Heart Attack – Treatment


In case of a heart attack it is necessary to intervene urgently. Prompt treatment with medications and angioplasty combined with mounting of stents or surgical procedures to restore blood flow after the onset of symptoms, may prevent permanent damage to the heart muscle, and can save your life.

Initial treatment

Percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty – Heart Attack

The goal of therapy during a heart attack is to prevent permanent myocardial damage by restoring blood flow as quickly as possible. During transport to the hospital by ambulance it will be administered oxygen, nitroglycerin and probably a strong painkiller like morphine. In addition it can be administered aspirin, heparin or other antiplatelet agents to prevent the increase in size of thrombus. Other medicines may be administered to relieve cardiac labor, improve pump function of the heart and prevent abnormal heart rhythms that can be fatal.

Time interval until reaching the hospital is very important as angioplasty for opening blocked artery lumen or thrombolysis which dissolves the thrombus are more effective in the early hours of the onset of symptoms.

metal stent coronary artery stenosis

BMS – bare metal stent

Angioplasty with or without stent mounting is the preferred therapeutic process, even it is not available in all hospitals and is required to be made in the first 12 hours after symptom onset. It is therefore important that ambulance personnel to recognize a heart attack and transport the patient to the nearest center that has the means to intervene in these cases.

If the treatment is done in a hospital that has the facilities necessary for such cases, the patient will undergo a cardiac catheterization and will be determined whether it is an indication for angioplasty or coronary bypass surgery. If angioplasty with or without stent implantation is not possible, either because of coronary stenosis location or due to a larger number of stenosis the coronary bypass surgery is indicated.

In case of unstable angina, treatment consists in hospitalization and administration of aspirin, heparin or other antiplatelet agents (medications that prevent clot formation). The patient will be closely monitored and will be performed various investigations. If symptoms do not resolve after initial treatment, and the risk of heart attack is considered high, it will be made a coronary catheterization and probably an angioplasty with a stent mounting to prevent heart attack.

Maintenance treatment

After a heart attack the patient will be hospitalized for several days, during this will be monitored: heart rate, blood pressure, effects of drugs. It will be performed in this period several electrocardiograms. Monitoring a heart attack is necessary because in the next period are frequent the complications, such as potentially fatal arrhythmias or heart failure.

The medicines used to prevent complications will be administered fairly quickly after heart attack. Angiotensin inhibitors and beta-blockers can prevent heart failure and arrhythmias. Drugs that lower cholesterol levels (statins) are administered to decrease the amount of LDL-cholesterol (a formation of atherogenic cholesterol) below 70 mg / dL or even lower values.

A recent study on a large number of patients, demonstrated that the administration of medications that lower cholesterol levels, reduce the risk of heart attack within a period of 5 years in people at high risk, for example those who have had a heart attack in the past.

Aspirin and other antiplatelet medicines such as clopidogrel or ticlopidine are administered after a heart attack. These drugs decrease the risk of a heart attack and prevent thrombus formation.

The proportion of irreversibly damaged heart tissue may be less than expected immediately after a heart attack. Certain portions of the myocardium may be affected temporarily, they will not shrink. Pump function of the heart will be monitored closely and treatment should be adjusted as required during this period.

Recent studies have demonstrated the importance of quitting smoking after a heart attack. People who continue to smoke have a risk 1.5 times higher to develop a new heart attack than those who do not smoke. When people stop smoking after a heart attack, the risk gradually decreases in the following 36 months, until it becomes equal to that of non-smokers. Studies have shown that nicotine replacement therapy with another substance such as bupropion and supportive therapies have increased the rate of stopping smoking for a long-term.

Your doctor may indicate some changes in lifestyle, for example performing physical activities or diet modification.

Medical treatment

Medications for unstable angina

Certain medicinal agents prevent thrombus formation, reduce the risk of unstable angina to progress to heart attack and reduce the risk of death. These agents are aspirin and other antiplatelet agents (clopidogrel or ticlopidine, ticagrelor).

Aspirin

Mode of action

The effect is quick (about 15 minutes) and prevents thrombus formation, decreases the risk of heart attack or stroke. All types of aspirin are equally effective.

Indication: aspirin can be given:

  • During a heart attack, in which case it will be chewed (do not swallow the whole tablet);

  • for individuals with stable angina;

  • In the treatment of unstable angina;

  • In people with heart disease, it reduces the risk of heart attack;

  • for healthy people aged over 50 which have one or more risk factors for cardiovascular disease;

  • After the bypass operation or angioplasty;

  • In people who have had a stroke, transient ischemic attack or have undergone surgery to prevent a stroke (carotid endarterectomy).

Effectiveness. Studies have shown that people who have increased risk of coronary artery disease or who already have coronary heart disease, benefit most from this therapy. A recent study showed that in people of 65 years or older with heart failure and coronary heart disease, death rate is significantly lower if aspirin is taken regularly.

Adverse effects of aspirin are:

  • Gastritis (inflammation of the stomach);

  • Gastrointestinal bleeding;

  • Allergic reactions;

  • Increased frequency of hematoma (blood clots) and bleeding in the brain or other internal organs.

Some doctors believe that people who have one or more risk factors for coronary artery disease should take aspirin every day. Others believe that daily administration of aspirin over a long period of time increases the risk of disease or bleeding in the stomach, in case it is associated hypertension which it is not treated.

Experts recommend the administration of 75-160 mg of aspirin daily. Because aspirin reduces the blood’s ability to form clots, its administration should be discontinued at least 5 days prior to surgery or a dental procedure involving bleeding.

Examples of antiplatelet agents

  • Clopidogrel (Plavix);

  • Ticlopidine (Ticlid);

  • ticagrelor.

Indications. Antiplatelet medication is used in people with unstable angina or heart attack and for those with angina who underwent angioplasty.

Ticlopidine and clopidogrel are administered to people who cannot take aspirin or the administration of aspirin is not sufficient to prevent thrombus formation. These drugs are given at least one month after the implantation of stents in the coronary arteries. These drugs are used in combination with aspirin to prevent clots in arteries that have stents.

The adverse effects of platelet aggregation inhibitors are:

  • Intracranial bleeding or other organs;

  • Bleeding in the stomach or intestines;

  • Bruises that occur frequently (bruises);

  • Gastric irritation;

  • Allergic reactions;

  • Thrombocytopenia (low platelet count), decreased number of white blood cells (neutropenia), low number of red blood cells (anemia).

All medicine used with the role of antiplatelet agents increase the risk of bleeding.

Anticoagulants

  • Heparin;

  • Enoxaparin;

  • Deltaparin.

Nitrates (nitroglycerin)

Some medications decrease the cardiac labor, improve blood flow and relieve chest pain. Are administered to individuals with unstable angina who are at risk of heart attack.

Examples of nitrates:

  • Nitroglycerin;

  • Isosorbit dinitrate;

  • Isosorbine mononitrate.

Nitrates are in the form of pills or spray used sublingual. It may also take the form of patches which are applied on the skin. In case of emergency, during a heart attack nitrates will be administered intravenously.

Mode of action. Nitrates dilate the coronary arteries, increase the blood flow, relieve chest pain and reduce the work of the heart.

Indications. Nitrates prevent and treat angina. It can be used:

  • During episodes of angina;

  • Before activities that may cause angina (sexual activity or climbing stairs);

  • in long-term management to prevent angina that occurs in daily activities.

Sublingual administration forms are useful to treat episodes of angina. Pills or patches that have long action are used to prevent chest pain during daily activities.

Advantages of nitroglycerin:

  • Acts fast;

  • Is easily administered either sublingually or intravenously;

  • Effects disappear within 24 hours.

The adverse effects of nitrates are:

  • headaches;

  • Sudden drop in blood pressure and can cause a sensation of dizziness

  • Sublingual burning (for sublingual administration).

The various types of nitrates are most often administered in combination. Some people develop a tolerance to nitrates when are administered consistently and over a long period of time. Tolerance occurs when medications lose their effectiveness and seems to have no effect. Your doctor may indicate a scheme of nitroglycerin administration, for example will be given at 12 to 18 hours, and 6-12 hours will not be covered, to prevent nitroglycerin tolerance. If the patient continues to have episodes of angina despite of the medication with beta-blockers or calcium channel blockers, the treatment with nitroglycerin will be long-lasting. Even if the pain goes through the administration of nitroglycerin, the patient will have to go to the doctor. If angina episodes are becoming more frequent and last longer, it is advisable to call your doctor to adjust medication.

If nitroglycerine compounds are old or are close to completion of validity, it is likely that they do not have an adequate effect. Tablets should be renewed at 3-6 months.

Beta-blockers

Examples of beta-blockers:

  • Atenolol;

  • Metoprolol;

  • Acebutolol;

  • Carvedilol;

  • Labetalol;

  • Propanolol;

  • Timolol;

  • Penbutolol;

  • Pindolol.

Mode of action. The body responds to stress following a heart attack or unstable angina by increasing heart rate and blood pressure. Beta-blockers slow the heart rate and reduce labor.

Indications. Beta-blockers reduce the heart rate, blood pressure and cardiac labor. If the work of the heart is decreased, the myocardium will require less oxygen to function. Beta-blockers are used in combination with other medications to treat heart attack in progress.

Effectiveness. Beta-blockers administered in the early hours of the onset of a heart attack reduce the risk of death and recurrence of the attack.

Adverse effects of beta-blockers are:

  • Fatigue, dizziness and insomnia;

  • Impotence (erectile disorders);

  • Decrease blood flow to the hands and feet, which will cause a cold sensation at these levels and emphasizing pain in the calf muscle during physical activity (intermittent claudication).

In people with diabetes, beta-blockers may increase blood sugar and can also cover the symptoms of hypoglycemia, the change of pulse.

Beta-blockers administered during and after a heart attack seem to reduce the risk of death. Studies have shown that beta-blockers should be administered at least 6 months after a heart attack to maximize the beneficial effects.

Administration of beta-blockers may interfere with other disorders, for example: asthma, heart failure, diabetes and certain types of arrhythmias.

Administration of beta-blockers should be discontinued if these conditions will worsen or if adverse effects occur and they cannot be controlled. In case of food allergies, medicines or insect bites, concurrent administration of beta-blockers can worsen the symptoms of these allergies and it will be more difficult to treat.

Sensation of dizziness is more common at the beginning of therapy with beta-blockers or when doses are increased. This symptom can also be emphasized in combination with alcohol or after spending a long time in hot water. Do not suddenly stop taking beta-blockers. The risk of heart attack increases if beta-blockers are stopped abruptly.

Other therapeutic agents

In some cases it can be used other therapeutic agents:

  • Inhibitors of glycoprotein IIb / IIIa inhibitors, which help to prevent thrombus formation in people at high risk of heart attack or requiring angioplasty;

  • Calcium channel blockers, which are administered in cases where beta-blockers are contraindicated;

  • Angiotensin converting enzyme inhibitors, used to control blood pressure and reduce cardiac labor.

Surgical treatment

In some cases, surgical procedure which involves coronary bypass is performed under emergency conditions to treat heart attack. Coronary bypass is performed when heart attacks cannot be effectively treated by medical therapy or angioplasty procedures.

For example, it will be performed a coronary bypass if the blockage is in an artery that cannot be addressed by angioplasty or in cases where angioplasty was performed, but the results were not satisfactory.

Also bypass procedures are recommended in patients with diabetes. Studies have shown that the coronary artery bypass reduce the death rate in patients with diabetes and heart attack compared to those treated by angioplasty or thrombolytic therapy.

Other treatments

In the last decade, angioplasty, which is also called percutaneous coronary intervention, has become the therapeutic procedure used to treat heart attack. Angioplasty is performed during cardiac catheterization.

Studies have proven that installing a stent during angioplasty reduces the risk of recurrence of artery narrowing and perhaps reduce the risk of death compared with angioplasty without stenting. Mounting a stent during angioplasty is a procedure less invasive than bypass surgical procedure and is the preferred therapy for most patients with heart attack.

Although the results of studies are not conclusive, it is assumed that folate therapy (combination of folic acid, vitamin B6 and vitamin B12) is harmful after the installation of stents, and should be avoided. Instead of taking nutritional supplements containing vitamins B, you have to choose a proper diet which contains optimal amounts of these vitamins.

Prophylaxis

The number of myocardial infarctions has declined in recent years, as the number of deaths after heart attacks. This is largely due to measures taken to prevent coronary heart disease, such as decreasing blood pressure, serum cholesterol, diet changes and new habits that include physical activity.

The most important measures that can be taken are stopping smoking and performing regular physical activity. It is also recommended a diet rich in fruits and vegetables and low in saturated fat.

Lifestyle changes involve:

  • Stop smoking;

  • Control of serum cholesterol;

  • Controlling blood pressure;

  • Physical activity;

  • Methods of relaxations and stress reduction;

  • Methods of therapy of depression and anger.

Cholesterol

An increased level of serum cholesterol increases the risk of coronary heart disease. If through diet and exercise will not achieve an optimal level of serum cholesterol, your doctor will prescribe statins, medicines that lower cholesterol agents. These drugs have proven efficacy in treating high cholesterol, and currently are widely prescribed by doctors worldwide.

Recent studies have shown that these medicines may be beneficial in people with normal or moderately elevated levels of serum cholesterol. In these individuals, medicinal agents that lower serum cholesterol levels in combination with lifestyle changes, slow the process of atherosclerosis and reduce the risk of heart attack and death.

Aspirin

Aspirin therapy reduces the risk of thrombus formation, which can cause a heart attack in people with coronary artery disease or for those with multiple risk factors for coronary artery disease (diabetes, hypertension, elevated serum cholesterol levels). Prior to starting the therapy with aspirin, consult your doctor as there are some risks of this therapy. If aspirin is contraindicated, the physician may prescribe another antiplatelet drug, clopidogrel, for example Plavix).

Hormone replacement therapy

In the past it was thought that hormone replacement therapy (estrogen and progestin) decrease the risk of heart disease. Now is demonstrated the opposite. The risk of heart attack doubles in the first year of hormone replacement therapy, and at 6 years the risk is about 24% higher in women who undergo hormone replacement therapy. It is assumed that hormone replacement therapy also increases the risk of breast cancer, dementia or other health problems, but also has benefits.

Precautions

After a heart attack, the biggest concern is the possible emergence of a new attack. Prescribed medications after a heart attack include substances for:

  • Prevention of thrombus formation;

  • Decreasing the cardiac labor;

  • Improving the pump function of the heart;

  • Lowering serum cholesterol;

  • Treating arrhythmias;

  • Lowering blood pressure.

After a heart attack, it is important to monitor the patient closely. Approximately half of the patients who had a heart attack will develop a severe complication.

The most common complications are:

  • Arrhythmias (abnormal heart rhythms): they may be ventricular tachycardia (rapid heart rate) and atrial fibrillation (irregular heart rhythm);

  • Heart failure, which may be temporary or may be permanent.

Angina Therapy

If after a heart attack, occur episodes of chest pain or discomfort (angina), seek immediate medical attention, as you may need aggressive treatment. These episodes may indicate impending heart attack. It is recommended to always have nitroglycerin tablets. Some doctors recommend taking nitroglycerin before physical activity to prevent episodes of angina.

Lifestyle after myocardial infarction

To reduce the risk of a heart attack your doctor may recommend:

  • Stopping smoking may be the most important step in reducing risk; There is evidence that people with coronary artery disease who do not smoke, decreases the risk of recurrent heart attack or death;

  • Daily administration of aspirin or another antiplatelet drug if aspirin is contraindicated;

  • Lowering serum cholesterol levels with the help of medications like statins or other drugs that lower serum cholesterol;

  • Controlling blood pressure with medication prescribed by the doctor; certain nutrients in the diet can affect blood pressure;

  • Diet that includes fish in larger quantities; the fish diets may be useful in weight loss, lowering blood pressure and cholesterol;

  • Reducing stress: there is evidence that reducing stress can influence the rate of heart attacks or deaths caused by heart attack in people with coronary artery disease;

  • Participation in cardiac rehabilitation programs; within these programs the patient is taught to alter habits that increase the risk of heart attack, solve stressful situations or strong emotions;

  • Drinking alcohol in moderation (1-2 glasses of wine per day maximum), reduces the risk of complications from a heart attack; in a recent study on middle-aged men, drinking alcohol in moderation was associated with a significant reduction in complications over a period of four years; some associations argue that it is not proven the link between wine consumption and reducing the severity of coronary artery disease;

One of the most common myths refers to the fact that sexual activity could cause a heart attack, a stroke or death. As medically indicated, sexual activity can be resumed whenever the patient feels able to do so.


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