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myocardial infarction and has powerful prognostic value Killip Class I is absence of rales and S3, Class II is rales that do not clear with coughing over one-third or less of the lung fields or presence of an S3, Class III is rales that do not clear with coughing over more than one-third of the lung fields, and Class IV is cardiogenic shock (rales, hypotension, and signs of hypoperfusion) 3 Heart The cardiac examination may be unimpressive or very abnormal An abnormally located ventricular impulse often represents the dyskinetic infarcted region Jugular venous distention reflects RA hypertension, which may indicate RV infarction or elevated LV filling pressures The absence of elevated central venous pressure, however, does not indicate normal LA or LV diastolic pressures Soft heart sounds may indicate LV dysfunction Atrial gallops (S4) are the rule, whereas ventricular gallops (S3) are less common and indicate significant LV dysfunction Mitral regurgitation murmurs are not uncommon and usually indicate papillary muscle dysfunction or, rarely, rupture Pericardial friction rubs are uncommon in the first 24 hours but may appear later 4 Extremities Edema is usually not present Cyanosis and cold temperature indicate low output The peripheral pulses should be noted, since later shock or emboli may alter the examination

1 Premonitory pain Many patients give a history of alteration in the pattern of angina preceding the time of onset of symptoms of myocardial infarction, classically the onset of angina with minimal exertion or at rest 2 Pain of infarction Unlike anginal episodes, most infarctions occur at rest, and more commonly in the early morning The pain is similar to angina in location and radiation but it may be more severe, and it builds up rapidly or in waves to maximum intensity over a few minutes or longer Nitroglycerin has little effect; even opioids may not relieve the pain 3 Associated symptoms Patients may break out in a cold sweat, feel weak and apprehensive, and move about, seeking a position of comfort They prefer not to lie quietly Lightheadedness, syncope, dyspnea, orthopnea, cough, wheezing, nausea and vomiting, or abdominal bloating may be present singly or in any combination 4 Painless infarction One-third of patients with acute myocardial infarction present without chest pain, and these patients tend to be undertreated and have poor outcomes Older patients, women, and patients with diabetes mellitus are more likely to present without classic chest pain As many as 25% of infarctions are detected on routine ECG without any recallable acute episode 5 Sudden death and early arrhythmias Of all deaths from myocardial infarction, about 50% occur before the patients arrive at the hospital, with death presumably caused by ventricular fibrillation

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The most valuable laboratory tests are cardiac-specific markers of myocardial damage, including quantitative determinations of CK-MB, troponin I, and troponin T Troponins are more sensitive and specific but stay elevated for days and, therefore, are generally not useful for evaluating suspected early reinfarction Each of these tests may become positive as early as 4 6 hours after the onset of a myocardial infarction and should be abnormal by 8 12 hours Circulating levels of troponins may remain elevated for 5 7 days or longer

lactic acid to glucose and its oxidation principally by the liver but also by the kidneys represent the chief pathways for its removal Overproduction of lactic acid (tissue hypoxia), deficient removal (hepatic failure), or both (circulatory collapse) can cause accumulation Lactic acidosis is not uncommon in any severely ill patient suffering from cardiac decompensation, respiratory or hepatic failure, septicemia, or infarction of bowel or extremities With the discontinuance of phenformin therapy in the United States, lactic acidosis in patients with diabetes mellitus has become uncommon but occasionally occurs in metformin-treated patients (see above) and it still must be considered in the acidotic diabetic, especially if the patient is seriously ill

If severe hypophosphatemia (serum phosphate < 1 mg/dL [< 032 mmol/L]) develops during insulin therapy, phosphate replacement can be given as described for ketoacidotic patients (at 3 mmol/h)

The main clinical feature of lactic acidosis is marked hyperventilation When lactic acidosis is secondary to tissue hypoxia or vascular collapse, the clinical presentation is variable, being that of the prevailing catastrophic illness However, in the idiopathic, or spontaneous, variety, the onset is rapid (usually over a few hours), blood pressure is normal, peripheral circulation is good, and there is no cyanosis

The overall mortality rate of hyperglycemic hyperosmolar, state coma is more than ten times that of diabetic ketoacidosis, chiefly because of its higher incidence in older patients, who may have compromised cardiovascular systems or associated major illnesses and whose dehydration is often excessive because of delays in recognition and treatment (When patients are matched for age, the prognoses of these two hyperglycemic emergencies are reasonably comparable) When prompt therapy is instituted, the mortality rate can be reduced from nearly 50% to that related to the severity of coexistent disorders

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