Lecture Notes: Myocardial Infarction (MI)
1. Definition
Myocardial Infarction (MI), commonly called a heart attack, is the irreversible necrosis
of heart muscle (myocardium).
Caused by prolonged ischemia due to reduced or complete obstruction of blood flow in
the coronary arteries.
Leads to loss of contractile function and may result in heart failure, arrhythmias, or
sudden death.
2. Etiology / Causes
Atherosclerosis of coronary arteries (most common).
Rupture of an atherosclerotic plaque with subsequent thrombus (blood clot)
formation.
Coronary artery spasm (Prinzmetal’s angina).
Embolism from the left atrium or ventricle.
Rare causes: coronary dissection, trauma, or vasculitis.
3. Pathophysiology
Coronary artery narrowed by plaque → rupture/erosion exposes lipid core → platelet
aggregation + thrombus formation.
Complete or partial occlusion → ↓ blood supply to myocardium.
Within 20–30 minutes: irreversible myocardial cell injury begins.
1–2 hours: coagulative necrosis progresses.
Transmural MI: full thickness of wall affected (STEMI).
Subendocardial MI: inner wall affected, not full thickness (NSTEMI).
Healing leads to scar formation over weeks to months.
4. Epidemiology / Risk Factors
Leading cause of death worldwide.
Risk factors:
o Hypertension, diabetes mellitus, hyperlipidemia.
o Smoking, obesity, sedentary lifestyle.
o Family history of coronary artery disease.
o Male gender and increasing age.
5. Clinical Features
Typical symptoms:
o Severe, crushing chest pain (retrosternal, radiates to left arm, jaw, back).
o Pain lasts >20 minutes, not relieved by rest or nitroglycerin.
o Associated with sweating, nausea, vomiting, anxiety, shortness of breath.
Atypical symptoms (common in elderly, women, diabetics): fatigue, indigestion-like
discomfort, syncope.
Physical exam: tachycardia, hypotension, pallor, weak pulse.
6. Complications
Immediate: arrhythmias (ventricular tachycardia/fibrillation), cardiogenic shock, acute
left ventricular failure, cardiac arrest.
Early (days): pericarditis, mural thrombus, extension of infarct.
Late (weeks–months): ventricular aneurysm, chronic heart failure, recurrent MI.
7. Diagnosis
Clinical history + ECG + cardiac biomarkers = gold standard.
ECG:
o STEMI: ST-segment elevation, pathological Q waves, T-wave inversion.
o NSTEMI: ST depression or T-wave changes.
Cardiac biomarkers:
o Troponin I/T → most specific, rises 3–6 hrs, peaks 24 hrs, stays elevated 7–10
days.
o CK-MB → rises 4–6 hrs, peaks 18–24 hrs, returns to normal in 2–3 days.
Imaging: echocardiography (wall motion abnormalities), coronary angiography.
8. Management
a. Emergency/Initial Management (MONA protocol):
Morphine → pain relief & anxiety reduction.
Oxygen → if hypoxemic.
Nitrates → vasodilation, reduces workload of heart.
Aspirin → antiplatelet to prevent further clot formation.
b. Definitive Management:
Reperfusion therapy:
o Thrombolysis (tPA, streptokinase) → dissolve clot.
o Percutaneous Coronary Intervention (PCI) → balloon angioplasty & stent
placement.
Adjunct medications:
o Beta-blockers, ACE inhibitors, statins, anticoagulants (heparin).
c. Long-term Management:
Lifestyle modifications: diet, exercise, stop smoking.
Secondary prevention: aspirin, statins, beta-blockers, ACE inhibitors for life.
9. Prognosis
Mortality highest in the first 24 hours (mainly due to arrhythmias).
Early reperfusion greatly improves survival.
Prognosis depends on infarct size, location, and speed of treatment.
10. Key Exam Points
Definition: irreversible myocardial necrosis due to ischemia.
Risk factors: hypertension, diabetes, smoking.
Diagnosis: ECG changes + elevated troponin.
Complications: arrhythmia, shock, ventricular aneurysm.
Management: MONA, reperfusion (PCI/thrombolysis), secondary prevention.
