Management of Heart Attacks

The heart is a muscle like any other in the body. Arteries supply it with oxygen-rich blood so that it can contract and push blood to the rest of the body. When there isn't enough oxygen flow to a muscle, its function begins to suffer. Block the oxygen supply completely, and the muscle starts to die. Heart muscle gets its blood supply from arteries that originate in the aorta just as it leaves the heart. The coronary arteries run along the surface of the heart and supply oxygen-rich blood to the heart muscle. The right coronary artery supplies the right ventricle of the heart and the inferior (lower) portion of the left ventricle. The left anterior descending coronary artery supplies the majority of the left ventricle, while the circumflex artery supplies the back of the left ventricle. The ventricles are the lower chambers of the heart; the right ventricle pumps blood to the lungs and left pumps it to the rest of the body.

During a heart attack, a clot forms in an artery that supplies blood to the heart and blocks blood flow to the area of heart muscle supplied by that artery. The portion of the heart muscle deprived of blood carrying the needed oxygen begins to become damaged. This is called a “myocardial infarction,” more commonly known as a heart attack. The amount of lasting damage to the heart muscle depends on a number of factors—the size of the clot, the location of the clot, and how long the clot blocks blood flow to the muscle. The longer the heart muscle is without blood and oxygen, the more extensive the damage to the muscle and the greater the size of the heart attack.

Heart Attack Symptoms and Signs

1.    Classic symptoms of a heart attack may include:

·         chest pain associated with shortness of breath,

·         profuse sweating, and

·         Nausea.

The chest pain may be described as tightness, fullness, a pressure, or an ache.

2.    Unfortunately, many people do not have these classic signs. Other signs and symptoms of heart attack may include:

·         indigestion,

·         jaw ache,

·         pain only in the shoulders or arms,

·         shortness of breath, or

·         Nausea and vomiting.

3.    This list is not complete, since many times people can experience a heart attack with minimal symptoms. In women and the elderly, heart attack symptoms can be atypical and sometimes so vague they are easily missed. The only complaint may be extreme weakness or fatigue.

4.    Pain may also radiate from the chest to the neck, jaw, shoulder, or back and be associated with shortness of breath, nausea, and sweating.

Heart Attack Causes

·         Over time, plaque can build up along the course of an artery and narrow the channel through which blood flows. Plaque is made up of cholesterol buildup and eventually may calcify or harden, with calcium deposits. If the artery becomes too narrow, it cannot supply enough blood to the heart muscle when it becomes stressed. Just like arm muscles that begin to ache or hurt when heavy things are lifted, or legs that ache when you run too fast; the heart muscle will ache if it doesn't get adequate blood supply. This ache or pain is called angina. It is important to know that angina can manifest in many different ways and does not always need to be experienced as chest pain. If the plaque ruptures, a small blood clot can form within the blood vessel, acting like a dam and acutely blocking the blood flow beyond the clot. When that part of the heart loses its blood supply completely, the muscle dies. This is called a heart attack, or an MI - a myocardial infarction.

·         Cocaine use: This drug can cause the coronary arteries to go into enough spasm to cause a heart attack. Because of the irritant effect on the heart's electrical system, cocaine can also cause fatal heart rhythms.

·         Prinzmetal angina or coronary artery vasospasm: Coronary arteries can go into spasm and cause angina without a specific cause, this is known as Prinzmetal angina. There can be EKG changes associated with this situation, and the diagnosis is made by heart catheterization showing normal coronary arteries that go into spasm when challenged with a medication injected in the cath lab. Approximately 2% to 3% of patients with heart disease have coronary artery vasospasm.

·         Anomalous coronary artery. In their normal position, the coronary arteries lie on the surface of the heart. On occasion, the course of part the artery can dive into the heart muscle itself. When the heart muscle contracts, it can temporarily kink the artery and cause angina. Again, diagnosis is made by heart catheterization.

·         Inadequate oxygenation. Just like any other muscle, heart muscle requires adequate oxygen supply for it to work. If there isn't adequate oxygen delivery, angina and heart attack can occur. There needs to be enough red blood cells circulating in the body and enough lung function to deliver oxygen from the air, so that heart cells can be supplied with the nutrients that they need. Profound anemia from bleeding or failure of the body to make enough red blood cells can precipitate angina symptoms. Lack of oxygen in the bloodstream can occur due to a variety of causes including respiratory failure, carbon monoxide poisoning or cyanide poisoning.

Heart Attack Risk Factors

Heart attack is most often caused by narrowing of the arteries by cholesterol plaque and their subsequent rupture. This is known as atherosclerotic heart disease (AHSD) or coronary artery disease (CAD).

The risk factors for ASHD are the same as those for stroke (cerebrovascular disease) or peripheral vascular disease. These risk factors include:

·         a family history or heredity,

·         cigarette smoking,

·         high blood pressure,

·         high cholesterol, and

·         Diabetes.

While heredity is beyond a person's control, all the other risk factors can be minimized to try to prevent coronary artery disease from developing. If atherosclerosis is already present, minimizing these risk factors can decrease further narrowing.

When to Seek Medical Care

Chest pain is almost always considered an emergency. Aside from heart attacks, pulmonary embolus (blood clot in the lung) and aortic dissection or tear can be fatal causes of chest pain.

Classic pain from a heart attack is described as chest pressure or tightness with radiation of the pain to the jaw and down the arm, accompanied by shortness of breath or sweating. But it is important to remember that heart problems may not always present as pain or with the classic symptoms. Indigestion, nausea, profound weakness, profuse sweating, or shortness of breath may be the main symptom of a heart attack.

Should any symptoms occur that you believe are related to your heart, activate the emergency medical system by calling 911 in USA, while in India, its 102, whereas in Europe its 112. First responders, emergency medical technicians, and paramedics can begin testing and treatment even before you arrive at the hospital.

Remember to take an aspirin immediately if you are concerned that you are having a heart attack. (Not for patient below 18 yrs of age)

If you have a history of chest pain for which your doctor has prescribed nitroglycerin, then take ONE dose right away. If your symptoms are not better 5 minutes after taking one dose, then you should call 102 immediately. In the past, you may have been told to take up to 3 doses of nitroglycerin before calling 102. However, the medical guidelines for the use of nitroglycerin have changed to help people who may be having a heart attack get to a hospital more quickly.

If you suspect you are having a heart attack, you should stop all physical activity immediately and lie or sit down. Alert anyone near you to call 102 for immediate medical attention and it is important to get to the nearest hospital emergency room as soon as possible. Immediate cardiopulmonary resuscitation (CPR) and direct-current shock (defibrillation) are essential for survival of sudden cardiac death.

Many people die before they seek medical care because they ignore their symptoms out of fear that something bad is happening, or by diagnosing themselves in error with indigestion, fatigue, or other illnesses. It is much better to seek medical care if you are unsure whether your symptoms are related to heart disease and find that all is well, than to die at home.

Heart Attack Diagnosis

Diagnosis and treatment tend to occur at the same time in patients who are experiencing chest pain. If there is concern that heart muscle is at risk, delays need to be minimized so that blood supply to that muscle can be restored.

Medical History

The diagnosis of angina is made by history of the patient. If the story that the patient tells is suggestive of cardiac ischemia, then the health care practitioner will continue on the path to determine whether a heart attack has occurred.

Important questions include:

1. When did the pain start?
2. What were you doing?
3. Did you have to stop?
4. Did the pain get better with rest?
5. Did the pain come back with activity?
6. Did the pain stay in your chest or did it move somewhere else, like the jaw, teeth, and arm or back?
7. Did you get short of breath?
8. Did you become nauseous?
9. Were you sweating profusely?

       The medical history also includes assessing risk factors for heart disease, including:

Smoking, hypertension or high blood pressure, high cholesterol, diabetes,

Questions may be asked about changes in exercise tolerance that might provide clues as to whether heart disease is present:

1. Have there been episodes of previous chest pain?
2. Is there shortness of breath on exertion?
3. Can you walk to get the mail?
4. Can you climb a flight of stairs?

The questions may try to distinguish between stable angina and unstable angina. Stable angina tends to be predictable. For example, it may occur after climbing a flight of stairs or walking a couple of blocks and then resolves quickly with rest. Unstable angina may occur without warning when the body is at rest and the heart is not stressed, for example while sitting or sleeping.

Since other diagnoses will be considered, some questions may be asked to identify potential symptoms of conditions such as reflux esophagitis (GERD), gastritis, trauma, pulmonary embolus (blood clot in the lung), or pneumonia.

Self-Care at Home

The first step to take when chest pain occurs is to call 911 in USA, while in India, its 102, whereas in Europe its 112. First responders, EMTs, and paramedics can begin treating a heart attack en-route to the hospital, alert the Emergency Department that the patient is on the way, and treat some of the complications of a heart attack should they occur.

       Step two is to take an aspirin. Aspirin makes platelets less sticky and can minimize blood clot formation and prevent further blockage of the artery. (Not for patient below 18 yrs of age)

       Step three is to rest. When the body does work, the heart has to pump blood to supply oxygen to the muscles and clear the waste products of metabolism. When heart function is limited because it doesn't have an adequate blood supply itself, asking it to do more work may cause more damage and risk further complications.

Heart Attack Prevention

While people cannot control their family history and genetics, they can minimize risk factors for heart disease by:

Quitting smoking; or smoking cessation,

            Controlling high blood pressure, cholesterol, diabetes;

Exercise regularly, weight loss, and

            Take a baby aspirin a day. (Not for patient below 18 yrs of age)

These are all lifelong challenges to prevent heart disease, stroke, and peripheral vascular disease.

Even with the best of preventive care, heart attacks happen. Develop an emergency plan so that if chest pain occurs make certain you, your family, and friends know how to activate the Emergency Medical Services in your area or call 102.