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Borobudur chaityas.

A chaitya is a Buddhist or Jain shrine including a stupa.^[1] In modern texts on Indian architecture, the term chaitya-griha is often used to denote assembly or prayer hall that houses a stupa.

History[link]

Chaityas were probably constructed to hold large numbers of devotees and to provide shelter for them.^[2] Early chaityas, such as at Bijak-ki-pahadi in Bairat which is ascribed to the emperor Ashoka, were built as standing structures with the stupa being surrounded by a colonnaded processional path enclosed by an outer wall with a congregation hall adjoining it,^[2] The more spectacular and more numerous chaityas, however, were cut into living rock as caves. This is an ancient practice has had a long tradition in Buddhism. All the ancient Buddhist Chaitya could be found in remote part of Maharashtra, specially at Ajanta rockcut architecture.

The earliest rock-cut chaityas, similar to free-standing ones, consisted of an inner circular chamber with pillars to create a circular path around the stupa and an outer rectangular hall for the congregation of the devotees. Over the course of time the wall separating the stupa from the hall was removed to create an apsidal hall with a colonnade around the nave and the stupa.^[3]

The chaitya at Bhaja Caves was constructed in the 1st century BCE. It consisted of an apsidal hall with stupa. The columns sloped inwards in the imitation of wooden columns that would have been structurally necessary to keep a roof up. The ceiling was barrel-vaulted with wooden ribs set into them. The walls were polished in the Mauryan style. It was faced by a substantial wooden facade. A large horseshoe-shaped window, the chaitya-window, was set above the arched doorway and the whole portico-area was carved to imitate a multi-storeyed building with balconies and windows and sculptured men and women who observed the scene below. This created the appearance of an ancient Indian mansion.^[3]

In Bhaja, as in other chatyas, the entrance acted as the demarcation between the sacred and the profane. The stupa inside the hall was now completely removed from the sight of anyone outside. In this context, in the 1st century CE, the earlier veneration of the stupa now changed to the veneration of an image of the Buddha. Chaityas were commonly part of a monastic complex, the vihara.

In Nepal, Chaityas are constructed and worshiped by the Sherpas, Magars, Gurungs, Tamangs and Newars, among others. The Newars in the Kathmandu Valley, mainly after the 12th century, started adding images of four Dhyani Buddhas on its four directions. They are constructed with beautifully carved stone and mud mortar. It is said to consist of the five basic elements - earth, air, fire, water and space. It is constructed in memory of a dead person by his or her family. In average, it is four to eight feet in height...

Architecture[link]

Architecturally Chaityas show similarities to Roman design concepts of column and arch. The monks built many structures which were carved out of a single massive rock, done with hammer and chisel, bare hands. These were known as cave temples. About 1200 such cave temples were built throughout India. The most important are at Karle, Ajanta, Ellora, Udaigiri, Aurangabad and Nasik. They were rectangular halls, with finely polished interior walls. There were a number of well proportioned pillars, generally around 35, and a semi-circular roof. Opposite one entrance stood a stupa. All the pillars have capitals on them, with carvings of a kneeling elephant mounted on bell-shaped bases.

The pillars had three parts: prop, which is the base which is buried into the ground; the shaft, the main body of the pillar which is polished and chiseled; capital, the head of the pillar where figures of animals are carved. The Stupa at the end of the Chaitya Hall has an umbrella at the top. This Umbrella suggests association with Buddhism. There is a wooden facade, made out of teak wood. The facade makes it look as if the entire structure was resting on the back of an elephant with ivory tusks and metal ornaments.

The Chaityas were almost 40 meters long, 15 meters wide and 15 meters high.

See also[link]

• Cetiya
• Pagoda
• Stupa

Notes[link]

References[link]

• Total History and Civics. A Morning Star Publishing. ICSE- IX standard.
• Dehejia, V. (1997). Indian Art. Phaidon: London. ISBN 0-7148-3496-3.

External links[link]

• Evolution of Chaitya Halls compiled by students of School of Planning & Architecture, New Delhi

Acharya Mahapragya
Born	Acharya Shri Mahapragya (1920-06-14)14 June 1920 Tamkor, Rajasthan, India
Died	9 May 2010(2010-05-09) (aged 89) Sardarshahar, Rajasthan, India
Predecessor	Acharya Tulsi
Political movement	Ahimsa Yatra

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Acharya Shri Mahapragya (आचार्य महाप्रज्ञ )(14 June 1920 – 9 May 2010) was the tenth Acharya, supreme head of the Svetambar Terapanth sect of Jainism.^[1] Mahapragya was a highly venerable saint, yogi, spiritual leader, philosopher, author, orator, poet.^[2] Many of his books and articles were published under the former name Muni Nathmal (मुनि नथमल).

He began his life of religious reflection and development as a Jain monk at the age of ten.^[3] Mahapragya played a major role in Anuvrat movement launched by his Guru Acharya Tulsi in 1949, and became the acknowledged leader of the movement in 1995.^[4] Acharya Mahapragya formulated the well organized Preksha meditation system in the 1970s,^[5] and developed the "Science of Living" education system which is a practical approach for the balanced development of a student and his character building.^[6]

He traversed more than 100,000 km on foot covering more than 10,000 villages reaching out to the masses spreading the message of harmony and peace.^{[citation needed]} He walked across the length and breadth of India From Kutch District in Gujarat to Kolkata and from Punjab to Kanyakumari. Mahapragya undertook this travel under the leadership of Acharya Tulsi and later with himself being the leader.^{[citation needed]} During these travels, he addressed thousands of public meetings. Mahapragya is an apostle of nonviolence. He launched the Ahimsa Yatra movement in 2001 which continued until 2009 to promote non-violence and harmony.^[7][8] Followers refer to him as Gurudev, which mean the Godly Teacher.^{[citation needed]} His discourses were telecasted daily on Indian television.

Biography[link]

Early life[link]

Mahapragya was born to Tola Ram Choraria and Baluji in the small village of Tamkor in the Jhunjhunu district in Rajasthan.^[9] It was a Jain Shwetambar Terapanthi Agrawal Jain family.^[10] He was called Nathmal by his family. He lost his father when he was just two and half months old.^[11] It was an extended family and he gained support from all the family members. Nathmal's mother was very affectionate for the child and took care with his upbringing.^[12] There was no formal school in Tamkor village in those days and he did not receive a formal education. He nonetheless had lessons on letters and mathematics tables from local teacher(s).^[13] Mahapragya's mother was religious lady who devoted her spare time to spiritual matters. She also used to recite religious songs which made an imprint on the young child. Her spirituality inspired him.^[14] Mahapragya received lessons on philosophy from Jain monks who visited the village. Eventually he conveyed to his mother his wish to be initiated into monkhood.^[15] On 29 January 1931, he became a monk at the age of ten. Acharya Kalugani, eighth Acharya of Jain Swetambar Terapanth initiated him to monkhood in the town of Sardarsahar (Rajasthan). With this, Nathmal became Muni Nathmal.^[16] Acharya Kalugani arranged for Muni Nathmal's studies under Muni Tulsi's classes, who later became the Ninth Acharya. Nathmal started getting lessons in the monastery on various subjects of Jain philosophy.^[17]

With Muni Tulsi, the child’s intellectual development accelerated and he memorised thousands of sermons and verses in Hindi, Sanskrit, Prakrit, and Rajasthani. His education at the monastery included history, philosophy, logic, and grammar.^[18] He made an in-depth study of Jain scriptures, became a scholar of Jain Agamas, and a critic of Indian and western philosophy. By the age of 22, he was competent in Hindi, Sanskrit, Prakrit, and Rajasthani languages and literature.^{[citation needed]} In Sanskrit, he was also an expert impromptu or extempore poet and demonstrated this skill in many gatherings of intellectuals.^{[citation needed]} He also studied physics, biology, ayurved, politics, economics, and sociology.^[19]

Spiritual endeavors (1945–1978)[link]

Anuvrat movement[link]

Mahapragya played an instrumental role in the Anuvrat movement launched on 2 March 1949 by his guru and the head of Jain Shwetambra Terapanth, Acharya Tulsi. The ultimate aim of the movement was and remains to create a nonviolent socio-political world order with the help of a worldwide network of self-transformed people.^{[citation needed]} Since its inception it has inspired millions of people to practice purity and self-discipline in their personal lives.^[20] Mahapragya helped Acharya Tulsi in the preparation of the contents of Anuvrat and worked as a core member in the movement, many times representing Acharya Tulsi by explaining the principles of Anuvrat.^[21]

Acharya Shri Tulsi nominated Muni Nathmal as the Secretary (Nikaya Sachiv) of Terapanth in 1965 at Hissar Harayana after being Group leader (Agraganya) for almost 21 years.^[22]

Agam research and editing[link]

Acharya Tulsi, Acharya Mahapragya during Jain Agamas research.

After consulting Mahapragya, Acharya Tulsi decided to start the research, translation and annotation of the Jain Agamas.^[23] The work started in 1955 in Ujjain under the leadership of Acharya Tulsi with Mahapragya being the editorial director.^[24] Joint activity of Acharya Tulsi, Mahapragya and other intellectual monks and nuns began to facilitate the permanent preservation of many thousands of years old canonical scriptures and embellished them with a scientific outlook acceptable to the people. Mahapragya edited and critically annotated the agamas. This old literature is in Prakrit language and its commentaries are either available in Prakrit or Prakrit mixed with Sanskrit.^[25] Mahapragya first undertook their deep, sustained study and started editing them and provided their new meanings and interpretations. Through strenuous work day and night for many years continuously, the original text of the thirty-two Agam scriptures was determined and their Hindi translation also completed.^[26] Detailed commentaries thereon made them more interesting and comprehensible. This task carried out in accordance with the verbal renderings by Acharya Tulsi was guided by an entirely non-sectarian and open mind and is therefore viewed with respect by the heads of other sects as well as intellectual and oriental scholars of the East and the West. Acharang Bhasyam is Mahapragya's commentary for Acharang in sanskrit. He uncovered many Agam mysteries and presented root philosophies and Mahavir's philosophy and vision in this commentary.^[27]

Formulation of Preksha Meditation System[link]

Acharya Mahapragya in meditation

While in his late twenties, Mahapragya started to realize the wonders of meditation.^[28] He was open to experiment with spiritual techniques. He discussed his discoveries w with Acharya Tulsi and thereafter Mahapragya started dedicating more time to meditation practices. He exercised deep practice of meditation and experimented with various techniques. He made a deep research of Jain Agamas, ancient scriptures, Yoga science, Biology, Modern Physics, Naturopathy, and Ayurveda, etc. After a deep practice for over 20 years, he formulated the Preksha Meditation system in 1970.^[29] He formulated the meditation system in a very well organized and scientific way. The basic four wings of the meditation system can be summarized as – Meditation, Yogasana and Pranaayam, Mantra, and therapy.^[30]

Before presenting Preksha meditation in formal training camps, Mahapragya made a special practice of meditation and spiritual exertion for a period of nine months which started on 3 March 1977.^[31] The First formal Preksha meditation camp was the organized later in 1977.^[32]

Since that time Acharya Mahapragya had conducted hundreds of camps for training in Preksha Meditation.^[5] Many Preksha Meditation centers are operative across the globe. Research, detail training, and studies on Preksha Meditation is an important activity at Jain Vishva Bharati University.^[33]

Science of Living Education System[link]

Science of Living education system is an effort to implement value-based education and moral education. Its goal and approach is overall development of student and not simply just the intellectual development. Mere intellectual development can't help in building real experience and character of the student.^[34] It aims for a balanced emotional, intellectual and physical development. It gives more emphasis on practical training as compared to mere philosophy.^[35] The model includes Yoga, Pranayam, Postures, Meditation, contemplation techniques, etc. Scientific techniques of Science of Living helps in balancing the emotions of the student. It helps in balanced functioning of the neuro-endocrine system in body.^[36] It works for the transformation of emotions, inculcate positive attitude and integrated development of personality.^[34]

Acharya Mahapragya conceived the idea of 'Science of Living' in 28 December 1979 at Jain Vishva Bharati, Ladnun, Rajasthan. Mahapragya developed the Science of Living education system model.^[34] Many camps were conducted for the teachers of Nagore distrcict, Rajasthan. Science of Living started getting positive reception from ministry of education and various educational society. Rajasthan ministry of education facilitated the training of teachers and camps were started.^[34] Some people started research in this field. Few schools were selected to start implementation of Science of Living. After one year of its implementation in schools, the results were surprising and very positive for students. It started getting wider acceptance with education ministry of Indian Government and state governments. Many schools started including it in their curriculum.^[37]

Science of Living got very positive feedback from teachers, student and parents on the student's emotional and overall development as such. Some of the feedback can be summarized as reduce in stress, improved efficiency in studies, better concentration and memory, better anger management, etc.^[34] Day by day Science of Living is gaining more recognition and wider acceptance in Indian education system.

Successor-designate to Acharya Tulsi[link]

Impressed by Muni Nathmal (later Mahapragya), Acharya Tulsi honored him with the qualitative epithet of Mahapragya (highly knowledged) on 12 November 1978.^[38]

On 4 February 1979, his appellation ‘Mahapragya’ was converted into his new name by Acharya Tulsi and he was also made ‘Yuvacharya’, successor designate to the present Acharya,^[39] the second highest position after the Acharya himself. With this elevation, he was now referred as Yuvacharya Mahapragya. As a Yuvacharya , Mahapragya became a close associate of Acharya Tulsi in major decisions and activities related to the sect.

In a public meeting on 18 February 1994, Acharya Tulsi declared that Mahapragya would now have the title of ‘Acharya’ also and that the former was renouncing this position forthwith. Subsequently, on 5 February 1995, Mahapragya was formally consecrated as the 10th Acharya – the supreme head – of the Terapanth religious order in a public meeting in Delhi.^[40] Having been elevated within Terapanth, Mahapragya received many responsibilities. Further intensification of the movements of Anuvrat, Preksha dhyan, and Jeevan Vigyan now became his primary concern. A Vikash Parishad – development council – has been constituted by Mahapragya to give further fillip to all these movements and underline their importance.^[41] The forum of Terapanth is now actively involved in propagating these movements.

Jain Vishva Bharati University[link]

Acharya Mahapragya was responsible for the conception of Jain Vishva Bharati University, Ladnun, Rajasthan and played a key role in its establishment.^[42] It was established under the spiritual patronage of Acharya Tulsi in 1991.^[43] Acharya Mahapragya served as head of this university since 1995. The University reportedly derived its spiritual strength and direction from him, as he was believed to be above any sectarian bias.^{[citation needed]} The university's objective is to revive truths and values hidden in the ancient Indian traditions in general and in the Jain tradition in particular. It provides platforms and infrastructures for doing research in various subjects and for the pursuance of doctorate degrees. One of the prime objectives of this University is to spread literacy in subjects like nonviolence and peace, Jainology, Sanskrit, Prakrit, yoga, meditation, and literature.^{[citation needed]} Regular degree courses leading to bachelors and masters degrees are presently being conducted.^[44]

Ahimsa Yatra (2001–2009)[link]

Acharya Mahapragya during Ahimsa Yatra.

The world's problems touched Acharya Mahapragya deeply.^[45] In response, he came up with the solution of Ahimsa Yatra, a journey on foot to advance the cause of non violence, was launched by Mahapragya 5 December 2001 at Sujangarh in Rajasthan.^[45] With Ahimsa Yatra, Acharyaji's mission is to train and spread nonviolence and its broad perspective to people. It is an endeavor to awaken a new faith in the infinite power of nonviolence. It aims at bringing the problems of all forms of violence into sharp focus.^[46] Its mission is to provide training for transforming the negative thoughts/emotions into positive direction. The spiritual aspect of non-violence training is to ignite the consciousness of non-violence and to cultivate the values of non-violence. And its practical aspect is the employment training for livelihood.^[47]

Having eschewed violence and pledged to refrain from killing innocent creatures; political leaders, social workers, and spiritual leaders came to him for advice.^[48] He took his Yatra from Gujarat to Maharashtra, Daman, Madhya Pradesh, Haryana, Delhi, some parts of Uttar Pradesh, Punjab, and Chandigarh.^[49] He passed through 87 districts of India, and covered more than 2400 villages, towns and cities, where he held meetings with many spiritual and political leaders and appealed for communal harmony. Approximately 40,000 volunteers were assigned to various responsibilities in their local areas.

This Yatra allowed him to come into direct contact with farmers and common and poor people of the villages which he visited. He stopped at all the small villages on his route and held open mass meetings. Through this public speaking, Acharyaji created awareness on the broad perspectives of nonviolence, unemployment eradication, leading a life free from drug addiction, bad habits, communal harmony, healthy living, and harmonious social and personal lives. Side by side volunteers spread out in different directions in order to establish personal contact with families afflicted by drug addictions, unemployment, and stress. These volunteers were then to stay behind in order to help solve the afflicted's problems. Verily the villages and towns trekked by the Acharya become centres of training in ahimsa.

The Yatra concluded January 4, 2009 at Sujangarh, the same place where it had been begun.^[50]

FUREC[link]

President of India, Dr. A P J Abdul Kalam's vision for a fully developed beautiful India with prosperous and harmonious life for its citizens, especially the youth, motivated enlightened spiritual and religious leaders who organized a Conclave under the aegis of Acharya Mahapragya at Surat on 15 October 2003, also the birthday of Dr. A.P.J. Abdul Kalam.^[51] The Action Plan discussed during the Conclave was documented and is known as 'Surat Spiritual Declaration' (SSD).

The SSD Action Plan envisages "Five Garland Projects". The emphasis of four projects was on celebration of inter religious festivals, multi religious projects, healthcare, and employment, imbibing value based education in schools and encouraging interfaith dialogue among religious/spiritual heads.^[52] In order to pursue these in a sustained manner and to coordinate all activities, a national level independent and autonomous organization managed by religious/ spiritual leaders as well as scholars and enlightened Citizens was set up. This organization was named "Foundation for Unity of Religious and Enlightened Citizenship' (FUREC). FUREC was launched by the President Dr. A P J Abdul Kalam on the birthday of Acharya Mahapragya, the 15th June 2004 at Rashtrapati Bhavan, New Delhi.^[53]

FUREC combines the objectives of the Surat Spiritual Declaration and President Dr. A P J Abdul Kalam's Vision 2020 and is a non-profit organization which was founded by 15 spiritual leaders.

Spiritual practices[link]

Meditation[link]

Mahapragya himself is a great practitioner of meditation. He has also written extensively on these topics. He started practicing mantra and meditation with his initiation to monkhood.^[54] In his twenties he started delving deeper into meditation and realized his profound interest for it. He used to practice it for hours and hours.^[55] His experience of meditation resulted in formulation of Preksha meditation system.

He also practiced Mantra chanting daily and became a Mantra expert with rich experience in it. He said from his experiences, the practice of Mantra can help people in awaking their hidden powers. Mahapragya used to practice Yogasana, Pranayama to keep himself fit.^[55] Mahapragya observed silence (Mauna) for more than three hours during the evening hours. Mahapragya used to be very conscious of his daily activity and meditative during all his activities like walking, eating, etc.^[56]

Mahapragya was an exemplary practitioner of Anekantavada and nonviolence.

Disciplines of monkhood[link]

This unreferenced section requires citations to ensure verifiability.

Mahapragya took five major vows as a part of initiation to monkhood at the age of ten. These Mahavrata are non-violence (Ahimsa), truth (Satya), non-stealing (Asteya), Chastity/Celibacy (Brahmacharya), and non-possession/non-attachment (Aparigraha). As a Jain Muni (monk), he traveled only on foot and could not make use of a vehicle unless and until he was incapable of walking. He did not eat or drink after sunset and before sunrise. He did not cook food but had to go out for alms. He accepted only vegetarian food. He did not own a house. He could not stay in a single place for long periods. He constantly had to change places and could only move in to a house with the owner's permission. He did not possess any thing except for few basic items like clothes and a bowl for alms.

Writing[link]

Acharya Mahapragya

Mahapragya started writing when he was 22 and did not cease until his death. He authored more than 300 books.^[57] These works deal with meditation and spirituality, the mind, the human psyche and its traits, the roots of emotions and their manifestation through behaviour, Mantra saadhana, Yog, Anekantavada, Non violence, and Jain philosophy and history.

In his book Art of Thinking Positive, he explored the root causes of negative thoughts and provided a methodology for its transformation.^[58] Some other book titles include Towards Inner Harmony, I and Mine, Mind beyond Mind, Mysteries of Mind, New Man New World, Mirror of Self. He analysed the hidden causes of emotions, the functioning of the human psyche, and the manifestation of the psyche through one's behaviour.^{[citation needed]}

Mahapragya formulated Preksha meditation and wrote extensively on this topic. In these books he described various techniques of meditations and their effects on the psyche, physiology, hormonal influences, the endocrine system, and the nervous system.^[59]

He has done extensive work on Anekantavada, the philosophy of non absolutism and relativity. He was a practitioner of this philosophy propounded by Lord Mahaveer which affirms that there is no problem that cannot be resolved with the application of Anekantavada. He showed ways how one can improve his thought process with Anekaant and use it for a peaceful life and co-existence.^[60] His book Anekanta The Third Eye discusses the details of the philosophy.

He has written many books on Jain Philosophy providing a serious material on Jain beliefs and vision. Jain darshan: manan and mimaansha is one of these creations and a research work in which Acharya Mahapragya elaborated numerous deep facets of the Jain belief system via a detailed interpretation. Another precise work is Philosophical Foundations Of Jainism. Shraman Mahaveer is biographical work on Mahaveer. Mahapragya tried to depict Mahaveer through his experience and achievements in meditation. Sambodhi is a rhymic conservation between Lord Mahaveer and the prince-monk Megha Kumar, in which Mahaveer enlightens the later. Mahapragya wrote extensively on the lives and philosophies of Acharya Bhiksu and Acharya Tulsi

Mahapragya made great contributions to Sanskrit through his poetry. Has also wrote poems and bhajans in Hindi. Ashruvina, Mukulam in Sanskrit and Rishabhayana in Hindi are some of his poetic creations.

Acharya Mahapragya wrote with great clarity. His sentences are short and his style was direct. He only suggested, he never forced his view. He may have asserted his belief, but his language is conscious of relativity even in expression. He often resorted to the passive voice. As one of his translator's once said "Between one full stop and the next sentence, a kingdom can be built".^[61]

Views[link]

Stand on religion[link]

Mahapragya says

"The religion which does not bring about a change in a man’s life, which does not impart peace to him, deserves to be thrown into the river Ganges rather than carried on as burden on one’s shoulders. Rituals or idol worship alone are not enough unless one’s conduct also gets transformed. Religion is not confined only to temples, mosques, or churches, but extends to the man’s day-to-day living as well."^[62]

"I believe in that religion which has moral values at its foundation and spirituality at its peak. I don't believe in that religion that doesn't have moral values and spirituality. I accepted that religion which made me physically, mentally, emotionally healthy. Religion is beyond rituals. Religion has the ability to solve our problems if you believe in pure religion."^[63]

Influence[link]

Rashtrakavi (National poet) Ram Dhari Singh Dinkar said “Mahapragya is a Modern Vivekananda. We have not seen Vivekananda, only heard and read about him. But now we can see Vivekananda through his Vision”.^[45]

Indian Prime Minister Atal Bihari Vajpayee has often stated: “I am a lover of Mahapragya’s literature”.^{[citation needed]} The Eminent Scholar of Philosophy, Dr. Daya Krishna has recognized Acharya Shri Mahapragya as the most knowledgeable person on the subject of Jain Logic.^{[citation needed]}

The famous Bangla writer Shri Bimal Mitra said: “I find new truth in Mahapragya’s work. When I read his books, I feel as if I write for the masses and he writes for me. If only I could have met him in the initial stages of my career, my literature would have had a new path to follow”.^{[citation needed]}

Dr. A.L. Bashim said: "While meeting Acharya Mahapragya, one gets the thrill of meeting the ‘Spiritual Ideal’ or the ‘Wonder that India was’".^{[citation needed]}

Awards and honours[link]

• Mother Teresa National award of peace by Inter faith Harmony foundation of India in 2005^{[citation needed]}
• Communal harmony award i.e. Sampradayika Sadbhavana Puraskar by Govt. of India in 2004^[64]
• Ambassador of Peace (London) by Inter Religions and international federation in 2003^{[citation needed]}
• Lokmaharshi by New Mumbai Municipal corporation in 2003^{[citation needed]}
• Indira Gandhi National Integration award in 2002^{[citation needed]}
• D.Litt by Netherland Inter Cultural Open University in 1999^{[citation needed]}

Death[link]

Acharya Mahapragya died on 9 May 2010 at 2:52 pm in Sardarshahar, in Churu district, the place where he gained monkhood. Subsequently, Acharya Maha Shraman was chosen the 11th acharya of Jain Terapanth, previously Acharya Mahapragya had made Acharya Mahashraman the Yuvacharya of the Terapanth sect at Gangashahar (Bikaner) in 1997.^[65]

See also[link]

• List of religious leaders in 2007
• List of Jains
• Sadhvi Kanakprabha

References[link]

External links[link]

Wikimedia Commons has media related to: Acharya Mahapragya

• Official site of Jain Shwetambar Terapanth

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The Marvelous Misadventures of Flapjack (also known as The Misadventures of Flapjack or simply Flapjack) is an Emmy award-winning American animated television series produced for Cartoon Network that premiered on June 5, 2008 and ended on August 31, 2010.^[1] The show was created by cartoonist Thurop Van Orman who has worked as a writer and storyboard artist on The Powerpuff Girls, The Grim Adventures of Billy & Mandy and Camp Lazlo. Flapjack was cancelled shortly after creative director JG Quintel and storyboard artist Pendleton Ward left to work on their own shows, Adventure Time and Regular Show.

On April 20, 2012, this series returned to Cartoon Network to show re-runs on the revived block, "Cartoon Planet".^[2]

Overview[link]

The series revolves around Flapjack and Cap'n K'nuckles. Flapjack is a young boy raised by a talking whale named Bubbie. Flapjack leads a peaceful life until the duo rescues a pirate by the name of Cap'n K'nuckles, who tells Flapjack of a place called Candied Island, which is made completely of candy. Inspired by the adventurous pirate, Flapjack, Cap'n K'nuckles and Bubbie get into strange predicaments and "misadventures" in search of candy, Candied Island and the coveted title of "Adventurer". The three spend most of their time in Stormalong Harbor, their place of residence, and home to many strange characters.

Production[link]

As a child, show creator Van Orman lived in Panama City, Florida, and "used to fantasize about living near the dock and having adventures all the time." When he was 13, his family moved to Utah, but Van Orman still dreamed of adventure. He worked after school as a janitor, saving money for a plane ticket back to Florida. There, he packed some rice and potatoes, and paddled a surfboard to Shell Island. He planned to live off sea urchins and "even speared a manta ray," but things soon went sour. Eventually he became badly sunburned and began to starve. He returned to the mainland, but later tried again: he "went to Mexico and lived in the jungles and found [himself] eating out of dumpsters." Orman took his failures in stride, chalking all these bad circumstances up as "part of the adventure".^[3]

The original take of the theme song for the show aired a select few times. Although it is not confirmed that he composed it, Modest Mouse singer Isaac Brock provided vocals for this original version.

Van Orman attempted to pitch the concept to Cartoon Network in 2001. He created a short and incorporated many childhood favorites, with visual inspiration from older adventure novels. His first pitch was rejected, but he received a lot of feedback and re-pitched the concept in 2003.^[3]

The series works with Screen Novelties to produce the stop-motion and title card portions of the show.^[3]

Paul Reubens was originally selected to be the voice of Flapjack, but when Reubens did not show up on the day of recording, Van Orman himself decided to voice Flapjack.^[3]

The series came to an end on August 31, 2010 after 46 episodes. The final episode entitled "Fish Out of Water" included live action sequences and featured an appearance by creator Thurop Van Orman, and his son Leif, who played Flapjack.

Setting[link]

Most characters live in the fictional city of Stormalong Harbor. The city is built entirely on a series of docks in the middle of the ocean with no surrounding land. It is possible to actually swim underneath the city, and is often done by Bubbie. However, Stormalong has a sewer system and a series of underground tunnels. Most inhabitants are sailors of some sort, and sailors and/or pirates are constantly visiting from other lands. Stormalong has a great variety of (often bizarre) shops, including a bar that serves candy instead of alcohol (The Candy Barrel). The wealthier citizens live on more elevated piers, while the lower class lives lower in the city, both figuratively and literally. The city appears to be relatively dystopian, with a large level of crime and loitering, with the only forms of law enforcement being the dock hag and a relatively small police force.

Characters[link]

Main characters[link]

• Flapjack - A boy who was found and raised by Bubbie, a talking whale. He is 7 years old. He is also shown sometimes with big blue eyes. Flapjack is very naive and oblivious to danger,^[3] thus he is easily caught up in perilous situations. He holds K'nuckles in extremely high regard, with his affection for the captain sometimes bordering on obsession. His catchphrase is "Adventure!" (said whenever excited). He is caught barefoot in two episodes. He is voiced by series creator Thurop Van Orman. In the live-action episode, Thurop's son Leif plays the role of Flapjack. Flapjack's original voice actor was meant to be Paul Reubens, but Reubens never showed up to any recording sessions.

• Cap'n K'nuckles - A washed-up and childish old sailor who claims to be the greatest adventurer the world has ever known. Nowadays, he prefers to nap and drink maple syrup, while telling outrageous tales of past adventures and getting Flapjack wrapped up in his high seas hi-jinks. In reality, his stories are either completely false, or nowhere near as adventurous or amazing as he leads Flapjack to believe. He may not be an entirely incompetent adventurer however, as he was able to steal the Mermaid Queen's heart and successfully escape her guards in "Gone Wishin'". He is a candy addict; he will do whatever it takes to get his hands on candy. Because of this, he is incredibly selfish, putting the well-being of himself and the acquisition of candy above all else. Because of his often selfish, rude, and openly villainous behavior, K'nuckles has earned the open hostility and disrespect of nearly everybody in Stormalong, but is still respected by other pirates. Although he has a habit of taking advantage of Flapjack for his own needs, he is actually fond of him and will often attempt to get him out of trouble when a scheme of theirs goes too far. He also defends Flapjack when others try to deceive him, something that he does on a regular basis. Most of his body is composed of wood: his hands are wooden, his legs are pegs and his buttocks (his "sittin' muscle", as he calls it) is a wooden board. He is also made of parts stolen by other pirates. Because of his artificial body, he makes mechanical noises when he moves. K'nuckles spends most of the adventures with Flapjack trying to find Candied Island. Flapjack often has to defend him when he is in trouble. It is revealed in "K'nuckles is a Filthy Rat" that K'nuckles parents have been turned into seagulls by a magic genie, and K'nuckles has been searching for that genie ever since. He is voiced by Brian Doyle Murray. In the final episode, Thurop Van Orman portrays live-action K'nuckles.

• Bubbie Bubbie - An anthropomorphic whale, she is Flapjack’s devoted, adoptive single mother. Bubbie serves as the primary home and transport of both Flapjack and K'nuckles. She frequently disapproves of Flapjack’s desire for adventure, but will always be won over. As told in "Oh Brother", she found Flapjack at sea in a bed of seaweed. Bubbie and K'nuckles frequently disapprove of each other's actions, especially concerning 'adventure'. She believes K'nuckles to be irresponsible, lazy, and a bad influence on Flapjack. However, Bubbie is classified as a hypocrite by K'nuckles because of how she has a consistency of being irresponsible and rule-breaking herself. It is revealed in "100 Per Census" that Bubbie's last name is the same as her first name. She is voiced by Roz Ryan.

Recurring characters[link]

• Peppermint Larry - The hare-lipped owner and manager of The Candy Barrel, the only place in Stormalong where adventurers can get candy (Besides the Candy Trough, only seen in one episode.) Peppermint Larry is shown as a generally nice person, but can also be hasty and selfish at times. Peppermint Larry is lonely and unsocial, so he made a woman of candy named Candy Wife. He loves Candy Wife as if she were real, while most other residents of Stormalong "played along" to humor him; until the episode "Just One Kiss," the show was deliberately vague as to whether or not she was actually "alive" or a delusion in Larry's mind. He often buys her candy rings telling everyone she has a taste for expensive items. It is also shown he hates pickles, as when he was stranded on Pickle Island and when Candy Wife put pickle juice in his drink to strike back at Larry, who exclaims, "PICKLE JUICE? I don't like pickle juice!" He was once fired by the Dock Hag because he was using dead rats as puppets, and after wanted to be called "Mr. Larry". Larry has a bit of rivalry with K'nuckles, partially because of how K'nuckles is constantly bringing Flapjack in to the Candy Barrel with him while yielding no money, but mostly because of K'nuckles' love intrest in Candy Wife, which is revealed in "Love Bugs." He is voiced by Jeff Bennett.

• Doctor Barber - The current doctor and barber of Stormalong. He is not only a doctor and a barber, but also a certified candyologist. Doctor barber has an odd demeanor, as do many of the characters in the show, he seems to have a driving ambition none other than to perform surgery (for the well being of patients or for his own twisted entertainment is unknown), or to give hair cuts, and as seen in the show feeds the left over hair to an odd monster living in a room beneath where is clients get their hair cut. He seems to have a very secretive lifestyle outside of what Flapjack and K'nuckles know, he sometimes gets shipments in from Candied Island. Flapjack sometimes helps Dr. Barber with his insane shenanigans, often without understanding what Dr. Barber is really up to. He is seen to live with his mother, though she resides in a dresser drawer and may simply be a voice Barber hears in his head a la Norman Bates in the film Psycho. Real or not, she seems to nag him about everything. He is obsessed with surgery, and always advises the simplest medical problems be addressed with a surgical procedure. (much to the denizens chagrin) He is often quoted to say, "Hmmm, yes." He is voiced by Steve Little.

• Dock Hag - The law enforcer of the Stormalong dock. She is portrayed as a semi-old woman with obvious obesity, and black hair. She is seen to have a crush on K'nuckles, making a doll of him out of his "dock tickets". She never shows this outside of her home, and is usually cold and bitter to everyone who comes in contact with her. She has a rotten nephew named Lawrence, who is almost as mean as she is (though he plays tricks on people rather than just acting mean). It was shown that when she has to fill her ticket quota, she gives them to K'nuckles. She gives tickets to him even though he isn't doing anything and makes up rules so that she can give him more tickets. She was temporarily fired in "Mayor May Not" but it was never stated that she was rehired, implying that she just enforces the rules and writes her tickets for her own amusement and enjoyment. She is voiced by Daran Norris.

• Sally Syrup is a young girl who sells seashells in Stormalong Harbor. Her name was influenced by the old nursery rhyme 'Sally sells seashells by the sea shore'. Flapjack seemed to have a crush on her (he was producing "sweethearts" that popped out of his head whenever someone mentioned Sally, which Captain K'nuckles and Peppermint Larry sold for profit). The sweethearts turned out to be Blood Gnats, which Doctor Barber reveals to the entire Candy Barrel. When Flapjack realizes he is not in love with her, Sally sadly asks, "So you're not in love with me?" even though she had displayed disgust at the prospect earlier. As she departs, Flapjack is seen taking off his scarf and waving it at the ship, shouting, "Farewell, Sally Syrup! I don't love you!" Sally answers, waving her own handkerchief at him, "I don't love you too!" Flapjack then sighs dreamily, indicating that, despite everything, he might love Sally Syrup. By the end of the episode she drifted away to Blood Island for more shells and to get rid of the Blood Gnats. Then in The Return of Sally Syrup, we found out that Sally Syrup's dad is The Professor and niece of The Inventor and she thought Stormalong Harbor was boring until Flapjack tried to show her how fun it could be there. When she had to leave she said she actually did have fun. She and Flapjack shared a moment before she had to leave, when she was in the air and flying away she said, "The best part about today was spending it with you" (speaking to Flapjack). When he asked, "Really?" she answered, "Just kidding dummy!" but she could've just been faking it to keep up her reputation. Flapjack then said "There goes my heart."

Villains[link]

• Eight-Armed Willy – An extremely large Giant Pacific Octopus with a cut sticking out of his head, resembling a hole. In "Skooled", Miss Leading dressed up like him to help Flapjack and Captain K'nuckles learn their left and rights. In "Willy! (Or Won't He?)", Flapjack tried to capture him with a group of people from Stormalong's only newspaper so that Flapjack could prove to a grouchy sailor that he was an adventurer and so that they can get more ink for the newspaper, but as it turned out, Willy was happy to give them ink and also helped Flapjack with his bet. Willy is shown to be larger than 100 ft. and is constantly making it difficult for Flapjack and K'nuckles to steal candy. Aside from Candied Island, Flapjack and K'nuckles attempt to get candy from Willy's secret stash of candy, located in Willy's ship. Willy has an eye patch over his right eye, and is shown to have terrorized Stormalong for years, as he is probably the reason for the Sea Monster Alarm. He is shown to be antagonistic, but he seems to care for Flapjack. Vocal effects are provided by Richard McGonagle.

• The Sailors
  • Patch - The mustache White guy.
  • Thomas Hatch - The Big nose White guy.
  • Satch - The African American.

• The Inventor is a man who invents stuff to force child labor and is also the dastardly brother of The Professor. He invented a whale named W.O.O.S.H, which was designed to force children to help him achieve the goal of fastest thing in the Seven Seas. He invented the camera, but it is also powered by kids (having one of the kids draw whatever he saw). He is classed as a villain because he enforces child labor and is vengeful to Flapjack and K'nuckles, but sometimes he acts as if he weren't as bad as he seems when he tried to help an overweight police officer move faster. (This, however, was really only to help him catch Flapjack and K'nuckles during their trash-diving shenanigans.) He is voiced by Jeff Bennett.

• Sea Urchins – Flapjack uses all of the polish Bubbie uses on her bells, so K'nuckles takes Flapjack to the other, bad side of Stormalong Harbor to get more. The duo encounter poor street urchin kids who demand their sea urchin back but Flapjack calls them sissies and the urchins track him down and try to fight Flapjack, only to be stopped by an angry Bubbie who threatens to flatten them if they come near him again. He invites them over for dinner and shelter & the urchins reward them with a song and dance routine. The next morning, however, they discover the urchins have taken off with their possessions, including Bubbie's prized bell collection. Flapjack and K'nuckles track them down, and the urchins challenge them to a dance-off. When the urchins' star dancer, Cheeks, takes a fall, the urchin's father steps in to intervene and accuses the urchins of killing his son and calls Jerry, who is the father of the urchins' leader, but then recognizes K'nuckles long-standing idol status in the bad part of Stormalong Harbor for his ability to "Do nothing for nobody". In the end, the urchins and their fathers give the bell collection back and Flapjack invites them inside Bubbie, who can't seem to take many people into her mouth. (Note: At the part of the episode where Bubbie intercepts the urchins' attempt to "get" Flapjack, Cheeks calls the urchins' leader "Ricky", when it is later revealed that his real name is "Oliver").

Episodes[link]

Other media[link]

DVDs[link]

The volume 1 DVD was released on September 15, 2009. It contains the first five episodes and four bonus featurettes.^[4] Originally, an interstitial (often falsely referred to as the pilot) that never aired on TV, Captain and ToeNeil, was intended as a bonus feature on the DVD, but was not included for unknown reasons. A volume two DVD was announced for a December 2010 release, but was canceled by the show's looming ending in July 2010.^{[citation needed]}

Video game[link]

A Flapjack video game was confirmed by series creator Thurop Van Orman in Spring 2010 for the Nintendo DS system. When the show was cancelled, the game was cancelled with it.^{[citation needed]} Flapjack and Captain K'nuckles will be appearing as playable characters in Cartoon Network: Punch Time Explosion; Peppermint Larry and Candy Wife will act as assist characters, while one of the stages will be set within Bubbie's Mouth. Eight-Armed Willy appears as part of Flapjack's special attack.

Reception[link]

This section is in a list format that may be better presented using prose. You can help by converting this section to prose, if appropriate. Editing help is available. (October 2009)

• Marilyn Moss (2008-06-04). "TV Review: The Marvelous Misadventures of Flapjack". The Hollywood Reporter. http://www.hollywoodreporter.com/hr/television/reviewsarticle_display.jsp?JSESSIONID=dyyWLHcSGdFJSRBrDqppYWmJFKLTTJgQJnhMDscGT7JSbHmnfJ1p!-61450796&&rid=11228. Retrieved 2008-06-11. "Bottom Line: Feisty and funny animated series that kids will fall for hook, line and sinker." ^{[dead link]}
• Ed Liu (2008-06-05). ""The Marvelous Misadventures of Flapjack" Needs a Weird Infusion, Me Hearties!". Toon Zone. http://news.toonzone.net/article.php?ID=24166. Retrieved 2008-06-11. 
• Ed Liu (2009-10-30). ""The Marvelous Misadventures of Flapjack" Vol. 1: It Got The Weird Infusion, Mateys!". Toon Zone. http://news.toonzone.net/article.php?ID=31628. Retrieved 2009-10-30. 

Awards[link]

References[link]

External links[link]

• Official website
• The Marvelous Misadventures of Flapjack at the Big Cartoon DataBase
• The Marvelous Misadventures of Flapjack at the Internet Movie Database
• The Marvelous Misadventures of Flapjack at TV.com

Myocardial infarction
Classification and external resources
Diagram of a myocardial infarction (2) of the tip of the anterior wall of the heart (an apical infarct) after occlusion (1) of a branch of the left coronary artery (LCA), right coronary artery = RCA
ICD-10	I21-I22
ICD-9	410
DiseasesDB	8664
MedlinePlus	000195
eMedicine	med/1567 emerg/327 ped/2520
MeSH	D009203

Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (cholesterol and fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and ensuing oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).

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).^[1] Women may experience fewer typical symptoms than men, most commonly shortness of breath, weakness, a feeling of indigestion, and fatigue.^[2] A sizeable proportion of myocardial infarctions (22–64%)^[3] are "silent", that is without chest pain or other symptoms.

Among the diagnostic tests available to detect heart muscle damage are an electrocardiogram (ECG), echocardiography, cardiac MRI and various blood tests. The most often used blood markers are the creatine kinase-MB (CK-MB) fraction and the troponin levels. Immediate treatment for suspected acute myocardial infarction includes oxygen, aspirin, and sublingual nitroglycerin.^[4]

Most cases of myocardial infarction with ST elevation on ECG (STEMI) are treated with reperfusion therapy, such as percutaneous coronary intervention (PCI) or thrombolysis.^[5] Non-ST elevation myocardial infarction (NSTEMI) may be managed with medication, although PCI may be required if the patient's risk warrants it.^[6] People who have multiple blockages of their coronary arteries, particularly if they also have diabetes mellitus, may benefit from bypass surgery (CABG),^[7][8]. The European Society of Cardiology guidelines in 2011 proposed treating the blockage causing the myocardial infarction by PCI and performing CABG later when the patient is more stable.^[7] Rarely CABG may be preferred in the acute phase of myocardial infarction, for example when PCI has failed or is contraindicated.^[7]

Ischemic heart disease (which includes myocardial infarction, angina pectoris and heart failure when preceded by myocardial infarction) was the leading cause of death for both men and women worldwide in 2004.^[9] Important risk factors are previous cardiovascular disease, older age, tobacco smoking, high blood levels of certain lipids (low-density lipoprotein cholesterol, triglycerides) and low levels of high density lipoprotein (HDL) cholesterol, diabetes, high blood pressure, lack of physical activity and obesity, chronic kidney disease, excessive alcohol consumption, the abuse of illicit drugs (such as cocaine and amphetamines), and chronic high stress levels.^[10][11][12]

Classification[link]

There are two basic types of acute myocardial infarction based on pathology:

• Transmural: associated with atherosclerosis involving a major coronary artery. It can be subclassified into anterior, posterior, inferior, lateral or septal. Transmural infarcts extend through the whole thickness of the heart muscle and are usually a result of complete occlusion of the area's blood supply.^[13]
• Subendocardial: involving a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles. The subendocardial area is particularly susceptible to ischemia.^[13]

In the clinical context, a myocardial infarction can be further subclassified into a ST elevation MI (STEMI) versus a non-ST elevation MI (non-STEMI) based on ECG changes.^[14]

The phrase heart attack is sometimes used incorrectly to describe sudden cardiac death, which may or may not be the result of acute myocardial infarction. A heart attack is different from, but can be the cause of cardiac arrest, which is the stopping of the heartbeat, and cardiac arrhythmia, an abnormal heartbeat. It is also distinct from heart failure, in which the pumping action of the heart is impaired; however severe myocardial infarction may lead to heart failure.^[7]

A 2007 consensus document classifies myocardial infarction into five main types:^[15]

• Type 1 – Spontaneous myocardial infarction related to ischaemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection
• Type 2 – Myocardial infarction secondary to ischaemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anaemia, arrhythmias, hypertension, or hypotension
• Type 3 – Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischaemia, accompanied by new ST elevation, or new LBBB, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of cardiac biomarkers in the blood
• Type 4 – Associated with coronary angioplasty or stents:
  • Type 4a – Myocardial infarction associated with PCI
  • Type 4b – Myocardial infarction associated with stent thrombosis as documented by angiography or at autopsy
• Type 5 – Myocardial infarction associated with CABG

Signs and symptoms[link]

Rough diagram of pain zones in myocardial infarction; dark red: most typical area, light red: other possible areas; view of the chest

Back view

The onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes, and rarely instantaneous.^[16] Chest pain is the most common symptom of acute myocardial infarction and is often described as a sensation of tightness, pressure, or squeezing. Chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle is termed angina pectoris. Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, and epigastrium,^[7][17] where it may mimic heartburn. Levine's sign, in which the patient localizes the chest pain by clenching their fist over the sternum, has classically been thought to be predictive of cardiac chest pain, although a prospective observational study showed that it had a poor positive predictive value.^[18]

Shortness of breath (dyspnea) occurs when the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema. Other symptoms include diaphoresis (an excessive form of sweating),^[1] weakness, light-headedness, nausea, vomiting, and palpitations. These symptoms are likely induced by a massive surge of catecholamines from the sympathetic nervous system^[19] which occurs in response to pain and the hemodynamic abnormalities that result from cardiac dysfunction. Loss of consciousness (due to inadequate cerebral perfusion and cardiogenic shock) and sudden death (frequently due to the development of ventricular fibrillation) can occur in myocardial infarctions.^[7]

Women and older patients report atypical symptoms more frequently than their male and younger counterparts.^[20] Women also report more numerous symptoms compared with men (2.6 on average vs 1.8 symptoms in men).^[20] The most common symptoms of MI in women include dyspnea (shortness of breath), weakness, and fatigue. Fatigue, sleep disturbances, and dyspnea have been reported as frequently occurring symptoms that may manifest as long as one month before the actual clinically manifested ischemic event. In women, chest pain may be less predictive of coronary ischemia than in men.^[21]

At least one-fourth of all myocardial infarctions are silent, without chest pain or other symptoms, ^[22][3] with silent myocardial infarcations being more common in younger people. These cases can be discovered later on electrocardiograms, using blood enzyme tests or at autopsy without a prior history of related complaints. Estimates of the prevalence of silent myocardial infarctions vary between 22 and 64% ^[3]. A silent course is more common in the elderly^[3], in patients with diabetes mellitus^[23] and after heart transplantation, probably because the donor heart is not fully innervated by the nervous system of the recipient.^[24] In people with diabetes, differences in pain threshold, autonomic neuropathy, and psychological factors have been cited as possible explanations for the lack of symptoms.^[23]

Any group of symptoms compatible with a sudden interruption of the blood flow to the heart are called an acute coronary syndrome.^[25]

The differential diagnosis includes other catastrophic causes of chest pain, such as pulmonary embolism, aortic dissection, pericardial effusion causing cardiac tamponade, tension pneumothorax, and esophageal rupture. Other non-catastrophic differentials include gastroesophageal reflux and Tietze's syndrome.^[26]

Causes[link]

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]

Acute severe infection, such as pneumonia, can trigger myocardial infarction. A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis.^[28] While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor.^[28] Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.^[29]

There is an association of an increased incidence of a heart attack in the morning hours, more specifically around 9 a.m.^[30][31][32] Some investigators have noticed that the ability of platelets to aggregate varies according to a circadian rhythm, although they have not proven causation.^[33]

Risk factors[link]

Myocardial infarction results from atherosclerosis.^[7] Risk factors for myocardial infarction include:

• Age^[10]
• Gender: At any given age men are more at risk than women, particularly before the menopause,^[27] but because in general women live longer than men ischemic heart disease causes slightly more total deaths in women.^[10]
• Diabetes mellitus type 1 or Diabetes mellitus type 2 ^[34]
• High blood pressure^[35]
• Dyslipidemia/hypercholesterolemia (abnormal levels of lipoproteins in the blood), particularly high low-density lipoprotein, low high-density lipoprotein and high triglycerides^[35]
• Tobacco smoking, including secondhand smoke^[35]
• Short term exposure to air pollution including: carbon monoxide, nitrogen dioxide, and sulfur dioxide but not ozone.^[36]
• Family history of ischaemic heart disease or myocardial infarction particularly if one has a first-degree relative (father, brother, mother, sister) who suffered a 'premature' myocardial infarction (defined as occurring at or younger than age 55 years (men) or 65 (women).^[10]
• Obesity^[37] (defined by a body mass index of more than 30 kg/m², or alternatively by waist circumference or waist-hip ratio).
• Lack of physical activity.^[10]
• Psychosocial factors including, low socio-economic status, social isolation, negative emotions and stress increase the risk of myocardial infarction and are associated with worse outcomes after myocardial infarction. Socioeconomic factors such as a shorter education and lower income (particularly in women), and unmarried cohabitation are also correlated with a higher risk of MI.^[38]
• Alcohol — Studies show that prolonged exposure to high quantities of alcohol can increase the risk of heart attack.
• Oral contraceptive pill – women who use combined oral contraceptive pills have a modestly increased risk of myocardial infarction, especially in the presence of other risk factors, such as smoking.^[39]
• Hyperhomocysteinemia (high homocysteine)in homocysteinuria is associated with premature atherosclerosis^[40], whether elevated homocysteine in the normal range is causal is contentious.^[41]

Inflammation is known to be an important step in the process of atherosclerotic plaque formation.^[42] C-reactive protein (CRP) is a sensitive but non-specific marker for inflammation. Elevated CRP blood levels, especially measured with high-sensitivity assays, can predict the risk of MI, as well as stroke and development of diabetes.^[42] Moreover, some drugs for MI might also reduce CRP levels.^[42] The use of high-sensitivity CRP assays as a means of screening the general population is advised against, but it may be used optionally at the physician's discretion in patients who already present with other risk factors or known coronary artery disease.^[43] Whether CRP plays a direct role in atherosclerosis remains uncertain.^[42] Inflammation in periodontal disease may be linked to coronary heart disease, and, since periodontitis is very common, this could have great consequences for public health.^[44] Serological studies measuring antibody levels against typical periodontitis-causing bacteria found that such antibodies were more present in subjects with coronary heart disease.^[45] Periodontitis tends to increase blood levels of CRP, fibrinogen and cytokines;^[46] thus, periodontitis may mediate its effect on MI risk via other risk factors.^[47] Preclinical research suggests that periodontal bacteria can promote aggregation of platelets and promote the formation of foam cells.^[48][49] A role for specific periodontal bacteria has been suggested but remains to be established.^[50] There is some evidence that influenza may trigger an acute myocardial infarction.^[51]

Baldness, hair greying, a diagonal earlobe crease (Frank's sign^[52]) and possibly other skin features have been suggested as independent risk factors for MI.^[53] Their role remains controversial; a common denominator of these signs and the risk of MI is supposed, possibly genetic.^[54]

Calcium deposition is another part of atherosclerotic plaque formation. Calcium deposits in the coronary arteries can be detected with CT scans. Several studies have shown that coronary calcium can provide predictive information beyond that of classical risk factors.^[55][56][57]

Many of these risk factors are modifiable, so many heart attacks can be prevented by maintaining a healthier lifestyle. Physical activity, for example, is associated with a lower risk profile.^[58] Non-modifiable risk factors include age, sex, and family history of an early heart attack, which is thought of as reflecting a genetic predisposition.^[27] To understand epidemiological study results, it is important to note that many factors associated with MI mediate their risk via other factors. For example, the effect of education is partially based on its effect on income and marital status.^[38]

The European Society of Cardiology and the European Association for Cardiovascular Prevention and Rehabilitation have developed an interactive tool for prediction and managing the risk of heart attack and stroke in Europe. HeartScore is aimed at supporting clinicians in optimising individual cardiovascular risk reduction. The Heartscore Programme is available in 12 languages and offers web-based or PC version.^[59]

Pathophysiology[link]

A myocardial infarction occurs when an atherosclerotic plaque slowly builds up in the inner lining of a coronary artery and then suddenly ruptures, causing catastrophic thrombus formation, totally occluding the artery and preventing blood flow downstream.

Drawing of the heart showing anterior left ventricle wall infarction

Acute myocardial infarction refers to two subtypes of acute coronary syndrome, namely non-ST-elevated myocardial infarction and ST-elevated myocardial infarction, which are most frequently (but not always) a manifestation of coronary artery disease.^[14] The most common triggering event is the disruption of an atherosclerotic plaque in an epicardial coronary artery, which leads to a clotting cascade, sometimes resulting in total occlusion of the artery.^[60][61] Atherosclerosis is the gradual buildup of cholesterol and fibrous tissue in plaques in the wall of arteries (in this case, the coronary arteries), typically over decades.^[62] Blood stream column irregularities visible on angiography reflect artery lumen narrowing as a result of decades of advancing atherosclerosis.^[63] Plaques can become unstable, rupture, and additionally promote a thrombus (blood clot) that occludes the artery; this can occur in minutes. When a severe enough plaque rupture occurs in the coronary vasculature, it leads to myocardial infarction (necrosis of downstream myocardium).^[60][61]

If impaired blood flow to the heart lasts long enough, it triggers a process called the ischemic cascade; the heart cells in the territory of the occluded coronary artery die (chiefly through necrosis) and do not grow back. A collagen scar forms in its place. Recent studies indicate that another form of cell death called apoptosis also plays a role in the process of tissue damage subsequent to myocardial infarction.^[64] As a result, the patient's heart will be permanently damaged. This myocardial scarring also puts the patient at risk for potentially life threatening arrhythmias, and may result in the formation of a ventricular aneurysm that can rupture with catastrophic consequences.

Injured heart tissue conducts electrical impulses more slowly than normal heart tissue. The difference in conduction velocity between injured and uninjured tissue can trigger re-entry or a feedback loop that is believed to be the cause of many lethal arrhythmias. The most serious of these arrhythmias is ventricular fibrillation (V-Fib/VF), an extremely fast and chaotic heart rhythm that is the leading cause of sudden cardiac death. Another life-threatening arrhythmia is ventricular tachycardia (V-Tach/VT), which may or may not cause sudden cardiac death. However, ventricular tachycardia usually results in rapid heart rates that prevent the heart from pumping blood effectively. Cardiac output and blood pressure may fall to dangerous levels, which can lead to further coronary ischemia and extension of the infarct.

The cardiac defibrillator is a device that was specifically designed to terminate these potentially fatal arrhythmias. The device works by delivering an electrical shock to the patient in order to depolarize a critical mass of the heart muscle, in effect "rebooting" the heart. This therapy is time dependent, and the odds of successful defibrillation decline rapidly after the onset of cardiopulmonary arrest.

Diagnosis[link]

The diagnosis of myocardial infarction can be made after assessing patient's complaints and physical status. ECG changes, coronary angiogram and levels of cardiac markers help to confirm the diagnosis. ECG gives valuable clues to identify the site of myocardial damage while coronary angiogram allows visualization of narrowing or obstructions in the heart vessels.^[65] At autopsy, a pathologist can diagnose a myocardial infarction based on anatomopathological findings.

A chest radiograph and routine blood tests may indicate complications or precipitating causes and are often performed upon arrival to an emergency department. New regional wall motion abnormalities on an echocardiogram are also suggestive of a myocardial infarction. Echo may be performed in equivocal cases by the on-call cardiologist.^[66] In stable patients whose symptoms have resolved by the time of evaluation, Technetium (99mTc) sestamibi (i.e. a "MIBI scan") or thallium-201 chloride can be used in nuclear medicine to visualize areas of reduced blood flow in conjunction with physiologic or pharmacologic stress.^[66][67] Thallium may also be used to determine viability of tissue, distinguishing whether non-functional myocardium is actually dead or merely in a state of hibernation or of being stunned.^[68]

WHO criteria^[69] formulated in 1979 have classically been used to diagnose MI; a patient is diagnosed with myocardial infarction if two (probable) or three (definite) of the following criteria are satisfied:

1. Clinical history of ischaemic type chest pain lasting for more than 20 minutes
2. Changes in serial ECG tracings
3. Rise and fall of serum cardiac biomarkers such as creatine kinase-MB fraction and troponin

The WHO criteria were refined in 2000 to give more prominence to cardiac biomarkers.^[70] According to the new guidelines, a cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression, or coronary intervention is diagnostic of MI.

Prevention[link]

The risk of a recurrent myocardial infarction decreases with strict blood pressure management and lifestyle changes, chiefly smoking cessation, regular exercise, a sensible diet for those with heart disease, and limitation of alcohol intake. People are usually commenced on several long-term medications post-MI, with the aim of preventing secondary cardiovascular events such as further myocardial infarctions, congestive heart failure or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:^[71][72]

• Antiplatelet drug therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of plaque rupture and recurrent myocardial infarction. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and aspirin may further reduce risk of cardiovascular events, however the risk of hemorrhage is increased.^[73]
• Beta blocker therapy such as metoprolol or carvedilol should be commenced.^[74] These have been particularly beneficial in high-risk patients such as those with left ventricular dysfunction and/or continuing cardiac ischaemia.^[75] β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.
• ACE inhibitor therapy should be commenced 24–48 hours post-MI in hemodynamically stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by ECG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling post-MI.^[76]
• Statin therapy has been shown to reduce mortality and morbidity post-MI.^[77][78] The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have plaque stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids.^[79]
• The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.^[80] Spironolactone is another option that is sometimes preferable to eplerenone due to cost.
• Evidence supports the consumption of polyunsaturated fats instead of saturated fats as a measure of decreasing coronary heart disease.^[81] Omega-3 fatty acids, commonly found in fish, have been shown to reduce mortality post-MI.^[82] While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of ventricular fibrillation.^[83] However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids.^[84][85]

Blood donation may reduce the risk of heart disease for men,^[86] but the link has not been firmly established.

A Cochrane review found that giving heparin to people with heart conditions like unstable angina and some forms of heart attacks reduces the risk of having another heart attack. However, heparin also increases the chance of suffering from minor bleeding.^[87]

Management[link]

An MI requires immediate medical attention. Treatment attempts to salvage as much myocardium as possible and to prevent further complications, hence the phrase "time is muscle".^[88] Oxygen, aspirin, and nitroglycerin may be administered. Morphine was classically used if nitroglycerin was not effective; however, it may increase mortality in the setting of NSTEMI.^[89] A 2009 and 2010 review of high flow oxygen in myocardial infarction found increased mortality and infarct size, calling into question the recommendation about its routine use.^[90][91] Other analgesics such as nitrous oxide are of unknown benefit.^[6] Percutaneous coronary intervention (PCI) or fibrinolysis are recommended in those with an STEMI.

Prognosis[link]

The prognosis post myocardial infarction varies greatly, depending on a person's health, the extent of the heart damage and the treatment given. For the period 2005–2008 in the United States, the median mortality at 30 days was 16.6% with a range from 10.9% to 24.9% depending on the hospital.^[92] Using variables available in the emergency room, people with a higher risk of adverse outcome can be identified. One study found that 0.4% of patients with a low-risk profile died after 90 days, whereas in high-risk people it was 21.1%.^[93]

Some of the more reproduced risk-stratifying factors 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, peripheral vascular disease and elevation of cardiac markers.^[93][94][95] Assessment of left ventricular ejection fraction may increase the predictive power.^[96] The prognostic importance of Q-waves is debated.^[97] Prognosis is significantly worsened if a mechanical complication such as papillary muscle or myocardial free wall rupture occurs.^[98] Morbidity and mortality from myocardial infarction has improved over the years due to better treatment.^[99]

Complications[link]

Complications may occur immediately following the heart attack (in the acute phase), or may need time to develop (a chronic problem). Acute complications may include heart failure if the damaged heart is no longer able to adequately pump blood around the body; aneurysm or rupture of the myocardium; mitral regurgitation, in particular if the infarction causes dysfunction of the papillary muscle; and arrhythmias, such as ventricular fibrillation, ventricular tachycardia, atrial fibrillation and heart block. Longer-term complications include heart failure, atrial fibrillation, and the increased risk of a second myocardial infarction.

Epidemiology[link]

Myocardial infarction is a common presentation of ischemic heart disease/coronary artery disease. The World Health Organization estimated in 2004, that 12.2% of worldwide deaths were from ischemic heart disease;^[9] with it being the leading cause of death in high or middle income countries and second only to lower respiratory infections in lower income countries.^[9] Worldwide more than 3 million people have STEMIs and 4 million have NSTEMIs a year.^[100]

Rates of death from ischemic heart disease have slowed or declined in most high income countries, although cardiovascular disease still accounted for 1 in 3 of all deaths in the USA in 2008.^[101] In contrast, ischemic heart disease is becoming a more common cause of death in the developing world. For example in India, ischemic heart disease had become the leading cause of death by 2004 accounting for 1.46 million deaths (14% of total deaths) and deaths due to ischemic heart disease were expected to double during 1985–2015.^[102] Globally it is predicted that disability adjusted life years (DALYs) lost to ischemic heart disease will account for 5.5% of total DALYs in 2030, making it the second most important cause of disability (after unipolar depressive disorder), as well as the leading cause of death by this date.^[9]

Legal implications[link]

At common law, in general a myocardial infarction is a disease, but may sometimes be an injury. This has implications for no-fault insurance schemes such as workers' compensation. In general, a heart attack is not covered;^[103] however, it may be a work-related injury if it results, for example, from unusual emotional stress or unusual exertion.^[104] In addition, in some jurisdictions, heart attacks suffered by persons in particular occupations such as police officers may be classified as line-of-duty injuries by statute or policy. In some countries or states, a person having suffered from a myocardial infarction may be prevented from participating in activity that puts other people's lives at risk, for example driving a car or flying an airplane.^[105]

Research[link]

Patients who receive stem cell treatment by coronary artery injections of stem cells derived from their own bone marrow after a myocardial infarction (MI) show improvements in left ventricular ejection fraction and end-diastolic volume not seen with placebo. The larger the initial infarct size, the greater the effect of the infusion. Clinical trials of progenitor cell infusion as a treatment approach to ST elevation MI are proceeding.^[106]

There are currently 3 biomaterial and tissue engineering approaches for the treatment of MI, but these are in an even earlier stage of medical research, so many questions and issues must be addressed before they can be applied to patients. The first involves polymeric left ventricular restraints in the prevention of heart failure. The second utilizes in vitro engineered cardiac tissue, which is subsequently implanted in vivo. The final approach entails injecting cells and/or a scaffold into the myocardium to create in situ engineered cardiac tissue.^[107]

References[link]