Diagnosis of myocardial infarction

A diagnosis of myocardial infarction is created by integrating the history of the presenting illness and physical examination with

According to the WHO criteria as revised in 2000,[6] a cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression or coronary intervention are diagnostic of MI.

Previous WHO criteria^[7] formulated in 1979 put less emphasis on cardiac biomarkers; according to these, a patient is diagnosed with myocardial infarction if two (probable) or three (definite) of the following criteria are satisfied:

1. Clinical history of ischaemic type chest pain lasting for more than 20 minutes
2. Changes in serial ECG tracings
3. Rise and fall of serum cardiac biomarkers such as creatine kinase-MB fraction and troponin

Physical examination

The general appearance of patients may vary according to the experienced symptoms; the patient may be comfortable, or restless and in severe distress with an increased

The primary purpose of the

The 12 lead ECG is used to classify patients into one of three groups:[11]

1. those with
   ST segment elevation or new bundle branch block (suspicious for acute injury and a possible candidate for acute reperfusion therapy with thrombolytics or primary PCI
   ),
2. those with ST segment depression or T wave inversion (suspicious for ischemia), and
3. those with a so-called non-diagnostic or normal ECG.

A normal ECG does not rule out acute myocardial infarction. Mistakes in interpretation are relatively common, and the failure to identify high risk features has a negative effect on the quality of patient care.[12]

It should be determined if a person is at high risk for myocardial infarction before conducting imaging tests to make a diagnosis.^[13] People who have a normal ECG and who are able to exercise, for example, do not merit routine imaging.^[13] Imaging tests such as stress radionuclide myocardial perfusion imaging or stress echocardiography can confirm a diagnosis when a person's history, physical exam, ECG and cardiac biomarkers suggest the likelihood of a problem.^[13]

Cardiac markers

Cardiac markers or cardiac enzymes are proteins that leak out of injured myocardial cells through their damaged cell membranes into the bloodstream. Until the 1980s, the enzymes SGOT and LDH were used to assess cardiac injury. Now, the markers most widely used in detection of MI are MB subtype of the enzyme creatine kinase and cardiac troponins T and I as they are more specific for myocardial injury. The cardiac troponins T and I which are released within 4–6 hours of an attack of MI and remain elevated for up to 2 weeks, have nearly complete tissue specificity and are now the preferred markers for assessing myocardial damage.^[14] Heart-type fatty acid binding protein is another marker, used in some home test kits. Elevated troponins in the setting of chest pain may accurately predict a high likelihood of a myocardial infarction in the near future.^[15] New markers such as glycogen phosphorylase isoenzyme BB are under investigation.^[16] Note that only the cardiac troponins are used clinically for myocardial infarction as creatine kinase adds little value in diagnosing MI while adding to system cost.^[17][18][19]

The diagnosis of myocardial infarction requires two out of three components (history, ECG, and enzymes). When damage to the heart occurs, levels of cardiac markers rise over time, which is why blood tests for them are taken over a 24-hour period. Because these enzyme levels are not elevated immediately following a heart attack, patients presenting with chest pain are generally treated with the assumption that a myocardial infarction has occurred and then evaluated for a more precise diagnosis.^[20]

Angiography

In difficult cases or in situations where intervention to restore blood flow is appropriate, coronary angiography can be performed. A catheter is inserted into an artery (typically the radial or femoral artery^[21]) and pushed to the vessels supplying the heart. A radio-opaque dye is administered through the catheter and a sequence of x-rays (fluoroscopy) is performed. Obstructed or narrowed arteries can be identified, and angioplasty applied as a therapeutic measure (see below). Angioplasty requires extensive skill, especially in emergency settings. It is performed by a physician trained in interventional cardiology.^{[citation needed]}

Histopathology

• 
  A one-week-old myocardial infarction of the posterior left ventricle, with focal rupture, in fresh state (left) and after formalin fixation (right). The infarcted area is pale whereas the rupture is hemorrhagic (dark red).
• 
  Cross-section of the heart, showing an old myocardial infarction of the posterior wall of the left ventricle (seen as pale areas).

Under the microscope, myocardial infarction presents as a circumscribed area of ischemic, coagulative necrosis (cell death). On gross examination, the infarct is not identifiable within the first 12 hours.^[22]

Although earlier changes can be discerned using

These features can be recognized in cases where the perfusion was not restored; reperfused infarcts can have other hallmarks, such as contraction band necrosis.^[25]

These tables gives an overview of the histopathology seen in myocardial infarction by time after obstruction.^{[citation needed]}

By individual parameters

Myocardial histologic parameters (HE staining)[26]	Earliest manifestation[26]	Full development[26]	Decrease/disappearance[26]	Image
Stretched/wavy fibres	1–2 h
cytoplasmic hypereosinophilia	1–3 h	1–3 days; cytoplasmic hypereosinophilia and loss of striations	> 3 days: disintegration
Interstitial edema	4–12 h
Coagulative necrosis: 'nuclear changes'	12–24 (pyknosis, karyorrhexis)	1–3 days (loss of nuclei)	Depends on size of infarction
Neutrophil infiltration	12–24 h	1–3 days	5–7 days
Karyorrhexis of neutrophils	1.5–2 days	3–5 days
Macrophages and lymphocytes	3–5 days	5–10 days (including 'siderophages')	10 days to 2 months
Vessel/endothelial sprouts*	5–10 days	10 days–4 weeks	4 weeks: disappearance of capillaries; some large dilated vessels persist
Fibroblast and young collagen*	5–10 days	2–4 weeks	After 4 weeks; depends on size of infarction;
Dense fibrosis	4 weeks	2–3 months	No

• Some authors summarize the vascular and early fibrotic changes as 'granulation tissue', which is maximal at 2–3 weeks

Differential diagnoses for myocardial fibrosis:

• Interstitial fibrosis, which is nonspecific, having been described in congestive heart failure, hypertension, and normal aging.^[27]
• Subepicardial fibrosis, which is associated with non-infarction diagnoses such as myocarditis^[28] and non-ischemic cardiomyopathy.^[29]

• 
  Healthy myocardium versus interstitial fibrosis in dilated cardiomyopathy. Alcian blue stain.
• 
  Subepicardial fibrosis (epicardium at top)

Chronological

See also

• Myocardial infarction management
• Myocardial infarction complications

Notes

References