Myocardial Infarction and Cardiac Pathology for USMLE Step...

Myocardial Infarction and Cardiac Pathologyfor USMLE Step One

Howard J. Sachs, MDAssociate Professor of Medicine

University of Massachusetts Medical Schoolwww.12DaysinMarch.com

E-mail: Howard@12daysinmarch.com

EKG and Infarct Localization

Atherogenesis

Infarction

NSTEMI(Subendocardial or

Non-Q wave infarction)

STEMI(Transmural or

Q wave infarction)

Definition (for USMLE): Clinical features, Diagnostic EKG and Biomarker Elevation

Infarction

STEMI(Transmural or

Q wave infarction)

Infarction

As biomarkers elevate by 4 hours, a patient can experience sudden cardiac death (SCD) without demonstrating evidence of myocardial injury.

Infarction

STEMI(Transmural)

48 y.o. presents to ER (1200) with severe nausea and heartburn. Partially relieved with GI cocktail (Maalox, lidocaine).

Troponin and EKG on admission to ER are negative. ER discharge (1600). Arrests at home 4 h later.

Infarction

Niche Derivative for CK

Infarction

Patient presented with MI. Three days later, he his having recurrent chest pain. Which is best test to determine extension of MI?

1. CK-MB2. Troponin

Subendocardium

V3, 4 = anteriorV5, 6 = lateral

Pathology of Myocardial Infarction

120 seconds 20-30 mins

Pathology of Myocardial Infarction

Biochemical changes in early ischemia

Onset of irreversible injury

Time (mins)

0 5 10 15 20 25 30 35

Lactate

Stunning (reversible)

Biochemical changes in early ischemia

Onset of irreversible injury

Time (mins)

0 5 10 15 20 25 30 35

Lactate

Stunning (reversible)

Do Not Confuse: Stunning versus HibernatingStunning – transient post-ischemic dysfunction (acute)Hibernating – refers to the diminished LV function ( EF%) that follows multiple low-grade ischemic events; chronic, but potentially reversible, ischemic dysfunction following revascularization

Depletion of ATP and loss of contractility

1-2 mins

Pick the point on the curve where the myocardium stops contracting?

Depletion of ATP and loss of contractility

1-2 mins

Contractility and Reversibilityare two different endpoints

Pick the point on the curve where the myocardium stops contracting?Answer: 120 secs

0-6 hours120 seconds 20-30 mins

Cardiac Pathology

Rupture:LV

Papillary MM

FibrinousPericarditis

>30 dAneurysm

Mural thrombusDressler’s

Injury Complications Microscopy

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

What cardiac pathology can you expect in the first 6 hours?

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Answer: None

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Answer: None

Proximal coronary occlusions can cause arrhythmogenic deaths before evidence of coagulative necrosis develops.

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Suspend Reality (for Step One):Link fatal cardiac arrhythmias with the initial six hours of myocardial necrosis

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Patient develops CP and dies one hour later. What was the most likely cause of death?

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

48 y.o. presents to ER with severe nausea and heartburn. Partially relieved with GI cocktail (Maalox, lidocaine).

Troponin and EKG on admission to ER are negative.Arrests at home 4 h later.

Which of the following was seen grossly/histologically?

Patient develops CP and dies one hour later. What was the most likely cause of death?

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

48 y.o. presents to ER with severe nausea and heartburn. Partially relieved with GI cocktail (Maalox, lidocaine).

Troponin and EKG on admission to ER are negative.Arrests at home 4 h later.

Which of the following was seen grossly/histologically?

Patient develops CP and dies. Most likely cause of death?

Answer: Normal Tissue [no histopathologic (coagulative necrosis) changes during initial presentation]

0-6 hours 1-3 days120 seconds 20-30 mins

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Neutrophilic Phase

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Neutrophilic Phase

Derivative One

Old woman found dead at home clutching bottle of SL NTG.

Autopsy reveals neutrophilic infiltrate. When did she kick it?

A. 1 hr agoB. 1 day agoC. 1 week ago

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Neutrophilic Phase

Derivative One

Old woman found dead at home clutching bottle of SL NTG.

Autopsy reveals neutrophilic infiltrate. When did she kick it?

A. 1 hr ago (normal histopathology)B. 1 day agoC. 1 week ago (macrophage phase)

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Overlying the necrotic segment of transmural infarction(i.e. do not to confuse with autoimmune pericarditis seen later in course)

Neutrophilic Phase

Derivative Two

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Neutrophilic Phase

Dude had STEMI 2 days ago. Now with recurrent chest pain. Refuses to lie down.

Cause of pain?

A. Extension of MIB. Pulmonary EmbolismC. TamponadeD. Chordae tendinae ruptureE. Coronary VasospasmF. Serofibrinous PericarditisG. Purulent PericarditisH. Decompensated CHF

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Neutrophilic Phase

Cause of pain?

A. Extension of MI (need CK)B. Pulmonary EmbolismC. Tamponade (day 5; need pulsus paradoxus)D. Chordae tendinae rupture (day 5; need murmur)E. Coronary VasospasmF. Serofibrinous PericarditisG. Purulent Pericarditis (infectious, not post-MI)H. Decompensated CHF (need rales, S3)

Cardiac Pathology

Rupture:LV

Papillary MM

>30 dAneurysm

Cause of pain?

A. Extension of MI (need CK)B. Pulmonary EmbolismC. Tamponade (day 5; need pulsus paradoxus)D. Chordae tendinae rupture (day 5; need murmur)E. Coronary VasospasmF. Serofibrinous PericarditisG. Purulent Pericarditis (infectious, not post-MI)H. Decompensated CHF (need rales, S3)

Quick Associations when briefly reviewing the wrong answers

0-6 hours 1-3 days 3-7 days120 seconds 20-30 mins

Cardiac Pathology

3-7 dRupture:

LVPapillary MM

Neutrophilic Phase

Macrophage Phase

‘…disintegration of dead myofibers…’

Cardiac Pathology

Rupture:LV

Papillary MM

Neutrophilic Phase

Macrophage Phase

‘…disintegration of dead myofibers…’

Cardiac Pathology

3-7 dRupture:

LVPapillary MM

Neutrophilic Phase

Macrophage Phase

Dude with STEMI 5 days ago. 1. Now with hypotension/pulsus paradoxus (diff dx of shock).2. Now with acute CHF and new 3/6 systolic murmur at apex

Diagnosis? Which cell most likely caused/contributed?

Cardiac Pathology

3-7 dRupture:

LVPapillary MM

Neutrophilic Phase

Macrophage Phase

Dude with STEMI 5 days ago. 1. Now with hypotension/pulsus paradoxus (diff dx of shock).2. Now with acute CHF and new 3/6 systolic murmur at apex

Diagnosis? Which cell most likely caused/contributed?

Cardiac Pathology

3-7 dRupture:

LVPapillary MM

Neutrophilic Phase

Macrophage Phase

Collagen DepositionFibroblast

Cardiac Pathology

LV Aneurysm →Mural Thrombus…what’s the end game of these questions?

Cardiac Pathology

They play the mural thrombus game with dilated cardiomyopathy.

Cardiac Pathology

LV Aneurysm →Mural Thrombus

Dressler’s Syndrome: Autoimmune Pericarditis• Pathology – serofibrinous • Target tissue – released myocardial antigens• Presentation - similar to acute pericarditis except timing 6-8 weeks

3-7 dRupture:

LVPapillary MM

Neutrophilic Phase

Macrophage Phase

The material presented will get you out of a few jams…

Cardiac Pathology

7-14 dGranulation Tissue and

Neovascularization(loose collagen and abundant capillaries)

0-6 hours

1-3 days 3-7 days

Loss of ContractilityOnset of Irreversible Injury

Fatal ArrhythmiaNo histopathology

Abundant NeutrophilsAcute Pericarditis

Abundant MacrophageNecrotic Debris → Rupture

> 30 days

Type I Collagen DepositionLV Aneurysm →Mural Thrombosis

Dressler’s Syndrome (autoimmune pericarditis)

0-6 hours

1-3 days 3-7 days

Loss of ContractilityOnset of Irreversible Injury

Fatal ArrhythmiaNo histopathology

Abundant NeutrophilsAcute Pericarditis

Abundant MacrophageNecrotic Debris → Rupture

Wavy fibers, edeman, punctate hemorrhage, contraction bands

and coagulative necrosis

6-24 hours 7-14 days

Granulation TissueNeovascularization

Myocardial Infarction and Cardiac Pathologyfor USMLE Step One

Howard J. Sachs, MDAssociate Professor of Medicine

University of Massachusetts Medical Schoolwww.12DaysinMarch.com

E-mail: Howard@12daysinmarch.com

Myocardial Infarction and Cardiac Pathology for USMLE Step...

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