The medical term for a heart attack is myocardial infarction (pronounced ‘myo-car-dee-al in-fark-shun’). The heart muscle is the myocardium; infarct means death – thus, death of heart muscle.
Some people also use the term ‘coronary’ because the cause is a block of a coronary artery. Every 30 seconds someone dies from coronary artery disease. It is the single most important cause of death for men and women.
Coronary artery disease kills more people than all the cancers put together.
Will I be able to avoid a heart attack?
There is no guarantee (never say never!) but your risks can be lessened by heeding the following advice.
• Do not smoke (not one cigarette, not at all).
• Avoid passive smoking (sit in non-smoking areas; if your family smokes, send them outside to do so).
• Watch your blood pressure (know your reading).
• Know your cholesterol level and keep it low by diet, and medication if necessary (this is very important).
• Eat plenty of fresh fruit and vegetables.
• Keep your weight down and take plenty of exercise.
• Enjoy alcohol in moderation.
Just as you service your car – service your body.
Can you tell me what causes a heart attack?
Aheart attack occurs when an area of heart muscle is deprived of blood because of a blockage in a coronary artery. As the muscle no longer has oxygen to feed it, it begins to die, chemicals build up and pain is felt. The cause is usually a clot forming on an area of narrowing in an artery.
I have recently heard that heart attacks can be caused by exhaust pollution. Is this true?
Recently, a statistical link has been reported between car exhaust pollution and heart attacks, with those most at risk being pedestrians, cyclists and drivers. Links like this have been shown before (for example, in railwaymen in fume-filled tunnels) but no medical proof exists that it causes a heart attack, and there could be other interpretations of the association. An association does not mean a cause, and most links like this raise more questions than are resolved. It is of course interesting, but there is little we can do about it other than change our travel methods on a large scale.
15.1 Symptoms
What are the symptoms of a heart attack?
Almost always there is chest pain. It usually builds up to become severe. It lasts longer than half an hour and, unless treated, may go on for 4 – 6 hours or more. The pain is most often across your chest and feels like a weight or tightness. Some people describe it with a clenched fist as if the pressure or squeezing of the pain resembles the clenching of the fist. The pain is rarely sharp like a knife and cannot be pointed to by one finger as it is spread across the chest.
The pain comes from the same place, even if you change your position from standing to sitting or lying down.
You may also get pain down your arms, usually the inside, to your wrists. The left arm is more often affected than the right. It can go to your jaw, throat, back or stomach. The pain may be severe, causing sweating, and be associated with feeling sick (nausea) or vomiting.
So, get help fast if you have:
• A heavy feeling – a feeling like a weight or pressure, or a squeezing feeling like a band in the chest – that lasts longer than 20 minutes and builds up (heart attack pain usually builds up rather than being at its worst when it starts);
• Pain from your chest, going to your neck, jaw or arms (left more common than right) and lasting longer than 20 minutes;
• Pain (or discomfort) along with nausea, sweating, feeling faint or short of breath.
Are there any warning signs that might point to an impending heart attack?
Many people complain of ‘indigestion’ for some days or weeks beforehand. What they have been experiencing is angina.
It is quite common for people who have had a heart attack to say that they have been very tired in the previous 3–6 months. Some complain of breathlessness (the tightness across the chest has a breathless feeling about it) and dropping off to sleep watching TV. Others have noticed an increased tendency to snore and irritability: feeling ‘out of sorts’, ‘just not themselves.’
A new warning sign is that of men complaining of difficulty getting an erection. The blood vessels to the penis do not function properly and can reflect problems with the blood vessels to the heart. Erection problems in men are caused by smoking, raised cholesterol, blood pressure or diabetes – exactly the same as for the coronary arteries! Play safe and go to the doctor. If you are worried about a friend or relative, do not take no for an answer – get them to see a doctor. If you think it is a heart attack, do not delay: for every 1 hour’s delay, one life in every hundred will be lost – dial the emergency services.
I know that I get angina and have learnt to recognise the symptoms. How will I recognise the difference between the pain of angina and that of a heart attack?
Angina is the result of a temporary shortage of oxygen available to the heart muscle and is usually caused by exercise (such as walking up a hill) or strong emotion, especially anger.
The pain is most often a tightness or a weight on your chest that may spread to your neck or arms. Anginal pain passes off when you stop or reduce exercise or when you take a nitrate tablet or spray. It does not last longer than half an hour.
The cause of angina is narrowing of the coronary arteries. Think of the artery as a three-lane motorway and angina as the result of two lanes being coned off. All the traffic will get through if people travel slow enough but, at high speeds, three lanes will only go into one if someone stops to give way. If no one gives way there will be a crash blocking the third lane. This is what happens in a heart attack. A clot forms on the narrowed part to block the artery totally. Narrow coronary arteries are often described as being hardened or furred-up.
My brother has had a heart attack – according to the hospital. He says that he did not feel it happening. I thought a heart attack was painful.
Some heart attacks can be so minor that they are barely noticed, but others can be more severe. The severity depends on which part of the artery is affected. If you look at the diagram of the heart in, you will see that there are two main arteries shown – the right and left.
The left divide into two main trunks. These branch again and again into smaller branches or tubes (vessels), supplying blood to all of the heart muscle. A blockage in one of the tiny vessels means that only a very small part of the heart is deprived of blood. A blockage in a larger branch affects a much larger area of heart muscle. Because the blood can no longer get through and feed the heart and remove waste from the muscle, chemicals build up to produce pain, as if the heart had been bruised.
15.2 The Event
My mother has been told that she is ‘at high risk’ of a heart attack. I am her carer and am worried about her. What should I do if I think she is having a heart attack?
Your mother should rest completely in a comfortable position, preferably lying flat with her feet slightly raised. Make her avoid any exertion: if you are at home, the floor is best, not the bed if stairs are involved. Call the ambulance immediately and tell them that you think that your mother is having a heart attack. Make sure that you stay on the line long enough to tell them precisely where she is. If you know her doctor’s name, contact the surgery immediately: the doctor may be able to start treatment before the ambulance arrives. If your mother has been given glyceryl trinitrate tablets or sprays for angina, then one or two tablets or sprays should be given.
She should also chew 300 mg aspirin, or dissolve and swallow it, unless she is allergic to it or she has a recently (inside 1 month) proven stomach ulcer; if in doubt, give it anyway – the benefit is greater than the risk.
Why do we have to say ‘heart attack’ when calling an ambulance?
Some areas have specially equipped ambulances which can give immediate care to coronary patients – these are known as ‘coronary ambulances’. The staff – often paramedics – are coronary trained and can deal with the situation and its problems with a great deal of expertise and skill.
Our doctor has advised us to go to the coronary care unit in the event of my husband having a heart attack. Why?
In the early hours after a heart attack, the build-up of chemicals can irritate the heart and upset the electrical system that controls the heartbeat. A very irregular rhythm known as ventricular fibrillation (VF) can occur. In effect, it is as if the heart has stopped; all that is happening is that the heart muscle (ventricle) is chaotically wriggling like a bag of worms (fibrillating), and there is no blood leaving the heart as a result. This can be corrected by prompt medical treatment so that normal heartbeats can be restored. Prompt treatment means being in the hands of the experts in a coronary care unit who can keep an eye on your husband hour by hour until the risk settles, usually after 24 hours.
Coronary care units employ highly trained nurses who deal with pain, monitor the heart and supervise specific treatments designed to minimise complications and speed recovery.
My partner is very stubborn and simply refuses to go to hospital. He is getting on now and not strong. He has been a life-long smoker. I do not want to upset him by making him go to hospital if he had a heart attack. Would he be able to stay at home?
Some doctors believe it is safe for people to stay at home provided that suitable facilities and care are available. The danger period is usually within the first 12 hours; if this time has passed already and there are no problems, it is probably as safe to be at home.
Older people like your partner may be happier at home also. Home care involves the family, local nurses and family doctor, and its quality will depend on their availability and workload. It is unwise to be at home alone following a heart attack. If the heart attack has just happened, it is better to be in hospital, where everything is immediately to hand. This applies to young and old people of both sexes.
There is clear evidence that otherwise fit people in their eighties benefit from thrombolysis (clot buster medication) and angioplasty (balloon treatment) where needed – and that means going to hospital.
15.3 Going to hospital
My husband has heart problems and I am told that he is ‘at risk’. If he had a heart attack, what actually happens after hospital admission?
If your husband has a heart attack at home, an assessment is usually made in the ambulance. He will then go to the hospital casualty department; some hospitals have a ‘fast-track’ system and he would go straight to the Coronary Care Unit (CCU) or for an angiogram.
The hospital doctor will take blood to look for evidence of damage (enzymes). Contents of the muscle cells leak out when there is damage. They help the doctor determine the size of the attack. Routinely now, another chemical test for troponin is performed; this is very sensitive at identifying damage – doctors talk of ‘trop positive’ (damage) or ‘trop negative’ (no damage).
A recording of the electrical activity of your husband’s heart (ECG or EKG) will be taken at least once and will usually confirm the diagnosis and help identify the precise area of damage. Eight out of 10 heart attacks show on the first ECG and it is after this that clots buster drugs or angioplasty is offered. A chest X-ray will be taken to see if there is any fluid in his lungs.
Your husband will probably be given medication (morphine) to relieve pain and limit complications. Tablets or injections may be used to reduce fluid in his lungs (diuretics) and stabilise his heartbeats if there is any irregularity causing concern.
There are three sorts of medications which are most often used (unless there are specific reasons why they should not be given) because they protect the heart, improve survival and reduce complications.
• Aspirin thins the blood to help prevent further clots. He will be able to take this in the soluble form, 75 mg/day, and will probably take it for the rest of his life.
• Beta-blockers are medications that slow the heart down and reduce blood pressure.
They protect the heart from too much physical and mental stress. Because these medications can improve your husband’s chances of survival after a heart attack, they will be probably be given long term. Commonly used preparations are atenolol, bisoprolol, propranolol, metoprolol and timolol.
• Angiotensin-converting enzyme inhibitors or ACE inhibitors help some people survive. Fewer people on these medications have heart failure and they help reduce the heart’s tendency to enlarge after a heart attack. Commonly used tablets are captopril, lisinopril, enalapril, ramipril and perindopril.
In the coronary care unit (CCU), rest is crucial to allow his heart to recover. Visiting by immediate family only should be brief as he will often tire easily. Young children can often be upset by the visit so care is needed if they come to see him.
A brief visit to see that ‘daddy’ or ‘mummy’ is okay may benefit both child and parent, but the child must be fully prepared for the sight of the equipment, which can be daunting. It may be better if a nurse takes the child into the unit in a matter of fact way; this can reduce the natural tendency for the family to become emotional at a time of great stress.
In the CCU meals are light, as heavy meals can increase the heart’s work by 20%, and rest is really what is needed. Your husband will find fluids; soups and salads are the easiest options. As part of life in the CCU, there are routine ECGs, chest X-rays and blood tests, all designed to monitor his progress.
My husband went straight for an angioplasty even in his outdoor clothes – why did they rush?
The paramedics or casualty staff will have diagnosed the heart attack and the best chance of saving the heart muscle from damage is to open the blocked artery as quickly as possible. This is known as a primary angioplasty and represents the state-of-the-art management. Time is of the essence so speed saves lives.
My husband has gone into a Coronary Care Unit. What will happen when he returns to the general ward?
Most people leave coronary care after 24 – 48 hours. Everyone is an individual, not a statistic, so some leave sooner than others. Once your husband is back on the cardiac or general ward, a restful atmosphere is still essential and visitors should be restricted to avoid fatigue. Fear and ignorance are the biggest problems at this stage, so it is very important for him to fully understand what is going on.
Questions need answers, so do not suffer in silence worrying about something. The key to your husband’s recovery will be for him and his family to participate actively in the rehabilitation process. Do not keep any facts from his family and friends, as this leads to emotional charades at a time when maximum support is needed.
He will normally leave hospital after 7–10 days, but your husband may be kept in a little longer if his doctor thinks that he needs longer to recover. During the recovery period he will be encouraged to increase his exercise gradually, and he will be given advice on how to live and eat healthily.
Just before discharge from hospital, or within 6 weeks of a heart attack, an exercise ECG on a treadmill will be arranged for him. This is designed to rule out any further heart trouble and allows the doctor and your husband to judge how well his recovery is progressing.
What drugs should a heart attack patient be taking on leaving hospital?
Drugs may be used to protect from further events and these are:
• Aspirin or clopidogrel, or both;
• Statins;
• Beta-blockers;
• ACE inhibitors or AII antagonists.
He should also be taking written information explaining what has happened and what to do next. An appointment with cardiac rehabilitation is strongly recommended. Specific drugs may be used to control symptoms, such as diuretics (water tablets) to relieve fluid retention and breathlessness. All heart attack patients should understand what the medication is for – if unsure, always ask.
