Look up Trey in Wiktionary, the free dictionary.

Trey is the anglicized spelling of "tre", the Italian word for the number "three".

It can refer to a nickname for those who are the third of their name. For example, this is William Henry Gates III's nickname within his family.

Others with the name or nickname "Trey" include:

• Trey Anastasio, American guitarist, composer and singer, lead guitarist of Phish
• Trey Azagthoth, guitarist for death metal band Morbid Angel
• Trey Brewer, competitive bodybuilder, NPC National Bodybuilding Competition Overall Winner
• Trey Bruce, country singer
• Trey Gunn, former member of the band King Crimson
• Trey Hillman, manager of the Kansas City Royals
• Trey Junkin, former American football player
• Trey Lewis, NFL defensive tackle for the Atlanta Falcons
• Trey Lewis (tennis), female tennis player from 1979 to 1986
• Trey Parker, co-creator of South Park, along with Matt Stone
• Trey Smith, son of actor and singer Will Smith
• Trey Songz, stage name of Tremaine Neverson, American R&B singer.
• Trey Spruance, American musician
• Trey Teague, American football player
• Trey of Triforia, a character in Power Rangers: Zeo
• Trey Wingo, American sportscaster
• Trey Racer, known in the manga and Japanese version as Horohoro, a Shaman King character
• Trey, a character in Gran Torino

Places[link]

• Trey, Vaud, a commune in Vaud, Switzerland

Other uses[link]

• Trey, a three-point field goal in basketball
• Standard Anglo-American playing cards of rank three, as in "the trey of hearts" (3♥)
• In dominoes, a piece (also called a tile/stone/bone or other name) with one "end" having three pips (also called dots or spots).
• The video game developer, Treyarch, has 3 arches in their logo, which is why the company is essentially called "3arch".
• Trey, slogan for video game console Playstation 3

See also[link]

• Tré Cool

This disambiguation page lists articles associated with the same title. If an internal link led you here, you may wish to change the link to point directly to the intended article.

Trey Songz
Background information
Birth name	Tremaine Aldon Neverson
Born	(1984-11-28) November 28, 1984 (age 27) Petersburg, Virginia, United States
Genres	R&B, hip hop
Occupations	Singer-songwriter, record producer, actor
Instruments	Vocals, keyboards, sampler
Years active	2004–present
Labels	Atlantic, Songbook
Associated acts	Drake, Troy Taylor, Twista, Juvenile, Bun B, Rick Ross, Plies
Website	www.treysongz.com

Tremaine "Trey" Aldon Neverson (born November 28, 1984), better known by his stage name Trey Songz, is an American singer-songwriter, rapper, record producer and actor. His debut album, I Gotta Make It, was released in 2005, while his second album, Trey Day, was released in 2007. His third album, Ready, was released in 2009 while his fourth studio album, Passion, Pain & Pleasure, was released on September 14, 2010.

Life and career[link]

1984–2004: Early life and career beginnings[link]

Songz was born Tremaine Aldon Neverson on November 28, 1984, in Petersburg, Virginia.^[1] Raised as a military brat, Songz did not have aspirations to have a musical career as a child due to his shyness, saying "Singing wasn't a reality for me, until other people started noticing I sounded good."^[2] He recognized his vocal abilities at the age of 14.^[2] Reluctant to sing, he began performing with encouragement by friends and family in high school. Record producer Troy Taylor discovered Songz during a talent show in 2000, which led him to signing a recording contract with Atlantic Records in 2002.^[2] After graduating from high school in 2002, Songz moved to New Jersey to begin recording his debut album, though recording didn't actually begin until 2003.^[1]

[edit] 2004–2008I Gotta Make It and Trey Day

While recording his debut album in 2004, Songz released multiple mixtapes under the alias Prince of Virginia.^[1] One of the mixtapes featured an "answer track" to R. Kelly's "Trapped in the Closet", entitled "Open the Closet". The song gave Trey some notoriety.^[3] His debut album, I Gotta Make It was released on July 26, 2005.^[4] It debuted at #20 on the Billboard 200, selling 40,000 copies in its first week of sales.^[5] It has sold 300,000 records in the US, but was never certified by the RIAA. Songz's debut single, Gotta Make It, featuring Twista, was released in March 2005 and reached #87 on the Billboard Hot 100 and #21 on the Hot R&B/Hip-Hop Songs. It garnered success in the R&B/urban community but failed to make a mark in mainstream music. The album's second and final single, Gotta Go, was released in July 2005 and reached #67 on the Hot 100 and #11 on the Hot R&B/Hip-Hop Songs chart, becoming even more successful than his debut single in the R&B/urban community and in the mainstream community. After promotion for his debut concluded, he was featured on the lead single from Twista's fifth album, The Day After. The single, "Girl Tonite", reached #14 on the Hot 100 and #3 on the Hot R&B/Hip-Hop Songs chart, becoming a huge hit.

Trey Songz performing in 2007.

In mid-2006, Songz began work on a follow-up album to his debut with longtime collaborator Troy Taylor and also employed hitmakers Bryan-Michael Cox, Danja, Stargate (production team) and R. Kelly to help create the album. Trey aimed for the album to be more mainstream-oriented than his debut album. His second studio album, Trey Day, was released on October 2, 2007. The album reached #11 on the Billboard 200,^[6] selling 73,000 copies in its first week. It has since sold 400,000 records in the US, becoming his second album not to be certified by the RIAA. The album was going to be released on May 8, 2007, but was continually delayed in order for a successful single to precede the album, as the lead single failed to impact charts.

His second album was preceded by the lead single, "Wonder Woman", which was released in February 2007. It reached #54 on the Hot R&B/Hip-Hop Songs chart, but failed to impact the Hot 100. Because of the single's failure, his second album was delayed from May 2007 to October 2007. The album's second single, "Can't Help but Wait", was released in August 2007 and was released to promote his second album and the film Step Up 2 the Streets soundtrack as a single for it. The single reached #14 on the Hot 100, and #2 on the Hot R&B/Hip-Hop Songs chart. It became Songz's first Top 20 hit on the Hot 100, and helped to boost his second album's sales. The single was also nominated for Best Male R&B Vocal Performance at the 2008 50th Grammy Awards. The third single from the album, "Last Time", was released in January 2008 and reached #69 on the Hot 100, and #9 on the Hot R&B/Hip-Hop Songs chart. The fourth and final single from the album, "Missin' You", was released in May 2008, but failed to chart completely. In mid-2008, Songz was nominated for a BET Award for Best Male R&B Artist but did not win the award.^[7]

[edit] 2009–2011: Ready and Passion, Pain & Pleasure

In late 2008, Trey began work on his third studio album with Bryan-Michael Cox, Sean Garrett, Stargate and Troy Taylor and aimed for the record to be more mature than his first two. Before releasing his third album, Songz released a mixtape titled Anticipation in June 2009 through his blog, which featured songs from his third album.^[8] Another mixtape from Trey was released in the summer of 2009, called Genesis. Genesis was a collection of Trey Songz's first recordings when he was fifteen years old and was released to show his fans the dedication that he had to making a record when he was young.^[9] Trey released his third studio album, Ready, on August 31, 2009. The album reached #3 on the Billboard 200, selling 131,000 copies in its first week.^[10] These are his best first week sales to date and the album was his first to reach the Top 10 on the Billboard 200. The album has since sold over 800,000 records in the US, earning a Gold certification from the RIAA in February 2010, becoming his first album to be certified by the RIAA.

Trey Songz performing at Summer Jam on June 5, 2010.

The lead single from the album, "I Need a Girl", was released in April 2009 and reached #5 on the Hot R&B/Hip-Hop songs chart and #59 on the Hot 100, becoming an R&B/urban hit but not a mainstream hit. A promotional single, "Successful", featuring rapper Drake, was released in June 2009 and reached #17 on the Hot 100, becoming Songz's third Top 20 hit. The single also served as the second and final single from Drake's EP, So Far Gone. The second official single from his third album, "LOL Smiley Face", featuring Soulja Boy Tell 'Em and Gucci Mane, was released in August 2009 and reached #51 on the Hot 100 and #12 on the Hot R&B/Hip-Hop Songs chart. The third single from the album, "I Invented Sex", featuring Drake, was released in October 2009 and reached #42 on the Hot 100 but #1 on the Hot R&B/Hip-Hop Songs chart, becoming his first single to top that chart. Like the first two singles from the album, it achieved success in the R&B/urban community but only some mainstream success. charted within the Billboard Hot 100, and topped the R&B chart. The fourth single from the album, "Say Aah", featuring rapper Fabolous, was released in January 2010 and reached #9 on the Hot 100 and #3 on the Hot R&B/Hip-Hop Songs chart. The single has become Trey's highest charting single on the Hot 100 and one of his most successful singles on the Hot R&B/Hip-Hop Songs chart.

The fifth and final single from the album, "Neighbors Know My Name", was released in February 2010 and reached #43 on the Hot 100 and #4 on the Hot R&B/Hip-Hop Songs chart. A sixth single, "Yo Side of the Bed", was going to be released in June 2010, but its release was canceled due to unknown reasons. A music video, featuring singer Keri Hilson, was filmed and released, however. Songz was also the opening act for Jay-Z on his Jay-Z Fall Tour in late 2009. The album was nominated for Best Contemporary R&B Album at the 52nd Grammy Awards in 2010, but lost to Beyoncé's I Am... Sasha Fierce. On April 1, 2010, he recorded an episode of MTV Unplugged, which aired on April 26, 2010.^[11] A documentary-series about Trey, Trey Songz: My Moment, began in June 2010 to positive reviews and high ratings. The 10-part series will end in August 2010 and follows Trey during his time as opening act on Jay-Z's Jay-Z Fall Tour in late 2009.

Songz's fourth studio album, Passion, Pain & Pleasure, was released on September 14, 2010.^[12] Trey began work on the album in early 2010 with Sean Garrett, Troy Taylor and Stargate and has stated that the album will be his most personal to date. The album was completed in July 2010. The album's lead single, "Bottoms Up", featuring female rapper Nicki Minaj, was released on July 27, 2010 and has reached number twenty-four on the Hot R&B/Hip-Hop Songs chart and was shared enough on Facebook to appear as a trending video on ItsTrending. Its video was filmed on July 31, 2010 and is pending release.^[13] Trey also filmed the video for the album's second single, "Can't Be Friends", on August 1, 2010.^[13] "Can't Be Friends" was released as the album's second single in August 2010.^[13] Songz embarked on the Passion, Pain & Pleasure Tour on August 6, 2010 with singer Monica. The tour is his first headlining tour to date and consists of shows in venues that seat 3,000 to 5,000 people. Songz also contributed the song "Already Taken" to the Step Up 3D soundtrack, which was released on July 27, 2010. He filmed a video for the song, which was released in July 2010. The leading lady in the video is former girlfriend and professional dancer Helen Gedlu. Songz appeared at the 2010 MTV Video Music Awards on September 12, 2010.^[14] Songz performed at BET Awards 2011 which broadcasted on June 26, 2011.^[15]

In July 2011, he was cast in The Texas Chainsaw Massacre 3D as Ryan, the male lead role.^[16]

[edit] 2011–present: Inevitable and Chapter 5

On August 18, 2011, it was announced Songz will be working on his fifth studio titled Chapter 5.^[17] In an interview Trey said the album, which will act as the follow-up to Passion, Pain & Pleasure, is said to be nearing completion. He also carried on to say "It’s my sixth year in the game so I’ve been here for a while now. You can expect the best me you’ve ever heard. I don’t have any release dates in mind right now but I’m just making music and enjoying myself in the studio and having fun. When I get to a place where I feel comfortable saying a date or all of that, people will definitely know. I have a few dream collaborations on that album that I want, but they say if you blow out your candle and make a wish you can’t tell people what you ask for or it won’t come true."^[18]

On November 28, 2011, on his birthday, Songz released his Inevitable EP to prepare for the release of his album. In February 2012, Songz will embark on his Anticipation 2our to promote his mixtape Anticipation 2 and to raise awareness of his new album.

Discography[link]

• I Gotta Make It (2005)
• Trey Day (2007)
• Ready (2009)
• Passion, Pain & Pleasure (2010)
• Chapter V (2012)

Tours[link]

• Passion, Pain & Pleasure Tour (headliner) (2010)
• OMG Tour (opening for Usher) (2010)
• Anticipation 2our (headliner) (2012)

Filmography[link]

Awards and nominations[link]

References[link]

External links[link]

Wikimedia Commons has media related to: Trey Songz

• Official website
• Trey Songz at the Internet Movie Database

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]

External links[link]

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• American Heart Association's Heart Attack web site – Information and resources for preventing, recognizing and treating heart attack.
• Heart Attack – overview of resources from MedlinePlus