Talk:Myocardial infarction/Archive 2

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Contents

merge Cardiac_markers

Cardiac_markers, I think, should be merged here.

No, it's long enough already.--Steven Fruitsmaak (Reply) 16:56, 6 December 2006 (UTC)

suggestion

Under chest pain, I suggest you add the term "angina pectoris" or "anginal pain". The characteristis of angina pectoris are: 1. Usually provoked by exertion, excitement. 2. The pain is dominated by a sense of pressure in the precordium with radiation commonly to the left arm. 3. The pain may be sensed from the eyballs to the umbilicus; e.g. jaw pain may be the only manifestation. 4. It is relieved by rest within 15 minutes ( if it lasts longer consider acute infarction. 5. It is usually relieved by sublingual nitroglycerin.

Shouldn't this entire page be under "Myocardial Infarction", with a redirection from Heart Attack to that page? Myocardial infarction is the medical term for the condition, so it should probably be used in the Wiki.

Anyone object to me making the switch over? Ksheka 16:03, Apr 15, 2004 (UTC)

In favour; argumentation on my talk page. JFW | T@lk 18:43, 15 Apr 2004 (UTC)

Below is a mirror of the discussion on my talk page (up to date until 11:15, 16 Apr 2004 (UTC)) JFW | T@lk

A mass-redirect question

Hi. I've been working on a few medical pages, and the page for [[Heart attack]] really annoys me a bit. Maybe that's not the right word -- I would like to move the entire page over to Myocardial infarction, and have "Heart attack" redirect over there. The problem is that there's a lot of pages that reference the page.
I feel that Myocardial infarction is much more professional for the wiki (and just about any other encyclopedia).
Is it okay to do the move? Do I need to get permission from someone? Does it need to be orchestrated in some way? Or should I just let sleeping dogs lie?
The last thing I want to do is break a hundred pages by doing this move... Ksheka 16:27, Apr 15, 2004 (UTC)

Heart attack is the common name for the problem. As a general interest reference this seems appropriate to Wikipedia. I understand what you mean, though. Kd4ttc 17:16, 15 Apr 2004 (UTC)

This is, again, a question that boils down to the medical side of WikiPedia in general (WikiDoc effort).
Some points:

  • Personally I find it educational to be redirected
  • Whenever a non-medical user types in "Heart attack" he will still see the relevant information.
  • In the scientific fields, terminology is everything. "Heart attack" is imprecise, as it does not specify the nature of the insult (chemical, biological or nuclear attack), nor the exact location of the insult (what part of the heart: pericardium? endocardium????).
  • Is every heart attack a myocardial infarction? Many patients who have suffered acute coronary syndromes have escaped with low or negative Troponin T, and have technically not had an MI, yet talk to everybody about their "heart attack".
  • I've had the same discussion with another user on neutrophil granulocyte, and the change also involved >30 redirects.

Please tell me if you need help with redirects. I'm personally in favour of moving the whole page to myocardial infarction. JFW | T@lk 18:42, 15 Apr 2004 (UTC)

Okay. I'll do the move this weekend. Any tips on redirection would be appreciated. I guess that the proper way to do it is to manually change all the links??? Ksheka 01:41, Apr 16, 2004 (UTC)

Previous experience has taught me that - unless you're capable of writing a bot do to it - moving it manually is the best way. I'll see if I can find some time on Saturday night (after Shabbat, when I'm dewikified) to help to perform the procedure. JFW | T@lk 11:11, 16 Apr 2004 (UTC)

hmmm... I tried using the "Move this page" link on the left of the page, but that didn't work because "Myocardial infarction" already has a page history (It's just to redirect to [[Heart attack]], but it's a history, none the less. :-( So I put Myocardial infarction on Wikipedia:Redirects for deletion, with the thought that after the deletion, we can do the page move (preferably before anyone re-creates Myocardial infarction). Is this the proper way? If I just cut and pasted the text, we lose all history for the page.Ksheka 13:25, Apr 18, 2004 (UTC)

You've been very good. I once made the mistake of moving a complete page (Haemochromatosis), upsetting some people (Talk:Haemochromatosis). This is probably the best way, indeed. I'll help you with the double-redirects when the move has become official.
PS I had some correspondence with User:Meelar, who's an admin, and he said he would support one of the WikiDoc members to become an admin, to deal with exactly these kind of problems. I think this in something to keep in mind; I'll remind him in a few weeks (see User_talk:Jfdwolff#Cgi-bin for details). JFW | T@lk 14:10, 18 Apr 2004 (UTC)

At the moment, the vote is 50/50... I'll see if I can rally some support through the WikiDoc network... JFW | T@lk 10:36, 22 Apr 2004 (UTC)
I noticed. :-( Any idea how long the vote should go on? Ksheka 10:38, Apr 22, 2004 (UTC)

I completely agree with the redirect in question. Benjaminstewart05 11:51, 12 April 2006 (UTC)

The naming issue

After Ksheka's attempt to move this page to Myocardial infarction, it became apparent that Wikipedia policy is the problematic factor. Naming is generally done with the general public in mind. This has advantages (easy to find, articles aimed at lay public etc.) but also a lot of downsides. Lay terms are imprecise, often evoke biased reactions, and can be confusing. In chemistry and biology, the articles generally follow scientific terminology, and adequate redirects are in place. The same ought to be for medicine.
As this is a policy issue, I have raised this at Naming conventions for medicine. Please offer your views there.
JFW | T@lk 17:02, 26 Apr 2004 (UTC)

Not to suggest that an issue that was settled two years ago ought to be reopened, but it didn't seem like the other side got much of a hearing here. Here's WP's naming policy in a nutshell:
Names of Wikipedia articles should be optimized for readers over editors; and for a general audience over specialists.
That's one of the things I love about Wikipedia. It's tough to say that this rule was followed in this case.
Of course there's reasons why doctors use terms like "myocardial infarction" rather than "heart attack"; hopefully they're not just using big words to confuse the rest of us. But there are also reasons why regular people use terms like "heart attack" rather than "myocardial infarction"; for one big thing, we don't know what "myocardial" or "infarction" mean, whereas we do know what a heart is and what an attack is.
I'm not saying that the article shouldn't explain the technical terminology in its lead paragraph. But if the article had stayed at "heart attack" (and again, I realize this is a done deal), it would have been an important reminder that this and every other medical article on Wikipedia should be aimed at people who think primarily in terms of "heart attacks" and not "myocardial infarctions". One hopes doctors are not turning to Wikipedia for their medical information. Nareek 11:12, 21 August 2006 (UTC)
As well as issues of one-to-one common name for technical terms, there is issue of whether a common name even describes the same thing or not. So "Heart attack" gets used both for Myocardial Infarction, as well as irregular heart rhythms (VF) and (incorrectly) for anginal episodes. Similarly earache covers both otitis externa and otitis media, and "a touch of flu" would have to merge every thing from the common cold, viral & bacteria sore throats, viral bronchitis, bacterial pneumonia as well as influenza. Patients do use such terms as "myocardial infarction" and if accurate descriptions are to be given, then articles need discuss specific conditions - by all means have non-technical introductions or header disambiguation tags (or even disambiguation pages), but myocardial infarction is not the same as ventricular fibrillation or cardiac arrest each of which are substantial articles in their own right. 17:17, 21 August 2006 (UTC)
If the commonly used term "heart attack" refers to more than one medical condition, than people who type in "heart attack" ought to get to a page that discusses all those conditions. This makes me think that renaming the heart attack page "myocardial infarction" was a bigger goof than I thought--and perhaps one that ought to be corrected after all. Nareek 18:40, 21 August 2006 (UTC)

Sex differences

I've heard (from reliable sources) that the symptoms of a heart attack are very different for women than for men. Assuming this is true, can somebody (who knows more about this than me) write up something on this for the section on symptoms?

They may be different. Men tend to experience classical symptoms (e.g. a poorly localized and uncomfortable squeezing or pressure in the center of the chest lasting for 15 minutes or more) while women may experience epigastric pain often mistaken for heart burn. Other groups at risk for atypical symptoms include diabetics (who may not experience any pain) and the elderly (who often complain of new exertional dyspnea). MoodyGroove 16:03, 23 December 2006 (UTC)MoodyGroove

It has been covered in the article.--Steven Fruitsmaak (Reply) 16:10, 23 December 2006 (UTC)

Massive Attack

Something I hoped to find out from this article but didn't: is there any actual technical meaning to the oft-heard term "massive heart attack"? Is there anything that makes one heart attack massive and another not? Or is the word "massive" in this context just padding? Bonalaw 12:51, 15 Aug 2004 (UTC)

It's a specification of severity. Heart attacks can be mild, serious or life-threatening. In itself, Massive Attack (yes, I know it's a band) has little specific meaning, apart from the fact that the patient is doing poorly (e.g. cardiac shock, arrhythmias, requiring cardiopulmonary resuscitation...) JFW | T@lk 13:10, 15 Aug 2004 (UTC)

yes good idea—The preceding unsigned comment was added by 81.150.209.145 (talk • contribs) 15:14, 18 August 2006(UTC).

Gastritis

I was told that gastritis may have confusingly similar symptoms, at least to those without a medicine background. Is it true? -- Paddu 06:41, 21 Oct 2004 (UTC)

Yes, lots of things can be confused with a myocardial infarction, and gastritis is one of them. Another is esophagitis (i.e. heartburn). Medical training alone doesn't allow these conditions to be reliably distinguished on the basis of symptoms only: even those with advanced training need such tests as EKGs and cardiac enzymes in order to diagnose a myocardial infarction. - Nunh-huh 06:49, 21 Oct 2004 (UTC)

Unreferenced edits

An anonymous editor inserted a lot of material, citing "studies" and "standards of care" that were completely unreferenced. Wikipedia is now in the business of citing references, and this important article lacks anything but Herrick's 1912 article that I cited. Adding bossy terms ("standards of care") without backing them up is extremely unencyclopedic. Furthermore, they were very much USA-biased (in the UK, troponin I or T are used in isolation).

Large articles on areas which are highly evidence-based (such as this one) should be properly referenced, or run the risk of being listed for cleanup. JFW | T@lk 10:15, 6 Feb 2005 (UTC)

Improvement drive

A related article, Obesity, is currently nominated to be improved on Wikipedia:This week's improvement drive. Please vote for this article there.--Fenice 08:38, 9 August 2005 (UTC)

The digitalis theory

I removed lengthy discussions, mainly with an unregistered user from Brazil, about inclusion of an alternative theory on this page. Despite numerous requests, this user has been unwilling to explain how many cardiologists actually lend credence to this theory. Under WP:NPOV, only significant views warrant inclusion in Wikipedia. I have now archived the discussion to Archive 1. JFW | T@lk 11:34, 11 December 2005 (UTC)

Zimetbaum article

I suggest using this article for the ECG diagnosis section. It is fairly comprehensive:

  • Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003;348:933-40. PMID 12621138.

Anyone interested? JFW | T@lk 23:22, 11 December 2005 (UTC)

WHO 1971

I've tried hard to find a reliable reference for the 1971 WHO criteria. It seems these were redefined in principle by the JACC/ECC[1]. Any comments? What should we represent? JFW | T@lk 00:30, 19 January 2006 (UTC)

You are probably looking for this: Nomenclature and Criteria for Diagnosis of Ischaemic Heart Disease (Circulation, 1979, Vol. 59, No. 3, 607609) [2] Can't find it on pubmed though... --WS 10:47, 19 January 2006 (UTC)

Apparently there are 1971 and 1983 criteria. JFW | T@lk 14:18, 19 January 2006 (UTC)

Cardiac Arrest

Is it really nescessary to go into detail about cardiac arrest in this article? It is a very common mistake by healthcare professionals and lay people alike that Heart Attack = Cardiac Arrest; and by mentioning treatment of cardiac arrest here we are doing nothing to dispell the myth. It is true that MI can be a cause of arrest (thrombosis, particularly of the heart, is the 4th of the 4Ts), but they are not the same thing. Any talk of treatment general to any arrest (such as defibrillation, VF, VT, asystole) are not really relevant to this article (other than perhaps a "In some cases, MI leads to cardiac arrest, for which the normal treatment is given" type comment under treatment). What do others think? --John24601 22:21, 20 January 2006 (UTC)

Leave In - I agree there is a technical distinction, but most cardiac arrests are a direct consequence of a patient having a myocardial infarction and this is where the reader will expect to see at least some mention of defibs for cardiac arrest following a heart attack. (see also discussion above re heart-attack vs myocardial infarction).

  • The risk is that we split items into loads of separate pages which are discussed at length and in so doing provide no framework of understanding to a reader without specialist knowledge. Example epistaxis, nose bleed and bleeding from the nostril is somewhat equivalent; yes a nasal polyp or tumour can cause nasal bleeding rather than the usual epistaxis from Little's areas, but not to write a singe main article of nose-bleeds (or under heading of epistaxis) would be to write a medical textbook rather than an encyclopedia.
  • A little duplication is therefore OK to prevent the reader having to excessively jump from page to page (they can follow a main link to look up on further information and differentials of course).
  • Most cardiac arrests are as a consequence of myocardial infarction and the addressing of this with community CPR & Defibrillators is important if immediate deaths from MIs is to be reduced. CPR is not that effective (witness recent change in Cardiac compression-Respiratory ratios of 15:2 to 30:2), so community CPR + Defib is much more likely to work than comunity CPR -> delay of ambulance transport (still doing CPR) -> Ambulance or Hospital defib.
  • The whole point of admitting concious patients following an MI to a Coronary Care Unit is so that they receive telemetry, the point of this being to allow prompt defibrillation (assuming no time for drug intervention for a more stabe arrhymthia).
  • The public do perceive the two terms as synonymous and so will look to this article to explain (they reach this article of course via a redirect from their search for [[Heart Attack]]).
  • I think therefore that this is a good place to discuss community defib for cardiac arrest, as well as the more common managment of many MIs (ie with no cardiac arrest), but treatent & monitoring seeks to help prevent further conseques of an MI (including cardiac arrest). To merely redirect the reader away to cardiac arrest or CPR is not to explain the distinction of how one may form part of the management of the other, but is not exclussively so.
  • The cardiac arrest article does its role of explaining the possible causes, but the initial qualifier of mostly due to CHD is both easily overlooked and not necessarily apparent to someone searching for heart attack (meaning myocardial infarction). The depth of information given about management of other causes of cardiac arrest is daunting, so leave a little information on the topic here in myocardial infarction please :-) David Ruben Talk 23:46, 20 January 2006 (UTC)
I do take your point, alot of out of hospital cardiac arrests are due to MI (two thirds springs to mind, although I'm not sure where I got that from); and community defibrillation using AEDs has been shown to improve the time to return of circulation (although some studies show it has no effect on the eventual outcome), and it's important that wikipedia tells readers this. But you don't see detailed information about treatment of cardiac arrest in the articles on any of the other causes (see Hypoxia, Hypovolemia, Hyperkalemia, Hypokalemia, Hypothermia, Tension pneumothorax, Cardiac tamponade, Pulmonary embolism etc... ). I'm not disputing that cardiac arrest occurs, but it does not warrant lengthy explanation here, because it is already well covered in the article on cardiac arrest, and it only adds to the confusion whereby many people think that arrest and MI are the same thing. It's be like saying that occasionally angioplasty leads to complications and requires emergency cardiothoracic surgery, and then going on to give an explanation of what cardiothoracic surgery is - nobody doubts that it happens, but it's not relevant. --John24601 10:50, 21 January 2006 (UTC)
I basically agree with you, its just that cardiac arrests are mostly due to MIs and conversely most deaths from an MI are due to cardiac arrest (vs say allergic reaction to medication given). So when I think of cardiac arrests, I associated this with MIs and not hypoxia/hypothermia etc etc. I agree there is no need discuss at length (cardiac arrest has its own good article), but a brief mention does need to be made (with suitable caveats of course advising that many patients with an MI will not arrest). David Ruben Talk 17:13, 21 January 2006 (UTC)


 : Put like that, most deaths from any condition are due to cardiac arrest... --John24601 17:35, 21 January 2006 (UTC)
True, but this is not a medical textbook and it is precisely because the non-medical reader associates cardiac arrests as occuring from MIs that this article needs make some reference, the question is how much to mention. Too little will seem like missing out entirely that MI's can cause arrests and deaths (for which rescus+defib sometimes helpful), too much I agree is excessive and both reinforces that all MIs result in an arrest and fails to suggest that there are many other causes of an arrest. David Ruben Talk 22:36, 21 January 2006 (UTC)

Arrythmias/Cardiac Arrest

I'm not responsible for the removal, but in retrospect I do agree with it - Cardiac arrest is just a term for a group of 4 arrythmias - asystole, PEA, VF and Pulseless VT. Adding "in case of arrythmias or..." or whatever makes it sound asthough you may have to do CPR for other arrythmias too, which is not true - those 4 are the only 4 which require CPR. Most people having an MI will have an arrythmia before, during and indeed after their MI, but none of those arrythmias require CPR... I suggest reverting the latest edit to put this comment back in --John24601 10:59, 5 February 2006 (UTC)

The most common cause of death after MI is an arrhythmia. Removing this is simply incorrect. JFW | T@lk 11:12, 5 February 2006 (UTC)
This may or may not be correct, I have no idea; but what does that have to do with the edit in question? --John24601 13:21, 5 February 2006 (UTC)

The point is that cardiac arrests in MI are typically ventricular arrhythmias, and that CPR may be necessary. I'll try to rephrase the sentence in question. JFW | T@lk 05:23, 6 February 2006 (UTC)


I think you're just digging holes now *rolleyes* Are we now to say that CPR is not required in cases of asystolic arrest following MI? And how is one to determine whether the arrest is VF/Pulseless VT or anything else in the context of first aid? First aiders in the UK are not even taught to check carotid pulse anymore; instead taught that cardiac arrest is confirmed in the absence of breathing - similar plans are in progress across Europe and North America and much of the rest of the world. There is absolutely no merit in including things which are not strictly relevant and only serve to confuse the situation. --John24601 06:20, 6 February 2006 (UTC)

This is an incorrect perspective. Cardiac arrest is not a term for an arrhythmia, as PEA is not an arrhythmia as such. Cardiac arrest refers to pulselessness. MoodyGroove 15:57, 23 December 2006 (UTC)MoodyGroove

Pain

I've heard, from a reliable source, that pain originating in a myocardial ischemia, will never be felt above the mandible (lower jaw). Ehudzel (talk · contribs)

If you could identify this reliable source we can debate whether it is worth mentioning in the article. JFW | T@lk 21:22, 29 April 2006 (UTC)
In Harrison's Principles of Internal Medicine, chapter 228 about ST elevation MI, it says that pain of STEMI may radiate as high as the occipital area but not below the umbilicus. Ehudzel 22:23, 19 May 2006 (UTC)

"Nose to navel" is the rule of thumb, although location and radiation are only a part of the OPQRST (onset, provoke, quality, radiation, severity, time). MoodyGroove 15:55, 23 December 2006 (UTC)MoodyGroove

Question

With the quick death of Richard Carleton today i was wondering - how often do heart attacks cause death within seconds? PMA 13:05, 7 May 2006 (UTC)

Without looking up any reference to back myself up, I was always taught rule of halves: half of all MIs are asymptomatic and the person is blissfully unaware of it having occured (until perhaps at a later date someone does an ECG/EKG and sees the evidence for one). Of the other half, half die immediately (difficult to know if in seconds or minutes) and the remainder get to hospital complaining of chest pain. I'm sure someone will lay into my rough ready-reconing with some actual percentages :-) David Ruben Talk 19:14, 7 May 2006 (UTC)

50% are silent MIs? I really doubt that. Diabetics and women are more likely not to report chest pain, but half is really a lot.

In response to PMA's question: ventricular fibrillation can kill within seconds, but Carleton's story does not reflect this (would cause immediate loss of conciousness). Ventricular tachycardia is a possibility - some forms are associated with cardiac output & hence maintaining conciousness. Finally, if the infarct was so large as to cause left ventricular failure, one could imagine that this would cause pulmonary oedema fairly quickly.

The pathologist will have the final word. Ruptured coronary plaque with non-recanalised thrombus. JFW | T@lk 12:40, 8 May 2006 (UTC)

True silent MIs more likely in diabetics, to quote from a study looking at diabetics: "Silent myocardial infarction was present in 3.9% of patients, or 44% of all Q-wave myocardial infarctions"

Davis TM, Fortun P, Mulder J, Davis WA, Bruce DG (2004). "Silent myocardial infarction and its prognosis in a community-based cohort of Type 2 diabetic patients: the Fremantle Diabetes Study". Diabetologia 47 (3): 395-9. PMID 14963648. 

However for the general population: "approximately one third of infarcts in the Framingham Study have no clinical counterpart, only being discovered by new Q-waves in a routine 2-year examination cycle"

Spodick DH (2004). "Decreased recognition of the post-myocardial infarction (Dressler) syndrome in the postinfarct setting: does it masquerade as "idiopathic pericarditis" following silent infarcts?". Chest 126 (5): 1410-1. PMID 15539705. 

So I'm not sure the simplistic message I received as a medical student, and now only hazily recalled, was that far off the mark. Perhaps I mis-recall and it was a rule of thirds rather than halves ? David Ruben Talk 15:53, 8 May 2006 (UTC)

Rearanging the outline

I would consider rearranging the outline of this article. After the introduction rather than starting with symptoms and diagnosis I would start with a basic section on normal cardiac anatomy and physiology. This section could explain the normal cadiac function with emphasis on cardiac vascular anatomy and the concept of myocardial oxygen demand. The pathophysiology section would then follow, however I would consider the addition elaboration of the concept of acute coronary syndromes (ACS) which is integral to the understanding of current diagnosis and treatment of myocardial infarction. At this point the difference between Anterior MI's (patients more likely to be tachycardiac and hypertensive with evidence of sympathetic nervous system hyperactivity) and Inferior MI's (patients tend to be bracycardic and hypotensive with predominance of the parasympathetic nervous system) as well as right ventricular MI's could be discussed.

Above posted by User:Sesquiculus on 04:22, 16 May 2006

A discussion of what is normal to help then illustrate the abnormal seems a reasonable approach, but a few cautions:

  • We don't want to excessively duplicate information on normal functioning that might be found on heart.
  • A long section on normal anatomy/physiology might distract from quickly getting on and discussing what the article is about, so keep it very short (just as a primer setting the scene).
  • There is an informal preferred style of writing articles on medical topics, see Wikipedia:WikiProject Clinical medicine/Template for medical conditions. Where the basic order is normally : Classification, Symptoms and signs, Cause/Etiology, Diagnosis, Pathophysiology, Treatment/Management, Prognosis, Prevention/Screening, Epidemiology, History, Social Impact, Notable cases, References, See also & External links. David Ruben Talk 17:18, 16 May 2006 (UTC)