heart attack

heart attack, death of a section of the myocardium, the muscle of the heart, caused by an interruption of blood flow to the area. A heart attack results from obstruction of the coronary arteries. The most common cause is a blood clot (thrombus) that lodges in an area of a coronary artery thickened with cholesterol-containing plaque due to atherosclerosis.

Factors that contribute to the risk of atherosclerosis include high blood pressure (hypertension), diabetes mellitus, increased blood levels of low-density lipoprotein (LDL) cholesterol, smoking, and a family history of the disease. Particularly vulnerable to atherosclerosis are middle-aged men and individuals with the hereditary disease hypercholesterolemia. In the early 21st century, heart attacks were becoming increasingly common among women under age 55. Although the reason for this increase was unclear, increased rates of diabetes, hypertension, and obesity in women likely played a role.

Most heart attacks occur in the morning, a phenomenon that researchers have linked to circadian rhythm. In the morning hours, increasing circadian-driven secretion of certain hormones, particularly epinephrine, norepinephrine, and cortisol, triggers subsequent increases in oxygen demand and blood pressure. These factors in turn increase circulatory activity. In addition, the production of endothelial progenitor cells, which appear to play a crucial role in repairing the lining of blood vessels, also follows a circadian pattern, with fewer cells present in the circulation in the early morning. Decreased levels of these cells results in depressed endothelial maintenance, which scientists suspect may facilitate the onset of a heart attack upon waking.

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Typically, a person experiencing a heart attack has severe chest pain, described as crushing, squeezing, or heavy, that is unremitting for 30 to 60 minutes and sometimes is experienced for longer periods. It often radiates to the arms, neck, and back. The pain is similar to that of angina pectoris, but it is of longer duration. Other common symptoms include shortness of breath; sweating; nausea; rapid heartbeat, often complicated by one or more arrhythmias (irregular heartbeats); and reduced blood pressure. The intensity of the symptoms depends on the size of the area of muscle affected by the heart attack. A small percentage of individuals do not experience pain; in these cases heart attack may be diagnosed from a routine electrocardiogram (ECG).

The focus of treatment is to limit the size of the area of tissue lost from lack of blood (infarct) and to prevent and treat complications, such as arrhythmia. Thus, the sooner the heart rate can be monitored by an ECG and the more promptly the arrhythmia is reversed by defibrillation with either antiarrhythmic drugs or electrical shock, the greater the chance of survival. Pain is treated with analgesics such as morphine, and rest and sedation are required. Other drugs that may be administered include beta-adrenergic-blocking drugs (beta-blockers) to relax the heart muscle, anticoagulants (e.g., heparin) to prevent clotting, fibrinolytic drugs to dissolve existing clots, and nitroglycerin to improve blood flow to the heart. Coronary thrombolysis therapy is widely used; it involves the administration of drugs such as streptokinase or tissue plasminogen activator (tPA) to prevent further blood clots from forming. Angioplasty or coronary artery bypass surgery are additional measures for patients requiring further treatment.

The prognosis for patients who survive a heart attack depends largely on the degree of injury to the heart and the associated decline in heart function. Reduced heart function following an attack is caused by the formation of scar tissue that interferes with the normal electrical activity of the heart, leading to reduced heart muscle contractility, progressive weakening of the heart, and heart failure. To prevent such outcomes, scientists are investigating stem cell-based regenerative therapies, which aim to replace scar tissue with new heart muscle cells.