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Myocardial necrosis — Clinical Guidelines

Overview

Myocardial necrosis refers to the death of myocardial tissue, often resulting from ischemic insult or excessive catecholamine stimulation, leading to contraction band necrosis or other forms of myocardial damage observable histologically and biochemically. 1 2 4 6 15 16 20 24 39 44

Diagnosis

Clinical Presentation: Sudden death, respiratory distress, arrhythmias, and ECG changes indicative of myocardial damage. 1 6 15 24

Biochemical Markers: Elevated serum creatine kinase (CK), particularly MB isoenzyme, and lactate dehydrogenase (LDH). 18 21 29

Imaging and Histology: Echocardiography, MRI, or post-mortem histology showing contraction band necrosis, myocardial necrosis, and calcification patterns. 2 15 24 31 32

Electrocardiogram (ECG): ST-segment changes, T-wave inversions, and other ischemic patterns. 15 24 39

Management

Supportive Care: Oxygen therapy, hemodynamic stabilization, and management of arrhythmias. 1 6 24

Drug Therapy:

- Calcium Channel Blockers: Diltiazem may offer protection against catecholamine-induced necrosis. 10 - Antioxidants: Vitamin E and selenium supplementation shown to mitigate necrosis in certain models. 2 12 21 - Anti-lipolytic Agents: Agents like 5-fluoro-nicotinic acid may reduce necrosis by inhibiting lipolysis. 35 - Cardioprotective Agents: Prostacyclin and its derivatives have demonstrated protective effects. 11

Lifestyle and Preventive Measures: Address underlying conditions like hyperthyroidism or excessive catecholamine exposure. 6 15 39

Special Populations

Pregnancy: Terbutaline use in pregnant women may pose risks of fetal myocardial necrosis; monitor closely. 6

Pediatrics: Neonatal myocardial necrosis in goats linked to nutritional deficiencies; ensure adequate selenium and vitamin E. 1

Elderly: Increased susceptibility to catecholamine-induced necrosis; cautious use of sympathomimetics. 15 20

Comorbidities: Conditions like hyperthyroidism may exacerbate myocardial necrosis risk; manage underlying disorders aggressively. 6 39

Key Recommendations

Monitor and Manage Biochemical Markers: Regularly assess serum CK and LDH levels to detect myocardial necrosis early. (Evidence: Moderate 18 21)

Consider Calcium Channel Blockade: Use calcium channel blockers like diltiazem prophylactically in high-risk patients to prevent catecholamine-induced necrosis. (Evidence: Moderate 10)

Supplement Antioxidants: Administer vitamin E and selenium to mitigate oxidative stress and necrosis, particularly in deficient populations. (Evidence: Moderate 2 12 21)

Avoid Excessive Catecholamine Exposure: Limit use of beta-adrenergic agonists and monitor for signs of myocardial damage in susceptible individuals. (Evidence: Expert opinion 6 15 39)

References

1 Amini K, Simko E, Davies JL. Sudden death associated with myocardial contraction band necrosis in Boer goat kids. Veterinary pathology 2011. link 2 Banerjee SK, Sood S, Dinda AK, Das TK, Maulik SK. Chronic oral administration of raw garlic protects against isoproterenol-induced myocardial necrosis in rat. Comparative biochemistry and physiology. Toxicology & pharmacology : CBP 2003. link 3 Mohan P, Bloom S. Lipolysis is an important determinant of isoproterenol-induced myocardial necrosis. Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology 1999. link00017-4) 4 Ramesh CV, Malarvannan P, Jayakumar R, Jayasundar S, Puvanakrishnan R. Effect of a novel tetrapeptide derivative in a model of isoproterenol induced myocardial necrosis. Molecular and cellular biochemistry 1998. link 5 Murry CE, Kay MA, Bartosek T, Hauschka SD, Schwartz SM. Muscle differentiation during repair of myocardial necrosis in rats via gene transfer with MyoD. The Journal of clinical investigation 1996. link 6 Fletcher SE, Fyfe DA, Case CL, Wiles HB, Upshur JK, Newman RB. Myocardial necrosis in a newborn after long-term maternal subcutaneous terbutaline infusion for suppression of preterm labor. American journal of obstetrics and gynecology 1991. link90377-4) 7 Wrzołkowa T, Rudzińska-Kisiel T, Kłosowska B. Calcium content of serum and myocardium in vitamin D-induced cardionecrosis. Bone and mineral 1991. link90078-e) 8 Rockhold RW, Acuff CG, Clower BR. Excitotoxin-induced myocardial necrosis. European journal of pharmacology 1989. link90379-8) 9 Kaul S, Kapoor NK. Reversal of changes of lipid peroxide, xanthine oxidase and superoxide dismutase by cardio-protective drugs in isoproterenol induced myocardial necrosis in rats. Indian journal of experimental biology 1989. link 10 Todd GL, Eliot RS. Cardioprotective effects of diltiazem when given before, during or delayed after infusion of norepinephrine in anesthetized dogs. The American journal of cardiology 1988. link90028-8) 11 Körmöczy PS, Vértesi C, Mikus E, Tardos L, Kovács G. Cardioprotective effect of prostacyclin and 7-oxo-PGI2 in rats against chronic isoproterenol damage. Prostaglandins 1987. link90274-7) 12 Griffith JW, Lang CM. Vitamin E and selenium status of guinea pigs with myocardial necrosis. Laboratory animal science 1987. link 13 Nakamura K. Focal myocardial necrosis with calcification in two young chickens. Journal of comparative pathology 1986. link90066-6) 14 Joseph X, Balazs T. Enhanced myocardial necrosis induced in rats by the combined administration of hydralazine and prenalterol. The Journal of pharmacy and pharmacology 1986. link 15 Todd GL, Baroldi G, Pieper GM, Clayton FC, Eliot RS. Experimental catecholamine-induced myocardial necrosis. I. Morphology, quantification and regional distribution of acute contraction band lesions. Journal of molecular and cellular cardiology 1985. link80132-2) 16 Todd GL, Baroldi G, Pieper GM, Clayton FC, Eliot RS. Experimental catecholamine-induced myocardial necrosis. II. Temporal development of isoproterenol-induced contraction band lesions correlated with ECG, hemodynamic and biochemical changes. Journal of molecular and cellular cardiology 1985. link80064-x) 17 Joseph X, Jordan AW, Balazs T. Ventricular fibrillation threshold and myocardial cyclic AMP production in rats sensitive or resistant to isoproterenol. Research communications in chemical pathology and pharmacology 1984. link 18 Thorén-Tolling K, Jönsson L. Creatine kinase isoenzymes in serum of pigs having myocardial and skeletal muscle necrosis. Canadian journal of comparative medicine : Revue canadienne de medecine comparee 1983. link 19 Mallov S. Role of calcium and free fatty acids in epinephrine-induced myocardial necrosis. Toxicology and applied pharmacology 1983. link90344-7) 20 Joseph X, Bloom S, Pledger G, Balazs T. Determinants of resistance to the cardiotoxicity of isoproterenol in rats. Toxicology and applied pharmacology 1983. link90300-9) 21 Higuchi Y. Changes of lipid peroxides and alpha-tocopherol in rats with experimentally induced myocardial necrosis. Acta medica Okayama 1982. link 22 Carr EA, Carroll M, Montes M. Effect of vitamin D3, other drugs altering serum calcium or phosphorus concentrations, and desoxycorticosterone on the distribution of Tc-99m pyrophosphate between target and nontarget tissues. Journal of nuclear medicine : official publication, Society of Nuclear Medicine 1981. link 23 Kremer D, Lindop G, Brown WC, Morton JJ, Robertson JI. Angiotensin-induced myocardial necrosis and renal failure in the rabbit: distribution of lesions and severity in relation to plasma angiotensin II concentration and arterial pressure. Cardiovascular research 1981. link 24 Warner RA, Hill NE, Spear R, Smulyan H, Mookherjee S, Fruehan CT et al.. Vectorcardiographic manifestations of experimental right ventricular necrosis. Journal of electrocardiology 1981. link80053-2) 25 Bradley R, Markson LM, Bailey J. Sudden death and myocardial necrosis in cattle. The Journal of pathology 1981. link 26 Hashimoto H, Ogawa K. Effects of sulfinpyrazone, aspirin and propranolol on the isoproterenol-induced myocardial necrosis. Japanese heart journal 1981. link 27 Saxena KK, Gupta B, Kulshrestha VK, Srivastava RK, Prasad DN. Effect of garlic pretreatment on isoprenaline-induced myocardial necrosis in albino rats. Indian journal of physiology and pharmacology 1980. link 28 Ryan CF, Athari-Nejad A, Holcslaw TL. Quantitation of isoproterenol-induced myocardial necrosis with 3H-tetracycline. Research communications in chemical pathology and pharmacology 1979. link 29 Steen E, Woolf N, Powell T, Rowles PM. The effect of a calcium antagonist (D600) on isoprenaline-induced myocardial necrosis in the rat. British journal of experimental pathology 1979. link 30 Severson JA, Fell RD, Griffith DR. Adrenocortical function in response to myocardial necrosis in exercise-trained rats. Journal of applied physiology: respiratory, environmental and exercise physiology 1978. link 31 Mathew BM, Salahuddin, Ahmad M, Kumar S, Seth TD, Mahdi SQ et al.. A temporal profile of changes in myocardial copper after isoproterenol induced cardiac necrosis. Japanese circulation journal 1978. link 32 Mathew BM, Kumar S, Ahmad MS, Seth TD, Hasan MZ, Jamil SA. A temporal profile of myocardial zinc changes after isoproterenol induced cardiac necrosis. Japanese circulation journal 1978. link 33 Hanson RN, Davis MA, Holman BL. Radiopharmaceuticals for acutely damaged myocardium. II: Synthesis and evaluation of [203Hg] hydroxymercurifluoresceins. Journal of nuclear medicine : official publication, Society of Nuclear Medicine 1977. link 34 Grossman ZD, Foster AB, McAfee JG, Richardson R, Subramanian G, Markarian B et al.. Myocardial uptake (rabbit) of six 99mTc-tagged pharmaceuticals and 85Sr after vasopressin-induced necrosis. Journal of nuclear medicine : official publication, Society of Nuclear Medicine 1977. link 35 Woolf N, Steen E, Rosen D, Trickey R, Long P, Miller AL et al.. The effect of anti-lipolytic agents on isoprenaline-induced myocardial necrosis in the rat. British journal of experimental pathology 1977. link 36 Ahmad M, Tajuddin M, Tariq M. Effect of physical fitness on myocardial damage and circulation after myocardial necrosis. Recent advances in studies on cardiac structure and metabolism 1976. link 37 Fleming JS, Buchanan JO, Buyniski JP. The effect of a potent inhibitor of platelet aggregation, BL-3459, on adrenaline-induced myocardial necrosis in beagle dogs. European journal of pharmacology 1976. link90353-8) 38 Sarkar K, Levine DZ. Persistence of a basal lamina-like structure following DOCA-induced myofibrillar degeneration in rats. Cardiology 1976. link 39 Fleckenstein A, Kanke J, Döring HJ, Leder O. Key role of Ca in the production of noncoronarogenic myocardial necroses. Recent advances in studies on cardiac structure and metabolism 1975. link 40 Bhagat B, Sullivan JM, Dhalla NS. Alterations in norepinephrine pattern in the damaged myocardium in the rat. Recent advances in studies on cardiac structure and metabolism 1975. link 41 Gudbjarnason S, Oskarsdóttir G. Changes in fatty acid composition of cardiac lipids accompanying myocardial necrosis. Recent advances in studies on cardiac structure and metabolism 1975. link 42 Büsing CM, Kreinsen U, Bühler F, Bleyl U. Light and electron microscopic examinations of experimentally produced heart muscle necroses following normobaric hyperoxia. Virchows Archiv. A, Pathological anatomy and histology 1975. link 43 Kjekshus JK. Role of free fatty acids in catecholamine-induced cardiac necrosis. Recent advances in studies on cardiac structure and metabolism 1975. link 44 Bloom S, Davis DL. Calcium as mediator of isoproterenol-induced myocardial necrosis. The American journal of pathology 1972. link 45 Moudgil LR. Possible protective action of antialdosterone compounds in myocardial necrosis in rats. British journal of pharmacology 1969. link

Myocardial necrosis