Conventional long name	Republic of Uganda Jamhuri ya Uganda
Common name	Uganda
Image coat	Coat of Arms of Uganda.jpg
National motto	For God and My Country
National anthem	"Oh Uganda, Land of Beauty"
Nickname	The Pearl of Africa
Official languages	English, Swahili
Languages type	Vernacular languages
Languages	Luganda, Luo, Runyankore, Ateso, Lumasaba, Lusoga, Lunyole, Samia
Demonym	Ugandan
Capital	Kampala
Largest city	capital
Government type	Democratic Republic
Leader title1	President
Leader name1	Yoweri Museveni
Leader title2	Prime Minister
Leader name2	Amama Mbabazi
Area km2	236,040
Area rank	81st
Area magnitude	1 E11
Area sq mi	91,136
Percent water	15.39
Population estimate	32,369,558
Population estimate year	2009
Population estimate rank	37th
Population census	24,227,297
Population census year	2002
Population density km2	137.1
Population density sq mi	355.2
Population density rank	80th
Gdp ppp year	2010
Gdp ppp	$42.194 billion
Gdp ppp per capita	$1,226
Gdp nominal	$17.703 billion
Gdp nominal year	2010
Gdp nominal per capita	$514
Hdi year	2010
Hdi	0.422
Hdi rank	143rd
Hdi category	low
Gini	43
Gini year	1998
Gini category	medium
Fsi	96.4 0.1
Fsi year	2007
Fsi rank	15th
Fsi category	Alert
Sovereignty type	Independence
Established event1	from the United Kingdom
Established date1	9 October 1962
Currency	Ugandan shilling
Currency code	UGX
Time zone	EAT
Utc offset	+3
Time zone dst	''not observed''
Utc offset dst	+3
Drives on	left
Cctld	.ug
Calling code	+2561
Footnotes	1 006 from Kenya and Tanzania.

Uganda ( or ), officially the Republic of Uganda, is a landlocked country in East Africa. Uganda is also known as the "Pearl of Africa". It is bordered on the east by Kenya, on the north by South Sudan, on the west by the Democratic Republic of the Congo, on the southwest by Rwanda, and on the south by Tanzania. The southern part of the country includes a substantial portion of Lake Victoria, which is also bordered by Kenya and Tanzania.

Uganda takes its name from the Buganda kingdom, which encompassed a portion of the south of the country including the capital Kampala.

The people of Uganda were hunter-gatherers until 1,700 to 2,300 years ago, when Bantu-speaking populations migrated to the southern parts of the country. Uganda gained independence from Britain on 9 October 1962.

The official languages are English and Swahili, although multiple other languages are spoken in the country.

History

The Ugandans were hunter-gatherers until 1,700 to 2,300 years ago. Bantu-speaking populations, who were probably from central Africa, migrated to the southern parts of the country. These groups brought and developed ironworking skills and new ideas of social and political organization. The Empire of Kitara covered most of the great lakes area, from Lake Albert, Lake Tanganyika, Lake Victoria, to Lake Kyoga. Its leadership headquarters were mainly in what became Ankole, believed to have been run by the Bachwezi dynasty in the fourteenth and fifteenth centuries, who may have followed a semi-legendary dynasty known as the Batembuzi. Bunyoro-Kitara is claimed as the antecedent of later kingdoms; Buganda and Ankole. The Nilotic Luo invasion is believed to have led the collapse of Chwezi empire. The twins Rukidi Mpuuga and Kato Kimera are believed to be the first kings of Bunyonro and Buganda after the Chwezi Empire collapsed, creating the Babiito and Bambejja Dynasty. Nilotic people including Luo and Ateker entered the area from the north, probably beginning about A.D. 120. They were cattle herders and subsistence farmers who settled mainly the northern and eastern parts of the country. Some Luo invaded the area of Bunyoro and assimilated with the Bantu there, establishing the Babiito dynasty of the current ''Omukama'' (ruler) of Bunyoro-Kitara. Luo migration continued until the 16th century, with some Luo settling amid Bantu people in Eastern Uganda, with others proceeding to the western shores of Lake Victoria in Kenya and Tanzania. The Ateker (Karimojong and Iteso) settled in the northeastern and eastern parts of the country, and some fused with the Luo in the area north of Lake Kyoga.

Arab traders moved inland from the Indian Ocean coast of East Africa in the 1830s. They were followed in the 1860s by British explorers searching for the source of the Nile. Protestant missionaries entered the country in 1877, followed by Catholic missionaries in 1879. The United Kingdom placed the area under the charter of the British East Africa Company in 1888, and ruled it as a protectorate from 1894.

As several other territories and chiefdoms were integrated, the final protectorate called Uganda took shape in 1914. From 1900 to 1920, a sleeping sickness epidemic killed more than 250,000 people, about two-thirds of the population in the affected lake-shore areas.

Uganda gained independence from Britain in 1962, maintaining its Commonwealth membership. The first post-independence election, held in 1962, was won by an alliance between the Uganda People's Congress (UPC) and Kabaka Yekka (KY). UPC and KY formed the first post-independence government with Milton Obote as executive Prime Minister, the Buganda Kabaka (King) Edward Muteesa II holding the largely ceremonial position of President and William Wilberforce Nadiope, the Kyabazinga (paramount chief) of Busoga, as Vice President.

In 1966, following a power struggle between the Obote-led government and King Muteesa, the UPC-dominated Parliament changed the constitution and removed the ceremonial president and vice president. In 1967, a new constitution proclaimed Uganda a republic and abolished the traditional kingdoms. Without first calling elections, Obote was declared the executive President.

Obote was deposed from office in 1971 when Idi Amin seized power. Amin ruled the country with the military for the next eight years. Amin's rule cost an estimated 300,000 Ugandans' lives. He forcibly removed the entrepreneurial South Asian minority from Uganda. The Ugandan economy was devastated.

Amin's reign was ended after the Uganda-Tanzania War in 1979 in which Tanzanian forces aided by Ugandan exiles invaded Uganda. This led to the return of Obote, who was deposed once more in 1985 by General Tito Okello. Okello ruled for six months until he was deposed after the so called "bush war" by the National Resistance Army (NRA) operating under the leadership of the current president, Yoweri Museveni, and various rebel groups, including the Federal Democratic Movement of Andrew Kayiira, and another belonging to John Nkwaanga.

Museveni has been in power since 1986. In the mid to late 1990s, he was lauded by the West as part of a new generation of African leaders. His presidency has included involvement in the civil war in the Democratic Republic of Congo (DRC) and other conflicts in the Great Lakes region, as well as the civil war against the Lord's Resistance Army, which has been guilty of numerous crimes against humanity including child slavery and mass murder. Conflict in northern Uganda has killed thousands and displaced millions.

Government

The President of Uganda, currently Yoweri Kaguta Museveni, is both head of state and head of government. The President appoints a Vice President, currently Edward Ssekandi, and a prime minister, currently Amama Mbabazi, who aid him in governing. The parliament is formed by the National Assembly, which has 332 members. 104 of these members are nominated by interest groups, including women and the army. The remaining members are elected for five-year terms during general elections.

Political parties were restricted in their activities from 1986, in a measure ostensibly designed to reduce sectarian violence. In the non-party "Movement" system instituted by Museveni, political parties continued to exist, but they could only operate a headquarters office. They could not open branches, hold rallies, or field candidates directly (although electoral candidates could belong to political parties). A constitutional referendum canceled this nineteen-year ban on multi-party politics in July 2005. Additionally, the time limit for president was changed in the constitution from the two-term limit, in order to enable the current president to continue in active politics.

The presidential elections were held in February, 2006. Yoweri Museveni ran against several candidates, the most prominent of whom being the exiled Dr. Kizza Besigye.

On Sunday, 20 February 2011, the Uganda Electoral Commission declared the 24-year reigning president Yoweri Kaguta Museveni the winning candidate of the 2011 elections that were held on the 18th of February 2011. The opposition were however not satisfied with the results, condemning them as full of sham and rigging. According to the results released, Museveni won with 68% of the votes, easily topping his nearest foe Kizza Besigye. Kizza Besigye who formerly was Museveni's physician told reporters that he and his supporters 'downrightly snub' the outcome as well as the unremitting rule of Museveni or any person he may appoint. Kizza Besigye added that the rigged elections would definitely lead to an illegitimate lead and added that it is up to Ugandans to critically analyse this.

The EU Election Observation Mission reported on improvements and flaws of the Ugandan electoral process against International Standards for democratic elections: « The electoral campaign and polling day were conducted in a peaceful manner (…) However, the electoral process was marred by avoidable administrative and logistical failures that led to an unacceptable number of Ugandan citizen being disfranchised ».

Yoweri Museveni will be heading Uganda for another 5 years and the next elections are anticipated to be in 2016.

Geography

The country is located on the East African plateau, lying mostly between latitudes 4°N and 2°S (a small area is north of 4°), and longitudes 29° and 35°E. It averages about above sea level, and this slopes very steadily downwards to the Sudanese Plain to the north. However, much of the south is poorly drained, while the centre is dominated by Lake Kyoga, which is also surrounded by extensive marshy areas. Uganda lies almost completely within the Nile basin. The Victoria Nile drains from the lake into Lake Kyoga and thence into Lake Albert on the Congolese border. It then runs northwards into Sudan. One small area on the eastern edge of Uganda is drained by the Turkwel River, part of the internal drainage basin of Lake Turkana.It was named after the Founder Adnan

Lake Kyoga serves as a rough boundary between Bantu speakers in the south and Nilotic and Central Sudanic language speakers in the north. Despite the division between north and south in political affairs, this linguistic boundary actually runs roughly from northwest to southeast, near the course of the Nile. However, many Ugandans live among people who speak different languages, especially in rural areas. Some sources describe regional variation in terms of physical characteristics, clothing, bodily adornment, and mannerisms, but others claim that those differences are disappearing.

Although generally equatorial, the climate is not uniform as the altitude modifies the climate. Southern Uganda is wetter with rain generally spread throughout the year. At Entebbe on the northern shore of Lake Victoria, most rain falls from March to June and the November/December period. Further to the north a dry season gradually emerges; at Gulu about 120 km from the Sudanese border, November to February is much drier than the rest of the year.

The northeastern Karamoja region has the driest climate and is prone to droughts in some years. Rwenzori in the southwest on the border with Congo (DRC) receives heavy rain all year round. The south of the country is heavily influenced by one of the world's biggest lakes, Lake Victoria, which contains many islands. It prevents temperatures from varying significantly and increases cloudiness and rainfall. Most important cities are located in the south, near Lake Victoria, including the capital Kampala and the nearby city of Entebbe.

Although landlocked, Uganda contains many large lakes, besides Lake Victoria and Lake Kyoga, there are Lake Albert, Lake Edward and the smaller Lake George.

Districts, counties and kingdoms

Uganda is divided into districts, spread across four administrative regions: Northern, Eastern, Central (Kingdom of Buganda) and Western. The districts are subdivided into counties. A number of districts have been added in the past few years, and eight others were added on July 1, 2006 plus others added in 2010. There are now over 100 districts. Most districts are named after their main commercial and administrative towns. Each district is divided into sub-districts, counties, sub-counties, parishes and villages.

Parallel with the state administration, six traditional Bantu kingdoms have remained, enjoying some degrees of mainly cultural autonomy. The kingdoms are Toro, Ankole, Busoga, Bunyoro, Buganda and Rwenzururu.

Economy

For decades, Uganda's economy suffered from devastating economic policies and instability, leaving Uganda as one of the world's poorest countries. The country has commenced economic reforms and growth has been robust. In 2008, Uganda recorded 7% growth despite the global downturn and regional instability.

Uganda has substantial natural resources, including fertile soils, regular rainfall, and sizable mineral deposits of copper and cobalt. The country has largely untapped reserves of both crude oil and natural gas. While agriculture used to account for 56% of the economy in 1986, with coffee as its main export, it has now been surpassed by the services sector, which accounted for 52% of percent GDP in 2007. In the 1950s the British Colonial regime encouraged some 500,000 subsistence farmers to join co-operatives. Since 1986, the government (with the support of foreign countries and international agencies) has acted to rehabilitate an economy devastated during the regime of Idi Amin and subsequent civil war. Inflation ran at 240% in 1987 and 42% in June 1992, and was 5.1% in 2003.

Between 1990 and 2001, the economy grew because of continued investment in the rehabilitation of infrastructure, improved incentives for production and exports, reduced inflation and gradually improved domestic security. Ongoing Ugandan involvement in the war in the Democratic Republic of the Congo, corruption within the government, and slippage in the government's determination to press reforms raise doubts about the continuation of strong growth.

In 2000, Uganda was included in the Heavily Indebted Poor Countries (HIPC) debt relief initiative worth $1.3 billion and Paris Club debt relief worth $145 million. These amounts combined with the original HIPC debt relief added up to about $2 billion. In 2006 the Ugandan Government successfully paid all their debts to the Paris Club, which meant that it was no longer in the (HIPC) list. Growth for 2001–2002 was solid despite continued decline in the price of coffee, Uganda's principal export. According to IMF statistics, in 2004 Uganda's GDP per capita reached $300, a much higher level than in the 1980s but still at half the Sub-Saharan African average income of $600 per year. Total GDP crossed the 8 billion dollar mark in the same year.

Economic growth has not always led to poverty reduction. Despite an average annual growth of 2.5% between 2000 and 2003, poverty levels increased by 3.8% during that time. This has highlighted the importance of avoiding jobless growth and is part of the rising awareness in development circles of the need for equitable growth not just in Uganda, but across the developing world.

With the Uganda securities exchanges established in 1996, several equities have been listed. The Government has used the stock market as an avenue for privatisation. All Government treasury issues are listed on the securities exchange. The Capital Markets Authority has licensed 18 brokers, asset managers and investment advisors including names like African Alliance, AIG Investments, Renaissance Capital and SIMMS. As one of the ways of increasing formal domestic savings, Pension sector reform is the centre of attention (2007).

Uganda depends on Kenya for access to international markets. Uganda is part of the East African Community and a potential member of the planned East African Federation.

Demographics

Uganda is home to many different ethnic groups, none of whom forms a majority of the population. Around forty different languages are regularly and currently in use in the country. English became the official language of Uganda after independence. Ugandan English is a local variant dialect.

The most widely spoken local language in Uganda is Luganda, spoken predominantly by the Ganda people (''Baganda'') in the urban concentrations of Kampala, the capital city and in towns and localities in the Buganda region of Uganda which encompasses Kampala. The Lusoga and Runyankore-Rukiga languages follow, spoken predominantly in the southeastern and southwestern parts of Uganda respectively.

Swahili, a widely used language throughout eastern and central East Africa, was approved as the country's second official national language in 2005, though this is somewhat politically sensitive. Though the language has not been favoured by the Bantu-speaking populations of the south and southwest of the country, it is an important ''lingua franca'' in the northern regions. It is also widely used in the police and military forces, which may be a historical result of the disproportionate recruitment of northerners into the security forces during the colonial period. The status of Swahili has thus alternated with the political group in power. For example, Amin, who came from the northwest, declared Swahili to be the national language.

Uganda’s population has grown from 4.8 million people in 1950 to 24.3 million in 2002. The current estimated population of Uganda is 32.4 million. Uganda has a very young population, with a median age of 15 years.

Religion

{{bar box |title=Religion in Uganda |titlebar=#ddd |left1=Religion |right1=percent |float=right |bars= }} According to the census of 2002, Christians made up about 84% of Uganda's population. The Roman Catholic Church has the largest number of adherents (41.9%), followed by the Anglican Church of Uganda (35.9%). Evangelical and Pentecostal churches claim the rest of the Christian population. The next most reported religion of Uganda is Islam, with Muslims representing 12% of the population. The Muslim population is primarily Sunni; there is also a minority belonging to the Ahmadiyya Muslim Community. The remainder of the population follow traditional religions (1%), Bahai (0.1%), or other non-Christian religions (0.7%), or have no religious affiliation (0.9%).

Traditional indigenous beliefs are practiced in some rural areas and are sometimes blended with or practiced alongside Christianity or Islam. In addition to a small community of Jewish expatriates centered in Kampala, Uganda is home to the Abayudaya, a native Jewish community dating from the early 1900s. One of the world's seven Bahá'í Houses of Worship is located on the outskirts of Kampala. See also Bahá'í Faith in Uganda.

According to the ''World Refugee Survey 2008'', published by the U.S. Committee for Refugees and Immigrants, Uganda hosted a population of refugees and asylum seekers numbering 235,800 in 2007. The majority of this population came from Sudan (162,100 persons), but also included refugees and asylum seekers from the Democratic Republic of the Congo (41,800), Rwanda (21,200), Somalia (5,700) and Burundi (3,100).

Indian nationals are the most significant immigrant population; members of this community are primarily Ismaili (Shi'a Muslim followers of the Aga Khan) or Hindu. More than 30 years ago, there were about 80,000 Indians in Uganda. Today there are about 15,000. The northern and West Nile regions are predominantly Catholic, while Iganga District in eastern Uganda has the highest percentage of Muslims. The rest of the country has a mix of religious affiliations.

Health

Uganda has been among the rare HIV success stories, one of the reasons being openness. In the 1980s, more than 30% of Ugandan residents had HIV; this had fallen to 6.4% by the end of 2008, the most effective national response to AIDS of any African country. This is supported by the findings of a 2006 study that modern contraceptive use in Uganda is low.

Infant mortality rate was at 79 per 1,000 in 2005. Life expectancy was at 50.2 for females, and 49.1 for males in 2005. There were 8 physicians per 100,000 persons in the early 2000s.

Uganda's elimination of user fees at state health facilities in 2001 has resulted in an 80% increase in visits; over half of this increase is from the poorest 20% of the population. This policy has been cited as a key factor in helping Uganda achieve its Millennium Development Goals and as an example of the importance of equity in achieving those goals.

Culture and sport

Owing to the large number of communities, culture within Uganda is diverse. Many Asians (mostly from India) who were expelled during the regime of Amin have returned to Uganda.

Cricket has experienced rapid growth although football is the most popular sport in Uganda. Recently in the Quadrangular Tournament in Kenya, Uganda came in as the underdogs and went on to register a historic win against archrivals Kenya. Uganda also won the World Cricket League (WCL) Division 3 and came in fourth place in the WCL Division 2. In February 2009, Uganda finished as runner-up in the WCL Division 3 competition held in Argentina, thus gaining a place in the World Cup Qualifier held in South Africa in April 2009. In 2007 the Ugandan Rugby Union team were victorious in the 2007 Africa Cup, beating Madagascar in the final.

Rallying is also a popular sport in Uganda with the country having successfully staged a round of the African Rally Championship (ARC), Pearl of Africa Rally since 1996 when it was a candidate event. The country has gone on to produce African rally champions such as Charles Muhangi who won the 1999 ARC crown. Other notable Ugandans on the African rally scene include the late Riyaz Kurji who was killed in an fatal accident while leading the 2009 edition, Emma Katto, Karim Hirji, Chipper Adams and Charles Lubega. Ugandans have also featured prominently in the Safari Rally.

Ugandans have since the early 1920s enjoyed the fast-paced sport of hockey. It was originally played by the Asians, but now it is widely played by people from other racial backgrounds. Hockey is the only Ugandan field sport to date to have qualified for and represented the country at the Olympics; this was at the Munich games in 1972. It is also believed in Ugandan hockey circles that Uganda's first and only Olympic gold medal may have been realized in part by the cheers from the representative hockey team that urged John Akii-Bua forward.

Also in July of 2011 Kampala,Uganda qualified for the 2011 Little League World Series in Williamsport, Pennsylvania for the first time beating Dharan LL in Saudi Arabia.

Education

Illiteracy is common in Uganda, particularly among females. Public spending on education was at 5.2 % of the 2002–2005 GDP. Much public education in primary and secondary schools focus upon repetition and memorization. There are also state exams that must be taken at every level of education. Uganda has both private and public universities. The largest university in Uganda is Makerere University located outside of Kampala. The system of education in Uganda has a structure of 7 years of primary education, 6 years of secondary education (divided into 4 years of lower secondary and 2 years of upper secondary school), and 3 to 5 years of post-secondary education. The present system has existed since the early 1960s.

Cuisine

Ugandan cuisine consists of traditional cooking with English, Arab, Asian and especially Indian influences. Like the cuisines of most countries, it varies in complexity, from the most basic, a starchy filler with a sauce of beans or meat, to several-course meals served in upper-class homes and high-end restaurants.

Main dishes are usually centered on a sauce or stew of groundnuts, beans or meat. The starch traditionally comes from ugali (maize meal) or matoke (boiled and mashed green banana), in the South, or an ugali made from millet in the North. Cassava, yam and African sweet potato are also eaten; the more affluent include white (often called "Irish") potato and rice in their diets. Soybean was promoted as a healthy food staple in the 1970s and this is also used, especially for breakfast. Chapati, an Asian flatbread, is also part of Ugandan cuisine.

Human rights

Respect for human rights in Uganda has improved significantly since the mid-1980s. There are, however, many areas which continue to attract concern.

Conflict in the northern parts of the country continues to generate reports of abuses by both the rebel Lord's Resistance Army (LRA) and the Ugandan Army. A UN official accused the LRA in February 2009 of "appalling brutality" in the Democratic Republic of Congo. The number of internally displaced persons is estimated at 1.4 million. Torture continues to be a widespread practice amongst security organisations. Attacks on political freedom in the country, including the arrest and beating of opposition Members of Parliament, has led to international criticism, culminating in May 2005 in a decision by the British government to withhold part of its aid to the country. The arrest of the main opposition leader Kizza Besigye and the besiegement of the High Court during a hearing of Besigye's case by heavily armed security forces – before the February 2006 elections – led to condemnation.

Recently, grassroots organisations have been attempting to raise awareness about children who were kidnapped by the Lord's Resistance Army to work as soldiers or be used as wives. Thousands of children as young as eight were captured and forced to kill. The documentary film ''Invisible Children'' illustrates the terrible lives of the children, known as night commuters, who still to this day leave their villages and walk many miles each night to avoid abduction.

The U.S. Committee for Refugees and Immigrants reported several violations of refugee rights in 2007, including forcible deportations by the Ugandan government and violence directed against refugees.

Homosexuality is illegal in Uganda. Gays and lesbians face discrimination and harassment at the hands of the media, police, teachers and other groups. In 2007, a Ugandan newspaper, ''The Red Pepper'', published a list of allegedly gay men, many of whom suffered harassment as a result. Also on October 9, 2010, the Ugandan newspaper ''Rolling Stone'' published a front page article—titled "100 Pictures of Uganda's Top Homos Leak"—that listed the names, addresses, and photographs of 100 homosexuals alongside a yellow banner that read "Hang Them". The paper also alleged that homosexuals aimed to "recruit" Ugandan children. This publication attracted international attention and criticism from human rights organisations, such as Amnesty International, No Peace Without Justice and the International Lesbian, Gay, Bisexual, Trans and Intersex Association. According to gay rights activists, many Ugandans have been attacked since the publication. On January 27, 2011, gay rights activist David Kato was murdered. Kato was on ''Rolling Stone'''s hitlist. Also a number of other gays and lesbian are missing and are believed to have been murdered.

The Uganda parliament recently considered an Anti-Homosexuality Bill, if enacted, would have broadened the criminalisation of homosexuality by introducing the death penalty for people who have previous convictions, or are HIV-positive, and engage in same sex sexual acts. The bill also included provisions for Ugandans who engage in same-sex sexual relations outside of Uganda, asserting that they may be extradited back to Uganda for punishment, and included penalties for individuals, companies, media organisations, or non-governmental organisations that support LGBT rights. The private member's bill was submitted by MP David Bahati in Uganda on 14 October 2009, and is believed to have had widespread support in the Uganda parliament. Debate of the bill was delayed in response to global condemnation.

See also

Cabinet of Uganda

List of schools in Uganda

List of national parks of Uganda

Kisizi

The Uganda Scouts Association

Uganda AIDS Orphan Children Foundation

''War/Dance''

References

External links

Talking Ugandans Forum

Chief of State and Cabinet Members

Uganda from ''UCB Libraries GovPubs''

Humanitarian news and analysis from IRIN – Uganda

Humanitarian information coverage on ReliefWeb

Map Uganda At UN.org

Country Profile from BBC News

Uganda Tourist Board

Uganda Humanist Schools Trust

Radio France International – dossier on Uganda and Lord's Resistance Army

Uganda Social Bookmarking;Discover and Share Uganda Web content and News

Category:African countries Category:Bantu countries and territories Category:East Africa Category:English-speaking countries and territories Category:Landlocked countries Category:Least developed countries Category:Member states of the African Union Category:Member states of the Commonwealth of Nations Category:Member states of the Organisation of Islamic Cooperation Category:States and territories established in 1962 Category:Swahili-speaking countries and territories Category:Member states of the United Nations

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name	Myocardial infarction
disasesdb	8664
icd10	-
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Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (''infarction'') of heart muscle tissue (''myocardium'').

Classical symptoms of acute myocardial infarction include sudden chest pain (typically radiating to the left arm or left side of the neck), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety (often described as a sense of impending doom). Women may experience fewer typical symptoms than men, most commonly shortness of breath, weakness, a feeling of indigestion, and fatigue. Approximately one quarter of all myocardial infarctions are "silent", without chest pain or other symptoms.

Among the diagnostic tests available to detect heart muscle damage are an electrocardiogram (ECG), echocardiography, and various blood tests. The most often used markers are the creatine kinase-MB (CK-MB) fraction and the troponin levels. Immediate treatment for suspected acute myocardial infarction includes oxygen, aspirin, and sublingual nitroglycerin.

Most cases of STEMI (ST elevation MI) are treated with thrombolysis or percutaneous coronary intervention (PCI). NSTEMI (non-ST elevation MI) should be managed with medication, although PCI is often performed during hospital admission. In people who have multiple blockages and who are relatively stable, or in a few emergency cases, bypass surgery may be an option.

Heart attacks are the leading cause of death for both men and women worldwide. Important risk factors are previous cardiovascular disease, older age, tobacco smoking, high blood levels of certain lipids (triglycerides, low-density lipoprotein) and low levels of high density lipoprotein (HDL), diabetes, high blood pressure, obesity, chronic kidney disease, heart failure, excessive alcohol consumption, the abuse of certain drugs (such as cocaine and methamphetamine), and chronic high stress levels.

Classification

There are two basic types of acute myocardial infarction: Transmural: associated with atherosclerosis involving major coronary artery. It can be subclassified into anterior, posterior, or inferior. 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. Subendocardial: involving a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles. Subendocardial infarcts are thought to be a result of locally decreased blood supply, possibly from a narrowing of the coronary arteries. The subendocardial area is farthest from the heart's blood supply and is more susceptible to this type of pathology.

Clinically, a myocardial infarction can be further subclassified into a ST elevation MI (STEMI) versus a non-ST elevation MI (non-STEMI) based on ECG changes.

The phrase "heart attack" is sometimes used incorrectly to describe sudden cardiac death, which may or may not be the result of acute myocardial infarction. A heart attack is different from, but can be the cause of cardiac arrest, which is the stopping of the heartbeat, and cardiac arrhythmia, an abnormal heartbeat. It is also distinct from heart failure, in which the pumping action of the heart is impaired; severe myocardial infarction may lead to heart failure, but not necessarily.

A 2007 consensus document classifies myocardial infarction into five main types:

Type 1 – Spontaneous myocardial infarction related to ischaemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection

Type 2 – Myocardial infarction secondary to ischaemia 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 presumably new ST elevation, or new 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 – Myocardial infarction associated with PCI

* Type 4b – Myocardial infarction associated with stent thrombosis as documented by angiography or at autopsy

Type 5 – Myocardial infarction associated with CABG

Signs and symptoms

The onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes, and rarely instantaneous. Chest pain is the most common symptom of acute myocardial infarction 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 epigastrium, where it may mimic heartburn. Levine's sign, in which the patient localizes the chest pain by clenching their fist over the sternum, has classically been thought to be predictive of cardiac chest pain, although a prospective observational study showed that it had a poor positive predictive value.

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), weakness, light-headedness, nausea, vomiting, and palpitations. These symptoms are likely induced by a massive surge of catecholamines from the sympathetic nervous system which occurs in response to pain and the hemodynamic abnormalities that result from cardiac dysfunction. Loss of consciousness (due to inadequate cerebral perfusion and cardiogenic shock) and sudden death (frequently due to the development of ventricular fibrillation) can occur in myocardial infarctions.

Women and older patients report atypical symptoms more frequently than their male and younger counterparts. Women also report more numerous symptoms compared with men (2.6 on average vs 1.8 symptoms in men). The most common symptoms of MI in women include dyspnea (shortness of breath), weakness, and fatigue. Fatigue, sleep disturbances, and dyspnea have been reported as frequently occurring symptoms which 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.

Approximately one fourth of all myocardial infarctions are silent, without chest pain or other symptoms. These cases can be discovered later on electrocardiograms, using blood enzyme tests or at autopsy without a prior history of related complaints. A silent course is more common in the elderly, in patients with diabetes mellitus and after heart transplantation, probably because the donor heart is not fully innervated by the nervous system of the recipient. In diabetics, differences in pain threshold, autonomic neuropathy, and psychological factors have been cited as possible explanations for the lack of symptoms.

Any group of symptoms compatible with a sudden interruption of the blood flow to the heart are called an acute coronary syndrome.

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 non-catastrophic differentials include gastroesophageal reflux and Tietze's syndrome.

Causes

Heart attack rates are higher in association with intense exertion, be it psychological stress or physical exertion, especially if the exertion is more intense than the individual usually performs. Quantitatively, the period of intense exercise and subsequent recovery is associated with about a 6-fold higher myocardial infarction rate (compared with other more relaxed time frames) for people who are physically very fit. For those in poor physical condition, the rate differential is over 35-fold higher. One observed mechanism for this phenomenon is the increased arterial pulse pressure stretching and relaxation of arteries with each heart beat which, as has been observed with intravascular ultrasound, increases mechanical "shear stress" on atheromas and the likelihood of plaque rupture.

Acute severe infection, such as pneumonia, can trigger myocardial infarction. A more controversial link is that between ''Chlamydophila pneumoniae'' infection and atherosclerosis. While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor. Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.

There is an association of an increased incidence of a heart attack in the morning hours, more specifically around 9 a.m. Some investigators have noticed that the ability of platelets to aggregate varies according to a circadian rhythm, although they have not proven causation.

Risk factors

Risk factors for atherosclerosis are generally risk factors for myocardial infarction:

Diabetes (with or without insulin resistance) – the single most important risk factor for ischaemic heart disease (IHD)

Tobacco smoking

Hypercholesterolemia (more accurately hyperlipoproteinemia, especially high low density lipoprotein and low high density lipoprotein)

Low HDL

High Triglycerides

High blood pressure

Family history of ischaemic heart disease (IHD)

Obesity (defined by a body mass index of more than 30 kg/m², or alternatively by waist circumference or waist-hip ratio).

Age — Men acquire an independent risk factor at age 45, Women acquire an independent risk factor at age 55; in addition individuals acquire another independent risk factor if they have a first-degree male relative (brother, father) who suffered a coronary vascular event at or before age 55. Another independent risk factor is acquired if one has a first-degree female relative (mother, sister) who suffered a coronary vascular event at age 65 or younger.

Hyperhomocysteinemia (high homocysteine, a toxic blood amino acid that is elevated when intakes of vitamins B₂, B₆, B₁₂ and folic acid are insufficient)

Stress — Occupations with high stress index are known to have susceptibility for atherosclerosis

Alcohol — Studies show that prolonged exposure to high quantities of alcohol can increase the risk of heart attack

Males are more at risk than females.

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. Non-modifiable risk factors include age, sex, and family history of an early heart attack (before the age of 60), which is thought of as reflecting a genetic predisposition.

Socioeconomic factors such as a shorter education and lower income (particularly in women), and unmarried cohabitation may also contribute to the risk of MI. To understand epidemiological study results, it's important to note that many factors associated with MI mediate their risk via other factors. For example, the effect of education is partially based on its effect on income and marital status.

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.

Inflammation is known to be an important step in the process of atherosclerotic plaque formation. C-reactive protein (CRP) is a sensitive but non-specific 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. Moreover, some drugs for MI might also reduce CRP levels. 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. Whether CRP plays a direct role in atherosclerosis remains uncertain.

Inflammation in periodontal disease may be linked to coronary heart disease, and since periodontitis is very common, this could have great consequences for public health. Serological studies measuring antibody levels against typical periodontitis-causing bacteria found that such antibodies were more present in subjects with coronary heart disease. Periodontitis tends to increase blood levels of CRP, fibrinogen and cytokines; thus, periodontitis may mediate its effect on MI risk via other risk factors. Preclinical research suggests that periodontal bacteria can promote aggregation of platelets and promote the formation of foam cells. A role for specific periodontal bacteria has been suggested but remains to be established. There is some evidence that influenza may trigger an acute myocardial infarction.

Baldness, hair greying, a diagonal earlobe crease (Frank's sign) and possibly other skin features have been suggested as independent risk factors for MI. Their role remains controversial; a common denominator of these signs and the risk of MI is supposed, possibly genetic.

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.

The European Society of Cardiology and the European Association for Cardiovascular Prevention and Rehabilitation have developed an interactive tool for prediction and managing the risk of heart attack and stroke in Europe. HeartScore is aimed at supporting clinicians in optimising individual cardiovascular risk reduction. The Heartscore Programme is available in 12 languages and offers web based or PC version.

Pathophysiology

Acute myocardial infarction refers to two subtypes of acute coronary syndrome, namely non-ST-elevated myocardial infarction and ST-elevated myocardial infarction, which are most frequently (but not always) a manifestation of coronary artery disease. 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. 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. Blood stream column irregularities visible on angiography reflect artery lumen narrowing as a result of decades of advancing atherosclerosis. Plaques can become unstable, rupture, and additionally promote a thrombus (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 myocardial infarction (necrosis of downstream myocardium).

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 its place. Recent studies indicate that another form of cell death called apoptosis also plays a role in the process of tissue damage subsequent to myocardial infarction. 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 may or may not cause sudden cardiac death. However, ventricular tachycardia 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 is a device that was specifically designed to terminate these potentially fatal arrhythmias. The device works by delivering an electrical shock to the patient in order 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.

Diagnosis

The diagnosis of myocardial infarction can be made after assessing patient's complaints and physical status. ECG changes, coronary angiogram and levels of cardiac markers help to confirm the diagnosis. ECG gives valuable clues to identify the site of myocardial damage while coronary angiogram allows visualization of narrowing or obstructions in the heart vessels. At autopsy, a pathologist can diagnose a myocardial infarction based on anatomopathological findings.

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 a myocardial infarction. Echo may be performed in equivocal cases by the on-call cardiologist. 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 physiologic or pharmocologic stress. Thallium may also be used to determine viability of tissue, distinguishing whether non-functional myocardium is actually dead or merely in a state of hibernation or of being stunned.

WHO criteria formulated in 1979 have classically been used to diagnose MI; a patient is diagnosed with myocardial infarction 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 such as creatine kinase-MB fraction and troponin

The WHO criteria were refined in 2000 to give more prominence to cardiac biomarkers. According to the new guidelines, a cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression or coronary intervention are diagnostic of MI.

Prevention

The risk of a recurrent myocardial infarction 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 commenced on several long-term medications post-MI, with the aim of preventing secondary cardiovascular events such as further myocardial infarctions, congestive heart failure or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:

Antiplatelet drug therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of plaque rupture and recurrent myocardial infarction. 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, however the risk of hemorrhage is increased. Beta blocker therapy such as metoprolol or carvedilol should be commenced. These have been particularly beneficial in high-risk patients such as those with left ventricular dysfunction and/or continuing cardiac ischaemia. β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI. ACE inhibitor therapy should be commenced 24–48 hours post-MI in hemodynamically-stable patients, particularly in patients 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 post-MI. Statin therapy has been shown to reduce mortality and morbidity post-MI. The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have plaque stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids. The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above. Spironolactone is another option that 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. Omega-3 fatty acids, commonly found in fish, have been shown to reduce mortality post-MI. While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of ventricular fibrillation. However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids.

Blood donation may reduce the risk of heart disease for men, but the link has not been firmly established.

A Cochrane review found that giving heparin to people who have 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 suffering from minor bleeding.

Management

An MI is a medical emergency which requires immediate medical attention. Treatment attempts to salvage as much myocardium as possible and to prevent further complications, thus the phrase "time is muscle". 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. A 2009 and 2010 review of high flow oxygen in myocardial infarction found increased mortality and infarct size, calling into question the recommendation about its routine use. Other analgesics such as nitrous oxide are of unknown benefit. Percutaneous coronary intervention (PCI) or fibrinolysis are recommended in those with an STEMI.

Prognosis

The prognosis post myocardial infarction varies greatly, depending on a person's health, the extent of the heart damage and the treatment given. For the period 2005–2008 in the United States the median mortality at 30 days was 16.6% with a range from 10.9% to 24.9% depending on the hospital. Using variables available in the emergency room, people with a higher risk of adverse outcome can be identified. One study found that 0.4% of patients with a low risk profile died after 90 days, whereas in high risk people it was 21.1%.

Some of the more reproduced risk stratifying factors 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. Assessment of left ventricular ejection fraction may increase the predictive power. The prognostic importance of Q-waves is debated. Prognosis is significantly worsened if a mechanical complication such as papillary muscle or myocardial free wall rupture occur. Morbidity and mortality from myocardial infarction has improved over the years due to better treatment.

Complications

Complications may occur immediately following the heart attack (in the acute phase), or may need time to develop (a chronicproblem). Acute complications may include heart failure if the damaged heart is no longer able to adequately pump blood around the body; aneurysm or rupture of the myocardium; mitral regurgitation, particularly if the infarction causes dysfunction of the papillary muscle; 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 myocardial infarction.

Epidemiology

Myocardial infarction is a common presentation of ischemic heart disease. The WHO estimated in 2002, that 12.6 percent of worldwide deaths were from ischemic heart disease with it the leading cause of death in developed countries, and third to AIDS and lower respiratory infections in developing countries. Worldwide more than 3 million people have STEMIs and 4 million have NSTEMIs a year.

Coronary heart disease is responsible for 1 in 5 deaths in the United States. It is becoming more common in the developing world such that in India, cardiovascular disease (CVD) is the leading cause of death. The deaths due to CVD in India were 32% of all deaths in 2007 and are expected to rise from 1.17 million in 1990 and 1.59 million in 2000 to 2.03 million in 2010. Although a relatively new epidemic in India, it has quickly become a major health issue with deaths due to CVD expected to double during 1985–2015. Mortality estimates due to CVD vary widely by state, ranging from 10% in Meghalaya to 49% in Punjab (percentage of all deaths). Punjab (49%), Goa (42%), Tamil Nadu (36%) and Andhra Pradesh (31%) have the highest CVD related mortality estimates. State-wise differences are correlated with prevalence of specific dietary risk factors in the states. Moderate physical exercise is associated with reduced incidence of CVD in India (those who exercise have less than half the risk of those who don't).

Legal implications

At common law, a myocardial infarction is generally a disease, but may sometimes be an injury. This has implications for no-fault insurance schemes such as workers' compensation. A heart attack is generally not covered; however, it may be a work-related injury if it results, for example, from unusual emotional stress or unusual exertion. Additionally, 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 who has suffered from a myocardial infarction may be prevented from participating in activity that puts other people's lives at risk, for example driving a car or flying an airplane.

Research

Patients who receive stem cell treatment by coronary artery injections of stem cells derived from their own bone marrow after a myocardial infarction (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 ST elevation MI are proceeding.

There are currently 3 biomaterial and tissue engineering approaches for the treatment of MI, but these are in an even earlier stage of medical research, so many questions and issues need to be addressed before they can be applied to patients. The first involves polymeric left ventricular restraints in the prevention of heart failure. The second utilizes ''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.

References

External links

American Heart Association's Heart Attack web site – Information and resources for preventing, recognizing and treating heart attack.

Heart Attack – overview of resources from MedlinePlus

Category:Aging-associated diseases Category:Causes of death Category:Ischemic heart diseases Category:Medical emergencies

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