Primary PCI for STEMI
doi:10.1161/CIR.0000000000000336 JFW | T@lk 16:38, 16 March 2016 (UTC)
doi:10.1016/S0140-6736(16)30677-8 JFW | T@lk 08:23, 2 September 2016 (UTC)
- This review is transcluded from Talk:Myocardial infarction/GA1. The edit link for this section can be used to add comments to the review.
Reviewer: Jclemens (talk · contribs) 05:20, 9 March 2017 (UTC)
|1. Well written:
||1a. the prose is clear and concise, and the spelling and grammar are correct.
||This is actually pretty good, for how disjointed the flow of topics and thought is.
||1b. it complies with the manual of style guidelines for lead sections, layout, words to watch, fiction, and list incorporation.
||No issues noted
|2. Verifiable with no original research:
||2a. it contains a list of all references (sources of information), presented in accordance with the layout style guideline.
||2b. all in-line citations are from reliable sources, including those for direct quotations, statistics, published opinion, counter-intuitive or controversial statements that are challenged or likely to be challenged, and contentious material relating to living persons—science-based articles should follow the scientific citation guidelines.
||Some are clearly outdated and need updating, as commented below.
||2c. it contains no original research.
||There are some citation needed (CN) tags, but overall this seems not to be that much of a problem. If anything, it's such a big topic that I'm more concerned about DUE weight.
||2d. it contains no copyright violations nor plagiarism.
||Nothing found with Earwig's tool.
|3. Broad in its coverage:
||3a. it addresses the main aspects of the topic.
||Yes, broad. Not always well-focused, but broad...
||3b. it stays focused on the topic without going into unnecessary detail (see summary style).
||There's too much detail on some things, but more frustratingly, there's quite a bit of inconsistency between subtopics.
||4. Neutral: it represents viewpoints fairly and without editorial bias, giving due weight to each.
||I've noted a few things where the level of focus on one area seems like potential advocacy. Nothing blatant, and I expect this will be ironed out in the process of review/revision.
||5. Stable: it does not change significantly from day to day because of an ongoing edit war or content dispute.
||Actively being edited, likely in response to the nom, but without any indications of edit warring.
|6. Illustrated, if possible, by images:
||6a. images are tagged with their copyright status, and valid fair use rationales are provided for non-free content.
||All OK, no fair use.
||6b. images are relevant to the topic, and have suitable captions.
||Good mix of diagrams and photographs.
||7. Overall assessment.
||Passing per improvements. This was a monumental undertaking, but one I hope benefits our readers for some time to come!
- Jclemens' Good Article Review expectations for Vital Articles.
- This is a vital article. As such, it requires an appropriate amount of scrutiny, because being wrong is just that much worse, so being right is just that much more important.
- This is a collaborative process. I offer suggestions, which editors are free to implement, ignore, reject, or propose counter-suggestions. If there's simply no meeting of the minds, there will be no GA pass from me, but please feel free to tell me to take a flying leap if I propose something stupid or counterproductive.
- I do not quick fail vital article GA reviews. In general, even if there is no clear path to meet all the GA criteria, working with conscientious editors is almost always going to improve the article and benefit our readers--just not to the extent all of us had hoped.
- This is not a quick process. Estimate a month, depending on my availability and the responsiveness of the nominator and other editors collaborating on the process.
- I am not a content expert. I generally have a reasonable background in the topic under consideration, often at the college undergraduate/survey level, or else I wouldn't have volunteered to review it. Thus, I depend on the content experts to help focus the article appropriately.
- The more the merrier. While many unimportant GA articles can be adequately reviewed by a single nominator and a single reviewer, Vital Article GA's can use more eyes, based on their increased importance. I always welcome other editors to jump in with suggestions and constructive criticisms.
- Thank you, Jclemens. I look forward to helping Winged Blades of Godric get this article to good article status and welcome further reviews. If you could reset your month clock to today I would be grateful as on quick glance I can see this article may have a number of issues you wish to raise. Seeing as I've just taken this up, I will spend a few days getting some up to date reviews and sources in preparation whilst I respond to your comments. Looking forward to working with you both :), --Tom (LT) (talk) 05:58, 8 April 2017 (UTC)
this article meets MEDMOS, however fails MEDRS due to the high number of uncited text (unless corrected)have not checked for reviews within 5 years or soWikipedia:Identifying reliable sources (medicine)#Basic advice--Ozzie10aaaa (talk) 13:17, 9 March 2017 (UTC)
I expect to complete the initial read-through within about 30 hours: tomorrow is a day off for me. Jclemens (talk) 17:31, 9 March 2017 (UTC)
- So, I've gotten much more delayed on this than I had anticipated. My apologies to anyone waiting for me. Jclemens (talk) 05:28, 23 March 2017 (UTC)
- No worries. --Tom (LT) (talk) 05:58, 8 April 2017 (UTC)
- @Jclemens goodness, this was a larger endeavor than I expected. I have marked some issues as "Addressed" so I can help focus on what's outstanding, please remove things from the list if you disagree, or add things if you think they are addressed so I can keep working on the article. --Tom (LT) (talk) 03:52, 7 May 2017 (UTC)
- Yeah, we may be working on this for a while. I'll see what I can get to, maybe Monday. Jclemens (talk) 04:26, 7 May 2017 (UTC)
- Slowly getting there... thank you for your patience... --Tom (LT) (talk) 23:56, 24 May 2017 (UTC)
- @Jclemens OK, I am hanging my hat up for a while. Have worked through almost every aspect of the article... I expect there are a number of areas that need copyediting. Thanks for waiting. Please consider me having responded to your first tranche of comments. --Tom (LT) (talk) 11:21, 6 June 2017 (UTC)
- Gotcha, will continue review from here. BTW, Tom (LT), did you just change your username to match your sig? Jclemens (talk) 16:22, 6 June 2017 (UTC)
- "Risk factors include [...] among others." That's a tad redundant--I tend to prefer "include (but are not limited to)"
- Not done The current formulation is a standard way, and the use of the word "include" implies "is not limited to" (otherwise it would say "Risk factors are") --Tom (LT) (talk) 05:51, 8 April 2017 (UTC)
- "A number of tests are useful to help with diagnosis, including electrocardiograms (ECGs), blood tests, and coronary angiography. An ECG may confirm an ST elevation MI if ST elevation is present. Commonly used blood tests include troponin and less often creatine kinase MB." If we're going to go into as much detail as the second and third sentences include, might it not be cleaner to integrate them. Also, do we want to introduce EKG as an older (but still commonly known by laypersons) acronym?
- Not done The article is complicated enough as is... such an abbreviation can be found instead on the ECG article--Tom (LT) (talk) 05:51, 8 April 2017 (UTC)
- Note that that only addresses one part of the suggestion. Did you think it workable to reword the sentences? Jclemens (talk) 04:25, 14 April 2017 (UTC)
- Do we want to define what ST elevation is (e.g. a variance seen on ECGs during the last phase of each heartbeat's electrical cycle) if we're going to refer to it multiple times during the lead?
- Done That is an excellent point. --Tom (LT) (talk) 05:51, 8 April 2017 (UTC)
- If we're going to talk about Aspirin, O2, etc. in the lead, and we expect this to be a widely read article, should we also consider including summoning local emergency services (911/999/etc.)?
will find a reference... --Tom (LT) (talk) 05:53, 8 April 2017 (UTC)
- CABG is used without the acronym being fully spelled out: "... bypass surgery (CABG)" I suspect that should be spelled out before the acronym is used, or the acronym can be saved for later in the body, as it is not reused in the lead.
- Done good point. --Tom (LT) (talk) 05:51, 8 April 2017 (UTC)
Signs and Symptoms
- "Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, and upper abdomen, where it may mimic heartburn." I'm wondering if this could (or should) be reworded to take into account the positive predictive value of right arm radiation. I haven't looked at the LRs on these recently, but ISTR that pain radiating to the right arm is still a very high PPV compared to most of the others.
still looking for a reliable non-primary source for these LRs... --Tom (LT) (talk) 01:44, 22 April 2017 (UTC)
- Done let me know what you think --Tom (LT) (talk) 07:08, 22 April 2017 (UTC)
- "Levine's sign, in which a person localizes the chest pain by clenching their fists over their sternum" should be reworded to note that a single fist is typically sufficient.
- "Atypical symptoms are more frequently reported by women, the elderly, and those with diabetes when compared to their male and younger counterparts." I want to know WHAT atypical MI symptoms are before you tell me who gets them. In other words, I believe this and the next few sentences should be essentially flip-flopped in order.
- "Women may also experience back or jaw pain during an episode." But men cannot? How about 'are more likely to'?
- Done I've removed the poorly sourced statements here and moved the statement about symptoms in women to a position closer to the start. I've also tried to reword the part about "atypical" symptoms to clarify that the symptoms in women are not atypical, but that when atypical symptoms occur they are more common in women. --Tom (LT) (talk) 07:08, 22 April 2017 (UTC)
- "at autopsy without a prior history of related complaints." I understand what this means, but it's awkward and may be opaque to our non-medical readers. Jclemens (talk) 07:13, 11 March 2017 (UTC)
- Done good point. --Tom (LT) (talk) 05:51, 8 April 2017 (UTC)
Doing... will find and update references and do a general copyedit of said section before I respond to a number of your (very pertinent) comments. --Tom (LT) (talk) 05:53, 8 April 2017 (UTC)
- Still Doing...... --Tom (LT) (talk) 01:44, 22 April 2017 (UTC)
- Done --Tom (LT) (talk) 00:37, 24 May 2017 (UTC)
- "Shortness of breath occurs when the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema." Is this completely and adequately correct? Right sided heart failure can reduce LV output even in the setting of an entirely healthy LV. Granted, that's rare, but... is this the way we want to say it? To put it another way, is this the only mechanism for persons suffering an acute MI to also have SOB that we want to mention?
Doing... will get back to you on this. --Tom (LT) (talk) 07:08, 22 April 2017 (UTC)
- Done surprisingly find a reliable source relating to the pathophysiology of dyspnoea in MI --Tom (LT) (talk) 00:37, 24 May 2017 (UTC)
- The relationship of smoking and obesity to CAD is great... but shouldn't we pair that closely with the risk of CAD to MI? That is, the relationship may be clear to us, but the readership probably would benefit from it being spelled out better.
- Done stated directly. --Tom (LT) (talk) 07:59, 22 April 2017 (UTC)
- Lack of exercise is mentioned in the first paragraph, and lack of physical activity in the second. Those could probably be paired for more impact.
- Done the whole order was strange. I have reordered this section so that significant risks are covered first, and less important risks are covered later. --Tom (LT) (talk) 07:59, 22 April 2017 (UTC)
- I'd really like the third paragraph in Lifestyle, on dietary effects, scrubbed by an expert. Just reading I worry that one or several of the studies cited may be cherry-picking evidence to support an agenda, and I'd like to make sure we don't have that.
- Done Please let me know what you think once I've finished rejigging this section. --Tom (LT) (talk) 07:59, 22 April 2017 (UTC)
- We need something much newer than a 14-year-old meta-analysis if we're going to dis combined oral contraceptives. Including them at all is UNDUE in light of what we know on NSAIDs and the increased risk of MI. Jclemens (talk) 04:39, 14 April 2017 (UTC)
- In Disease " dyslipidemia/high levels of blood cholesterol (abnormal levels of lipoproteins in the blood), particularly high low-density lipoprotein, low high-density lipoprotein, high triglycerides," seems to be rather extensive compared to what we mention about the other diseases. Well, except that obesity gets a similar elongated treatment.
- Done very good point. Reworded. --Tom (LT) (talk) 00:58, 24 May 2017 (UTC)
- The paragraph on infection impact on MI should be reviewed by an expert.
- Not done I have had a look around and there are quite a few high-quality sources that support chronic infections as a risk factor for cardiovascular disease, presumably as such infections cause inflammation which speeds up atherosclerosis. --Tom (LT) (talk) 00:58, 24 May 2017 (UTC)
Still Doing... --Tom (LT) (talk) 07:59, 22 April 2017 (UTC)
- What's a clotting cascade?
- Some more concrete statements about probabilities would be welcome: "most frequently" and "most common" are weasely and could stand more precision.
- "It is estimated that one billion cardiac cells are lost in a typical MI." That is a cool trivial factoid, but absent context (How many cells are there in the heart? How many can we live without?) I'm afraid that's all it remains.
- Done removed factoid. --Tom (LT) (talk) 01:29, 17 April 2017 (UTC)
- "Hyperhomocysteinemia [...] is associated with premature atherosclerosis" So how many steps removed from the actual MI do we want to go? I count at least two (Hyperhomocysteinemia->Atherosclerosis->MI) which seems like an inconsistent level of coverage.
- Done moved to 'risk factors' section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC)
- "Calcium deposition as calcification is another part of atherosclerotic plaque formation." Is it just me, or are we bouncing back and forth between pathophys and diagnosis here?
- Done reworded, and moved to 'risk factors' section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC)
- "Myocardial infarction in the setting of plaque results from underlying atherosclerosis." Didn't we cover this in the first paragraph in this section?
- Done rearranged section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC)
- "the heart cells in the territory of the occluded coronary artery die" I'm not sure territory is the best word here. Perhaps "the heart cells supplied by the occluded coronary artery die" or something along those lines to make the causal relationship even more explicit?
- "If impaired blood flow to the heart lasts long enough," The article hasn't yet described any circumstances where blood flow would be impaired on a temporary basis.
- Done reworded section. --Tom (LT) (talk) 03:41, 7 May 2017 (UTC)
- "Bloodstream column irregularities visible on angiography reflect artery lumen narrowing as a result of decades of advancing atherosclerosis." Nice sentence, but it seems to break up the logical flow between what comes before and after. Also, angiography hasn't been wikilinked since the lead, and probably should be.
- "As a result, the person's heart will be permanently damaged." We haven't personalized the heart before now. Do we want to start?
- The Pathological types aren't entirely clear. It seems like this could be a binary option, but it's clearly not.
Overall, this section really needs a complete re-outline and rewrite. It doesn't follow a consistent taxonomy or logical progression, in the one section of the article that could most clearly benefit from such a top-down approach. Jclemens (talk) 05:00, 15 April 2017 (UTC)
- Do we want to talk about pulseless vs. perfusing VTach?
- Thanks for continuing :). I've split this section into subsections to try and improve how we cover it. I'll see how this is received and continue when there's consensus--Tom (LT) (talk) 01:29, 17 April 2017 (UTC)
- Partly done have rolled the pathophysiology related complications into 'tissue death' and left the other complications section. I think it is a little beyond the scope of the article to talk about variant complications (MI -> complications -> VT -> perfusing / pulseless) --Tom (LT) (talk) 00:18, 3 June 2017 (UTC)
- "A cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression, or coronary intervention is diagnostic of MI" Sure it is, but that is because cardiac troponins belong inside cardiac muscle cells, and finding them in the bloodstream indicates cardiac muscle cell destruction.
- "Previously, a recent left bundle branch block was considered the same as ST elevation, however, this is no longer the case." Tell me more... Why? By whom? When did it change?
- "There are a number of different biomarkers." How about listing them all in turn, and then talking about the advantages/disadvantages/timing of each?
- "A chest radiograph and routine blood tests may indicate complications or precipitating causes and are often performed upon arrival to an emergency department." Not only does it have a citation needed tag, it really could use some more elaboration, too.
- "Medical societies and professional guidelines recommend that the physician confirm a person is at high risk for myocardial infarction before conducting imaging tests to make a diagnosis." Why?
- Done clarified (and simplified the references) --Tom (LT) (talk) 01:09, 24 May 2017 (UTC)
- "The differential diagnosis for MI includes other catastrophic causes of chest pain" I think this is still backwards. How about, "In addition to MI, the differential diagnosis for chest pain includes..." or similar construction instead?
- "Chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle is termed angina pectoris." 1) this should probably be more prominent, and 2) would it be appropriate to note that areas of ischemia often surround the areas of infarction? Looking through the section, I don't see it mentioned anywhere obvious.
- Done I have almost completely reworded this section --Tom (LT) (talk) 11:19, 6 June 2017 (UTC)
I note that you're working on this and reorganizing things as you go. Good deal! Jclemens (talk) 03:02, 27 April 2017 (UTC)
- Thanks, I am still gradually working through this. --Tom (LT) (talk) 10:40, 28 April 2017 (UTC)
- Done I have given this section a thorough copyedit. --Tom (LT) (talk) 11:19, 6 June 2017 (UTC)
- "Treatment attempts to save as much viable heart muscle as possible" Viable is redundant.
- Done good point; removed.--Tom (LT) (talk) 01:15, 24 May 2017 (UTC)
- "hence the phrase "time is heart muscle"." Yeah, but so what? Who actually says that? Needs a better setup than 'hence'.
- NSTEMI: Every NSTEMI is NSTEACS, but not every NSTEACS is NSTEMI, right? That's not quite so clear in the text.
- Done (I hope) now that we have the introductory section. --Tom (LT) (talk) 01:15, 24 May 2017 (UTC)
- GRACE score is currently redlinked, and should be explained or de-redlinked.
- Not done unfortunately there is no GRACE article at present. --Tom (LT) (talk) 01:15, 24 May 2017 (UTC)
- P2Y12 gets far more airplay--COI?
- Done decreased their prominence. --Tom (LT) (talk) 01:15, 24 May 2017 (UTC)
- "Nitroglycerin (administered under the tongue or intravenously) may be administered to improve the blood supply to the heart." 1) It's also a dermal paste, 2) there's no evidence it improves mortality.
- Partly done not mentioning dermal paste; this is not mentioned in any of the sources I have looked at (and that's quite a few at present), sublingual is I am guessing preferred due to its rapid absorption; I have mentioned the lack of mortality benefit.--Tom (LT) (talk) 22:31, 24 May 2017 (UTC)
- Good that the updated O2 recommendations are included, but it really makes things look quite haphazard. Aspirin only gets a mention, without description of mechanism of action.
- Done reordered, good point --Tom (LT) (talk) 22:31, 24 May 2017 (UTC)
- Thrombolysis gets a lot more airplay than PCI, and CABG is not mentioned at all in the STEMI section. Is that really correct? Obviously PCI is preferred to CABG, but I've always understood that CABG is a backup for PCI.
- Does targeted temperature management *only* belong to the STEMI branch? Seems to me it's agnostic about how you get to a cardiac arrest.
- Of all the parts of this section, the secondary prevention portion seems to be the only part which doesn't need to be completely rewritten... But yeah, as I noted above, secondary prevention probably belongs to prevention, not management. Jclemens (talk) 02:34, 29 April 2017 (UTC)
- Done noted and completely rewritten. --Tom (LT) (talk) 11:35, 27 May 2017 (UTC)
- It's not clear to me how ASA or PCI treatment differ between STEMI and NSTEMI.
- Question: what is 'ASA'? --Tom (LT) (talk) 22:31, 24 May 2017 (UTC)
- Acetylsalycilic acid... better known as aspirin. Jclemens (talk) 22:07, 27 May 2017 (UTC)
- Can we get an update on the diet recommendations? 'five portions' etc. seem oddly specific and out of context.
- Question: these do indeed reflect reliable sources. What changes would you suggest? --Tom (LT) (talk) 10:48, 6 June 2017 (UTC)
- Never seen Killip class; NYHA categorization is more familiar to me.
- One more CN tag in the Complications section. I would also like to see some stats on the incidence and prevalence of these complications. Gotta be some out there somewhere... Jclemens (talk) 02:42, 1 May 2017 (UTC)
- Partly done? added and expanded --Tom (LT) (talk) 10:45, 6 June 2017 (UTC)
- That CN tag on the first sentence is annoying. I'm sure we can find something.
- TIMI scores somewhat lack context. How does their use relate to the previous paragraph?
- Doing... the use of TIMI is currently in discussion, see the talk page. --Tom (LT) (talk) 00:45, 3 June 2017 (UTC)
- This is some interesting prose, but I'd prefer to see some tables illustrating this. I may be alone in this, so consider it a suggestion.
- Obviously, this needs a refresh and update. I get that 2016 numbers won't be available for a while, but surely we can do better than 2008. I'm thinking 2012-14 should be available somewhere. Jclemens (talk) 02:42, 1 May 2017 (UTC)
- @Jclemens AMI-specific numbers are oddly hard to come by. IHD, CAD, no problem - AMI, a different story. Have had a look on google scholar, medline... any ideas? --Tom (LT) (talk) 09:59, 6 June 2017 (UTC)
Society and Culture
- Is it just me, or is this a trivia section by another name? Seriously, it should be broken up and integrated elsewhere, unless there's something else to add to it. "Heart attacks in popular culture" could have a section of how they ONLY shock Asystole on TV... Jclemens (talk) 02:48, 1 May 2017 (UTC)
- Partially implemented-I am looking to add details about "Heart attacks in popular culture" soon.Winged Blades Godric 04:45, 1 May 2017 (UTC)
- @Winged Blades of Godric how's this section going? --Tom (LT) (talk) 00:45, 3 June 2017 (UTC)
- "The mechanism of an MI often involves the complete blockage of a coronary artery caused by a rupture of an atherosclerotic plaque." Would reversing cause and effect make this sentence more clear?
- "In ST elevation MIs treatments which attempt to restore blood flow to the heart are typically recommended and include..." What about "IN STEMI, treatments to restore the heart's blood flow include..." I think the recommendation verbiage is sufficiently obvious per WP:BLUE that even mentioning it is redundant. Jclemens (talk) 22:09, 10 June 2017 (UTC)
- "It is a type of acute coronary syndrome" Would subdivision or category be better words than 'type'?
- Not done splitting hairs here; I think 'type' is adequate --Tom (LT) (talk) 00:29, 11 June 2017 (UTC)
- We imply that CK-MB is specific to cardiac muscle death, but skeletal muscle can also provoke its elevation, can it not? Do we want to clarify that, or would that be splitting too many hairs?
- Not done Splitting hairs. It is discussed in more detail below, but I think it's important to introduce the concepts here so readers have some idea what we are talking about.--Tom (LT) (talk) 00:29, 11 June 2017 (UTC)
- We reintroduce STEMI and NSTEMI here, but use Myocardial Infarction first and MI thereafter without the parenthetical (MI) after the first usage. This should be consistent, and matching whatever the MOS says to do wouldn't hurt even if it's not strictly required at the GA level. Jclemens (talk) 22:09, 10 June 2017 (UTC)
- Question: I will put "(MI)" next to "myocardial infaction"... other than that, am not sure what specific change you are proposing here? --Tom (LT) (talk) 00:29, 11 June 2017 (UTC)
- No other change, that covers it. I'd just wanted the repeated acronym use standardized. Jclemens (talk) 00:59, 11 June 2017 (UTC)
Signs and Sympoms
- "Shortness of breath is a common, and sometimes the only symptoms, that occurs the damage to the heart limits the output of the left ventricle, wither breathlessness arising either from subsequent hypoxemia or pulmonary edema" Needs to be clarified and quite possibly broken up.
- "Atypical symptoms, such as cardiac arrest and palpitations, occur more frequently in women, the elderly, those with diabetes, in people who have just had surgery, and in critically ill patients." I'm not familiar with calling cardiac arrest an atypical symptom of MI. Is that correct? Jclemens (talk) 02:13, 12 June 2017 (UTC)
- Done good point. I suppose technically this is a "sign". I've reworded this sentence slightly to reflect this. --Tom (LT) (talk) 23:45, 16 June 2017 (UTC)
- All the other risk factors are either boolean (DM II), or state directionality (older age, high blood pressure). I think High total cholesterol and LOW HDL should be explicitly stated.
- "Many risk factors of MI are shared with coronary artery disease, the primary cause of myocardial infarction," If you're going to write one out (but there's already one spelled out in the first paragraph in this sentence/section) and abbreviate another, the first one should be written in full. In this case, I think either both instances abbreviated as MI or the sentence restructured to avoid the redundancy would be fine.
- "At any given age, men are more at risk than women for the development of cardiovascular disease." Doesn't that start substantially evening out after menopause? If so, we might want to note that.
- Not done I couldn't find a high-quality source to verify this. --Tom (LT) (talk) 11:29, 19 June 2017 (UTC)
- Might want to explicitly state who is guessing what risk factors contributed to which MIs, rather than just reeling off percentages.
- Done agree. I think it is simplistic to say that 36% of MIs are caused be obesity. Atherosclerosis is multifactorial and humans are multidimensional.--Tom (LT) (talk) 11:56, 22 June 2017 (UTC)
- Note that this got reverted, so further discussion and refinement may be appropriate. Jclemens (talk) 20:12, 22 June 2017 (UTC)
- "High levels of blood cholesterol, particularly high (increased levels of) low-density lipoprotein, low (reduced levels of) high-density lipoprotein, high (increased levels of) triglycerides." This should either be expanded with more context, or rolled into the opening sentence in this section.
- "The evidence for saturated fat['s role in MI risk] is unclear"
- Do we have anything on high sugar intake contributing directly to MI?
- Done no reliable sources of enough weight to justify inclusion that I could find. --Tom (LT) (talk) 11:03, 1 July 2017 (UTC)
- "Family history of ischemic heart disease or MI [is a risk factor for MI], particularly if one has a male first-degree relative (father, brother) who had a myocardial infarction before age 55 years, or a female first-degree relative (mother, sister) less than age 65."
- Do we really care which genes have been associated with MI, given that we're not talking about any of them at all? Might a separate article be called for? Not only does correlation not imply causality, but it seems to be hit or miss whether the linked articles even mention the risk association at all; I didn't see any that gave an odds ratio or statistical strength of association. Jclemens (talk) 04:30, 18 June 2017 (UTC)
- Yes we do. I haven't given prominence to these, but they do merit a mention. I think genetic risk and personalised medicine will only become more important and we should mention what little we know here. --Tom (LT) (talk) 11:56, 22 June 2017 (UTC)
- Well, if you'd like to keep 'em in, I'm fine with that but would prefer a bit more context rather than just the bare list (including some redlinks) that we had before. Jclemens (talk) 20:10, 22 June 2017 (UTC)
- "Plaques can become unstable, rupture, and additionally promote the formation of a blood clot that blocks the artery; this can occur in minutes." [...] "Exposed to the pressure associated with blood flow, plaques, especially those with a thin lining, may rupture and trigger the formation of a thrombus." Can these be harmonized so the reader understands what is going on when, and why?
- Not sure about this one. I have tried to split up the paragraphs so that one is talking in more general terms about atherosclerosis, whereas the second is talking in specific terms about clots. What do you suggest? --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
- I guess a single note about blocking of coronary arteries, with reference within it to the multiple underlying etiologies? Would that be reasonable? Jclemens (talk) 20:06, 22 June 2017 (UTC)
- "A heart with a limited blood supply with increased oxygen demands on the heart (such as in fever, tachycardia, hyperthyroidism, anaemia and hypotension)." Verb missing.
- "These changes are seen on gross pathology and cannot be predicted by the presence of absence of Q waves on an ECG." Presence OR absence, right?
- Done I wish all these points were this simple to address... --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
- Isch[a]emic cascade is linked twice in the Tissue Death section.
- Nowhere does the Tissue Death section make it clear that 'infarction' is cell death. That may seem obvious to you and I, but not to all of our readers.
- Done Good point... except I do mention this in the lead. Clarified in the section as well. --Tom (LT) (talk) 10:16, 19 June 2017 (UTC)
- It would be nice if the tissue death section talked about the various zones, c.f. this (presumably non-free, included for example, not use in the article absent licensing . Jclemens (talk) 04:17, 19 June 2017 (UTC)
- For Criteria, it's not entirely clear: You need to have biomarkers and one of the bulleted items, or all of them?
- For cardiac biomarkers, I think it would be appropriate to mention that CK-MB, etc. have been superseded, rather than that they're just discouraged. In other words, paint a bit of history into describing the current state of practice.
- Not sure here. In my mind, these are different investigations with one being preferred for MI, and the other two being discouraged for use. It is (in my mind) not the same as saying CK has been superseded by CK-MB, or Troponin T with high-sensitivity troponin, etc.--Tom (LT) (talk) 11:51, 22 June 2017 (UTC)
- For ECGs: Are we correctly differentiating between the stickers and the printout? Between wires and leads? Also, I'd consider wikilinking the first electrocardiogram in the section, even if it means taking it out of the Criteria section, since this is the most relevant section. I'd go so far as to suggest the current Criteria wikilink to ECG be retargeted to the Electrocardiogram section, rather than being a true Wikilink.
- Linked the first entry. Could you clarified what specfic parts of this paragraph you are concerned about? --Tom (LT) (talk) 11:51, 22 June 2017 (UTC)
- For DDx, consider adding costochondritis? While it's pretty trivial to differentiate for providers, it is still a common cause of non-cardiac chest pain.
- Overall, this section is much cleaner and better organized during the first go-round. I'm very happy with what I'm seeing. Jclemens (talk) 03:16, 22 June 2017 (UTC)
- "Thrombolysis is not recommended in a number of situations, particularly when associated with a high risk of bleeding, past strokes or bleeds into the brain, severe hypertension, and active bleeding" Is a high risk of bleeding the first list entry, or does it describe the rest of the list? Everything except severe hypertension appears to be bleeding-related in this sentence.
- High risk of bleeding -- on anticoagulants, coagulation disorders, thrombocytopaenia etc. Active bleeding - as stated. Past bleeds into the brain - as stated. These are different things; so one entry can't unfortunately encompass all three. --Tom (LT) (talk) 11:04, 22 June 2017 (UTC)
- I guess my concern is that a previous hemorrhagic stroke IS a high risk for bleeding. Maybe "who are currently bleeding or have high risk for problematic bleeding such as current ABC or history of XYZ" or something like that? Jclemens (talk) 20:09, 22 June 2017 (UTC)
- Done wording clarified. --Tom (LT) (talk) 12:03, 1 July 2017 (UTC)
- "Therefore, oxygen is currently only recommended if oxygen levels are found to be low or if someone is in respiratory distress." Would it hurt to increase specificity and call "someone" a patient?
- I lean towards trying not to use the word "patient" as I feel that approaches the article from a medical perspective, whereas we are lay encyclopedia. No specific guidance when I checked WP:MEDMOS. --Tom (LT) (talk) 11:04, 22 June 2017 (UTC)
- Fair enough. Sufferer? Victim? How do we denote in-text that the person in question is the one having the MI? Jclemens (talk) 20:09, 22 June 2017 (UTC)
- I feel this is implied. --Tom (LT) (talk) 12:00, 1 July 2017 (UTC)
- "After PCI, people are generally placed on dual antiplatelet therapy for at least a year (which is generally aspirin and clopidogrel)" 1) People could again be 'patients'--should it be? 2) I've seen differing durations of dual antiplatelet therapy based on drug-eluting vs. bare metal stents. Is that worth mentioning here?
- Recommendation for anticoagulation for antiplatelet therapy for PCI in AMI appears to be at least one year irrespective of stent type .--Tom (LT) (talk) 12:50, 1 July 2017 (UTC)
- In rehab, do we really need to link driving and sexual intercourse? Seems overlinkage to me. Jclemens (talk) 03:27, 22 June 2017 (UTC)
- Done agree, there is no need for these to be linked. --Tom (LT) (talk) 11:04, 22 June 2017 (UTC)
- Make the time differentiation between primary and secondary prevention a bit more explicit? I understand exactly what you're saying, but could we benefit from being a tad more pedantic/explicit here?
- I feel further exploration of the time course of primary and secondary prevention may confuse matters. Both terms are defined in the section introduction. Secondary prevention often starts within the day or two after an event. Some (eg no smoking or drinking) may be thought of as starting instantly, given that most hospitals do not allow these on site. --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
- "non drinking or drinking alcohol within the recommended limits" Not drinking any more alcohol than recommended, maybe?
- Good point... Reworded both instances. --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
- "The dietary pattern with the greatest support" Scientific support? Reduced all cause mortality?
- "Olive oil, rapeseed oil and related products are to be used instead of saturated fat." .. recommended instead of?
- Had to laugh at how prescriptive that sounded. Reworded. --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
- Overall, there's a lot here that relies on Ref 94, a UK government document which I have no reason to believe is any less bought and paid for by various food lobbies than the US FDA equivalents are. Do we have anything better? I fear not, but thought I'd ask.
- Good point. I've rejigged and copyedited the paragraph to decrease the prominence of their suggestions, but included the dietary advice as a (common, worth mentioning) example of advice that is given.--Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
- The statement in favor of statins for primary prevention should likely be stronger.
- Good point. I have increased its prominence, clarified it, and improved the source used (And also corrected the secondary prevention source). --Tom (LT) (talk) 14:02, 2 July 2017 (UTC)
- The statement in favor of HRT seems too strong for what I understand of the topic. Jclemens (talk) 04:16, 23 June 2017 (UTC)
- "... clots transmitted from the heart during PCI" Traveling?
- Not done the meanings are equivalent. --Tom (LT) (talk) 10:08, 24 June 2017 (UTC)
- The meanings may be equivalent and transmission a technically correct term, but I do suggest not needlessly inflating the reading level of the article. In common U.S. usage, nothing physical is transmitted, while knowledge, radio waves, etc. can be. Jclemens (talk) 17:38, 24 June 2017 (UTC)
- "...and [is] the largest cause of in-hospital mortality" While it looks like the 'is' from the previous clause might serve double duty, it looks less awkward to repeat it here, I think. Jclemens (talk) 04:16, 23 June 2017 (UTC)
- No issues. I know I've already asked for more current data once and you couldn't find any. Jclemens (talk) 06:32, 23 June 2017 (UTC)
Society and Culture
- Gotta have something on there about shocking asystole! I kid, that would be under depictions of cardiac arrest in popular culture... No other issues, and THAT is the second read-through. Jclemens (talk) 06:32, 23 June 2017 (UTC)
- I'm going to be picking on these based on age, which I know is not the sole determinant of whether a study should be included. Feel free to disagree, and to make sure the journals in question are top tier, but I've not seen anything obviously predatory. I get that some of these are seminal references with lasting impact beyond a 5-10 year window, but I want to make sure each pre-2007 reference is scrutinized appropriately.
- Thank you, I really appreciate this.--Tom (LT) (talk) 01:23, 11 June 2017 (UTC)
- DAVIDSONS2010B is defined twice, which looks to be just different pages of the same book.
- "Little RA, Frayn KN, Randall PE, Stoner HB, Morton C, Yates DW, Laing GS (1986). "Plasma catecholamines in the acute phase of the response to myocardial infarction"" is 30+ years old. Please replace with something current.
- "Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB (1998). "Prediction of coronary heart disease using risk factor categories"" is almost 20 years ago, please replace if possible.
- Done removed and updated the European Guidelines (now 2012). --Tom (LT) (talk) 01:23, 11 June 2017 (UTC)
- "Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group.". Lancet. 343 (8899): 311–22. Mar 1994" is 20+ years old, please replace if possible.
- "http://www.thennt.com/nnt/beta-blockers-for-heart-attack/" Needs full citation info.
- "Antman EM; Cohen M; et. al. (2000). "The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making."" also "David A. Morrow; et. al. (2000). "TIMI Risk Score for ST-Elevation Myocardial Infarction: A Convenient, Bedside, Clinical Score for Risk Assessment at Presentation: An Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial Substudy."" 15+ years old--is there something newer?
- "Becker RC, Gore JM, Lambrew C, Weaver WD, Rubison RM, French WJ, Tiefenbrunn AJ, Bowlby LJ, Rogers WJ; Gore; Lambrew; Weaver; Rubison; French; Tiefenbrunn; Bowlby; Rogers (1996). "A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction"." Anything newer?
- Done no newer secondary sources. Because therapies have changed in the last 21 years, I've opted to remove this statement. --Tom (LT) (talk) 00:01, 17 June 2017 (UTC)
- "Perry, K; Petrie, KJ; Ellis, CJ; Horne, R; Moss-Morris, R (July 2001). "Symptom expectations and delay in acute myocardial infarction patients."" Anything newer?
- Not done nothing newer I can locate. --Tom (LT) (talk) 00:01, 17 June 2017 (UTC)
- Overall, I am really happy with the prevalence of 2010-present dated citations in the ref list. Jclemens (talk) 22:25, 10 June 2017 (UTC)
@Doc James, Jclemens, do you know any editors who might be willing to do a review of the sources used on this article? I would like a separate reviewer to just focus on the sources used here... there seems to be quite a lot which are either primary sources or very old, and if they are identified I can get to work updating or removing them. --Tom (LT) (talk) 01:29, 17 April 2017 (UTC)
- Anything older than 2010 should likely be updated. Was looking at getting a tool that would tag all articles that are reviews as reviews. Doc James (talk · contribs · email) 01:33, 17 April 2017 (UTC)
- I don't personally know any cardiologists inclined to spend time on Wikipedia, no, but I expect either of us could find more current sources. I know I have all the usual suspects of medical databases at my disposal through my non-Wikipedia affiliations. Jclemens (talk) 01:39, 17 April 2017 (UTC)
Taking over review
Hi Arubaska (Winged Blades of Godric), I note that you are in school, and (as far as I can see) haven't made any major edits to this article. I expect that you are very busy and may not have the full time to address all the concerns raised here. If you and Jclemens are happy, given the importance of this article, I am happy to take on a role as a conominator to help address reviewer concerns. I'll get to responding above and, if you feel like you would like to take back the baton, please let me know :). Cheers --Tom (LT) (talk) 05:29, 8 April 2017 (UTC)
- @Jclemens and LT910001:--Sorry, the last time I was pinged related to this was long back when JC started reviewing the page.For the next two or three days there wasn't any progress from him--(due to certain concerns by him) and I lost my interest.Gotcha watchlisted it!And JC even a simple ping would have attracted my attention!I am receiving the next ping today and seeing all the progress, all of a sudden!Anyway I will be improving the article w.r.t to the concerns raised by JC and if you(Tom) want to help the article in it's way to GA status, I am generously and gladly accepting it!Cheers!Winged Blades Godric 12:35, 8 April 2017 (UTC)
- Sounds good. I'll help out as I can. --Tom (LT) (talk) 23:41, 8 April 2017 (UTC)
- I hadn't had any feedback from anyone on anything here, so I admit it has been less of a priority because of that. I am willing to continue reviewing, but honestly will have limited time for the next few weeks due to non-Wikipedia concerns, so having someone else take over makes sense to me. Jclemens (talk) 16:11, 9 April 2017 (UTC)
- @LT910001: Ok, I've none through more of the article, and will continue to try to slog through it--as a break from the things I should be doing, actually... Hopefully, once I get to the bottom we can start at the top again... Jclemens (talk) 06:39, 15 April 2017 (UTC)
So here I changed Coronary artery bypass surgery to coronary artery bypass surgery as the word is not at the beginning of a sentence it does not need a capital letter.
This text was trimmed "An ECG, which displays the electrical currents associated with contraction of heart muscle, produces a regular form." as it is without a reference and does not really make sense.
Why was myocardial infarction bolded in the caption? Where does the MOS support this? Doc James (talk · contribs · email) 09:02, 10 April 2017 (UTC)
How are we doing? Are we ready for any part of a re-review? Jclemens (talk) 01:11, 13 May 2017 (UTC)
- Sorry, I have been unusually busy this week. I am slowly making my way through this article, adding content, fixing, simplifying and adding / replacing sources. When that's done, I'll run through and address what is remaining. You can use my little lists of 'addressed' as as a guide to what I'm working on - so far only signs & symptoms is ready for a re-review. --Tom (LT) (talk) 11:55, 13 May 2017 (UTC)
- @Jclemens responded to second trache. Thanks for your patience. I have left a message on your talk page. Looking forward to your response, --Tom (LT) (talk) 14:17, 2 July 2017 (UTC)
This process appears to be ongoing. Why did Legobot change the status of the article to GA on 2 July, and should we remove that? Jytdog (talk) 17:43, 4 July 2017 (UTC)
- I passed it. It's still being improved, but has met all the GA criteria for a while now. Apologies for not making this clearer; hopefully this note clears things up better than the annotation to the GATable did. Jclemens (talk) 17:51, 4 July 2017 (UTC)
- Thanks for clarifying. Jytdog (talk) 18:08, 4 July 2017 (UTC)
The ECG deserves to be explained in the lead, so that the average reader has some idea of what it is talking about. I don't think this text is perfect, but we should make some attempt to explain what the ECG is.
- Attempted addition: "An ECG, which displays the electrical currents associated with contraction of heart muscle, produces a regular form. An elevation in the ST section may indicate a type of MI."
- Revert by Doc James (described as "adjust") back to "An ECG may confirm an ST elevation MI if ST elevation is present"
Can I point out the sentence that has been reinstated has three acronyms (ECG, ST, MI) and is tautologous ? Suggest other editors, including Jclemens may need to weigh in here. --Tom (LT) (talk) 09:03, 10 April 2017 (UTC)
- What does "produces a regular form" mean? Where does this definition come from?
- We sell out what ECG stands for in the sentence immediately before that one. Have adjusted the linking of that sentence to make the terms more clear.
- MI is spelled out in the first sentence of the article. Doc James (talk · contribs · email) 09:07, 10 April 2017 (UTC)
- Our aim should be to improve the readability of articles, so that the text written can be read and understood by readers. If possible we should reduce our use of acronyms in this light. Where do we spell out what an ECG? We state it is a test in the sentence before - that is not "spelling out". As stated above this is an attempted improvement. Would you say the sentence is perfect as is? If not, perhaps we can discuss ways to improve it. --Tom (LT) (talk) 21:03, 10 April 2017 (UTC)
- Sure we can add a definition of ECG. How about a "a recording of the heart’s electrical activity" with this as a ref
- Thus we get thisDoc James (talk · contribs · email) 22:44, 10 April 2017 (UTC)
- I'd call that a definite improvement over what was there before, but we still don't explain what the ST segment is, let alone why ST elevation is bad, just wikilinks it. I think anything contained in the lead of an article should be self-contained, and question whether the best way forward is to explain everything, or rather to abbreviate further in the lead and leave the detailed, acronym-filled explanation to the body text. Oh, and thanks for the ping. Jclemens (talk) 05:02, 11 April 2017 (UTC)
- How about An ECG, which is a recording of the heart's electrical activity, may confirm an ST elevation MI (STEMI) if a change known as ST elevation is present. ?
- Doc James (talk · contribs · email) 17:22, 11 April 2017 (UTC)
(shrug) I'd be tempted to add something along the lines of "... ST elevation, an abnormality of the final phase of the heart's per-beat electrical cycle which can indicate ischemia or infarction, is present." But I know good and well that's waaaaay too detailed for the lead. I'm just not one to introduce a term without providing at least a minimal amount of contextualization, even if it is wikilinked. Jclemens (talk) 04:13, 12 April 2017 (UTC)
- Hum. We could leave out "if a change known as ST elevation is present" altogether. Doc James (talk · contribs · email) 05:31, 12 April 2017 (UTC)
- This seems like the best solution. --Tom (LT) (talk) 01:05, 17 April 2017 (UTC)
Am thinking about a "classification" section at the top. I think it would be very useful for readers to have a clear definition of what an MI is at the top, that it is an ACS, and that there are ST and non-ST variants. I think this would add to (rather than only duplicate) the lead, and that it would help clarify the peace-meal presentation of this in the article below. Thoughts? --Tom (LT) (talk) 01:02, 17 April 2017 (UTC)
- Haved moved an existing sentence to this section. If there's consensus to keep, I will expand it further. --Tom (LT) (talk) 02:02, 17 April 2017 (UTC)
- @Doc James, Jclemens any thoughts here? --Tom (LT) (talk) 21:10, 18 April 2017 (UTC)
- Sure happy with a section on classification going first. Doc James (talk · contribs · email) 21:26, 18 April 2017 (UTC)
- Agreed--and then let's make sure it's inclusive, at least mentioning the appropriate zebras. Jclemens (talk) 00:42, 19 April 2017 (UTC)
- @Ozzie10aaaa you have removed the initial "classification" section with this summary " MEDMOS/ this sectionis REPEATED in the 'Diagnosis' section, thank you". I am hoping to introduce some basic concepts to the reader by including this section, rather than leaving them somewhat confused by our peacemeal mentions until they hit the diagnosis section. This section does not just repeat the 'diagnosis' section as it covers the relationship between ACS and AMI and some basic concepts to help orientate the reader.
- As you can see there are some other editors who support this too and I am in the process of expanding this as stated above ("I will expand it further"). Also not too sure what you mean by "MEDMOS" -- perhaps have a look at WP:MEDORDER? Classification is the first section. So to summarise: please read the talk page, the MEDMOS, and the article before removing a chunk of text in an active GA in the future.--Tom (LT) (talk) 20:36, 25 April 2017 (UTC)
- so...per Wikipedia:Manual of Style/Medicine-related articles#Diseases or disorders or syndromes, I removed the section as it seemed repetitive, as such a sub-section usually goes under diagnosis.Now then, if your "creating" something different in the body of the article, well that's different(I've reverted myself, though I believe it should follow MEDMOS)--Ozzie10aaaa (talk) 21:02, 25 April 2017 (UTC)
To split up content into logical groups I've added the subheadings 'atherosclerosis', 'infarction' and 'complications'. This (I hope) will help separate out the discussion. It will also help split up coverage so that non atherosclerosis-related MI can be covered in a less confusing way. Thoughts? --Tom (LT) (talk) 01:11, 17 April 2017 (UTC)
- Sounds good. Doc James (talk · contribs · email) 21:27, 18 April 2017 (UTC)
Typically is part of the section on diagnosis not signs and symptoms per MEDMOS. Doc James (talk · contribs · email) 03:40, 17 April 2017 (UTC)
- Thanks, noted. --Tom (LT) (talk) 20:36, 25 April 2017 (UTC)
Diagram of Areas where pain is experienced
In this diagram, more area towards right side is colored which should be left instead as I understand. The diagram can be changed accordingly. -- Abhijeet Safai (talk) 06:41, 2 May 2017 (UTC)
- But I am reading following sentence too which says that "The pain most suggestive of an acute MI, with the highest likelihood ratio, is pain radiating to the right arm and shoulder." Hence if the diagram is correct, it need not be changed. Thank you. -- Abhijeet Safai (talk) 06:44, 2 May 2017 (UTC)
- Yes rt sided chest pain is more specific while left side from what I understand is more common Doc James (talk · contribs · email) 17:22, 2 May 2017 (UTC)
- Thanks a lot for sharing that. -- Abhijeet Safai (talk) 10:23, 3 May 2017 (UTC)
Merging 'prevention' and 'secondary prevention'
I am inclined to merge 'prevention' and 'secondary prevention' and put the combined section after treatment, given that both refer really to a common underlying process of atherosclerosis and coronary artery disease. This is a bit of a grey area in WP:MEDMOS... I think because there is a fair amount of overlap between these two sections, it is logical to group them, and if they are to be grouped, this would be best done after the treatment section. Secondary prevention is best, I think, described after ACS, once medications and surgical procedures have been introduced.
- @Doc James, Jclemens, thoughts? --Tom (LT) (talk) 09:33, 22 May 2017 (UTC)
- I agree with the spacing and grouping in principle. There are multiple good ways to address the grouping, so I have no strong preferences. Jclemens (talk) 17:46, 22 May 2017 (UTC)
- For gout we have place primary prevention under "prevention" and secondary prevention under treatment. I have no strong preference either. Doc James (talk · contribs · email) 21:56, 22 May 2017 (UTC)
doi:10.1056/NEJMra1606915 - review. JFW | T@lk 08:39, 25 May 2017 (UTC)
- @Jfdwolff unbelievable, two detailed reviews within months. It was clearly time to summarise where we're at. Thanks for plopping this down, will trawl through this shortly. --Tom (LT) (talk) 21:31, 27 May 2017 (UTC)
Treatment does not begin with "risk factor stratification using a scoring system such as the thrombosis in myocardial ischaemia (TIMI) or GRACE scores".
Treatment begins with giving ASA (and maybe clopidogrel or ticagralor), give O2 if sats are low, starting an iv, giving nitro if the BP is okay, reading the ECG and giving TNK if their are no contraindications / doing PCI if the ECG shows a STEMI. Doc James (talk · contribs · email) 17:55, 27 May 2017 (UTC)
- Disagree, this is a simplistic view of emergency management. As you know treatment happens in parallel rather than sequential fashion in the ED, and begins with a practitioner's assessment of stability and urgency of treatment required for each condition, whether they realise it or not. Risk factor stratification is important and mentioned in multiple sources. I will replace this sentence with "may include" risk factor stratification to assuage your concerns.--Tom (LT) (talk) 21:27, 27 May 2017 (UTC)
- Usually one starts initial treatments such as ASA and addresses ABCs before risk stratifying. Risk stratification is more used when determining discharge and workup. Would put it under diagnosis or prognosis not treatment. As risk stratification is NOT treatment. By the way TIMI is dealt with here Doc James (talk · contribs · email) 00:11, 28 May 2017 (UTC)
- This review  provides a good overview. Doc James (talk · contribs · email) 05:54, 28 May 2017 (UTC)
- @Doc James even the abstract (I can't access full text from home) states "Fibrinolysis is not recommended in patients with non-ST elevation acute coronary syndrome; therefore, these patients should be treated with medical management if they are at low risk of coronary events or if percutaneous coronary intervention cannot be performed". Further:
- "Early risk stratification of patients with myocardial infarction allows for prognostication and triage via initiation of one of several vital treatment pathways" (Reed et al., 2017)
- "Risk stratification is important because it guides the use of more complex pharmacological and interventional treatment" (Davidsons, 2010)
- I would really like to include some reference to risk stratification in the management section, and I think there are sufficient verifiable references to support their use in management. Is there a way you would be happy for me to include this information? --Tom (LT) (talk) 11:25, 6 June 2017 (UTC)
- Fibrinolysis is definitely contraindicated in NSTEMIs. It is only given in STEMIs. That decision is made based on the ECG rather than risk stratification. The TIMI or GRACE scoring system is not really explicitly used outside of trials. Management is partly based on the risk the person is having a myocardial infarction. I would be okay with that, just do not think the stratification belongs. Doc James (talk · contribs · email) 13:20, 6 June 2017 (UTC)
Concerns of negative effects in AMI Doc James (talk · contribs · email) 18:02, 27 May 2017 (UTC)
- Lots of refs cover this. Have added a bit. Doc James (talk · contribs · email) 18:09, 27 May 2017 (UTC)
- Thanks for your addition. It has been difficult to strike a balance comprehensiveness between deep discussion of treatment vs. maintaining readability and avoiding prescriptive guides. --Tom (LT) (talk) 21:27, 27 May 2017 (UTC)
Symptom not noted in this article:
numbness in the hands and neck discomfort
But I don't know how to insert it into the "Other symptoms" part...
The patients experiencing MI reported significantly more nausea (46% vs. 32%), vomiting (19% vs. 2%), indigestion (42% vs. 16%), and fainting (9% vs. 2%). The patients experiencing UA reported significantly more chest discomfort (97% vs. 87%), lightheadedness (52% vs. 39%), numbness in the hands (43% vs. 28%), and neck discomfort (31% vs. 13%). Patients with MI rated the peak intensity of the chest discomfort higher than patients with UA (mean 8.4 vs. mean 7.7).
- ^ DeVon, HA; Zerwic, JJ (NaN). "Differences in the symptoms associated with unstable angina and myocardial infarction". Progress in cardiovascular nursing. 19 (1): 6–11. PMID 15017150.