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Infarction

Infarction is a pathological process characterized by the localized necrosis of tissue due to prolonged ischemia, resulting from an abrupt reduction or cessation of blood flow, most often caused by arterial occlusion.^[1] This tissue death, known as an infarct, arises when the affected area is deprived of oxygen and nutrients, leading to irreversible cellular damage if the ischemia persists beyond a critical threshold, typically minutes to hours depending on the organ.^[2] The primary causes of infarction include thrombosis (formation of a blood clot within a vessel), embolism (a clot or other material traveling from elsewhere in the body to occlude a vessel), and vascular torsion or extrinsic compression, though less common etiologies involve vasospasm, atherosclerosis progression, or systemic hypotension such as in shock.^[2] Infarcts are broadly classified into white (anemic) infarcts, which appear pale due to minimal hemorrhage and occur in solid organs with limited collateral circulation like the heart, spleen, and kidneys, and red (hemorrhagic) infarcts, which are congested with extravasated blood and typically develop in tissues with dual blood supplies or loose structure, such as the lungs, or following reperfusion of a white infarct.^[2] The morphological distinction reflects the organ's vascular anatomy and the presence of reperfusion, with white infarcts often wedge-shaped and based on the occluded vessel.^[2] Infarction can affect virtually any organ but most frequently involves the heart (myocardial infarction), brain (cerebral infarction, a major cause of stroke), intestines (leading to bowel ischemia), kidneys, spleen, and lungs (via pulmonary embolism).^[2] The clinical consequences vary by site and extent, ranging from acute life-threatening events like cardiac arrest or massive stroke to chronic complications such as organ dysfunction or rupture, underscoring the importance of rapid diagnosis and intervention to restore perfusion.^[2]

Fundamentals

Definition

Infarction refers to the death of tissue, known as necrosis, caused by prolonged ischemia resulting from an obstruction in the blood supply to the affected area. This process occurs when blood flow is sufficiently interrupted to deprive cells of essential oxygen and nutrients, leading to irreversible cellular damage. Unlike transient reductions in perfusion, infarction represents a critical threshold where tissue viability is lost, often manifesting as a localized area of dead tissue called an infarct.^[3] Infarcts are broadly classified into two basic types based on their gross appearance and underlying vascular pathology: pale (anemic) infarcts and red (hemorrhagic) infarcts. Pale infarcts typically arise from arterial occlusion in solid organs with end-arterial blood supplies, such as the heart, kidney, or spleen, resulting in a white or pale wedge-shaped area due to the absence of significant bleeding. In contrast, red infarcts occur in settings of venous occlusion or in tissues with loose structure and collateral circulation, like the lungs, intestines, or testes, where reperfusion allows blood to extravasate into the necrotic zone, producing a red or hemorrhagic appearance.^[4] A key distinction exists between ischemia and infarction: ischemia denotes a reversible state of reduced blood flow and oxygen deprivation that can potentially resolve without permanent harm if addressed promptly, whereas infarction marks the progression to irreversible necrosis following sustained ischemia. This differentiation is crucial in clinical contexts, as early intervention during ischemia may prevent the onset of infarction.^[5] The term "infarction" originates from the Latin verb infarcire, meaning "to stuff" or "to cram," reflecting the historical analogy to a blocked or stuffed vessel; it entered medical usage in the late 17th century as a descriptor for tissue congestion and death due to vascular obstruction.^[6]

Pathophysiology

Infarction initiates with ischemia, characterized by reduced blood flow that deprives tissues of oxygen and nutrients, leading to hypoxia. The earliest biochemical alteration is the depletion of adenosine triphosphate (ATP), as hypoxic conditions impair mitochondrial oxidative phosphorylation and aerobic metabolism.^[7] This ATP shortage disrupts energy-dependent processes, notably the failure of the Na+/K+ ATPase pump, which normally maintains ionic gradients across the cell membrane.^[7] Consequently, sodium ions accumulate intracellularly, causing osmotic water influx and cellular swelling (oncosis), while mitochondrial dysfunction exacerbates the energy crisis through impaired electron transport and reactive oxygen species (ROS) production.^[7] As ischemia persists beyond a critical threshold—which varies by tissue, from minutes in the brain to 20-40 minutes or more in the heart and other organs with lower metabolic demands—the injury becomes irreversible, progressing to cell membrane rupture and enzymatic digestion of cellular components.^[7] The duration of ischemia tolerated before irreversible damage varies depending on the organ's metabolic rate, collateral blood supply, and environmental factors like temperature. The hallmark pathological change is coagulation necrosis, where protein denaturation preserves the basic tissue architecture but results in anucleate, eosinophilic cells.^[7] This is followed by an acute inflammatory response, initiated by damage-associated molecular patterns (DAMPs) such as high-mobility group box 1 (HMGB1) and ATP, which activate the NLRP3 inflammasome and cytokine release (e.g., IL-1β).^[7] Neutrophils arrive within hours, followed by macrophages that phagocytose debris, demarcate the infarct zone, and promote granulation tissue formation over days to weeks.^[7] Restoration of blood flow through reperfusion, although essential for salvage, paradoxically amplifies damage via ischemia-reperfusion injury.^[8] This involves a burst of ROS from sources like xanthine oxidase and activated neutrophils, causing lipid peroxidation, protein oxidation, and DNA damage.^[8] Calcium overload further contributes by activating proteases (e.g., calpains) and phospholipases, leading to membrane instability and mitochondrial permeability transition.^[8] At the molecular level, key events include caspase activation (e.g., caspase-3 and -9) in the intrinsic apoptosis pathway, triggered by cytochrome c release from damaged mitochondria, resulting in programmed cell death alongside necrosis.^[9] Cytokines such as TNF-α and IL-6 amplify the inflammatory cascade, recruiting leukocytes and perpetuating tissue injury.^[10] Tissue-specific variations in infarct morphology depend on vascular anatomy and blood flow dynamics. Organs with end-arterial supply, such as the heart and kidney, typically form pale (anemic) infarcts due to minimal collateral circulation, resulting in bland ischemia without significant hemorrhage.^[4] In contrast, tissues with dual or collateral blood supplies, like the lungs, are predisposed to hemorrhagic (red) infarcts, where reperfusion allows blood extravasation into the necrotic zone.^[4]

Etiology

Causes

Infarction typically results from vascular obstruction that deprives tissue of oxygen and nutrients, with arterial causes being the most common. Arterial thrombosis occurs when a blood clot forms in situ, often due to the rupture or erosion of an atherosclerotic plaque, which exposes thrombogenic material and activates platelets and the coagulation cascade, leading to occlusion.^[11] Embolism, another key arterial mechanism, involves dislodged material—such as thrombi from the heart (e.g., in atrial fibrillation or ventricular aneurysms) or atherosclerotic debris from proximal arteries—traveling downstream to block vessels, commonly causing ischemic events like stroke or limb ischemia.^[12] Venous infarction arises from outflow obstruction, primarily through venous thrombosis (often termed thrombophlebitis when associated with inflammation), which impedes drainage and leads to congestion, hemorrhage, and tissue necrosis, as seen in cerebral venous sinus thrombosis or mesenteric vein occlusion.^[11] Compression of veins by external factors, such as tumors or abscesses, can also precipitate this by mechanically restricting flow. Additional mechanisms include vasospasm, where transient arterial constriction—triggered by factors like subarachnoid hemorrhage or drug use—reduces blood flow and may promote secondary thrombosis, resulting in infarction.^[13] Extrinsic compression by masses, such as tumors encroaching on vessels, can cause gradual or acute occlusion, as reported in cases of intrathoracic malignancies compressing coronary arteries.^[14] Hypotension in watershed zones, the border areas between major arterial territories, heightens vulnerability to infarction during episodes of systemic hypoperfusion, such as in cardiogenic shock.^[15] Non-occlusive causes involve global hypoperfusion without direct vessel blockage, often in shock states where reduced cardiac output fails to meet tissue demands, leading to multifocal infarcts in vulnerable regions like the kidneys or brain.^[16] A representative example is myocardial infarction from atherosclerotic plaque rupture in coronary arteries, where thrombosis acutely obstructs flow and causes cardiac muscle necrosis. Risk factors like hypertension or smoking can amplify these mechanisms but are detailed separately.^[11]

Risk Factors

Risk factors for infarction can be broadly categorized into modifiable and non-modifiable types, with many overlapping across different organs such as the heart and brain. Modifiable risk factors include behaviors and conditions that can be addressed through lifestyle changes or medical intervention, while non-modifiable factors are inherent traits that cannot be altered. These factors contribute to the development of conditions leading to ischemic events, such as atherosclerosis or thromboembolism, increasing susceptibility to tissue infarction.^[17]^[18] Among modifiable risk factors, smoking is a major contributor due to its role in endothelial damage and promotion of thrombus formation, significantly elevating the risk of myocardial and cerebral infarction. Hypertension imposes chronic vascular stress, accelerating arterial wall damage and plaque buildup, which is a primary driver for both cardiac and ischemic stroke events. Hyperlipidemia fosters atherosclerotic plaque formation by elevating low-density lipoprotein levels, thereby narrowing vessels and predisposing to occlusion. Diabetes accelerates atherosclerosis through hyperglycemia-induced vascular inflammation and endothelial dysfunction, heightening infarction risk in multiple tissues. Obesity and a sedentary lifestyle compound these effects by promoting insulin resistance, inflammation, and dyslipidemia, with studies showing a dose-dependent increase in cardiovascular infarction incidence among affected individuals.^[19]^[20]^[21] Non-modifiable risk factors include advancing age, with infarction risk rising sharply after 45 years in men and 55 years in women due to cumulative vascular wear and hormonal changes post-menopause. Male sex confers a higher baseline risk for infarction events compared to premenopausal women, though this disparity narrows with age. Family history of cardiovascular disease indicates genetic predisposition, often linked to inherited patterns of lipid metabolism or coagulation abnormalities. Specific genetic variants, such as factor V Leiden mutation, increase thrombotic tendencies and are associated with elevated risk of arterial infarction, particularly myocardial infarction in young women and ischemic stroke in younger adults.^[22]^[23]^[24] Certain underlying diseases further specify infarction risk in targeted vascular beds; for instance, atrial fibrillation predisposes to embolic cerebral infarction by facilitating thrombus formation in the heart that can dislodge to brain arteries. Sickle cell disease heightens the likelihood of microvascular infarcts through vaso-occlusive crises that impair cerebral and other tissue perfusion.^[25]^[26] Epidemiologically, cardiovascular infarcts, including myocardial and ischemic stroke, represent a substantial global burden, with cardiovascular diseases as the leading cause of death worldwide, accounting for approximately 19.2 million fatalities in 2023 according to recent analyses. This underscores the impact of these risk factors, as ischemic heart disease and stroke alone contribute over half of cardiovascular mortality.^[27]^[28]

Classification

By Histopathology

Infarction typically manifests histopathologically as coagulative necrosis in most tissues, characterized by preservation of the basic cellular and tissue architecture for several days despite cell death, due to protein denaturation that maintains structural outlines. Microscopically, affected cells exhibit hypereosinophilic cytoplasm on hematoxylin and eosin (H&E) staining, with nuclear changes progressing from pyknosis (shrinkage and basophilia) to karyorrhexis (fragmentation) and eventually karyolysis (fading). This pattern results from ischemia-induced hypoxia, where cellular enzymes remain functional initially but fail to cause rapid autolysis, distinguishing it from other necrotic types.^[7] Infarcts are classified microscopically into pale (anemic or white) and red (hemorrhagic) patterns based on the presence of hemorrhage within the necrotic zone. Pale infarcts, seen in solid organs with end-arterial blood supply such as the heart, kidney, and spleen, display ischemic coagulative necrosis without significant extravasation of red blood cells (RBCs), appearing as sharply demarcated areas of pale tan to gray tissue.^[29] In contrast, red infarcts occur in tissues with dual blood supply or loose parenchyma, like the lungs, or following reperfusion, where extravasated RBCs fill the necrotic area alongside coagulative necrosis, imparting a hemorrhagic appearance.^[29] Both patterns share the core features of coagulative necrosis but differ in vascular permeability and collateral flow.^[29] The histologic evolution of infarction follows a characteristic timeline in organs undergoing coagulative necrosis, such as the heart. In myocardial infarction, subtle changes begin shortly after ischemia onset. Within 0-4 hours, early signs include wavy fibers or interstitial edema, though these may not be visible on routine microscopy.^[30] By 4-12 hours, early coagulative necrosis emerges with hypereosinophilic cytoplasm and pyknotic nuclei, while 12-24 hours show continuing necrosis with contraction bands at margins.^[30] Neutrophil infiltration peaks at 1-3 days, marking acute inflammation; macrophages predominate from 3-7 days, phagocytosing debris; granulation tissue forms by 5-10 days; and progressive fibrosis leads to scar formation over 2 weeks to months, with collagen deposition replacing necrotic tissue.^[30] Special stains enhance visualization of infarct progression. H&E remains the primary stain for identifying coagulative necrosis through eosinophilic cytoplasm and nuclear alterations, while Masson's trichrome highlights fibrosis in later stages by staining collagen blue against red muscle or cytoplasm.^[31] These stains aid in confirming the ischemic nature without relying on gross features. Unlike liquefactive necrosis seen in brain infarcts or bacterial abscesses, coagulative necrosis in infarction preserves tissue architecture without rapid enzymatic digestion into a viscous liquid, lacking the extensive karyorrhexis and complete tissue dissolution characteristic of liquefactive processes.^[7] This distinction arises from differences in tissue enzyme content and hypoxia response, with brain tissue prone to hydrolytic breakdown due to high lipid and glial activity.^[7]

By Localization

Infarctions are classified by their localization to specific organs or tissues, which influences their morphology, etiology, and clinical implications due to variations in vascular anatomy and collateral circulation. This categorization highlights how ischemic events manifest differently across body regions, often resulting from arterial occlusion by thrombi or emboli. Cardiac infarction, or myocardial infarction, occurs when coronary artery occlusion leads to ischemia of the heart muscle. It is typically classified as transmural, affecting the full thickness of the ventricular wall due to complete vessel blockage, or subendocardial, involving only the inner myocardial layer from partial occlusion.^[32] Transmural infarcts are associated with ST-elevation myocardial infarction (STEMI), while subendocardial ones correlate with non-ST-elevation myocardial infarction (NSTEMI).^[32] Cerebral infarction, commonly known as ischemic stroke, arises from occlusion of cerebral arteries, leading to brain tissue necrosis. The middle cerebral artery (MCA) territory is most frequently affected, supplying the lateral cerebral hemispheres, basal ganglia, and internal capsule, while the posterior cerebral artery (PCA) territory involves the occipital lobe, thalamus, and medial temporal regions.^[33] In the United States, these infarcts account for approximately 87% of all strokes.^[33] They exhibit site-specific patterns based on arterial distribution. Pulmonary infarction results from pulmonary embolism obstructing pulmonary arteries, though it is uncommon due to the lung's dual blood supply from pulmonary and bronchial arteries. When it occurs, it presents as a peripheral wedge-shaped consolidation on imaging, often pleural-based, reflecting the segmental nature of the occlusion.^[34] This morphology arises because infarction happens only when collateral bronchial flow is insufficient to compensate for the blockage.^[34] Splenic and renal infarctions are frequently embolic in origin, occluding segmental branches of the splenic or renal arteries and producing characteristic wedge-shaped peripheral lesions. In the spleen, these infarcts stem from the organ's end-arterial supply, with emboli often from cardiac sources like atrial fibrillation.^[35] Renal infarcts similarly show wedge-shaped hypodense areas on contrast imaging, typically involving the cortex and medulla due to abrupt vascular cutoff.^[36] Intestinal infarction, or mesenteric infarction, involves occlusion of the superior mesenteric artery, leading to ischemia and subsequent necrosis of the bowel wall. This condition progresses rapidly to full-thickness bowel necrosis if blood flow is not restored, affecting the small intestine and proximal colon due to the artery's dominant supply.^[37] Limb infarction in peripheral arteries results from acute occlusion, often atherosclerotic or embolic, causing severe ischemia in the extremities. This can culminate in gangrene, characterized by tissue necrosis and dry or wet gangrenous changes, particularly in the toes or forefoot when infrapopliteal vessels are involved.^[38] Infarctions of the heart and brain constitute the majority of clinically significant cases, driven by their high prevalence and profound impact on morbidity and mortality worldwide.^[39]

Clinical Presentation

Symptoms and Signs

Infarction manifests through a range of clinical signs and symptoms primarily driven by tissue ischemia, with severe pain being a hallmark feature across affected organs. Common general signs include pallor, profuse sweating (diaphoresis), nausea, and vomiting, often accompanying the primary localized symptoms. These autonomic responses reflect the body's reaction to acute oxygen deprivation in the infarcted tissue.^[18] In cardiac infarction, such as myocardial infarction (MI), patients typically experience crushing or squeezing chest pain that may radiate to the shoulder, arm, back, neck, or jaw, lasting more than a few minutes and unrelieved by rest. Associated symptoms include shortness of breath (dyspnea), lightheadedness, and cold sweats. Electrocardiographic changes, such as ST-segment elevation, may be observed as an early sign, though interpretation requires diagnostic confirmation.^[40]^[41]^[30] Cerebral infarction, often presenting as ischemic stroke, is characterized by sudden onset of focal neurological deficits, including unilateral weakness or numbness of the face, arm, or leg, aphasia (difficulty speaking or understanding speech), and altered consciousness ranging from confusion to coma. Visual disturbances, such as blurred vision or loss of vision in one eye, and severe headache may also occur.^[42]^[43]^[44] Abdominal infarction, particularly mesenteric infarction, features acute, severe abdominal pain that is often out of proportion to physical findings on examination, along with an urgent need to defecate and bloody stools in cases of bowel involvement. Nausea, vomiting, and abdominal distention are frequent accompaniments.^[45]^[37] Pulmonary infarction, typically resulting from pulmonary embolism, presents with sudden dyspnea, pleuritic chest pain, cough, and hemoptysis in some cases. Fever and tachycardia may also occur.^[46] Renal infarction commonly causes sudden-onset flank or abdominal pain, nausea, vomiting, fever, and hematuria, often accompanied by a rise in serum creatinine indicating impaired kidney function.^[36] Splenic infarction is marked by acute left upper quadrant abdominal pain, which may radiate to the left shoulder, along with fever, nausea, and splenomegaly on examination.^[47] Symptoms of infarction typically begin within minutes of vascular occlusion, with intensity peaking over the ensuing hours as ischemic damage progresses.^[30] A subset of infarctions, known as silent infarcts, occur without noticeable symptoms, particularly in elderly individuals or those with diabetes, accounting for approximately 20-30% of myocardial infarctions. These asymptomatic cases are often detected incidentally through imaging or electrocardiography.^[48]^[49]

Diagnosis

Diagnosis of infarction begins with a thorough clinical history and physical examination to assess the timeline of symptoms and evaluate risk factors such as hypertension, diabetes, smoking, and hyperlipidemia, which guide suspicion toward specific organ involvement.^[30] For myocardial infarction, the history typically includes sudden-onset chest pain radiating to the arm or jaw, while cerebral infarction may present with focal neurological deficits like hemiparesis or aphasia; physical exam findings, such as abnormal heart sounds or asymmetric pulses, further support localization.^[50]^[51] Biomarkers play a central role in confirming tissue injury, particularly for cardiac infarction where high-sensitivity cardiac troponin levels rise within 3-6 hours of onset, peak around 24 hours, and normalize over 1-2 weeks, with a rise and/or fall pattern indicating acute damage.^[52] Creatine kinase-MB (CK-MB) can provide early detection within 4-6 hours but is less specific than troponin.^[53] In the context of acute stroke, biomarkers such as glial fibrillary acidic protein (GFAP) help differentiate ischemic from hemorrhagic events, with low GFAP levels supporting ischemic infarction. D-dimer may be elevated in thromboembolic cases but lacks specificity. No routine blood biomarker confirms cerebral infarction like troponin does for myocardial infarction; diagnosis relies on clinical and imaging findings.^[54] Imaging modalities are essential for localization and confirmation. Electrocardiography (ECG) detects ST-segment elevation or Q waves in myocardial infarction, supporting acute ischemia.^[30] For cerebral infarction, non-contrast computed tomography (CT) rules out hemorrhage, while diffusion-weighted magnetic resonance imaging (MRI) identifies acute infarcts within minutes of onset via restricted diffusion.^[51] Angiography visualizes vascular occlusions in both cardiac and cerebral cases, and CT angiography is preferred for mesenteric infarction to detect arterial narrowing or thrombosis.^[55] Additional diagnostic tools include Doppler ultrasound for limb infarction, which assesses arterial flow and detects absent pulses indicative of acute ischemia.^[56] In suspected intestinal infarction, exploratory laparotomy may be required if imaging is inconclusive, though CT is the initial modality.^[37] Diagnostic criteria vary by type but emphasize integration of clinical, biomarker, and imaging evidence. The Fourth Universal Definition of Myocardial Infarction requires detection of a rise and/or fall in cardiac troponin with at least one value exceeding the 99th percentile upper reference limit, alongside evidence of ischemia such as symptoms, ECG changes, or imaging findings.^[52] For cerebral infarction, diagnosis relies on clinical symptoms and imaging confirmation of infarction without hemorrhage, as no universal biomarker threshold exists.^[51] Challenges in diagnosis include differentiating infarction from mimics, such as unstable angina in cardiac cases (where troponin remains normal) or transient ischemic attack (TIA) in cerebral events (where imaging shows no permanent infarct).^[57]^[58] These distinctions require serial testing and may delay confirmation, underscoring the need for rapid, multimodal evaluation.^[59]

Management

Acute Treatment

The acute treatment of infarction prioritizes rapid restoration of blood flow to the ischemic tissue to minimize necrosis and improve outcomes, with strategies tailored to the affected organ and underlying cause. Reperfusion therapies form the cornerstone, particularly for myocardial infarction (MI) and ischemic stroke, where time-sensitive interventions are critical. Supportive measures address hemodynamic instability and prevent further thrombosis, while site-specific approaches account for variations in anatomy and pathophysiology. Guidelines from major cardiovascular and neurological societies emphasize adherence to strict time windows to maximize efficacy. For myocardial infarction, primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy when performed within the "golden hour" (ideally door-to-balloon time under 90 minutes), involving catheter-based angioplasty and stenting to open the occluded coronary artery. If PCI is unavailable within 120 minutes of first medical contact, fibrinolytic therapy with thrombolytics such as alteplase (tPA) is recommended, though it carries a higher risk of intracranial hemorrhage. Adjunctive pharmacotherapy includes immediate aspirin (162-325 mg chewed) to inhibit platelet aggregation, anticoagulation with unfractionated heparin or bivalirudin to prevent reocclusion, and beta-blockers like metoprolol to reduce myocardial oxygen demand, provided there is no contraindication such as bradycardia. In cases of cardiogenic shock, mechanical circulatory support such as intra-aortic balloon pump or Impella devices may be employed to stabilize perfusion. In acute ischemic stroke, intravenous thrombolysis with recombinant tPA is indicated within 4.5 hours of symptom onset for eligible patients, achieving recanalization in approximately 30-50% of cases and reducing disability when administered promptly (target door-to-needle time of 60 minutes). Endovascular thrombectomy extends the treatment window up to 24 hours in select patients with large vessel occlusion, using stent retrievers to mechanically remove the clot and restore cerebral blood flow. Supportive care involves blood pressure management (typically maintaining systolic <185 mmHg pre-thrombolysis) and antiplatelet therapy with aspirin initiated 24 hours post-tPA, alongside statins for secondary prevention in the acute phase. For pulmonary infarction secondary to embolism, anticoagulation with low-molecular-weight heparin (e.g., enoxaparin) or direct oral anticoagulants is initiated immediately after diagnosis to prevent clot propagation, unless contraindicated by active bleeding. Thrombolysis is reserved for massive pulmonary embolism with hemodynamic instability, while catheter-directed therapies offer targeted reperfusion in intermediate-risk cases. In mesenteric infarction due to arterial occlusion, emergency surgical revascularization or embolectomy is often required, supplemented by systemic heparinization to limit thrombotic extension. Contraindications to thrombolytic therapy, common across infarct types, include recent major surgery, active bleeding, or uncontrolled hypertension, as these increase the risk of hemorrhagic complications by up to 6-10 fold. Overall, multidisciplinary protocols in specialized centers, such as stroke units or cardiac catheterization labs, enhance coordination and reduce treatment delays.

First Aid

Upon suspecting an infarction, such as a heart attack or stroke, the immediate priority is to activate emergency medical services by calling 911 or the local emergency number without delay, as timely intervention can significantly improve outcomes.^[60]^[61] While waiting for professional help, keep the person calm and reassured to reduce stress on the body, and continuously monitor their breathing and responsiveness.^[62]^[63] For a suspected cardiac infarction (heart attack), if the person is conscious and able to chew and swallow, assist them in taking 325 mg of aspirin (one regular-strength tablet) to help prevent further blood clotting, but only after calling emergency services.^[62] If the person becomes unresponsive and stops breathing normally, begin cardiopulmonary resuscitation (CPR) immediately: perform hands-only compressions at a rate of 100-120 per minute if untrained, or 30 compressions followed by 2 rescue breaths if trained, continuing until emergency responders arrive or an automated external defibrillator (AED) is used.^[63]^[60] For a suspected cerebral infarction (stroke), quickly perform the FAST assessment to confirm symptoms: Face drooping (ask them to smile and check for asymmetry); Arm weakness (have them raise both arms and see if one drifts downward); Speech difficulty (ask them to repeat a simple phrase and note slurring); Time to call 911 if any sign is present.^[64]^[61] Do not give the person any food or drink, as it may lead to choking or aspiration, especially if swallowing is impaired.^[61] Position the person based on their condition to optimize comfort and circulation: place them supine (flat on their back) with legs elevated about 12 inches if signs of shock (such as pale, clammy skin) are present, unless it causes pain or suspected injury; for shortness of breath (dyspnea), position them semi-upright or seated leaning forward to ease respiration.^[65]^[62] Avoid delaying the call for help by attempting to transport the person yourself or waiting for symptoms to resolve, and do not administer fluids or food if they are unconscious or semi-conscious, as this risks aspiration.^[60]^[61] Effective first aid relies on training in basic life support (BLS) protocols, as outlined by the American Heart Association and American Red Cross, which emphasize scene safety, rapid activation of emergency services, and high-quality CPR.^[63]^[62]

Outcomes

Complications

Infarction can lead to a range of short- and long-term complications depending on the affected organ, with cardiac infarction often resulting in arrhythmias such as ventricular tachycardia or fibrillation, which occur in up to 20% of cases and contribute significantly to early mortality.^[66] Heart failure develops in approximately 10-40% of patients post-myocardial infarction due to loss of viable myocardium, leading to reduced ejection fraction and symptomatic congestion.^[67] Cardiogenic shock, a severe manifestation, arises in 5-10% of acute myocardial infarctions and is associated with multi-organ hypoperfusion, with mortality exceeding 40% even with intervention.^[68] Mechanical ruptures, including free wall rupture (incidence 1-2%) and ventricular septal rupture (0.5-1%), typically occur 3-7 days post-infarction and present with acute hemodynamic instability.^[69] Cerebral infarction complications include cytotoxic and vasogenic edema, which peaks within 3-5 days and can cause malignant middle cerebral artery syndrome with herniation in large infarcts.^[70] Hemorrhagic transformation occurs in 10-40% of ischemic strokes overall, with symptomatic cases in 2-7% particularly after thrombolysis, and ranges from asymptomatic petechiae to symptomatic parenchymal hematoma that worsens neurological outcomes.^[71] Secondary epilepsy develops in 2-10% of patients within the first year, often triggered by cortical involvement, and is linked to poorer functional recovery.^[72] For other organs, renal infarction may lead to acute kidney injury in up to 50% of cases, chronic hypertension, or renal failure requiring dialysis.^[73] Splenic infarction can result in abscess formation, pseudocysts, or hypersplenism, with rupture occurring in 1-5% of cases.^[74] Intestinal infarction beyond mesenteric vessels often causes bowel perforation, peritonitis, and sepsis, contributing to high mortality.^[75] Systemic effects of infarction encompass multi-organ failure in severe cases, such as cardiogenic shock from myocardial infarction leading to renal and hepatic dysfunction due to prolonged hypoperfusion.^[68] Thromboembolism arises from left ventricular mural thrombi in 5-15% of anterior myocardial infarctions, potentially causing stroke or peripheral embolization.^[76] In-hospital mortality for myocardial infarction is 5-7%, reflecting advances in care, while untreated mesenteric infarction carries a mortality rate of 50-80% due to bowel necrosis and sepsis.^[77]^[75] Chronic sequelae involve post-infarction remodeling, where progressive ventricular dilation and hypertrophy occur over months, increasing the risk of heart failure and arrhythmias.^[78] This process can culminate in left ventricular aneurysms in 5-10% of transmural infarctions, predisposing to thrombus formation and rupture.^[79] Recent guidelines emphasize that timely reperfusion therapy reduces these complication rates by 30-50%, improving long-term survival.^[80]

Prevention and Prognosis

Primary prevention of infarction, particularly myocardial infarction (MI) and ischemic stroke, emphasizes lifestyle modifications, pharmacological interventions, and regular screening to mitigate underlying risk factors such as atherosclerosis and hypertension.^[81] Adopting a Mediterranean-style diet rich in fruits, vegetables, whole grains, lean proteins, and fish, while limiting processed meats, sugars, and sodium, reduces the risk of both MI and ischemic stroke by improving lipid profiles and blood pressure control.^[82] Regular physical activity, including at least 150 minutes per week of moderate-intensity aerobic exercise, lowers cardiovascular risk by 20-30% and is recommended for adults without contraindications.^[81] Smoking cessation is critical, as tobacco use doubles the risk of ischemic stroke and significantly elevates MI incidence; counseling combined with pharmacotherapy like varenicline achieves sustained quit rates of up to 30%.^[83] For medications, statins are indicated for individuals with elevated low-density lipoprotein cholesterol (LDL-C ≥190 mg/dL) or a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥7.5%, reducing MI risk by 25-35% through LDL-C lowering.^[84] Antihypertensive therapy targeting systolic blood pressure below 130 mm Hg with agents like thiazide diuretics or ACE inhibitors prevents up to 40% of strokes and 20-25% of MIs in high-risk populations.^[85] Screening includes annual blood pressure measurement for adults aged 40 and older, lipid profiles every 4-6 years for ages 20-39 and more frequently thereafter, and diabetes assessment via HbA1c for overweight individuals aged 35-70.^[81] Secondary prevention following an infarction event focuses on reducing recurrence through rehabilitation, antithrombotic therapy, and device-based interventions tailored to the infarction type. Cardiac rehabilitation programs, involving supervised exercise and education, are recommended post-MI and post-stroke, improving functional capacity by 15-20% and reducing recurrent cardiovascular events by 20-30%.^[86] Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (e.g., clopidogrel or ticagrelor) for 6-12 months after acute coronary syndrome prevents stent thrombosis and reduces MI recurrence by 20-25%, transitioning to single antiplatelet therapy thereafter.^[83] For ischemic stroke or transient ischemic attack, antiplatelet monotherapy with aspirin or clopidogrel is standard, lowering recurrence risk by 20%; anticoagulation with direct oral anticoagulants is preferred for atrial fibrillation-related events, reducing the risk of recurrent stroke by approximately 20% compared to warfarin.^[87] In post-MI patients with heart failure and left ventricular dyssynchrony (ejection fraction ≤35%), cardiac resynchronization therapy via biventricular pacing improves symptoms and reduces heart failure hospitalizations by 30-40%.^[88] Prognosis after infarction is influenced by infarct size, timeliness of reperfusion therapy, and comorbidities such as diabetes or prior vascular disease. Larger infarct size, assessed via peak troponin levels or ejection fraction <40%, correlates with higher mortality, while door-to-balloon times under 90 minutes in ST-elevation MI improve 30-day survival by 30-50%.^[89] Comorbidities like chronic kidney disease double the risk of adverse outcomes, and older age (>75 years) increases 1-year mortality to 15-20%. For MI, 1-year mortality ranges from 5-10% in uncomplicated cases with optimal therapy, rising to 15-20% with heart failure or shock. In cerebral infarction, prognosis depends on National Institutes of Health Stroke Scale score at presentation; scores >16 predict poor functional outcome in 70% of cases, with 30-day mortality around 20% for large-vessel occlusions. Survival trends for infarction have improved due to advances in acute care, risk factor management, and secondary prevention, though disparities persist by race and region. Age-adjusted MI mortality in the US declined by approximately 4% annually from 1968 to 2019, reflecting widespread statin use and percutaneous interventions.^[90] For ischemic stroke, mortality rates fell by 20-25% from 2000 to 2012 per CDC data, stabilizing thereafter with a slight uptick during the COVID-19 pandemic, but overall 30-day survival for ischemic stroke reached 89% by 2018.^[91] Cardiac rehabilitation contributes to these trends by enhancing ejection fraction by 5-10% post-MI and reducing all-cause mortality by 20% in participants.^[86]

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### General First Aid for Heart Attack
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