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complications of myocardial infarction

Complications: 1) mortality from MI is greatest within the 1st 2 hours 2) left ventricular infarction a) occurs 2-7 days after MI b) congestive heart failure c) cardiogenic shock - intra-aortic balloon pump +/- left ventricular assist device - emergency revascularization d) pulmonary edema e) hepatic congestion from right heart failure f) myocardial rupture - generally occurs after 3-7 days, but may occur later - interventricular septum - ventricular septal defect (10%) - stabilize with intra-aortic balloon pump - afterload reduction with nitroprusside, diuretics - surgical emergency [1] - left ventricular free wall (85%) - pericardial effusion [1] - pulseless electrical activity, sudden death - surgical emergency [1] g) left ventricular aneurysm h) myocardial pump failure general occurs with large anterior wall MI i) rupture of papillary muscle (5%) - most common complication of inferior wall MI resulting in cardiogenic shock - generally occurs after 3-7 days, but may occur later - mitral regurgitation - loud holosystolic murmur, thrill - diastolic rumble in cases of large regurgitant volume [1] - murmur may be faint or inaudible with complete papillary muscle rupture - elevated pulmonary capillary wedge pressure with large V waves - normal right atrial pressure - pulmonary edema - stabilize with intra-aortic balloon pump - afterload reduction with nitroprusside, diuretics - emergency cardiac surgery [1] j) evaluate with emergent echocardiography 3) cardiac arrhythmias a) ventricular arrhythmias most lethal - sustained ventricular arrhythmias early post-infarction are predictive of recurrent arrhythmias & 1-year mortality [13] - premature ventricular depolarizations - ventricular tachycardia (VT) - ventricular fibrillation (VF) - accelerated idioventricular rhythm (AIVR) b) supraventricular arrhythmias - sinus tachycardia - paroxysmal supraventricular tachycardia (PSVT) - atrial fibrillation (AF) - excess risk of death is highest for AF developing > 30 days after MI [6] - atrial flutter c) bradyarrhythmias - sinus bradycardia - AV block - temporary cardiac pacing if indicated - delay insertion of a permanent pacemaker for several days to determine if heart block is transient or permanent [1] 4) pericarditis a) acute pericarditis - results from transmural infarction & irritation of the pericardium - may occur within a few days of myocardial infarction (2 days [12]) b) Dressler's syndrome 2-10 weeks post MI c) non-acetylated salicylate is treatment of choice; avoid NSAIDs (with anti-platelet activity) 5) thromboembolism - intracardiac thrombus occurs in 40% of patients with anterior wall MI - systemic thromboembolism occurs in 50% of patients with anterior wall MI 6) right ventricular infarction - occurs in 40% of patients with inferior wall MI - jugular venous distension - clear lung fields 7) recurrent myocardial infarction [1] - risk about 10% in the 1st year - peak incidence within 1st 6 weeks - 4-6 weeks necessary for myocardium & ruptured coronary plaque to heal - life time risk of 2nd MI is 50% [2] 8) renal disease associated higher risk of death after MI [3] - small increase in serum creatinine during hospitalization for MI associated with increased risk of ESRD & death [5,7] 9) depression increases risk of adverse outcomes [4] - 20% of patients hospitalized with acute MI - sexual dysfunction common among young adults after MI - 73% of young women & 85% of men sexually active after MI - 59% of women & 46% at least 1 sexual problem 10) women treated with fibrinolytic therapy, antiplatelet agents, or anticoagulation have a higher risk of bleeding complications than men [1] 11) 30 day rehospitalization 19%; 43% of these related to incident MI [8]

Related

myocardial infarction (MI); heart attack

Specific

Dressler's syndrome. post MI syndrome, postcardiac injury syndrome (PCIS) ventricular septal rupture

General

complication heart disease (cardiac disease)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Prescriber's Letter 9(12):68 2002 (subscription needed) http://www.prescribersletter.com
  3. Journal Watch 22(23):173, 2002 Shlipack MG et al Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients. Ann Intern Med 137:555, 2002 PMID: 12353942 - Wright RS et al Acute myocardial infarction and renal dysfunction: a high-risk combination. Ann Intern Med 137:563, 2002 PMID: 12353943 - Townsend RR Cardiac mortality in chronic kidney disease: a clearer perspective. Ann Intern Imed 137:615, 2002 PMID: 12353950
  4. Parashar S et al, for Premier Registry Investigators Time Course of depression and outcome of myocardial infarction. rch Intern Med 2006, 166:2035 PMID: 17030839
  5. Newsome BB, Warnock DG, McClellan WM, Herzog CA et al Long-term Risk of Mortality and End-Stage Renal Disease Among the Elderly After Small Increases in Serum Creatinine Level During Hospitalization for Acute Myocardial Infarction. Arch Intern Med. 2008 Mar 24;168(6):609-16. PMID: 18362253
  6. Jabre P et al. Atrial fibrillation and death after myocardial infarction: A community study. Circulation 2011 May 17; 123:2094. PMID: 21536994
  7. Fox CS et al. Short-term outcomes of acute myocardial infarction in patients with acute kidney injury: A report from the National Cardiovascular Data Registry. Circulation 2012 Jan 24; 125:497 PMID: 22179533
  8. Dunlay SM et al. Thirty-day rehospitalizations after acute myocardial infarction: A cohort study. Ann Intern Med 2012 Jul 3; 157:11 PMID: 22751756
  9. Lindau ST, Abramsohn E, Bueno H Sexual Activity and Function in the Year After an Acute Myocardial Infarction Among Younger Women and Men in the United States and Spain. JAMA Cardiol. Published online August 31, 2016 PMID: 27579897 http://cardiology.jamanetwork.com/article.aspx?articleid=2546890 - Weinfurt KP The Need to Improve Care and Research on Sexual Functioning in Cardiology. JAMA Cardiol. Published online August 31, 2016 PMID: 27579794 http://cardiology.jamanetwork.com/article.aspx?articleid=2546889
  10. Lopez-Sendon J, Gurfinkel EP, Lopez de Sa E Factors related to heart rupture in acute coronary syndromes in the Global Registry of Acute Coronary Events. Eur Heart J. 2010 Jun;31(12):1449-56. Epub 2010 Mar 15. PMID: 20231153
  11. Kutty RS, Jones N, Moorjani N. Mechanical complications of acute myocardial infarction. Cardiol Clin. 2013 Nov;31(4):519-31, vii-viii. Review. PMID: 24188218
  12. NEJM Knowledge+
  13. Echivard M, Sellal JM, Ziliox C et al Prognostic value of ventricular arrhythmia in early post-infarction left ventricular dysfunction: the French nationwide WICD-MI study. Eur Heart J. 2024 Sep 20:ehae575. PMID: 39299922 https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehae575/7762185