no obvious precipitating factors, and it may be intermittent or persistent. The pain usually lasts for more than 20 minutes. [15]  It is usually not affected by positional changes or active movement of the region. Additional symptoms, such as sweating, nausea, abdominal pain, dyspnea, and syncope, may also be present. [14] [16] [17]  The MI can also present atypically with subtle findings such as palpitations, or more dramatic manifestations, such as cardiac arrest. The MI can sometimes present with no symptoms. [18]

The three components in the evaluation of the MI are clinical features, ECG findings, and cardiac biomarkers.

The resting 12 lead ECG is the first-line diagnostic tool for the diagnosis of acute coronary syndrome (ACS). It should be obtained within 10 minutes of the patient’s arrival in the emergency department. [17]  Acute MI is often associated with dynamic changes in the ECG waveform. Serial ECG monitoring can provide important clues to the diagnosis if the initial EKG is non-diagnostic at initial presentation. [14]  Serial or continuous ECG recordings may help determine reperfusion or re-occlusion status. A large and prompt reduction in ST-segment elevation is usually seen in reperfusion. [14]

ECG findings suggestive of ongoing coronary artery occlusion (in the absence of left ventricular hypertrophy and bundle branch block): [19]

ST-segment elevation in two contiguous lead (measured at J-point) of

  • Greater than 5 mm in men younger than 40 years, greater than 2 mm in men older than 40 years, or greater than 1.5 mm in women in leads V2-V3 and/or
  • Greater than 1 mm in all other leads

ST-segment depression and T-wave changes

  • New horizontal or down-sloping ST-segment depression greater than 5 mm in 2 contiguous leads and/or T inversion greater than 1 mm in two contiguous leads with prominent R waves or R/S ratio of greater than 1

The hyperacute T-wave amplitude, with prominent symmetrical T waves in two contiguous leads, maybe an early sign of acute MI that may precede the ST-segment elevation. Other ECG findings associated with myocardial ischemia include cardiac arrhythmias, intraventricular blocks, atrioventricular conduction delays, and loss of precordial R-wave amplitude (less specific finding). [14]

ECG findings alone are not sufficient to diagnose acute myocardial ischemia or acute MI as other conditions such as acute pericarditis, left ventricular hypertrophy (LVH), left bundle branch block (LBBB), Brugada syndrome, Takatsubo syndrome (TTS), and early repolarization patterns also present with ST deviation.

ECG changes associated with prior MI (in the absence of left ventricular hypertrophy and left bundle branch block):

  • Any Q wave in lead V2-V3 greater than 0.02 s or QS complex in leads V2-V3
  • Q wave > 03 s and greater than 1 mm deep or QS complex in leads I, II, aVL, aVF or V4-V6 in any two leads of contiguous lead grouping (I, aVL; V1-V6; II, III, aVF)
  • R wave > 0.04 s in V1-V2 and R/S greater than 1 with a concordant positive T wave in the absence of conduction defect.

Biomarker Detection of MI

Cardiac troponins (I and T) are components of the contractile apparatus of myocardial cells and expressed almost exclusively in the heart. Elevated serum levels of cardiac troponin are not specific to the underlying mode of injury (ischemic vs. tension) [14]   [20] . The rising and/or falling pattern of cardiac troponins (cTn) values with at least one value above the 99 percentile of upper reference limit (URL) associated with symptoms of myocardial ischemia would indicate an acute MI. Serial testing of cTn values at 0 hours, 3 hours, and 6 hours would give a better perspective on the severity and time course of the myocardial injury. Depending on the baseline cTn value, the rising/falling pattern is interpreted. If the cTn baseline value is markedly elevated, a minimum change of greater than 20% in follow up testing is significant for myocardial ischemia. Creatine kinase MB isoform can also be used in the diagnosis of MI, but it is less sensitive and specific than cTn level. [4] [21]

Different imaging techniques are used to assess myocardial perfusion, myocardial viability, myocardial thickness, thickening and motion, and the effect of myocyte loss on the kinetics of para-magnetic or radio-opaque contrast agents indicating myocardial fibrosis or scars. [14]  Some imaging modalities that can be used are echocardiography, radionuclide imaging, and cardiac magnetic resonance imaging (cardiac MRI). Regional wall motion abnormalities induced by ischemia can be detected by echocardiography almost immediately after the onset of ischemia when greater than 20% transmural myocardial thickness is affected. Cardiac MRI provides an accurate assessment of myocardial structure and function. [14]

  • Treatment / Management

Acute Management

Reperfusion therapy is indicated in all patients with symptoms of ischemia of less than 12-hours duration and persistent ST-segment elevation. Primary percutaneous coronary intervention (PCI) is preferred to fibrinolysis if the procedure can be performed <120 minutes of ECG diagnosis. If there is no immediate option of PCI (>120 minutes), fibrinolysis should be started within 10 minutes of STEMI after ruling out contraindications. If transfer to a PCI center is possible in 60 to 90 minutes after a bolus of the fibrinolytic agent and patient meets reperfusion criteria, a routine PCI can be done, or a rescue PCI can be planned. [19] [17]  If fibrinolysis is planned, it should be carried out with fibrin-specific agents such as tenecteplase, alteplase, or reteplase (class I). [19]

Relief of pain, breathlessness, and anxiety: The chest pain due to myocardial infarction is associated with sympathetic arousal, which causes vasoconstriction and increased workload for the ischemic heart. Intravenous opioids (e.g., morphine) are the analgesics most commonly used for pain relief (Class IIa). [19]  The results from CRUSADE quality improvement initiative have shown that the use of morphine may be associated with a higher risk of death and adverse clinical outcomes. [22]  The study was done from the CIRCUS (Does Cyclosporine Improve outcome in STEMI patients) database, which showed no significant adverse events associated with morphine use in a case of anterior ST-segment elevation MI. [23] A mild anxiolytic (usually a benzodiazepine) may be considered in very anxious patients (class IIa). Supplemental oxygen is indicated in patients with hypoxemia (SaO2 <90% or PaO2 <60mm Hg) (Class I). [19]

Nitrates: Intravenous nitrates are more effective than sublingual nitrates with regard to symptom relief and regression of ST depression (NSTEMI). The dose is titrated upward until symptoms are relieved, blood pressure is normalized in hypertensive patients, or side effects such as a headache and hypotension are noted. [17]

Beta-blockers: This group of drugs reduces myocardial oxygen consumption by lowering heart rate, blood pressure, and myocardial contractility. They block beta receptors in the body, including the heart, and reduce the effects of circulating catecholamines. Beta-blockers should not be used in suspected coronary vasospasm.

Platelet inhibition: Aspirin is recommended in both STEMI and NSTEMI in an oral loading dose of 150 to 300 mg (non-enteric coated formulation) and a maintenance dose of 75 to 100 mg per day long-term regardless of treatment strategy (class I). [17] Aspirin inhibits thromboxane A2 production throughout the lifespan of the platelet. [24]

Most P2Y12 inhibitors are inactive prodrugs (except for ticagrelor, which is an orally active drug that does not require activation) that require oxidation by hepatic cytochrome P450 system to generate an active metabolite which selectively inhibits P2Y12 receptors irreversibly. Inhibition of P2Y12 receptors leads to inhibition of ATP induced platelet aggregation. The commonly used P2Y12 inhibitors are clopidogrel, prasugrel, and ticagrelor.

The loading dose for clopidogrel is 300 to 600 mg loading dose followed by 75 mg per day.

Prasugrel, 60 mg loading dose, and 10 mg per day of a maintenance dose have a faster onset when compared to clopidogrel. [19]

Patients undergoing PCI should be treated with dual antiplatelet therapy (DAPT) with aspirin + P2Y12 inhibitor and a parenteral anticoagulant. In PCI, the use of prasugrel or ticagrelor is found to be superior to clopidogrel. Aspirin and clopidogrel are also found to decrease the number of ischemic events in NSTEMI and UA. [17]

The anticoagulants used during PCI are unfractionated heparin, enoxaparin, and bivalirudin. The bivalirudin is recommended during primary PCI if the patient has heparin-induced thrombocytopenia. [19]

Long-Term Management

Lipid-lowering treatment: It is recommended to start high-intensity statins that reduce low-density lipoproteins (LDLs) and stabilize atherosclerotic plaques. High-density lipoproteins are found to be protective. [19]

Antithrombotic therapy: Aspirin is recommended lifelong, and the addition of another agent depends on the therapeutic procedure done, such as PCI with stent placement.

ACE inhibitors are recommended in patients with systolic left ventricular dysfunction, or heart failure, hypertension, or diabetes.

Beta-blockers are recommended in patients with LVEF less than 40% if no other contraindications are present.

Antihypertensive therapy can maintain a blood pressure goal of less than 140/90 mm Hg.

Mineralocorticoid receptor antagonist therapy is recommended in a patient with left ventricular dysfunction (LVEF less than 40%).

Glucose lowering therapy in people with diabetes to achieve current blood sugar goals.  [19]

Lifestyle Modifications

Smoking cessation is the most cost-effective secondary measure to prevent MI. Smoking has a pro-thrombotic effect, which has a strong association with atherosclerosis and myocardial infarction. [6]

Diet, alcohol, and weight control: A diet low in saturated fat with a focus on whole grain products, vegetables, fruits, and the fish is considered cardioprotective. The target level for bodyweight is body mass index of 20 to 25 kg/m2  and waist circumference of <94 cm for the men and <80 cm for the female. [25]

  • Differential Diagnosis
  • Angina pectoris
  • Non-ST segment elevation myocardial infarction (NSTEMI)
  • ST-segment elevation myocardial infarction (STEMI)
  • Pulmonary embolism
  • Pneumothorax

Despite many advances in treatment, acute MI still carries a mortality rate of 5-30%; the majority of deaths occur prior to arrival to the hospital. In addition, within the first year after an MI, there is an additional mortality rate of 5% to 12%. The overall prognosis depends on the extent of heart muscle damage and ejection fraction. Patients with preserved left ventricular function tend to have good outcomes. Factors that worsen prognosis include:

  • Advanced age
  • Delayed reperfusion
  • Low ejection fraction
  • Presence of congestive heart failure
  • Elevations in C-reactive protein and B-type natriuretic peptide ( BNP ) levels
  • Complications

Type and Manifestation

I: Ischemic

  • Reinfarction
  • Extension of infarction

II: Arrhythmias

  • Supraventricular or ventricular arrhythmia
  • Sinus bradycardia and atrioventricular block

III: Mechanical

  • Myocardial dysfunction
  • Cardiac failure
  • Cardiogenic shock
  • Cardiac rupture (Free wall rupture, ventricular septal rupture, papillary muscle rupture)

IV: Embolic

  • Left ventricular mural thrombus,
  • Peripheral embolus

V: Inflammatory

  • Pericarditis (infarct associated pericarditis, late pericarditis, or post-cardiac injury pericarditis)
  • Pericardial effusion
  • Enhancing Healthcare Team Outcomes

The diagnosis and management of patients with ischemic heart disease are best done with an interprofessional team. In most hospitals, there are cardiology teams that are dedicated to the management of these patients.

For patients who present with chest pain, the key to the management of MI is time to treatment. Thus, healthcare professionals, including nurses who work in the emergency department, must be familiar with the symptoms of MI and the importance of rapid triage. A cardiology consult should be made immediately to ensure that the patient gets treated within the time frame recommendations. Because MI can be associated with several serious complications, these patients are best managed in an ICU setting.

There is no cure for ischemic heart disease, and all treatments are symptom-oriented. The key to improving outcomes is to prevent coronary artery disease. The primary care provider and nurse practitioner should educate the patient on the benefits of a healthy diet, the importance of controlling blood pressure and diabetes, exercising regularly, discontinuing smoking, maintaining healthy body weight, and remaining compliant with medications. The pharmacist should educate the patient on types of medication used to treat ischemic heart disease, their benefits, and potential adverse effects.

Only through such a team approach can the morbidity and mortality of myocardial infarction be lowered. [Level 5]

  • Review Questions
  • Access free multiple choice questions on this topic.
  • Comment on this article.

Myocardial Infarction (Heart Attack) Warning Signs in Women. U.S. Department of Health and Human Services Office on Women's Health

ECG With Pardee Waves Indicating AMI. Pardee waves indicate acute myocardial infarction in the inferior leads II, III, and aVF with reciprocal changes in the anterolateral leads. Wikimedia Commons, Glenlarson

Transesophageal echocardiography, Thrombo embolism, Pulmonary artery, Pulmonary Embolism, Thromboembolic , Right Pulmonary artery, TE, RPA, Acute ECG segment elevation mimicking myocardial infarction in a patient with pulmonary embolism Contribute by (more...)

Ischemic ventricular tachycardia in a patient with an old inferior myocardial infarction Contributed by Alina Negru, MD

Disclosure: Niranjan Ojha declares no relevant financial relationships with ineligible companies.

Disclosure: Amit Dhamoon declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

  • Cite this Page Ojha N, Dhamoon AS. Myocardial Infarction. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

In this Page

Bulk download.

  • Bulk download StatPearls data from FTP

Related information

  • PMC PubMed Central citations
  • PubMed Links to PubMed

Similar articles in PubMed

  • Myocardial Infarction (Nursing). [StatPearls. 2024] Myocardial Infarction (Nursing). Ojha N, Dhamoon AS, Chapagain R. StatPearls. 2024 Jan
  • Review Context-independent identification of myocardial ischemia in the prehospital ECG of chest pain patients. [J Electrocardiol. 2024] Review Context-independent identification of myocardial ischemia in the prehospital ECG of chest pain patients. Swenne CA, Ter Haar CC. J Electrocardiol. 2024 Jan-Feb; 82:34-41. Epub 2023 Nov 7.
  • Enhanced External Counterpulsation (EECP): An Evidence-Based Analysis. [Ont Health Technol Assess Ser....] Enhanced External Counterpulsation (EECP): An Evidence-Based Analysis. Medical Advisory Secretariat. Ont Health Technol Assess Ser. 2006; 6(5):1-70. Epub 2006 Mar 1.
  • Association of Silent Myocardial Infarction and Sudden Cardiac Death. [JAMA Cardiol. 2019] Association of Silent Myocardial Infarction and Sudden Cardiac Death. Vähätalo JH, Huikuri HV, Holmström LTA, Kenttä TV, Haukilahti MAE, Pakanen L, Kaikkonen KS, Tikkanen J, Perkiömäki JS, Myerburg RJ, et al. JAMA Cardiol. 2019 Aug 1; 4(8):796-802.
  • Review Prevention of ventricular fibrillation, acute myocardial infarction (myocardial necrosis), heart failure, and mortality by bretylium: is ischemic heart disease primarily adrenergic cardiovascular disease? [Am J Ther. 2004] Review Prevention of ventricular fibrillation, acute myocardial infarction (myocardial necrosis), heart failure, and mortality by bretylium: is ischemic heart disease primarily adrenergic cardiovascular disease? Bacaner M, Brietenbucher J, LaBree J. Am J Ther. 2004 Sep-Oct; 11(5):366-411.

Recent Activity

  • Myocardial Infarction - StatPearls Myocardial Infarction - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

statistics

This paper is in the following e-collection/theme issue:

Published on 18.3.2024 in Vol 8 (2024)

Using Principles of Digital Development for a Smartphone App to Support Data Collection in Patients With Acute Myocardial Infarction and Physical Activity Intolerance: Case Study

Authors of this article:

Author Orcid Image

Original Paper

  • Diana Isabel Cáceres Rivera 1 * , MSc, PhD   ; 
  • Luz Mileyde Jaimes Rojas 1 * , MSc   ; 
  • Lyda Z Rojas 2 * , MSc, PhD   ; 
  • Diana Canon Gomez 2 * , MD   ; 
  • David Andrés Castro Ruiz 1 * , MSc   ; 
  • Luis Alberto López Romero 3 , MSc  

1 Facultad de Enfermería, Universidad Cooperativa de Colombia, Bucaramanga, Colombia

2 Centro de Investigaciones, Fundación Cardiovascular de Colombia, Floridablanca, Colombia

3 Departamento de Pediatría, de Obstetricia y Ginecología y de Medicina Preventiva y Salud Pública, Universidad Autónoma de Barcelona, Barcelona, Spain

*these authors contributed equally

Corresponding Author:

Diana Isabel Cáceres Rivera, MSc, PhD

Facultad de Enfermería

Universidad Cooperativa de Colombia

Torre 2 Apto 203

Bucaramanga, 64000

Phone: 57 3014006658

Email: [email protected]

Background: Advances in health have highlighted the need to implement technologies as a fundamental part of the diagnosis, treatment, and recovery of patients at risk of or with health alterations. For this purpose, digital platforms have demonstrated their applicability in the identification of care needs. Nursing is a fundamental component in the care of patients with cardiovascular disorders and plays a crucial role in diagnosing human responses to these health conditions. Consequently, the validation of nursing diagnoses through ongoing research processes has become a necessity that can significantly impact both patients and health care professionals.

Objective: We aimed to describe the process of developing a mobile app to validate the nursing diagnosis “intolerance to physical activity” in patients with acute myocardial infarction.

Methods: We describe the development and pilot-testing of a mobile system to support data collection for validating the nursing diagnosis of activity intolerance. This was a descriptive study conducted with 11 adults (aged ≥18 years) who attended a health institution for highly complex needs with a suspected diagnosis of coronary syndrome between August and September 2019 in Floridablanca, Colombia. An app for the clinical validation of activity intolerance (North American Nursing Diagnosis Association [NANDA] code 00092) in patients with acute coronary syndrome was developed in two steps: (1) operationalization of the nursing diagnosis and (2) the app development process, which included an evaluation of the initial requirements, development and digitization of the forms, and a pilot test. The agreement level between the 2 evaluating nurses was evaluated with the κ index.

Results: We developed a form that included sociodemographic data, hospital admission data, medical history, current pharmacological treatment, and thrombolysis in myocardial infarction risk score (TIMI-RS) and GRACE (Global Registry of Acute Coronary Events) scores. To identify the defining characteristics, we included official guidelines, physiological measurements, and scales such as the Piper fatigue scale and Borg scale. Participants in the pilot test (n=11) had an average age of 63.2 (SD 4.0) years and were 82% (9/11) men; 18% (2/11) had incomplete primary schooling. The agreement between the evaluators was approximately 80% for most of the defining characteristics. The most prevalent characteristics were exercise discomfort (10/11, 91%), weakness (7/11, 64%), dyspnea (3/11, 27%), abnormal heart rate in response to exercise (2/10, 20%), electrocardiogram abnormalities (1/10, 9%), and abnormal blood pressure in response to activity (1/10, 10%).

Conclusions: We developed a mobile app for validating the diagnosis of “activity intolerance.” Its use will guarantee not only optimal data collection, minimizing errors to perform validation, but will also allow the identification of individual care needs.

Introduction

In recent decades, the ability to produce, collect, and communicate data around the world has increased exponentially with access to technologies such as smartphones. These technologies have improved data storage as well as its handling and analysis [ 1 ]. In the field of health, electronic record systems facilitate data collection that can be used for various purposes, allowing data retrieval that promotes the improvement of research processes such as identification and recruitment of patients for clinical projects [ 2 , 3 ].

In addition to obtaining individual data from each patient, the collection of large amounts of data can be useful to obtain information that more effectively supports the exploration of diseases, treatment, and rehabilitation. This creates the need to develop research platforms that optimize the capacity to conduct informative and innovative research and enable scientific approaches where objective data can be obtained with a minimum of errors and expended resources [ 4 ].

As part of the health staff providing care to cardiovascular patients, nurses can be the first to identify individual needs. To aid this, tools are available such as the NANDA (North American Nursing Diagnosis Association) taxonomy, which identifies the response of a person, family, or community to real health problems and potential vital processes. However, these diagnoses and their respective defining characteristics must be validated according to the context where they will be assessed, which constitutes a challenge in research into the use, implementation, and dissemination of technologies of information [ 5 - 7 ]. For this purpose, the use of digital platforms has demonstrated its applicability from the early stages of research, such as the assessment of care needs [ 8 , 9 ].

Mobile apps in health, education, and work in Colombia are promoting efficient new practices to streamline processes and improve access to information at the national level, with the intention of contributing to the modernization and globalization of different socioeconomic sectors. These technologies are important to innovate in the health sector because they can benefit both patients and health staff. However, the uptake of this type of technological tool is still slow and limited [ 10 ]. Thus, this paper describes the process of developing a mobile app for collecting health research data. Specifically, it is intended that this app will be a tool that allows speeding up the validation of a nursing diagnosis in an objective and practical way.

This was a descriptive study conducted with 11 adults (aged ≥18 years) with a suspected diagnosis of coronary syndrome who attended a health institution for highly complex needs between August and September 2019 in Floridablanca, Colombia. An app for clinical validation of the “activity intolerance” diagnosis (NANDA code 00092) in patients with acute coronary syndrome was developed in three steps, outlined in the following sections.

Step 1: Operationalization of the Nursing Diagnosis

The first step consisted in the operationalization of the defining characteristics of the nursing diagnosis [ 11 ] of activity intolerance (NANDA code 00092), defined by NANDA-I [ 6 ] as “the lack of sufficient physiological or psychological energy to tolerate or complete the required or desired daily activities.” This diagnosis is categorized as “Domain 4: Activity / Rest, Class 4: Cardiovascular / pulmonary responses Need: Move and Pattern Activity-exercise.” It is also related to an imbalance between oxygen supply and demand, a sedentary lifestyle, immobility, and bed rest; it has defined characteristics [ 12 ]. Through an extensive search of the literature, we selected scales or instruments to standardize the measurement of each defining characteristic of this nursing diagnosis [ 11 ]. An interdisciplinary group that included 2 nurses, an epidemiologist, and a cardiologist verified the face validity of the operationalization.

Step 2: App Development Process

Initial requirements evaluation.

Health professionals, along with a systems engineer, carried out the structural design of the data collection forms or case report forms. The digitization process was carried out using CommCare [ 7 ], which is an open source, cloud-based platform that helps researchers develop data capture tools using mobile devices. An open source tool was also used to create an Android-based mobile app for a low-income setting. Mobile apps can be used as a tool to track beneficiaries through a service lifecycle and can also streamline data collection [ 13 ]. Our app used the HTTPS protocol, which made it cryptographically secure. Access to data was password protected. The CommCare [ 7 ] platform was selected because it has been widely used for health projects all over the world and because of its ease of use and compatibility with older versions of Android. CommCare is a platform that works on Android mobile phones from version 2.3, but the platform recommends reviewing the documentation for these older versions because they may have limitations in terms of functionality and compatibility with the latest features developed by CommCare, so it is recommended to have at least Android version 4.0.3 or later, a storage space of at least 100MB, a minimum of 1GB of RAM, and a processor with at least 2 cores for a better user experience.

Finally, we did not use any programming language because we used a platform that prevents us from reaching that level. We worked directly with CommCare, which allowed us to create data collection applications without touching or programming source code ( Figure 1 ).

CommCare requires the use of a password to access the app and the data stored on the platform. This helps to ensure that only authorized users can access information. The platform uses the secure HTTPS communications protocol, uses role-based access, and is in compliance with data security regulations and standards such as the European Union’s General Data Protection Regulation (GDPR). This ensures that the platform follows good practices in terms of privacy and personal data protection.

case study acute myocardial infarction

Development and Digitization of the Forms

The principles of the Scrum methodology for agile software development were applied. This is a regularly applied process that includes a set of best practices to work collaboratively in teams and obtain the best possible outcome of projects. It is characterized by a strategy of incremental development, boosting the quality of the result by getting to know people in self-organized teams and matching the different phases of development, rather than doing one after the other in a sequential or cascading cycle [ 14 ]. Through this methodology, an app was developed to gather data. This phase included the following six steps: (1) specifying the forms to be digitized, which contained the questions or variables to be obtained in the field; (2) dividing the various sections of the form into smaller subforms, depending on the size of the questionnaire or the time of application; (3) defining the variables as the simple question-and-answer type or as more complex ones containing calculations, depending on others, or having a different logical flow; (4) building the form on the CommCare platform; (5) generating app versions (eg, test versions); and (6) testing the app with health professionals who simulated data from possible patients and followed the flow of questions within the app to check if the different flows worked correctly; if errors or possible improvements were found during the process, the entire procedure was repeated from step 4.

Ethical Considerations

The Ethics Committee of Universidad Cooperativa de Colombia thoroughly reviewed and approved the research (report 003; April 16, 2018), as did the Fundación Cardiovascular de Colombia ethics committee (report 450; May 22, 2018). The study was carried out in strict adherence to the established protocol, regulatory requirements, Good Clinical Practice, the Declaration of Helsinki, and the clinical investigation guidelines of Universidad Cooperativa de Colombia. All participants provided their informed consent by signing a form. Participation in this study was entirely voluntary, and no financial compensation or reimbursements were offered to the participants.

The information obtained has been securely stored in the archives of the Universidad Cooperativa de Colombia to safeguard the privacy of individuals. Each patient was assigned a code to ensure that their names or identification did not appear in the database. Access to the collected data was restricted to the researchers, and the data will be used exclusively for the study’s intended purposes. Personal information is being protected in compliance with Colombian Law 1581 of 2012, which pertains to the right of “habeas data.”

After repeatedly performing the entire process and correctly digitizing all the forms proposed in advance, the last version of the app (the production version) was generated. The result of the development process was an app that allowed obtaining information using the forms shown in Table 1 .

Table 2 shows the scales and instruments used for the operationalization of the defining characteristics of nursing.

The resulting app allowed the simultaneous collection, data entry, and follow-up of patients in different stages of investigation. Two previously trained nurses conducted a pilot test with the first 11 patients included in the research. Taking into account the inclusion and exclusion criteria, a cardiologist selected potential patients. Subsequently, the patient received an explanation of the study; if they agreed to participate, they provided informed written consent. The information was filled out on tablet-type mobile device. Once the data were collected, a process of sending or synchronizing the data with the database in the cloud was carried out, for which it was necessary to have an internet connection (Wi-Fi network).

a TIMI-RS: thrombolysis in myocardial infarction risk score.

b GRACE: Global Registry of Acute Coronary Events.

Later, the systems engineer reviewed the database obtained through the web platform CommCare, which allows downloading information as a flat file or in spreadsheet format. In this way, the research team verified the correct operation of the app and its use in the field, obtaining positive results that allowed the continuity of the investigation with more patients. Figures 2 - 4 show 3 screenshots of the app.

The pilot test yielded descriptive data (n=11). The participants had an average age of 63.2 (SD 4.0) years, 82% (9/11) were men, and 18% (2/11) had incomplete primary schooling. We found that 64% (7/11) had a history of hypertension and 73% (8/11) had ever smoked. The defining characteristics present in this group of patients were exercise discomfort in 91% (10/11), electrocardiogram abnormalities in 9% (1/10), abnormal heart rate in response to exercise in 20% (2/10), dyspnea in 27% (3/11), weakness in 64% (7/11) and abnormal blood pressure in response to activity in 10% (9/10) ( Table 3 ). The κ agreement index ranged from 73% to 100%.

case study acute myocardial infarction

Principal Findings

We describe the development process of a mobile app for collecting health research data in an easy, agile, and practical way. This strategy may be used for the complete collection of samples in the process of clinical validation of the nursing diagnosis “activity intolerance.” In addition, a good rate of agreement was found among the evaluators thanks to the standardization used in the app.

In recent years there has been an increase in the use of computer technologies to replace paper records by means of mobile apps, web forms, and specialized software; likewise, it has become evident that these are key tools to improve quality in health care [ 22 ]. However, it is still a challenge to continue implementing new strategies, achieve their efficient use by health professionals, and make their implementation easier and more accessible.

This process enabled us to validate the app’s use for identifying prevalent nursing diagnoses, such as activity intolerance, in patients with acute myocardial infarction. Among the 9 defining characteristics we evaluated, there was an agreement of over 80% among the evaluators for 5 of them. This, in turn, helped us identify the most prevalent characteristics, namely dyspnea on exertion and heart rate alteration in response to activity. It is also noteworthy that none of the evaluators identified fatigue in any of the users.

Mobile Apps

We evaluated this strategy for identifying nursing diagnoses that require an objective definition of their characteristics and clinical judgment [ 23 ]. The precise operationalization of the defining characteristics through a predefined registry structure, as seen in this mobile app, enhances the precision of nursing diagnoses [ 1 ]. In this sense, it enables the evaluation of these characteristics, which can improve documentation for nursing staff, thereby aiding in the inference and evaluation of diagnoses [ 2 ]. Therefore, this app aims not only to enhance the quality and safety of care processes but also to promote the adoption of standardized nursing language, addressing the limitations in its use.

Another possible use of this app is in education, where it would potentially help to strengthen the precision of documentation in nursing diagnoses [ 3 ]. This strategy is adapted to current conditions, in which the use of virtual methods and mobile technologies has been shown to be a new basic input for the teaching process, making it necessary for professionals and trainers to make an adequate use of this type of strategy.

A relationship where nurse and patient can contribute to improving administrative processes that benefit others has been described in settings such as outpatient care [ 5 ]. This is expected to contribute to research scenarios that promote improved caregiving. Apps can assist in the assessment and generation of nursing diagnoses in hospital practice [ 24 ], and they have been used in research studies such as clinical trials for the self-management of angina [ 25 ].

Limitations

This work was limited to a specific nursing diagnosis. Future work should include other prevalent diagnoses in patients with cardiac disease. An evaluation of usability among end users could help improve our strategy, and more data is also needed to better specify the large-scale feasibility and cost of this strategy with other nursing diagnoses.

Other aspects to improve in the design of future research are to include scales and instruments used in health care to measure different variables. These sources of information should be updated according to the context, clinical conditions, and even environmental conditions. An additional challenge is the integration of these types of apps to existing health systems. A recent review with the objective to provide an overview of studies that have collected patient data using an app-based approach indicated that using mobile technologies could help to overcome challenges linked with data collection in epidemiological research. However, further feasibility studies need to be conducted to test the applicability and acceptance of these mobile apps for epidemiological research in various subpopulations [ 26 ].

Conclusions

We developed a mobile app for use in the validation process of the nursing diagnosis activity intolerance. This app enabled the evaluation of defining characteristics, which can enhance documentation for nursing staff, facilitate more effective inference and evaluation of diagnoses, and reduce errors in information recording. One significant potential of this app lies in its impact on education, as it aids in improving the precision of nursing diagnosis documentation and, as a result, enhances the quality of care planning.

Data Availability

The data sets generated during and/or analyzed during this study are available in the Mendeley repository [ 27 ].

Conflicts of Interest

None declared.

  • Carrillo G, Mesa Y. La investigación en validación de diagnósticos de enfermería. Rev Cubana Enferm. Sep 1, 2007;23(3):23. [ FREE Full text ]
  • van Dam J, Omondi Onyango K, Midamba B, Groosman N, Hooper N, Spector J, et al. Open-source mobile digital platform for clinical trial data collection in low-resource settings. BMJ Innov. Feb 2017;3(1):26-31. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Style S, Beard BJ, Harris-Fry H, Sengupta A, Jha S, Shrestha BP, et al. Experiences in running a complex electronic data capture system using mobile phones in a large-scale population trial in southern Nepal. Glob Health Action. 2017;10(1):1330858. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Martinez AD, Salazar C. Impacto de las aplicaciones móviles en Colombia a nivel de la salud, educación y trabajo. Fund Univ Católica Lumen Gentium. Feb 19, 2018;1:7. [ FREE Full text ]
  • Martín FA, Marco CG, Antonio SOJ. Evaluation and acreditation of mobile health applications. Rev Esp Salud Publica. Aug 11, 2020;94(1):1-11. [ FREE Full text ]
  • NANDA Internacional. Diagnósticos Enfermeros. Definiciones y Clasificación. 2021-2023. Spain. Elsevier España; Aug 13, 2021;60.
  • CommCare. URL: http://www.commcarehq.org/ [accessed 2020-02-09]
  • Bissi W. Metodologia De Desenvolvimento Ágil. Campo Digit. 2007;2(1):3-6. [ FREE Full text ]
  • Kerwin TC, Leighton H, Buch K, Avezbadalov A, Kianfar H. The effect of adoption of an electronic health record on duplicate testing. Cardiol Res Pract. 2016;2016:1950191. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Rojas Sánchez LZ, Hernández Vargas JA, Trujillo Cáceres SJ, Roa Díaz ZM, Jurado Arenales AM, Toloza Pérez YG. Usefulness of the diagnosis "decreased cardiac output (00029)" in patients with chronic heart failure. Int J Nurs Knowl. Oct 2017;28(4):192-198. [ CrossRef ] [ Medline ]
  • Orozco-Vargas LC. Validez y validación o de cómo construir la validez de un constructo. In: Santander UID, editor. Medición en salud: Diagnóstico y evaluación de resultados. Un manual crítico más allá de lo básico. Bucaramanga, Colombia. División de Publicaciones UIS; 2010;105-114.
  • Paans W, Sermeus W, Nieweg RM, Krijnen WP, van der Schans CP. Do knowledge, knowledge sources and reasoning skills affect the accuracy of nursing diagnoses? a randomised study. BMC Nurs. Aug 01, 2012;11:11. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Facione N, Facione PA. The Health Sciences Reasoning Test. Milbrae, CA. The California Academic Press; 2006.
  • Baraki Z, Girmay F, Kidanu K, Gerensea H, Gezehgne D, Teklay H. A cross sectional study on nursing process implementation and associated factors among nurses working in selected hospitals of Central and Northwest zones, Tigray Region, Ethiopia. BMC Nurs. 2017;16:54. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Guía de práctica clínica para El Síndrome Coronario Agudo. Sistema General de Seguridad Social en Salud, Colombia. 2013. URL: http://gpc.minsalud.gov.co/Documents/Guias-PDF-Recursos/SCA/GPC_Comple_SCA.pdf [accessed 2024-02-08]
  • Bazán Riverón GE, Osorio Guzmán M, Miranda AL, Alcántara Vázquez O, Uribe Ortiz G. Validación del cuestionario breve sobre percepción de la enfermedad (BIPQ) en hipertensos. Revista De Psicología (Trujillo). 2013;15(1):78-91. [ FREE Full text ]
  • Clasificación de insuficiencia cardíaca de la New York Heart Association (NYHA). Manual MSD. URL: https://tinyurl.com/y4re6whn [accessed 2024-02-08]
  • Lamino DDA, Andruciolli de Mattos C, Braga PE, Corrêa de Faria Mota DD. Fadiga clinicamente relevante em mulheres com câncer de mama: prevalência e fatores associados. Investg Enferm Imagen Desarollo. Dec 15, 2014;17(1):157-168. [ CrossRef ]
  • Alahmari KA, Rengaramanujam K, Reddy RS, Samuel PS, Kakaraparthi VN, Ahmad I, et al. Cardiorespiratory fitness as a correlate of cardiovascular, anthropometric, and physical risk factors: using the Ruffier test as a template. Can Respir J. 2020;2020:3407345. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Williams N. The Borg Rating of Perceived Exertion (RPE) scale. Occup Med. Jul 2017;67(5):404-405. [ FREE Full text ] [ CrossRef ]
  • Guía de práctica clínica: Hipertensión arterial primaria (HTA). Vol. 18, Guía No. 18. Ministerio de Salud y Protección Social-Colciencias. 2013. URL: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/INEC/IETS/GPC_Completa_HTA.pdf [accessed 2024-02-08]
  • Lunney M. Critical need to address accuracy of nurses’ diagnoses. Online J Issues Nurs. Jan 31, 2008;13(1). [ FREE Full text ] [ CrossRef ]
  • De Groot K, Sneep EB, Paans W, Francke AL. Patient participation in electronic nursing documentation: an interview study among community nurses. BMC Nurs. May 01, 2021;20(1):72. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Melo EBMD, Primo CC, Romero WG, Sant'Anna HC, Sequeira CADC, Lima EDFA, et al. Construction and validation of a mobile application for development of nursing history and diagnosis. Rev Bras Enferm. 2020;73(suppl 6):e20190674. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Wang W, Chan S, He H. Developing and testing a mobile application programme to support self-management in patients with stable angina: a feasibility study protocol. Stud Health Technol Inform. 2014;201:241-248. [ Medline ]
  • Fischer F, Kleen S. Possibilities, problems, and perspectives of data collection by mobile apps in longitudinal epidemiological studies: scoping review. J Med Internet Res. Jan 22, 2021;23(1):e17691. [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Cáceres D. Using the principles for digital development. Mendeley Data. URL: https://data.mendeley.com/datasets/bn66j567kb/1 [accessed 2024-02-08]

Abbreviations

Edited by A Mavragani; submitted 10.02.23; peer-reviewed by T Behera, J King; comments to author 07.07.23; revised version received 18.10.23; accepted 02.01.24; published 18.03.24.

©Diana Isabel Cáceres Rivera, Luz Mileyde Jaimes Rojas, Lyda Z Rojas, Diana Canon Gomez, David Andrés Castro Ruiz, Luis Alberto López Romero. Originally published in JMIR Formative Research (https://formative.jmir.org), 18.03.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

IMAGES

  1. Mechanical Complications in Acute Myocardial Infarction Acute ...

    case study acute myocardial infarction

  2. (PDF) Management of acute perioperative myocardial infarction: A case

    case study acute myocardial infarction

  3. Acute Myocardial Infarction Clinical Trials

    case study acute myocardial infarction

  4. SOLUTION: Myocardial infarction case study

    case study acute myocardial infarction

  5. (PDF) Risk factors for first-time acute myocardial infarction patients

    case study acute myocardial infarction

  6. Myocardial Infarction: Nursing Care Management and Study Guide

    case study acute myocardial infarction

VIDEO

  1. Case Study || Acute Gastroenteritis

  2. CASE PRESENTATION ON MYOCARDIAL INFARCTION

  3. Myocardial Infarction Case Study Nursing: NCLEX WEDNESDAY Episode 7

COMMENTS

  1. Educational Case: A 57-year-old man with chest pain

    This is an educational case report including multiple choice questions and their answers. ... 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither. the ISIS-2 (second international study of infarct survival) collaborative group ...

  2. A Case Report: Acute Myocardial Infarction in a 29-year-old Male

    A Case Report: Acute Myocardial Infarction in a 29-year-old Male. 2/5/2019 Aaron Tiffee, MD, FACEP , Zariad Saran, DO , Tyler Ingersoll, MS. The HEART score is a go-to tool in assessing the risk of an acute coronary syndrome. But in this case, a score of 3 did not mean the 29-year-old patient was safe. Cardiovascular disease (CVD) is currently ...

  3. Case 4/2014

    Case 4/2014 - A 66-Year-Old Man with Acute Myocardial Infarction and Death in Asystole after Primary Coronary Angioplasty ... acute myocardial infarction involving the left ventricular anterosseptal wall and the right ventricular anterior ... Sudden death risk in overt coronary heart disease: the Framingham Study. Am Heart J. 1987; 113 (3):799 ...

  4. Case 8-2024: A 55-Year-Old Man with Cardiac Arrest, Cardiogenic Shock

    Acute myocardial infarction complicated by cardiogenic shock is defined by a systolic blood pressure of less than 90 mm Hg, end-organ hypoperfusion, and a cardiac index of less than 2.2 liters per ...

  5. Case 6

    A 67-year-old woman sought emergency medical care due to prolonged chest pain. In April 2009 the patient had prolonged chest pain and at that time she sought medical care. She was admitted at the hospital and diagnosed with myocardial infarction. The patient had hypertension, diabetes mellitus, dyslipidemia and was a smoker.

  6. Case report: assessment and management of myocardial infarction and non

    Myocardial infarction with non-obstructive CAD (MINOCA) is clinically defined as acute myocardial infarction in the absence of (≥50% stenosis) obstructive CAD in any artery . The Women's Ischemic Syndrome Evaluation (WISE) study at 10-year follow-up demonstrated that women with no obstructive CAD were at increased risk of death or nonfatal ...

  7. Case Rates, Treatment Approaches, and Outcomes in Acute Myocardial

    Key Points. Question How have case rates, treatment approaches, and in-hospital outcomes changed for patients with acute myocardial infarction (AMI) during the coronavirus disease 2019 (COVID-19) pandemic?. Findings In this cross-sectional study of 15 244 hospitalizations involving 14 724 patients with AMI, case rates began to decrease on February 23, 2020, followed by a modest recovery after ...

  8. Acute Myocardial Infarction

    Since 1987, the adjusted incidence rate of hospitalization for acute myocardial infarction or fatal coronary artery disease in the United States has declined by 4 to 5% per year. 2 Nevertheless ...

  9. Evidence-based nursing care of patient with acute myocardial infarction

    This case study aims to explain and illustrate how to care for patients with acute myocardial infarction based on the rationale and nursing practice evidence underlying the holistic approach.

  10. Risk of acute myocardial infarction and ischaemic stroke following

    Individuals (regardless of COVID-19 status) who had had an acute myocardial infarction previously were excluded from this analysis. The results of the matched cohort study for acute myocardial infarction excluding day 0 are shown in table 2, and including day 0 are shown in the appendix (p 7). The overall number of patients with missing ...

  11. Acute Myocardial Infarction after Laboratory-Confirmed Influenza

    Incidence Ratios for Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection. There were 20 admissions for acute myocardial infarction (20.0 admissions per week) during the risk ...

  12. Acute triggers of myocardial infarction: A case-crossover study

    Background: Acute myocardial infarction (AMI) is one of the most preventable non-communicable diseases in human. Identifying triggers of myocardial infarction (MI) and prevention ways of exposure-induced complications can reduce morbidity and mortality in people at risk. ... Methods: This case-crossover study was conducted on 269 patients with ...

  13. What's new in VA-ECMO for acute myocardial infarction-related

    The predominant cause of CS is acute myocardial infarction (AMICS), occurring in 6-10% of AMI cases, and with persistently high mortality rates of 40-50% despite contemporary revascularization strategies. ... the study used an unvalidated CS definition, was underpowered to evaluate mortality, only 60% of patients had AMICS, and 42% of ...

  14. Paclitaxel-induced acute myocardial infarction: a case report and

    Background Paclitaxel is a chemotherapeutic agent commonly used for ovarian, lung, breast carcinoma, and Kaposi's sarcoma. Its common side effects include hypersensitivity reaction, bone marrow suppression, and peripheral neuropathy. However, a rare and life-threatening side effect is paclitaxel-induced myocardial infarction. Case presentation A 71-year-old man with type 2 diabetes mellitus ...

  15. A case report of myocardial infarction with non-obstructive coronary

    Introduction. Myocardial infarction in the absence of obstructive (>50% stenosis) coronary artery disease (MINOCA) is found in approximately 6% of all patients with acute myocardial infarction (MI) who are referred for coronary angiography. 1, 2 The term MINOCA should be reserved for patients in whom there is an ischaemic basis for their clinical presentation and should be considered a ...

  16. Application of Random Forest Survival Models to Increase

    Application of Random Forest Survival Models to Increase Generalizability of Decision Trees: A Case Study in Acute Myocardial Infarction Comput Math Methods Med. 2015;2015: ... Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman 7616911317, Iran. PMID: 26858773

  17. Myocardial Infarction (MI): Bob Carlson

    Myocardial Infarction (MI): Bob Carlson - Nursing Case Studies by and for Student Nurses. Mr. Bob Carlson is a 59 year old male who came to Ventura County Medical Center (VCMC) with nausea, upper back pain he rated 7/10, and diaphoretic. His vital signs were BP 156/92, HR 90, RR 22 SpO2 90%, and temperature 99.5.

  18. Myocardial Infarction (MI) Case Study (45 min)

    Understanding the risk factors associated with myocardial infarction is vital for prevention and early detection. This case study will examine both modifiable and non-modifiable risk factors, including age, gender, family history, smoking, high blood pressure, diabetes, and high cholesterol levels. Recognizing these risk factors is instrumental ...

  19. Myocardial Infarction in a Neonate with Severe Hypertrophic

    Acute myocardial infarction is a prevalent cardiac emergency that arises as a consequence of coronary artery disease, resulting in a significant number of global fatalities annually [1]. ... which can predispose them to other cardiac conditions such as myocardial infarction (MI). This case report describes the clinical presentation of a ...

  20. Prognostic impact and predictors of persistent renal ...

    Acute kidney injury (AKI) is a frequent complication in patients with acute myocardial infarction (AMI) undergoing primary percutaneous intervention (PCI) compared to those undergoing elective PCI ...

  21. Frontiers

    Myocardial infarc-on (MI) remains a significant global health concern with evolving diagnos-c and therapeu-c approaches. Accurate assessment of myocardial viability is crucial for guiding therapeu-c decisions and predic-ng pa-ent outcomes. While the cardiac MRI (CMR) literature provides insights into assessing viability, exis-ng studies lack the necessary depth to inform prac--oners about the ...

  22. A Case of acute Myocardial Infarction in a Patient with Essential

    In this report, we present a case of a 60-year-old female with a history of ET who developed an acute ST-segment elevation myocardial infarction (STEMI) while on cytoreductive therapy with anagrelide. This patient lacked any cardiovascular risk factors, implying the potential association of anagrelide with the onset of her acute STEMI.

  23. Myocardial Infarction: Nursing Care Management and Study Guide

    Nursing Assessment. One of the most important aspects of care of the patient with MI is the assessment. Assess for chest pain not relieved by rest or medications. Monitor vital signs, especially the blood pressure and pulse rate. Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.

  24. PDF Evidence-based nursing care of patient with acute myocardial infarction

    assessment process. This case study aims to explain and illustrate how to care for patients with acute myocardial infarction based on the rationale and nursing practice evidence underlying the holistic approach. Nurses have been shown to have an essential role in the diagnosis, management, and treatment of acute coronary syndromes.

  25. Acute MI Case Study

    Acute Myocardial Infarction - Page 3 Case continued: Enroute to the ER, the patient's acute symptoms had been relieved by the prompt action of the emergency care personnel. Vital signs had stabilized, his chest pain was relieved by nitroglycerin, and breathing was made easier by the increased oxygen flow.

  26. INTER-HEART: A global study of risk factors for acute myocardial infarction

    Our knowledge of risk factors for acute myocardial infarction (AMI) is largely derived from studies in the former. Applicability of these results to other populations is unknown. The objectives of INTER-HEART are to determine the association between risk factors and AMI within populations defined by ethnicity and/or geographic region and to ...

  27. Acute Myocardial Infarction

    Acute myocardial infarction (AMI) is a life-threatening condition that requires prompt diagnosis and treatment. This book chapter provides a comprehensive overview of the causes, types, diagnosis, management, and complications of AMI, based on the latest evidence and guidelines. Learn from the experts how to optimize the care and outcomes of patients with AMI.

  28. Acute Myocardial Infarction Case Study

    Acute Myocardial Infarction Case Study. Myocardial infarction (heart attack) is the leading cause of death in the United States. It is estimated that one in every five deaths in the US is due to a heart attack. Approximately one million patients are admitted to hospitals each year due to heart attacks. 200,000 to 300,000 individuals die from ...

  29. Myocardial Infarction

    Myocardial infarction (MI), colloquially known as "heart attack," is caused by decreased or complete cessation of blood flow to a portion of the myocardium. Myocardial infarction may be "silent" and go undetected, or it could be a catastrophic event leading to hemodynamic deterioration and sudden death.[1] Most myocardial infarctions are due to underlying coronary artery disease, the ...

  30. JMIR Formative Research

    The agreement level between the 2 evaluating nurses was evaluated with the κ index. Results: We developed a form that included sociodemographic data, hospital admission data, medical history, current pharmacological treatment, and thrombolysis in myocardial infarction risk score (TIMI-RS) and GRACE (Global Registry of Acute Coronary Events ...