Talk:Myocardial infarction/Archive 1

Can anyone take a closer look to ouabain. strange claims there without valid references. Jeff

Excuse me, but at the end of the ouabain site there is a link to an article, which has 264 references !!! Many with direct links to pubmed and additional informations (location of the university). Where do you find this service anywhere else ? The most of the clinical references are unfortunately only published in german language, but there are also studies published in english and partly at pubmed. Regarding the pathogenesis of myocardial infarction there is a host of references from pubmed. My book about ouabain has 1380 references and a preface from Prof. Dr. med. Hans Schaefer / Heidelberg, who was a leading physiologist for several decades and international renowned. Why is there this sharp opposition against a medication that has surpassing positive effects in myocardial infarction and angina pectoris ? For more text see below. I will add more information on the ouabain site when I´ll find the time... regarding the topics "oral absortion" and "ouabain as a newfound hormone" please see the discussion of the ouabain site. I have worked on the topic ouabain meticulously for several years. Every little detail is supported by references. --RJ Petry 23:23, 4 September 2005 (UTC)

Quintiliano H. de Mesquita

Dear Dr. Wolff

I have sent to you last monday the reasons why Dr. Quintiliano H. de Mesquita is notable. However my message disappeared by magic.

Do you want I send it again?

Hoping you are not a watchdog for the interests of the medical establishment, I send

My best regards

Carlos Monteiro

Infarct Combat Project

secretary@infarctcombat.org

Do you have any evidence at all supporting his theory? --WS 14:24, 17 August 2005 (UTC)

Dear WS

Do you have any evidence at all supporting the Thrombogenic Theory???

I strongly suggest you to see Dr. Mesquita's article "Myogenic Theory Explains or The Thrombogenic Theory Tumbled Down and the Orthodox Cardiology Didn't Noticed" at http://www.infarctcombat.org/MyogenicTheoryExplains.html and also his book about the Myogenic Theory of Myocardial Infarction with a Summary in English at http://www.infarctcombat.org/LivroTM/parte8.htm

Carlos Monteiro

Infarct Combat Project

Carlos, you are making a mistake. Dr Mesquita may be correct, but the fact that he is a lone voice in a desert full of misguided cardiologists does not make him notable. Honestly. Only if the field recognises him as a dissenter (of which you have provided no evidence) or a significant minority of the field aknowledges his views is there any hope of including him.

The thrombogenic theory is supported by angiographic studies, the effectiveness of thrombolysis, postmortem studies, animal models and many other avenues of research. I know that you will be able to answer every single assertion with some obscure study, so I will not endeavour to continue the discussion. JFW | T@lk 18:15, 17 August 2005 (UTC)

Please help -- a request

I have noticed that this article contains no list of symptoms or reasons for immediate action in cases of heart attack. I understand that pain radiating into the left arm is not universal, but I also understand that some other common symptoms are not either. While WP is not intended to be a medical (or emergency treatment) resource, at least something along this line should be here. Many readers will, now that WP has become the astonishing resource that it is, refer to it for some information when they think there might be a problem. Wording should, of course, contain the necessary disclaimers and warnings so as to diffuse the possibility of WP being sued for 'malpractice', but nevertheless something like this is needed here.

I invite the medical folk who contribute to WP to add something responsible along these lines.

Thanks.

The most relevant symptoms are all there. There is no need for a disclaimer - the Wikipedia:General disclaimer specifically disclaims medical information. You don't need to be a doctor to edit this article! JFW | T@lk 07:20, 1 September 2005 (UTC)

I agree it could have a more detailed features or symptoms section, will look into it later... --WS 10:56, 1 September 2005 (UTC)

Added symptoms section. --WS 15:23, 5 September 2005 (UTC)

Prof. DeMesquita and others and the effects of ouabain in acute myocardial infarction

There has to be made a differentiation: 1) the alternative view of the pathogenesis of myocardial infarction, 2) the surpassing positive effetcs of ouabain in this indication (and angina pectoris !). Regarding point 1) we can debate for a long time. There are astonishing facts (with many references) supporting an alternative view. But I don´t like a war against the orthodox position. Perhaps the “truth“ is a complementary one. The German advocates of the ouabain therapy, especially Dr.med. Berthold Kern, the explorer of the oral ouabain therapy, and the International Society of Infarct Prevention (in the 1960ies up to the 1980ies) always closely associated the topic “ouabain“ with the “new cardiac infarction hypothesis“ and presented the latter often in a sometimes too unilateral manner, and so the resistance of the official medicine regarding new aspects in the pathogenesis of cardiac infarction was perhaps carried over to the topic of ouabain. For an interesting reading see http://ouabain.twoday.net/ and look for Part II: Mostly unknown aspects of myocardial infarction (many references). The advance in science is dependent on (good) hypotheses !!!

The pathogenesis of infarction is interesting, but not as important as the concrete clinical experiences with ouabain. Here some facts - not all (without references, for them please see http://ouabain.twoday.net/.

In acute mayocardial infarction (AMI) 1975-1987 Prof.R.Dohrmann from Berlin (West), the leader of a public hospital, used a new therapy with 1) i.v. cortison to stabilize the lysosomal membranes and 2) from 1975 -1976 oral ouabain (lingual absorption, capsule to break with the teeth, 6 mg) and then from 1976-1987 i.v. k-strophanthin (0,25 mg every 24 h). The quota of nonsurvivors (30 days) after myocardial infarction previously was very high (38,8 %) because in Berlin (West) have been much more elderly people than in the rest of Germany. With this therapy Prof. Dohrmann reached the worldwide best rate of survival of that time - in the first year with oral ouabain 17,6 % nonsurvivors (3), and 1987, after 12 years, 15,1 % with experiences with 1056 patients (4). A multicenter study of northern Germany reported a quota of 26 % mortality in a comparable period (5). Prof. Dohrmann was outnumbered only by Prof.DeMesquita from a clinic in Sao Paolo (6) who used ouabain i.v. from 1972 -1979 in 1037 cases (until ouabain lost the license in Brasilia): they reached 9,6 % mortality during the stay in hospital, which could be reduced to 5-7 days with the ouabain therapy.

Another example is a coal mine in Gelsenkirchen/Germany (7) where the average number of workers dying because of acute myocardial infarction (AMI) in the mine, under the surface of the earth, was 3 every year; the way to the doctor lasted more than half an hour. After the doctors of the mine began with oral ouabain therapy directly in the mine in 1974 - given only when there was an acute heart attack, not prophylactically given -, the mortality concearning AMI was reduced to zero in the following 10 years with this therapy. In two cases there was no possibility to give oral ouabain (accidents) and the workers died. The cases concearning severe angina pectoris attacks and non-mortal cardiac infarctions that forced to drive the workers out of the mine were reduced by 80 % with oral ouabain in 1974-1984.

The best example for the indeed excellent therapeutic results of oral ouabain in angina pectoris and myocardial infarction is a study of Prof. Dohrmann starting 1975 with this therapy. 1984 Dohrmann & Dohrmann published a study (1) dealing with oral ouabain therapy in unstable angina pectoris. 148 patients with severe stenosis visable in coronary angiography, who received for years all the medicaments modern medicine offers and who are dissatisfied because of continous heart attacks and in part unpleasant side effects, have been switched over (with their agreement after an information discourse) to the therapy with oral ouabain from one day to the other, i.e. the other medicaments including the ß-blockers (!) were discontinued immediately. After one week 122 of 148 patients were completely free from angina pectoris, and after two weeks this success could be seen with 146 patients. They were also free from the side effects of the former medication.

An study in english language supporting the numerous studies in german is Sharma B, P.A.Majid, M.K.Meeran; W.Whitaker & S.H.Taylor (Leeds / GB): Clinical, electrocardiographic, and haemodynamic effects of digitalis (ouabain) in angina pectoris. Br Heart J 34: 631-637, 1972

For all aspects of this complex topic please see my article. --RJ Petry 00:03, 5 September 2005 (UTC)

How many adherents does this theory have? And outside Germany? Please note that Wikipedia only mentions significant minority views. JFW | T@lk 06:34, 5 September 2005 (UTC)

At first I have to beg your pardon for my probably bad english. I have read many studies, but to write in english is not my strongest discipline / ability.

Outside Germany at least Mr. Monteiro (former Mr. DeMesquita) with experiences in his clinic in Sao Paulo since 1972 is an adherent. I think the workgroup of Mr. Baroldi in Milan / Italy have great sympathy. I will contact soon... In Germany 2000-3000 doctors are using orally administered ouabain in the prophylaxis and treatment of angina pectoris and heart infarction. There are dozens of clinical and pharmyco-dynamical studies (in part double-blind) !

I think, that in this point the number of adherents is not important. This is a quantitative aspect. In this topic the quality of data content is so extraordinary (see above, my first text), that the formal aspect of the number of adherents or citations is only of secondary importance.

Really, it´s an inherent attribute of a new hypothesis / paradigm shift, that in the beginning there are only few adherents. Excuse the overconfident comparison, but the heliocentric world view also had only very few adherents in the beginning.

Don´t victimise the really optimal solution of the problem of myocardial infarction that is unsolved for many decades on the altar of the financial fundament of medical business, which is dominated by the interests of the big combines. No big company will spend the immense sum for a substance like ouabain that has lost its patent rights for long and that could displace most of the actual medicaments in a cost-saving way.

Please read my article on http://ouabain.twoday.net/ and think about it. The ordinary formal aspects had to step back, I think. I have worked for some years intensively on my book about ouabain and have documented every detail by references meticulously. --RJ Petry 09:22, 5 September 2005 (UTC)

You appear to be misunderstanding Wikipedia. It is not a scientific review. It does therefore not need to mention scientifically relevant opinions unless they are widely held or notorious (or both).

If you have been writing a book advocating the use of ouabain you may actually not be the ideal person to judge the notability of this treatment. You should not be turning to Wikipedia to popularise your view, but recruit patients for randomised trials and presenting the results at cardiology conferences. Perhaps that will lead to the paradigm shift you're hoping for. I find "some doctors in Germany, Brazil and Italy" not a significant representation of the cardiological field. JFW | T@lk 12:10, 5 September 2005 (UTC)

I agree with JFW for the most part. I wouldn't object to a neutral mention that some practitioners use ouabain for treatment purposes, but that such use has neither been thoroughly tested nor peer reviewed. There have been few research efforts in this area, and their statistical validity is thus questionable; peer review depends on repeatability of the research and its findings in order for a claim to become accepted, or at least to pass the stage of testable hypothesis.

The link to your website certainly doesn't belong here. Also, how many references you cite is irrelevant; what's important is how many authors cite the studies you mention in their own work. Keep in mind that Wikipedia requires both neutrality and verifiability, and rejects original research. Mindmatrix 20:21, 5 September 2005 (UTC)

There are always persons that are defending the orthodox positions and keep them clean from all facts that don´t fit in the dominant theory. Is it really harmful to Wikipedia that in this article there is one link to an article with many indices for a really outstanding therapy in a situation where we have this problem of myocardial infarction unsolved for decades ? I want to accent that I don´t work for the producer of the ouabain medication.

You (JFW) write: "You should ... recruit patients for randomised trials and presenting the results at cardiology conferences. Perhaps that will lead to the paradigm shift you're hoping for." Oh, I whish it could be so simple. Ähem: A randomized trial does cost a lot of money, especially if it is a big one. This money no company will spend on a substance without patent rights, as I wrote above. AND: No big company will spend the immense sum for a substance like ouabain that has lost its patent rights for long and that could displace most of the actual medicaments in a cost-saving way.

In this situation I see no general way for the undoubtly optimal therapy for myocardial infarction and angina pectoris. A real tragedy. But this information has to be preserved for better times in the future...

But there is already a randomized placebo-controlled clinical trial, even if it is including only 30 patients and is published only in german language: Salz & Schneider 1985 (8, for the full text with references please see http://ouabain.twoday.net) carried out a placebo controlled doeble-blind study with 30 patients with coronary heart disease. They found after 14 days of prophylactic application of oral ouabain (3 x 6 mg Strodival mr® daily) a highly significant effect on the ECG (elevation of the lowered S-T-segment), the angina pectoris attacks and the subjective state of health in comparison of the verum and the placebo group and also an amelioretion of hypertension. With placebo there was seen a deterioration of all parameters, see table below:

Salz & Schneider 1985, double-blind study

the effect of Strodival® in 16 patients

...........patients without change ...moderate improvement..essential improvement

exercise-ECG..............0........................5...........................11

angina pectoris-attacks..1......................2...........................13

subjective condition......0........................1...........................15

the effext of the placebo in 14 patients

...............................patients with deterioration

exercise-ECG...........................12

angina pectoris-attacks.............10

subjective condition...................10

Saradeth & Ernst 1991 (47) made a randomized, double-blind and placebo-controlled crossover-study with healthy volunteers and found a reduced rise of diastolic blood pressure in exercise after lingually administered ouabain (6 mg).

The double-blind experiment of Kubicek and Reisner 1973 (69) with angina pectoris-patients under hypoxia showed in 19 of 22 patients a marked improvement of the electrocardiogram (S-T-alterations) - in 7 cases a total normalization - after 6 mg oral Strophoral® (90 % ouabain, 10 % k-strophanthin) in comparison to a control group, and the result of subjective state of health is as follows: control: 18 patients with pain or giddiness and only 4 without trouble. After oral ouabain: Only 4 patients with pain or giddiness and 18 patients are without trouble. A placebo showed no effect. Digitalis had a negative effect, so that some experiments had to stop before the regular end (several drugs in differentiated dosis: Digoxin i.v. 0,4 mg, 0,8 mg, ß-Methyl-Digoxin oral 0,05 mg, 0,2 mg, 0,8 mg). Also Sharma et al. 1972 (70) had similar good results with 0,7 mg i.v. ouabain. After ouabain the patients had much less angina pectoris pain using bicycle exercise. The ECG didn´t change, perhaps because of the very high dosage. This is the corroboration of the therapeutical results reported by Prof. Dohrmann and others.

Belz et al 1984 (71) made a placebo-controlled double-blind crossover-study, which shows that lingually administered ouabain (12 mg) has a constant and significant (in part highly significant) effect on the heart contractility of healthy volunteers that is different from the effect of ouabain i.v. and similar to that of nitroglycerine, that is a negative inotropic effect. The double-blind experiment of Kubicek and Reisner 1973 (69) with angina pectoris-patients under hypoxia showed in 19 of 22 patients a marked improvement of the electrocardiogram (S-T-alterations) - in 7 cases a total normalization - after 6 mg oral Strophoral® (90 % ouabain, 10 % k-strophanthin) in comparison to a control group, and the result of subjective state of health is as follows: control: 18 patients with pain or giddiness and only 4 without trouble. After oral ouabain: Only 4 patients with pain or giddiness and 18 patients are without trouble. A placebo showed no effect. Digitalis had a negative effect, so that some experiments had to stop before the regular end (several drugs in differentiated dosis: Digoxin i.v. 0,4 mg, 0,8 mg, ß-Methyl-Digoxin oral 0,05 mg, 0,2 mg, 0,8 mg). Also Sharma et al. 1972 (70) had similar good results with 0,7 mg i.v. ouabain. After ouabain the patients had much less angina pectoris pain using bicycle exercise. The ECG didn´t change, perhaps because of the very high dosage. This is the corroboration of the therapeutical results reported by Prof. Dohrmann and others, see above.

Belz et al 1984 (71) made a placebo-controlled double-blind crossover-study, which shows that lingually administered ouabain (12 mg) has a constant and significant (in part highly significant) effect on the heart contractility of healthy volunteers that is different from the effect of ouabain i.v. and similar to that of nitroglycerine, that is a negative inotropic effect. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6428911&query_hl=4 Dohrmann & Schlief-Pflug 1986 (72) repeated the above mentioned study with patients which had severe coronary heart disease and instable angina pectoris.

I know that the documentation of the orally administered ouabain therapy has formal weakness regarding the contemporary pretensions of a "evidence based madicine" which are unaffordable for every little or medium-sized pharmaceutical company. But the content is extraordinary and sensationally positive, and everyone who reads the multitude of all the studies has no doubt that ouabain could be the solution of the problem of myocardial infarction. The severity of this problem and the quality of the data pro ouabain outweighs the formal aspects that you are emphasising.

Mindmatrix: Naturally I know what you adress, but in this case the conventional formal criteria are failing. There is a strange opposition against ouabain: The deceased doctor of the coal mine in Gelsenkirchen / Germany in which ouabain had sensationally therapeutical success over 10 years (see above), Dr. Brembach, told me that after the appearance of an article about the ouabain therapy in the factory there has been a meeting of managers of the german pharmaceutic industry with the employer, who thereupon has forbidden the continuation of the ouabain therapy in the factory, which had prevented 30 statistically probable deaths by cardiac infarction. (!) Prof. Belz, who made the randomized placebo-controlled crossover study with ouabain (see pubmed-link above) got problems after the publication of his study - the threat that he would not receive orders any more if he would continue his research. Ouabain seems to be something like a taboo - also here at Wikipedia ?

I know that it is a problem to ask for reading literature, but I do so: Did you read my article ? Please don´t sabotage very important informations that are solving many lives and could solve much more of them and are demanding only a place at the end of the site at "external links". --RJ Petry 21:29, 5 September 2005 (UTC)

RJ, please give briefer responses. I have little care for your page and the 267 references. Ouabain is not a taboo - it is too poorly supported by evidence. Wikipedia is not going to be your forum in recruiting adherents to your theory. I wish you stopped your attempts at using it for that purpose. Even if ouabain was a miracle cure, it would be denied a place in Wikipedia unless it was recognised as such by the relevant professionals. Unless you can indicate this is indeed the case, I will not accept your external link.

Please write a grant proposal to a large cardiovascular charity, recruit investigators and start including patients into large randomised, double-blind placebo-controlled trials. You will be saving more lives than by writing on Wikipedia. JFW | T@lk 22:14, 5 September 2005 (UTC)

I'd also prefer if you kept your responses brief. To answer one question, Wikipedia does not consider ouabain taboo, otherwise that article wouldn't exist at all (I note you've already edited that article). You say: which had prevented 30 statistically probable deaths by cardiac infarction; probable and definite are two different things. There is no certainty that infarction would have occurred. Irrespective of that, I re-iterate that this simply needs more peer review. If it costs too much for small pharma companies, then either cardio charities (as mentioned by JFW) or governments may fund such research. The peer review system exists for a reason.

Case in point: how do you know that the study you mention didn't lie outside of the statistical confidence interval? This can only be determined by successive experimentation and research. The more research exists, the more likely it will trend towards an accurate representation of that which it studies. We're not preventing you from adding neutral comments into these articles - feel free to mention ouabain, that some alternative medicine practitioners use it to treat patients etc. But the fact that most cardiologists do not believe in its potency will also be noted in the article; so too for potential risks etc. Wikipedia will maintain neutrality in this matter, but will present facts as they exist. We're not trying to be difficult, just well-grounded in realism with a small dose of scepticism. Mindmatrix 02:23, 6 September 2005 (UTC)

Briefer responses

Okay, this time only a brief response (not having time and not willing to be impertinent) and only to the topic of the sequence ot the sub-topics. I have clicked on every "see also" links", none of them has all three sub-topics. Only "Dresslers Disease": 1) see also, 2) references. At "Bypass" I found 1) references 2) see also 3) external links. So the statement: "all Wikipedia articles follow this sequence" is much more invalid as the results of the ouabain studies (...smile...). I think, at least the references have to had their place before "see also". Regarrding the other points I will add a notice later... --RJ Petry 08:03, 6 September 2005 (UTC)

I've fixed the article at Coronary artery bypass surgery - I think that's the one you mentioned. Thanks for pointing it out. Note that at one time, Wikipedia did not have standards about this, but to ensure that articles have some consistency, this policy was eventually chosen by consensus. There are still many articles that have not been modified to match this new standard, but they will be eventually. Mindmatrix 17:21, 6 September 2005 (UTC)

Thrombogenic Theory (Herrick, 1912) X Myogenic Theory (Mesquita, 1972): Almost the same therapeutic conduct

Dear JFW

For your better clarification follows the (hidden or forgotten, due contradiction) part of the classic text "Clinical features of sudden obstruction of the coronary arteries, JAMA, 59: 2015-2020, 1912 by James B. Herrick. There was presented, besides the proposition of a mechanism, his therapeutical experience using digitalis and strophanthin in front of angina pectoris and coronary thrombosis:

“”...................................................................................................................................... If these cases are recognized, the importance of absolute rest in bed for several days is clear. It would seem to be far wiser to use Digitalis, Strophantus or their congeners than to follow the routine practice of giving Nitroglycerin or allied drugs. The hope for the damaged Myocardium lies in the direction of securing a supply of blood through friendly neighboring vessels, so as to restore so far as possible its functional integrity. Digitalis or Strophantus by increasing the force of the heart’s beat, would tend to help in the direction more than the Nitrites. The prejudice against Digitalis in cases in which the Myocardium is weak is only partially grounded in fact. Clinical experience shows this remedy of great value in Angina, and especially in cases of angina with low blood pressure, and these obstructive cases come under this head. The timely use this remedy may occasionaly in such cases save life. Quick results should also be sought by using it hypodermically or intravenously. Other quickly acting heart remedies would also be of service."”

This little disagreement about the pathophysiological mechanism and the therapeutic conduct in Herrick’s paper is not told or discussed at medical schools or in scientific papers. So, nearly all doctors still in total medical ignorance about the subject until today. The Herrick’s Thrombogenic Teory was adopted and his therapeutical conduct was forgotten.

The Myogenic Theory of myocardial infarction, by the way, is entirely compatible with the therapeutic conduct by digitalis and strophanthin.

Sincerely yours

Carlos Monteiro

Infarct Combat Project

Carlos, you're starting to get repetitive. The Herrick paradigm, as I said above, has been confirmed endlessly by literally 1000s of studies, from post-mortem to angiographic to interventional studies. The use of cardiac glycosides, which Herrick may have supported, has now been abandoned by most practicioners. The number of cardiologists that adheres to the thrombogenic paradigm is many, many times the number of adherents to your Mosquito therapy. I have asked yourself and RJ Petry to cite clear evidence that a substantive minority of cardiologists supports the theory. So far all you have done is quote your master and insist that cardiac glycosides will mean the end of all heart disease. Start conducting studies, and we will talk again. JFW | T@lk 17:23, 7 September 2005 (UTC)

Dear JFW (jfdwollf)

As you requested I am sending you a link to the last paper by Mesquita and Baptista. In this paper published at Ars Cvrandi Magazine in 2002 presented the follow-up of 28 years (1972-2000) using digitalis in daily doses to prevent acute coronary syndromes in nearly 1200 patients with coronary-myocardial disease. As a result it had a very low mortality of 14.2% in cases without previous myocardial infarction (0.5% per year) and of 41% in cases with previous myocardial infarction (1.4% per year). This paper was republished at Internet in 2005: The link is http://www.infarctcombat.org/28anos/digitalicos.html

This article by Mesquita and Baptista is the most complete and definitive proof that the medical therapy by digitalis or strophanthin in prevention or treatment of acute coronary syndromes can save many lives as occurred in the past in Germany (Ex: Ernst Edens; Berthold Kern; R. Dohrmann, and many others), In US (Ex: James Bryan Herrick 1912; Louis Hamman, 1926; Ferdinand R. Schemm, 1950; John Martin Askey, 1951; Norman H. Boyer,1955 - see at http://www.infarctcombat.org/heartnews-02.html) and in Brazil (Quintiliano H. de Mesquita, Cláudio Baptista et al, since 1972 - See at http://www.infarctcombat.org/MyogenicTheory.html ).

Let’s talk now about the convenient and heroic procedures like bypass surgery, angioplasty, stents and drugs like clot-busters, statins, and beta blockers that you and the substantive majority of cardiologists support. Do you KNOW how many million lives are being SAVED with these modern approaches?

Regards

Carlos Monteiro

Infarct Combat Project

These modern approaches save a lot of lives, to the point that the most spendthrift health authorities are advocating the routine use of statins in many cardiovascular diseases. But you have not been listening. The fact that there is evidence is not the determining factor for inclusion on Wikipedia. Notability is. Unless you can quote evidence that many cardiologists support the Mosquito theory, it will not be mentioned here. I will not respond to your postings anymore unless you can produce this evidence, as you have not been responding to my repeated enquiries on this matter. JFW | T@lk 17:04, 8 September 2005 (UTC)

Dear JFW (jfdwollf)

Please remember that our initial intention was just to place the existence of another theory (Myogenic) opposing the dogmatic coronary thrombosis theory (thrombogenic) to explain the triggering mechanism of the myocardial infarction.

Unfortunately our request was denied by professionals that apparently have a large investment in the status quo.

You as a doctor and presumable as a scientist must accept that your version of reality will be overturned in the fullness of time. If you can’t accept that you are not a true doctor or scientist.

Sincerely, taking in account your responses, I do not see sufficient scientific honestly or expertise from you to administrate this important subject at Wikipidia. Moreover looking to hide your real identity as a protection from this kind of censorship attitudes you are taking. In fact I do not like to discuss science with anonymous.

For your information we don’t want to transform the myocardial infarction section at Wikipidia in a permanent tribunal to accuse or to judge the inefficacy of modern medical approaches dealing with coronary artery disease and/or to open a page at our website denouncing that Wikipidia is making censorship in this theme.

However, we are prepared to do so

Regards

Carlos Monteiro

Infarct Combat Project

While your comments were directed at JFW, I'll add my reply too.

First, you state that "our request was denied by professionals that apparently have a large investment in the status quo". This is not so; outside of Wikipedia, I am a programmer and systems administrator - I am not involved in medicine in any way, nor do I have a vested interest in it.

Secondly, "a scientist must accept that your version of reality will be overturned in the fullness of time. If you can’t accept that you are not a true doctor or scientist." This is false. A scientist accepts that in the future, competing hypotheses will be presented, but that they must withstand the peer review process before becoming a theory and displacing entrenched beliefs.

Thirdly, "I do not see sufficient scientific honestly or expertise from you to administrate this important subject at Wikipidia". Nobody that participates in Wikipedia administers a subject or article; all articles are written by consensus by any authors that wish to contribute to it. Contentious items will require discussion, as is the case here, and anything which is not resolved to your satisfaction with the authors can be brought to arbitration, or raised for discussion elsewhere in Wikipedia, to be analyzed by parties with no vested interest in the topic. See dispute resolution for more details.

Finally, "looking to hide your real identity as a protection from this kind of censorship attitudes you are taking. In fact I do not like to discuss science with anonymous." An individual's identity or anonymity does not change the facts of the situation. Furthermore, if you feel there is censorship, bring it to the attention of other Wikipedia authors. To me, it appears that you don't understand how Wikipedia works, nor any of its policies. Mindmatrix 21:39, 8 September 2005 (UTC)

Filed for RfC

Note that I have raised this issue at Wikipedia:Requests for comment/Maths, natural science, and technology. Mindmatrix 22:08, 8 September 2005 (UTC)

It's suddenly very quiet here. A myocardial infraction? JFW | T@lk 05:19, 17 October 2005 (UTC)

As a secondary character in a B-rate horror movie might reply: "Too quiet." Mindmatrix 18:27, 17 October 2005 (UTC)

Taking in view you want some noise follows the current myths on human coronary atherosclerotic plaque* according the great and notable, recognized internationally, Professor Giorgio Baroldi, cardiovascular pathologist from Italy, which we totally agree:

1. Experimental hypercholesterol model and correspondent human conditions do not represent the natural history of atherosclerosis in coronary arteries in the general population. 2. Physiological intimal thickening can not be interpreted as starting point of the atherosclerotic process. 3. Fatty streak does not represent the early atherosclerotic lesion. 4. Calcification is not synonymous of severe stenosis. 5. Hemorrhage is not consequent to endothelial fissuration. 6. Prevention of macrophage “inflammation” as source of substances able to disrupt the fibrous cap allowing rupture and thrombosis as well as identification of the thickness of fibrous cap to diagnose a vulnerable plaque may have little, if any, sense. Rupture and thrombosis may be secondary phenomena and not the cause of an acute coronary syndrome. 7. Degree and number of severe coronary plaques do not predict onset, course, complications and death in CHD.

Unfortunately the maintenance of these myths is very convenient to many and many doctors, hospitals and pharmaceutical industry. The reason is that many current treatments are dependable of these myths.

Carlos Monteiro

secretary@infarctcombat.org

• Ultrasound imaging versus morphopathology in cardiovascular diseases. Coronary atherosclerotic plaque, Giorgio Baroldi et al. Cardiovascular Ultrasound 2004; 2: 29 http://www.cardiovascularultrasound.com/content/2/1/29

Oh yeah, sure. Everything we believe in is wrong. Listen buddy, I worked for a large trial that looked into people with LDL receptor mutations. High LDL cholesterol, otherwise healthy. Their medical records were rather scary: young women dead at 26 with heart attacks. The kids with homozygous disease have heart attacks when they're toddlers.

Just spare us your spin and attempts to rewrite medical science. I have absolutely no idea why you, with a site called "infarct combat", should subscribe to all that sort of bizarre ideas. You are not doing the world any favours. They will carry on smoking and eating rubbish, firmly believing that those doctors are lying anyway. JFW | T@lk 02:21, 23 October 2005 (UTC)

Here is a typical example of conservative reaction exposed by a professional when he receives new information that defies his beliefs, mainly when his pocket is affected.

About the cholesterol myths and regarding the very few benefits (by pleitrotropic effects) and many risks from statins to the health, you can instruct yourself at The International Network of Cholesterol Skeptics (http://www.thincs.org)

Anyway, I would like to know in what large cholesterol trial you have worked and also if your name was reported as author.

Infarct Combat Project publishes scientific medical matters based in scientific evidence, not rubbish.

Moreover the Infarct Combat Project doesn’t receive any funding support in donations, advertisements or else, from pharmaceutical companies or through its representatives.

So we do not have conflicts of interest in medical matters published at ICP

Carlos Monteiro

Infarct Combat Project

secretary@infarctcombat.org

I have only two words for you, Carlos: Go Away. JFW | T@lk 02:45, 28 October 2005 (UTC)

Mindmatrix,it is hard to believe in Wikepedia when we see your response of September 8, and now your colleague tells that he has just two words for me as above:

"Nobody (????) that participates in Wikipedia administers a subject or article; all articles are written by consensus by any authors that wish to contribute to it. Contentious items will require discussion, as is the case here, and anything which is not resolved to your satisfaction with the authors can be brought to arbitration, or raised for discussion elsewhere in Wikipedia, to be analyzed by parties with no vested interest in the topic".

I regret to know the preference from Wikipedia about marketing over Science.

I still waiting the response about my claim regarding censorship you raised at Wikipedia:Requests for comment/Maths, natural science, and technology. Mindmatrix on 22:08, 8 September 2005 (UTC)

Carlos Monteiro

secretary@infarctcombat.org

Ah, it's marketing now, eh? Nobody has actually been censoring you. You've just been making nonsensical claims about an unsupported fringe theory. Just because you think something is notable is fairly poor grounds for inclusion. I suggest you start conducting serious trials and presenting the results at international cardiology conferences. This will have more of an impact than complaining on this page that you're not being listened to. JFW | T@lk 01:53, 30 October 2005 (UTC)

Yes, maybe by narrow-mindedness or ignoring the science but still marketing. A good example of “marketing” you are doing is for statins. The data from the Heart Protection Study tells the truth. HPS involved 20.536 patients aged 40-80 years with coronary disease, other vascular diseases or diabetes, representing high-risk individuals. The patients in the HPS study were randomly allocated to receive 40 mg Simvastatin daily or matching placebo during a scheduled 5 year treatment period, aiming to verify mortality and fatal and non-fatal events. Follows the findings of HPS Study (1):

1) Simvastatin, mortality in 5 years: Total = 12.9% (2.58% year); Cardiac mortality = 5.7% (1.14% year); Cancer mortality = 3.5% (0,7% year) 2) Placebo, mortality in 5 years: Total = 14.7% (2.94% year); Cardiac mortality = 6.9% (1.38% year); Cancer mortality = 3.4% (0,68% year)

As you can see, at the end of the 5 years of continuous treatment with Simvastatin less than 2% of patients will be benefited in the reduction of cardiac mortality or in total mortality and 98% will not. Unfortunately the patients are misinformed about the correct data, receiving instead, through a massive marketing, just the relative risk reduction numbers which cause an inappropriate spin.

Please compare the HPS numbers with those got by Mesquita and Baptista in a follow-up of 28 years (1972-2000) using digitalis in daily doses to prevent acute coronary syndromes in nearly 1200 patients with coronary-myocardial disease (Informed here on September 7). The result was a very low mortality of 14.2% in cases without previous myocardial infarction (0.5% per year) and of 41% in cases with previous myocardial infarction (1.4% per year).

1.The effects of cholesterol lowering with simvastatin on cause-specific mortality and on cancer incidence in 20,536 high-risk people: a randomised placebo-controlled trial, Heart Protection Study Collaborative Group. BMC Medicine 2005, 3:6 http://www.biomedcentral.com/1741-7015/3/6 (Table 2)

Do you need more examples??

Carlos Monteiro

Infarct Combat Project

Regarding the subject please see the article “Two Heart Disease Theories, Same Therapeutic Treatment”, published this month in Dr. Thomas Cowan’s newsletter with comments at http://www.fourfoldhealing.com/NL%20NovDec%202005.htm

Regards

Carlos Monteiro

Infarct Combat Project

Carlos, we don't need more of your preaching. What we need is evidence that the Mesquita theory has a significant following in the international field of cardiology. I'm fully aware of the Heart Protection Study, but am unconvinced we should be treating all our MIs with foxglove instead of alteplase. Have a nice day. JFW | T@lk 12:56, 6 December 2005 (UTC)

Dr Cowan has a website about nutrition, therapeutics, movement and medication. Very traditional indeed. He actually kills off your whole effort here: "I would venture that there are not five western trained physicians on the planet who are not completely convinced that the cause of heart attacks are the blockages in the coronary arteries. In fact, a common synonym for a heart attack is to say the patient has had a coronary, meaning he has an illness of his coronary arteries." In other words, Cowan admits that the Mesquita theorem has no adherents! How on earth are we supposed to cover this! There are well over 5 people who believe that heart attacks are caused by mothers-in-law. So is that going to go into the article? Nope. JFW | T@lk 13:01, 6 December 2005 (UTC)

Doctors living in illusion: “People, doctors included, have a tendency to see what they expect to see. It's the premise of every sleight-of-hand game. If it makes sense that a treatment will work -- or if one stands to make money if a treatment works -- then a doctor will, with alarming and disheartening reliability, perceive that it does in fact work. What is surprising is that a profession that dresses itself up in the garb of science has taken so long to acknowledge a principle that every small-town carny understands”. (1)

If you are not totally convinced to treat all your MIs with foxglove instead of alteplase I think you need to read a little more before any final decision. The proof of efficacy of thrombolysis for AMI depends on 9 randomized placebo-controlled trials totalling 58,511 patients. The meta-analysis of these trials showed an overall survival advantage of about only 2% (11.5% vs 9.6 %) in favor of thrombolysis – meaning that 2% of patients will be benefited by thrombolysis and 98% will not. Please take into account that the use of thrombolytics comes also with an additional clinical price besides potentially fatal bleeding complications. (2)

Our article published at Dr. Cowan’s Newsletter breaks the silence imposed to the subject by the medical establishment. So, we have now the opportunity to convince others (perhaps you) that are in search of the medical truth.

1. What Doctors Don't Know (Almost Everything) By Kevin Patterson, May 5, 2002, New York Times Magazine

2. Thrombolysis for Acute Myocardial Infarction: Drug Review, David K. Cundiff, Medscape General Medicine, January 2, 2002. http://www.medscape.com/viewarticle/414942 (excellent review!!)

Regards

Carlos Monteiro

Infarct Combat Project

You are not to use Wikipedia to popularise your theories. Your bleating about the "medical establishment" is getting particularly tiresome. I will stop replying to your posts, because you have consistently failed to show that anyone believes in the digitalis theory. This is after many weeks of repeated messages from you that we should enlighten ourselves. In fact, I will remove your posts without comment if they do not contain the information I asked for, because your criticism of the medical establishment has no direct bearing on the content of this Wikipedia article. JFW | T@lk 22:12, 7 December 2005 (UTC)

First reference is incorrect

First reference links to a report on HIV/AIDS, not on heart attacks, and only goes up to page 96 (reference cites 120-4). Would fix, but I have no idea how. —Preceding unsigned comment added by 118.138.209.138 (talk) 03:52, 11 May 2008 (UTC)

Merge First Aid and Treatment

Has anyone given thought to merging the "first aid" and "treatment" sections? We could divide it up into immediate care and hospital care, or something like that. Thanks! Scope2776 21:09, 5 March 2007 (UTC)

Categories

What's up with the categories at the bottom of the page? I belive this article has plenty of sources, and I tried to remove the tags but could not find the code. Scope2776 09:46, 5 March 2007 (UTC)

FA status: Needs More Info On . . .

Think this is good enough? TheKillerAngel 21:19, 12 July 2006 (UTC)

This article still lacks a lot of relevant information - epidemiological trends, modification of risk factors etc. It is relatively poor on references, given that MI is one of the most heavily researched subjects in modern medical science. JFW | T@lk 22:43, 26 July 2006 (UTC)

It would be a good idea to include some statistics on mortality rate from myocardial infarctions, with and without treatment.

Needs more info on drug overdoses from cocaine and Methamphetamine & Amphetamines, especially motality rates among young & healthy kids. Raquel Baranow (talk) 05:00, 18 March 2009 (UTC)

Should the effects of personality types (Type A or hostile, easily-angered), psychological stress, catecholamines such as adrenaline etc., cortisol, and contraction band lesions be discussed as risk factors for heart attacks? H Padleckas 07:36, 27 July 2006 (UTC)

The actual evidence for personality types is deeply rubbish. A type C (depressed/dependable) was recently given much more prominence. It's science that has long been discredited. Same with stress and peptic ulcer (unless we're talking a stress ulcer, seen in intensive care). JFW | T@lk 22:58, 27 July 2006 (UTC)

History

Gene Braunwald sums up some important paradigms in MI research in a 1993 editorial here. JFW | T@lk 22:43, 26 July 2006 (UTC)

Choice of antiplatelet drug

The cite below just got reverted. Noting the complaints about the lack on numbers on the project page, this cite gives some valuable and reassuring nummbers about bleeding during antiplatelet drug prophylaxis as well as the relative cost of aspirin verses more expensive treatment. All-in-all, a very interesting matter, since so many persons are on antiplatelet treatment. IMHO it would get lost over on aspirin. Perhaps it could be set up as a separate page, but that seems an unecessary complication.

• "Choice of Antiplatelet drug: A recent review [1] states: "....low-dose aspirin increases the risk of major bleeding 2-fold compared with placebo. However, the annual incidence of major bleeding due to low-dose aspirin is modest—only 1.3 patients per thousand higher than what is observed with placebo treatment. Treatment of approximately 800 patients with low-dose aspirin annually for cardiovascular prophylaxis will result in only 1 additional major bleeding episode." Further, "...the cost to prevent one major GI bleeding episode from aspirin in 1 year by substituting clopidogrel therapy would be $1,216,180..." Pprotctor (talk · contribs)

I removed that, and the reason is that (1) it is germane to all indications for aspirin, hence belongs on aspirin or antiplatelet drug, (2) leaving it here would overload the article - imagine if we listed the side-effects of ACEi, β-blockers, potassium-sparing diuretics? In a major disease like MI I'd prefer references either to official guidelines (which are based on systematic reviews) or to studies that have looked specifically at MI. JFW | T@lk 07:11, 4 September 2006 (UTC)

Pericarditus

I just redirected the entry on Pericarditus here. If someone wants expand that article, please feel free to, I just didn't consider the one-line article ("This is a type of condition in which the sac arond the heart becomes inflamed. It is usually associated with a acute-heart attack, but it really isnt.") encyclopedic enough to keep. ~ trialsanderrors 18:04, 21 September 2006 (UTC)

Erm, I think it's a mis-spelling of Pericarditis and needs deleting. --John24601 18:11, 21 September 2006 (UTC)

Thanks, I simply changed the redirect. No need to delete if it's a possible misspelling. ~ trialsanderrors 18:14, 21 September 2006 (UTC)

Self help in case of attack ?

I received an email about what to do if you have a heart attack and help is not immediately available. Basicaly it says that you should take a deep breath and (strongly) cough out the air, every 2 seconds. Does that really help or is this a hoax ? xerces8, --213.253.102.145 08:20, 7 November 2006 (UTC)

Umm... Kinda a hoax, based on a rare occurrence. If your heart were to stop completely you will pass out in about five seconds. If you were to know exactly when your heart stopped (for instance, if you were on a telemetry monitor that someone was watching), they could prompt you to cough to presumably create some cardiac output while waiting for your heart to restart. This is only really useful in a controlled setting in which someone was with you while you are on telemetry in a hospital or doctor's office. Particularly useful if there is a prolonged pause after the administration of adenosine or in a cardiac cath lab or EP lab when asystole or ventricular fibrillation is induced. Ksheka 16:56, 25 November 2006 (UTC)

"Cough CPR" does work in a controlled environment like the cath lab, but I agree it was a hoax. Cough CPR is for the supine patient on the cardiac monitor who is being coached by medical professionals to buy a little time while they attach and charge up the defibrillator. In other words, they see VF on the monitor and coach you to cough. How would you know you were in VF? By the time you figured it out you would be unconscious, especially if you were standing up. MoodyGroove 16:21, 23 December 2006 (UTC)MoodyGroove

Omega-3 and VF

The following provide a counterpoint to the reference I added:

• Brouwer I, Zock P, Camm A, Böcker D, Hauer R, Wever E, Dullemeijer C, Ronden J, Katan M, Lubinski A, Buschler H, Schouten E (2006). "Effect of fish oil on ventricular tachyarrhythmia and death in patients with implantable cardioverter defibrillators: the Study on Omega-3 Fatty Acids and Ventricular Arrhythmia (SOFA) randomized trial". JAMA. 295 (22): 2613–9. PMID 16772624.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Raitt M, Connor W, Morris C, Kron J, Halperin B, Chugh S, McClelland J, Cook J, MacMurdy K, Swenson R, Connor S, Gerhard G, Kraemer D, Oseran D, Marchant C, Calhoun D, Shnider R, McAnulty J (2005). "Fish oil supplementation and risk of ventricular tachycardia and ventricular fibrillation in patients with implantable defibrillators: a randomized controlled trial". JAMA. 293 (23): 2884–91. PMID 15956633.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Fvasconcellos 20:39, 26 November 2006 (UTC)

AMI vs MI

Why the lead says that AMI is equal with MI ? — Indon (reply) — 11:01, 27 November 2006 (UTC)

Because chronic myocardial infarction exists, but is very rare, I guess.--Steven Fruitsmaak (Reply) 13:02, 27 November 2006 (UTC)

Correction: AMI is what is generally considered under MI; look at the ICD-10 classification and you will see how AMI and chronic ischemic heart disease are organised.--Steven Fruitsmaak (Reply) 16:24, 27 November 2006 (UTC)

When you talk about myocardial infarction, it must have been acute at some point. There is no such thing as a "chronic" myocardial infarction (implying progressive death of myocardium over weeks to months due to an occlusion of a coronary artery). "Acute" just means recent in this setting. If someone has a history of an acute myocardial infarction in the past, we just say they have a history of an MI. Ventricular remodeling after a myocardial infarction with subsequent cell death is a totally different animal. Ksheka 15:23, 28 November 2006 (UTC)

Statins

I removed the following bit from the article:

There is no evidence that LDL cholesterol reduction alone predicts the decrease in cardiovascular risk, and emerging evidence suggests multiple beneficial effects of statins after a MI, for example via a decrease in C-reactive protein levels.

There is definitely something wrong about it (it's just not true), and it actually contradicts the previous line in the article. The bit about C-reactive protein is actually backwards. C-reactive protein (CRP) is a marker of inflammation. I don't believe there is any study that decreasing the CRP level itself (via plasmapheresis) is of benefit. Rather, decreasing inflammation is of benefit, and the decrease in inflammation is seen as a decrease in CRP levels. (This should be addressed in an article on coronary artery disease, and not in this article.) Ksheka 16:28, 29 November 2006 (UTC)

The first reference about (PMID 17015870) is a review article which doesn't really make much sense, since it is contradicted by a number of mega-trials (4S for instance). Ksheka 16:35, 29 November 2006 (UTC)

Of course statins are beneficial in MI, but the question is wether this is via LDL-c alone: there seems to be some research about other effects ("pleiotropic") too. Also, I saw some studies who just treated MI patients with statins and it reduced cardiovascular risk, without looking at the patients reduce in LDL: would you not say then, that it can be beneficial to all patients, even those with LDL, say, <130? The first reference, in my eyes, doesn't contradict 4S: the question is wether people with normal LDL-c could benefit from statins, no?--Steven Fruitsmaak (Reply) 16:47, 29 November 2006 (UTC)

Okay. This should be made more clear, then. Maybe mentioning that the effects of statins may be more than their LDL lowering effects and that general consensus is that statins have plaque stabilization and other pleiotropic effects that may prevent myocardial infarction. Ksheka 16:52, 29 November 2006 (UTC)

Okay. I put in a different sentence in the article. I'll reference it later if no one beats me to it. :-) Ksheka 17:01, 29 November 2006 (UTC)

Length warning

The article is now 64Kb! We should really try to keep it short and readable, certainly not above 64K! If stuff is covered in subtopic articles, it should be left out here. While comprehensiveness is important, citation seems to be a big priority too for the moment...--Steven Fruitsmaak (Reply) 19:40, 1 December 2006 (UTC)

I noticed earlier today about the size, and really wasn't sure what to make of it. We're about 12 printed pages not including references, with a lot of content still to be added (the reperfusion section is what I am working on now). The general guideline is that the text should not be more than 10 pages. I personally think we should ignore the guideline on this one and let it overflow, at least until the edits quiet down (I plan on working on this for another month). If, at that time, it seems too large, then break away parts into smaller articles (ie: an article on reperfusion during an acute MI could easily be 64k itself). Ksheka 22:21, 1 December 2006 (UTC)

Another reason to let the text get to be more than 64k is that we have a lot of well broken out sections, and each section is of manageable size. Ksheka 22:22, 1 December 2006 (UTC)

Another thing to note: Medical topics tend to run long. AIDS is a 108k article and 13 printed pages. And there is a lot more to talk about in myocardial infarction. So let's not worry about page length for now. And use more citations, not less. :-) If you want to delete some text to clean up the language, that's fine. Just please don't do it to keep the page length down. Ksheka 00:27, 2 December 2006 (UTC)

If you look closely, I'll hope you agree that I only removed things from the reperfusion section that were already mentioned elsewhere. I think a better strategy than writing first and splitting into new articles later, is just write stubs in the individual sections now, with the essentials, and expand on those in new articles later -but that's just my opinion. However, I agree that a featured article on this topic would be over 64Kb, more around 80Kb, if I compare with, for example, Bacteria.

About the references, maybe it's a better strategy to look for quality papers and guidelines and write starting from them, instead of writing from our basic knowledge and looking for references afterwards.--Steven Fruitsmaak (Reply) 13:33, 2 December 2006 (UTC)

The problem with writing to the guidelines is that the guidelines are always a bit behind current practice. A lot of the references I put in the article are the articles that the guidelines reference themselves. A lot of the other references should probably be changed in the future, once the rough text is all in place. I'll have to check about one of the larger paragraphs you deleted. Ksheka 14:30, 2 December 2006 (UTC)

Copyright issues

While looking for references for the first aid section, I found a site (http://heart-disease.health-cares.net/survive-heart-attack.php) that apparently copied content from this article, so I reported it on Wikipedia:Mirrors_and_forks/Ghi#Health-cares.net. The original structure seems to have been introduced in this rewrite from JFW.--Steven Fruitsmaak (Reply) 21:00, 3 December 2006 (UTC)

Delay caused by ASA?

According to this website, people should call 911 prior to looking for an ASA. Probably correct, but could use some real pubmed references. :-)

You should not delay calling 9-1-1 to take an aspirin. Studies have shown that people sometimes delay seeking help if they take an aspirin (or other medicine). Emergency department personnel will give people experiencing a heart attack an aspirin as soon as they arrive. So, the best thing to do is to call 9-1-1 immediately and let the professionals give the aspirin.

Ksheka 00:26, 5 December 2006 (UTC)

Okay. I looked this up in the guidelines. It seems to be based on a single study, and the guidelines don't have an opinion on whether ASA should be administered before calling EMS. Ksheka 03:20, 5 December 2006 (UTC)

A one-sided affair?

The article is coming along nicely. There is only one problem: A lot of what we write, and the references we use, make it sound like things are certain. This is probably the way we should do it for this sort of article. Is there a benefit in giving other opinions on matters? As an example, I have a bunch of references I will (hopefully) add today to show that PCI is better than thrombolytics for treatment of an STEMI. However, this is the consensus opinion that has developed after a long series of studies have looked at the matter. And some of the studies (which I will likely not reference) showed that there was no benefit of PCI over thrombolytics.

Again, I think we are doing this the correct way, but was wondering if this will be a sticking point if we aim for feature article status in the future. Ksheka 14:23, 5 December 2006 (UTC)

I think there's no need for such nuances; we should inform about the highest forms of consensus, and disclose uncertainties were debate exists: if meta-analyses have shown that there is a general trend, that overrules the negative findings of some studies. As long as we are being objective, no-one can accuse us of favouring certain views, even if we do not mention things in the extreme detail.--Steven Fruitsmaak (Reply) 17:03, 5 December 2006 (UTC)

Most common presentation of IHD?

Looking at these statistics, I would suppose that MI is more frequent than angina. Of course, WHO groups coronary atherosclerosis under ischemic heart disease, and together with silent ischemia this may be very frequent, but not with symptoms. But this study says in the omitted table which I looked up, that of their 74 patients, 10 showed stable angina, 11 AMI, and 53 unstable angina. But then again, that first sentence was mainly ment to establish a link with the WHO data, to indicate that it's the nr. cause of death worldwide. And angina doesn't kill you, MI does.--Steven Fruitsmaak (Reply) 13:27, 7 December 2006 (UTC)

Yeah. I wasn't sure about the fact myself. I just thought that it would show up as true, based on other stuff I had read. Just goes to show you that really everything in this article has to be properly references. Most of the epidemiology facts I have relate more to CAD than to MI (I haven't put any of these in any article yet.):

• The prevalence of CAD is higher in men than women at all ages.
• CAD is the leading cause of death in the U.S. and Western Europe.
• There is an epidemic increase in CAD in Eastern Europe, Far East, and Asia.
• The prevalence of reversible risk factors are decreasing except DM.
• Cardiovascular deaths are decreasing in men but not in women.
• The incidence of MI is decreasing in men but increasing in women.
• Health care makes up 15% of the GDP.
• The incidence of CAD is decreasing.
• The prevalence of CAD is increasing.
• There is a shift in coronary heart disease burden to the women and elderly.
• In patients presenting with ACS, each increment of 10 years of age increases the risk of death or MI by a factor of 1.3.

The ACC guidelines for STEMI do have an epidemiology section. I'll try to look some stuff up in the near future.

Ksheka 14:27, 7 December 2006 (UTC)

I would imagine that MI is the most prevalent presentation of IHD (most people who have one end up in a hospital), but it is probably not the most frequently occuring (angina attacks can be self-limiting or can be treated by the patient taking their medication; so they don't present to a doctor). As for total number of patients suffering from MI vs suffering from angina (which is I think what this is getting at), I really don't know, although I would expect a big overlap between the two groups. --John24601 17:00, 7 December 2006 (UTC)

Immediate care

The following line is under immediate care: "When symptoms of myocardial infarction occur, people wait on average 3 hours, instead of calling for help immediately." This should probably be reworded, since it sounds like we are advocating waiting around for 3 hours before calling for help. Maybe add a line about community teaching to call 9-1-1 immediately, the whole "time is myocardium" thing and progressive permanent myocardial damage prior to being evaluated? Ksheka 17:58, 13 December 2006 (UTC)

I was under the impression a heart attack was a pretty rapid thing, could somebody even live 3 hours whilst "having" one?, let alone operate a phone at the end of that time —Preceding unsigned comment added by 86.154.37.35 (talk) 01:22, 26 July 2008 (UTC)

Image in Histopathology section

Am I being dense, or is the caption in Image:Myocardial infarct emmolition phase histopathology.jpg confusing, i.e. "7 days of duration"? Does it mean 7 days post-onset, or an MI that went on for 7 days? :) Fvasconcellos 01:23, 14 December 2006 (UTC)

Changed it to post-infarction. Sounds better. Ksheka 01:28, 14 December 2006 (UTC)

Thanks. Fvasconcellos 01:30, 14 December 2006 (UTC)

Image:Intracoronary_thrombus.png

Great that we have PCI images, wow! But, as often with footage from interventions, students like myself have difficulties to understand what exactly were looking at; you say they have been removed, so were are they now? What is the blue edge? I have difficulty understanding so maybe the caption needs to explain more.--Steven Fruitsmaak (Reply) 12:25, 14 December 2006 (UTC)

Hmmm.... Well, what I used is known as a transit catheter (particularly, the Export catheter (tm)), which is basically just a really long hollow tube. I put the catheter in the coronary artery down to the level of the thrombus and sucked back the contents of the artery (a combination of blood and thrombus) using a syringe. I then ejected the contents of the syringe onto a wire mesh filter that comes with the Export catheter. This filter is basically a small blue cup with a fine wire mesh for the walls. Feel free to adjust the caption as needed to make it more clear (I'm too subjective to know what "clear" means in this case).

By the way, I'll put in the references for the PCI section when I have time. Things are quite busy for the next couple days at least. I want to keep the wording as PCI, and not angioplasty because (as this picture shows) angioplasty (using a balloon to dilate the artery) is only a small part of the procedure.Ksheka 12:35, 14 December 2006 (UTC)

Maybe it will look better if I include a zoom-out of the cup with thrombus in the upper left corner of the picture? Ksheka 12:46, 14 December 2006 (UTC)

Well, yes that would indeed make it more clear, at least for me.--Steven Fruitsmaak (Reply) 15:33, 14 December 2006 (UTC)

Done. Ksheka 22:05, 16 December 2006 (UTC)

CPort trial

Just a reminder to myself (or if anyone can take a look), this reference [2] needs to be fixed. It's the CPort trial. I'll try to look it up properly later. Ksheka 14:53, 18 December 2006 (UTC)

Took the liberty of looking it up. Is this it?

Aversano T; et al. (2002). "Thrombolytic therapy vs primary percutaneous coronary intervention for myocardial infarction in patients presenting to hospitals without on-site cardiac surgery: a randomized controlled trial". JAMA. 287 (15): 1943–51. PMID 11960536. {{cite journal}}: Explicit use of et al. in: |author= (help)

Fvasconcellos 16:06, 18 December 2006 (UTC)

That look like it. Thanks. Ksheka 16:17, 18 December 2006 (UTC)

Epidemiology and Risk Factors

The article says the risk factors for atherosclerosis may be risk factors for coronary artery disease. This is like saying the risk factors for losing all of your money may be the risk factors for bankruptcy. Coronary artery disease is caused by atherosclerosis. MoodyGroove 16:11, 23 December 2006 (UTC)MoodyGroove

Reperfusion

The citation needed to show that fibrinolytic therapy is contraindicated for Non-ST Segment Elevation MI is _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. Lancet 1994;343:311-22_. Unfortunately, I do not yet possess the skills to insert this in the article. MoodyGroove 16:44, 23 December 2006 (UTC)MoodyGroove

Thrombolytic Therapy

The citations needed for the first paragraph are _Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348:771-75._ Figure 4. on page 773 should be of particular interest, which is essentially a graph of the data from the FTT Collaborative Group (see previous citation under reperfusion) showing mortality against treatment delay. No reason you can't use that citation as well as it was a meta-analysis of all major thrombolytic trials and looked at over 60,000 patients. MoodyGroove 17:39, 23 December 2006 (UTC)MoodyGroove

Added to article. MoodyGroove 15:22, 26 December 2006 (UTC)MoodyGroove

C Reactive Protein (CRP)

Under risk factors, the article states, "Moreover, some drugs for MI might also reduce CRP levels." This could be more clear, in my opinion. I didn't edit it because I wasn't sure what the previous author was trying to say. "Drugs for MI" is very ambiguous. Are we talking about drugs used to prevent MI? MoodyGroove 21:45, 23 December 2006 (UTC)MoodyGroove

It refers to the pleiotropic effects of statins.--Steven Fruitsmaak (Reply) 17:37, 24 December 2006 (UTC)

Acute Coronary Syndromes

I think it would simplify matters greatly if we placed acute myocardial infarction in its appropriate context under the umbrella of the acute coronary sydromes (ACS). That way, we could clearly separate atherosclerosis, plaque rupture, coronary ischemia, chronic stable angina, acute myocardial infarction (including non-ST segment elevation MI and ST segment elevation MI), cardiac arrest, cardiac biomakers (myoglobin, CK-MB, the troponins, etc.) and makers of infammation like CRP. We're trying to throw it all under the heading of myocardial infarction or "heart attack" and the article is suffering. I would like some comments on this suggestion. Thanks! MoodyGroove 21:55, 23 December 2006 (UTC)MoodyGroove

Hi. It looks like you know what you are talking about. I take it you are a cardiologist? I had the same thought a couple months ago, but didn't know what to do with it. How about we do this in a 3 pronged approach:

• 1. Move the current article (Myocardial infarction) to Acute coronary syndrome, since that is really what the article is about. Myocardial infarction and [[Heart attack]] should redirection to Acute coronary syndrome.

Agreed. MoodyGroove 14:43, 24 December 2006 (UTC)MoodyGroove

The article should focus on physiology of plaque rupture and treatment options for ACS. It will define STEMI/NSTEMI. It should also talk about acute coronary ischemia and cardiac biomarkers.

Agreed, especially since USA and NSTEMI are indistinguishable without a rise and fall of cardiac biomarkers. I also like the idea of a more precise discussion of ischemia. MoodyGroove 14:43, 24 December 2006 (UTC)MoodyGroove

• 2. Create separate articles for Chronic stable angina and Coronary artery disease. Coronary artery disease will talk about the physiology of progression of atherosclerotic plaque, the role of inflammation (and markers of inflammation) and about primary prevention. Chronic stable angina will likely talk about treatment options for chronic stable angina (This is likely to be a small article). The article should refer to the section on coronary ischemia in the ACS article.

Definitely agree that chronic stable angina should be separate from ACS. MoodyGroove 14:43, 24 December 2006 (UTC)MoodyGroove

• 3. Create a different article on Post-infarction complications (or something like that. I'm not married to the name :-) ). The article will take about the various mechanical complications post-MI (both short-term and late complications), with links to the various articles on Congestive heart failure, cardiogenic shock, etc. Cardiac arrest may go here as well, but I consider that a grab-bag sort of term (no really good definition).

Congestive heart failure will be quite an undertaking. I reviewed the current ACS article, and I feel like it needs to be scrapped and supplanted with information from the current myocardial infarction article. MoodyGroove 14:44, 24 December 2006 (UTC)MoodyGroove

I understand that CHF would be a huge undertaking. I'm not sure if I know enough to take a stab at it (I know enough about CHF to sound intelligent but be wrong :-) ) Ksheka 15:52, 24 December 2006 (UTC)

How about we call the article Complications of coronary artery disease? And list acute coronary syndrome as one of the complications as well? You are absolutely correct in calling ACS as a manifestation of CAD, and makes the categorization a bit easier as well. Ksheka 16:05, 24 December 2006 (UTC)

What do you think about the proposal? I think I addressed the particular issues you mentioned, but there is more that needs to be ironed out. For instance, should secondary prevention be in the ACS article, the Coronary artery disease article, or somewhere else?

I would put it in the coronary artery disease article. I personally don't even like referring to a heart attack as a disease. In my opinion, coronary artery disease is the disease. ACS (including AMI) is a clinical event that is a manifestation of that disease. MoodyGroove 14:44, 24 December 2006 (UTC)MoodyGroove

It's somewhat ironic that I'm the one suggesting the move, since I was the one a couple years about that asked that the article be moved to _Myocardial infarction_, from _Heart attack_. Ksheka 01:09, 24 December 2006 (UTC)

There's a lot of great material to work with here. I just think the restructuring will help out, and enable each topic to be explored in more depth. Should we think about an article on risk stratification? I'm going to do some looking around right now and see how many of these articles already exist. MoodyGroove 14:43, 24 December 2006 (UTC)MoodyGroove

If you see any stray articles, please insert them in the appropriate place over at Cardiology. I've been using that article as a sort of Table of Contents for all cardiovascular disease topics. Ksheka 17:25, 24 December 2006 (UTC)

I agree that there is much clutter and there is a need to sort this out. I wouldn't move the article anywhere, just move parts of it to where they actually belong, and leave stub paraghaphs with a {{main}} tag, explaining the basics, as is appropriate in an article of this size. But as David Ruben points out here, I think only the symptoms section should move to ACS, since a syndrome is still a group of syndromes. Pathophysiology etc. should go to coronary artery disease. Basically, diagnosis and treatment are the core sections that should remain. Risk factors could be tricky; I think that research that is actually about MI, belongs here. I also believe that we should somehow filter out NSTEMI in this article: but we need something for the readers out there who want to read about "heart attack". Please take enough time to discuss this entire operation.--Steven Fruitsmaak (Reply) 17:46, 24 December 2006 (UTC)

Why the attachment to the title myocardial infarction? It just doesn't lend itself to exactness or completeness. As evidence, you indicate a wish to filter out NSTEMI. But this would be a mistake, since NSTEMI is just as much a heart attack as a STEMI. They are all manifestations of coronary artery disease, and they all tend to cause chest pain. Isn't it quite arbitrary to pick out one type of ACS and proclaim it to be a true heart attack? MoodyGroove 18:55, 24 December 2006 (UTC)MoodyGroove

I totally agree with MoodyGroove, which is why I suggested the move. The pathophysiology is near-identical for STEMI and NSTEMI, and there is little distinction between UA and NSTEMI. As for time, I won't personally do anything about a move for another week at the very least, to allow people to have time to chime in. Ksheka 03:15, 25 December 2006 (UTC)

I think there must be something wrong with the reasoning here (maybe it's cardiologists bias I don't know), but you seriously cannot expect to have an encyclopedia without an article labelled "myocardial infarction"?

Come now, Steven. You can come up with a better argument than accusing us of some kind of bias and then making an arbitrary statement like this. Myocardial infarction can still be an article. But the lion's share of the current content belongs under acute coronary syndromes. It has nothing to do with bias. It has to do with the prevailing research. You know as well as I do that we are in the evidence based medicine era, and that medicine has been advancing in leaps and bounds. Nowhere is this more evident than in emergency cardiac care. There's a reason the umbrella term acute coronary syndrome was created, and there's a reason that myocardial infarction was divided into STEMI and NSTEMI. What makes the term myocardial infarction more acceptable as the main title for this topic from the average reader's perspective? It's a medical term, and we're already redirecting the layman's term "heart attack." As long as the average reader is redirected to the acute coronary syndromes article, what difference does it make? MoodyGroove 15:19, 25 December 2006 (UTC)MoodyGroove

I don't see why we should put the entire article under ACS, since that would add more content to it, i.e. angina pectoris.

That's not true. Chronic stable angina pectoris might be mentioned, but it's unstable angina that's listed with STEMI and NSTEMI as an acute coronary syndrome. MoodyGroove 15:19, 25 December 2006 (UTC)MoodyGroove

As David puts it, ACS is just a "clinical impression from history and examination, that pain may originate from the heart".

I'm sorry, but that's not correct. An acute coronary syndrome is a set of signs and symptoms suggestive of sudden cardiac ischemia, which is almost always a manifestation of coronary artery diease. Because the history and exam are not reliable in this complicated set of patients, there are evidence based guidelines for risk stratification, triage, and management. In other words, you cannot have an article about myocardial infarction and reasonably discuss the diagnosis and treatment without opening up the can of worms that is the acute coronary syndromes. So the question becomes, what is the most reasonable portal to the discussion? I can't put it any more clearly than that. MoodyGroove 15:19, 25 December 2006 (UTC)MoodyGroove

Redirecting to ACS seems like a really bad idea to me. The suggestion to create a separate post-MI article illustrates the need to have an article on AMI itself. I adhere to the title "myocardial infarction" because there's simply some much research under that header. You cannot say that it is a non-entity, a vague concept that does not allow clear discussion.

I do not recall anyone making the claim that AMI is a non-entity. The issue at hand is how to approach the discussion. See above. MoodyGroove 15:19, 25 December 2006 (UTC)MoodyGroove

I've suggested earlier to remove content from this article that is not exclusive to this article: indeed, ischemia doesn't need to be discussed in detail here, and can move to ACS. But we should at least leave a stub explanation of all these concepts in this article, because we want to provide our readers with an overview in a single article, and the possibility to read more if they want to. I think David's idea will really help readers to navigate trough the maze here.

I think what you are suggesting is drastic, and unlikely a definitive solution.

What makes it drastic? I think the strongest argument in favor of moving it under acute coronary syndromes is the fact that it will definitively solve a lot of these problems by making it the main table of contents for a complicated issue. MoodyGroove 15:19, 25 December 2006 (UTC)MoodyGroove

I think we can solve the problems of "throwing it all under MI" by following the simple rule that anything that is specific for MI should be discussed here, and anything that belongs in a more general concept, should be discussed there.--Steven Fruitsmaak (Reply) 13:57, 25 December 2006 (UTC)

How do you discuss the diagnosis and treatment of AMI without opening up a discussion of the acute coronary syndromes? I don't think that's possible. MoodyGroove 15:19, 25 December 2006 (UTC)MoodyGroove

I didn't mean to accuse you guys of anything or to offend you, and if I did I'd like to apologise. ACS is a relative newcomer. I will hapilly move out the lion's share of this article to that page, provided that we still have an article with sufficient basics here. As for the redirect from heart attack, I think that should be replaced with a discussion to explain what the relation is to MI, ACS etc.--Steven Fruitsmaak (Reply) 15:31, 25 December 2006 (UTC)

No offense taken! I apologize if I've given that impression. MoodyGroove 16:33, 25 December 2006 (UTC)MoodyGroove

It would be easier to follow the discussion it was set-up as Oppose/Support. I OPPOSE merging into myocardial infarction into ACS -- based on the definition. ACS is:

Pronunciation: ( a-kyut kor¢ŏ-nar-e sin¢drom) A general term for clinical syndromes due to reduction of blood flow in coronary arteries (unstable angina, acute myocardial infarction). syn: acute myocardial infarction syn: unstable angina syn: preinfarction angina [3]

I think it is definitely worthwhile to disambig and I think renal dialysis should be a guide to how it is done. Beyond that... one can create a flowchart/family tree (as in dysphagia) that shows the relationship and/or a template. Nephron  T|C 07:13, 31 December 2006 (UTC)

I'm not sure I understand why your definition of ACS precludes you from enthusiastically supporting the merge (if it's even a merge we're talking about). My position is that the majority of the current article belongs under Acute Coronary Syndromes, and that "heart attack" should redirect to Acute Coronary Syndromes. Consider the following:

"It has been recognized that acute coronary syndromes are a diagnostic and pathophysiologic continuum ranging from unstable angina to Q-wave myocardial infarction. At the interface between unstable angina and myocardial infarction, these entities become nearly indistinct as most features are shared."

Also consider:

"Traditionally, ischemic heart disease has been divided into several separate syndromes: stable coronary artery disease, unstable angina, non-Q-wave myocardial infarction (MI), and Q-wave MI. However, recent understanding of the conversion of a stable atherosclerotic lesion to a plaque rupture with thrombosis has provided a unifying hypothesis for the etiology of acute coronary syndromes. The concept of myocardial ischemia as a spectrum provides a framework for understanding the pathogenesis, clinical features, treatment, and outcome of patients."

In other words, it's impossible to intelligently discuss acute myocardial infarction without placing it in its proper context within the acute coronary syndromes. Why the attachment to the phrase Myocardial Infarction as the portal to this discussion? MoodyGroove 16:57, 31 December 2006 (UTC)MoodyGroove

The argument you bring above could be made about autism and Asperger's syndrome--they are both on a spectrum yet have separate articles. I think it makes sense to make some distinction as, clinically, MI and unstable angina have different outcomes.

Clinically speaking, how do UA and NSTEMI have different outcomes? MoodyGroove 23:28, 1 January 2007 (UTC)MoodyGroove

I don't find the argument about etiology particularly convincing 'cause atherosclerosis in the coronaries, carotids, and abdominal aorta isn't much different -- yet their symptoms (classically)--chest pain, unilateral weakness, claudication are quite different--as is the associated morbidity and mortality. I think it makes sense to explain that it is a spectrum... but that doesn't have to be done with a merge and can be done in the ACS article.

That's fine. I'm not advocating a merge as such, and major improvements have been made to the article since this discussion started. MoodyGroove 23:28, 1 January 2007 (UTC)MoodyGroove

Also, if "the majority of the article" belongs under ACS-- that doesn't precluding rearranging and moving things between articles. Nephron  T|C 19:10, 1 January 2007 (UTC)

I agree with that. MoodyGroove 23:28, 1 January 2007 (UTC)MoodyGroove

Proposal

The above discussion was kinda difficult because it was poorly structured and not clearly defined what was exactly proposed. I propose the following, please indicate support or oppose.

• Moving part of the content that would be better discussed under the general header of acute coronary syndrome or ischemic heart disease to those article, but leaving enough material to still discuss myocardial infarction itself as an entity, using tags like Further information: acute coronary syndrome.. This will off-load the article and reduce the confusion caused by trying to explain everything related to ischemic heart disease and ACS under this header.

• Support as nom.--Steven Fruitsmaak (Reply) 17:15, 31 December 2006 (UTC)
• Support. Sounds good to me. I'm all for offloading + making less confusing... remember WP is for the masses. Nephron  T|C 19:36, 1 January 2007 (UTC)
• Support.Ksheka 00:28, 2 January 2007 (UTC)
• Support.MoodyGroove 13:33, 28 April 2007 (UTC)MoodyGroove

• Changing the redirect from [[heart attack]] to myocardial infarction into a short page explaining what can be meant by heart attack: it's actually an acute coronary syndrome, but it could by myocardial infarction or unstable angina. Reader entering heart attack might equally be looking for myocardial infarction as for a general article on chest pain originating from the heart.

• Support as nom.--Steven Fruitsmaak (Reply) 17:15, 31 December 2006 (UTC)
• Support. It is essential to disambig this. Comment - I think myocardial infarction is the most commonly understood meaning of heart attack.[4][5] If someone says... "I've had a heart attack", in my experience, it refers to a MI not a past episode of unstable angina. Nephron  T|C 19:36, 1 January 2007 (UTC)

Just like a "stroke" refers to a CVA and not a TIA? And yet, laypersons call TIAs "mini-strokes" or "pin strokes." And many people who experience TIA have microinfarcts on their CT scan. The line between UA and NSTEMI is not as clear as you make it out to be. I treat patients all the time who say they've had "small heart attacks." There's no way to know what they mean without looking at their medical chart. I understand the bias toward STEMI. It's sexier than UA/STEMI. But there's a good reason the ACS paradigm was invented. Any line you attempt to draw will be, in the last analysis, arbitrary. MoodyGroove 23:28, 1 January 2007 (UTC)MoodyGroove

• Opposed. I think heart attack should redirect to myocardial infarction or acute coronary syndrome. MoodyGroove 13:33, 28 April 2007 (UTC)MoodyGroove

Deciding whether a given patient has a MI or not isn't so arbitrary-- troponins are either considered positive or negative, an EKG either has ST elevation or it doesn't... the WHO criteria are either satisfied or they aren't.

That's not true. The WHO criteria is not that straight forward in clinical practice. What if only 2 of the 3 criteria are met? What if the chief complaint is new exertional dyspnea or acute pulmonary edema, there are T wave changes on serially obtained 12 lead ECGs, and the troponins are negative, or there's a small bump with a negative CK-MB? Forget about ST segment elevation. Most chest pain patients who present with ST segment elevation are not experiencing AMI (so that criteria is also not straight forward in clinical practice). Regardless, the issue at hand is the commonality between UA and NSTEMI. Actually, there is no issue at hand, since I support the current proposal. MoodyGroove 15:01, 3 January 2007 (UTC)MoodyGroove

On the topic of continuum vs. discrete... you're not going to convince me. A person with a fasting blood glucose of 6.6 mmol/L... isn't normal but they don't have DM. A person with a sodium of 134 mmol/L is hyponatremia... 135 isn't. The concept of threshold is all over medicine. As for what people call what... I think majority rules is the way to go--WP should NOT redefine terms. The lay terms are perfectly fine as long as one explains things along the way. Doctors don't talk to their patients in medical-speak. Nephron  T|C 06:38, 3 January 2007 (UTC)

Well, it doesn't seem arbitrary until you deal with these people on a daily basis. I have patients that tell me that they had a MI 10 years ago. I do an echo & a nuclear stress test and they are both absolutely normal. Records from the hospital state that his biomarkers (at the time, CPK/CPK-MB) were elevated during an episode of sepsis and ARF. Did he have an MI? Did he have an acute coronary syndrome? I told him I wasn't sure if he had a problem with his arteries at the time, but there is no evidence of infarction/dead heart muscle. I had a lady last month who developed a fairly large MI (EF went from 40-50 to 20-25) due to tachycardia causing ischemia without any acute coronary rupture. I told her she had an infarction/death of some heart muscle without any unstable plaque in the artery. (She had humongous collaterals from the apical LAD supplying a chronically occluded proximal RCA.) While I am sorry I can't convince you, that doesn't mean that you are correct. We are running into a language issue here because either are terms are not precise or we don't understand them sufficiently. Ksheka 13:04, 3 January 2007 (UTC)

It is well known that renal failure can cause a bump in the enzymes without there actually being any damage to the heart muscle. Thresholds have a place in medicine and they help guide treatment. Any case, I didn't say "...ignore the patient and treat the numbers" as you seem to suggest. A lab value doesn't necessarily drive treatment... but an abnormal value needs some explanation/rationalization why it is so. Nephron  T|C 01:24, 30 January 2007 (UTC)

• Support. We are running into 2 problems. One is that the general belief for decades (even among cardiologists) is that coronary artery is a progressive disease; that coronary artery plaques gradually increase in size, with the lumen area (eventually) slowly becoming stenotic. Based on this belief, people could slowly (insidiously) develop exertional symptoms that slowly worsen with time as a "stable" angina. This is wrong. Coronary artery plaques rupture and heal all the time (without clinical sequelae), and the stenotic lesion is a lesion that has (possibly) ruptured and healed a number of times prior to causing symptoms. Under this model, the first symptoms are due to a plaque rupture event.

The second problem is the definition of unstable angina. I don't recall the exact numbers, but everyone with stable angina has had an episode of unstable angina. This is because the definition of unstable angina includes angina of recent onset. Given the plaque rupture model that I just described, it is obvious (but sometimes difficult to believe) that everyone with stable angina has had an acute coronary syndrome. Ksheka 00:28, 2 January 2007 (UTC)

Navigation Box

Would creating a navigation box help direct readers through the maze of related terms for pathology, symproms, diagnoses? As a outline (yes description need be summarised right down):

Atherosclortic cardiac disorder outline
(Conditions may have more than one cause) 
Pathology in arteries
 Atheroma - lump of inflammatory cells, lipids and connective tissue within artery walls
 Atherosclerosis - atheroma, underlying cholesterol crystals and calcification
 * Coronary heart disease (aka coronary artery disease) - disease (atherosclorisis or other) occuring in the heart
 * Ischaemic heart disease - reduced blood supply to the heart muscle.
Symptoms
 Angina pectoris - chest pain due to ischemia
 Acute coronary syndrome - clinical impression from history and examination, that pain may originate from the heart.
Clinical events
 Myocardial infarction (aka heart attack) - interruption to blood supply to part of heart.
 Cardiac Arrest -  abrupt stop of normal circulation due to failure of the heart

David Ruben ^Talk 03:27, 24 December 2006 (UTC)

• Great big Support.--Steven Fruitsmaak (Reply) 17:15, 31 December 2006 (UTC)

MI = disease?

The intro says it's a disease, but is it not a clinical event? I admit it's kinda weird to call it a disease, but the term disease, although not clearly defined, is in my view a pathophysiological state with a known cause. There is no way of proving that it is or is not a disease, since the term "disease" is ill defined. But it's a convenient way to keep the intro simple.--Steven Fruitsmaak (Reply) 13:57, 25 December 2006 (UTC)

Some reverts

For the lead section, I'd like to refer to WP:LEAD:

• Is MI a "clinical event" or a "disease"? Well, I think we should write for the average, 65-year-old reader who just suffered a MI and comes here to read the article: we need clarity, and writing for the average reader (cf. WP:MEDMOS). So, let's keep it simple. Similarly, I don't think we need to mention diaphoresis.
• Someone should try to find a decent definition for "heart attack", a reference explaining what it encompasses besides MI.
• I've re-added "a shorter education and lower income (particularly in women)" for clarity; that's what the referenced study showed.
• For the average reader, I would explain "myocardial infarction" in the intro of the pathophysiology section.
• In the intro, the details of therapy and diagnosis don't mather that much, imho: so no IV medication, 12 lead ECG, the addition of anticoagulants... Also I prefered the "break down of blood clots" for the average reader.

--Steven Fruitsmaak (Reply) 17:36, 24 December 2006 (UTC)

Like Einstein said, we should attempt to make things as simple as possible, but not more so. In my opinion, ACS (MI) is a clinical event that is a manifestation of CAD, which is a disease. Why must we underestimate the intelligence of the average 65 year old reader? 204.116.176.131 17:49, 24 December 2006 (UTC)MoodyGroove

I agree. Let's not underestimate the reader. If the reader has a problem with a word or phrase, it should be wikified to a new article. If we need a "simpler" version of the article for people that have trouble with the main text (Remember, ACS is a complex topic), we can direct them to the Simple English translation (which we should try to update at some point). Taken from the Simple English page, [...]if someone has trouble understanding a concept in complex English they can "fall back" to the Simple. I'm only half-joking here. We should make this article the best it can be. It's going to be technical. It's going to be long. It's going to be complex. (But hopefully only as complex as it has to be.) It's going to take a whlie to get correct. But we're doing great so far, and moving to ACS is just another step to making this article perfect.

Dumbing down the article is going to cause more problems than it solves. Just like you couldn't do the article and have it be called Heart attack, you are going to have to let the technical terms seep in. We should just make sure the first time they are introduced they have a short explaination (couple words) in the main article and (if possible) a link to another article with deeper explaination. Ksheka 19:37, 24 December 2006 (UTC)

I have to say that I completely disagree . Simple-wikipedia is a disgrace because it shows that wikipedia isn't fulfilling the need for an understandable encyclopedia. Don't make the most frequent mistake made by editors of medical articles: trying to write a medical textbook instead of writing for the Average Reader. And that's not synonymous with dumb, it just takes a great editor to explain a difficult concept to an average reader. Have you seen statistics of how much the Average Patient has understood of what the doctor tried to tell them???--Steven Fruitsmaak (Reply) 14:10, 25 December 2006 (UTC)

What does that prove, except that most doctors are not good communicators? MoodyGroove 15:19, 25 December 2006 (UTC)MoodyGroove

I've just made some changes in the intro, which per WP:LEAD is ment only to "ease the reader into the subject instead of being dropped into it". Jargon and technicalities should be tried to make accessable, that's all I'm saying.--Steven Fruitsmaak (Reply) 15:33, 25 December 2006 (UTC)

Just check out the article for DNA. A common word (A word that your grandparent probably has heard about) that has a fairly complex article. (69K long with 95 references) I like how the DNA article uses breakout sections of the form "Further information: xxx". We should use that eventually. Our challenge is that people are more likely to look for useful information under heart attack than under DNA. :-( Ksheka 16:14, 25 December 2006 (UTC)

Classification image

I've drawn a sketch to illustrate this paragraph... On Commons there is another version in German, probably better, which I've asked the author to translate. Please comment here so I can make improvements on this preliminary version, or remove if it contains big mistakes...--Steven Fruitsmaak (Reply) 15:23, 25 December 2006 (UTC)

I think it looks great! MoodyGroove 16:36, 25 December 2006 (UTC)MoodyGroove

Excellent! Ksheka 20:27, 25 December 2006 (UTC)

The alternative from the German version.--Steven Fruitsmaak (Reply) 12:43, 26 December 2006 (UTC)

I think the one you have posted to the main article is great. It's simple and accurate. It also shows that STEMI does not always develop Q waves. Conversely, it shows that NSTEMI sometimes does develop Q waves. The alternate example is confusing. It also seems to suggest that typical angina is a prerequisite for ACS. I like the original! MoodyGroove 14:46, 26 December 2006 (UTC)MoodyGroove

Sgarbossa's Criteria

Here is the reference: Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle branch block. N Engl J Med 1996;334:481-7. MoodyGroove 15:28, 25 December 2006 (UTC)MoodyGroove

Added to article. MoodyGroove 15:22, 26 December 2006 (UTC)MoodyGroove

Pathophysiology, Causes, Classification

I've noticed a lot of overlap between these sections. I'm wondering if they shouldn't be combined into one section that addresses all three topics. If we're going to keep the format the way it is, then it seems to me that we should make a conscious effort to separate the content a little more strictly. I'd like to hear comments, please. MoodyGroove 16:11, 27 December 2006 (UTC)MoodyGroove

I think we should make the effort because the three seem to be separate to me: the causes are atherosclerosis and some rare others which aren't mentioned yet, the pathophysiology is ischemia, remoddeling, wave front of necrosis, subendocardial and transmural... and the classification explains the whole Q-wave troponin ST-bussiness. Of course you need one to understand the other, but merging would lead to a very lenghty paragraph IMHO.--Steven Fruitsmaak (Reply) 20:22, 27 December 2006 (UTC)

Pathophysiology also includes disruption of atherosclerotic plaque (which is currently mentioned under Classificaiton -- perhaps it should be relocated to Pathophysiology). The other possible mechanism is spastic coronary vasospasm (which can also complicate thrombogenic AMI). Is there a need for a section called Causes? Classification is similar to Risk Stratification, and is difficult to separate from the ECG section. I think you're correct that Pathophysiology and Classification can remain separate. MoodyGroove 20:40, 27 December 2006 (UTC)MoodyGroove

Plaque rupture should indeed be under pathophysiology. A section on etiology (causes for the Average Reader) could contain rare causes of MI, such as spasms, systemic conditions such as Kawasaki's disease, syfilitic aortitis, mechanical trauma, aortic dissection, transplantationcoronaropathy... The idea of the classification section is to set out the different terms for the reader such as STEMI etc, basically explain the figure in that section; other content can be purged. That's why I also believe it should be moved higher up, as the first paragraph to create more context for the rest of the article.--Steven Fruitsmaak (Reply) 23:16, 27 December 2006 (UTC)

Take a look at my last edit and let me know what you think. I moved the first paragraph about ACS from Classification to Pathophysiology and wrote a new introduction to the Classification section with a discussion of risk stratification. I also eliminated some redundant text, and removed a request for references because I wanted to see how the formatting looked. I don't think there's going to be an issue with references between you, me, and Ksheka. MoodyGroove 00:29, 28 December 2006 (UTC)MoodyGroove

Looks good so far. I apologize for not being too active lately. Family issues around the Holidays. :-) Should be better in the next week or two. If you don't have it yet and have access to a Pfizer drug rep, I suggest you ask them for a copy of _Cardiovascular Trials Review_, an excellent book (small format, ~1400 pages) that just summarizes all cardiac trials and broken up into topics. I have to find my rep to get a newer copy. Mine is a few years old. :-) Ksheka 12:51, 28 December 2006 (UTC)

The bit about risk stratification was already mentioned in the prognosis section, so I'd like for it to be removed. The rest looks ok. I'll re-add the reference tags: I know they're annoying but it's a reminder, and I think this is top priority (as mentioned in the to do-box).--Steven Fruitsmaak (Reply) 17:56, 28 December 2006 (UTC)

I thought we were going to explain the pathophysiology more in the ACS article, so I've re-added {{main|Acute coronary syndrome}}. Of course a brief synopsis should be provided here, so I've readded a bit on atherosclerosis under pathophysiology. The explanation of STEMI - NSTEMI should, imho, be in the classification section, next to the scheme. It should be explained more there. Correct me if I misinterpreted something here.--Steven Fruitsmaak (Reply) 18:11, 28 December 2006 (UTC)

I must say, I'm not entirely pleased with the revert. I don't believe that risk stratification belongs at the bottom of the article under Prognosis. I'm also not sure the content has already been covered. Let's compare the two paragraphs in question:

Risk stratification has become the centerpiece of initial evaluation of patients with suspected acute myocardial infarction. Because urgent therapeutic decisions need to be made, the initial assessment must occur rapidly. Currently guidelines recommend that the intial 12 lead ECG be read within 10 minutes of the patient's arrival in the emergency department. A number of factors are considered, including the nature of the chief complaint, the presence or absence of ST segment elevation, ST segment depression or T wave inversion, the patient's age, a history of diabetes, prior revascularization, the presence or absence of congestive heart failure, and serial blood tests to determine if the cardiac biomarkers are elevated, particularly Troponin I or Troponin T.

Now let's look at the Prognosis section at the bottom of the article:

The prognosis for patients with myocardial infarction varies greatly, depending on the patient, the condition itself and the given treatment. Using simple variables which are immediately available in the emergency room, patients with a higher risk of adverse outcome can be identified. For example, one study found that 0.4% of patients with a low risk profile had died after 90 days, whereas the mortality rate in high risk patients was 21.1%.[118] Although studies differ in the identified variables, some of the more reproduced risk stratifiers include age, hemodynamic parameters (such as heart failure, cardiac arrest on admission, systolic blood pressure, or Killip class of two or greater), ST-segment deviation, diabetes, serum creatinine concentration, peripheral vascular disease and elevation of cardiac markers.[118][119][120] Assesment of left ventricular ejection fraction may increase the predictive power of some risk stratification models.[121] The prognostic importance of Q-waves is debated.[122] Prognosis is significantly worsened if a mechanical complication (papillary muscle rupture, myocardial free wall rupture, and so on) were to occur.[citation needed]

The risk statification I'm referring to happens immediately on the patient's arrival, and guides therapy. It may be possible to predict mortality rates based on this information, but the most important aspect is to determine whether or not the patient is a candidate for immediate reperfusion therapy. Perhaps risk statification needs its own heading above Classification, but if not, in my opinion it belongs more to Classificaiton than Prognosis. MoodyGroove 15:14, 29 December 2006 (UTC)MoodyGroove

In my opinion, classification is ment to "Describe the varieties of the condition, and explain how they are differentiated." In a way, stratification could be interpreted like that, but my natural feeling is that it's more about prognosis: the prognosis guides the therapy. The sections are clearly not identical but there was considerable overlap. I suggest moving the prognosis section higher up, before treatment, and then explaining the prognosis of each treatment under their heading. The main difference between your version and mine seems to be the emphasis on the fact that it guides therapy: this could be added to the current paragraph, and it would be very logical to put it before treatment, no?--Steven Fruitsmaak (Reply) 17:26, 29 December 2006 (UTC)

There's no doubt that risk stratification directly influences the prognosis. Hence the emphasis on evidence based guidelines, so that optimal care is delivered to the correct subsets of patients. If mistakes are made during risk stratification, and there is a delay in therapy, or the wrong therapy is delivered, then the prognosis becomes worse. In other words, I don't necessarily agree that the prognosis guides the therapy. Rather, the therapy (or lack of therapy) alters the prognosis, for better or for worse.

I think of it like this: Chief complaint suggestive of ACS > Risk stratification > Therapy > Prognosis. MoodyGroove 18:06, 29 December 2006 (UTC)MoodyGroove

Prognosis section rewrite

I've added somewhat to this section, but I mostly found info on risk stratification... Could anyone provide prognostic information after specific therapeutic interventions, e.g. after reperfusion, CABG, ... ?--Steven Fruitsmaak (Reply) 23:18, 27 December 2006 (UTC)

Ventricular Tachycardia

I recognized this scanned image from another website. It came from here: http://www.emedu.org/ecg/images/wide_3a.jpg. Do we know for a fact that the image isn't copyrighted? MoodyGroove 13:09, 28 December 2006 (UTC)MoodyGroove

I've certainly got good EKGs of VT. I'll scan one in in the next couple of days. I should probably replace (overwrite) the image that is already in wikipedia, right? Ksheka 13:14, 28 December 2006 (UTC)

Seems that way to me, Ksheka! But then I haven't been around very long! :) MoodyGroove 14:58, 28 December 2006 (UTC)MoodyGroove

I don't think it's actually really necessary to have a VT image in this article...--Steven Fruitsmaak (Reply) 17:57, 28 December 2006 (UTC)

Not sure myself if it is necessary. The more pictures, the better however. ;-) Anyway, I uploaded a new image so we are okay for now. When I find one in color I will overwrite the black-and-white one. (My teaching EKGs are all photocopies.) Ksheka 02:53, 29 December 2006 (UTC)

Too much of a good thing can be bad too, however.--Steven Fruitsmaak (Reply) 17:26, 29 December 2006 (UTC)

Emergency Services

I totally rewrote this section. I may need some help formatting the references. I'm guessing that some of you may not appreciate the hyperlink to the ACC's D2B Initiative (only because I don't see any other hyperlinks throughout the article) but it's the cutting edge of what's happening, and I think it deserves an explanation. Can anyone provide some guidance on this? Steven? Ksheka? MoodyGroove 03:18, 6 January 2007 (UTC)MoodyGroove

I solved the issue by creating a new article for door to balloon and placing the external link to the ACC's D2B page there. MoodyGroove 15:03, 6 January 2007 (UTC)MoodyGroove

Beta blockers?

What about beta-blockers? I don't see them listed under "First-line treatment", or mentioned until "Secondary prevention" - but at least the last time I was in the ER or CCU, beta-blockers were usually given shortly after arrival (in fact, the mnemonic was amended to B-MOAN), and there is mortality data supporting it. I'm assuming this is still the case - should we add beta-blocker administration to the first-line remedies? MastCell 17:33, 7 March 2007 (UTC)

I think it's one of the first drugs to start, but not in the emergency situation... would need to look it up.--Steven Fruitsmaak (Reply) 16:34, 8 March 2007(UTC)

I added beta blockers and heparin and (possibly) plavix under first line and made it somewhat clear that they are usually not administered by first responders.Ksheka 12:12, 13 March 2007 (UTC)

Prognostic indicators

"Loss of consciousness and even sudden death can occur in myocardial infarctions and are poor prognostic indicators."

I had a double take reading that line. Yes, loss of consciousness is probably a bad prognostic indicators, but saying that death is a poor prognostic indicator seems a little silly. "Oh, you've died. That doesn't mean you're having a heart..." -72.77.65.81 08:29, 17 March 2007 (UTC)

Hmmm... Not sure about that. (Someone please correct me if I am wrong, I may be a little out of my field on this one) The problem is, sudden cardiac death is a medical term that includes an arrhythmic cause for the heart to stop pumping (generally ventricular fibrillation). There are a number of sudden cardiac death survivers that make it to the hospital. If they develop anoxic brain damage, they likely won't make it out alive. The ones that were resuscitated right away and don't have any brain damage will generally do better so long as a defibrillator is implanted prior to discharge from the hospital. Ksheka 11:17, 18 March 2007 (UTC)

---

Cleaning up references... found a problem...

I was cleaning up some of the reference to make them use Cite properly. The advantage is that if the Cite template changes, we get the template changes for free. I ran into this reference that's in the article (currently reference #37):

Sulfi S, Timmis A; Heart failure complicating acute myocardial infarction in patients with diabetes: pathophysiology and management strategies, Br J Diabetes Vasc Dis. 2006 Sep – Oct; 6(5); 191-6. url=http://www.bjdvd.co.uk/pdf/2532.pdf

I was going to find it in pubmed and clean the formatting. The problem is that it's not in pubmed, and the pdf file itself has a nasty-looking copyright notice right across it. My guess is that it's not a peer-reviewed journal. Maybe we should use a better reference? Ksheka 22:43, 17 April 2007 (UTC)

I took care of it (I changed the reference to something better.)Ksheka 00:56, 18 April 2007 (UTC)

Someone is trying to re-add this reference. My guess is (from edit history of this article and other articles) that it is one of the authors of the article. Regardless, it's an extraneous reference, the article has no pubmed ID, and the .pdf file has a horrendous copyright notice across every page (much more in-your-face than the typical notice on the footer of the page in most journal references). I'm calling it spam unless anyone has a good argument to keep the reference.Ksheka 16:11, 26 April 2007 (UTC)

Spam!--Steven Fruitsmaak (Reply) 18:19, 26 April 2007 (UTC)

This journal is a peer reviewed journal and is listed in EMBASE and not in Pubmed. EMBASE as every one knows has a more European slant. May be useful as the full article is freely available (in Medscape too) James convey 09:12, 27 April 2007 (UTC)

I'm still against adding this particular reference, for the same reasons as above. I am somewhat embarrassed that I had never heard of EMBASE before, however. Do you have a link to the search engine? When I googled for it, everything needed registration to do a search.Ksheka 11:40, 27 April 2007 (UTC)

I am not sure how popular EMBASE is in US, but is as respected as Medline in Europe and is one of the major biomedical bibliographic databases. Many of the reputed journals have only citations in EMBASE. The problem with EMBASE is that there is no free gateway like Pubmed. It is available through OVID and Dialog Datastar. In United Kingdom, NHS empolyees get access through Athens gateway. My point is against discriminating a journal which is not listed in MEDLINE but listed in EMBASE just because there is free gateway to MEDLINE through Pubmed. But I am relatively new to the Wikipedia and not very familiar with the editorial policies. So do not take much notice of me!!

The EMBASE reference is as follows.

Heart failure complicating acute myocardial infarction in patients with diabetes: Pathophysiology and management strategies. British Journal of Diabetes and Vascular Disease {BR-J-DIABETES-VASC-DIS}, 2006, Vol/Iss/Pg. 6/5 (191-196), ISSN: 1474-6514. Sulfi-S, Timmis-A-D.

Thanks. James convey 15:28, 27 April 2007 (UTC)

Name of the article

This article title should be named [[Heart attack]] per popular name standards. ~ UBeR 19:31, 27 April 2007 (UTC)

I'm aware that there has been some discussion on this before, which I think just kinda fizzled out without reaching any agreement - perhaps now is the time to open it up again. I have to say I'm firmly on the side of pages on medical topics using the proper medical name as a title (so Myocardial Infarction stays), with redirects from lay terms such as heart attack. I think it's particularly relevant in this case because lay people take "heart attack" to mean both myocardial infarction and cardiac arrest, and on some occasions I've come across people who've meant cerebrovascular accident (stroke). There are probably other definitions too (for example, I'm sure there must be someone somewhere who considers angina to be a "mini heart attack", although I've never heard the term used myself). All of these things are completely seperate medical entities requiring their own page: by all means have redirects, disambiguation pages etc., but the actual articles dealing with each topic need to be on the right page, albeit perhaps with common lay terms feature prominently within them. I realise that's a bit waffly, but I hope I've made some sense! It would be useful to get the opinion of others. --John24601 21:00, 27 April 2007 (UTC)

• I am opposed to changing the name of the article to heart attack. I think a redirect is adequate and educational. While it's true that cerebrovascular accident (CVA) redirects to stroke, there is a compelling rationale that does not apply to myocardial infarction. As far as I'm concerned, the only question is whether or not a substantial portion of the current article should be moved to acute coronary syndrome. Steven Fruitsmaak came up with a proposal on this in December, but I wasn't ready to support at the time because I was concerned about the consequences of chopping up the article, which in my opinion has a decent chance of achieving featured article status after some bugs are worked out. Best, MoodyGroove 22:36, 27 April 2007 (UTC)MoodyGroove
• Oppose. I would more readily move most (if not all) of the article over to acute coronary syndrome. Heart attack is a confusing term. The redirect is educational. Changing the article as it is now likely involves changing many of the instances of "myocardial infarction" to "heart attack" and makes the article sound amateurish to those that have done some reading in the field. If anything, maybe a paragraph at the top of the article that talks about the confusion of the term and differentiation from sudden cardiac death and VTach arrest. Ksheka 23:51, 27 April 2007 (UTC)
• Oppose per John24601, MoodyGroove, Ksheka. tomasz. 16:11, 28 April 2007 (UTC)
• Support. The term myocardial infarction is too obscure and does not, in itself, enlighten or explain. Per WP:NAME, The names of Wikipedia articles should be optimized for readers over editors, and for a general audience over specialists.. Note that because our article has a poor title, it is not top in a Google search. The winner is Heart attack. Colonel Warden (talk) 17:21, 16 May 2008 (UTC)
• Oppose, although it might boost our listing on Google. The term heart attack is indeed ill-defined and is more likely to signify acute coronary syndrome. --Steven Fruitsmaak (Reply) 10:53, 17 May 2008 (UTC)

predictive instruments?

I can tell I'm no expert relative to some of you folks, but is there perhaps a place here (under 'diagnosis,' perhaps?) for predictive instruments like the ACI-TIPI? since there's already a section on the ECGs, and one on risk factors, it seems that at least a link might be in order. and they do make huge differences in quality of care, door to balloon time, etc.

Vivisel 13:51, 29 May 2007 (UTC)

Regenerating hearts after damage

At the cellular level, the periostin-treated group had a 100-fold increase in the number of cardiomyocytes entering the cell cycle, and grew, on average, 6 million more cardiomyocytes, far exceeding the number of dying cells. [6] Brian Pearson 18:45, 17 July 2007 (UTC)

I'll take it that you are putting this here as a question to whether this should be mentioned in the article. I reviewed the topic a couple years ago, and there are a number of problems with all the various therapies that grow/generate/regenerate cardiac myocytes. 1. The cells have to be able to be grown in regular sheets, so that electrical activity will cause ordered contraction. This is probably solved in the test tube. 2. The cells have to be delivered or "grown" in situ in necrotic, infarcted regions of the heart, or grown in such a mass that the necrotic areas can be removed. No one has come even close to figuring this out yet. 3. Once new myocytes are grafted onto the living heart, the graft must be electrically stable, without reentry. Otherwise, arrhythmias such as ventricular tachycardia or ventricular fibrillation may be more pronounced. No one is even sure how much of a problem this is going to be. Ksheka 00:46, 18 July 2007 (UTC)

No, I just thought it was in interesting development. Whether or not it would have been something to add would have been very speculative thinking. :) It's interesting to learn more about it, though. Thanks. Brian Pearson 02:01, 18 July 2007 (UTC)

Another interesting development:

Human derived stem cells can repair rat hearts damaged by heart attack

"This is one of the most successful attempts so far using cells to repair solid tissues -- every one of the treated hearts had a well-developed tissue graft," said Dr. Chuck Murry, director of the Center for Cardiovascular Biology in the UW Institute for Stem Cell and Regenerative Medicine, and corresponding author on the study. Brian Pearson 05:42, 28 August 2007 (UTC)

Brian, I agree with Ksheka that you should only post "interesting developments" if they are possibly suitable for inclusion. In medical articles, it is generally not advisable to mention treatments that have only been tested in vitro or on animals; I personally even discourage phase II human trials, and on a topic like this I would strongly question inclusion of phase III trials. JFW | T@lk 14:48, 2 December 2007 (UTC)

GIK is dead

A good thing we never mentioned DIGAMI on this page. The general feeling seems to be that DIGAMI II undid all the work done in DIGAMI I, and now "glucose-insulin-potassium" (GIK), which is a related attempt to interfere with the glucose metabolism in STEMI. In this study, hyperglycaemia, hyperkalaemia and fluid overload were not necessarily corrected, and the authors suggest that further studies may need to incorporate this. JFW | T@lk 14:48, 2 December 2007 (UTC)

Should include more recent research

I briefly browsed over Pathophysiology and the contents section and it is not inclusive nor consistent with new research that suggests that only 15% of heart attacks are caused by the type of clot described. The other 85% is caused by a buildup of a fatty deposit in the arteries in much the same way, except, instead of growing large enough to block blood flow enough to kill part of the heart muscle, it grows just large enough to be burst open by rapidly moving blood (especially as in a person not accustomed to physical exertion, or having obesity or cholesterol deposits), cholesterol, free radicals (smoking), etc (the exact cause is unknown) and a blood clot forms on the surface of the plaque. I saw this in ABC health (or was it discovery health) and will try to get citation information. You can already see that new research is appearing as the PRIMARY cause on the third result on Google http://www.medicinenet.com/heart_attack/article.htm#tocc , so I suggest anyone interested in taking the time to edit it with information from new research. (Actually, I looked over the templates and could not find "needs to be updated".) Nobodymk2 01:15, 4 December 2007 (UTC)

What you describe (blood clot forming on the surface of the plaque) is exactly what the pathophysiology section describes (disruption of an atherosclerotic plaque in an epicardial coronary artery, which leads to a clotting cascade, sometimes resulting in total occlusion of the artery). Plaque rupture is the clinical event believed to be responsible for the vast majority of acute coronary syndromes. That's not controversial, and the article is up to date in this respect. If you are aware of new research, then please cite the peer reviewed literature. I just attended AHA Scientific Sessions 2007 in Orlando and saw nothing to suggest that the theory of plaque rupture is in quesiton. MoodyGroove 01:25, 4 December 2007 (UTC)MoodyGroove

MEDMOS

I'm surprised that this article seems to have WP:MEDMOS backwards. The last thing readers need to know about is epidemiology. Is there any compelling reason why we need to deviate from the WP:MED article structure in this particular instance? JFW | T@lk 22:58, 5 January 2008 (UTC)

Silent Myocardial Infarctions discrepancy

I was surprised to see that in the introduction, it is stated that "Approximately one third of all myocardial infarctions are silent, without chest pain or other symptoms." However, further down the page, under the symptoms section, it is stated "Approximately one fourth of all myocardial infarctions are silent, without chest pain or other symptoms."

The reference that the second statement links to isn't particularly helpful; it just says "More than one in four myocardial infarctions that occurred over 30 years in the Framingham Study were detected only because of routine biennial electrocardiographic examinations. Of these, almost half were completely silent."

So what does that mean? Almost half of more than one in four? 1/8th of all myocardial infarctions are silent? Not quite sure where the 1/3 and the 1/4 figures stated in the article come from. Nitroshockwave (talk) 16:46, 16 January 2008 (UTC)

risk factor missing?

previous MI? Please have a cardiologist access. Tkjazzer (talk) 05:07, 31 January 2008 (UTC)

signs and symptoms

I have never figured out what the difference in sensation is between heart attack and non-cardiac chest pain. The lead of myocardial infarction states:

“ Classical symptoms of acute myocardial infarction include chest pain (typically radiating to the left arm or left side of the neck), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety (often described as a sense of impending doom). Patients frequently feel suddenly ill. Women often experience different symptoms from men. The most common symptoms of MI in women include shortness of breath, weakness, a feeling of indigestion, and fatigue. Approximately one fourth of all myocardial infarctions are silent, without chest pain or other symptoms. A history of diabetes should heighten the index of suspicion, particularly if the patient has diabetic neuropathy (diabetes-related nerve damage). ”

(I highlighted the “and” because it is the focus of my question: should it be “and,” “and/or,” or “or”?)

Farther down in the article, we have a section that explains the symptoms in somewhat more detail, but begins with “The onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes, and rarely instantaneous,” which seems to contradict the lead.

Additionally, we have this source, which suggests that a heart attack can be indicated by chest pain alone, with no other symptoms. Is it recommended that everybody who has chest pain call 911 every time?

Finally, I might add that the article renders incorrectly in Netscape 7.2 for Mac OS X; the ECG covers up part of the table of contents. 69.140.152.55 (talk) 04:14, 31 May 2008 (UTC)

Hi, and thanks for your comments.

1. The lead begins "Classical symptoms of acute myocardial infarction include...", so I think it could be and. Of course these symptoms don't need to occur simultaneously, but that is the classic description. Of course any symptoms could be the only symptom present; and yes, everyone experiencing chest pain should call 911 every time.
2. "Over several minutes" is still "suddenly ill" in medicine, I would say.

--Steven Fruitsmaak (Reply) 13:25, 31 May 2008 (UTC)

The description of symptoms does not mention if there is any sensations of the heart pounding, or anything you could detect by feeling the pulse in your or someone else's wrist. Intuitively, I would expect such symptoms, but if they are rarely present, that is important too. Martino3 (talk) 03:41, 22 November 2009 (UTC)

Too long

This article is too long. Some of the sections are of appropriate length and have a {{mainarticle|Main Article}} link. We need to cut the oversize sections down to size and put the whole contents of each into a separate article. See Wikipedia:Article size#Very long articles. Heroeswithmetaphors (talk) 09:54, 16 June 2008 (UTC)

I'm not sure if I agree. Which measures of length are you using? Much of the 186 K is due to the almost 200 references, which is only a drop in the ocean of literature actually available on heart attacks. Which sections should be split off? JFW | T@lk 11:21, 16 June 2008 (UTC)

Number of words of prose is the best measure there is. This article has over 10,000 words of prose, which, by any measure for a non-core topic, is a bit on the long size. WP:SIZE says that anything in the range of 6,000 to 10,000 is probably getting too long and really needs to either be an exceptionally important topic (think world wars or core topic categories such as chemsitry) or have damn good writing, esp if the subject is technical. Thus a bit of summarizing and spinning off may be in order. --mav (talk) 05:09, 28 September 2008 (UTC)

As the risk factors are similar to those of atherosclerosis can that section be moved out from MI article? DOCtraind (talk) 00:31, 28 February 2009 (UTC)

Issues

This article has numerous issues. Have started to try and fix many of them. Organized the text to fit MOS. There are however many small inaccuracies. Much of the text is disorganized with info in one section that belongs in another.

Do not think it is either A or GA at this point. There is no section on history, economic impact, or public health. The section on epidemiology does not yet provide a good world overview. The prose is kind of rambling.

--Doc James (talk · contribs · email) 22:18, 21 March 2009 (UTC)

first paragrah needs to be corrected

In view of peer reviewed data Baroldi and Silver summarize in"The Etiopathogenesis of Coronary Heart Disease: A Heretical Theory Based on Morphology" http://www.baroldi.com/public/baroldi.pdf the first paragraph of the article needs to be corrected: quote from Baroldi and Silver publication "“We present above much morpho-functional and clinical data that make us doubt the value of the currently accepted simplistic “unifying theory” and the cause/effect relationship between an occlusive coronary thrombus and all forms of myocardial necrosis. Rather, we believe that morpho-functional and clinical data support a secondary role for plaque rupture, thrombosis and embolism and that metabolic mechanisms rather than ischemia explain complications and deaths in acute and chronic ischemic syndromes (Fig. 25). Amongst morphologic variables we have listed all those which may allow a reinterpretation of the natural history of our epidemic.” " In contrast to the current belief our data show that: 1. In human hearts coronary collaterals exist and compensate severe atherosclerotic stenoses. At the initial presentation of coronary heart disease in apparenlty normal subjects, severe single or multiple coronary stenoses preexisted in absence of symptoms and signs. 2. Atherosclerosis is due to increased hemodynamic stress on the vessel wall secondary to recurrent or stable regional myocardial dysfunction and increased peripheral resistance. The latter is due to extravascular compression of the intramural vessels within an asynergic zone of myocardium. All changes seen at the plaque level (hemorrhage, rupture, thrombosis) are secondary phenomena to obstruction of flow. 3. Coronary atherosclerosis in man has a different history and structure from atherosclerosis following hypercholesterol diet or familial hypercholesterolemia. 4. Myocardial necrosis in coronary heart disease is not a pool of different myocardial changes (coagulation necrosis, contraction band necrosis or apoptosis) due to ischemia.1 It is a collection of distinct forms of myocardial injury each with its own etiopathogenesis: blood flow reduction for infarct necrosis, catecholamine myonecrosis for contraction band necrosis linked to malignant arrhythmia/ventricular fibrillation and colliquative myocytolysis due to a non ischemic metabolic disorder of myocardial cells ending in congestive heart failure. 5. Morphologic data support the hypothesis that coronary heart disease is more an adrenergic stress-dependent disease than a hydraulic problem." --Koronarfürst (talk) 08:52, 3 May 2009 (UTC)

This seems like a novel theory rather than the commonly accepted ones? Appears to be somewhat logical but we need a reliable review to show that this kind of theory is widely accepted. Otherwise it's Wikipedia:Recentism. --Steven Fruitsmaak (Reply) 08:56, 3 May 2009 (UTC)

Baroldi and Silver present facts, not just a theory! have you read the real-time observation of an infarction they describe on page 60 in their report? what else do we need? science is not politics, science is about facts, not about opportunistic voting.

quote from Baroldi and Silver: “for millennia the earth remained the center of the universe; an unquestionable, objective fact documented already from the first man by looking every morning from his cavern, at the rise of the sun and its course from East to West. A few, by looking at the stars, questioned this undeniable fact and, despite the Inquisition, were right” (Baroldi, 1978). However the truth was recognized after almost 800 years from Aristarco (270 BC) to Copernico and Galileo (1550 AC). Today, dogma provides another supposedly undeniable fact viz—it “is hardly credible that there should be continuing debate about what is ostensibly so simple a morphologic problem: the relationship of coronary thrombosis to acute myocardial infarction” (Davies et al, 1976). This has in turn promoted and promotes sophisticated, highly technological, preventive and therapeutic procedures, ranging from manipulation of gene expression that will stop plaque rupture, to new vessel growth to vascularize myocardial scar and hibernating myocardium to implantations of new myocardial cells to resolve insufficient contractility, all under the aegis of the “thrombocentric” CHD universe. These are fascinating perspectives for the new millenium amongst which the old Virchowian concept on the inflammatory nature of atherosclerosis (“chronic endoarteritis deformans; 1856) is revitalized by (a) a relation between the severity of the latter and antibodies against Clamydia pneumoniae (Ericson et al, 2000); or (b) by C-reactive and amyloid A proteins as generic indicators of inflammation related to higher mortality (Liuzzo et al, 1994, 1998; Morrow et al, 1999); or (c) monocytic/granulocytic activation in CHD (Neri Serneri et al, 1992; Mazzone et al, 1998). We were able to see medial neuritis only at the proteoglycan stage of the atherosclerotic plaqu as an unique (autoimmune?) process in the natural history of coronary heart disease. The impression is that CHD needs to be reinterpreted, or, unfortunatelly, it will remain an important if unknown “universe” jeopardizing our evolution." so, please correct the first paragraph. --Koronarfürst (talk) 08:42, 4 May 2009 (UTC)

Actually, in Medieval times, Wikipedia would say that the earth is flat, until it would be generally believed that it were not. We don't blindly follow new theories. If the authors themselves say it is a heretical theory, we are unlikely to use it. --Steven Fruitsmaak (Reply) 09:13, 4 May 2009 (UTC)

why don't you read the book before posting?

so a last quote:

"Heresy from the Greek (αιρεσισ) means “choice” and semantically indicates an opinion or doctrine at variance with what is currently orthodox. A heresy is mainly considered an error by the orthodox and one that must be eradicated to preserve current thought and their dominion. Nevertheless, human knowledge, including science, progresses through paradoxes or heresies. It takes time for the latter to be proven wrong or be accepted. ... In proposing a heretical scientific opinion one must define the natural history, step-by-step and fact by fact, rationalizing the construction of the opinion and its right to exist." In exactly such a carefull manner Baroldi and Silver proof that myocardial infarction is not due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque. If you can proof them wrong, show us peer reviewed results, otherwise correct the article. --Koronarfürst (talk) 10:45, 4 May 2009 (UTC)

Reference didn't match the statement

A sentence was included which stated that Aspirin was the only first line agent that had been shown to reduce mortality. However the refence stated that Aspirin and Streptokinase both were effective in reducing mortality (I actually knew this earlier so I think the study is right!) so for starters, the statement is proven wrong by the reference.

Secondly, the reference did NOT say that other treatments were ineffective (perhaps they are? but the reference doesn't back that up). I'm not aware of any evidence to suggest morphine does aid at all, but I'm not a cardiologist either... M0rt (talk) 08:14, 4 May 2009 (UTC)

Sorry, didn't include the sentence or reference at fault. Here they are M0rt (talk) 08:21, 4 May 2009 (UTC)

Of the first line agents, only aspirin has been proven to decrease mortality.[77]

^ ISIS-2 Collaborative group (1988). "Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2". Lancet 2 (8607): 349–60. PMID 2899772.

Article intro

Article intro is too long by far. It should be a concise paragraph. Whole article looks pretty long though. ROxBo (talk) 15:58, 13 August 2009 (UTC)

Move to -> Heart Attack

Shouldn't this article be moved to 'Heart Attack'? This will be more intuitive to general public as many of us are not aware about the current technical title. Probably, the current title should be a redirect to 'Heart Attack', instead of the other way. Thanks. 99.32.118.211 (talk) 07:45, 23 July 2009 (UTC)

Oppose. It is MI. Wiki is encyclopedic.ROxBo (talk) 15:58, 13 August 2009 (UTC)

Just for the record, this article is mentioned specifically at Wikipedia:Manual_of_Style_(medicine-related_articles)#Naming_conventions. If you would like it moved to heart attack, you'll have to change the policy first. ProhibitOnions ^(T) 11:24, 14 February 2010 (UTC)

Dietary concern.....Repost from the topic of Heart attack to here...

as someone has deleted the topic in whole

• http://scholar.google.com/scholar?as_q=myocardial+infarction+diet&num=10&btnG=Search+Scholar&as_epq=&as_oq=&as_eq=&as_occt=title&as_sauthors=&as_publication=&as_ylo=&as_yhi=&as_sdt=1.&as_sdtp=on&as_sdts=5&hl=en

--222.64.218.235 (talk) 09:20, 20 January 2010 (UTC)

• http://scholar.google.com/scholar?hl=en&q=allintitle%3A+myocardial+infarction+dietary&btnG=Search&as_sdt=2000&as_ylo=&as_vis=0

--222.64.218.235 (talk) 09:21, 20 January 2010 (UTC)

• http://scholar.google.com/scholar?hl=en&q=allintitle%3A+heart+attack+dietary&btnG=Search&as_sdt=2000&as_ylo=&as_vis=0

--222.64.218.235 (talk) 09:22, 20 January 2010 (UTC)

• http://scholar.google.com/scholar?hl=en&q=allintitle%3A+heart+attack+diet&btnG=Search&as_sdt=2000&as_ylo=&as_vis=0

--222.64.218.235 (talk) 09:23, 20 January 2010 (UTC)

Disclaimer If the contents in the above links are involved in Glycemic index, Glycemic load and Insulin index, please ignore them as the measures have been questioned--222.64.218.235 (talk) 09:31, 20 January 2010 (UTC)

Hmm...I'm not sure about that...do you have, like, a source or something so we can double-check? Celestialwarden11 (talk) 20:22, 28 January 2010 (UTC)

References

• Have a copy of this review and will add / update. White HD, Chew DP (2008). "Acute myocardial infarction". Lancet. 372 (9638): 570–84. doi:10.1016/S0140-6736(08)61237-4. PMID 18707987. {{cite journal}}: Unknown parameter |month= ignored (help) Doc James (talk · contribs · email) 07:27, 22 February 2010 (UTC)

Salicylate therapy in 1653

I was actually not so surprised to read in Nicholas Culpeper's herbal,[7] that wintergreen boiled in wine and water "takes away any inflammations rising upon pains of the heart". Though I might go too far if I draw the conclusion myself, it would seem that the idea of using aspirin after a heart attack is not new at all. Wnt (talk) 05:36, 7 March 2010 (UTC)

A class review

I started a review a while back regarding A class status [8] There are a number of ongoing issues with this page. Probably the most prominent is that parts need to be summarized a split off to make it a little less technical. It is also as a mentioned limited in scope. Thus changed to B.Doc James (talk · contribs · email) 04:10, 21 February 2010 (UTC)

I totally agree that this article needs work to get up to GA standard. I'm not even sure how much actually needs to be split off (although subpages on STEMI, NSTEMI and primary PCI are probably needed). There are currently way too many references - most of them are observational studies or clinical trials that don't meet WP:MEDRS. We also need to discuss TIMI, GRACE, the 5 types of MI per the latest classification, and so on. JFW | T@lk 11:09, 21 February 2010 (UTC)

doi:10.1136/hrt.2007.135202 discusses recent attempts to review the classification of MI, and I think the 2007 classification needs to be mentioned - doi:10.1093/eurheartj/ehm355 JFW | T@lk 14:16, 21 March 2010 (UTC)

Classification section

I have added references, to the section, shall I remove the unreferenced tag, and about the last sentences, its just an explanation on why we shouldn't refer to MI by heart failure or cardiac arrest?? what references do we need there??, By the way I can improve references more if they are not satisfactory. MaenK.A._Talk 10:00, 17 April 2010 (UTC)

evolutionary considerations

I believe there should be some mention in the article about the lack of an evolved cognisance of a heart attack. It would be impossible for a "sense" of a heart attack to evolve because that sense would not influence the survival of the carrier. Imagine a mutant individual who was aware they were experiencing a myocardial infarction. This individual would not benefit from this information because he cannot influence the odds of his own survival by averting the heart attack in some way. Such a sensor in the body would not get itself propagated into subsequent generations because the carrier of the sensor would not live longer or leave more children just because he can sense heart attacks. Any sensations that we can attribute to a heart attack is purely incidental to the side effects, such as numbness in the fingers due to the lack of blood flow.

This addition would be useful because #1) it raises awareness of the importance of evolutionary considerations in medicine #2) it is a truthful statement about the nature of our awareness of our heart and the nervous system that has evolved between our heart and brain #3) it fights the implication that we have nerves connected to our heart so that we can "feel" our heart. if this were true why then don't we have nerves to every other organ so we can be aware of their malfunctioning? —Preceding unsigned comment added by 63.77.95.90 (talk) 23:44, 11 November 2010 (UTC)

Nothing the body could do would have any good effect in the course of the heartattack or in the harm to the body? --TiagoTiago (talk) 06:44, 12 November 2011 (UTC)

Treatment?

Looking at the contents of this article, I'm curious why there is no section titled "Treatment". To me "treatment" is "short-term" and "management" is "longer-term". But those are only my perceptions.

From a medical POV, what is the distinction between "treatment" and "management"? Thanks, Wanderer57 (talk) 17:02, 2 June 2011 (UTC)

I feel these can generally be used interchangeably, although the idea of treatment being short term and management being long term does 'feel' right. I think the heading of management seems okay. Tannim101 (talk) 18:19, 20 November 2011 (UTC)

Symptoms.

"Classical symptoms of acute myocardial infarction include sudden chest pain (typically radiating to the left arm or left side of the neck), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety (often described as a sense of impending doom)." This is a terrible sentence. It justs lists a set of things that are in so many conditions -- like, almost all of them -- so as to be useless. If anyone knows the more dramatic, more obvous symptoms of this (nail or mouth color change for instance) they would be far more useful. Currently, its the type of sentence that terrifies already paniced people, so I think we should make absolutely clear the most dangerous signs, not all of them. 74.128.56.194 (talk) 13:42, 2 July 2011 (UTC)

I do know what you mean, however that is a pretty chassic explaination of the symptoms of MI. When you talk about nail or mouth colour change, this would be a sign, not a symptom. Tannim101 (talk) 18:17, 20 November 2011 (UTC)

Common name

So why doesn't WP:COMMONNAME apply to this article? 99.99% of people wouldn't known what a myocardial infarction is but they sure have heard of heart attacks. The article cancer isn't named malignant neoplasm. Most Wikipedia readers aren't medical professionals or students. S_peakF_ree ^(talk) 18:54, 29 September 2011 (UTC)

Requested move

The following discussion is an archived discussion of the proposal. Please do not modify it. Subsequent comments should be made in a new section on the talk page. No further edits should be made to this section.

No consensus to move. Vegaswikian (talk) 06:33, 17 November 2011 (UTC)

Myocardial infarction → heart attack – Relisted. Vegaswikian (talk) 03:03, 10 November 2011 (UTC) The proposed name is the common name, end of story. Ohconfucius ^¡digame! 04:25, 3 November 2011 (UTC)

• Comment. I was about to fully agree with you, Ohconfucius, until I had a quick look at google scholar. I get 1.41 million hits for "Myocardial infarction", compared with 207,000 for "heart attack". Seems that myocardial infarction actually is the common name in scholarly sources. Jenks24 (talk) 06:44, 3 November 2011 (UTC)
• Oppose Heart attack is used non technically to mean a number of things including cardiac arrest due to none coronary artery causes. Thus these two terms are NOT synonymous.--Doc James (talk · contribs · email) 10:14, 3 November 2011 (UTC)
  • I notice that heart attack is linked from the intro to cardiac arrest, but not vice versa - this would help people be clear on the difference. 81.142.107.230 (talk) 12:00, 3 November 2011 (UTC)
• Oppose Heart attack could be created as a disambiguation page linking to both here and cardiac arrest. --WS (talk) 13:06, 3 November 2011 (UTC)
• Support. It's no surprise that Google Scholar prefers myocardial infarction; medical literature always prefers the more complex and more precise forms of words. I don't think we want to go down the route of titling our articles the way a medical encyclopedia would -- especially articles on common subjects such as this one. From reading cardiac arrest, the use of "heart attack" to refer to that condition is rarer and erroneous; rather, it most often refers to the subject of this article, so the redirect is appropriate. And it's clearly the common name for the incident. Powers ^T 23:26, 3 November 2011 (UTC)

I do not have a problem with redirecting heart attack here just do not suggest we move this page their.--Doc James (talk · contribs · email) 00:21, 5 November 2011 (UTC)

• Oppose Because "heart attack" can have multiple meanings, it would be inappropriate to move this page there. A disambig page for "heart attack" seems appropriate. Yobol (talk) 05:51, 10 November 2011 (UTC)
  • What multiple meanings? "Heart attack" only rarely refers to cardiac arrest, and even less rarely to cardiac arrest not resulting from myocardial infarction. That the term is occasionally misapplied by laymen is no reason to avoid using the term in our article's title. Powers ^T 14:16, 10 November 2011 (UTC)
    • That it is misapplied seems to bolster the need for a disasmbiguation page, don't you think? Yobol (talk) 19:14, 15 November 2011 (UTC)
• Oppose This article is about myocardial infarctions, not all forms of cardiac arrest. IMHO in common usage "heart attack" refers to all forms of cardiac arrest. Anyone who knows that this is technically incorrect will know that the more proper term for heart attack is myocardial infarction. The redirect from "heart attack" with the hat note referring to the "cardiac arrest" disambiguation page is therefore appropriate.--Wikimedes (talk) 19:11, 15 November 2011 (UTC)
• Oppose Myocardial infarction is simply the correct term for what is being described in the article. Meanwhile, one might use the term "heart attack" to also describe the syndrome resulting from a severe arrhythmia caused by, say, electrocution.--Rossd (talk) 10:23, 16 November 2011 (UTC)

The above discussion is preserved as an archive of the proposal. Please do not modify it. Subsequent comments should be made in a new section on this talk page. No further edits should be made to this section.

Contradiction

The article intro says of symptoms "Classical symptoms of acute myocardial infarction include sudden chest pain (typically radiating to the left arm or left side of the neck)"; the image (AMI_pain_front.png) in the "Signs and symptoms" section has pain zones extending up and to what is anatomically the the right side of the body in the image (although it is viewer-left). Unless this follows some convention generally in medicine, anatomy, or diagnosis guides, the image is contradicted by the text. — Preceding unsigned comment added by 66.67.51.190 (talk) 23:55, 14 May 2012 (UTC)

Inaccurate references

Causes
"Heart attack rates are higher in association with intense exertion, be it psychological stress or physical exertion, especially if the exertion is more intense than the individual usually performs.[27] The period of intense exercise and subsequent recovery is associated with about a 6-fold higher myocardial infarction rate (compared with other more relaxed time frames) for people who are physically very fit.[27] For those in poor physical condition, the rate differential is over 35-fold higher.[27] One observed mechanism for this phenomenon is the increased arterial pulse pressure stretching and relaxation of arteries with each heart beat, which, as has been observed with intravascular ultrasound, increases mechanical "shear stress" on atheromas and the likelihood of plaque rupture.[27]"

There is no mention at all about this in the reference provided:

27. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. (1998). "Prediction of coronary heart disease using risk factor categories" (PDF). Circulation 97 (18): 1837–47. DOI:10.1161/01.CIR.97.18.1837. PMID 9603539

http://circ.ahajournals.org/cgi/reprint/97/18/1837.pdf - http://www.ncbi.nlm.nih.gov/pubmed/9603539

I wonder whether this false reference has been caused by the replacement of an earlier reference in which such statements did actually appear, or some editor was unable to find a good reference to support such claims (either accurate or not) and he or she decided to provide some previous reference to make it look as if it was based on contrastable facts. Eyesighter (talk) 10:42, 8 June 2012 (UTC)

Here you are, an example of editing mala praxis:

http://en.wikipedia.org/w/index.php?title=Myocardial_infarction&diff=next&oldid=112891718

This User:Scope2776 may have made up other references.

Yet, the information had been there for months, so it may be still accurate. Obviously, it should be appropriately referenced. Eyesighter (talk) 11:29, 8 June 2012 (UTC)

That information was added in August, 2006:

http://en.wikipedia.org/w/index.php?title=Myocardial_infarction&diff=prev&oldid=21337787

by User:MAlvis. According to his page he is "a US physician, specializing in preventive, non-invasive and invasive cardiology and internal medicine in San Antonio.", so those statements may well be accurate in case MAlvis was inspired by the current knowledge in his or her professional field. Even so, any encyclopedia needs reliable and verifiable sources of information, otherwise users could not easily assess the strength of evidence of every statement. Eyesighter (talk) 12:22, 8 June 2012 (UTC)

Signs & Symptoms

There seems to be a continuity error in the section relating to silent MI's, which first says that it is more common in young people, then says it is more common in the elderly. — Preceding unsigned comment added by 122.148.213.48 (talk) 14:31, 5 September 2012 (UTC)

Thanks, have adjusted text accordingly. Yobol (talk) 21:52, 9 September 2012 (UTC)

Anterior vs posterior

The cross section of the heart is probably the short axis view (see here), and is a similar view as if one were looking at a CT scan (R side of the body is on the left of the image). This means the area in question would be the anterior of the heart. Yobol (talk) 17:06, 24 August 2012 (UTC)

New definition as of 2012

http://eurheartj.oxfordjournals.org/content/early/2012/08/23/eurheartj.ehs184.full Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:55, 8 October 2012 (UTC)

Article move

The following discussion is an archived discussion of a requested move. Please do not modify it. Subsequent comments should be made in a new section on the talk page. Editors desiring to contest the closing decision should consider a move review. No further edits should be made to this section.

The result of the move request was: Not moved. Nathan Johnson (talk) 03:43, 13 November 2012 (UTC)

---

Myocardial infarction → Heart attack – Heart attack is clearly the more common and widely used name for this, and clearly falls under WP:COMMONNAME, which is why I’m requesting this move. WoodyAllenGuy (talk) 07:04, 5 November 2012 (UTC)

We typically use the more precise or technical name for medical stuff. The term "heart attack" is also used to mean cardiac arrest which is completely different. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:52, 5 November 2012 (UTC)

Oppose per Doc James. The term "heart attack" is also used in popular media to mean cardiac arrest. Blue Rasberry (talk) 14:06, 5 November 2012 (UTC)

• Oppose. There is a huge difference between a common name and colloquial language. Myocardial infarctions are colloquially referred to as heart attacks. But the actual, precise common name is myocardial infarction. --87.78.139.251 (talk) 17:46, 5 November 2012 (UTC)
• Oppose Based on correct naming for medical-related articles. Lugnuts ^{Dick Laurent is dead} 10:21, 6 November 2012 (UTC)
• Support. Heart attack redirects here, so there is no ambiguity with cardiac arrest. Given that, we should use the most common name, "heart attack", which is used in all but the most technical literature. Powers ^T 15:46, 9 November 2012 (UTC)

• The ambiguity mentioned above stems from outside of Wikipedia and can't be resolved by how we arrange and disambiguate between topics. The term "heart attack" can in real life refer to either a myocardial infarction or to cardiac arrest. So why should we sacrifice accuracy for common-ness? --87.79.231.4 (talk) 22:26, 9 November 2012 (UTC)
  • What I'm saying is that we've already decided that someone searching for heart attack most likely intends to read this article. By not titling the article with that name, then, we're leaving the poor layman confused as to whether he's actually at the right article. Powers ^T 16:56, 11 November 2012 (UTC)

• No, we're not. The opposite is true. If we move this article to "heart attack", the reader may be confused because they were actually looking for cardiac arrest. Under the current, proper name, there is no ambiguity. --87.79.176.39 (talk) 22:44, 11 November 2012 (UTC)
  • If they were looking for cardiac arrest, they can follow the hatnote, just like today. Powers ^T 02:22, 12 November 2012 (UTC)

• Oppose. The term, and its abbreviation "M.I." are common and prevalent--medical records do not use the term "heart attack." For those WP readers who truly are unfamiliar with the term, there is, as is pointed out above, a redirect from "heart attack" to this article, whereupon those readers will be introduced to the correct name. Steveozone (talk) 00:52, 10 November 2012 (UTC)
  • That's not what article titles are for. We don't redirect Heroin to Diacetylmorphine, for instance. Powers ^T 16:56, 11 November 2012 (UTC)
• Wikipedia:Article titles says:

"Generally, article titles are based on what the subject is called in reliable sources."

Wikipedia:Manual of Style (medicine-related articles)#Naming conventions further specifies:

"The article title should be the scientific or recognised medical name that is most commonly used in recent, high-quality, English-language medical sources, rather than a lay term (unscientific or slang name) or a historical eponym that has been superseded. These alternative names may be specified in the lead. Create redirects to the article to help those searching with alternative names. For example, heart attack redirects to myocardial infarction."

Even WP:COMMONNAME says:

"The most common name for a subject, as determined by its prevalence in reliable English-language sources, is often used as a title because it is recognizable and natural. Editors should also consider the criteria outlined above. Ambiguous[4] or inaccurate names for the article subject, as determined in reliable sources, are often avoided even though they may be more frequently used by reliable sources."

Footnote [4] further clarifies:

"[...] For example, heart attack is an ambiguous title, because the term can refer to multiple medical conditions, including cardiac arrest, myocardial infarction, and panic attack."

This article will never be moved to "heart attack", the request is a pure waste of time. --87.79.176.39 (talk) 23:08, 11 November 2012 (UTC)

The above discussion is preserved as an archive of a requested move. Please do not modify it. Subsequent comments should be made in a new section on this talk page or in a move review. No further edits should be made to this section.

New definition as of 2012

http://eurheartj.oxfordjournals.org/content/early/2012/08/23/eurheartj.ehs184.full Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:55, 8 October 2012 (UTC)

2013 AHA guidelines

[9] Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:49, 16 January 2013 (UTC)

Don't transfuse too much!

doi:10.1001/2013.jamainternmed.1001 - too much is bad. JFW | T@lk 17:21, 30 January 2013 (UTC)

Rename article?

Hi. Sorry if I'm mistaken, but I believe this is a pretty clear case of WP:COMMONNAME for a speedy rename to the heart attack article. TBrandley 01:02, 8 April 2013 (UTC)

Heart attack is not specific for myocardial infarction. People also use heart attack to mean cardiac arrest. Doc James (talk · contribs · email) (if I write on your page reply on mine) 01:46, 8 April 2013 (UTC)

Maybe Talk:Myocardial_infarction/Archive_1#Article_move was archived too soon? Steveozone (talk) 02:14, 8 April 2013 (UTC)

See Wikipedia:Manual of Style/Medicine-related articles#Naming conventions for another reason why this article is titled Myocardial infarction instead of Heart attack. Flyer22 (talk) 01:35, 12 May 2013 (UTC)

Refs

2013 Lancet http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61454-3/abstract http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61453-1/abstract Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:16, 20 August 2013 (UTC)

"Not enough" vs "lack of" oxygen

Why use "not enough" in the introductory paragraph when "lack of" is shorter & more concise? Thoughts anyone? Sounds more encyclopedic & professional. If this is an online encyclopedia, it should read like one. Tommyt (talk) 03:24, 19 September 2013 (UTC)

I thought "not getting enough" to "not enough" was a fair compromise. Our goal is to write, at least the lead, in easy to understand language. We are trying to write a general encyclopedia which is accessible to as many people as possible. This article will be eventually translated (after I get around to improving / updating it) into as many languages as possible per Wikipedia:WikiProject_Medicine/Translation_task_force. The translators have really emphasized the importance for simple languages especially for languages with smaller vocabulary.Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:37, 19 September 2013 (UTC)

So "lack of" will not translate very well? Tommyt (talk) 20:14, 23 September 2013 (UTC)

Type 2 MI

doi:10.1016/j.amjmed.2013.09.031 - type 2 MI is frequently encountered in clinical practice, but diagnostic and therapeutic strategies are unclear. This is a review of this particular entity. JFW | T@lk 13:12, 21 October 2013 (UTC)

Trial to Assess Chelation Therapy (TACT). Its relevance here.

I'm surprised this article hasn't gotten a request for inclusion of this study as a source since it is relevant to the closely related subjects of myocardial infarction and diabetes, so I'm going to drop some information here. We have discussed it at the Chelation therapy article and rejected using it. You can read the discussion and the reasons for rejection here:

• Talk:Chelation_therapy#TACT_Study_Re-Analysis_of_Diabetic_Subgroup

Here is the abstract of the study:

• Escolar E., et al. The Effect of an EDTA-based Chelation Regimen on Patients With Diabetes Mellitus and Prior Myocardial Infarction in the Trial to Assess Chelation Therapy (TACT), American Heart Association, Circulation, Published online before print November 19, 2013, doi: 10.1161/​CIRCOUTCOMES.113.000663

The full article can be downloaded free as a PDF document:

• http://circoutcomes.ahajournals.org/content/early/2013/11/19/CIRCOUTCOMES.113.000663.full.pdf+html

In the "Methods and Results" section of the abstract you'll find this: "However, after adjusting for multiple subgroups, those results were no longer significant." There was no effect on the group of patients without diabetes nor a mechanism of action to explain why it would work on diabetes patients, but not other patients. The difference was about 11 patients out of 300+ patients or about 3%. So, it is probably just chance rearing its ugly head and giving misleading results. As the study authors say: "These findings support efforts to replicate these findings and define the mechanisms of benefit. However, they do not constitute sufficient evidence to indicate the routine use of chelation therapy for all post–myocardial infarction patients with diabetes mellitus."

It is definitely an interesting study and we'll be allowed to report this in the article when it clears our WP:MEDRS rules, which will be when reviews of multiple studies are finished. These are preliminary and uncertain results: "...more studies are needed before it’s known whether this promising finding leads to a treatment option."[10] We don't use primary studies like this as sources, IOW we don't present the latest findings and "promising studies". We are not a news agency when it comes to medical matters. If anyone disagrees, they can go to the MEDRS talk page and try to get the rules changed. We can't do anything until that is done. -- Brangifer (talk) 17:52, 1 December 2013 (UTC)

Reviews

• 2012 Writing Committee, Members (2012 Aug 14). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 126 (7): 875–910. PMID 22800849. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: numeric names: authors list (link)
• O'Gara, PT (2013 Jan 29). "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (4): e362-425. PMID 23247304. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:08, 2 February 2014 (UTC)

Medical / common name

I agree myocardial infarction is accurate and professional name of the disease, but I since professional names don't have advantage over most commonly used ones (current name of the article is pretty unfamiliar with most of the readers) and this is not a dictionary of medical terms, we should rename the article to simply hearth attack, but then I'm not sure that would be correct, since most of the practitioners would disagree. I'm asking for opinions. Thanks. Alex ^{discussion ★} 15:25, 26 November 2013 (UTC)

Heart attack also means cardiac arrest which is not necessarily myocardial infarction. This is why we have a dab for heart attack. Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:55, 26 November 2013 (UTC)

I agree that heart attack sounds a little unspecified. But, at least, "myocard" isn't quite an English word, could we use heart infarction (or even cardiac muscle infarction) instead? Alex ^{discussion ★} 16:57, 26 November 2013 (UTC)

For technical topics we use the technical name pre WP:MEDMOS We have discussed this a bunch before. Doc James (talk · contribs · email) (if I write on your page reply on mine) 17:10, 26 November 2013 (UTC)

@Jmh649: out of interest, where has this been discussed a bucnh before? I think there's an interesting question going on here, because personally I think articles like this shuold use the common name, not the medical one, and also the guideline outlined at WP:MEDMOS seems to be in contradiction to the policy of WP:COMMONNAME. Offhand, I can think of three types of readers who may come to this article, (1) People involved in the medical profession, or medical students. (2) Non-medical people with a general interest in a medical topic. (3) Patients seeking advice. For category (1) it would make sense to use the scientific term, but really such people would be far better served reading actual medical journals, Wikipedia is not really intended to be a tool for academic study. For category (2), the common name would appear to be the best one because that will be the term most lay people associate with the disease; of course, the scientific name would appear prominently in the lead and infobox to assist those people's learning. As for category (3), I fully appreciate all the amazing work that you and the med project guys do to ensure that no spurious or misleading health "advice" creeps into Wikipedia articles, that might be used erroneously by a patient; however, I think those people are also served best by titling articles at the common name; if I think I might be having a heart attack, it would make sense to check out the symptoms at the Wikipedia Heart attack page, not that for Myocardial infarction. On your point about heart attack being ambiguous, that seems to be a slight red herring because heart attack is already a redirect to myocardial infarction. If there's really ambiguity, then that redirect should be a disambiguation page. Thanks  — Amakuru (talk) 14:47, 6 March 2014 (UTC)

Amakuru"Heart attack" is an unusual case. The term is supposed to mean myocardial infarction, but people say "heart attack" when they mean myocardial infarction, cardiac arrest, heart failure, stroke, died in sleep, died of old age, or any peaceful cause of death. Whereas what you say applies to almost any other health article, in this case since people use the term "heart attack" to mean all kinds of things, when they want medical information it seems best to clarify exactly what they are reading. Everyone here wants to use the simplest possible language without confusing people but since the term "heart attack" already has confusion around it, right now the consensus is that emphasizing the term "heart attack" would not help layman readers. Blue Rasberry (talk) 15:29, 6 March 2014 (UTC)

• Wikipedia:Manual_of_Style_(medicine-related_articles)#Article_titles
• Talk:Myocardial_infarction/Archive_2#The_naming_issue
• Talk:Myocardial_infarction/Archive_1#Acute_Coronary_Syndromes
• Talk:Myocardial_infarction/Archive_1#Name_of_the_article
• Talk:Myocardial_infarction/Archive_1#Move_to_-.3E_Heart_Attack
• Talk:Myocardial_infarction/Archive_1#Article_move

Here are some previous discussions. Obviously a lot of people are confused but I do not think that the solution is more ambiguous information. Blue Rasberry (talk) 15:33, 6 March 2014 (UTC)

Actually, you make a very good point there. Although that does add weight to the notion that heart attack should be a disambig page rather than a redirect. In the current arrangement people who think a cardiac arrest is a heart attack would land up on this page regardless, and might end up inferring information about the wrong condition. In fact I first started looking at this question because I was on the Diabetes mellitus page and was surprised to find that it wasn't called just "diabetes" given that that's a redirect. Well similar logic applies, because there's diabetes insipidus as well, but having a redirect from the general term to the specific doesn't really help there either IMHO.  — Amakuru (talk) 15:56, 6 March 2014 (UTC)

It seems that by using redirect from HA to MI, we are somehow telling readers that by heart attack they should mean MI. I don't think that is our business; Instead I favor a disamb page where we could list the options and briefly explain them

• Myocardial infarction (Heart Muscle Injury)
• Acute coronary syndrome (Heart damage risk)
• Sudden death (from any cause)

etc Bakerstmd (talk) 22:29, 6 March 2014 (UTC)

MINOCA

Myocardial infarction with normal coronary arteries - reviewed in detail doi:10.1161/CIRCULATIONAHA.114.011201:

• Prevalence 6% in people with MI, more patients younger and female with less hyperlipidaemia but otherwise similar proportions of risk factors
• Mortality lower than with confirmed coronary artery disease
• Only 24% have CMR appearance suggestive of coronary ischaemia, and 33% had myocarditis with 26% no abnormality at all
• 27% had inducible coronary artery spasm, and 14% had some form of detectable thrombophilia

Unsure how to work this into the article. JFW | T@lk 21:43, 9 March 2015 (UTC)

I can start a classification section and it could probably be integrated into a section like that. TylerDurden8823 (talk) 22:46, 9 March 2015 (UTC)

Better yet, there's already a classification section under diagnosis, we can simply expand it and include this content. TylerDurden8823 (talk) 22:47, 9 March 2015 (UTC)

Could fit under cause, mechanism or diagnosis. Doc James (talk · contribs · email) 06:00, 10 March 2015 (UTC)

Outdated

This 2014 BMJ review [11] was called outdated and replaced by a 2011 paper [12]? Doc James (talk · contribs · email) 18:57, 28 April 2015 (UTC)

Will look at it further. There does seem to be contention on this point. Doc James (talk · contribs · email) 06:28, 30 April 2015 (UTC)

User:Hyoib I guess there are two question 1) do they need to be given before PCI which appears to be no and 2) do they need to be given for 12 months which the EU guideline recommends yes. Adjusted text to reflect both Doc James (talk · contribs · email) 14:19, 30 April 2015 (UTC)

USA Death Rates decline

Is this statistic worth including in the article? I did not find death rates listed.

In the USA: The coronary heart disease death rate disease has decreased 38 percent in the 10 years ending 2013. Sources: http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html?emc=edit_th_20150621&nl=todaysheadlines&nlid=58413496&_r=0

http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf

Thank you,--Jcardazzi (talk) 17:21, 21 June 2015 (UTC)jcardazzi

The CDC ref is good. What page is that info on? Doc James (talk · contribs · email) 19:46, 21 June 2015 (UTC)

---

The NY Times article states: "From 2003 to 2013, the death rate from coronary heart disease fell about 38 percent" but I could not find the source. The CDC tables linked in the NY Times article are only the 2013 statistics

I did find: "From 2001 to 2011, the death rate from heart disease has fallen about 39 percent." source: American Heart Association Heart Disease and Stroke Statistics – At-a-Glance https://www.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_470704.pdf "The source for the health statistics is the association’s 2015 Heart Disease and Stroke Statistics Update, which is compiled annually by the American Heart Association, the Centers for Disease Control and Prevention, the National Institutes of Health and other government sources."

In the 2015 Heart Disease & Stroke statistics Update: http://www.heart.org/HEARTORG/General/Heart-and-Stroke-Association-Statistics_UCM_319064_SubHomePage.jsp I could not find how the American heart Association derived "From 2001 to 2011, the death rate from heart disease has fallen about 39 percent." in the 500+page report. --Jcardazzi (talk) 23:49, 21 June 2015 (UTC)jcardazzi

---

Okay AHA is good awell. Maybe the NY Times got the 38 / 39 bit wrong. Doc James (talk · contribs · email) 12:23, 22 June 2015 (UTC)

Actual ref says "From 2001 to 2011, death rates attributable to CVD declined 30.8%." [13] Doc James (talk · contribs · email) 13:02, 22 June 2015 (UTC)

Prevention

Asking about the inclusion of plant-based diets as a significant factor in the prevention of MI? A 20-year nutritional study done by Dr. Caldwell B. Esselstyn, Jr., a former internationally known surgeon, researcher and clinician at the Cleveland Clinic, explains in his book how myocardial infarction can be prevented, reversed, and even abolished. Dr. Esselstyn argues that conventional cardiology has failed patients by developing treatments that focus only on the symptoms of heart disease, not the cause. Dr. Esselstyn convincingly argues and produces convincing results that a plant-based, oil-free diet can not only prevent and stop the progression of heart disease, but also reverse its effects. http://dresselstyn.com/JFP_06307_Article1.pdf As stated in the National Center for Biotechnology Information “Nutritional Update for Physicians” (which includes its own comprehensive list of citations), “Research shows that plant-based diets are cost-effective, low-risk interventions that may lower body mass index, blood pressure, HbA1C, and cholesterol levels.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662288/ The American Journal of Clinical Nutrition concludes, “…substantial evidence indicates that plant-based diets including whole grains as the main form of carbohydrate, unsaturated fats as the predominate form of dietary fat, an abundance of fruit and vegetables, and adequate n−3 fatty acids can play an important role in preventing CVD. Such diets—which have other health benefits, including the prevention of other chronic diseases—deserve more emphasis in dietary recommendations.” http://ajcn.nutrition.org/content/78/3/544S.full Karyn Swaney (talk) 16:31, 3 December 2015 (UTC)

What the review says is fairly different than what the primary source says. This is not controversial "can play an important role in preventing CVD" Doc James (talk · contribs · email) 18:04, 3 December 2015 (UTC)

That would be my mistake in not thinking the text had to be word-for-word to the citation and that instead the results of the text could be easily demonstrated by the reading of the citation. This can be easily re-worded or cited, it is simply the factual bio of one of many doctors who have demonstrated the same conclusions and could even be omitted as specific only to this doctor. Thank you. Karyn Swaney (talk) 20:00, 3 December 2015 (UTC)

Doc James I can supply hundreds of articles that use the same terminology "substantial evidence", "research indicates"...not sure how many would be needed before sufficient. I can even include the citation for Dr. Esselstyn's book that clearly demonstrates the medical proof that unbiased medical professionals now easily accept as self-evident truth. Recent movie "Plant Pure Nation" also can be referenced and includes the contributions of many doctors with solid medical evidence of the effectiveness of a plant-based diet in reversing and preventing heart disease. Interested in your feedback. Thank you. Karyn Swaney (talk) 20:10, 3 December 2015 (UTC)

Please provide citations. Yogesh Khandke (talk) 02:28, 4 December 2015 (UTC)

Yes their is evidence for prevention. What we are disagreeing over is the claim of "reversing heart disease" Doc James (talk · contribs · email) 03:32, 4 December 2015 (UTC)

A clinically proven programme based on plant based diet, stress management and exercise that reverses heart diseases.[14] Yogesh Khandke (talk) 04:07, 4 December 2015 (UTC)

Not a useful source. Doc James (talk · contribs · email) 05:40, 4 December 2015 (UTC)

May I ask why? Yogesh Khandke (talk) 06:43, 4 December 2015 (UTC)

comment "My patients demonstrate much more dramatic cholesterol lowering since the advised dietary program is based on nutrient density," he explains, "and reversals from 20 to 40 percent per year are typical in my experience. I even have a patient who reversed his carotid blockage from 80 percent to undetectable in one year on carotid ultrasound." http://www.diseaseproof.com/archives/cardiovascular-disease-reversing-heart-disease-with-a-nutrient-dense-diet.html

Directory of sources:

http://www.dresselstyn.com/site/articles-studies/

“The low-fat, vegetarian diet devised by Dean Ornish, M.D. provided the first hard evidence that heart disease could be reversed -- that atherosclerotic plaques could regress -- with diet and lifestyle changes alone.” (6) “Similar results were found by Caldwell Esselstyn, M.D.” (7) http://www.huffingtonpost.com/joel-fuhrman-md/heart-health-prevent-and-reverse_b_783565.html Karyn Swaney (talk) 00:41, 5 December 2015 (UTC)

In the prevention section we already say "Recommendations include increasing the intake of wholegrain starch, reducing sugar intake (particularly of refined sugar), consuming five portions of fruit and vegetables daily, consuming two or more portions of fish per week, and consuming 4–5 portions of unsalted nuts, seeds, or legumes per week." Doc James (talk · contribs · email) 05:59, 4 December 2015 (UTC)

Doc James We both know that is not saying the same thing. We could potentially save millions of lives by including this factual data. Karyn Swaney (talk) 00:41, 5 December 2015 (UTC)

We strike with MEDRS recommendations for sources. Doc James (talk · contribs · email) 04:04, 5 December 2015 (UTC)

Doc James (1) I've asked MEDRS whether Dean Ornish's book is a reliable source. (2) Doesn't this conclusion "Modest regression of coronary artery stenoses after risk factor modification is associated with decreased size and severity of perfusion abnormalities on rest-dipyridamole PET images. Progression or regression of coronary artery disease can be followed noninvasively by dipyridamole PET reflecting the integrated flow capacity of the entire coronary arterial circulation.(JAMA. 1995;274:894-901)" say in English that eating low-fat, plant-based, stress management and exercise caused reversal of heart disease. Please help in collecting and helping readers know it has been proven that it does. For you,: a medical professional it will be easier to find, access, interpret and post accurate information that would help mankind's horizon of free knowledge expand. Yogesh Khandke (talk) 05:54, 5 December 2015 (UTC)

A better source on Dean Ornish's views would be this in the Scientific American. However, mentioning either Ornish's dubious views, or the skeptical reaction to them, in this article would be undue in my view. We should just abide by WP:MEDRS and report what the best sources say. Alexbrn (talk) 08:39, 5 December 2015 (UTC)

"Ornish’s diet would probably be an improvement on the current American diet—if people could actually follow it long-term." This from Melinda Wenner Moyer who wrote the above article, and that is what she says in response to Ornish's response that Scientific American has published. She also admits she lacks a clinicians expertise, not being one. She surely isn't Ornish's peer. I ask by what yardstick this article should be treated as a good source, Scientific American being lay press, without peer review. Please maintain consistency of standards. Yogesh Khandke (talk) 10:49, 5 December 2015 (UTC)

See WP:MEDPOP: Scientific American can be useful. That Ornish has some odd WP:FRINGE ideas could be supported by many non-heavyweight sources, because it's kind of obvious. However I'm not advocating using this Scientific American source. To repeat: "We should just abide by WP:MEDRS and report what the best sources say". Alexbrn (talk) 11:10, 5 December 2015 (UTC)

(1)Please provide WP:MEDRS quality sources that call Ornish's programme or results dubious or fringe. (2) Scientific American has published Ornish's rebuttal including his description of Moyer's attacks as ad hominem, Moyer says she doesn't have the necessary expertise (3) A JAMA (journal) study is quoted above and you bring a controversial article in a lay journal in reply. This needs explanation. Yogesh Khandke (talk) 11:19, 5 December 2015 (UTC)

You mean to say that JAMA that has the third highest Impact factor in its category as "non-heavyweight", and think a lay publication is heavyweight? Yogesh Khandke (talk) 11:23, 5 December 2015 (UTC)

You don't need a WP:MEDRS-quality source to frame a fringe view, but something which shows WP:PARITY. Ornish's recent pronouncements have been taken down by pieces such as this. The JAMA article mentioned is a twenty year old primary source, so no good for our purposes. Alexbrn (talk) 12:02, 5 December 2015 (UTC)

(1) First you ought to use neutral language, there isn't any need for language like "have been taken down by pieces". (2)Don't bring blogs into this discussion, we need MEDRS quality sources like the JAMA study that has been quoted above. Yogesh Khandke (talk) 12:33, 5 December 2015 (UTC)

I am a medical professional, but being new to Wikipedia makes it hard to read and understand some of the discussion about sources and MEDRS, am learning. I never initially suggested using Ornish specifically, Dr. Esselstyn's research is wider-known and more scientifically sourced, multiple publications cited in one of the links I left above. The only reason I initially thought it would be good to be specific (Esselstyn) is because I didn't want people thinking they could eat lettuce and carrots and be healthy...the heart disease reversal diet is admittedly more specific than that, so I included the sentence I initially entered (about Esselstyn) - to allow people who wanted to improve their health know where to start - safely and responsibly. The facts are becoming very widely known (recent Washington DC plant-based conference drew over 500 doctors) and I agree that getting accurate, current, medical info posted is our responsibility as medical professionals to the people desperately searching for a truthful source to help them manage their disease. I appreciate all the help and guidance from all as I learn terms, acceptable sources, etc. Karyn Swaney (talk) 15:09, 7 December 2015 (UTC)

I am just seeing the line "The dietary pattern with the greatest support is the Mediterranean diet" which is not in line with the current science on what dietary pattern provides the best results for MI prevention. I am hoping something can get posted soon that tells people the truth.Karyn Swaney (talk) 04:11, 8 December 2015 (UTC)

What MEDRS-compliant ref(s) do you have to back up the claim that the Mediterranean diet is not the diet with the most support? Please be specific! TylerDurden8823 (talk) 04:52, 8 December 2015 (UTC)

I put up several sources above of strong evidence of heart disease reversal with WFPB diets. I am not saying there is not proof supporting Mediterranean diets as better than most, but am only aware of evidence of actual heart disease reversal with WFPB diet.

http://www.huffingtonpost.com/joel-fuhrman-md/heart-health-prevent-and-reverse_b_783565.html

http://ajcn.nutrition.org/content/78/3/544S.full

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662288/

http://www.pcrm.org/health/heart/treat-and-prevent-atherosclerosis

And though this page http://www.dresselstyn.com/site/articles-studies/ may be re-posting of the articles, the source of publication is listed with the reposted article, so not sure why this wouldn’t qualify as containing secondary sources, as easily can use the publication listed.

The word vegan should not be used in discussions of health management, but anyways:

http://drjaygordon.com/in-the-news/the-president-of-the-american-college-of-cardiology-goes-vegan.html

I do not claim to have half the knowledge The President of the American College of Cardiology does, but if his (and a growing group of cardiologists) interpretation of the available data makes them feel strongly that WFPB should be recommended to their patients, that is a might convincing fact in itself. Karyn Swaney (talk) 07:32, 8 December 2015 (UTC)

There are no reliable sources there supporting the idea that diet can "reverse" heart disease. This appears to be a WP:FRINGE view based on skimpy evidence, and touted by people like Ornish and Esselstyn whose chief objective seems to be large volumes of book sales etc. This is an extraordinary claim and would need a super-strong source, not the Huffington Post or some fringey journal. I think we may however note this idea as a popular misconception promoted by some prominent altmed types and not supported by good medical evidence. The Science-based medicine site has published some posts on this topic[15][16] and per WP:PARITY would be a usable counter-source. Alexbrn (talk) 07:43, 8 December 2015 (UTC)

So are we saying that: Preventive Cardiology, The Am J of Cardiology, Cleveland Clinic, The Journal of Family Practice, Experimental and Clinical Cardiology are not good sources, as all are listed in this .

Statements can also say comment "There is evidence to suggest that WFPB diet can have major impact on managing and improving CV disease and decreasing MI risk. The current President of the American College of Cardiology Dr. Kim A. Williams feels the data is strong enough to recommend a WFPB diet to his patients, but acknowledges that more extensive clinical trials are necessary." (as cited above)Karyn Swaney (talk) 16:06, 8 December 2015 (UTC)

References

Sorry, the reference you give there is to Esselstyn's commercial site, which is not a good source. Are you proposing something from a good source and if so what specifically? Alexbrn (talk) 16:11, 8 December 2015 (UTC)

Are you not clicking on it? He cites where those papers were published! Karyn Swaney (talk) 16:14, 8 December 2015 (UTC)

I tried one and it was some junk journal and the article was written by - Esselstyn himself. I gave up then. If you find anything of worth, please indicate. Alexbrn (talk) 16:36, 8 December 2015 (UTC)

They are published articles so the bottom line is you are saying all those listed sources are not valid. What is increasingly 'skimpy" is the meat and dairy propaganda, which is why I say the paragraph I do above, which is well-evidenced and cited. (added word comment to highlight). There is no argument that what I say above is factually correct and easily evidenced, as doesn't even draw an absolute set-in-stone conclusion, but not when we discredit extremely notable physicians and call them bias for trying to get word out because they know truth about what really helps their patients. People are dying, and those who have read the trials know how to best help them, so that is all I am suggesting, give patients the opportunity to decide for themselves and include the evidence.Karyn Swaney (talk) 17:05, 8 December 2015 (UTC)

No I checked one and it was poor enough I looked no further. Look, if you want stuff in the article the onus is on you to find good WP:MEDRS sources. Then we can reflect them. It is nt our job to give medical advice, but to reflect accepted knowledge, which is subtly different. Alexbrn (talk) 17:11, 8 December 2015 (UTC)

"Physicians should consider recommending a plant-based diet to all their patients, especially those with high blood pressure, diabetes, cardiovascular disease, or obesity." Karyn Swaney (talk) 17:13, 8 December 2015 (UTC)

References

For those who have read the studies it is already accepted knowledge, now we who know truth are trying to demonstrate it to those who still have not updated their own knowledge. I am not looking for medical advice, I have done the research. I am hoping others do the same so we can let people know their options and help them live a better life with less disease. Thanks.Karyn Swaney (talk) 17:21, 8 December 2015 (UTC)

break

It presents a case study, one of the weakest types of source according to WP:MEDRS. The words you quote don't strike me as hugely contentious (and note they do not mention "reversing" heart disease). But we need strong WP:MEDRS for sourcing such statements. Are there any? Alexbrn (talk) 17:24, 8 December 2015 (UTC)

I feel like I am posting the same things over and over - my statement above does NOT say that.

sorry for repetition but my actual words are not being debated: "There is evidence to suggest that WFPB diet can have major impact on managing and improving CV disease and decreasing MI risk. The current President of the American College of Cardiology Dr. Kim A. Williams feels the data is strong enough to recommend a WFPB diet to his patients, but acknowledges that more extensive clinical trials are necessary."Karyn Swaney (talk) 17:32, 8 December 2015 (UTC)

Again, source? If we're going to make statements like this we need more than what one dude "feels". Alexbrn (talk) 17:47, 8 December 2015 (UTC)

"One dude" is one of the most powerful physicians in the USA, and many sources are in the texts above but continue to be called invalid even though it is easily demo'd that many MDs agree and are "prescribing" WFPB diets.

http://health.usnews.com/health-news/blogs/eat-run/2015/09/02/absence-of-meat-makes-the-heart-grow-stronger

http://www.forksoverknives.com/why-i-abandoned-traditional-cardiology-to-become-the-healthy-heart-doc/

http://ajcn.nutrition.org/content/78/3/544S.full

http://www.jeffnovick.com/RD/Articles/Entries/2013/12/5_The_Specturm_Of_Health__The_Evidence_For_A_Whole_Food_Plant_Base_Diet_-_Pt_1.html

http://www.hindawi.com/journals/cric/2015/978906/

http://www.pcrm.org/health/medNews/plant-based-diet-reverses-angina

http://business.inquirer.net/167214/genes-load-the-gun-lifestyle-pulls-the-trigger

Karyn Swaney (talk) 17:58, 8 December 2015 (UTC)

Feedback accepted, instead of "feels" - "After the current President of the American College of Cardiology Dr. Kim A. Williams reviewed the data and saw his own health measurements improve after changing his diet, now recommends a WFPB diet to his patients, yet acknowledges that more extensive clinical trials of the impact of WFPB diets are necessary." - or something such as? Karyn Swaney (talk) 18:19, 8 December 2015 (UTC)

http://wellandgood.com/2014/12/29/meet-the-new-york-doctor-who-prescribes-vegan-diets/

http://www.montefiore.org/cardiacwellnessprogram

http://www.losaltosonline.com/special-sections2/sections/your-health/48685-

http://health.usnews.com/health-news/blogs/eat-run/2015/01/28/plant-based-diets-a-prescription-for-optimal-health

http://nutritionstudies.org/reversing-heart-disease-diet/

Karyn Swaney (talk) 18:36, 8 December 2015 (UTC)

Right, so nothing reliable. I think we're done here. Alexbrn (talk) 18:38, 8 December 2015 (UTC)

Wow...any medical pro who would discount opportunity to present clinically significant info? Wiki medical editing is clearly not the place for me, I pursue current data, maybe someday we can agree to reflect that without bias.Karyn Swaney (talk) 18:49, 8 December 2015 (UTC)

I just looked at Dr. Esselstyn's Wiki page, and am seeing that even though some of the most powerful doctors in the country support and cite his research, and is backed in other clinical trials, Wikipedia editors have chosen the word "skimpy." I find this very surprising. Even our more-comprehensive studies on vegetarians should be able to suggest these claims are much more than just "skimpy" ideas to "sell a book". I find that assertion appalling in the absence of any proof that he is wrong or shady. I am not interested in bashing other doctors. Take care.

Comprehensive lifestyle changes may be able to bring about regression of even severe coronary atherosclerosis after only 1 year, without use of lipid-lowering drugs.

http://www.sciencedirect.com/science/article/pii/014067369091656U

Results: After a mean of 10.6 years…vegetarians had a 24% reduction in mortality from ischaemic heart disease.

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=550912&fileId=S136898009800007

Pending answers to these questions, a plant-based low-carbohydrate diet high in vegetable proteins and oils may be an effective option in treating those with dyslipidemia for whom both weight loss and lower LDL-C concentrations are treatment goals.

http://archinte.jamanetwork.com/article.aspx?articleid=415074&resultClick=3

http://healthletter.mayoclinic.com/editorial/editorial.cfm/i/397/t/The%20risks%20of%20not%20going%20meatless/

Karyn Swaney (talk) 19:53, 8 December 2015 (UTC)

Three primary sources and an editorial, none of which is a WP:MEDRS. Please read WP:MEDRS (and maybe WP:WHYMEDRS for background) - we need good secondary sources for this kind of major biomedical information. Alexbrn (talk) 20:00, 8 December 2015 (UTC)

That is kind of funny, because for this last post I clicked on a bunch of sites that are currently cited by Wiki editors and used their data. Am also seeing sources from pages I have cited now being called unacceptable, i.e. The Am J of Cardiology and others. I do think we are done here.Karyn Swaney (talk) 20:09, 8 December 2015 (UTC)

I don't understand your point. The Am J of Cardiology is a journal. It will contain articles (sources) that are both reliable and unreliable per WP:MEDRS. So far nobody has suggested a reliable one. This is all explained in WP:MEDRS and WP:WHYMEDRS. Please do read them. Alexbrn (talk) 20:17, 8 December 2015 (UTC)

Saying that doctors are reproducing primary data in their own practice and not all of that was 'primary' spurces. Also saying "strong research suggests" which it clearly does. Truth can't stay hidden forever, no worries. We will see the edit soon, one one or another. Karyn Swaney (talk) 20:38, 8 December 2015 (UTC)

The people on here seem to lack interest in collaboration or science, only in refuting sources without acknowledging a readily apparent truth and assisting with their knowledge to be able to factually include clinically significant data. As said, the bashing of others who are well-respected and have saved many lives by offering a simple and self-evident truth is appalling. To use words such as 'skimpy' when the research is so widely supported - it is insulting. I was looking for another way to bring real help, offer a real solution, based on widely-scientifically supported data. This is clearly not the forum to do that, wasting time arguing such simplistic ideas (food as medicine?) and simple biology (our lean scientifically towards herbivore physiology) with 'peers' rather than collaboration, support (as I may have been a new user but these are NOT new ideas) and the true desire to be objective and factual. No thanks.Karyn Swaney (talk) 17:48, 9 January 2016 (UTC)

Lifestyle section "Cholesterol Skeptic" Bias

Lifestyle section in this article contained a biased link to a widely discredited (but very popular in yellow journalism, and paleo fad diet circles) meta-analysis which claims to contradict scientific consensus on saturated fat. I added the rebuttal and noted the current scientific consensus, the lipid hypothesis which contains a controversy section with the same meta-analysis and rebuttal (neither the controversial meta-analysis NOR the refutation really belong on this page OR that one, but if the meta-analysis link is going to be here the refutation needs to be as well).

If you doubt the scientific consensus, the page on the Saturated fat and cardiovascular disease controversy is already well written and covers the "controversy" well. IMO any rejection of scientific and medical consensus should really be kept there, rather than spread across Wikipedia (Cholesterol skepticism, not unlike the similar anti-vaccination position, is not credible and poses a public health risk when it results in misinformation).

I also clarified the point about Cholesterol, regarding hyper-responders, and included a link (if anybody has a better link or can go into more detail for readers, that might be good). People shouldn't be getting health advice from wikipedia to begin with, but this page still needs to contain responsible information. As with vaccines, listen to your doctor and you'll do fine. Wkuahngo (talk) 19:34, 8 January 2016 (UTC)

This ref is a strong source [17]. We do not refute it with a power point presentation.[18] We can balance it with other sources. We also have this BMJ review that says the same [19] Doc James (talk · contribs · email) 23:08, 8 January 2016 (UTC)

The clear bias this section still shows against the scientific consensus on this matter makes Wikipedia appear unreliable for medical information (I'm sure that's not what any of us want). The scientific consensus (as always) could be mistaken, but it's not our job to decide that and downgrade it by use of biased wording to what appears to be a minority opinion, or one held by only a few people. The "alternative POV" (the actual consensus) that was added back in is extremely weak by comparison to the real minority view following it, and the apparent result is the same as giving equal time in school classrooms to evolution and "intelligent design", when the two are by no means equal in terms of evidence or general acceptance in the scientific community. Two flawed and widely criticized meta-analyses (note that the linked criticism of that original source was also removed) are not enough to overturn scientific and government consensus, which is the lipid hypothesis. It is the scientific consensus, and not the supposed controversy that belongs on this page. If somebody wants to provide evidence for his or her personal opinions on the topic, that should be done where it belongs: in the article on the Saturated fat and cardiovascular disease controversy. This section should note that there is controversy and link to the full article on the topic for people to read if they are interested in that debate. In regard to dietary cholesterol and hyper/hypo responders (which is a different issue, distinct from saturated fat intake and serum cholesterol), if anybody doesn't like the source I linked to, please replace it with a superior one. Here's an option: http://www.ncbi.nlm.nih.gov/pubmed/3328488 Although some government recommendations now do not suggest limiting cholesterol for the general population (saturated fat limits already keep dietary cholesterol low for most people), it's still recognized as important for people at high risk (which are the people most likely to be reading this article). Maybe some day more research will come out and show some confounding factors that prove the minority view right and overturn current consensus (maybe evolution will be proven false too?), but assuming that doesn't happen because the consensus is right after all, let's not let Wikipedia be a contributor to somebody ignoring his or her doctor's advice on saturated fat and cholesterol and dying an early death because of it. Wkuahngo (talk) 04:28, 14 January 2016 (UTC)

So you are saying that the BMJ[20] and Annals of Internal Medicine[21] two of the worlds most respected journals are horribly biased?

Instead you wish to replace these 2014 and 2015 reviews with a 1987 paper[22] Doc James (talk · contribs · email) 05:34, 14 January 2016 (UTC)

Doc James, you are putting words in my mouth, and I don't feel like you are reading what I have written in good faith (you have three times now misrepresented what I have said). The dietary cholesterol issue is completely separate from the dietary saturated fat issue: the fact that you seem not to understand that while continuing to edit this article is concerning. I have said this twice, and twice you ignored it. Dietary cholesterol recommendations are more legitimately controversial, and government recommendations vary, dietary saturated fat is not controversial in the scientific or medical community. Also, in terms of date (even if I were replacing those recent studies, which I was not) recent is not inherently better, due to research bias favoring doing studies attempting to contradict mainstream opinion, since more confirmation of established consensus is not really beneficial to the researcher. It's not like people didn't know how to do research 30 years ago. The more important issue is that those meta analyses are of poor quality, have been debunked (have you read criticism of them?) and the wording of the lifestyle section on this wikipedia page indicates clear bias of the writer of the page in favor of those two limited studies over the overwhelming scientific consensus. The lipid hypothesis is consensus. This should not even be a discussion; any contrary minority opinions and the controversial and flawed studies that support them can be found on the Saturated fat and cardiovascular disease controversy page. "Medical, scientific, heart-health, governmental and intergovernmental, and professional authorities, such as the World Health Organization, the American Dietetic Association, the Dietitians of Canada, the British Dietetic Association, American Heart Association, the British Heart Foundation, the World Heart Federation, the British National Health Service, the United States Food and Drug Administration, and the European Food Safety Authority advise that saturated fat is a risk factor for cardiovascular disease (CVD), and recommend dietary limits on saturated fats as one means of reducing that risk." It is important to challenge long held assumptions in science, but this is not the place for it (the article on the controversy is). I encourage you to re-evaluate your opinions on this topic, and talk with some actual cardiologists to challenge your own assumptions on the matter (if you have, you may have had the exceptionally bad luck of meeting one rare 'quack' among the bunch, in which case please seek a second opinion). I think it's great what you have done for Wikipedia, but I also understand that means you have more pull here, and if you want to write a biased article propping up these few recent controversial and deeply flawed studies as equal or greater in weight to the overwhelming governmental and non-governmental consensus on the topic regarding the risk of saturated fat on heart disease there is nothing I can do to stop you (I have neither the time nor resources to wage a war here). I fear the only way this page will ever be fixed is if you change your mind on this commitment you have to this opinion, but based on how you have misrepresented me so far and your seeming unwillingness to consider criticism of those studies I feel like it may be impossible for me to convince you no matter what I present. Please do a little soul searching, and please talk to experts you trust on the topic and consider the possible harm this fringe advice might do to people seeking knowledge here outside of the full context of the criticism available of those controversial studies. I sincerely hope that you will do the right thing here. Real human lives are on the line when bad information is disseminated like this and represented as equally credible to medical consensus. You're surely not a bad person, you have just been misinformed on this issue somehow, and have misunderstood how consensus works and why two limited meta-analyses don't overturn it. Wkuahngo (talk) 10:28, 14 January 2016 (UTC)

You could try to get the BMJ and Annals to retract these two meta analysis. Within the hierarchy of evidence expert opinion is lower than systematic review and meta analysis. What we tend to do here is set both those types of evidence. Doc James (talk · contribs · email) 11:12, 14 January 2016 (UTC)

That's blatantly false, at least in terms of new research. Do you not understand research bias on controversial issues like this? It took six years for Andrew Wakefield's fraudulent research on the link between MMR vaccines and autism to be retracted. Had Wikipedia been around and you in charge then, can we assume you would have been consistent in proudly declaring that vaccines likely cause autism on the Wikipedia page based on that study (despite no mainstream health authorities agreeing with that claim)? And how many children have died because of this bad information? In another section you rejected the claim that predominately plant based diets can actually reverse (rather than just help prevent which is clearly true) heart disease because it isn't consensus, and is based on more limited and controversial research: that would seem more appropriate, and will help prevent people from attempting to self-medicate with diet change alone without the help of a doctor. But here you do the opposite, in trivializing the overwhelming consensus in favor of limited and controversial research that supports your personal opinions. There are wealths of meta analyses supporting the conclusion that saturated fat intake increases cardiovascular risk, but you reject them because they're older than these newer studies, despite them being more credible and supported by mainstream opinion: they have stood the test of time, and these newer analyses have not. Just have an open enough mind to read the criticisms of these studies and talk to some cardiologists. If you care about human health, you will allow this section to be reworded to better reflect consensus and direct people who question this to the controversy page where the issue of these meta-analyses is better explained (with criticism) so they can decide for themselves without your biases restricting their access to this information or making it seem less credible. Just as if somebody is fully informed and chooses not to vaccinate his or her children and they die of disease as a result, if somebody is fully informed and chooses to eat butter and full fat meat over vegetable oil and lean meats/fish/vegetable resulting in fatal heart attack or stroke, so be it (it's unfortunate, but that's personal choice). We have a duty to provide the most reliable and unbiased information possible so people can decide for themselves, and this article fails to do so with its obvious bias against mainstream scientific and medical consensus on this topic. Wkuahngo (talk) 20:20, 14 January 2016 (UTC)

Ah was Wakefields paper a systematic review and meta analysis? Doc James (talk · contribs · email) 07:43, 15 January 2016 (UTC)

I believe it was the only available study on that specifically, at the time. I don't know why you're obsessed with meta-analyses, since they are less reliable than well designed studies due to the greater tendency to reflect biases (from publication bias to selection bias), and the lack of well established scientific or statistical methodology for them makes matters worse. There is an excellent article on Meta-analysis here, including the problems inherent in the methodology (which should make it particularly suspect when a meta-analysis seems to come up with such an extreme conclusion in opposition to consensus). This is a good summary of the issue which you should read if you are interested in being intellectually honest and ethical as a health practitioner in giving this potentially dangerous advice (which I hope you are, and that your biases aren't strong enough to prevent you from considering that these studies you like might be flawed, and the conclusions you have drawn from them unwarranted): http://www.hsph.harvard.edu/magazine-features/is-butter-really-back/ A short excerpt which makes the point about these meta-analyses: "Willett had taken a similarly strong stand against a meta-analysis published in the Journal of the American Medical Association (JAMA) in 2012, which reported that overweight people were 6 percent less likely to die than those of normal weight. Willett says the analysis did not properly account for factors like the tendency of frail elderly people to lose weight (not healthy), smokers to be skinny (also not healthy), and people with serious diseases to lose weight before they die. Willett also noted that the National Cancer Institute, partly in response to the JAMA paper, later sponsored a pooled analysis on the same subject. A pooled analysis, in which scientists gather raw data directly from the source rather than using data summaries from published papers, is more time-consuming and expensive than a meta-analysis, but the results can be more meaningful. The study, published in the New England Journal of Medicine, said that being overweight was indeed deleterious. According to Willett, it got almost no press. Similarly, an international collaboration of investigators had examined the relationship between type of fat and coronary heart disease—the same topic of the recent meta-analysis—by combining the original data from large cohort studies (more studies than in the recent Annals meta-analysis). Because they had access to the original data collected on individuals, the researchers were able to compare calories from saturated fat with the same number of calories from carbohydrates (which showed no difference in risk) and from polyunsaturated fat (which showed lower risk). They, too, received virtually no media attention." The analysis referred to in the last paragraph would be a better source. As shown in that article, with quotes, the authors of the Annals study (flawed though it is) even disagree with the conclusions you are drawing from it. You fail to understand the source material and its limitations, and you do so at risk to the health of those who may read this article and be confused away from sound mainstream health advice. Replacing saturated fat with polyunsaturated fats (all other things being equal) is good. But in Willet's words: "People don't just remove saturated fat from their diets. They replace it with something else, says Walter Willett, chair of the HSPH Department of Nutrition. Exchanging a hot buttered cheesesteak for a half-dozen donuts does not help your heart; swapping it for grilled salmon with greens and olive oil does." When controlled for processed sugar and other heart damaging foods we find polyunsaturated fat is more health promoting than saturated fat, but the source matters and you can't just replace it with junk food. The bottom line was that the issue is more complicating than just replacing fats. Mozaffarian has some good quotes about focusing on foods rather than nutrients. If you will read the article and the quotes from the authors of the Annals study with an open mind to the possibility you may have misunderstood something or misrepresented the issue here, surely you will change your mind and make the right decision to allow this article to be edited to better reflect both what is consensus and the complexity of this topic in terms of dietary recommendations. Wkuahngo (talk) 04:08, 18 January 2016 (UTC)

Added another review that found a small benefit. Doc James (talk · contribs · email) 23:56, 19 January 2016 (UTC)

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Saturated fat is unassociated with heart disease? The Chowdhury paper.

I find it amusing that saturated fat is being described as being unassociated with an increase in risk of myocardial infarction, based on the Chowdhury paper. This paper has had major criticism leveled against it. See descriptions:

http://www.hsph.harvard.edu/nutritionsource/2014/03/19/dietary-fat-and-heart-disease-study-is-seriously-misleading/

http://plantpositive.com/blog/2014/3/23/recent-articles-by-drs-chowdhury-and-dinicolantonio.html

http://nutritionfacts.org/video/the-saturated-fat-studies-set-up-to-fail/

I also find it amusing that dietary cholesterol is being described as unassociated with serum cholesterol, but that's another issue.

Research section

I have deleted a "research" section mentioning several random projects on the basis that this section appeared to be biased and incomplete. For example the first project mentioned was a phase I stem cell infusion trial that showed a "small but significant improvement" in an echocardiographic endpoint (only survival or event-free survival are meaningful clinical endpoints in MI research). There are literally thousands of research projects ongoing around the world and it is nearly impossible to give a brief overview of research in this area; if such a section is included it would need likely need to speak more generally about research methodologies important in the field (prospective cohort studies, case-control studies based on large databases, and randomized clinical trials) with a few classic examples.

Lancet seminar

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

GA Review

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 [23]MEDMOS, however fails [24]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?  Not done The article is complicated enough as is... such an abbreviation can be found instead on the ECG article--Tom (LT) (talk) 05:51, 8 April 2017 (UTC) Note that that only addresses one part of the suggestion. Did you think it workable to reword the sentences? Jclemens (talk) 04:25, 14 April 2017 (UTC) 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?  Done That is an excellent point. --Tom (LT) (talk) 05:51, 8 April 2017 (UTC) 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.)? will find a reference... --Tom (LT) (talk) 05:53, 8 April 2017 (UTC)  Done inserted --Tom (LT) (talk) 07:15, 22 April 2017 (UTC) 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.  Done good point. --Tom (LT) (talk) 05:51, 8 April 2017 (UTC)

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. still looking for a reliable non-primary source for these LRs... --Tom (LT) (talk) 01:44, 22 April 2017 (UTC)  Done let me know what you think --Tom (LT) (talk) 07:08, 22 April 2017 (UTC) "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.  Done --Tom (LT) (talk) 07:08, 22 April 2017 (UTC) "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.  Done --Tom (LT) (talk) 01:44, 22 April 2017 (UTC) "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)  Done good point. --Tom (LT) (talk) 05:51, 8 April 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?  Doing... will get back to you on this. --Tom (LT) (talk) 07:08, 22 April 2017 (UTC)  Done surprisingly find a reliable source relating to the pathophysiology of dyspnoea in MI --Tom (LT) (talk) 00:37, 24 May 2017 (UTC)

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.  Done stated directly. --Tom (LT) (talk) 07:59, 22 April 2017 (UTC) 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.  Done Please let me know what you think once I've finished rejigging this section. --Tom (LT) (talk) 07:59, 22 April 2017 (UTC) 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)  Done updated.--Tom (LT) (talk) 07:59, 22 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.  Done very good point. Reworded. --Tom (LT) (talk) 00:58, 24 May 2017 (UTC) 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)  Done --Tom (LT) (talk) 00:58, 24 May 2017 (UTC)

Pathophysiology

Addressed

What's a clotting cascade?  Done reworded. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC) 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.  Done removed factoid. --Tom (LT) (talk) 01:29, 17 April 2017 (UTC) "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.  Done moved to 'risk factors' section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC) "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?  Done reworded, and moved to 'risk factors' section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC) "Myocardial infarction in the setting of plaque results from underlying atherosclerosis." Didn't we cover this in the first paragraph in this section?  Done rearranged section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC) "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?  Done reworded. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC) "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.  Done reworded section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC) "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.  Done reworded --Tom (LT) (talk) 23:55, 24 May 2017 (UTC) "As a result, the person's heart will be permanently damaged." We haven't personalized the heart before now. Do we want to start?  Done --Tom (LT) (talk) 23:55, 24 May 2017 (UTC) 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)  Done --Tom (LT) (talk) 23:55, 24 May 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.  Done reworded --Tom (LT) (talk) 03:41, 7 May 2017 (UTC) "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?  Done clarified. --Tom (LT) (talk) 01:09, 24 May 2017 (UTC) "There are a number of different biomarkers." How about listing them all in turn, and then talking about the advantages/disadvantages/timing of each?  Doing... --Tom (LT) (talk) 03:41, 7 May 2017 (UTC)  Done --Tom (LT) (talk) 01:09, 24 May 2017 (UTC) "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.  Done reworded. --Tom (LT) (talk) 01:09, 24 May 2017 (UTC) "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?  Done clarified (and simplified the references) --Tom (LT) (talk) 01:09, 24 May 2017 (UTC) "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?  Done reworded --Tom (LT) (talk) 11:19, 6 June 2017 (UTC) "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.  Done I have almost completely reworded this section --Tom (LT) (talk) 11:19, 6 June 2017 (UTC) 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.  Done good point; removed.--Tom (LT) (talk) 01:15, 24 May 2017 (UTC) "hence the phrase "time is heart muscle"." Yeah, but so what? Who actually says that? Needs a better setup than 'hence'.  Done removed. --Tom (LT) (talk) 01:15, 24 May 2017 (UTC) NSTEMI: Every NSTEMI is NSTEACS, but not every NSTEACS is NSTEMI, right? That's not quite so clear in the text.  Done (I hope) now that we have the introductory section. --Tom (LT) (talk) 01:15, 24 May 2017 (UTC) GRACE score is currently redlinked, and should be explained or de-redlinked.  Not done unfortunately there is no GRACE article at present. --Tom (LT) (talk) 01:15, 24 May 2017 (UTC) P2Y12 gets far more airplay--COI?  Done decreased their prominence. --Tom (LT) (talk) 01:15, 24 May 2017 (UTC) "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.  Done reordered, good point --Tom (LT) (talk) 22:31, 24 May 2017 (UTC) 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.  Done mentioned --Tom (LT) (talk) 22:31, 24 May 2017 (UTC) Does targeted temperature management *only* belong to the STEMI branch? Seems to me it's agnostic about how you get to a cardiac arrest.  Done good point. --Tom (LT) (talk) 11:35, 27 May 2017 (UTC) 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)  Done noted and completely rewritten. --Tom (LT) (talk) 11:35, 27 May 2017 (UTC) It's not clear to me how ASA or PCI treatment differ between STEMI and NSTEMI.  Question: what is 'ASA'? --Tom (LT) (talk) 22:31, 24 May 2017 (UTC) Acetylsalycilic acid... better known as aspirin. Jclemens (talk) 22:07, 27 May 2017 (UTC)  Done --Tom (LT) (talk) 23:39, 2 June 2017 (UTC)

Prevention

Addressed

Do we want to break into primary and secondary prevention?  Done --Tom (LT) (talk) 22:48, 24 May 2017 (UTC) The relative space allocated to diet rather than smoking seems UNDUE. Ditto with Aspirin over Statins.  Done? reworded and reordered --Tom (LT) (talk) 10:48, 6 June 2017 (UTC) 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)  Partly done what do you think now? --Tom (LT) (talk) 10:48, 6 June 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

Never seen Killip class; NYHA categorization is more familiar to me. NYHA is for heart failure. Killip class is used for prognostic purposes in AMI. --Tom (LT) (talk) 00:45, 3 June 2017 (UTC) One more CN tag in the Complications section. I would also like to see some stats on the incidence and prevalence of these complications. Gotta be some out there somewhere... Jclemens (talk) 02:42, 1 May 2017 (UTC)  Partly done? added and expanded --Tom (LT) (talk) 10:45, 6 June 2017 (UTC) That CN tag on the first sentence is annoying. I'm sure we can find something.  Done --Tom (LT) (talk) 10:45, 6 June 2017 (UTC)

• TIMI scores somewhat lack context. How does their use relate to the previous paragraph?
  •  Doing... the use of TIMI is currently in discussion, see the talk page. --Tom (LT) (talk) 00:45, 3 June 2017 (UTC)

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. Noted. --Tom (LT) (talk) 09:59, 6 June 2017 (UTC)

• 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)
  • @Jclemens AMI-specific numbers are oddly hard to come by. IHD, CAD, no problem - AMI, a different story. Have had a look on google scholar, medline... any ideas? --Tom (LT) (talk) 09:59, 6 June 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)

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?
  •  Done --Tom (LT) (talk) 00:29, 11 June 2017 (UTC)
• "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)
  •  Done --Tom (LT) (talk) 00:29, 11 June 2017 (UTC)

Terminology

• "It is a type of acute coronary syndrome" Would subdivision or category be better words than 'type'?
  •  Not done splitting hairs here; I think 'type' is adequate --Tom (LT) (talk) 00:29, 11 June 2017 (UTC)
• 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)
  •  Question: I will put "(MI)" next to "myocardial infaction"... other than that, am not sure what specific change you are proposing here? --Tom (LT) (talk) 00:29, 11 June 2017 (UTC)
    • No other change, that covers it. I'd just wanted the repeated acronym use standardized. Jclemens (talk) 00:59, 11 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.
  •  Done --Tom (LT) (talk) 12:07, 13 June 2017 (UTC)
• "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)
  •  Done good point. I suppose technically this is a "sign". I've reworded this sentence slightly to reflect this. --Tom (LT) (talk) 23:45, 16 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.
  •  Done clarified. --Tom (LT) (talk) 11:29, 19 June 2017 (UTC)
• "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.
  •  Done --Tom (LT) (talk) 11:29, 19 June 2017 (UTC)
• "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.
  •  Not done I couldn't find a high-quality source to verify this. --Tom (LT) (talk) 11:29, 19 June 2017 (UTC)
• Might want to explicitly state who is guessing what risk factors contributed to which MIs, rather than just reeling off percentages.
  •  Done agree. I think it is simplistic to say that 36% of MIs are caused be obesity. Atherosclerosis is multifactorial and humans are multidimensional.--Tom (LT) (talk) 11:56, 22 June 2017 (UTC)
    • Note that this got reverted, so further discussion and refinement may be appropriate. Jclemens (talk) 20:12, 22 June 2017 (UTC)
• "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.
  •  Done --Tom (LT) (talk) 11:29, 19 June 2017 (UTC)
• "The evidence for saturated fat['s role in MI risk] is unclear"
  •  Done --Tom (LT) (talk) 11:03, 1 July 2017 (UTC)
• Do we have anything on high sugar intake contributing directly to MI?
  •  Done no reliable sources of enough weight to justify inclusion that I could find. --Tom (LT) (talk) 11:03, 1 July 2017 (UTC)
• "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."
  •  Done fixed --Tom (LT) (talk) 11:56, 22 June 2017 (UTC)
• 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)
  • Yes we do. I haven't given prominence to these, but they do merit a mention. I think genetic risk and personalised medicine will only become more important and we should mention what little we know here. --Tom (LT) (talk) 11:56, 22 June 2017 (UTC)
    • Well, if you'd like to keep 'em in, I'm fine with that but would prefer a bit more context rather than just the bare list (including some redlinks) that we had before. Jclemens (talk) 20:10, 22 June 2017 (UTC)
      •  Done clarified --Tom (LT) (talk) 10:54, 1 July 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.
  •  Done --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
• "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?
  •  Done I wish all these points were this simple to address... --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
• Isch[a]emic cascade is linked twice in the Tissue Death section.
  •  Done --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
• 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.
  •  Done Good point... except I do mention this in the lead. Clarified in the section as well. --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
• 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 [25]. Jclemens (talk) 04:17, 19 June 2017 (UTC)
  •  Done --Tom (LT) (talk) 11:58, 1 July 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?
  •  Done clarified. --Tom (LT) (talk) 11:51, 22 June 2017 (UTC)
• 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.
  • Linked the first entry. Could you clarified what specfic parts of this paragraph you are concerned about? --Tom (LT) (talk) 11:51, 22 June 2017 (UTC)
• 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.
  •  Done good point --Tom (LT) (talk) 11:51, 22 June 2017 (UTC)
• 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)
  • Thanks :) --Tom (LT) (talk) 11:51, 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)
    • I guess my concern is that a previous hemorrhagic stroke IS a high risk for bleeding. Maybe "who are currently bleeding or have high risk for problematic bleeding such as current ABC or history of XYZ" or something like that? Jclemens (talk) 20:09, 22 June 2017 (UTC)
      •  Done wording clarified. --Tom (LT) (talk) 12:03, 1 July 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?
  • I lean towards trying not to use the word "patient" as I feel that approaches the article from a medical perspective, whereas we are lay encyclopedia. No specific guidance when I checked WP:MEDMOS. --Tom (LT) (talk) 11:04, 22 June 2017 (UTC)
    • Fair enough. Sufferer? Victim? How do we denote in-text that the person in question is the one having the MI? Jclemens (talk) 20:09, 22 June 2017 (UTC)
      • I feel this is implied. --Tom (LT) (talk) 12:00, 1 July 2017 (UTC)
• "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?
  • Recommendation for anticoagulation for antiplatelet therapy for PCI in AMI appears to be at least one year irrespective of stent type [26].--Tom (LT) (talk) 12:50, 1 July 2017 (UTC)
• In rehab, do we really need to link driving and sexual intercourse? Seems overlinkage to me. Jclemens (talk) 03:27, 22 June 2017 (UTC)
  •  Done agree, there is no need for these to be linked. --Tom (LT) (talk) 11:04, 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?
  • Good point... Reworded both instances. --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
• "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?
  • Had to laugh at how prescriptive that sounded. Reworded. --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
• 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)
  • Agree. Removed. --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)

Prognosis

• "... clots transmitted from the heart during PCI" Traveling?
  •  Not done the meanings are equivalent. --Tom (LT) (talk) 10:08, 24 June 2017 (UTC)
    • The meanings may be equivalent and transmission a technically correct term, but I do suggest not needlessly inflating the reading level of the article. In common U.S. usage, nothing physical is transmitted, while knowledge, radio waves, etc. can be. Jclemens (talk) 17:38, 24 June 2017 (UTC)
• "...and [is] the largest cause of in-hospital mortality" While it looks like the 'is' from the previous clause might serve double duty, it looks less awkward to repeat it here, I think. Jclemens (talk) 04:16, 23 June 2017 (UTC)
  •  Done fixed --Tom (LT) (talk) 10:08, 24 June 2017 (UTC)

Epidemiology

• No issues. I know I've already asked for more current data once and you couldn't find any. Jclemens (talk) 06:32, 23 June 2017 (UTC)

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.
  • Thank you, I really appreciate this.--Tom (LT) (talk) 01:23, 11 June 2017 (UTC)
• DAVIDSONS2010B is defined twice, which looks to be just different pages of the same book.
  •  Done Fixed. --Tom (LT) (talk) 01:23, 11 June 2017 (UTC)
• "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.
  •  Done --Tom (LT) (talk) 12:06, 13 June 2017 (UTC)
• "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.
  •  Done removed and updated the European Guidelines (now 2012). --Tom (LT) (talk) 01:23, 11 June 2017 (UTC)
• "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.
  •  Done Replaced. --Tom (LT) (talk) 01:23, 11 June 2017 (UTC)
• "http://www.thennt.com/nnt/beta-blockers-for-heart-attack/" Needs full citation info.
  •  Done --Tom (LT) (talk) 01:23, 11 June 2017 (UTC)
• "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?
  •  Done --Tom (LT) (talk) 12:06, 13 June 2017 (UTC)
• "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?
  •  Done no newer secondary sources. Because therapies have changed in the last 21 years, I've opted to remove this statement. --Tom (LT) (talk) 00:01, 17 June 2017 (UTC)
• "Perry, K; Petrie, KJ; Ellis, CJ; Horne, R; Moss-Morris, R (July 2001). "Symptom expectations and delay in acute myocardial infarction patients."" Anything newer?
  •  Not done nothing newer I can locate. --Tom (LT) (talk) 00:01, 17 June 2017 (UTC)
• 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[27]

Thus we get this[28]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)

Meaning of a sentence not clear

I am not able to understand the meaning of coronary intervention in the following sentence "A cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression, or coronary intervention is diagnostic of MI"

Does coronary intervention means angioplasty? If it is, how can it be a cause (part of diagnosis) of MI? Thank you. -- Abhijeet Safai (talk) 09:46, 2 May 2017 (UTC)

Would mean angiogram. Doc James (talk · contribs · email) 17:15, 2 May 2017 (UTC)

Ok. Great. But in that case, "......ST elevation or depression, or findings in coronary intervention is diagnostic of MI" would be more appropriate. I am changing the sentence as a result. Kindly modify if not found accurate. Thank you. -- Abhijeet Safai (talk) 10:25, 3 May 2017 (UTC)

It seems that, that particular sentence is removed. So I could not make this change. But thank you for the information. -- Abhijeet Safai (talk) 10:31, 3 May 2017 (UTC)

Sensitivity of ECG to diagnose an MI is about 30%

I remember that I have read in the autobiographical book by Dr. Abhay Bang that the sensitivity of ECG to diagnose MI is only 30%. If I am not wrong he has referred to books by Eugene Braunwald. This reference can be found out and can be used in the article if found appropriate and if the article does not mention it. Thank you. -- Abhijeet Safai (talk) 06:31, 2 May 2017 (UTC)

Yes NSTEMIs often have normal ECGs Doc James (talk · contribs · email) 17:22, 2 May 2017 (UTC)

Thank you. -- Abhijeet Safai (talk) 10:26, 3 May 2017 (UTC)

Primary PCI for STEMI

doi:10.1161/CIR.0000000000000336 JFW | T@lk 16:38, 16 March 2016 (UTC)