Heart Attack (Also Called Mycardial Infarction)

What is a Heart Attack? 

Dictionary: death or damage to part of the heart.
World Health Organization – Old consensus: two out of three characteristics; chest discomfort, Cardiac Enzyme elevation, or ECG with Q waves.
Post 2000: Joint European Society of Cardiology / American College of Cardiology Committee redefines it by myocardial cell death, biochemical markers of myocardial cell death, evidence of myocardial ischemia (ST-T changes), Q waves (loss of electrically functioning cardiac tissue), or imaging that indicates loss of tissue perfusion and cardiac wall motion abnormalities. (i.e. many “heart attacks” were missed in the past, and were documented as other than heart attack at the time of the event. Goal is to not miss or misdiagnose as many of them).

Symptoms (clinical presentation):  shortness of breath, loss of stamina, sweating, nausea, vomiting, light-headedness, or faiting; discomfort in areas of central chest, epigastric, arm, wrist, jaw, shoulder, neck and/or back.

–         May be 20 minutes, but can be less, and may be more.

–         Not usually affected my movement, position, or deep inspiration.

Problems in Identification of Symptoms: May present with all, some, or none of the identifying symptoms. Symptoms can also be related to other pathologies and confused (i.e. “stomach” pain).

Differential Diagnosis: Angina (stable and unstable), lung bleb, pleuritis, collapsed lung, tension pneumothorax, tear in aorta, precordial catch syndrome, rupture of the esophagus, esophagitis, perforating peptic ulcer, pulmonary embolus, pericarditis, or mitral valve prolapse.

What happens during a Heart Attack? Ischemia (lack of blood flow), cardiac muscle weakness from acute reduction in blood supply, loss of electrical activity because it can affect cardiac conduction cells, pH changes from accumulation of lactic acid, etc. Temporary vs. permanent damage and changes – the longer the heart does not have its proper blood supply, the higher the odds are that the damage will become permanent. How long does this take? Damage starts within the first hour. Permanent damage starts before 2 hours. However, if the cells that produce the electrical activity are affected, the heart can fibrillate (beat too fast and too shallow to pump blood) which can result in death within a few minutes (3 to 5 usually) without CPR and/or a defibrillator.

What is the Reality?: From primary care setting reports, the actual causes of chest pain are: musculoskeletal 36% to 49%, gastrointestinal 8% to 19%, pulmonary 5% to 10%, and psychiatric 8% to 11%.  Cardiac is only actually 15% to 18% of the cause.

If it probably is not a Heart Attack, why bother? Embarrassment, inconvenience, cost. You may not always know for sure. If in doubt, it is better to seek medical attention. If it is a heart attack, by the time you arrive at the hospital, it will be easier to know for sure. At worst, you made a trip for nothing. At best, you are in a place that can treat you if needed.

If it is a Heart Attack? What then? Where? (Chapala, Guadalajara, USA/Canada)? How (What do I do, who do I call, what can I take, what treatment do I want)? When (Now, minutes, hours, days)? How can I be sure it is a Heart Attack? Sometimes you cannot be sure. Thus, as stated above, seek treatment. However, the symptoms are sometimes very clear. In that case:

You need to be treated as fast as possible, this means as close as possible. Treatment sometimes needs to be started in seconds to minutes.
If it is an acute heart attack, do not look for the cheapest hospital. Go to the closest hospital. No hospital can deny emergency medical care based on money. Emergency means risk of life, not headache, gastritis, or other “assumed emergencies” that simply keep you from sleeping. The hospital needs to have the ability to treat the emergency, and it has to be a real emergency (unstable with risk of death… ). If it is a real emergency (you are unstable and could die), and the hospital has the means to stabilize you, they legally must do their best to treat you to the point of stabilization. No hospital can deny emergency service to a patient who is at risk of dying.

ARTICULO 158. QUIENES EJERZAN LA MEDICINA Y, SIN CAUSA JUSTIFICADA, SE NIEGUEN A PRESTAR SERVICIOS A UN ENFERMO QUE LO SOLICITE POR NOTORIA URGENCIA, PONIENDO EN PELIGRO LA VIDA DE DICHO ENFERMO, SERAN SANCIONADOS CON MULTA POR EL IMPORTE DE VEINTE A DOSCIENTOS DIAS DE SALARIO.

SI SE PRODUJERE DAÑO EN LA SALUD POR FALTA DE INTERVENCION, SE LES IMPONDRAN ADEMAS DE SEIS MESES A DOS AÑOS DE PRISION E INHABILITACION PARA EL EJERCICIO PROFESIONAL, POR EL TERMINO DE UN MES A DOS AÑOS.

HAVE A PLAN ! Have a plan “A” and a plan “B” Plan “A” is what will you do at the moment. Plan “B” is what you will want others to do for you in case you are incapacitated.

Treatment: 

– Aspirin, oxygen, nitroglycerine, defibrillator, CPR. (Treatments that need to be available at the time of onset of the heart attack)

– Angioplasty and stents (Treatments that may be needed, but in a hospital in Guadalajara or other major city)

– Thrombolytics*: Streptokinase (AKA “Cheap-O-Kinase”), Alteplase, Reteplase, Anistreplase, Tenecteplase, etc. (Treatments that if used, need to be given in the first 30 minutes. Can dissolve the blockage. May eliminate need for stent. Cannot be given if patient has had CPR or chest trauma). *Not functional after two hours when clot hardens.

-Aspirin (acetylsalicylic acid). About 300mg. This means aspirin, not ibuprofen, acetaminophen or other pain medications. Chew the tablet. Do not put it under your tongue or swallow it whole. To reach an effective level in your body, it takes 5 minutes if chewed and washed down. Taking it whole takes longer to work. Aspirin WILL NOT reverse the clot causing the heart attack, but will prevent it from growing bigger.

-Oxygen. In a heart attack or stroke, giving the patient oxygen will help slow the progression of damage caused by the blockage, that in turn reduced the flow of oxygen.

-Nitroglycerine. Talk with your doctor to see if you are at risk, and should have it available.

-CPR and Defibfillator. Everyone should learn CPR. You will not likely have your personal doctor at your side when you have a heart attack. Most heart attacks occur with friends and family. They can either watch you die, or help save your life. Training is important. Whether you live or die after a heart attack if often determined at the site, not in an ambulance or hospital.
Defibrillators are the most useful tool to bring a heart back to a normal beat. More people should consider purchasing an automated defibrillator for areas of recreation and home. You can be dead by the time an ambulance arrives with one.

Aftercare:
–  After infarction (heart cell death), healing process leaves weak area that takes time to scar, and during this time there is a risk of heart rupture. The first week or two requires time to heal. Follow your doctor’s advice and take the required medication.

–  Electrical alterations: Blocks, atrial fibrillation. Etc. Warfarin, antidysrrythmics, etc. You may be left with permanent alterations in the heart structure or its  electrical function that will require lifestyle changes and/or new medications.

How Will YOU be Prepared?

*      How will you know or recognize if you are having a heart attack?
*      What will you do?
*      Where will you go, and How will you get there?
*      Who will help you?
*      Do your friends or family what you want to do (level of treatment you want and can afford) and where you want to go (local medical services, Guadalajara, which hospital)?
*      Who knows your medical history, and can help doctors treat you best?