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Archive 1Archive 2Archive 3

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.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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)

Lancet seminar

doi:10.1016/S0140-6736(16)30677-8 JFW | T@lk 08:23, 2 September 2016 (UTC)

GA Review

GA toolbox
Reviewing
This review is transcluded from Talk:Myocardial infarction/GA1. The edit link for this section can be used to add comments to the review.

Reviewer: Jclemens (talk · contribs) 05:20, 9 March 2017 (UTC)


Rate Attribute Review Comment
1. Well-written:
1a. the prose is clear, concise, and understandable to an appropriately broad audience; spelling and grammar are correct. This is actually pretty good, for how disjointed the flow of topics and thought is.
1b. it complies with the Manual of Style guidelines for lead sections, layout, words to watch, fiction, and list incorporation. No issues noted
2. Verifiable with no original research:
2a. it contains a list of all references (sources of information), presented in accordance with the layout style guideline. Looks fine
2b. reliable sources are cited inline. All content that could reasonably be challenged, except for plot summaries and that which summarizes cited content elsewhere in the article, must be cited no later than the end of the paragraph (or line if the content is not in prose). Some are clearly outdated and need updating, as commented below.
2c. it contains no original research. There are some citation needed (CN) tags, but overall this seems not to be that much of a problem. If anything, it's such a big topic that I'm more concerned about DUE weight.
2d. it contains no copyright violations or plagiarism. Nothing found with Earwig's tool.
3. Broad in its coverage:
3a. it addresses the main aspects of the topic. Yes, broad. Not always well-focused, but broad...
3b. it stays focused on the topic without going into unnecessary detail (see summary style). There's too much detail on some things, but more frustratingly, there's quite a bit of inconsistency between subtopics.
4. Neutral: it represents viewpoints fairly and without editorial bias, giving due weight to each. I've noted a few things where the level of focus on one area seems like potential advocacy. Nothing blatant, and I expect this will be ironed out in the process of review/revision.
5. Stable: it does not change significantly from day to day because of an ongoing edit war or content dispute. Actively being edited, likely in response to the nom, but without any indications of edit warring.
6. Illustrated, if possible, by media such as images, video, or audio:
6a. media are tagged with their copyright statuses, and valid non-free use rationales are provided for non-free content. All OK, no fair use.
6b. media are relevant to the topic, and have suitable captions. Good mix of diagrams and photographs.
7. Overall assessment. Passing per improvements. This was a monumental undertaking, but one I hope benefits our readers for some time to come!
Jclemens' Good Article Review expectations for Vital Articles.
  • This is a vital article. As such, it requires an appropriate amount of scrutiny, because being wrong is just that much worse, so being right is just that much more important.
  • This is a collaborative process. I offer suggestions, which editors are free to implement, ignore, reject, or propose counter-suggestions. If there's simply no meeting of the minds, there will be no GA pass from me, but please feel free to tell me to take a flying leap if I propose something stupid or counterproductive.
  • I do not quick fail vital article GA reviews. In general, even if there is no clear path to meet all the GA criteria, working with conscientious editors is almost always going to improve the article and benefit our readers--just not to the extent all of us had hoped.
  • This is not a quick process. Estimate a month, depending on my availability and the responsiveness of the nominator and other editors collaborating on the process.
  • I am not a content expert. I generally have a reasonable background in the topic under consideration, often at the college undergraduate/survey level, or else I wouldn't have volunteered to review it. Thus, I depend on the content experts to help focus the article appropriately.
  • The more the merrier. While many unimportant GA articles can be adequately reviewed by a single nominator and a single reviewer, Vital Article GA's can use more eyes, based on their increased importance. I always welcome other editors to jump in with suggestions and constructive criticisms.
Thank you, Jclemens. I look forward to helping Winged Blades of Godric get this article to good article status and welcome further reviews. If you could reset your month clock to today I would be grateful as on quick glance I can see this article may have a number of issues you wish to raise. Seeing as I've just taken this up, I will spend a few days getting some up to date reviews and sources in preparation whilst I respond to your comments. Looking forward to working with you both :), --Tom (LT) (talk) 05:58, 8 April 2017 (UTC)

Ozzie10aaaa

this article meets [3]MEDMOS, however fails [4]MEDRS due to the high number of uncited text (unless corrected)have not checked for reviews within 5 years or soWikipedia:Identifying reliable sources (medicine)#Basic advice--Ozzie10aaaa (talk) 13:17, 9 March 2017 (UTC)

Timing

I expect to complete the initial read-through within about 30 hours: tomorrow is a day off for me. Jclemens (talk) 17:31, 9 March 2017 (UTC)

So, I've gotten much more delayed on this than I had anticipated. My apologies to anyone waiting for me. Jclemens (talk) 05:28, 23 March 2017 (UTC)
No worries. --Tom (LT) (talk) 05:58, 8 April 2017 (UTC)
@Jclemens goodness, this was a larger endeavor than I expected. I have marked some issues as "Addressed" so I can help focus on what's outstanding, please remove things from the list if you disagree, or add things if you think they are addressed so I can keep working on the article. --Tom (LT) (talk) 03:52, 7 May 2017 (UTC)
Yeah, we may be working on this for a while. I'll see what I can get to, maybe Monday. Jclemens (talk) 04:26, 7 May 2017 (UTC)
Slowly getting there... thank you for your patience... --Tom (LT) (talk) 23:56, 24 May 2017 (UTC)
@Jclemens OK, I am hanging my hat up for a while. Have worked through almost every aspect of the article... I expect there are a number of areas that need copyediting. Thanks for waiting. Please consider me having responded to your first tranche of comments. --Tom (LT) (talk) 11:21, 6 June 2017 (UTC)
Gotcha, will continue review from here. BTW, Tom (LT), did you just change your username to match your sig? Jclemens (talk) 16:22, 6 June 2017 (UTC)

First read-through

Lead

 Addressed
  • "Risk factors include [...] among others." That's a tad redundant--I tend to prefer "include (but are not limited to)"
    •  Not done The current formulation is a standard way, and the use of the word "include" implies "is not limited to" (otherwise it would say "Risk factors are") --Tom (LT) (talk) 05:51, 8 April 2017 (UTC)
  • "A number of tests are useful to help with diagnosis, including electrocardiograms (ECGs), blood tests, and coronary angiography.[11] An ECG may confirm an ST elevation MI if ST elevation is present.[2] Commonly used blood tests include troponin and less often creatine kinase MB.[11]" If we're going to go into as much detail as the second and third sentences include, might it not be cleaner to integrate them. Also, do we want to introduce EKG as an older (but still commonly known by laypersons) acronym?
  • Do we want to define what ST elevation is (e.g. a variance seen on ECGs during the last phase of each heartbeat's electrical cycle) if we're going to refer to it multiple times during the lead?
  • If we're going to talk about Aspirin, O2, etc. in the lead, and we expect this to be a widely read article, should we also consider including summoning local emergency services (911/999/etc.)?
  • CABG is used without the acronym being fully spelled out: "... bypass surgery (CABG)" I suspect that should be spelled out before the acronym is used, or the acronym can be saved for later in the body, as it is not reused in the lead.

Signs and Symptoms

 Addressed
  • "Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, and upper abdomen,[19] where it may mimic heartburn." I'm wondering if this could (or should) be reworded to take into account the positive predictive value of right arm radiation. I haven't looked at the LRs on these recently, but ISTR that pain radiating to the right arm is still a very high PPV compared to most of the others.
  • "Levine's sign, in which a person localizes the chest pain by clenching their fists over their sternum" should be reworded to note that a single fist is typically sufficient.
  • "Atypical symptoms are more frequently reported by women, the elderly, and those with diabetes when compared to their male and younger counterparts." I want to know WHAT atypical MI symptoms are before you tell me who gets them. In other words, I believe this and the next few sentences should be essentially flip-flopped in order.
  • "Women may also experience back or jaw pain during an episode." But men cannot? How about 'are more likely to'?
    •  Done I've removed the poorly sourced statements here and moved the statement about symptoms in women to a position closer to the start. I've also tried to reword the part about "atypical" symptoms to clarify that the symptoms in women are not atypical, but that when atypical symptoms occur they are more common in women. --Tom (LT) (talk) 07:08, 22 April 2017 (UTC)
  • "at autopsy without a prior history of related complaints." I understand what this means, but it's awkward and may be opaque to our non-medical readers. Jclemens (talk) 07:13, 11 March 2017 (UTC)

 Doing... will find and update references and do a general copyedit of said section before I respond to a number of your (very pertinent) comments. --Tom (LT) (talk) 05:53, 8 April 2017 (UTC)

Still  Doing...... --Tom (LT) (talk) 01:44, 22 April 2017 (UTC)
 Done --Tom (LT) (talk) 00:37, 24 May 2017 (UTC)
  • "Shortness of breath occurs when the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema." Is this completely and adequately correct? Right sided heart failure can reduce LV output even in the setting of an entirely healthy LV. Granted, that's rare, but... is this the way we want to say it? To put it another way, is this the only mechanism for persons suffering an acute MI to also have SOB that we want to mention?

Causes

 Addressed
  • The relationship of smoking and obesity to CAD is great... but shouldn't we pair that closely with the risk of CAD to MI? That is, the relationship may be clear to us, but the readership probably would benefit from it being spelled out better.
  • Lack of exercise is mentioned in the first paragraph, and lack of physical activity in the second. Those could probably be paired for more impact.
    •  Done the whole order was strange. I have reordered this section so that significant risks are covered first, and less important risks are covered later. --Tom (LT) (talk) 07:59, 22 April 2017 (UTC)
  • I'd really like the third paragraph in Lifestyle, on dietary effects, scrubbed by an expert. Just reading I worry that one or several of the studies cited may be cherry-picking evidence to support an agenda, and I'd like to make sure we don't have that.
  • We need something much newer than a 14-year-old meta-analysis if we're going to dis combined oral contraceptives. Including them at all is UNDUE in light of what we know on NSAIDs and the increased risk of MI. Jclemens (talk) 04:39, 14 April 2017 (UTC)
  • In Disease " dyslipidemia/high levels of blood cholesterol (abnormal levels of lipoproteins in the blood), particularly high low-density lipoprotein, low high-density lipoprotein, high triglycerides," seems to be rather extensive compared to what we mention about the other diseases. Well, except that obesity gets a similar elongated treatment.
  • The paragraph on infection impact on MI should be reviewed by an expert.
    •  Not done I have had a look around and there are quite a few high-quality sources that support chronic infections as a risk factor for cardiovascular disease, presumably as such infections cause inflammation which speeds up atherosclerosis. --Tom (LT) (talk) 00:58, 24 May 2017 (UTC)

Still  Doing... --Tom (LT) (talk) 07:59, 22 April 2017 (UTC)

Pathophysiology

 Addressed
  • What's a clotting cascade?
  • Some more concrete statements about probabilities would be welcome: "most frequently" and "most common" are weasely and could stand more precision.
  • "It is estimated that one billion cardiac cells are lost in a typical MI." That is a cool trivial factoid, but absent context (How many cells are there in the heart? How many can we live without?) I'm afraid that's all it remains.
  • "Hyperhomocysteinemia [...] is associated with premature atherosclerosis" So how many steps removed from the actual MI do we want to go? I count at least two (Hyperhomocysteinemia->Atherosclerosis->MI) which seems like an inconsistent level of coverage.
  • "Calcium deposition as calcification is another part of atherosclerotic plaque formation." Is it just me, or are we bouncing back and forth between pathophys and diagnosis here?
  • "Myocardial infarction in the setting of plaque results from underlying atherosclerosis." Didn't we cover this in the first paragraph in this section?
  • "the heart cells in the territory of the occluded coronary artery die" I'm not sure territory is the best word here. Perhaps "the heart cells supplied by the occluded coronary artery die" or something along those lines to make the causal relationship even more explicit?
  • "If impaired blood flow to the heart lasts long enough," The article hasn't yet described any circumstances where blood flow would be impaired on a temporary basis.
  • "Bloodstream column irregularities visible on angiography reflect artery lumen narrowing as a result of decades of advancing atherosclerosis." Nice sentence, but it seems to break up the logical flow between what comes before and after. Also, angiography hasn't been wikilinked since the lead, and probably should be.
  • "As a result, the person's heart will be permanently damaged." We haven't personalized the heart before now. Do we want to start?
  • The Pathological types aren't entirely clear. It seems like this could be a binary option, but it's clearly not.

Overall, this section really needs a complete re-outline and rewrite. It doesn't follow a consistent taxonomy or logical progression, in the one section of the article that could most clearly benefit from such a top-down approach. Jclemens (talk) 05:00, 15 April 2017 (UTC)

  • Do we want to talk about pulseless vs. perfusing VTach?
    • Thanks for continuing :). I've split this section into subsections to try and improve how we cover it. I'll see how this is received and continue when there's consensus--Tom (LT) (talk) 01:29, 17 April 2017 (UTC)
      •  Partly done have rolled the pathophysiology related complications into 'tissue death' and left the other complications section. I think it is a little beyond the scope of the article to talk about variant complications (MI -> complications -> VT -> perfusing / pulseless) --Tom (LT) (talk) 00:18, 3 June 2017 (UTC)

Diagnosis

 Addressed
  • "A cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression, or coronary intervention is diagnostic of MI" Sure it is, but that is because cardiac troponins belong inside cardiac muscle cells, and finding them in the bloodstream indicates cardiac muscle cell destruction.
  • "Previously, a recent left bundle branch block was considered the same as ST elevation, however, this is no longer the case." Tell me more... Why? By whom? When did it change?
  • "There are a number of different biomarkers." How about listing them all in turn, and then talking about the advantages/disadvantages/timing of each?
  • "A chest radiograph and routine blood tests may indicate complications or precipitating causes and are often performed upon arrival to an emergency department." Not only does it have a citation needed tag, it really could use some more elaboration, too.
  • "Medical societies and professional guidelines recommend that the physician confirm a person is at high risk for myocardial infarction before conducting imaging tests to make a diagnosis." Why?
  • "The differential diagnosis for MI includes other catastrophic causes of chest pain" I think this is still backwards. How about, "In addition to MI, the differential diagnosis for chest pain includes..." or similar construction instead?
  • "Chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle is termed angina pectoris." 1) this should probably be more prominent, and 2) would it be appropriate to note that areas of ischemia often surround the areas of infarction? Looking through the section, I don't see it mentioned anywhere obvious.

I note that you're working on this and reorganizing things as you go. Good deal! Jclemens (talk) 03:02, 27 April 2017 (UTC)

Thanks, I am still gradually working through this. --Tom (LT) (talk) 10:40, 28 April 2017 (UTC)
 Done I have given this section a thorough copyedit. --Tom (LT) (talk) 11:19, 6 June 2017 (UTC)

Management

 Addressed
  • "Treatment attempts to save as much viable heart muscle as possible" Viable is redundant.
  • "hence the phrase "time is heart muscle"." Yeah, but so what? Who actually says that? Needs a better setup than 'hence'.
  • NSTEMI: Every NSTEMI is NSTEACS, but not every NSTEACS is NSTEMI, right? That's not quite so clear in the text.
  • GRACE score is currently redlinked, and should be explained or de-redlinked.
  • P2Y12 gets far more airplay--COI?
  • "Nitroglycerin (administered under the tongue or intravenously) may be administered to improve the blood supply to the heart." 1) It's also a dermal paste, 2) there's no evidence it improves mortality.
    •  Partly done not mentioning dermal paste; this is not mentioned in any of the sources I have looked at (and that's quite a few at present), sublingual is I am guessing preferred due to its rapid absorption; I have mentioned the lack of mortality benefit.--Tom (LT) (talk) 22:31, 24 May 2017 (UTC)
  • Good that the updated O2 recommendations are included, but it really makes things look quite haphazard. Aspirin only gets a mention, without description of mechanism of action.
  • Thrombolysis gets a lot more airplay than PCI, and CABG is not mentioned at all in the STEMI section. Is that really correct? Obviously PCI is preferred to CABG, but I've always understood that CABG is a backup for PCI.
  • Does targeted temperature management *only* belong to the STEMI branch? Seems to me it's agnostic about how you get to a cardiac arrest.
  • Of all the parts of this section, the secondary prevention portion seems to be the only part which doesn't need to be completely rewritten... But yeah, as I noted above, secondary prevention probably belongs to prevention, not management. Jclemens (talk) 02:34, 29 April 2017 (UTC)
  • It's not clear to me how ASA or PCI treatment differ between STEMI and NSTEMI.

Prevention

 Addressed

There's a LOT to be considered in this section. I think it should probably be entirely rewritten. Jclemens (talk) 03:11, 27 April 2017 (UTC)

  • Can we get an update on the diet recommendations? 'five portions' etc. seem oddly specific and out of context.
  •  Question: these do indeed reflect reliable sources. What changes would you suggest? --Tom (LT) (talk) 10:48, 6 June 2017 (UTC)

Prognosis

 Addressed
  • TIMI scores somewhat lack context. How does their use relate to the previous paragraph?

Epidemiology

 Addressed
  • This is some interesting prose, but I'd prefer to see some tables illustrating this. I may be alone in this, so consider it a suggestion.
  • Obviously, this needs a refresh and update. I get that 2016 numbers won't be available for a while, but surely we can do better than 2008. I'm thinking 2012-14 should be available somewhere. Jclemens (talk) 02:42, 1 May 2017 (UTC)

Society and Culture

 Addressed
  • Is it just me, or is this a trivia section by another name? Seriously, it should be broken up and integrated elsewhere, unless there's something else to add to it. "Heart attacks in popular culture" could have a section of how they ONLY shock Asystole on TV... Jclemens (talk) 02:48, 1 May 2017 (UTC)
check Partially implemented-I am looking to add details about "Heart attacks in popular culture" soon.Winged Blades Godric 04:45, 1 May 2017 (UTC)
@Winged Blades of Godric how's this section going? --Tom (LT) (talk) 00:45, 3 June 2017 (UTC)

Second read-through

Lead

  • "The mechanism of an MI often involves the complete blockage of a coronary artery caused by a rupture of an atherosclerotic plaque." Would reversing cause and effect make this sentence more clear?
  • "In ST elevation MIs treatments which attempt to restore blood flow to the heart are typically recommended and include..." What about "IN STEMI, treatments to restore the heart's blood flow include..." I think the recommendation verbiage is sufficiently obvious per WP:BLUE that even mentioning it is redundant. Jclemens (talk) 22:09, 10 June 2017 (UTC)

Terminology

  • "It is a type of acute coronary syndrome" Would subdivision or category be better words than 'type'?
  • We imply that CK-MB is specific to cardiac muscle death, but skeletal muscle can also provoke its elevation, can it not? Do we want to clarify that, or would that be splitting too many hairs?
    •  Not done Splitting hairs. It is discussed in more detail below, but I think it's important to introduce the concepts here so readers have some idea what we are talking about.--Tom (LT) (talk) 00:29, 11 June 2017 (UTC)
  • We reintroduce STEMI and NSTEMI here, but use Myocardial Infarction first and MI thereafter without the parenthetical (MI) after the first usage. This should be consistent, and matching whatever the MOS says to do wouldn't hurt even if it's not strictly required at the GA level. Jclemens (talk) 22:09, 10 June 2017 (UTC)

Signs and Sympoms

  • "Shortness of breath is a common, and sometimes the only symptoms, that occurs the damage to the heart limits the output of the left ventricle, wither breathlessness arising either from subsequent hypoxemia or pulmonary edema" Needs to be clarified and quite possibly broken up.
  • "Atypical symptoms, such as cardiac arrest and palpitations, occur more frequently in women, the elderly, those with diabetes, in people who have just had surgery, and in critically ill patients." I'm not familiar with calling cardiac arrest an atypical symptom of MI. Is that correct? Jclemens (talk) 02:13, 12 June 2017 (UTC)

Causes

  • All the other risk factors are either boolean (DM II), or state directionality (older age, high blood pressure). I think High total cholesterol and LOW HDL should be explicitly stated.
  • "Many risk factors of MI are shared with coronary artery disease, the primary cause of myocardial infarction," If you're going to write one out (but there's already one spelled out in the first paragraph in this sentence/section) and abbreviate another, the first one should be written in full. In this case, I think either both instances abbreviated as MI or the sentence restructured to avoid the redundancy would be fine.
  • "At any given age, men are more at risk than women for the development of cardiovascular disease." Doesn't that start substantially evening out after menopause? If so, we might want to note that.
  • Might want to explicitly state who is guessing what risk factors contributed to which MIs, rather than just reeling off percentages.
  • "High levels of blood cholesterol, particularly high (increased levels of) low-density lipoprotein, low (reduced levels of) high-density lipoprotein, high (increased levels of) triglycerides." This should either be expanded with more context, or rolled into the opening sentence in this section.
  • "The evidence for saturated fat['s role in MI risk] is unclear"
  • Do we have anything on high sugar intake contributing directly to MI?
  • "Family history of ischemic heart disease or MI [is a risk factor for MI], particularly if one has a male first-degree relative (father, brother) who had a myocardial infarction before age 55 years, or a female first-degree relative (mother, sister) less than age 65."
  • Do we really care which genes have been associated with MI, given that we're not talking about any of them at all? Might a separate article be called for? Not only does correlation not imply causality, but it seems to be hit or miss whether the linked articles even mention the risk association at all; I didn't see any that gave an odds ratio or statistical strength of association. Jclemens (talk) 04:30, 18 June 2017 (UTC)

Mechanism

  • "Plaques can become unstable, rupture, and additionally promote the formation of a blood clot that blocks the artery; this can occur in minutes." [...] "Exposed to the pressure associated with blood flow, plaques, especially those with a thin lining, may rupture and trigger the formation of a thrombus." Can these be harmonized so the reader understands what is going on when, and why?
    • Not sure about this one. I have tried to split up the paragraphs so that one is talking in more general terms about atherosclerosis, whereas the second is talking in specific terms about clots. What do you suggest? --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
      • I guess a single note about blocking of coronary arteries, with reference within it to the multiple underlying etiologies? Would that be reasonable? Jclemens (talk) 20:06, 22 June 2017 (UTC)
  • "A heart with a limited blood supply with increased oxygen demands on the heart (such as in fever, tachycardia, hyperthyroidism, anaemia and hypotension)." Verb missing.
  • "These changes are seen on gross pathology and cannot be predicted by the presence of absence of Q waves on an ECG." Presence OR absence, right?
  • Isch[a]emic cascade is linked twice in the Tissue Death section.
  • Nowhere does the Tissue Death section make it clear that 'infarction' is cell death. That may seem obvious to you and I, but not to all of our readers.
  • It would be nice if the tissue death section talked about the various zones, c.f. this (presumably non-free, included for example, not use in the article absent licensing [5]. Jclemens (talk) 04:17, 19 June 2017 (UTC)

Diagnosis

  • For Criteria, it's not entirely clear: You need to have biomarkers and one of the bulleted items, or all of them?
  • For cardiac biomarkers, I think it would be appropriate to mention that CK-MB, etc. have been superseded, rather than that they're just discouraged. In other words, paint a bit of history into describing the current state of practice.
    • Not sure here. In my mind, these are different investigations with one being preferred for MI, and the other two being discouraged for use. It is (in my mind) not the same as saying CK has been superseded by CK-MB, or Troponin T with high-sensitivity troponin, etc.--Tom (LT) (talk) 11:51, 22 June 2017 (UTC)
  • For ECGs: Are we correctly differentiating between the stickers and the printout? Between wires and leads? Also, I'd consider wikilinking the first electrocardiogram in the section, even if it means taking it out of the Criteria section, since this is the most relevant section. I'd go so far as to suggest the current Criteria wikilink to ECG be retargeted to the Electrocardiogram section, rather than being a true Wikilink.
  • For DDx, consider adding costochondritis? While it's pretty trivial to differentiate for providers, it is still a common cause of non-cardiac chest pain.
  • Overall, this section is much cleaner and better organized during the first go-round. I'm very happy with what I'm seeing. Jclemens (talk) 03:16, 22 June 2017 (UTC)

Management

  • "Thrombolysis is not recommended in a number of situations, particularly when associated with a high risk of bleeding, past strokes or bleeds into the brain, severe hypertension, and active bleeding" Is a high risk of bleeding the first list entry, or does it describe the rest of the list? Everything except severe hypertension appears to be bleeding-related in this sentence.
    • High risk of bleeding -- on anticoagulants, coagulation disorders, thrombocytopaenia etc. Active bleeding - as stated. Past bleeds into the brain - as stated. These are different things; so one entry can't unfortunately encompass all three. --Tom (LT) (talk) 11:04, 22 June 2017 (UTC)
  • "Therefore, oxygen is currently only recommended if oxygen levels are found to be low or if someone is in respiratory distress." Would it hurt to increase specificity and call "someone" a patient?
  • "After PCI, people are generally placed on dual antiplatelet therapy for at least a year (which is generally aspirin and clopidogrel)" 1) People could again be 'patients'--should it be? 2) I've seen differing durations of dual antiplatelet therapy based on drug-eluting vs. bare metal stents. Is that worth mentioning here?
  • In rehab, do we really need to link driving and sexual intercourse? Seems overlinkage to me. Jclemens (talk) 03:27, 22 June 2017 (UTC)

Prevention

  • Make the time differentiation between primary and secondary prevention a bit more explicit? I understand exactly what you're saying, but could we benefit from being a tad more pedantic/explicit here?
    • I feel further exploration of the time course of primary and secondary prevention may confuse matters. Both terms are defined in the section introduction. Secondary prevention often starts within the day or two after an event. Some (eg no smoking or drinking) may be thought of as starting instantly, given that most hospitals do not allow these on site. --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
  • "non drinking or drinking alcohol within the recommended limits" Not drinking any more alcohol than recommended, maybe?
  • "The dietary pattern with the greatest support" Scientific support? Reduced all cause mortality?
  • "Olive oil, rapeseed oil and related products are to be used instead of saturated fat." .. recommended instead of?
  • Overall, there's a lot here that relies on Ref 94, a UK government document which I have no reason to believe is any less bought and paid for by various food lobbies than the US FDA equivalents are. Do we have anything better? I fear not, but thought I'd ask.
    • Good point. I've rejigged and copyedited the paragraph to decrease the prominence of their suggestions, but included the dietary advice as a (common, worth mentioning) example of advice that is given.--Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
  • The statement in favor of statins for primary prevention should likely be stronger.
    • Good point. I have increased its prominence, clarified it, and improved the source used (And also corrected the secondary prevention source). --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
  • The statement in favor of HRT seems too strong for what I understand of the topic. Jclemens (talk) 04:16, 23 June 2017 (UTC)

Prognosis

Epidemiology

Society and Culture

  • Gotta have something on there about shocking asystole! I kid, that would be under depictions of cardiac arrest in popular culture... No other issues, and THAT is the second read-through. Jclemens (talk) 06:32, 23 June 2017 (UTC)

References

  • I'm going to be picking on these based on age, which I know is not the sole determinant of whether a study should be included. Feel free to disagree, and to make sure the journals in question are top tier, but I've not seen anything obviously predatory. I get that some of these are seminal references with lasting impact beyond a 5-10 year window, but I want to make sure each pre-2007 reference is scrutinized appropriately.
  • DAVIDSONS2010B is defined twice, which looks to be just different pages of the same book.
  • "Little RA, Frayn KN, Randall PE, Stoner HB, Morton C, Yates DW, Laing GS (1986). "Plasma catecholamines in the acute phase of the response to myocardial infarction"" is 30+ years old. Please replace with something current.
  • "Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB (1998). "Prediction of coronary heart disease using risk factor categories"" is almost 20 years ago, please replace if possible.
  • "Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group.". Lancet. 343 (8899): 311–22. Mar 1994" is 20+ years old, please replace if possible.
  • "http://www.thennt.com/nnt/beta-blockers-for-heart-attack/" Needs full citation info.
  • "Antman EM; Cohen M; et. al. (2000). "The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making."" also "David A. Morrow; et. al. (2000). "TIMI Risk Score for ST-Elevation Myocardial Infarction: A Convenient, Bedside, Clinical Score for Risk Assessment at Presentation: An Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial Substudy."" 15+ years old--is there something newer?
  • "Becker RC, Gore JM, Lambrew C, Weaver WD, Rubison RM, French WJ, Tiefenbrunn AJ, Bowlby LJ, Rogers WJ; Gore; Lambrew; Weaver; Rubison; French; Tiefenbrunn; Bowlby; Rogers (1996). "A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction"." Anything newer?
  • "Perry, K; Petrie, KJ; Ellis, CJ; Horne, R; Moss-Morris, R (July 2001). "Symptom expectations and delay in acute myocardial infarction patients."" Anything newer?
  • Overall, I am really happy with the prevalence of 2010-present dated citations in the ref list. Jclemens (talk) 22:25, 10 June 2017 (UTC)

Source review

@Doc James, Jclemens, do you know any editors who might be willing to do a review of the sources used on this article? I would like a separate reviewer to just focus on the sources used here... there seems to be quite a lot which are either primary sources or very old, and if they are identified I can get to work updating or removing them. --Tom (LT) (talk) 01:29, 17 April 2017 (UTC)

Anything older than 2010 should likely be updated. Was looking at getting a tool that would tag all articles that are reviews as reviews. Doc James (talk · contribs · email) 01:33, 17 April 2017 (UTC)
I don't personally know any cardiologists inclined to spend time on Wikipedia, no, but I expect either of us could find more current sources. I know I have all the usual suspects of medical databases at my disposal through my non-Wikipedia affiliations. Jclemens (talk) 01:39, 17 April 2017 (UTC)

Taking over review

Hi Arubaska (Winged Blades of Godric), I note that you are in school, and (as far as I can see) haven't made any major edits to this article. I expect that you are very busy and may not have the full time to address all the concerns raised here. If you and Jclemens are happy, given the importance of this article, I am happy to take on a role as a conominator to help address reviewer concerns. I'll get to responding above and, if you feel like you would like to take back the baton, please let me know :). Cheers --Tom (LT) (talk) 05:29, 8 April 2017 (UTC)

@Jclemens and LT910001:--Sorry, the last time I was pinged related to this was long back when JC started reviewing the page.For the next two or three days there wasn't any progress from him--(due to certain concerns by him) and I lost my interest.Gotcha watchlisted it!And JC even a simple ping would have attracted my attention!I am receiving the next ping today and seeing all the progress, all of a sudden!Anyway I will be improving the article w.r.t to the concerns raised by JC and if you(Tom) want to help the article in it's way to GA status, I am generously and gladly accepting it!Cheers!Winged Blades Godric 12:35, 8 April 2017 (UTC)
Sounds good. I'll help out as I can. --Tom (LT) (talk) 23:41, 8 April 2017 (UTC)
I hadn't had any feedback from anyone on anything here, so I admit it has been less of a priority because of that. I am willing to continue reviewing, but honestly will have limited time for the next few weeks due to non-Wikipedia concerns, so having someone else take over makes sense to me. Jclemens (talk) 16:11, 9 April 2017 (UTC)
@LT910001: Ok, I've none through more of the article, and will continue to try to slog through it--as a break from the things I should be doing, actually... Hopefully, once I get to the bottom we can start at the top again... Jclemens (talk) 06:39, 15 April 2017 (UTC)

Changes

So here I changed Coronary artery bypass surgery to coronary artery bypass surgery as the word is not at the beginning of a sentence it does not need a capital letter.

This text was trimmed "An ECG, which displays the electrical currents associated with contraction of heart muscle, produces a regular form." as it is without a reference and does not really make sense.

Why was myocardial infarction bolded in the caption? Where does the MOS support this? Doc James (talk · contribs · email) 09:02, 10 April 2017 (UTC)

Status

How are we doing? Are we ready for any part of a re-review? Jclemens (talk) 01:11, 13 May 2017 (UTC)

Sorry, I have been unusually busy this week. I am slowly making my way through this article, adding content, fixing, simplifying and adding / replacing sources. When that's done, I'll run through and address what is remaining. You can use my little lists of 'addressed' as as a guide to what I'm working on - so far only signs & symptoms is ready for a re-review. --Tom (LT) (talk) 11:55, 13 May 2017 (UTC)
@Jclemens responded to second trache. Thanks for your patience. I have left a message on your talk page. Looking forward to your response, --Tom (LT) (talk) 14:17, 2 July 2017 (UTC)

Status

This process appears to be ongoing. Why did Legobot change the status of the article to GA on 2 July, and should we remove that? Jytdog (talk) 17:43, 4 July 2017 (UTC)

I passed it. It's still being improved, but has met all the GA criteria for a while now. Apologies for not making this clearer; hopefully this note clears things up better than the annotation to the GATable did. Jclemens (talk) 17:51, 4 July 2017 (UTC)
Thanks for clarifying. Jytdog (talk) 18:08, 4 July 2017 (UTC)

ST elevation

The ECG deserves to be explained in the lead, so that the average reader has some idea of what it is talking about. I don't think this text is perfect, but we should make some attempt to explain what the ECG is.

  • Attempted addition: "An ECG, which displays the electrical currents associated with contraction of heart muscle, produces a regular form. An elevation in the ST section may indicate a type of MI."
  • Revert by Doc James (described as "adjust") back to "An ECG may confirm an ST elevation MI if ST elevation is present"

Can I point out the sentence that has been reinstated has three acronyms (ECG, ST, MI) and is tautologous ? Suggest other editors, including Jclemens may need to weigh in here. --Tom (LT) (talk) 09:03, 10 April 2017 (UTC)

What does "produces a regular form" mean? Where does this definition come from?
We sell out what ECG stands for in the sentence immediately before that one. Have adjusted the linking of that sentence to make the terms more clear.
MI is spelled out in the first sentence of the article. Doc James (talk · contribs · email) 09:07, 10 April 2017 (UTC)
Our aim should be to improve the readability of articles, so that the text written can be read and understood by readers. If possible we should reduce our use of acronyms in this light. Where do we spell out what an ECG? We state it is a test in the sentence before - that is not "spelling out". As stated above this is an attempted improvement. Would you say the sentence is perfect as is? If not, perhaps we can discuss ways to improve it. --Tom (LT) (talk) 21:03, 10 April 2017 (UTC)
Sure we can add a definition of ECG. How about a "a recording of the heart’s electrical activity" with this as a ref[7]
Thus we get this[8]Doc James (talk · contribs · email) 22:44, 10 April 2017 (UTC)
I'd call that a definite improvement over what was there before, but we still don't explain what the ST segment is, let alone why ST elevation is bad, just wikilinks it. I think anything contained in the lead of an article should be self-contained, and question whether the best way forward is to explain everything, or rather to abbreviate further in the lead and leave the detailed, acronym-filled explanation to the body text. Oh, and thanks for the ping. Jclemens (talk) 05:02, 11 April 2017 (UTC)
How about An ECG, which is a recording of the heart's electrical activity, may confirm an ST elevation MI (STEMI) if a change known as ST elevation is present. ?
Doc James (talk · contribs · email) 17:22, 11 April 2017 (UTC)

(shrug) I'd be tempted to add something along the lines of "... ST elevation, an abnormality of the final phase of the heart's per-beat electrical cycle which can indicate ischemia or infarction, is present." But I know good and well that's waaaaay too detailed for the lead. I'm just not one to introduce a term without providing at least a minimal amount of contextualization, even if it is wikilinked. Jclemens (talk) 04:13, 12 April 2017 (UTC)

Hum. We could leave out "if a change known as ST elevation is present" altogether. Doc James (talk · contribs · email) 05:31, 12 April 2017 (UTC)
This seems like the best solution. --Tom (LT) (talk) 01:05, 17 April 2017 (UTC)

Pathophysiology subheadings

To split up content into logical groups I've added the subheadings 'atherosclerosis', 'infarction' and 'complications'. This (I hope) will help separate out the discussion. It will also help split up coverage so that non atherosclerosis-related MI can be covered in a less confusing way. Thoughts? --Tom (LT) (talk) 01:11, 17 April 2017 (UTC)

Sounds good. Doc James (talk · contribs · email) 21:27, 18 April 2017 (UTC)

Differential

Typically is part of the section on diagnosis not signs and symptoms per MEDMOS. Doc James (talk · contribs · email) 03:40, 17 April 2017 (UTC)

Thanks, noted. --Tom (LT) (talk) 20:36, 25 April 2017 (UTC)

Classification section?

Am thinking about a "classification" section at the top. I think it would be very useful for readers to have a clear definition of what an MI is at the top, that it is an ACS, and that there are ST and non-ST variants. I think this would add to (rather than only duplicate) the lead, and that it would help clarify the peace-meal presentation of this in the article below. Thoughts? --Tom (LT) (talk) 01:02, 17 April 2017 (UTC)

Haved moved an existing sentence to this section. If there's consensus to keep, I will expand it further. --Tom (LT) (talk) 02:02, 17 April 2017 (UTC)
@Doc James, Jclemens any thoughts here? --Tom (LT) (talk) 21:10, 18 April 2017 (UTC)
Sure happy with a section on classification going first. Doc James (talk · contribs · email) 21:26, 18 April 2017 (UTC)
Agreed--and then let's make sure it's inclusive, at least mentioning the appropriate zebras. Jclemens (talk) 00:42, 19 April 2017 (UTC)
@Ozzie10aaaa you have removed the initial "classification" section with this summary " MEDMOS/ this sectionis REPEATED in the 'Diagnosis' section, thank you". I am hoping to introduce some basic concepts to the reader by including this section, rather than leaving them somewhat confused by our peacemeal mentions until they hit the diagnosis section. This section does not just repeat the 'diagnosis' section as it covers the relationship between ACS and AMI and some basic concepts to help orientate the reader.
As you can see there are some other editors who support this too and I am in the process of expanding this as stated above ("I will expand it further"). Also not too sure what you mean by "MEDMOS" -- perhaps have a look at WP:MEDORDER? Classification is the first section. So to summarise: please read the talk page, the MEDMOS, and the article before removing a chunk of text in an active GA in the future.--Tom (LT) (talk) 20:36, 25 April 2017 (UTC)
so...per Wikipedia:Manual of Style/Medicine-related articles#Diseases or disorders or syndromes, I removed the section as it seemed repetitive, as such a sub-section usually goes under diagnosis.Now then, if your "creating" something different in the body of the article, well that's different(I've reverted myself, though I believe it should follow MEDMOS)--Ozzie10aaaa (talk) 21:02, 25 April 2017 (UTC)

Diagram of Areas where pain is experienced

In this diagram, more area towards right side is colored which should be left instead as I understand. The diagram can be changed accordingly. -- Abhijeet Safai (talk) 06:41, 2 May 2017 (UTC)

But I am reading following sentence too which says that "The pain most suggestive of an acute MI, with the highest likelihood ratio, is pain radiating to the right arm and shoulder." Hence if the diagram is correct, it need not be changed. Thank you. -- Abhijeet Safai (talk) 06:44, 2 May 2017 (UTC)
Yes rt sided chest pain is more specific while left side from what I understand is more common Doc James (talk · contribs · email) 17:22, 2 May 2017 (UTC)
Thanks a lot for sharing that. -- Abhijeet Safai (talk) 10:23, 3 May 2017 (UTC)

Merging 'prevention' and 'secondary prevention'

I am inclined to merge 'prevention' and 'secondary prevention' and put the combined section after treatment, given that both refer really to a common underlying process of atherosclerosis and coronary artery disease. This is a bit of a grey area in WP:MEDMOS... I think because there is a fair amount of overlap between these two sections, it is logical to group them, and if they are to be grouped, this would be best done after the treatment section. Secondary prevention is best, I think, described after ACS, once medications and surgical procedures have been introduced.

@Doc James, Jclemens, thoughts? --Tom (LT) (talk) 09:33, 22 May 2017 (UTC)
I agree with the spacing and grouping in principle. There are multiple good ways to address the grouping, so I have no strong preferences. Jclemens (talk) 17:46, 22 May 2017 (UTC)
For gout we have place primary prevention under "prevention" and secondary prevention under treatment. I have no strong preference either. Doc James (talk · contribs · email) 21:56, 22 May 2017 (UTC)

NEJM

doi:10.1056/NEJMra1606915 - review. JFW | T@lk 08:39, 25 May 2017 (UTC)

@Jfdwolff unbelievable, two detailed reviews within months. It was clearly time to summarise where we're at. Thanks for plopping this down, will trawl through this shortly. --Tom (LT) (talk) 21:31, 27 May 2017 (UTC)

Management

Treatment does not begin with "risk factor stratification using a scoring system such as the thrombosis in myocardial ischaemia (TIMI) or GRACE scores".

Treatment begins with giving ASA (and maybe clopidogrel or ticagralor), give O2 if sats are low, starting an iv, giving nitro if the BP is okay, reading the ECG and giving TNK if their are no contraindications / doing PCI if the ECG shows a STEMI. Doc James (talk · contribs · email) 17:55, 27 May 2017 (UTC)

Disagree, this is a simplistic view of emergency management. As you know treatment happens in parallel rather than sequential fashion in the ED, and begins with a practitioner's assessment of stability and urgency of treatment required for each condition, whether they realise it or not. Risk factor stratification is important and mentioned in multiple sources. I will replace this sentence with "may include" risk factor stratification to assuage your concerns.--Tom (LT) (talk) 21:27, 27 May 2017 (UTC)
Usually one starts initial treatments such as ASA and addresses ABCs before risk stratifying. Risk stratification is more used when determining discharge and workup. Would put it under diagnosis or prognosis not treatment. As risk stratification is NOT treatment. By the way TIMI is dealt with here Doc James (talk · contribs · email) 00:11, 28 May 2017 (UTC)
This review [9] provides a good overview. Doc James (talk · contribs · email) 05:54, 28 May 2017 (UTC)
  • @Doc James even the abstract (I can't access full text from home) states "Fibrinolysis is not recommended in patients with non-ST elevation acute coronary syndrome; therefore, these patients should be treated with medical management if they are at low risk of coronary events or if percutaneous coronary intervention cannot be performed". Further:
  • "Early risk stratification of patients with myocardial infarction allows for prognostication and triage via initiation of one of several vital treatment pathways" (Reed et al., 2017)
  • "Risk stratification is important because it guides the use of more complex pharmacological and interventional treatment" (Davidsons, 2010)
  • I would really like to include some reference to risk stratification in the management section, and I think there are sufficient verifiable references to support their use in management. Is there a way you would be happy for me to include this information? --Tom (LT) (talk) 11:25, 6 June 2017 (UTC)
    • Fibrinolysis is definitely contraindicated in NSTEMIs. It is only given in STEMIs. That decision is made based on the ECG rather than risk stratification. The TIMI or GRACE scoring system is not really explicitly used outside of trials. Management is partly based on the risk the person is having a myocardial infarction. I would be okay with that, just do not think the stratification belongs. Doc James (talk · contribs · email) 13:20, 6 June 2017 (UTC)

Morphine

Concerns of negative effects in AMI[10] Doc James (talk · contribs · email) 18:02, 27 May 2017 (UTC)

Lots of refs cover this[11]. Have added a bit. Doc James (talk · contribs · email) 18:09, 27 May 2017 (UTC)
Thanks for your addition. It has been difficult to strike a balance comprehensiveness between deep discussion of treatment vs. maintaining readability and avoiding prescriptive guides. --Tom (LT) (talk) 21:27, 27 May 2017 (UTC)

Symptom not noted in this article:

numbness in the hands and neck discomfort

But I don't know how to insert it into the "Other symptoms" part...

https://www.ncbi.nlm.nih.gov/pubmed/15017150

The patients experiencing MI reported significantly more nausea (46% vs. 32%), vomiting (19% vs. 2%), indigestion (42% vs. 16%), and fainting (9% vs. 2%). The patients experiencing UA reported significantly more chest discomfort (97% vs. 87%), lightheadedness (52% vs. 39%), numbness in the hands (43% vs. 28%), and neck discomfort (31% vs. 13%). Patients with MI rated the peak intensity of the chest discomfort higher than patients with UA (mean 8.4 vs. mean 7.7).[1]

Universal definition

Now updated doi:10.1161/CIR.0000000000000617 JFW | T@lk 12:46, 26 August 2018 (UTC)

Per this text

" Pain in arm(s), back, neck, jaw or stomach (for women)"

These symptoms are not exclusively in women. Doc James (talk · contribs · email) 09:06, 26 December 2018 (UTC)

No one said any of these symptoms were “exclusively” in women; they are symptoms that the AHA wants women to recognize that they are likely to experience differently than men. Reading comprehesion. The very lede of the article already says, “Women more often present without chest pain and instead have neck pain, arm pain, or feel tired.” Grammatically incorrect but no different than what I put in the infobox. Trillfendi (talk) 17:07, 30 December 2018 (UTC)
These are also relatively common in older people and diabetics. Have shortened. Doc James (talk · contribs · email) 03:57, 31 December 2018 (UTC)

A small verifiability issue

Hi Doc James. I have seen that you have restored this ref: "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction" [12] but I have had a look at it and couldn't locate a discussion on risk factors. Can you help? Thanks, Cinadon36 07:49, 25 February 2020 (UTC)

User:Cinadon36 you are correct. Have removed it. Thank for finding a reference that does support the text. Doc James (talk · contribs · email) 00:23, 26 February 2020 (UTC)

NLRP3 inflammasome

There are two review articles discussing the role of the NLRP3 inflammasome in relation to myocardial infarction. Could someone check, please, whether there is something in this that is worth mentioning in the article?

  • Toldo S, Abbate A (April 2018). "The NLRP3 inflammasome in acute myocardial infarction". Nature Reviews. Cardiology. 15 (4): 203–214. doi:10.1038/nrcardio.2017.161. PMID 29143812.
  • Takahashi M (2019). "Role of NLRP3 Inflammasome in Cardiac Inflammation and Remodeling after Myocardial Infarction". Biological & Pharmaceutical Bulletin. 42 (4): 518–523. doi:10.1248/bpb.b18-00369. PMID 30930410.

Thanks --Chris Howard (talk) 05:18, 5 October 2019 (UTC)

Hi Chris Howard. I 've had a look and these two papers are indeed interesting reviews. Maybe we could mention NLRP3 somewhere but we risk turning the article too technical. -4-5 Textbooks on cardiology or MI that I have searched do not mention it though- (apart one mention at Morrow 2016- see article for full citation). This could be due to a variety of factors. I would feel much more comfortable if I could find a classic textbook or a formal guideline discussing the NLRP3 inflammasome. One more factor is that the article does not discuss cardiac remodeling after an MI and therefor neither the inflammatory cascade is mentioned. Anyway, I will work on it and I will let you know. Cinadon36 08:00, 25 February 2020 (UTC)
Yes, a textbook or formal guideline would be ideal. --Chris Howard (talk) 09:27, 3 March 2020 (UTC)
  1. ^ DeVon, HA; Zerwic, JJ (NaN). "Differences in the symptoms associated with unstable angina and myocardial infarction". Progress in cardiovascular nursing. 19 (1): 6–11. PMID 15017150. {{cite journal}}: Check date values in: |date= (help)
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