Cell Biochem Biophys DOI 10.1007/s12013-015-0553-4
ORIGINAL PAPER
Myocardial Infarction: Symptoms and Treatments Lei Lu • Min Liu • RongRong Sun Yi Zheng • Peiying Zhang
•
Ó Springer Science+Business Media New York 2015
Abstract Myocardial infarction (MI) is a term used for an event of heart attack which is due to formation of plaques in the interior walls of the arteries resulting in reduced blood flow to the heart and injuring heart muscles because of lack of oxygen supply. The symptoms of MI include chest pain, which travels from left arm to neck, shortness of breath, sweating, nausea, vomiting, abnormal heart beating, anxiety, fatigue, weakness, stress, depression, and other factors. The immediate treatment of MI include, taking aspirin, which prevents blood from clotting, and nitro-glycerin to treat chest pain and oxygen. The heart attack can be prevented by taking an earlier action to lower those risks by controlling diet, fat, cholesterol, salt, smoking, nicotine, alcohol, drugs, monitoring of blood pressure every week, doing exercise every day, and loosing body weight. The treatment of MI includes, aspirin tablets, and to dissolve arterial blockage injection of thrombolytic or clot dissolving drugs such as tissue plasminogen activator, streptokinase or urokinase in blood within 3 h of the onset of a Lei Lu and Min Liu have contributed equally to this work. L. Lu M. Liu R. Sun Y. Zheng Graduate School, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu, China P. Zhang (&) Department of Cardiology, Xuzhou Central Hospital, 199# South Jiefang Road, Xuzhou 221009, Jiangsu, China e-mail: [email protected] P. Zhang Affiliated Xuzhou Hospital, Medical School of Southeast University, Xuzhou 221009, Jiangsu, China P. Zhang Xuzhou Clinical Medical College of Nanjing University of Chinese Medicine, Xuzhou 221009, Jiangsu, China
heart attack. The painkillers such as morphine or meperidine can be administered to relieve pain. Nitroglycerin and antihypertensive drugs such as beta-blockers, ACE inhibitors or calcium channel blockers may also be used to lower blood pressure and to improve the oxygen demand of heart. The ECG, coronary angiography and X-ray of heart and blood vessels can be performed to observe the narrowing of coronary arteries. In this article the causes, symptoms and treatments of MI are described. Keywords Myocardial infarction Coronary angiography Antihypertensive drugs
Introduction Myocardial infarction (from Latin: Infarctus myocardii, MI) or acute myocardial infarction (AMI) is a term for an event of heart attack. MI occurs when blood stops flowing properly to a part of the heart, and the heart muscle is injured because of lack of oxygen supply. And one of the coronary arteries which supplies blood to the heart develops a blockage due to an unstable buildup of plaques, white blood cells, cholesterol and fat. If the event becomes serious then it is called as ‘‘acute’’ AMI, acute myocardial infarction. The symptoms of MI are chest pain, which travels to the left arm or left side of the neck, shortness of breath, sweating, nausea, vomiting, abnormal heart beating, anxiety, fatigue, and other factors [6]. About 64 % of people who have MI do not experience chest pain which is called ‘‘silent’’ MI [9]. The old age, tobacco smoking, high blood pressure, high levels of low density lipoprotein (LDL), high cholesterol and fat, diabetes, lack of physical activity, obesity, chronic kidney disease, excessive alcohol consumption, use of drugs such as cocaine and
123
Cell Biochem Biophys
amphetamines all contribute to MI [1, 3]. The electrocardiogram (ECG) determines the MI by electrical signals in the heart and damage to blood supply to the heart muscle. The common blood tests are troponin and creatine kinase (CK-MB). ECG testing is used to differentiate between two types of myocardial infarctions based on the shape of the tracing. An ST section of the tracing higher than the baseline is called an ST segment elevation myocardial infarction (STEMI) which requires aggressive treatment. The immediate treatment of MI includes taking aspirin, which prevents blood from clotting, and nitroglycerin to treat chest pain and oxygen [2]. The STEMI is treated by restoring blood circulation to the heart, which is called as reperfusion therapy, and angioplasty, where arteries are pushed open, thrombolysis, and blockage is removed by medications [8]. If a person is considered to be at high risk of MI, the angioplasty may be required [7]. In case of multiple blockages of coronary arteries in diabetic people can be treated with the bypass surgery [4, 10]. Ischemic heart disease, MI, angina and heart attack, all are leading cause of heart failure and death in men and women [11].
heart attack’’. The warning signs of heart attack are as follows: Chest pain or high blood pressure, tightness of chest, squeezing, burning sensations, aching, and heaviness in the chest for more than 10 min, pain in left shoulder or left arm, up into the neck or along the jaw line, shortness of breath, profuse sweating and dizziness, muscles weakness, nausea or vomiting, choking with smoke inhalation, anxiety or stress, feeling of impending doom and depression. But there are no symptoms for a silent heart attack.
Causes of Myocardial Infarction
Diagnosis of Myocardial Infarction
The myocardial infarction or heart attack occurs when coronary arteries become narrow and blocked with plaques, cholesterol and fat deposits resulting in blood clots which inhibit blood flow into the heart. This is known as hardening of arteries walls as atherosclerosis disease. Build up of fatty materials in the coronary arteries is the cause of heart attack [5]. The risk of heart attack increases with age commonly after 65 years, and men are more at risk compared to women. The other risks of heart attacks include cigarette smoking, high blood pressure, high cholesterol and LDL, diet rich in saturated fats (animal meats), obesity, lack of exercise, and diabetes (more sugar in the blood). A family history is also a cause of heart attack, a spasm of muscles of arterial walls, narrowing of arteries, emotional stress, heavy exertion or exercises, such as snow shoveling and exposure to very cold weather or air, carrying heavy things up stairs, drug (cocaine or amphetamines) abuse, all these trigger a heart attack. After first heart attack, the risk of another one increases in future. Therefore, care should be taken for diet, lower fat and sugar intake, daily exercise and normal sleep every day with low stress.
Patients with myocardial infarction or heart attack are commonly treated in emergency in the hospital under Coronary Care Unit and Management. The patient‘s history, physical examination, and blood pressure are determined in the hospital. An ECG or EKG is taken for the heart beating or rhythms which determine the abnormality of the blood flow to the heart. A blood test is also performed to analyze the level of proteins and fats in the blood stream which could damage the heart muscles. The coronary angiography or X-ray of the heart and blood vessels is performed to see narrowing of coronary arteries. A tiny catheter is inserted into the artery of leg or arm and threaded up into the coronary arteries. A contrast material is then injected from the end of catheter into coronary arteries, and X-rays are taken to observe heart disease.
Symptoms of Myocardial Infarction The common symptoms of heart attack are chest pain, angina with no prior warning signs. Sometimes, a mild heart attack produces no symptoms and is called as ‘‘silent
123
Prevention of Myocardial Infarction A person can prevent a heart attack by knowing the risk for coronary artery disease and taking an earlier action to lower those risks. Controlling fat, cholesterol, and salt in the diet, smoking, nicotine, alcohol, drugs, monitoring blood pressure, doing exercise every day, loose body weight, take Aspirin tablet in case of chest pain and reduce anxiety or stress. In case of women with menopause the cardio protective estrogen therapy is advisable.
Treatment of Myocardial Infarction In case of an individual having a heart attack, it is advisable to call for an emergency service and go to the nearest hospital immediately. And if the heart beating of the person has slowed down or stopped cardiopulmonary resuscitation (CPR) or electrical defibrillator should be used to restore the heart beat without delay. The blood flow to the heart should be re-established and continued quickly to protect heart muscles from any further damage. The following are the treatments usually given to MI or heart attack patients:
Cell Biochem Biophys
An aspirin should be taken right away for the symptoms of a heart attack as it may help break up the blood clot. Also, to dissolve arterial blockage, thrombolytic or clot dissolving drugs such as tissue plasminogen activator (tPA), Streptokinase or Urokinase are injected in the blood within 3 h of the onset of a heart attack. The painkillers such as morphine or meperidine can also be administered to relieve pain. A nitroglycerin and antihypertensive drugs such as Beta-blockers, ACE inhibitors or Calcium channel blockers may be administered to lower the blood pressure and to reduce the heart’s oxygen demand. The diuretics may enhance the effect of these drugs. Oxygen is administered through nasal tubes. Anticoagulants such as heparin, aspirin or warfarin may also be administered to reduce the risk of blood clots. Digitalis glycosides, such as digoxin, may be prescribed in some cases to strengthen heart muscle contraction. Dopamine or dobutamine is administered to increase the blood flow to the heart and strengthen the heartbeat. The angioplasty, a procedure to open narrowed arteries, may be performed, using local anesthesia, a catheter (a long narrow tube with a deflated balloon at its tip), is inserted into the narrowed part of the artery. Then the balloon is inflated, which compresses the plaque, and enlarges the inner diameter of the blood vessel, so blood could flow more easily. Coronary bypass surgery may be performed to go around blocked blood vessels and restore adequate blood flow to the heart. Electronic implants such as a pacemaker or a defibrillator is usually attached to the heart to maintain strong, regular contractions of the heart muscle. In severe cases of badly damaged heart tissues it may require a heart transplant. During recovery, patients are to follow prevention tips related to diet, exercise and stress etc. as suggested by their doctor to reduce the risk of having another heart attack.
References 1. Devlin, R. J., & Henry, J. A. (2008). Clinical review: Major consequences of illicit drug consumption. Critical Care, 12(1), 202. doi:10.1186/cc6166.PMC2374627.PMID18279535.
2. Erhardt, L., Herlitz, J., Bossaert, L., Halinen, M., Keltai, M., Koster, R., et al. (2002). Task force on the management of chest pain (PDF). European Heart Journal, 23(15), 1153–1176. doi:10. 1053/euhj.2002.3194.PMID12206127. 3. Graham, I., Atar, D., Borch-Johnsen, K., Boysen, G., Burell, G., Cifkova, R., et al. (2007). European guidelines on cardiovascular disease prevention in clinical practice: Executive summary: Fourth joint task force of the european society of cardiology and other societies on cardiovascular disease prevention in clinical practice (Constituted by representatives of nine societies and by invited experts). European Heart Journal, 28(19), 2375–2414. doi:10.1093/eurheartj/ehm316.PMID17726041. 4. Hamm, C. W., Bassand, J. P., Agewall, S., Bax, J., Boersma, E., Bueno, H., et al. (2011). 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). European Heart Journal, 32(23), 2999–3054. doi:10.1093/eurheartj/ehr236.PMID21873419. 5. John Hopkins Medicine (2014). School of Medicine, Baltimore, MD, USA (Internet reference). 6. Kosuge, M., Kimura, K., Ishikawa, T., Ebina, T., Hibi, K., Tsukahara, K., et al. (2006). Differences between men and women in terms of clinical features of ST-segment elevation acute myocardial infarction. Circulation Journal, 70(3), 222–226. doi:10.1253/circj.70.222.PMID16501283. 7. O’Connor, R. E., Brady, W., Brooks, S. C., Diercks, D., Egan, J., Ghaemmaghami, C., et al. (2010). Part 10: acute coronary syndromes: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(18 Suppl 3), S787–S817. doi:10.1161/CIRCU LATIONAHA.110.971028.PMID20956226. 8. Roe, M. T., Messenger, J. C., Weintraub, W. S., Cannon, C. P., Fonarow, G. C., Dai, D., et al. (2010). Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. Journal of the American College of Cardiology, 56(4), 254–263. doi:10.1016/j.jacc.2010.05.008.PMID20633817. 9. Valensi, P., Lorgis, L., & Cottin, Y. (2011). Prevalence, incidence, predictive factors and progno-sis of silent myocardial infarction: a review of the literature. Archives of Cardiovascular Diseases, 104(3), 178–188. doi:10.1016/j.acvd.2010.11.013.PMID21497307. 10. Van de Werf, F., Bax, J., Betriu, A., Blomstrom-Lundqvist, C., Crea, F., Falk, V., et al. (2008). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The task force on the management of ST-segment elevation acute myocardial infarction of the European society of cardiology. European Heart Journal, 29(23), 2909–2945. doi:10. 1093/eurheartj/ehn416.PMID19004841. 11. WHO (2013). The top 10 causes of death. World Health Organization. Retrieved 13 Aug 2013.
123
ORIGINAL PAPER
Myocardial Infarction: Symptoms and Treatments Lei Lu • Min Liu • RongRong Sun Yi Zheng • Peiying Zhang
•
Ó Springer Science+Business Media New York 2015
Abstract Myocardial infarction (MI) is a term used for an event of heart attack which is due to formation of plaques in the interior walls of the arteries resulting in reduced blood flow to the heart and injuring heart muscles because of lack of oxygen supply. The symptoms of MI include chest pain, which travels from left arm to neck, shortness of breath, sweating, nausea, vomiting, abnormal heart beating, anxiety, fatigue, weakness, stress, depression, and other factors. The immediate treatment of MI include, taking aspirin, which prevents blood from clotting, and nitro-glycerin to treat chest pain and oxygen. The heart attack can be prevented by taking an earlier action to lower those risks by controlling diet, fat, cholesterol, salt, smoking, nicotine, alcohol, drugs, monitoring of blood pressure every week, doing exercise every day, and loosing body weight. The treatment of MI includes, aspirin tablets, and to dissolve arterial blockage injection of thrombolytic or clot dissolving drugs such as tissue plasminogen activator, streptokinase or urokinase in blood within 3 h of the onset of a Lei Lu and Min Liu have contributed equally to this work. L. Lu M. Liu R. Sun Y. Zheng Graduate School, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu, China P. Zhang (&) Department of Cardiology, Xuzhou Central Hospital, 199# South Jiefang Road, Xuzhou 221009, Jiangsu, China e-mail: [email protected] P. Zhang Affiliated Xuzhou Hospital, Medical School of Southeast University, Xuzhou 221009, Jiangsu, China P. Zhang Xuzhou Clinical Medical College of Nanjing University of Chinese Medicine, Xuzhou 221009, Jiangsu, China
heart attack. The painkillers such as morphine or meperidine can be administered to relieve pain. Nitroglycerin and antihypertensive drugs such as beta-blockers, ACE inhibitors or calcium channel blockers may also be used to lower blood pressure and to improve the oxygen demand of heart. The ECG, coronary angiography and X-ray of heart and blood vessels can be performed to observe the narrowing of coronary arteries. In this article the causes, symptoms and treatments of MI are described. Keywords Myocardial infarction Coronary angiography Antihypertensive drugs
Introduction Myocardial infarction (from Latin: Infarctus myocardii, MI) or acute myocardial infarction (AMI) is a term for an event of heart attack. MI occurs when blood stops flowing properly to a part of the heart, and the heart muscle is injured because of lack of oxygen supply. And one of the coronary arteries which supplies blood to the heart develops a blockage due to an unstable buildup of plaques, white blood cells, cholesterol and fat. If the event becomes serious then it is called as ‘‘acute’’ AMI, acute myocardial infarction. The symptoms of MI are chest pain, which travels to the left arm or left side of the neck, shortness of breath, sweating, nausea, vomiting, abnormal heart beating, anxiety, fatigue, and other factors [6]. About 64 % of people who have MI do not experience chest pain which is called ‘‘silent’’ MI [9]. The old age, tobacco smoking, high blood pressure, high levels of low density lipoprotein (LDL), high cholesterol and fat, diabetes, lack of physical activity, obesity, chronic kidney disease, excessive alcohol consumption, use of drugs such as cocaine and
123
Cell Biochem Biophys
amphetamines all contribute to MI [1, 3]. The electrocardiogram (ECG) determines the MI by electrical signals in the heart and damage to blood supply to the heart muscle. The common blood tests are troponin and creatine kinase (CK-MB). ECG testing is used to differentiate between two types of myocardial infarctions based on the shape of the tracing. An ST section of the tracing higher than the baseline is called an ST segment elevation myocardial infarction (STEMI) which requires aggressive treatment. The immediate treatment of MI includes taking aspirin, which prevents blood from clotting, and nitroglycerin to treat chest pain and oxygen [2]. The STEMI is treated by restoring blood circulation to the heart, which is called as reperfusion therapy, and angioplasty, where arteries are pushed open, thrombolysis, and blockage is removed by medications [8]. If a person is considered to be at high risk of MI, the angioplasty may be required [7]. In case of multiple blockages of coronary arteries in diabetic people can be treated with the bypass surgery [4, 10]. Ischemic heart disease, MI, angina and heart attack, all are leading cause of heart failure and death in men and women [11].
heart attack’’. The warning signs of heart attack are as follows: Chest pain or high blood pressure, tightness of chest, squeezing, burning sensations, aching, and heaviness in the chest for more than 10 min, pain in left shoulder or left arm, up into the neck or along the jaw line, shortness of breath, profuse sweating and dizziness, muscles weakness, nausea or vomiting, choking with smoke inhalation, anxiety or stress, feeling of impending doom and depression. But there are no symptoms for a silent heart attack.
Causes of Myocardial Infarction
Diagnosis of Myocardial Infarction
The myocardial infarction or heart attack occurs when coronary arteries become narrow and blocked with plaques, cholesterol and fat deposits resulting in blood clots which inhibit blood flow into the heart. This is known as hardening of arteries walls as atherosclerosis disease. Build up of fatty materials in the coronary arteries is the cause of heart attack [5]. The risk of heart attack increases with age commonly after 65 years, and men are more at risk compared to women. The other risks of heart attacks include cigarette smoking, high blood pressure, high cholesterol and LDL, diet rich in saturated fats (animal meats), obesity, lack of exercise, and diabetes (more sugar in the blood). A family history is also a cause of heart attack, a spasm of muscles of arterial walls, narrowing of arteries, emotional stress, heavy exertion or exercises, such as snow shoveling and exposure to very cold weather or air, carrying heavy things up stairs, drug (cocaine or amphetamines) abuse, all these trigger a heart attack. After first heart attack, the risk of another one increases in future. Therefore, care should be taken for diet, lower fat and sugar intake, daily exercise and normal sleep every day with low stress.
Patients with myocardial infarction or heart attack are commonly treated in emergency in the hospital under Coronary Care Unit and Management. The patient‘s history, physical examination, and blood pressure are determined in the hospital. An ECG or EKG is taken for the heart beating or rhythms which determine the abnormality of the blood flow to the heart. A blood test is also performed to analyze the level of proteins and fats in the blood stream which could damage the heart muscles. The coronary angiography or X-ray of the heart and blood vessels is performed to see narrowing of coronary arteries. A tiny catheter is inserted into the artery of leg or arm and threaded up into the coronary arteries. A contrast material is then injected from the end of catheter into coronary arteries, and X-rays are taken to observe heart disease.
Symptoms of Myocardial Infarction The common symptoms of heart attack are chest pain, angina with no prior warning signs. Sometimes, a mild heart attack produces no symptoms and is called as ‘‘silent
123
Prevention of Myocardial Infarction A person can prevent a heart attack by knowing the risk for coronary artery disease and taking an earlier action to lower those risks. Controlling fat, cholesterol, and salt in the diet, smoking, nicotine, alcohol, drugs, monitoring blood pressure, doing exercise every day, loose body weight, take Aspirin tablet in case of chest pain and reduce anxiety or stress. In case of women with menopause the cardio protective estrogen therapy is advisable.
Treatment of Myocardial Infarction In case of an individual having a heart attack, it is advisable to call for an emergency service and go to the nearest hospital immediately. And if the heart beating of the person has slowed down or stopped cardiopulmonary resuscitation (CPR) or electrical defibrillator should be used to restore the heart beat without delay. The blood flow to the heart should be re-established and continued quickly to protect heart muscles from any further damage. The following are the treatments usually given to MI or heart attack patients:
Cell Biochem Biophys
An aspirin should be taken right away for the symptoms of a heart attack as it may help break up the blood clot. Also, to dissolve arterial blockage, thrombolytic or clot dissolving drugs such as tissue plasminogen activator (tPA), Streptokinase or Urokinase are injected in the blood within 3 h of the onset of a heart attack. The painkillers such as morphine or meperidine can also be administered to relieve pain. A nitroglycerin and antihypertensive drugs such as Beta-blockers, ACE inhibitors or Calcium channel blockers may be administered to lower the blood pressure and to reduce the heart’s oxygen demand. The diuretics may enhance the effect of these drugs. Oxygen is administered through nasal tubes. Anticoagulants such as heparin, aspirin or warfarin may also be administered to reduce the risk of blood clots. Digitalis glycosides, such as digoxin, may be prescribed in some cases to strengthen heart muscle contraction. Dopamine or dobutamine is administered to increase the blood flow to the heart and strengthen the heartbeat. The angioplasty, a procedure to open narrowed arteries, may be performed, using local anesthesia, a catheter (a long narrow tube with a deflated balloon at its tip), is inserted into the narrowed part of the artery. Then the balloon is inflated, which compresses the plaque, and enlarges the inner diameter of the blood vessel, so blood could flow more easily. Coronary bypass surgery may be performed to go around blocked blood vessels and restore adequate blood flow to the heart. Electronic implants such as a pacemaker or a defibrillator is usually attached to the heart to maintain strong, regular contractions of the heart muscle. In severe cases of badly damaged heart tissues it may require a heart transplant. During recovery, patients are to follow prevention tips related to diet, exercise and stress etc. as suggested by their doctor to reduce the risk of having another heart attack.
References 1. Devlin, R. J., & Henry, J. A. (2008). Clinical review: Major consequences of illicit drug consumption. Critical Care, 12(1), 202. doi:10.1186/cc6166.PMC2374627.PMID18279535.
2. Erhardt, L., Herlitz, J., Bossaert, L., Halinen, M., Keltai, M., Koster, R., et al. (2002). Task force on the management of chest pain (PDF). European Heart Journal, 23(15), 1153–1176. doi:10. 1053/euhj.2002.3194.PMID12206127. 3. Graham, I., Atar, D., Borch-Johnsen, K., Boysen, G., Burell, G., Cifkova, R., et al. (2007). European guidelines on cardiovascular disease prevention in clinical practice: Executive summary: Fourth joint task force of the european society of cardiology and other societies on cardiovascular disease prevention in clinical practice (Constituted by representatives of nine societies and by invited experts). European Heart Journal, 28(19), 2375–2414. doi:10.1093/eurheartj/ehm316.PMID17726041. 4. Hamm, C. W., Bassand, J. P., Agewall, S., Bax, J., Boersma, E., Bueno, H., et al. (2011). 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). European Heart Journal, 32(23), 2999–3054. doi:10.1093/eurheartj/ehr236.PMID21873419. 5. John Hopkins Medicine (2014). School of Medicine, Baltimore, MD, USA (Internet reference). 6. Kosuge, M., Kimura, K., Ishikawa, T., Ebina, T., Hibi, K., Tsukahara, K., et al. (2006). Differences between men and women in terms of clinical features of ST-segment elevation acute myocardial infarction. Circulation Journal, 70(3), 222–226. doi:10.1253/circj.70.222.PMID16501283. 7. O’Connor, R. E., Brady, W., Brooks, S. C., Diercks, D., Egan, J., Ghaemmaghami, C., et al. (2010). Part 10: acute coronary syndromes: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(18 Suppl 3), S787–S817. doi:10.1161/CIRCU LATIONAHA.110.971028.PMID20956226. 8. Roe, M. T., Messenger, J. C., Weintraub, W. S., Cannon, C. P., Fonarow, G. C., Dai, D., et al. (2010). Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. Journal of the American College of Cardiology, 56(4), 254–263. doi:10.1016/j.jacc.2010.05.008.PMID20633817. 9. Valensi, P., Lorgis, L., & Cottin, Y. (2011). Prevalence, incidence, predictive factors and progno-sis of silent myocardial infarction: a review of the literature. Archives of Cardiovascular Diseases, 104(3), 178–188. doi:10.1016/j.acvd.2010.11.013.PMID21497307. 10. Van de Werf, F., Bax, J., Betriu, A., Blomstrom-Lundqvist, C., Crea, F., Falk, V., et al. (2008). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The task force on the management of ST-segment elevation acute myocardial infarction of the European society of cardiology. European Heart Journal, 29(23), 2909–2945. doi:10. 1093/eurheartj/ehn416.PMID19004841. 11. WHO (2013). The top 10 causes of death. World Health Organization. Retrieved 13 Aug 2013.
123
