ST elevation myocardial infarction triggers
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| Myocardial infarction Classification and external resources | |
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| The sudden death of Tim Russert has prompted interest in the triggers of an MI | |
| ICD-10 | I21.-I22. |
| ICD-9 | 410 |
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 Discuss ST elevation myocardial infarction triggers further in the WikiDoc Cardiology Network |
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Following the sudden death of Tim Russert of NBC's Meet the Press on June 13th 2008, many laypeople and physicians alike have asked "what are the triggers of a sudden heart attack"? Barbara Walters speculated that Tim Russert may have died from "the stress of the job". Others were concerned about a recent weight gain and lack of sleep. This chapter reviews the literature pertaining to triggers of acute MI.
Overview
Several factors have been associated with an increased risk of developing ST elevation myocardial infarction (STEMI). These factors include physical exertion, psychological stress, sexual activity, diurnal (daily) variations in cortisol and platelet aggregation and circannual (yearly) variations in lipids and infectious etiologies, exposure to pollution and or particulate matter, cocaine and ingestion of a recent fatty meal.
Nomenclature
Muller et al have developed the following nomenclature to categorize and analyze data pertaining to triggers of MI [1]:
- (1) Trigger: An activity that produces short-term physiological changes that may lead directly to onset of acute CVD.
- (2) Acute risk factor: A short-term physiological change, such as a surge in arterial pressure or heart rate, an increase in coagulability, or vasoconstriction, that follows a trigger and may result in disease onset.
- (3) Hazard period: The time interval after trigger initiation associated with an increased risk of disease onset because of the trigger. The onset and offset times of the hazard period, which could also be designated a “vulnerable period,” may be sharply defined, as in heavy exertion, or less well defined, as with respiratory infection. The duration of the hazard period may also vary, eg from < 1 hour during heavy physical exertion to weeks or months with bereavement.
- (4) Triggered acute risk prevention (TARP): Cardiovascular risk reduction that focuses on the short-term increase in risk associated with a trigger.
Putting Relative Risk of MI and Absolute Risk of MI Into Clinical Context
In the following sections, you will read that certain triggers are associated with a dramatic rise in the relative risk of having an MI (e.g. heavy exertion among patients with a sedentary lifestyle increases their risk of an MI 107 fold). These dramatic increases in relative risk, must, however, be placed in the appropriate clinical context.
It must be born in mind that while triggers are frequent events, MI or sudden death are relatively infrequent events. The risk of sudden death with exercise provides a nice example. The relative risk of sudden death within 30 minutes after >/= 6 METS of exercise goes up 16.9 fold. However, because sudden death is so infrequent, this translates into 1 sudden cardiac death for every 1.51 million episodes of heavy exertion. [2] The number of absolute events is even lower among nurses in the Nurses Health Study undertaking mild to meoderate exertion: 1 sudden death for every 36.5 hours of exertion. [3]
While the presence of triggers increases the relative risk of MI dramatically, the absolute number of MIs attributable to the trigger may be quite low.
A dramatic rise in the relative risk of a very, very, very infrequent event therefore translates clinically into a very small rise in the absolute number of events attributable to the trigger.
Differential Diagnosis of Underlying Causes and Triggers of ST Segment Elevation in the Presence of Myonecrosis (STEMI)
While plaque rupture is the most common cause of ST segment elevation MI, other conditions can cause ST elevation and myocardial necrosis. In order to expeditiously treat an alternate underlying cause of myonecrosis, it is important to rpadily identify conditions other than plaque rupture that may also cause ST elevation and myonecrosis. Indeed, the management of some of these conditions might be differ substantially from that of plaque rupture: cocaine induced STEMI would not be treated with beta-blockers, and myocardial contusion would not be treated with an antithrombin. These conditions include the following:
| Cardiovascular | Aortic dissection more often extends to occlude the ostium of the right coronary artery
Aortic stenosis can cause subendocardial ischemia and infarction if demand grossly exceeds supply
|
| Chemical / poisoning | Carbon monoxide poisoning |
| Dermatologic | No underlying causes |
| Drug Side Effect | Oral contraceptive pills, particularly among women who smoke |
| Ear Nose Throat | A recent upper respiratory tract infections has been associated with a 4.9 fold rise in the risk of MI |
| Endocrine | Thyrotoxicosis |
| Environmental | Blizzards and snow shoveling, and inhalation of fine particulate matter in areas with air pollution and high traffic have been identified as triggers of MI. |
| Gastroenterologic | A heavy meal has been associated with a 4 fold rise in the risk of MI, and it is not clear if this is mediated by hyperadrenergic tone [4]; |
| Genetic | Familial hypercholesterolemia |
| Hematologic | Disseminated intravascular coagulation (DIC) |
| Iatrogenic | Epinephrine overdose
Sudden withdrawal of Beta blockers or nitrates |
| Infectious Disease | A recent upper respiratory tract infections has been associated with a 4.9 fold rise in the risk of MI
Infectious endocarditis may STEMI as a result of embolization |
| Musculoskeletal / Ortho | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional / Metabolic | A heavy meal has been associated with a 4 fold rise in the risk of MI and it is not clear if this is mediated by hyperadrenergic tone[5];
Mucopolysaccharidoses or Hurler disease Thiamine deficiency has been associated with ST elevation and myonecrosis [6][7][8] |
| Obstetric/Gynecologic | Spontaneous coronary dissection in the setting of pregnancy |
| Oncologic | Radiation therapy can accelerate atherosclerosis particularly in the distribution of the left anterior descending artery; |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | Cocaine ingestion which may result in direct myocyte injury due to an adrendergic surge, vasoconstriction of the microvasculature or plaque rupture and thrombus formation;
Marijuana ingestion has been identified as a trigger of MI. |
| Psychiatric | Anger, anxiety, bereavement, work-related stress, earthquakes, bombings and other psychosocial stressors have been identified as triggers of MI, and it is not clear if the mechanism is plaque rupture or hyperadrenergic tone;
Stress cardiomyopathy or Broken heart syndrome causes ST segment elevation most often in the anterior precordium and is thought to be due to direct myocyte injury from a hyperadrenergic stimulation emanating from the central nervous system. |
| Pulmonary | A recent upper respiratory tract infections has been associated with a 4.9 fold rise in the risk of MI |
| Renal / Electrolyte | Homocystinuria |
| Rheum / Immune / Allergy | Takayasus |
| Sexual | Sexual activity has been identified as a trigger of MI |
| Trauma | Both penetrating and non-penetrating trauma to the heart or myocardial contusion, commotio cordis can be associated with ST elevation and myonecrosis. |
| Urologic | No underlying causes |
| Miscellaneous | Hypotension particularly if it is prolonged |
Physical Exertion and MI
Physical exertion, especially if the exertion is much more intense than the individual usually performs has been associated with the onset of STEMI. [9][10][11] [12] [13][2][3][14] The ONSET study demonstrated that intense exertion (defined as >/= 6 metabloic equivalents of METS) within the previous hour was associated with a 5.9 fold rise in the risk of MI [11].
Studies Linking Physical Exertion to MI
Blizzards have often been cited as a trigger of MI, and the physical exertion of snow shoveling has frequently been cited as a contributor. [15] [16]
Impact of a Sedentary Lifestyle
The relative risk of MI quoted above increases dramatically among those individuals who lead a sedentary lifestyle. For those in poor physical condition, the relative risk was 107 fold higher in the ONSET study. In contrast, among those individuals who reported that they engaged in physical activity 5 days a week or more, the risk was only doubled.
Mechanism
It has been hypothesized that exertion increases blood pressure, pulse and oscillatory shear which in turn may increase the risk of plaque rupture.
Physical Exertion and Sudden Death
While the above discussion pertains to documented nonfatal MI, approximately a quarter of MI patients may die of sudden death or fatal MI before reaching the hospital. In a cohort of 21,481 male physicians in the United States who by self report who had no prior history of coronary artery disease, there was a 16.9 fold rise in the risk of sudden cardiac death within 30 minutes of intense exertion (>/= 6 METS). [2] Similar to what has been reported with respect to the onset of MI, there was no increase in the risk of sudden death with heavy exertion among those nurses who exercised more than 2 hours per week.
Psychological Stress
Psychological stress associated with anger [17], work related stressful events [18], wartime bombing [19] [20] , earthquakes [21] and other natural disasters has been associated with an increased risk of onset of myocardial infarction.
Anger
Intense anger (fist / teeth clenched) has been associated with a risk in the risk of MI in the 2 hours following the episode in the following studies:
ONSET: 2.3 fold rise [17]
SHEEP: 9 fold rise [22]
Kotton et al: 14 fold rise [23]
The psychosocial stressors that precipitated the anger were as follows:
- Argument with family members (25%)
- Conflicts at work (22%)
- Legal problems (8%)
Anxiety
If a patient is in the >75th percentile for anxiety, this increases the relative risk of MI 1.6 fold for the 2 hours following the period of anxiety. [17]
Bereavement and the Broken Heart Syndrome
Stress cardiomyopathy which is also known as Left Ventricular Apical Ballooning Syndrome, Takotsubo cardiomyopathy, or Ampulla-Shaped Cardiomyopathy is a cardiac syndrome characterized by a reversible transient apical ventricular dysfunction. Since the cardiomyopathy is often triggered by emotional stress, such as the death of a loved one, the condition is sometimes also referred to as the Broken Heart Syndrome. In 2006, the syndrome was renamed Stress Cardiomyopathy, and was classified as an acquired cardiomyopathy. [24]
The typical presentation of someone with takotsubo cardiomyopathy is a sudden onset of congestive heart failure or chest pain associated with EKG changes suggestive of an anterior wall acute MI. During the course of evaluation of the patient, a bulging out of the left ventricular apex with a hypercontractile base of the left ventricle is often noted. It is the hallmark bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus trap in Japan, where it was first described. Evaluation of individuals with takotsubo cardiomyopathy typically include a coronary angiogram, which does not reveal any significant blockages that would cause the left ventricular dysfunction. Provided that the individual survives their initial presentation, the left ventricular function improves within days to weeks.[25] Takotsubo cardiomyopathy is more commonly seen in post-menopausal women.[26] Often there is a history of a recent severe emotional or physical stress.[26]
Work Related Stress
Deadlines
An agressive timeline or deadline at work has been associated with a rise in the risk of MI:
The SHEEP study: 6 fold rise
The ONSET study: 2.3 fold rise
Firing an Employee
The stress of firing an employee has been associated with a rise in the risk of MI:
The ONSET study: 2.2 fold rise
Natural Disasters
Natural disasters have been associated with an increased risk of MI. The best documented association has been with earthquakes. For instance the 1994 earthquake in Los Angeles was associated with a 4 fold rise in the risk of sudden death and a 35% rise in the relative risk of a non-fatal MI. [27] [28] It is notable that the association of earthquakes with MI is variable depending upon the time of day that the earthquake occurs. The LA eathquake occurred just after 4 A.M., just when platelet aggregation may be at a peak (see below). However, the earthquake that struck San Francisco Bay in 1989 at 5 P.M. was not associated with an increased risk of MI. [29]
Wartime Stress and Missile Attacks
9/11/2001
Within 50 miles of the world trade center, there was a 49% increase in the relative risk of an MI in the 60 days following the 9/11 attack: There were 118 MIs in the 60 days after the attack versus 79 MIs in the 60 days before (p=0.01). How much of this is attributable to particulate matter versus psychological stress is not clear. [30]
Missile Attacks
The stress of missile attacks has been associated with a doubling in the risk of non fatal MI and sudden death. [31]
Sporting Events
The stress of sporting events has been associated with an increased risk of MI in a population. An example that has been cited is the 50% increase in the risk of MI or stroke among Dutch men associated with the loss of Holland to France in the 1996 European football finals. It is notable that no such rise in risk was observed among Dutch women or the French. [32] [33]
Sexual Activity
The association of sexual activity with the onset of MI may represent components of physical exertion as well as psychologic stress. In both the SHEEP and the ONSET studies, recent sexual activity increased the risk of MI by 2.5 fold. [34][35] Again, to place this relative risk into clinical context, it should be noted that only 3% of MI patients had had sexual intercourse within the past 2 hours prior to the onset of MI. It should also be noted that the increase in risk of MI with sexual activity did not differ between patients with and without a history of coronary artery disease.
The risk of MI with sexual intercourse is a frequent concern among patients who have coronary artery disease. Again, the data above indicates that recent sexual activity doubles the risk of an MI, and this may on the surface appear to be disconcerting to both a patient and healthcare professional. But again, to place this relative risk into context, the absolute risk must be taken into account. The average risk of an MI in a patient at average risk has been estimated to be about 1 chance in a million during any given hour during middle age. Sexual activity increases that risk to 2 in a million per hour for the 2 hours after sexual intercourse. If the annual risk of MI is about 1%, weekly sexual intercourse will increase this annual risk to just 1.01%. [36] As is the case with physical exertion, regular exercise (6 METS >/= 3 times per week) reduced the relative risk of MI with sexual intercourse from 3.0 to 1.2 in the ONSET study.[34]
Thus, because the risk is small, because the frequency of sexual activity is relatively small, and because the period of increased risk is short (approximately 2 hours) the absolute risk of MI associated with sexual intercourse is quite small.
Air Pollution / Fine Particulate Matter
Exposure to high levels of ambeint air pollution (exposure to fine particulate matter in the past 2 - 24 hours) has been associated with a transient elevation in the risk of myocardial infarction [37]. There is a rise in CRP and plasma viscosity following exposure to fine particulate matter and it has been speculated that the pulmonary inflammation that follows such exposure may trigger a systemic state of hypercoagulability [38][39]. Exposure to fine particulate matter has also been associated with changes in autonomic tone manifested by sinus tachycardia [40] [41], as well as a reduction in heart rate variability [42] [43] [44]. Finally, ventricular arrhythmias as manifested by firing of AICDs has been associated with exposure to fine particulate matter [45].
Antecedent Infection
Acute severe infection, such as pneumonia, can trigger myocardial infarction [46]. A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis.[47] While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor.[47] Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.[48]
A Heavy Meal
There have been reports of a 4 fold rise in the risk of MI following a heavy meal. [5]
This rise in risk may account for a second peak in the circadian variation in the onset of MI around 8 P.M. in the evening. The mechanism underlying the association is not clear. It has been speculated that ingestion of a heavy fatty meal may be associated with a rise in prothrombotic factors and heart rate, and a reduction in vascular reactivity. [49] [50]
Cocaine
Ingestion of cocaine has been associated with STEMI [51].
Marijuana
Marijuana use has been associated with a 4.8 fold rise in the risk of MI. [52]
Circadian Variation in Onset of STEMI
Most MIs occur in the early morning hours when cortisol and adrenaline rise and platelets are more activated. This diurnal variation is obliterated with aspirin therapy, pointing to the putative role of platelets in the initiation of MI. [53] [54] [55] [56] [57] [58] [59]
Relative Frequency of Triggers in Association with MI
When a creful history is obtained, approximately half (48%) of MI patients will report a trigger [60]. It is notable that 13% of patients will report that there were of 2 or more triggers. The following triggers were most commonly associated with the onset of MI in the Multicenter Investigation of Limitation of Infarct Size (MILIS) study [60].:
- Emotional upset (18%)
- Moderate physical activity (14%)
- Heavy physical activity (9%)
- Lack of sleep (8%)
- Overeating (7%)
Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [61]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [62]
References
- ↑ Muller JE, Abela GS, Nesto RW, Tofler GH (March 1994). "Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier". J. Am. Coll. Cardiol. 23 (3): 809–13. PMID 8113568.
- ↑ 2.0 2.1 2.2 Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE (November 2000). "Triggering of sudden death from cardiac causes by vigorous exertion". N. Engl. J. Med. 343 (19): 1355–61. PMID 11070099.
- ↑ 3.0 3.1 Whang W, Manson JE, Hu FB, et al (March 2006). "Physical exertion, exercise, and sudden cardiac death in women". JAMA 295 (12): 1399–403. doi:10.1001/jama.295.12.1399. PMID 16551711.
- ↑ Lipovetsky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS. Heavy meals as a trigger for a first event of the acute coronary syndrome:a case-crossover study. Isr Med Assoc J. 2004;6:728 –731.
- ↑ 5.0 5.1 Lipovetzky N, Hod H, Roth A, Kishon Y, Sclarovsky S, Green MS (December 2004). "Heavy meals as a trigger for a first event of the acute coronary syndrome: a case-crossover study". Isr. Med. Assoc. J. 6 (12): 728–31. PMID 15609883.
- ↑ Kawano H, Koide Y, Toda G, Yano K (June 2005). "ST-segment elevation of electrocardiogram in a patient with Shoshin beriberi". Intern. Med. 44 (6): 578–85. PMID 16020883.
- ↑ Hundley JM, Ashburn LL, Sebrell WH. The electrocardiogram in chronic thiamine deficiency in rats. Am J Physiol 144: 404–414, 1954.
- ↑ Read DH, Harrington DD (June 1981). "Experimentally induced thiamine deficiency in beagle dogs: clinical observations". Am. J. Vet. Res. 42 (6): 984–91. PMID 7197132.
- ↑ 9.0 9.1 Willich SN, Lewis M, Löwel H, Arntz HR, Schubert F, Schröder R (December 1993). "Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group". N. Engl. J. Med. 329 (23): 1684–90. PMID 8232457.
- ↑ Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB (May 1998). "Prediction of coronary heart disease using risk factor categories". Circulation 97 (18): 1837–47. PMID 9603539.
- ↑ 11.0 11.1 11.2 Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE (December 1993). "Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators". N. Engl. J. Med. 329 (23): 1677–83. PMID 8232456.
- ↑ 12.0 12.1 Hallqvist J, Möller J, Ahlbom A, Diderichsen F, Reuterwall C, de Faire U (March 2000). "Does heavy physical exertion trigger myocardial infarction? A case-crossover analysis nested in a population-based case-referent study". Am. J. Epidemiol. 151 (5): 459–67. PMID 10707914.
- ↑ Giri S, Thompson PD, Kiernan FJ, et al (November 1999). "Clinical and angiographic characteristics of exertion-related acute myocardial infarction". JAMA 282 (18): 1731–6. PMID 10568645.
- ↑ Siscovick DS, Weiss NS, Fletcher RH, Lasky T (October 1984). "The incidence of primary cardiac arrest during vigorous exercise". N. Engl. J. Med. 311 (14): 874–7. PMID 6472399.
- ↑ Glass RI, Zack MM (March 1979). "Increase in deaths from ischaemic heart-disease after blizzards". Lancet 1 (8114): 485–7. PMID 85066.
- ↑ Franklin BA, Bonzheim K, Gordon S, Timmis GC (April 1996). "Snow shoveling: a trigger for acute myocardial infarction and sudden coronary death". Am. J. Cardiol. 77 (10): 855–8. doi:10.1016/S0002-9149(97)89181-3. PMID 8623739.
- ↑ 17.0 17.1 17.2 Mittleman MA, Maclure M, Sherwood JB, et al (October 1995). "Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators". Circulation 92 (7): 1720–5. PMID 7671353.
- ↑ Möller J, Theorell T, de Faire U, Ahlbom A, Hallqvist J (January 2005). "Work related stressful life events and the risk of myocardial infarction. Case-control and case-crossover analyses within the Stockholm heart epidemiology programme (SHEEP)". J Epidemiol Community Health 59 (1): 23–30. doi:10.1136/jech.2003.019349. PMID 15598722.
- ↑ Johnston SC, Sorel ME, Sidney S (November 2002). "Effects of the September 11th attacks on urgent and emergent medical evaluations in a Northern California managed care plan". Am. J. Med. 113 (7): 556–62. PMID 12459401.
- ↑ Vukovic DS, Krotin ME, Babic MM, Zivanovic BM (2005). "Anxiety level and responses to stress caused by air raids among patients with ischemic heart disease". Prehosp Disaster Med 20 (4): 249–52. PMID 16128473.
- ↑ Trichopoulos D, Katsouyanni K, Zavitsanos X, Tzonou A, Dalla-Vorgia P (February 1983). "Psychological stress and fatal heart attack: the Athens (1981) earthquake natural experiment". Lancet 1 (8322): 441–4. PMID 6131167.
- ↑ Möller J, Hallqvist J, Diderichsen F, Theorell T, Reuterwall C, Ahlbom A (1999). "Do episodes of anger trigger myocardial infarction? A case-crossover analysis in the Stockholm Heart Epidemiology Program (SHEEP)". Psychosom Med 61 (6): 842–9. PMID 10593637.
- ↑ Koton S, Tanne D, Bornstein NM, Green MS (December 2004). "Triggering risk factors for ischemic stroke: a case-crossover study". Neurology 63 (11): 2006–10. PMID 15596741.
- ↑ Maron BJ, Towbin JA, Thiene G, et al (2006). "Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention". Circulation 113 (14): 1807–16. doi:10.1161/CIRCULATIONAHA.106.174287. PMID 16567565.
- ↑ Akashi YJ, Barbaro G, Sakurai T, Nakazawa K, Miyake F (2007). "Cardiac autonomic imbalance in patients with reversible ventricular dysfunction takotsubo cardiomyopathy". QJM 100 (6): 335–43. doi:10.1093/qjmed/hcm028. PMID 17483198.
- ↑ 26.0 26.1 Azzarelli S, Galassi AR, Amico F, Giacoppo M, Argentino V, Tomasello SD, Tamburino C, Fiscella A. (2006). "Clinical features of transient left ventricular apical ballooning". Am J Cardiol. 98 (9): 1273-6. PMID 17056345.
- ↑ Leor J, Kloner RA (June 1996). "The Northridge earthquake as a trigger for acute myocardial infarction". Am. J. Cardiol. 77 (14): 1230–2. PMID 8651102.
- ↑ Leor J, Poole WK, Kloner RA (February 1996). "Sudden cardiac death triggered by an earthquake". N. Engl. J. Med. 334 (7): 413–9. PMID 8552142.
- ↑ Brown DL (May 1999). "Disparate effects of the 1989 Loma Prieta and 1994 Northridge earthquakes on hospital admissions for acute myocardial infarction: importance of superimposition of triggers". Am. Heart J. 137 (5): 830–6. PMID 10220631.
- ↑ Allegra JR, Mostashari F, Rothman J, Milano P, Cochrane DG (September 2005). "Cardiac events in New Jersey after the September 11, 2001, terrorist attack". J Urban Health 82 (3): 358–63. doi:10.1093/jurban/jti087. PMID 16000653.
- ↑ Meisel SR, Kutz I, Dayan KI, et al (September 1991). "Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians". Lancet 338 (8768): 660–1. PMID 1679475.
- ↑ Witte DR, Bots ML, Hoes AW, Grobbee DE (2000). "Cardiovascular mortality in Dutch men during 1996 European football championship: longitudinal population study". BMJ 321 (7276): 1552–4. PMID 11124170.
- ↑ Toubiana L, Hanslik T, Letrilliart L (May 2001). "French cardiovascular mortality did not increase during 1996 European football championship". BMJ 322 (7297): 1306. PMID 11403063.
- ↑ 34.0 34.1 Muller JE, Mittleman MA, Maclure M, Sherwood JB, Tofler GH (May 1996). "Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical exertion. Determinants of Myocardial Infarction Onset Study Investigators". JAMA 275 (18): 1405–9. PMID 8618365.
- ↑ Möller J, Ahlbom A, Hulting J, et al (October 2001). "Sexual activity as a trigger of myocardial infarction. A case-crossover analysis in the Stockholm Heart Epidemiology Programme (SHEEP)". Heart 86 (4): 387–90. PMID 11559674.
- ↑ Tofler GH, Muller JE (October 2006). "Triggering of acute cardiovascular disease and potential preventive strategies". Circulation 114 (17): 1863–72. doi:10.1161/CIRCULATIONAHA.105.596189. PMID 17060396.
- ↑ Peters A, Dockery DW, Muller JE, Mittleman MA (June 2001). "Increased particulate air pollution and the triggering of myocardial infarction". Circulation 103 (23): 2810–5. PMID 11401937.
- ↑ Peters A, Döring A, Wichmann HE, Koenig W (May 1997). "Increased plasma viscosity during an air pollution episode: a link to mortality?". Lancet 349 (9065): 1582–7. doi:10.1016/S0140-6736(97)01211-7. PMID 9174559.
- ↑ Peters A, Fröhlich M, Döring A, et al (July 2001). "Particulate air pollution is associated with an acute phase response in men; results from the MONICA-Augsburg Study". Eur. Heart J. 22 (14): 1198–204. doi:10.1053/euhj.2000.2483. PMID 11440492.
- ↑ Pope CA3rd, Dockery DW, Kanner RE, Villegas GM, Schwartz J (February 1999). "Oxygen saturation, pulse rate, and particulate air pollution: A daily time-series panel study". Am. J. Respir. Crit. Care Med. 159 (2): 365–72. PMID 9927345.
- ↑ Peters A, Perz S, Döring A, Stieber J, Koenig W, Wichmann HE (November 1999). "Increases in heart rate during an air pollution episode". Am. J. Epidemiol. 150 (10): 1094–8. PMID 10568625.
- ↑ Liao D, Creason J, Shy C, Williams R, Watts R, Zweidinger R (July 1999). "Daily variation of particulate air pollution and poor cardiac autonomic control in the elderly". Environ. Health Perspect. 107 (7): 521–5. PMID 10378998.
- ↑ Pope CA, Verrier RL, Lovett EG, et al (November 1999). "Heart rate variability associated with particulate air pollution". Am. Heart J. 138 (5 Pt 1): 890–9. PMID 10539820.
- ↑ Gold DR, Litonjua A, Schwartz J, et al (March 2000). "Ambient pollution and heart rate variability". Circulation 101 (11): 1267–73. PMID 10725286.
- ↑ Peters A, Liu E, Verrier RL, et al (January 2000). "Air pollution and incidence of cardiac arrhythmia". Epidemiology 11 (1): 11–7. PMID 10615837.
- ↑ Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P (December 2004). "Risk of myocardial infarction and stroke after acute infection or vaccination". N. Engl. J. Med. 351 (25): 2611–8. doi:10.1056/NEJMoa041747. PMID 15602021.
- ↑ 47.0 47.1 Saikku P, Leinonen M, Tenkanen L, Linnanmaki E, Ekman MR, Manninen V, Manttari M, Frick MH, Huttunen JK. (1992). "Chronic Chlamydia pneumoniae infection as a risk factor for coronary heart disease in the Helsinki Heart Study.". Ann Intern Med 116 (4): 273-8. PMID 1733381.
- ↑ Andraws R, Berger JS, Brown DL. (2005). "Effects of antibiotic therapy on outcomes of patients with coronary artery disease: a meta-analysis of randomized controlled trials.". JAMA 293 (21): 2641-7. PMID 15928286.
- ↑ Miller GJ, Martin JC, Mitropoulos KA, et al (February 1991). "Plasma factor VII is activated by postprandial triglyceridaemia, irrespective of dietary fat composition". Atherosclerosis 86 (2-3): 163–71. PMID 1872911.
- ↑ Vogel RA, Corretti MC, Plotnick GD (February 1997). "Effect of a single high-fat meal on endothelial function in healthy subjects". Am. J. Cardiol. 79 (3): 350–4. PMID 9036757.
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- ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (August 2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation 110 (9): e82–292. PMID 15339869.
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External links
- The MD TV: Comments on Hot Topics, State of the Art Presentations in Cardiovascular Medicine, Expert Reviews on Cardiovascular Research
- Clinical Trial Results: An up to date resource of Cardiovascular Research
- Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack - based on information of the Framingham Heart Study, from the United States National Heart, Lung and Blood Institute
- Heart Attack - overview of resources from MedlinePlus.
- Heart Attack Warning Signals from the Heart and Stroke Foundation of Canada
- Regional PCI for STEMI Resource Center - Evidence based online resource center for the development of regional PCI networks for acute STEMI
- STEMI Systems - Articles, profiles, and reviews of the latest publications involved in STEMI care. Quarterly newsletter.
- American College of Cardiology (ACC) Door to Balloon (D2B) Initiative.
- American Heart Association's Heart Attack web site - Information and resources for preventing, recognizing and treating heart attack.
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
