**What is a heart attack?**
A heart attack is a sudden closure of a coronary artery, which supplies blood and oxygen to the heart muscle. As a result, the heart muscle tissue starts to die due to the lack of oxygen and nutrients needed for viability.
**What are the risk factors for coronary artery disease?**
Risk factors for coronary artery disease can be classified as non modifiable and modifiable risk factors.
Nonmodifiable risk factors include male sex, advanced age, and a family history of myocardial infarction (males below the age of 55 and females below the age of 65).
Modifiable risk factors include smoking, hypertension, diabetes, hyperlipidemia (especially high LDL and low HDL), overweight (obesity, metabolic syndrome, increased waist circumference), lack of physical activity, depression, poor oral hygiene, alcohol and drug use, type A personality, and high stress levels.
**What are the major symptoms during a heart attack?**
The symptoms may vary from person to person. It might be difficult to diagnose in patients with diabetes, female patients, and elderly patients because the symptoms may be vague in these groups. The most common symptoms are tightness and pain in the chest, dyspnea, pain radiating to the chin, back, neck, left shoulder, arms, and epigastric areas, nausea and lightheadedness, sweating and cool extremities, severe exercise intolerance, syncope or seizure in cases of ventricular arrhythmias, and sudden cardiac arrest.
**What do patients feel during a heart attack?**
A mixture of tightness, pain, and dyspnea is the main symptom during a heart attack. The patient feels like a weight of about 10-20 kg has been placed on their chest, and they have to breathe with that weight. Some may also feel the fear of impending death. **What should be done during a heart attack?**
As soon as symptoms related to a heart attack start, the patient should seek professional healthcare support by calling an ambulance. In a heart attack, death usually occurs in the first hours, so it is crucial to start first aid as soon as possible and transfer the patient to a center with a catheter laboratory where the blocked coronary vessel can be opened with angioplasty and stent.
If you are alone and feel like you are having a heart attack:
- Keep your door open, inform your relatives, and seek professional healthcare help by calling an ambulance.
- Coughing may increase blood flow through the coronary arteries and increase the heart rate in patients with severe bradycardia.
- Stay in a supine position to ensure the perfusion of vital organs is not hampered and to prevent syncope (fainting) and trauma.
- If you have aspirin, take 300 mg of it and nothing else. Do not exercise to relieve pain.
If you see a person having a heart attack, do not intervene unless you have first aid training. Do not give medication except for 300 mg of aspirin. Call an ambulance and transfer the patient to the nearest hospital with a catheter laboratory. Make the patient lie down and lift their legs to increase blood flow to the heart, and remove any tight clothing.
**How do you diagnose a heart attack?**
The main factor in preventing death during a heart attack is promptly diagnosing it and starting treatment. An ECG should be taken within 10 minutes of encountering the patient. Patients with ST segment elevation on an ECG should be transferred to a catheter laboratory for emergency coronary angiography, angioplasty, and stent placement.
If the ECG does not show ST segment elevation, the doctor should evaluate the patient based on their history, symptoms, and certain laboratory tests. The tests used to diagnose a heart attack include:
- **ECG:** Should be taken for every patient with a complaint of chest pain and differential diagnosis of a heart attack, and should be repeated according to the persistence of the symptoms.
- **Blood Tests:** Cardiac Troponin and CK-MB are used to diagnose a heart attack without ST segment elevation on an ECG. These tests also help determine the magnitude of the injury.
- **Coronary Angiography:** Performed to diagnose the culprit vessel responsible for the attack, which should be revascularized (opened) whenever possible either by angioplasty and stent or open bypass surgery.
**What are the treatment options for a heart attack?**
Patients with ST segment elevation in an ECG are immediately transferred to the catheter laboratory, without waiting for blood test results, for angiography and revascularization (opening the vessel) when needed.
In ST segment elevation heart attacks, the main therapy is to open the blocked vessel without any delay. While trying to open the totally blocked vessel, we should also manage arrhythmia, chest pain, hypoxemia, pulmonary congestion, and sudden cardiac arrest in some cases.
Patients without ST segment elevation in ECG can either be followed by medical treatment or should undergo coronary angiography. After angiography, patients can be followed with medical treatment or revascularization (opening the blood vessel) with angioplasty and stent or open bypass surgery.
**Balloon Angioplasty:** After diagnosing a blocked or severely stenotic coronary vessel compromising the blood flow to the heart tissue, the lesion is crossed with a guidewire with a floppy end, and a balloon is advanced to the stenotic/blocked segment and then inflated to open the vessel.
**Coronary Stenting:** Vessels predilated with balloon angioplasty are treated with drug-eluting stents most of the time to reduce the chance of restenosis and recoil of vessel walls. Stents are made of inert materials like nickel or cobalt and resemble the springs in dot pens. These stents help maintain the patency of blood vessels.
**Coronary Bypass Operation:** After coronary angiography, a score called SYNTAX score is calculated, considering coronary blood vessel anatomy, the number and characteristics of lesions, the number of vessels involved, angulation in the vessels, and lesions feasible for stenting. Patients with multivessel disease, systolic dysfunction, diabetes, and a high SYNTAX score benefit more from bypass surgery.
**Operation of Valves:** Sometimes patients with heart attacks undergoing bypass surgery may also have moderate to severe valvular problems. These problems should be fixed or replaced during the open surgery.
**Cardiac Pacemaker:** Sometimes heart attacks may cause irreversible damage to the conducting system of the heart, which should be fixed with a cardiac pacemaker. A cardiac pacemaker has a battery and leads; the battery is implanted above the pectoral muscle below the fascia, and the leads are inserted through the axillary vein and advanced to the right heart (atrial appendage, coronary sinus, or ventricle).
Some patients with heart attacks and life-threatening arrhythmias or patients with severe left ventricular dysfunction (ejection fraction below 35%) and potential for life-threatening arrhythmias require a pacemaker with defibrillation capability (ICD, CRT-D).
**Heart Transplant:** When there is irreversible damage to most parts of the heart and the patient has symptoms at rest, frequent hospitalizations, and the need for inotropes, but with good life expectancy if treated with a transplant, they should be listed for a heart transplant.
Medical Therapy Used In Heart Attack Patients
**Anticoagulant Drugs:** Heparin and bivalirudin are used during hospital stays.
**Antiplatelet Drugs:** Acetylsalicylic acid, clopidogrel, prasugrel, and ticagrelor are used after a heart attack.
**Beta Blockers:** These are used to decrease heart rate, reduce heart muscle wall stress, decrease the oxygen demand of heart tissue, and increase diastolic filling of the ventricle and coronary arteries.
**ACE Inhibitors/Angiotensin Receptor Blockers:** These are used to lower blood pressure and prevent remodelling in patients who have heart damage and systolic dysfunction due to a heart attack.
**Nitrates:** These are used to decrease preload and afterload and can be used to reduce pulmonary congestion. They are also used by patients with stable chest pain (angina) to relieve the pain.
**Thrombolytics:** These drugs are used in ST segment elevation heart attacks if the patient cannot be transferred to a center with a catheter laboratory within 2 hours after seeing a doctor. They are also used in massive pulmonary embolism and early stages of cerebrovascular embolism (stroke).
**What should be done to prevent a heart attack?**
The first step is to adopt healthier lifestyle changes. Secondly, we should modify the risk factors that are modifiable (e.g., smoking cessation, blood pressure and diabetes control, cholesterol therapy, weight control, regular exercise, avoiding polyunsaturated fatty acids, increasing vegetables and fruits in the diet, and consuming fish twice a week).
**What should be done to prevent a second heart attack?**
The preventive measures discussed in the previous paragraph are also used to prevent a second heart attack. Additionally, patients should take medications as prescribed by their doctor. Patients should be aware of their body, recognize symptoms, and go to the hospital whenever there are signs and symptoms of a heart attack. Stress is inevitable in this modern world, so stress management, anger management, and controlling reactions to stress are important for a healthy heart.
Frequently Asked Questions
What are the main symptoms of heart attack?
The most common symptom is the combination of chest pain, heaviness and dyspnea. Patient feels like a heavy weight is placed in his chest and he has to breathe with it. Later the pain may radiate to neck, chins, left shoulder, back and arms( especially to left arm)
How long does the pain last in a heart attack?
Not all chest pain is a heart attack. Specially pains which last for seconds or less than 5 minutes, which do not recur, which can be located easily, changes with position and with deep breath are not signs of a heart attack.
Chest pain in a heart attack usually lasts more than 5 minutes, cannot be located precisely, has symptoms of heaviness, tightness and dyspnea, increases with exertion and is relieved with rest or drugs like nitroglycerin.
Chest pain which lasts for more than 20 minutes and is not relieved with medication is a sign of massive heart attack and requires immediate medical attention and the patient should be carried to a hospital.
Are all chest pain related to the heart?
There are several causes for chest pain- pain related to the muscles of the chest wall, nerves, ligaments, cartilages, bile duct and gallbladder, stomach, esophagus etc.
What is the relation of smoking with heart attack?
Smokers are at high risk for heart attack compared to nonsmokers. Smoking also increases blood pressure, increases heart rate, increases oxygen demand of the heart, increases the coagulability of blood. Smoking is a major risk factor for atherosclerotic cardiovascular disease and pulmonary diseases .
Why do young people have heart attacks?
Patients with a higher number of risk factors are at higher risk of heart attack and have a tendency to have heart attack at younger age. Besides, vasculitis, hypercoagulability, type 1 diabetes, severe stress( war, loss of loved ones, migration, divorce ets), low life standard, poor hygiene , major depression are the causes of having a heart attack at a young age.
What is Broken Heart Syndrome?
Major stress like loss of loved ones, divorce, migration, diagnosis of diseases like cancer, major surgical procedures, loss of major cases in a court etc can cause catecholamine surge and damage to the myocardium, which is reversible most of the time. ECG and blood tests resemble a heart attack but the epicardial coronary arteries are open and do not need any intervention. Although the condition is reversible most of the time patients should be admitted and monitored for certain arrhythmias and should be treated with optimal medical therapy.
Is there a Happy Heart Syndrome?
Yes, Happy Heart Syndrome is a condition similar to Broken Heart Syndrome but the incident here is not a major stress, rather a joyful event like surprise birthday celebration, marriage, university graduation etc.
Can stress cause a heart attack?
Stress is one of the major risk factors for both heart attack and other cardiovascular diseases like hypertension, hyperlipidemia. It affects the normal healthy lifestyle and patients may adopt unhealthy habits like smoking, alcohol consumption, sedentary lifestyle, weight gaining etc. Chronic stress can cause hormonal imbalance and increase in inflammation inside blood vessels, which in turn lead to atherosclerosis and increase the risk of heart attack.
Are the heart attack symptoms same for female patients?
The signs and symptoms of heart attack may be different in elderly, patient with diabetes and in females. These patients may not present with chest pain, instead, they may present with chest pain equivalent symptoms like chest tightness, heaviness and dyspnea. Doctors should be extra careful while interpreting these patients.