The management goals in heart attack patients are centered around:
- Relieving the symptoms
- Minimizing the infarct size (extent of the dead tissue)
- Detecting and treating the complications
- Preventing further attacks
Heart attack is a medical emergency and patient should be hospitalised immediately, preferably in a coronary care unit (CCU).
Remember, EVERY MINUTE COUNTS.
- Initial management
- Absolute bed rest is mandatory.
- Oxygen therapy
- Aspirin (160-325 mg) chewable tablet improves the chances of survival and enhances the effect of thrombolytic (clot dissolving) therapy.
- Pain control – Relief from pain is very important from the patient’s point of view. The following measures can be taken for this purpose.
- Morphine – It is very effective in managing pain due caused by heart attack. Low dose morphine is given intravenously and can be repeated after 5 minutes. Nausea, vomiting, fall in blood pressure and decrease in heart rate are common side-effects of morphine.
- Nitroglycerine – Sublingual (below the tongue) nitroglycerine can be used for patients of heart attack to relieve the pain but it should be avoided if the blood pressure is low or when right ventricular infarction is suspected. Intravenous nitroglycerine can be used for control of recurrent chest pain.
- Beta blocker drugs – Intravenous beta blockers not only control the pain by decreasing heart muscle oxygen demand but also decrease short term mortality rate.
II. Subsequent management
Limitation of infarct size: The area of infarction can be minimised by timely restoration of blood flow. This can be done with the help of clot dissolving drugs (thrombolysis) or mechanical devices (angioplasty).
- Thrombolysis – Best results are obtained if done within 1-3 hours but may be beneficial up to 12 hours after a heart attack. It greatly improves the chances of survival after the attack. Many agents like streptokinase, urokinase, alteplase (t-PA), reteplase, anistreplase (APSAC) are used for the purpose of thrombolysis. The choice of agent is not so important, the speed of starting the treatment is what matters. Streptokinase and t-PA are commonly used to dissolve the clot. Bleeding is the most serious problem associated with thrombolytic therapy. Allergic reactions and hypotension may happen with streptokinase. This therapy is not suitable for patients with a history of brain hemorrhage, blood pressure more than 180 mm systolic or 110 mm diastolic, bleeding disorders or active peptic ulcer disease. It is also not suitable for patients above 70 years of age, those who are pregnant, have diabetic retinopathy, or have suffered recent head trauma or undergone any major surgical procedure.
- Angioplasty – Removal of the clot can be done within hours by means of coronary catheters. This approach is particularly useful in patients who are not suitable for thrombolytic (clot dissolving) therapy.
Anticoagulants – Once the clot has been dissolved, anticoagulants are used to prevent clot formation by heparin infusion.
ACE inhibitors – Enalapril, lisinopril, ramipril etc. increase the chance of surviving the attack especially, in high-risk patients.
Sedation – Diazepam or lorazepam is required in most patients to allay anxiety and to enforce bed rest.
Ambulation – The patient may be allowed to walk in the room after 48-72 hours of a heart attack (as per medical advice).
Diet – Liquid diet is recommended for the first 24 hours. Semisolid or normal diet can be allowed gradually after that.
Bowel – Constipation is common due to bed rest. Use of analgesics which can be taken care of by diet rich in fibers and stool softeners.
III. PREVENTION OF FURTHER ATTACKS
The risk of suffering from further attacks can be reduced by taking care of the risk factors and routine drug therapy.
A. Taking care of risk factors –
Smoking – Smoking is one of the greatest ‘self-induced’ risk factors. If continued, smoking, can increase the risk of further attacks significantly.
- Hyperlipidemia – Lowering of the “bad cholesterol LDL ” below 100 mg/dl and total cholesterol below 200 mg/dl reduces the risk of further attacks as well as stroke. Dietary modifications and lipid lowering agents are recommended.
- Diabetes & Hypertension – Control of hypertension and diabetes is essential for preventing complications.
- Obesity – Maintaining ideal body weight is equally important.
- Sedentary lifestyle – An Individualised exercise programme can greatly reduce chances of heart attack in the future.
B. Routine drug therapy
Aspirin – Low dose aspirin not only reduces the risk of further attacks and stroke but also helps decrease the severity of an attack. Regular intake of aspirin is essential. Side-effects can be reduced by using enteric coated tablets.
- ACE inhibitors – These drugs are particularly effective in improving the functioning of the heart (left ventricular function) and reducing the chances of further attacks (if used for a long duration).
- Beta blockers – These drugs also improve long term survival, but should be used with caution in patients with low pulse rate (bradycardia), low blood pressure or asthma.
IV. ROLE OF REVASCULARISATION
Coronary artery revascularisation in the form of Angioplasty (PTCA) or Coronary Artery Bypass Grafting (CABG) may be considered in selected patients (evaluation after 4-6 weeks of suffering a heart attack is required).