Physiological and Biochemical Changes in Acute Heart Failure as A Sequent to Acute Myocardial Infarction

Ghafil Saihood Hassan
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Keywords : Acute heart failure, acute myocardial infarction, ejection fraction.
Medical Journal of Babylon  14:1 , 2017 doi:1812-156X-14-1
Published :16 July 2017

Abstract

Acute heart failures (AHF) can develop after acute myocardial infarction (AMI) early or later. It is a major cause of mortality especially in old age. The aim of current study was to detect the site of infarction in AHF patients, evaluation of parameter of AHF and comparison with control group. The present study was done in Marjan Medical City, Hilla, at cardiac center unit. Thirty (30) random patients of AHF sequent to AMI. They include (19male, 11female). The random control subjects include 30 healthy persons (20 male, 10 female) with matching age. The ages of both groups were 50 – 80 years. All patients were diagnosed by a specialist doctor. Medical history, physical examination, echocardiography, electrocardiography blood pressure measurement, body mass and laboratory tests (Serum troponin T and I, serum potassium, serum calcium and serum sodium) are performed to all subjects. The incidence of DM, HT, and smoking in AHF were 56.7%,60%, and 73% respectively. The serum troponin T, serum troponin I, serum calcium, were increased significantly while serum potassium, serum sodium and EF were decreased significantly in AHF compared to control group. The most common site of infarction in AMI with AHF was anterior infarction. Parameters of AHF were increased significantly (HR, serum troponin T, serum troponin I, and serum calcium)while other parameters were decreased significantly (serum potassium, serum sodium, and ejection fraction) were decreased significantly compared with control group.

Introduction

Heart failure is common complication of myocardial infarction which may develop early or later. Understanding nature of risks could help patients that receive therapy [1]. It is becoming more common in adult older than 65 years because of increased survival after acute myocardial infarction and improved treatment of coronary artery disease (CAD), valvular disease, and hypertension. Heart failure is a common clinical syndrome characterized by dyspnea, fatigue, edema and pulmonary rales. Heart failure has high morbidity and mortality rates, especially in older persons. The initial evaluation includes a history and physical examination, chest radiography, electrocardiography, and laboratory assessment to identify causes or precipitating factors [2]. The ejection fraction (EF) is the most reprehensive parameter for HF by ECHO. The major trials in patients with HF and a reduced EF (HF-REF), or ‘systolic HF’, mainly enrolled patients with an EF?35%, and it is only in these patients that effective therapies have been demonstrated to date [3]. After acute coronary occlusion, blood flow ceases in coronary vessels beyond the occlusion except for small amount of collateral flow from surrounding vessels. When the blood supply to part of myocardium is interrupted lead to irreversible changes an death of muscle cells [4]. The local muscle tissue become edematous and swell due to diminished cellular metabolism within few hours, no blood supply, the cardiac muscle cells die. Subendocardial muscles cells frequently become infarcted even there is no evidence of infarct in the surface portion of heart. The reason subendocardial muscle cells have difficulty obtaining adequate blood, is that the blood vessels in it, are compressed by systolic contraction of the heart, so damage of subendocardial regions occur first then spread toward the epicardium [5]. Cardiac troponin I and T are components of the contractile apparatus of myocardial cells. Elevations of these biomarkers in the blood reflect injury leading to necrosis of myocardial cells. The preferred biomarker is cardiac troponin I (cTn I) or cardiac troponin T (cTn T), which has high myocardial tissue specificity as well as high clinical sensitivity. Detection of a rise of the measurements is essential to the diagnosis of acute MI [6]. The systolic and diastolic hypertensions have been associated with an increased risk of AMI. The control of hypertension with appropriate medication has been shown to reduce the risk of MI significantly [7]. Cigarette smoking increases inflammation, thrombosis, and oxidation of low-density lipoprotein cholesterol [8]. It enhanced platelet activation, increased the likelihood of a thrombotic event, encouraged thrombus propagation, impaired the action of thrombolytic drugs and increased the chance of re-occlusion [9]. Physical activity (7 – 15 miles per week) of regular aerobic exercise increases serum HDL-C and decreases serum triglyceride (TG) [10]. Alcohol consumption has both favorable and unfavorable effects on metabolism, lipid profile, blood coagulation and fibrinolysis, blood pressure and vascular tone depending on the amount of alcohol consumed and the way that it is drunk [11]. Heart failure reduces output by activation of sympathetic nervous system (SNS). This leads to renal vasoconstriction and decrease glomerular filtration rate. This results in an increase reabsorption of sodium and water. And enhance renin- angiotensin –altos treron [12].

Materials and methods

The patients of current study were thirty 30 patients with AHF (19 male, 11 female). The control subjects include 30 healthy persons (20 male, 10 female) with matching age. Age of both groups was 50 – 80 years. All patients were diagnosed by a specialist.
A history, physical examination, echocardiography, electrocardiography were obtained and laboratory tests were performed to all subjects. The present study was conducted at Cardiac Unit in Marjan Medical City, Hilla. February to April 2016.    Materials are electrocardio-graph (ECG), echocardiograph (Echo), sphygmomanometer, centrifuge, weight and height scale, serum troponin T and I kit, serum potassium kit, Serum sodium ions kit, serum calcium ions kit.




Results

Effect of Gender of Patient on AHF No significant difference in gender in AHF as shown in table 1. Therefore, the data of both sexes were polled together and were considered as one group.

Discussions

Site of Infarction in AHF: In current study the most common site of infarction in AHF patients was anterior site. This result was in agreement with study of [14] who stated that the heart failure is more common after anterior infarction than other site, due to papillary muscles of mitral valve attach to anterior wall of left ventricle. History and clinical examination: Frequency of DM: It was 56 % in AHF after AMI. DM accelerated condition of hypertension, coronary artery disease. It may contribute directly to cardiac dysfunction, increased local activation of the renin- angiotensin system [15]. Frequency of hypertension (HT): It was 60%in AHF after AMI. The hypertensive patients seem to be related to endothelial damage, atherosclerosis, insulin resistance, left ventricular hypertrophy, and ventricular arrhythmias [16]. Frequency of smoking: It was 76% in AHF after AMI. Cigarette smoking leads to impair endothelial function via decreased nitric oxide production. Also increase oxidative stress and activated in inflammatory pathway. [17]. Body mass index (BMI) kg/m2 in patients of AHF (25.1±2.7) was increased but not significant (P value =<0.21) compared to control group (24.6±1.7). This result was agreement with (18)who reached that the average BMI became weaker and more limited effect on association with heart failure risk in AMI. Heart rate (HR) beats/minute was increased in patients with AHF (102±6.5) high significant (P value=<0.01) compared to control group (73.6±13.9). This result was agreement with study by [19], who mentioned that myocardial ischemia is disorder balance between myocardial oxygen demand and supply. Heart rate influences both factors. Biochemical analyses: Serum K level was decreased in patients with AHF (3.9±1.1 mmol/l) high significant (P value =<0.01) compared to control group (4.6±0.7 mmol/l. This result may be due to intake diuretic drugs with depletion of potassium or by use other drugs in management of AHF which decrease concentration of potassium concentration [20]. Serum calcium level was decreased in AHF (9 ± 1.2 mmol/l) significantly (P value =<0.05) compared to control group (9.3 ± 0.6mmol/l). See table 5. There is positive correlation between serum calcium and level of vascular calcification [21]. Serum troponin T and I level was increased in AHF (58.5± 18.1 µg/ml, 7.3±1.6 ng/ml) significantly (P value = 0.01) compared to control group (5.7 ±1.3 µg/ml, 0.8± 0.2ng). Elevated cTn values indicate of myocardial injury with necrosis. Serum sodium level: Sodium level in heart failure was decreased (141.2 ± 6.1) significantly (P value =<0.01) compared to control group (150.2 mmol/l). This result may be due touse of diuretic drugs [22]. Clinical examination and biochemical parameters according age groups: a- Ejection fraction % was decreased in patients with AHF in all age group, compared with control group due to systolic dysfunction. b- Heart rate (beats/min) was increased in patients with all ages compared with control group due to sympathetic nervous system. c- Body mass index (Kg/m2) in patients with AHF at age 50 – 59 years was not significant, while it was significant in patient with age 60 -69 compared to control group because child and old age predisposal to low blood volume more than middle age. d- Serum sodium (mmol/l) with patients of AHF in all age groups was decreased compared with control group due to secretion of antidiuretic hormones ADH from posterior lobe of pituitary gland and reach to kidney, where increase the permeability of water in distal duct to increase water reabsorption and excrete small concentrated urine. e- Serum potassium level (mmol/l) with patients of AHF in all age groups was decreased compared with control group by better diuretic response.

Conclusions

The most common site of infarction in AHF was anterior infarction. Parameters of AHF were increased significantly (HR, serum troponin T, serum troponin I, and serum calcium) while other parameters were decreased significantly (serum potassium, serum sodium, and ejection fraction were decreased significantly compared with control groups.

References

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