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It's Hatched! 267 Bought
Come into Blue Agave Mexican Cantina for authentic Mexican fare in a festive environment. Enjoy icy cold margaritas in flavors like strawberry, apple and watermelon and martinis in flavors like Cherry Kiss, Chocotini and Tuscan Sunset. Once you've quenched your thirst, dig into menu offerings such as chicken taquitos, fire-roasted shrimp salad and black bean & corn enchiladas. You won't leave hungry when you take advantage of this great DealChicken deal and pay just $15 for $30 worth of food and drink. Don't forget to save room for dessert!
Located on East Mayo Boulevard in Phoenix, you will find Blue Agave Mexican Cantina just south of the 101 off Scottsdale Road. Its convenient location, fun atmosphere, great-tasting food and friendly staff make it a favorite stop among locals and travelers alike.
$15 for $30 worth of food and drinks ($30 value)
Blue Agave Mexican Cantina
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Bert James Weidner
Position: G-C
Height: 6-2 Weight: 295 lbs.
Born: January 20, 1966 in Eden, NY
College: Kent St. (school history)
Drafted by the Miami Dolphins in the 11th round (288th overall) of the 1989 NFL Draft.
Weighted Career AV (100-95-...): 24 (4004th overall since 1950)
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subset: commoncrawl


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Santa-sized Scrapbook Giveaway!
You're plenty busy buying, wrapping, cooking, and planning this holiday season. How about a little treat for you? We're celebrating Christmas the Making Memories way by delivering five of our wonderful and loyal readers with a Santa-sized helping of their (scrapbook) wish list.
If you want a Santa-sized helping, leave a comment on our blog with your wishes.
Five lucky winners will be awarded on Friday, December 14th.


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Facebook lets advertisers target people with same traits as customers
The specialized audience targeting tool, which the social network has been testing with select advertisers for a few weeks, goes a step beyond the company's custom audiences targeting option, introduced last fall, to help marketers intelligently go after new business.
With custom audiences, advertisers can serve Facebook ads to their existing customers. Lookalike audiences extends the targeting option so that advertisers can target ads, based on demographic qualities or geographic region, to … Read more


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UNK Quick Links Quick Links A-Z Website Listing Office of the Chancellor Campus Maps UNK Factbook Calendar of Events Policies & Procedures Contact Information Registrar's Office UNK Alert Undergraduate Graduate International eCampus Scholarships & Fin. Aid Academic Affairs American Democracy Undergraduate Studies International Education Study Abroad Academic Calendar Colleges & Departments Computer Use Policy Course Catalog Library eCampus Classes Schedule of Classes Transcripts Firefly Academic Calendar Blackboard LoperMail eCampus Helpdesk (ITS) Major/Advisor Change (ugrad) Student Union Student Government LoperCAREERS Telecommunications The Antelope Online KLPR Radio UNK ID Card MyBLUE Blackboard Ektron Login Faculty Senate Firefly Future Catalog Helpdesk (ITS) Email Staff Senate Telephone Directory UNK ID Card myBlue Assessment Current Catalog Faculty Handbook Policies & Procedures The Antelope Online UNK Today UNK Factbook Business & Finance Academic & Career Services Contact Information Employment at UNK Human Resources ITS Police/Parking Services Dining Services Alumni Association NU Foundation NU System
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In the division of Academic and Student Affairs,We promote an educational experience that fully prepares UNK students for careers and citizenship, and we strongly support the faculty and staff who provide it.
The functions of the various groups within the Division of Academic and Student Affairs encompass the broad diversity of students' experiences.
The Senior Vice Chancellor works closely with each of the college deans – including the College of Business and Technology, the College of Education, the College of Fine Arts and Humanities, the College of Natural and Social Sciences, the Graduate College, and the Library – to provide oversight and support for the development and maintenance of a high quality academic experience at the University of Nebraska at Kearney. The SVCASA and deans meet frequently in the Deans' Council.
Additionally, the Division of Academic and Student Affairs houses the offices for several programs that complement and enrich students' education, including Ethnic Studies, General Studies, Honors, International Studies, and Women's and Gender Studies.
The offices within the division provide support to students and ensure timely and efficient functioning: Academic Publications, Assessment, Center for Teaching Excellence, eCampus, Graduate Studies and Research, Information Technology Services, Institutional Research, International Education, Student Affairs, and Student Records and Registration.
Office of the Senior Vice Chancellor for Academic and Student AffairsUniversity of Nebraska at Kearney905 West 25th StreetKearney, NE 68849Phone: (308)865-8209


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by BurnzyDoctors in China have successfully reattached a man's severed hand after it was attached to his ankle for a month.
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Whether You Prefer "Merry Christmas" or "Happy Holidays," Punching Someone Who Doesn't Share Your View Isn't Advised!
by Kelly MeyerCheck this out.
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CBP makes pot bust
U.S. Customs and Border Protection officers nabbed a man, 60, with almost 160 pounds of pot.
CBP says the bust happened Monday night at the Calexico downtown port of entry.
Officers lifted the hood of the driver's pick up and found seven wrapped packages of marijuana.
There were additional packages in other parts of the truck.
The drugs have an estimated street value of more than $94,000.
The Mexican citizen arrested is behind bars at the Imperial County Jail.
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Shortly after midnight April 9, the Delta County Communication Center received a call about a structure fire at the Thunder Mountain Lodge, located at 20703 Baron Lake Drive on Grand Mesa. The caller stated the structure was fully engulfed in flames.
Deputies from the Delta County Sheriff's Office responded along with the Cedaredge Fire Department. It appears the structure is a complete loss; cause of the fire is under investigation. Fire investigators from the Colorado Bureau of Investigations are expected on scene by Wednesday morning to assist with the investigation.
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Be the prettiest and most graceful vampire this Halloween in our Vampirina Child Costume !This Vampirina Child Costume is the perfect costume if you are looking for just a little bit of scare. This costume includes a tutu dress, lace gloves, a choker with an attached collar, and footless tights. Your little girl will be the best looking vampire and ballerina this year!The Vampirina Child Costume must be hand washed.
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25% Off Online Orders Over $125
Use promotional code LAMB25 at checkout to receive discount. Receive 25% off your total purchase of $125 or more of regularly priced in-stock single parts or accessories purchased online. Enter promo code LAMB25 in cart when purchased online to receive discount. Offer is not valid in combination with any other offers, rebates or discounts; not available to Pep Boys' Fleet & Commercial accounts; does not apply to labor, special order merchandise, tires or the purchase of gift cards. Valid online until 2:59 am EST on 3/11/14. Online orders scheduled for in-store pick up must be completed in store by closing on 3/10/14 for discount to apply.
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Free Ground Shipping on Ship to Address orders over $75. No code needed. Offer only valid on in-stock merchandise valued at a total of $75, after any discounts have been applied, and before any core charges, shipping charges, fees and taxes have been added. Certain items exceeding weight and size limitations are excluded. See item descriptions for details.
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Cedaredge residents have answered the call of their town government to find ways for voluntarily cutting back on water usage in response to the town's Stage I drought declaration.
But people are conserving so much water that revenue from water sales is down enough to make trustees take notice.
The August financial report given during the town board's Aug. 15 meeting showed that user revenues for water are down last month by $15,334. On an annualized basis, the town budget predicts about $44,000 per month in water user fees for 2013.
In other business, the Cedaredge trustees dealt with the following matters:
• Trustees approved a resolution raising the maximum allowable municipal court fine from $1,000 to $2,650. The levy of fines is the sole and exclusive province of Cedaredge's municipal judge.
• The trustees received a state-issued time line for complying with the town's sewer treatment effluent requirements. According to the schedule presented to the board and revised on Aug. 27, the town has until July 1, 2018, to have construction of a new sewer treatment plant completed and the new plant on line.
Though the new sewer plant project has remained in its early planning stages for well over a year, public works director Dave Smith said the town "is ahead of the curve on most things" required by the compliance schedule.
• Golf pro Larry Murphy told the board that a lot of time has been spent on repair and maintenance of the sprinkler system at the golf course. He said that five people had been working all week long. The problem is caused by a lack of filter element for the incoming ditch-sourced irrigation water. Silt making its way into the lines plugs sprinkler heads and small rocks can damage them.
• Stated cost of the town's enhancement project at Grand Mesa Drive ant Main Street scheduled for 2014 has gone from about $250,000 to over $400,000. The $250,000 is a grant from CDOT. There is also about $50,000 of matching town funds needed for the work. Just announced is the town's bid for another $100,000 grant for the project.
• Trustees gave final approval to the Sarver subdivision.
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Ron in CA
I wear 36" jeans and this is a bit small. But works great for the lower back
Read All ReviewsJustin in CA
Used these braces for 4 full day rides of 60+ miles, and they are awesome. Very comfortable, more so than my old thor knee guards, and they seem like they would provide excellent support in a crash. I don't even notice them when I ride any more, and they don't even bother me walking around.
Read All ReviewsBrandon in FL
I would have to say this is the first bad review i have ever written. Hinge bolts fell out after 2 rides. Material almost completely unglued from the plastic after 4 rides. Poor hook design causes them to come on strapped during use. very cheap and bendy feeling. All in all Knee guards are very important and would highly recommend investing a few extra bucks for a higher quality product. As for Rocky Mountain they contacted EVS and EVS wants me to go through them for repair but there is nothing they can do to repair the quality of the product so not even gonna waste my time.
Read All Reviewsderek in CA
These seem decent quality.. I use Asterisk every time I ride but my son on a CRF50 that is an overkill. These knee pads must be designed for older kids maybe on 65's or 85's because they were way to big for him at age 6 on a 50.
Read All ReviewsPaul in NM
I have been using these for about a year now and they are still holding up well. Several races and lots of practice riding. Would recommend and buy again. The extra padding is worth the $.
Read All ReviewsBrandt in TX
These knee guards are bulky and do not fit well at all. They slide down even with my awesome ARC knee guard socks. I would spend the extra $$ and get some nice ones. I wore them once and am stuck with them now, collecting dust. Went back to my old wornout ones. Saving up to get some better made ones.
Read All Reviews


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Home > News and Events > Events |
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New Fundamentals of Accessing Capital |
Wednesday, December 14, 2011
Overview You'll also be matched with financial representatives with experience in small business lending to receive customized guidance. During these meetings, you will receive feedback on your business plan and advice about applying for financing. Representatives from a range of financial institutions including community banks, CDFIs, SBA loan providers, and private equity investors, will participate in the forum. Discussion Topics:
Audience: Businesses that:


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With this collection you won't take no prisoners! An armory filled with thousands of high quality source recordings to create any kind of medieval weapon sound.
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If Bedenbaugh is going to be able to instill that nastiness in this year's offensive line he has a good group to work with. All five starters - Madsen at center, Josh Jenkins and Jeff Braun at guard and Quinton Spain and Pat Eger at tackle - have experience. They've been in the system for a year and understand the technique and the assignments. The hope is that those things come naturally now.
And then they can add a certain edge.
"Coach Bedenbaugh preaches that,'' Jenkins said. "He says one thing we will not be is we will not be soft. You won't step on the field if you're soft.
"I think we're more physical than we've ever been in the past. But you can't really talk about that. You have to show it.''
The truth is, West Virginia's offensive line schemes are devised to allow players to be more physical perhaps than in the past. It's all about simplicity. Sometimes coaches can out-think themselves, creating so many keys and reads and different blocking schemes that those blockers are overwhelmed by details. In this system, the blocking up front can be almost identical no matter what the skill position players are doing.
"Now it's more technique stuff and basically toughness,'' Madsen said. "You already know which guys to block. Now it's just putting them on the ground and being nasty.''
Jenkins agreed.
"This offense is great for us because they keep it as simple as they can,'' Jenkins said. "When you don't have to think as much it allows you to just play. They do everything in their power to keep things as simple as they can. And then because it's so simple they expect us to fly around and they expect us to be nasty.
"It's not just the offensive line, either. When the receivers are blocking they expect them to be nasty. And when you get that mindset as a team, I think that's a huge benefit.''
Much of that starts with Bedenbaugh, in his second year at WVU after spending the previous four at Arizona, including 2010 as offensive coordinator.
"He has an edge to him. The way he acts rubs off on us and that's the way he expects us to be,'' Jenkins said. "He doesn't settle. He doesn't settle for anything less than being great. He doesn't settle for anything less than being nasty. And if you're not nasty, well, you're not playing.''


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By: Diana Johnsen
It's more than doubling in size.
Quatro Composites of Orange City, a maker of aerospace and medical equipment parts, is adding a 45,000 square foot building to manufacture more parts.
"In the last 12 or so months we've been awarded 2 or 3 major contracts so that precipitated us to do the expansion," said Steve Roesner, Quatro Composites President.
The $11.8 million dollar project will include two phases.
First, build the new addition to the existing 29,000 square foot original building.
Then, remodel the original building.
The project is expected to add close to one hundred new jobs to the area.
"The state has supported us with some financial assistance in our expansion and our contribution to that is to add 99 jobs in the next 36 months," said Roesner.
Roesner said the expansion is currently on schedule and is expected to be completed this June.


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Second Bennington Rural firefighter accused of sexual assaultBy Patrick McArdle
STAFF WRITER | December 28,2012BENNINGTON A second member of the Bennington Rural Fire Department was arraigned last week after police said he had sexual contact with a 14-year-old girl who had also accused a captain in the department of having sexual contact with her when she was 13.
Zachary J. Spaulding, 21, of Bennington, was arraigned in Bennington criminal court on Dec. 21 on a felony charge of repeated aggravated sexual assault, a felony charge of sexual assault with no consent and a misdemeanor charge of contributing to the delinquency of a minor.
Spaulding pleaded innocent and was released without bail.
On Dec. 17, Bryan Watson, 25, of Bennington, was charged in the same court with felony charges of sexual assault on a victim younger than 16 and repeated aggravated sexual assault. He also pleaded innocent.
The charge of repeated aggravated sexual assault, which was filed against Spaulding and Watson, is punishable by up to life in prison.
Detective Anthony Silvestro, of the Bennington Police Department and who investigated both cases as the officer assigned to the Bennington County Special Investigations Unit, said he had interviewed the 14-year-old girl along with Wendy Nolan, an investigator with the Vermont Department of Children and Families, on Nov. 27. During that interview, the girl said Watson had initiated sexual contact with her during the summer of 2011 on more than 10 occasions.
The girl, who was 13 at the time, said she had told Watson no on several occasions.
Watson admitted to knowing the girl and being alone with her at times but denied there had been any inappropriate contact, according to an affidavit written by Silvestro.
In a second affidavit, Silvestro said the girl had also talked during the Nov. 17 interview about having sexual contact with Spaulding.
The girl told investigators that there had been two incidents that took place at her home during the summer of 2012. According to the girl, Spaulding had been drinking alcohol before having contact with her.
Silvestro said he also interviewed a 13-year-old friend of the girl Dec. 10. The friend said the girl had told her about having sexual contact with Watson and Spaulding.
When Silvestro interviewed Spaulding on Dec. 18, he also admitted to knowing the girl and spending time with her alone but denied any inappropriate contact.
Neither Watson nor Spaulding have prior criminal records.
On Thursday, there was a hearing in Bennington criminal court during which Jennifer Barrett, a deputy states attorney for Bennington County, asked Judge Cortland Corsones to hold Watson without bail because one of the charges against him was punishable by life in prison.
In Vermont, there is a presumption that a person charged with what court personnel refer to as a life offense should be held without bail because the possible penalty might cause the defendant to flee.
Jeffrey Rubin, who represented Watson, pointed out his lack of criminal record, the length of time between the alleged sexual assaults, during which no new accusations have been made, and Watsons strong family ties which include a baby born one week ago.
Corsones released Watson without bail but ordered him to observe a curfew from 10 p.m. to 5 a.m.
In 2008, two members of the Bennington Rural Fire Department, including a first assistant chief, Shawn LaFountain, were accused of having sexual contact with a girl who had been a member of the departments junior firefighter program. The girl was 15 at the time.
LaFountain pleaded guilty in 2009 and was sentenced to serve three to 10 years in prison. The other man, Colby Harwood, pleaded guilty in 2008. His charges were reduced to misdemeanors and he received a suspended sentence.
email@example.com IN Southern VermontLUDLOW — Think March Cinderella stories only center on college basketball players scoring... Full StorySome enterprising thief has siphoned off about 100 gallons of fuel oil from a Newfane home. Full StoryWOODSTOCK — Franklin S. Billings Jr. Full Story -
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Bouchra Jarrar is an exceptional creature indeed: one of the very few French talents to have emerged in the past few seasons, and certainly the only woman. She didn't spring from nowhere as an untested newcomer, though. After ten years as Nicolas Ghesquière's assistant at Balenciaga, Jarrar worked for Christian Lacroix before his business sadly failed, and then decided it was time to speak up for herself. All elements of that pedigree shine in her work—French subtlety and exactitude worked into every seam, combined with her own compellingly practical mission to assist a young woman in building a sense of chic into her daily wardrobe.
"Force, elegance, and continuity," is how she described a collection in which she added pantsuits in English menswear-tailoring fabric and knitwear to her growing line of expertly proportioned dresses—the sort of thing which carries that inimitably Parisian quiet sense of quality and good taste. This season, she branched into more color and pattern, injecting shots of electric blue and black-and-white stripes to the monochrome palette she began with. The thing to recognize and applaud, however, is the care she takes in considering the finish—the crucial placement of a dropped waist, the precise way a jacket wraps, and the narrow lines of silk piping she inserts as her signature. It's that finesse which distinguishes her aesthetic from merely the "wearable" to something that belongs in the realm of a new generation of modern luxury.
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On View: Sunk Relief Representation of a God
The identification of this figure is based on his long, curved beard and the remains of a solar disk resting immediately above his head in t...
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Maso was one of the most gifted pupils and associates of Giotto (1267–1337). This triptych, intended for private devotion, is the only...
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Marahoué or Haut Sassandra Region, Ivory Coast


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Beyond: Two Souls review: an interactive experience you won't want to miss
- Posted October 8th, 2013 at 11:00 EDT by Steven Williamson
Review Score
- PSU Review Score
- 9.5
- Avg. user review score:
- 9.5
Beyond: Two Souls is so unique, powerful and engaging that it's easy to forgive some of its gameplay flaws. Quite simply, a stunning production.
We like
- Visually it's in a different league to many games on PS3. Stunning facial animation and locations.
- Great characters, great plot, excellent twists and a fitting conclusion.
- The action sequences are superb and switching between Jodie and Aiden delivers a unique mechanic.
We dislike
- Some interactions are over excessive and gameplay plods along on occasions
- The action sequences are so good, we would have liked to have seen more.
See PSU's review on Metacritic & GameRankings
As a tear rolled down my cheek, it all began to make sense. The roller-coaster ride of highs and lows, presented via a mish-mash of out-of-sequence stages throughout the life of the vulnerable, yet incredibly strong, lead character, Jodie Holmes, had eventually led me to one of the finest video game endings of this generation. Though it was slow to get there (and I often questioned why I was forced to carry out seemingly meaningless Heavy Rain-like gestures, such as gathering hay for a horse at a ranch owned by ancestors of the Navajo tribe, cooking a romantic chicken curry in my lush city apartment for a work colleague, or dancing alone at a teenager's party that I didn't even want to be at), it turns out that it was all part of the master plan: Quantic Dream's director David Cage was taking me on a journey; and what a journey it was.
The conclusion to Beyond: Two Souls just seems so fitting and poignant at this particular time, when we sit at the birth of the next generation of consoles and the impending decline of the PlayStation 3. Maybe, just maybe, part of that tear I shed was because Beyond: Two Souls is the last big blockbuster exclusive before my PS3 gets shoved away in a cupboard to make way for the PlayStation 4. Whatever the case, the twist, the reveal and the immersive storytelling, which eventually leads to one of the biggest decisions I've ever had to make in a video game, has made for a truly memorable interactive movie that will stay with me for a long time.
The main focus of Beyond is Jodie Holmes and a mysterious entity that floats and moves around while connected to her by an invisible cord. Jodie is a special child and through Aiden (who is also a controllable character via single player or co-op mode), she can perform a variety of supernatural tricks, such as flipping over tables, possessing people and communicating with the spirit world. The game follows Jodie through stages of her turbulent life, switching randomly between the ages of 8 and 23 as you see a re-enactment of important stages that have shaped her character, including the time she spent locked up in in a secure government facility where they monitored her supernatural abilities and the tough decisions she had to make during her career in the C.I.A.
Continued overleaf...


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Year | 1961 |
Make | Chevrolet |
Model | Impala |
Engine | 409/409 HP |
Trans | 4-Speed |
Color | White |
Interior | Red |
Web No. AN1112-139633
INV No. 75840 |
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Lot S190 1961 Chevrolet Impala
409/409 HP, 4-Speed
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Anaheim, CA Auction
November 15-17, 2012
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HIGHLIGHTS- White with the correct Red interior - Multiple award winner, including the prestigious VCCA Senior Award of Excellence with 996 out of 1000 points - Real 409/409 HP engine date coded 1962, factory replacement - Hidden CD player was installed - Correct 4-speed transmission - Power steering - Power brakes - All original sheet metal - Believed to have just over 69,000 original miles DESCRIPTIONIncorporating all original sheet metal and showing just over 69,000 miles, this 1961 Chevrolet Impala has earned multiple awards, including the prestigious VCCA Senior Award of Excellence with 996 out of 1000 points. It uses a genuine date-coded 1962 409/409 HP factory replacement engine, correct 4-speed manual and power steering and brakes to deliver the definitive 409 experience, all in a beautiful and iconic color combination of White with a correct Red interior that includes a hidden CD player. Information found on the website is presented as advance information for the auction lot. Photos, materials for videos, descriptions and other information are provided by the consignor/seller and is deemed reliable, but Mecum Auction does not verify, warrant or guarantee this information. The lot and information presented at auction on the auction block supersedes any previous descriptions or information. Mecum is not responsible for information that may be changed or updated prior to the auction. The decision to purchase should be based solely on the buyers personal inspection of the lot at the auction site prior to the auction.


text:
Myocardial infarction
Myocardial infarction | |
Classification and external resources | |
Diagram of a myocardial infarction (2) of the tip of the anterior wall of the heart (an apical infarct) after occlusion (1) of a branch of the left coronary artery (LCA). In the diagram, RCA is the right coronary artery.
DiseasesDB | 8664 |
MedlinePlus | 000195 |
eMedicine | med/1567 emerg/327 ped/2520 |
MeSH | D009203 |
Myocardial infarction (from Latin: Infarctus myocardii, MI) or acute myocardial infarction (AMI) is the medical term for an event commonly known as a heart attack. It happens when blood stops flowing properly to part of the heart and the heart muscle is injured due to not receiving enough oxygen. Usually this is because one of the coronary arteries that supplies blood to the heart develops a blockage due to an unstable buildup of white blood cells, cholesterol and fat. The event is called "acute" if it is sudden and serious.
A person having an acute MI usually has sudden chest pain that is felt behind the breast bone and sometimes travels to the left arm or the left side of the neck. Additionally, the person may have shortness of breath, sweating, nausea, vomiting, abnormal heartbeats, and anxiety. Women experience fewer of these symptoms than men, but usually have shortness of breath, weakness, a feeling of indigestion, and fatigue.[1] In many cases, in some estimates as high as 64%, the person does not have chest pain or other symptoms.[2] These are called "silent" myocardial infarctions.
Important risk factors are previous cardiovascular disease, old age, tobacco smoking, high blood levels of certain lipids (low-density lipoprotein cholesterol, triglycerides) and low levels of high density lipoprotein (HDL) cholesterol, diabetes, high blood pressure, lack of physical activity, obesity, chronic kidney disease, excessive alcohol consumption, and the use of cocaine and amphetamines.[3][4] The main way to determine if a person has had a myocardial infarction are electrocardiograms (ECGs) that trace the electrical signals in the heart and testing the blood for substances associated with damage to the heart muscle. Common blood tests are creatine kinase (CK-MB) and troponin. ECG testing is used to differentiate between two types of myocardial infarctions based on the shape of the tracing. An ST section of the tracing higher than the baseline is called an ST elevation MI (STEMI) which usually requires more aggressive treatment.
Immediate treatments for a suspected MI include aspirin, which prevents further blood from clotting, and sometimes nitroglycerin to treat chest pain and oxygen.[5] STEMI is treated by restoring circulation to the heart, called reperfusion therapy, and typical methods are angioplasty, where the arteries are pushed open, and thrombolysis, where the blockage is removed using medications.[6] Non-ST elevation myocardial infarction (NSTEMI) may be managed with medication, although angioplasty may be required if the person is considered to be at high risk.[7] People who have multiple blockages of their coronary arteries, particularly if they also have diabetes, may also be treated with bypass surgery (CABG).[8][9] Ischemic heart disease, which includes MI, angina, and heart failure when it happens after MI, was the leading cause of death for both men and women worldwide in 2011.[10][11]
Signs and symptoms[edit]
The onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes, and rarely instantaneous.[12] Chest pain is the most common symptom of acute MI and is often described as a sensation of tightness, pressure, or squeezing. Chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle is termed angina pectoris. Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, and upper abdomen,[8][13] where it may mimic heartburn. Levine's sign, in which patients localize the chest pain by clenching their fists over their sternums, has classically been thought to be predictive of cardiac chest pain, although a prospective observational study showed it had a poor positive predictive value.[14]
Shortness of breath (dyspnea) occurs when the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema. Other symptoms include diaphoresis (an excessive form of sweating),[15] weakness, light-headedness, nausea, vomiting, and palpitations. These symptoms are likely induced by a massive surge of catecholamines from the sympathetic nervous system[16] which occurs in response to pain and the hemodynamic abnormalities that result from cardiac dysfunction. Loss of consciousness (due to inadequate blood flow to the brain and cardiogenic shock) and sudden death (frequently due to the development of ventricular fibrillation) can occur in MIs.[8]
Female, elderly, and diabetic patients report atypical symptoms more frequently than their male and younger counterparts.[17][18] Women also report more numerous symptoms compared with men (2.6 on average vs. 1.8 symptoms in men).[17] The most common symptoms of MI in women include dyspnea, weakness, and fatigue. Fatigue, sleep disturbances, and dyspnea have been reported as frequently occurring symptoms that may manifest as long as one month before the actual clinically manifested ischemic event. In women, chest pain may be less predictive of coronary ischemia than in men.[19] Women may also experience back or jaw pain during an episode.[20]
At least one-fourth of all MIs are silent, without chest pain or other symptoms.[2][21] These cases can be discovered later on electrocardiograms, using blood enzyme tests or at autopsy without a prior history of related complaints. Estimates of the prevalence of silent MIs vary between 22 and 64%.[2] A silent course is more common in the elderly,[2] in patients with diabetes mellitus[22] and after heart transplantation, probably because the donor heart is not fully innervated by the nervous system of the recipient.[23] In people with diabetes, differences in pain threshold, autonomic neuropathy, and psychological factors have been cited as possible explanations for the lack of symptoms.[22]
Any group of symptoms compatible with a sudden interruption of the blood flow to the heart are called an acute coronary syndrome.[24]
The differential diagnosis includes other catastrophic causes of chest pain, such as pulmonary embolism, aortic dissection, pericardial effusion causing cardiac tamponade, tension pneumothorax, and esophageal rupture. Other noncatastrophic differentials include gastroesophageal reflux and Tietze's syndrome.[25]
Many of these risk factors are modifiable, so many heart attacks can be prevented by maintaining a healthier lifestyle. Physical activity, for example, is associated with a lower risk profile.[26] The effect of education is partially based on its effect on income and marital status.[27]
Smoking appears to be the cause of about 36% and obesity the cause of 20% of coronary artery disease.[28] Lack of exercise has been linked to 7-12% of cases.[28][29] Job stress appears to play a minor role, accounting for about 3% of cases.[28] Chronic high stress levels may cause some cases.[30]
Tobacco smoking, including secondhand smoke[31] Short-term exposure to air pollution, including carbon monoxide, nitrogen dioxide, and sulfur dioxide, but not ozone.[32] Lack of physical activity[3] Psychosocial factors including, low socioeconomic status, social isolation, negative emotions and stress increase the risk of and are associated with worse outcomes after MI. Socioeconomic factors such as a shorter education and lower income (particularly in women), and unmarried cohabitation are also correlated with a higher risk of MI.[27] Alcohol — prolonged exposure to high quantities of alcohol can increase the risk of heart attack.
Diabetes mellitus (type 1 or 2),[33] high blood pressure,[31] dyslipidemia/hypercholesterolemia (abnormal levels of lipoproteins in the blood), particularly high low-density lipoprotein, low high-density lipoprotein and high triglycerides[31] Obesity[34] (defined by a body mass index of more than 30 kg/m², or alternatively by waist circumference or waist-hip ratio).
A number of acute and chronic infections including: Chlamydophila pneumoniae, influenza, Helicobacter pylori, and Porphyromonas gingivalis among others have been linked to atherosclerosis and myocardial infarction.[35] As of 2013, there is no evidence of benefit from antibiotics or vaccination, however, calling the association into question.[35][36]
Male sex: at any given age, men are more at risk than women, particularly before menopause,[37] but because in general women live longer than men, ischemic heart disease causes slightly more total deaths in women.[3] Family history of ischaemic heart disease or MI, particularly if one has a first-degree relative (father, brother, mother, sister) who suffered a 'premature' myocardial infarction (defined as occurring at or younger than age 55 years (men) or 65 (women).[3]
Oral contraceptive pill–women who use combined oral contraceptive pills have a modestly increased risk of myocardial infarction, especially in the presence of other risk factors, such as smoking.[38]
An increased incidence of a heart attack is associated with time of day especially in the morning hours, more specifically around 9 am.[39][40][41]
Acute myocardial infarction refers to two subtypes of acute coronary syndrome, namely non-ST-elevated and ST-elevated MIs, which are most frequently (but not always) a manifestation of coronary artery disease.[42] The most common triggering event is the disruption of an atherosclerotic plaque in an epicardial coronary artery, which leads to a clotting cascade, sometimes resulting in total occlusion of the artery.[43][44] Atherosclerosis is the gradual buildup of cholesterol and fibrous tissue in plaques in the wall of arteries (in this case, the coronary arteries), typically over decades.[45] Blood stream column irregularities visible on angiography reflect artery lumen narrowing as a result of decades of advancing atherosclerosis.[46] Plaques can become unstable, rupture, and additionally promote the formation of a blood clot that occludes the artery; this can occur in minutes. When a severe enough plaque rupture occurs in the coronary vasculature, it leads to MI (necrosis of downstream myocardium).[43][44]
If impaired blood flow to the heart lasts long enough, it triggers a process called the ischemic cascade; the heart cells in the territory of the occluded coronary artery die (chiefly through necrosis) and do not grow back. A collagen scar forms in their place. Recent studies indicate that another form of cell death, apoptosis, also plays a role in the process of tissue damage subsequent to MI.[47] As a result, the patient's heart will be permanently damaged. This myocardial scarring also puts the patient at risk for potentially life-threatening arrhythmias, and may result in the formation of a ventricular aneurysm that can rupture with catastrophic consequences.
Injured heart tissue conducts electrical impulses more slowly than normal heart tissue. The difference in conduction velocity between injured and uninjured tissue can trigger re-entry or a feedback loop that is believed to be the cause of many lethal arrhythmias. The most serious of these arrhythmias is ventricular fibrillation (V-Fib/VF), an extremely fast and chaotic heart rhythm that is the leading cause of sudden cardiac death. Another life-threatening arrhythmia is ventricular tachycardia (V-tach/VT), which can cause sudden cardiac death. However, VT usually results in rapid heart rates that prevent the heart from pumping blood effectively. Cardiac output and blood pressure may fall to dangerous levels, which can lead to further coronary ischemia and extension of the infarct.
The cardiac defibrillator device was specifically designed to terminate these potentially fatal arrhythmias. The device works by delivering an electrical shock to the patient to depolarize a critical mass of the heart muscle, in effect "rebooting" the heart. This therapy is time-dependent, and the odds of successful defibrillation decline rapidly after the onset of cardiopulmonary arrest.
Myocardial infarction results from atherosclerosis.[8] Inflammation is known to be an important step in the process of atherosclerotic plaque formation.[48] C-reactive protein (CRP) is a sensitive but nonspecific marker for inflammation. Elevated CRP blood levels, especially measured with high-sensitivity assays, can predict the risk of MI, as well as stroke and development of diabetes.[48] Moreover, some drugs for MI might also reduce CRP levels.[48] The use of high-sensitivity CRP assays as a means of screening the general population is advised against, but it may be used optionally at the physician's discretion in patients who already present with other risk factors or known coronary artery disease.[49] Whether CRP plays a direct role in atherosclerosis remains uncertain.[48]
Calcium deposition is another part of atherosclerotic plaque formation. Calcium deposits in the coronary arteries can be detected with CT scans. Several studies have shown that coronary calcium can provide predictive information beyond that of classical risk factors.[50][51][52]
Hyperhomocysteinemia (high blood levels of the amino acid homocysteine) in homocysteinuria is associated with premature atherosclerosis;[53] whether elevated homocysteine in the normal range is causal is controversial.[54]
Pathological types[edit]
The two main types of acute myocardial infarction, based on pathology, are:
- Transmural AMI is associated with atherosclerosis involving a major coronary artery. It can be subclassified into anterior, posterior, inferior, lateral, or septal. Transmural infarcts extend through the whole thickness of the heart muscle and are usually a result of complete occlusion of the area's blood supply.[55] In addition, on ECG, ST elevation and Q waves are seen.
- Subendocardial AMI involves a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles. The subendocardial area is particularly susceptible to ischemia.[55] In addition, ST depression is seen on ECG.
A cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression, or coronary intervention is diagnostic of MI.[56]
WHO criteria[57] formulated in 1979 have classically been used to diagnose MI; a patient is diagnosed with MI if two (probable) or three (definite) of the following criteria are satisfied:
- Clinical history of ischaemic type chest pain lasting for more than 20 minutes
- Changes in serial ECG tracings
- Rise and fall of serum cardiac biomarkers
At autopsy, a pathologist can diagnose an MI based on anatomopathological findings.
Myocardial infarctions are generally classified into ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI).[42] A STEMI is the combination of symptoms related to poor oxygenation of the heart with elevation of the ST segments on the electrocardiogram followed by an increase in proteins in the blood related to heart muscles death.[58] They make up abut 25 to 40 percent of cases.[58]
The phrase "heart attack" is often used non-specifically to refer to a myocardial infarction and to sudden cardiac death. An MI is different from, but can cause cardiac arrest, which is the stopping of the heartbeat. It is also distinct from heart failure, in which the pumping action of the heart is impaired. However, an MI may lead to heart failure.[8]
A 2007 consensus document classifies MI into five main types:[59]
- Type 1 – spontaneous MI related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection
- Type 2 – MI secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anaemia, arrhythmias, hypertension, or hypotension
- Type 3 – sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischaemia, accompanied by new ST elevation, or new left bundle branch block (LBBB), or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of cardiac biomarkers in the blood
- Type 4 – associated with coronary angioplasty or stents:
- Type 4a – MI associated with Percutaneous coronary intervention (PCI)
- Type 4b – MI associated with stent thrombosis as documented by angiography or at autopsy
- Type 5 – MI associated with CABG
For a person to qualify as having an STEMI, the ECG must show new ST elevation in two or more contiguous leads.[58] This must be greater than 2 mm (0.2 mV) for males and greater than 1.5 mm (0.15mV) in females if in leads V2 and V3 or greater than 1 mm (0.1 mV) if it is in other ECG leads.[58] A left bundle branch block that is believed to be new used to be considered the same as ST elevation; however, this is no longer the case.[58] In early STEMIs there may just be peaked T wave with ST elevation developing later.[58]
Cardiac biomarkers[edit]
While there are a number of different biomarkers, troponins, are considered to be the best.[58]
A chest radiograph and routine blood tests may indicate complications or precipitating causes, and are often performed upon arrival to an emergency department. New regional wall motion abnormalities on an echocardiogram are also suggestive of an MI. Echo may be performed in equivocal cases by the on-call cardiologist.[60] In stable patients whose symptoms have resolved by the time of evaluation, technetium (99mTc) sestamibi (i.e. a "MIBI scan") or thallium-201 chloride can be used in nuclear medicine to visualize areas of reduced blood flow in conjunction with physiological or pharmacological stress.[60] Thallium may also be used to determine viability of tissue, distinguishing whether nonfunctional myocardium is actually dead or merely in a state of hibernation or of being stunned.[61]
Medical societies recommend that the physician confirm a person is at high risk for myocardial infarction before conducting imaging tests to make a diagnosis.[62] Patients who have a normal ECG and who are able to exercise, for example, do not merit routine imaging.[62] Imaging tests such as stress radionuclide myocardial perfusion imaging or stress echocardiography can confirm a diagnosis when a patient's history, physical exam, ECG, and cardiac biomarkers suggest the likelihood of a problem.[62]
The risk of a recurrent MI decreases with strict blood pressure management and lifestyle changes, chiefly smoking cessation, regular exercise, a sensible diet for those with heart disease, and limitation of alcohol intake. People are usually started on several long-term medications after an MI, with the aim of preventing further cardiovascular events such MIs, congestive heart failure, or cerebrovascular accident. Unless contraindicated, such medications may include the following:[63][64]
- Antiplatelet drug therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of plaque rupture and recurrent MI. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and aspirin may further reduce risk of cardiovascular events, but the risk of hemorrhage is increased.[65]
- Beta blocker therapy such as metoprolol or carvedilol should be started.[66] These have been particularly beneficial in those who are high-risk such as those with left ventricular dysfunction and/or continuing cardiac ischaemia.[67] β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.
- ACE inhibitor therapy should be commenced 24–48 hours after MI in those who are hemodynamically stable, particularly with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by ECG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling.[68]
- Statin therapy has been shown to reduce mortality and morbidity.[69] The protective effects of statins may be due to more than their LDL lowering effects. The general consensus is that statins have the ability to stabilize plaques and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids.[70]
- The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death after MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.[71] Spironolactone, another option, is sometimes preferable to eplerenone due to cost.
- Evidence supports the consumption of polyunsaturated fats instead of saturated fats as a measure of decreasing coronary heart disease.[72] In high-risk people, no clear-cut decrease in potentially fatal arrhythmias occurs due to omega-3 fatty acids and may actually increase risk in some groups.[73]
- Giving heparin to people with heart conditions like unstable angina and some forms of heart attacks reduces the risk of having another heart attack. However, heparin also increases the chance of minor bleeding.[74]
An MI requires immediate medical attention. Treatment attempts to save as much viable heart muscle as possible and to prevent further complications, hence the phrase "time is muscle".[75] Oxygen, aspirin, and nitroglycerin may be administered. Morphine was classically used if nitroglycerin was not effective; however, it may increase mortality in the setting of NSTEMI.[76] Reviews of high flow oxygen in myocardial infarction found increased mortality and infarct size, calling into question the recommendation about its routine use.[77][78] Other analgesics such as nitrous oxide are of unknown benefit.[7]
Percutaneous coronary intervention (PCI) is the treatment of choice for STEMI if it can be performed in a timely manner.[79] If PCI cannot be performed within 90 to 120 minutes then fibrinolysis, preferably within 30 minutes, is recommended.[80][81] If after fibrinolysis, significant cardiogenic shock, continued severe chest pain, or less than a 50% improvement in ST elevation after 90 minutes occurs, then rescue PCI is indicated emergently.[81][82] After PCI, people are generally placed on dual antiplatelet therapy for at least a year (which is generally aspirin and clopidogrel).[83]
Long term[edit]
Beta blockers are recommended in those without signs of heart failure or a heart block.[58] If used, they should be started in the first 24 hours.[58]
The prognosis after MI varies greatly depending on a person's health, the extent of the heart damage, and the treatment given.
In those who have an STEMI in the United States, between 5 to 6 percent die before leaving hospital and 7 to 18 percent die within a year.[58]
Using variables available in the emergency room, people with a higher risk of adverse outcome can be identified. One study found 0.4% of patients with a low-risk profile died after 90 days, whereas in high-risk people it was 21.1%.[84]
Some risk factors for death include: age, hemodynamic parameters (such as heart failure, cardiac arrest on admission, systolic blood pressure, or Killip class of two or greater), ST-segment deviation, diabetes, serum creatinine, peripheral vascular disease, and elevation of cardiac markers.[84][85][86] Assessment of left ventricular ejection fraction may increase the predictive power.[87] Prognosis is worse if a mechanical complication such as papillary muscle or myocardial free wall rupture occurs.[88] Morbidity and mortality from myocardial infarction has improved over the years due to better treatment.[89]
Complications may occur immediately following the heart attack (in the acute phase), or may need time to develop (a chronic problem). Acute complications may include heart failure if the damaged heart is no longer able to pump blood adequately around the body; aneurysm or rupture of the myocardium; mitral regurgitation, in particular if the infarction causes dysfunction of the papillary muscle; Dressler's syndrome; and arrhythmias, such as ventricular fibrillation, ventricular tachycardia, atrial fibrillation, and heart block. Longer-term complications include heart failure, atrial fibrillation, and the increased risk of a second MI.
Myocardial infarction is a common presentation of coronary artery disease. The World Health Organization estimated in 2004, that 12.2% of worldwide deaths were from ischemic heart disease;[11] with it being the leading cause of death in high- or middle-income countries and second only to lower respiratory infections in lower-income countries.[11] Worldwide, more than 3 million people have STEMIs and 4 million have NSTEMIs a year.[90] STEMIs occur about twice as often in men as women.[58]
Rates of death from ischemic heart disease (IHD) have slowed or declined in most high-income countries, although cardiovascular disease still accounted for one in three of all deaths in the USA in 2008.[91] In contrast, IHD is becoming a more common cause of death in the developing world. For example in India, IHD had become the leading cause of death by 2004, accounting for 1.46 million deaths (14% of total deaths) and deaths due to IHD were expected to double during 1985–2015.[92] Globally, disability adjusted life years (DALYs) lost to ischemic heart disease are predicted to account for 5.5% of total DALYs in 2030, making it the second-most-important cause of disability (after unipolar depressive disorder), as well as the leading cause of death by this date.[11]
Society and culture[edit]
In the United States, women who have had an MI are often treated with less medical interventions than men.[58]
In 2011, AMI was one of the top five most expensive conditions seen during inpatient hospitalizations in the U.S., with an aggregate cost of about $11.5 billion for 612,000 hospital stays.[93]
Legal implications[edit]
At common law, in general, a myocardial infarction is a disease, but may sometimes be an injury. This can create coverage issues in administration of no-fault insurance schemes such as workers' compensation. In general, a heart attack is not covered;[94] however, it may be a work-related injury if it results, for example, from unusual emotional stress or unusual exertion.[95] In addition, in some jurisdictions, heart attacks suffered by persons in particular occupations such as police officers may be classified as line-of-duty injuries by statute or policy. In some countries or states, a person having suffered from an MI may be prevented from participating in activity that puts other people's lives at risk, for example driving a car or flying an airplane.[96]
Patients who receive stem cell treatment by coronary artery injections of stem cells derived from their own bone marrow after an MI show improvements in left ventricular ejection fraction and end-diastolic volume not seen with placebo. The larger the initial infarct size, the greater the effect of the infusion. Clinical trials of progenitor cell infusion as a treatment approach to STEMI are underway.[97]
Currently, three biomaterial and tissue engineering approaches are used for the treatment of post-MI conditions, but these are in an even earlier stage of medical research. Many questions and issues must be addressed before they can be applied to patients. The first involves polymeric left ventricular restraints in the prevention of heart failure. The second uses in vitro-engineered cardiac tissue, which is subsequently implanted in vivo. The final approach entails injecting cells and/or a scaffold into the myocardium to create in situ-engineered cardiac tissue.[98]
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External links[edit]
Find more about Myocardial infarction at Wikipedia's sister projects | |
Definitions and translations from Wiktionary | |
Media from Commons | |
Quotations from Wikiquote | |
Source texts from Wikisource | |
Textbooks from Wikibooks | |
Learning resources from Wikiversity |
- Cardiac disorders - Open Directory Project
- American Heart Association's Heart Attack web site — Information and resources for preventing, recognizing and treating heart attack.


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