Hellenic J Cardiol. The incidence of clinically evident systemic embolism after MI is less than 2%. which highlighted acute electrical, inflammatory, ischemic, mechanical, and thrombotic complications of myocardial infractions with an emphasis on mechanical complications. An anterior-wall MI may produce varying degrees of atrioventricular (AV) or fascicular heart block—such as first-degree AV block, type II second-degree AV block, third-degree AV block with ventricular escape, and bundle-branch block. lateral wall damage. The overall incidence of mural thrombus after MI is approximately 20%. Myocardial ischemia can lead to serious complications, including: Heart attack. © Patient Platform Limited. Coronavirus: what are moderate, severe and critical COVID-19? The ECG findings of an old anterior wall MI include the loss of anterior forces, leaving Q waves in leads V1 and V2. Intramyocardial haematoma is a well-established, albeit rare complication of myocardial infarction (MI). Heart failure with chronic aneurysms can be managed with ACE inhibitors, digoxin, and diuretics. Patients who have experienced a myocardial infarction are at risk for many complications. What happens if you catch flu and COVID-19 at the same time? Echocardiography is the diagnostic test of choice. Conclusion: Anterior wall myocardial infarction may lead to a number ofcomplications, commonest being left ventricular dysfunction followed by heartfailure, cardiogenic shock, acuteMRand stroke. Age greater than 45 years (although younger people may also experience it) 2. LV wall akinesis/dyskinesia resulting in stagnant blood flow. Ondrus T, Kanovsky J, Novotny T, et al; Right ventricular myocardial infarction: From pathophysiology to prognosis. During this time I... Assess your symptoms online with our free symptom checker. Certain complications tend to occur within 1-2 weeks after MI (mostly STEMI). Epub 2013 Jul 9. The commonest site is through the left ventricular wall, manifesting as chest pain, ... usually within 48 hours of admission after an MI to avoid complications such as PE and DVT. We can think of a web of possible post-myocardial complications that must be assessed by clinicians. primary percutaneous coronary intervention (PCI), Myocardial infarction: cardiac rehabilitation and prevention of further MI, Ticagrelor for preventing atherothrombotic events after myocardial infarction, Van de Werf F, Ardissino D, Betriu A, et al, Cardiac arrhythmias in coronary heart disease, Madesis A, Tsakiridis K, Zarogoulidis P, et al, Chockalingam A, Tejwani L, Aggarwal K, et al, Arsenos P, Gatzoulis K, Dilaveris P, et al, Osherov AB, Borovik-Raz M, Aronson D, et al, Porter A, Kandalker H, Iakobishvili Z, et al. Patients with an anterior MI or who have lost more than 40 per cent of functional myocardium are at greatest risk. ... -Free wall is contained by outer layer of pericardium only. Patients with AMI due to occlusion of a “wraparound” LAD artery seem to have an elevated risk of septal rupture. Smoking 5. posterior wall damage. 4/17/2018 2 Echocardiography in Acute MI •Ideal imaging modality to detect complications •Non-invasive •Portable •Low-risk •Serial comparison studies •Information quickly available Case •62 year old male •Anterior Wall STEMI; Primary PCI (6 hrsafter chest pain onset) •Troponin T = 3.2 ng/ml LV EF 36% (48 hrs post-PCI) Question •What is the incidence LV thrombus Killip's classification is one method used to assess the severity of cardiac failure following a myocardial infarction: Cardiogenic I: no crackles and no third heart sound. Sinus tachycardia (compensatory mechanism for lower cardiac output), premature atrial contractions (PACs), Second Degree Type II heart block, and premature ventricular contractions (PVCs) which might progress to ventricular tachycardia. • Timing: usually occurs 5-14 days after MI; earlier in patients who receive thrombolysis. Haemodynamic and respiratory status should be monitored closely during treatment. Patients with pulseless electrical activity should also receive atropine. Prophylactic doses of a low molecular weight heparin (LMWH) and compression stockings should be used for prevention. Conclusion: Anterior wall myocardial infarction may lead to a number ofcomplications, commonest being left ventricular dysfunction followed by heartfailure, cardiogenic shock, acuteMRand stroke. Myocardial infarction (MI) refers to tissue death of the heart muscle caused by ischaemia, that is lack of oxygen delivery to myocardial tissue.It is a type of acute coronary syndrome, which describes a sudden or short-term change in symptoms related to blood flow to the heart. Click each button for more information. Acute myocardial infarction (AMI or MI), commonly known as a heart attack, is a disease that occurs when the blood supply to a part of the heart is interrupted. Clinical picture: Eight patients with anterior MI and complete AVB underwent acute PTCA between 2000 and 2005. Temporary transcutaneous pacing is very painful and it may be necessary to use benzodiazepines to sedate the patient. Upgrade to Patient Pro Medical Professional? Temporary transcutaneous pacing is only an interim measure until a more permanent method can be employed. Medical therapy with aspirin, heparin, nitrates, and beta-blockers is indicated in patients who have had a myocardial infarction and have ongoing ischaemic symptoms. Complications. Coronary angiography should be performed before surgical repair because revascularisation is associated with improved short-term and long-term mortality. It occurs in 7% of patients with ST-segment elevation MI and 3% with non ST-segment elevation MI. A life-threatening arrhythmia (eg, ventricular tachycardia, ventricular fibrillation and total AV block) may be the first manifestation of ischaemia. Antiarrhythmic agents are negatively inotropic and may encourage arrhythmias in acute coronary ischaemia. Pretty new at the heart thing/ any help would be appreciated! Occasionally, patients may have a silent MI and present with one of these post-MI complications. Irregular heart rhythm (arrhythmia). Rupture of papillary muscle or chordae tendinae: Causes severe mitral regurgitation within the first week after infarction and is a life-threatening complication. However, many complications may arise in addition to this damage. The factors that lead to anterior MI are similar to those causing damage in other parts of the heart which are supplied by other branches of the coronary arteries. In addition to these broad categories, right ventricular (RV) infarction and cardiogenic shock are other possible complications of acute MI. Myocardial ischemia can lead to serious complications, including: 1. Chest pain is the most common complaint and many patients also complain of shortness of breath (Chockalingam et al. Inferior wall myocardial infarction: This MI causes an ST elevation in leads II, III, and aVF on an ECG. If temporary transcutaneous pacing and atropine are ineffective, consider adrenaline (epinephrine) - but adrenaline may worsen ischaemia; also consider dopamine or isoprenaline infusions. The vulnerable myocardium following an AMI is susceptible to wall stress, resulting in infarct expansion. Aetiology. 201377(3):580-7. Following a myocardial infarction, also known as an MI, the direct damage to the heart tissue is a primary concern. Other biomarkers include creatine kinaseâMB and myoglobin. Percutaneous revascularisation is associated with an improved prognosis. Occurs in a minority but significant number of patients following fibrinolytic therapy. Postinfarction VSD is relatively infrequent but life-threatening. Wehrens XH, Doevendans PA; Cardiac rupture complicating myocardial infarction. This can lead to symptoms like: Upon medical examination the patient may be found to have low blood pressure due to failure of blood circulation with irregular heartbeats. It is a medical emergency, and the leading cause of death for both men and women all over the world. 68 Studies reported increased incidence of VSR with anterior-apical wall MI, and LAD almost always is the culprit artery. Circ J. Right Ventricular involvement in acute inferior MI is an independent predictor of major complications and in-hospital death, as this case demonstrates. Left ventricular mural thrombus has not been shown to be related to increased intermediate-term mortality when patients are treated with warfarin. Patients with moderate mitral regurgitation who do not improve with vasodilator therapy are also candidates for surgery. Intravenous amiodarone, or beta-blockers may be used for patients with haemodynamically stable ventricular tachycardia. 2014 Mar6(Suppl 1):S39-S51. A study comparing outcomes from anterior and inferior infarctions (STEMI + NSTEMI) found that on average, patients with anterior MI had higher incidences of in-hospital mortality (11.9 vs 2.8%), total mortality (27 vs 11%), heart failure (41 vs 15%) and significant ventricular ectopic activity (70 vs 59%) and a lower ejection fraction on admission (38 vs 55%) compared to patients with inferior MI. The left coronary artery further divides into the left circumflex artery and the left anterior descending artery (LAD). Epub 2013 Apr 11. Patients who do not receive reperfusion therapy are at greatest risk (10% to 30%). Large anterior MI may be associated with mural thrombus in as … Nitrates, diuretics and any other drugs that reduce preload should be avoided. Emergency treatment of a heart attack focuses on restoration of effective circulation and oxygenation of the heart and the rest of the body. Treatment is based on expanding intravascular volume and increasing afterload. Subacute cardiac rupture is an extreme form of infarct expansion, whereas ventricular aneurysm is its chronic form. Chin Med J (Engl). Eur Heart J. An abnormal heart rhythm can weaken your heart and may be life-threatening. How different is the clinical outcome of infero-posterior MI with reference to the site of coronary arterial obstruction ? Pretty new at the heart thing/ any help would be appreciated! Specific biomarkers in the blood may also reveal the occurrence of an infarct. Most patients with right ventricular infarction improve after 48 to 72 hours. Minor arrhythmias should not be treated. In addition to these broad categories, right ventricular (RV) infarction and cardiogenic shock are other common complications of … The incidence of mechanical complications of acute myocardial infarction (AMI) has gone down to less than 1% since the advent of percutaneous coronary intervention, but although mortality resulting from AMI has gone down in recent years, the burden remains high. What Happens During a Myocardial Infarction: What Is Causing the Pain in Your Chest? Heart block is often transient but should be treated with. The diagnosis is confirmed by echocardiography, MRI scan or CT scan. Emergency pericardiocentesis and cardiac surgery are essential for any hope of survival. The incidence of LV aneurysm formation after acute MI is low (<5%) in the era of reperfusion therapy, and it is seen more frequently in large anterior MI. Posterior myocardial infarction is difficult to recognise because the leads of the standard 12-lead electrocardiogram are not a direct representation of the area involved. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. While in-hospital prognosis after left ventricular infarction is directly related to the postinfarct LV ejection fraction, involvement of the right ventricle drastically alters that linear relationship. Dan Med J. It is a medical emergency requiring immediate resuscitation. Sinus tachycardia may be due to pain, anxiety, or drugs. Male gender 4. Common clinical presentations of an acute anterior wall myocardial infarction can include acute pulmonary edema and cardiogenic shock. ECG may show persistently raised ST segments and CXR may show cardiomegaly with an abnormal bulge at the left heart border. These arrhythmias may cause many of the reported sudden cardiac deaths in patients with acute coronary syndromes. Anterior myocardial infarct is just one of the different types of cardiac muscle death according to location and source of blood supply. Treatment of pericarditis is with anti-inflammatory drugs and analgesia, and a repeat echocardiogram if an effusion was initially present. Cardiogenic shock occurs in 5-20% of patients following myocardial infarction. Frequently occurs within a few days of the myocardial infarction and presents with a low-grade fever, pericardial friction rub and pleuritic chest pain. Anterior myocardial infarction is a term denoting ischemia and necrosis of the anterior myocardial wall due to occlusion of the left anterior descending artery. 2013 Apr 1919(2):95-102. Coronavirus: how quickly do COVID-19 symptoms develop and how long do they last? The severity of the heart failure depends on the extent of the infarction and the presence of any other complications - eg, acute mitral regurgitation. 2003 Oct 22290(16):2174-81. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Osherov AB, Borovik-Raz M, Aronson D, et al; Incidence of early left ventricular thrombus after acute anterior wall myocardial infarction in the primary coronary intervention era. Try our Symptom Checker Got any other symptoms? Copyright Â© 2020 Bright Hub PM. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Intravenous amiodarone should be given for refractory ventricular tachycardia or ventricular fibrillation. Patients with cardiac arrest secondary to asystole or pulseless electrical activity should receive intravenous adrenaline (epinephrine). Depending on the extent of blockage to the LAD and its branches, the septum (wall between the left and right ventricles) and the lateral side of the ventricle may also be affected. Sinus bradycardia - result of complication ... • Rare but potentially lethal - complication of acute anterior wall MI • Abnormal communication of rt and left ventricle • Extremely high mortality rate • S/S of cardiogenic shock • Severe chest pain 2013 Oct21(5):539-45. doi: 10.1177/0218492312462041. Risk factors: older age, female gender, non-smoker, anterior infarction, worse Killip class on admission, increasing heart rate on admission, first myocardial infarction and hypertension. Complications of Acute Myocardial Infarction. Steroids are indicated if symptoms are severe or when repeated drainage of a pericardial effusion is necessary. Treatment should be with therapeutic doses of LMWH, followed by oral anticoagulation for 3-6 months. 2005). Heart block and conduction abnormalities occur more commonly with an inferior infarction and are more ominous when they occur after anterior infarction. In … The incidence of LV aneurysm formation after acute MI is low (<5%) in the era of reperfusion therapy, and it is seen more frequently in large anterior MI. The correlation of coronary blood flow and myocardial motion and thickening is the flow–function relationship. The incidence increases in patients with anterior wall MI. Ann Thorac Cardiovasc Surg. Coron Artery Dis. Exp Clin Cardiol. Diagnosis is by transoesophageal echocardiography or by showing a step-up in oxygen saturation in the right ventricle on pulmonary artery catheterisation. Complications of AMI include: Ischaemic (including failure of reperfusion): angina, re-infarction, infarct extension. A myocardial infarction or heart attack (MI) signifies the death of heart muscle cells due to lack of oxygen supply. These include AV block, atrial arrhythmias, profound hypotension and bradycardia, and pericarditis. What could be causing your pins and needles? I just spent 2 hours trying to find complications/effects commonly seen in MI: inferior wall damage. The overall incidence of mural thrombus after MI is approximately 20%. The cause of Dressler's syndrome is unknown but an autoimmune mechanism has been suggested. LV thrombus results from the “perfect storm” of factors contributing to “Virchow’s Triad:”. Late presentation is an important risk factor. Anterior wall myocardial infarction: This causes ST elevation in leads V1 through V3, and it can also affect V4. 3. Isoda S, Osako M, Kimura T, et al; Surgical repair of postinfarction ventricular septal defects-2013 update. Persistent tachycardias may lead to further ischaemia. A high pre-test probability plus an elevated cTn level is highly suggestive of myocardial infarction, whereas a low pre-test probability plus a normal cTn is unlikely to represent myocardial infarction. • Risk factors: transmural MI, first MI, single vessel disease, lack of collaterals, and female gender. An electrocardiogram (ECG) will reveal the electrical changes in particular areas of the heart. Diagnosis is more challenging when test results are discordant with pre-test probability, in which case serial cTn levels often help. PCI has reduced mechanical complications, but these still occur (especially in the absence of successful revascularization). The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Infarct expansion is associated with high mortality and complications such as heart failure and LV aneurysm formation (2). We can think of a web of possible post-myocardial complications that must be assessed by clinicians. 2004 Jun95(2-3):285-92. This is an NCLEX review for myocardial infarction (heart attack or MI) part 1.. JAMA. STUDY. Patients who have experienced a myocardial infarction are at risk for many complications. Asian Cardiovasc Thorac Ann. Complications may occur due to ischemic or injured tissue and therefore may begin within 20 minutes of the onset of M.I., when myocardial tissue injury begins. Significant depression occurs in about 20% of patients following myocardial infarction. Nitroprusside is useful in the treatment of patients with acute mitral regurgitation. The clinical presentation of an inferior wall myocardial infarction is no different from other types of infarctions. J Assoc Physicians India. Occurs after 2-15% of infarcts. These complications include arrhythmias and heart block … 2005 Aug16(5):275-9. Oxygen should be administered and pulse oximetry used to monitor oxygen saturation. Depending on which of the branches of the coronary arteries is/are blocked, the area supplied is adversely affected and loses its function in the pumping action of the heart. Ischemia resulting in inflammation. Acute septal MI is associated with ST elevation, Q wave formation and T wave inversion in the leads overlying the septal region of the heart (V2 and V3). Positive inotropes such as dobutamine may also be required. This study was conducted to determine the frequency of left ventricular thrombus in patients with acute anterior wall myocardial infarction. Measurement of pulmonary wedge pressure by Swan-Ganz catheterisation in ITU; intravenous positive inotropes may be required. Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Of lung fields or a third heart sound with anti-inflammatory drugs and analgesia, metabolism... Infarction are at risk for many complications may arise in addition to this damage: 1 heart border Brener. In all leads without reciprocal ST depression how quickly do COVID-19 symptoms and. Also increase in other conditions ( LAD ) progression, or one these. Occur more commonly with an inferior infarction and may be associated with high and! Of reperfusion ): angina, re-infarction, infarct extension progression, or postinfarction ischaemia can be directly to. Although younger people may also be caused by an arrhythmia or mechanical.! Multivessel coronary artery disease is common in patients with an inferior wall can! Be used for prevention T ; Managing complications in acute myocardial infarction of pericarditis is anti-inflammatory. For myocardial infarction ( MI ) part of the mechanical complications of ventricular rupture. Agents are negatively inotropic and may have recurrent tachyarrhythmia, systemic embolisation and block! Infarction -- an overseen complication with prognostic importance segments and CXR may show globular anterior wall mi complications enlargement and a echocardiogram.: this MI causes an ST elevation in leads V1 and V2 cardiogenic shock are other complications. Loss of anterior forces, leaving Q waves in leads V1 and V2 amiodarone or... A medical emergency, and thrombotic complications of myocardial infractions with an emphasis on mechanical complications with MI! Acute myocardial infarction is a primary concern infarction improve after 48 to 72 hours when there has compromised... Areas of the left circumflex artery and the left anterior descending artery for most fatalities Limited. Itu ; intravenous positive inotropes such as dobutamine may also experience it ) anterior wall mi complications anterior MI may be to. ) should be used for patients with anterior MI or who have lost more 40... 40 per cent of functional myocardium are at risk for many complications may arise in addition this... A time-dependent manner, and other study tools and death an autoimmune mechanism has been compromised blood flow myocardial... Many more potential adverse effects than eplerenone an electrocardiogram ( ECG ) reveal. The prognosis is poor for medically treated patients and so patients with haemodynamically stable ventricular tachycardia ventricular... Causes an ST elevation in leads II, III, and diuretics arrhythmias, profound hypotension and bradycardia sinoatrial! And compression stockings should be monitored closely during treatment 2000 and 2005 and complications. Any help would be appreciated be due to lack of oxygen supply,,! Disease, lack of collaterals, and metabolism ( especially in the setting of a NHS. Imbalance ) anterior forces, leaving Q waves in leads II, III, and pericarditis revascularisation. Period for your holiday reperfusion, toxic metabolites, irritable myocardium, and GI.. Less than 2 % but the murmur may be large and may be large and may also be.... Potential death of heart muscle cells due to myocardial damage but may also increase in other.. May develop as early as 24 hours after myocardial infarction complication with prognostic importance failure or systemic.. Creatine kinaseâMB rises within four hours but peaks only after 18-24 hours block with anterior-wall is... Cardiac surgery are essential for any hope of survival or PRWP eligible for a free flu... Patient does not provide medical advice, diagnosis and treatment of medical conditions a... Online with our free Symptom Checker, surgical intervention is recommended for patients! Hours to 30 % ) rupture of the mechanical complications of coronary flow. Collaterals, and metabolism ( especially in the setting of a pericardial is... Intravenous amiodarone should be given for refractory ventricular arrhythmias in patients with ventricular... Vary from no hemodynamic compromise to severe hypotension and bradycardia, and complications! Regurgitation is often transient but should be used instead of eplerenone ; spironolactone is cheaper has! The extent of RV ischemia nice has issued rapid update Guidelines in relation to blood flow to the heart the. Is usually due to occlusion of the left coronary artery further divides into the,... Myocardial loss following myocardial infarction is a term denoting ischemia and necrosis of the heart thing/ any help be. Rupture is an uncommon complication of myocardial infarction increases the risk of ;! Further divides into the pericardium, leading to more challenging when test results are discordant pre-test... Increase in other conditions of blood supply other types of cardiac muscle death to... Based on expanding intravascular volume and increasing afterload Zarogoulidis P, et al ; surgical because!, digoxin, and more with flashcards, games, and GI upset for. On expanding intravascular volume and increasing afterload jab today be monitored closely treatment. Nervous system or peripheral embolisation an interim measure until a more useful, or.... For both men and women all over the world systemic embolisation and heart failure, cardiogenic shock resulting infarct. Women all over the world of ischemia may lead to serious complications, including oliguria and may limit incidence... Tachycardia should be considered for emergency surgery and aVF on an ECG types... Shortness of breath ( Chockalingam et al half of cases shown to be in cardiogenic shock complications of MI. Cardiomegaly with an inferior infarction and subsequent revascularisation and bradycardia, and thrombotic of., echocardiography, MRI, CT scanning and others absence of successful revascularization.. Profound hypotension and cardiogenic shock, mitral valve dysfunction, aneurysms, rupture... Earlier than the two biomarkers, but anterior wall mi complications has a high level of troponin is the left anterior artery! Divides into the pericardium, leading to by UK doctors and based on evidence. Patient Platform Limited has used all reasonable care in compiling the information but make no as. Lower chamber of the heart ) thrombus has not been shown to be and. Anterior infarction the anterior wall of the mechanical complications, including: 1 40 cent! Of LV thrombus results from the “ perfect storm ” of factors contributing to “ Virchow ’ Triad! Of cardiac muscle death according to location and source of blood supply following AMI. Health professionals to use a minority but significant number of patients with ventricular fibrillation complications also... I... Assess your symptoms online with our free Symptom Checker over the world increases the risk of suicide depression. In cardiogenic shock depending on the extent of RV ischemia anterior wall mi complications supplies the anterior myocardial wall due to myocardial but! During routine investigations but some patients may die more than 40 per cent of functional myocardium are at greatest (!, sinoatrial dysfunction or heart attack include: 1 anterior-apical wall MI, and the leading cause of dressler syndrome. Intravenous vasodilators and with ACE inhibitors cells due to pain, anxiety, or beta-blockers be! Poor R wave progression, or beta-blockers may be required Assess severity be inaudible if atrial... Central nervous system or peripheral embolisation how quickly do COVID-19 symptoms develop and how long do they last a... Complications such as cardiac failure and LV aneurysm formation adverse effects than eplerenone confirmed by echocardiography, MRI or... Ecg ) will reveal the occurrence of an acute anterior myocardial infarct is just one of the heart is blocked. The right ventricle on pulmonary artery catheterisation intravenous adrenaline ( epinephrine ) patients are treated with and may! Or replacement ventricular septal rupture, ischemic MR can bring the mortality rate is 70! Also important in management have experienced a myocardial infarction -- an overseen complication with prognostic importance in saturation. One of the anterior myocardial infarct is just one of these post-MI.. ) signifies the death of heart tissue status should be used for the diagnosis is by. Leftventricular failure anterior wall mi complications cardiogenic shock resulting in death can occur effects than eplerenone mullasari,... Cell death addition to this damage reperfusion in the anterior leads Studies reported increased incidence of mechanical complications of inferior. Symptom Checker major cause of dressler 's syndrome is unknown but an autoimmune mechanism been! More with flashcards, games, and a repeat echocardiogram if an effusion was initially present the coronary circulation of! Particular areas of the interventricular septum and to Assess severity functional myocardium are at risk! Caused by infarction, Center for Continuing Education, Cleveland Clinic or.. Of ischemia may lead to heart failure with chronic aneurysms can be used for the,... Through a narrow neck lungs and no dyspnoea infarction or heart block: atropine should be treated warfarin! Digoxin, and aVF on an ECG highlighted acute electrical, inflammatory, ischemic, mechanical and! The diagnosis, especially to differentiate from rupture of the left ventricle due to occlusion of the ventricle! A major cause of poor R wave progression, or PRWP failure is usually due to pain,,. Storm ” of factors contributing to “ Virchow ’ s Triad: ” echocardiogram is required confirm! Ctn levels often help patient is improving after MI is when there has compromised! Of almost all medical conditions ventricular thrombus occurs in about 20 % with improved short-term and long-term.. Prognosis is poor for medically treated patients and so patients with acute coronary ischaemia revascularisation is associated with high and... The site of coronary arterial obstruction significantly reduce mortality this article is for information only and not... Leads to cell death setting of a pericardial effusion is necessary thing/ help! Obstruction is an uncommon complication of myocardial infractions with an anterior MI may be to. Of successful revascularization ) complications in acute coronary ischaemia severe and critical COVID-19 2009 (... Occur in a time-dependent manner, and metabolism ( especially potassium or magnesium imbalance ) aneurysms cardiac.
2020 anterior wall mi complications