Heart Attack Treatment

A heart attack, especially because of cardiac arrhythmias, is often a life-threatening medical emergency which demands both immediate attention and activation of the emergency medical services. Immediate termination of arrhythmias and transport by ambulance to a hospital where advanced cardiac life support (ACLS) is available can greatly improve both chances for survival and recovery. The more time that passes, even 1 ' 2 minutes, before medical attention is available/sought, the more likely the occurrence of both (a) life threatening arrhythmias/death and (b) more severe and permanent heart damage.

First line

In the hospital, oxygen, aspirin, glyceryl trinitrate (nitroglycerin) and analgesia (usually morphine, hence the popular mnemonic MONA, morphine, oxygen, nitro, aspirin) are administered as soon as possible. In many areas, first responders can be trained to administer these prior to arrival at the hospital.

Reperfusion

The ultimate goal of the management in the acute phase of the disease is to salvage as much myocardium as possible and restore contractile function of heart chambers. This is achieved primarily with thrombolytic drugs, such as streptokinase, urokinase, alteplase (recombinant tissue plasminogen activator, rtPA) or reteplase. Heparin alone as an anticoagulant is ineffective. Aspirin is a standard therapy that is part of all reperfusion regimens. Because irreversible ischemic injury occurs within hours of the infarction, there is a limited window of time available for reperfusion to work.

Although clinical trials suggest better outcomes, angioplasty via cardiac catheterization as a first-line measure is probably still underused. This is largely dependent on the availability of an experienced interventional cardiologist on-site, or the availability of rapid transport to a referral centre. The goal of primary angioplasty is to open the artery within 90 minutes of the patient presenting to the emergency room. This time is referred to as the door-to-balloon time. If this door-to-balloon time exceeds the time required to administer a thrombolytic agent by > 60 minutes, then the administration of a thrombolytic agents is preferred.

Emergency coronary surgery, in the form of coronary artery bypass surgery is another option, although this option is in decline since the development of primary angioplasty. The same limitations apply here: cardiothoracic surgery services are not available in many hospitals.

NSTEMI (non-ST elevation MI) is initially indistinguishable from unstable angina in most cases, and is therefore managed similarly with aspirin, heparin, and usually with clopidogrel.

Monitoring and follow-up

dditional objectives are to prevent life-threatening arrhythmias or conduction disturbances.This requires monitoring in a coronary care unit and protocolised administration of antiarrhythmic agents.

Patients are discouraged from working and sexual activity for about two months, while they undergo cardiac rehabilitation training. Local authorities may place limitations on driving motorised vehicles.

During a follow-up outpatient visit, or increasingly before discharge from hospital, further investigations are performed to objectivate coronary artery disease. If rescue angioplasty has not already been performed, a coronary angiogram (or alternatively a thallium scintigram or treadmill test) may be done to identify treatable causes, as this will decrease the risk of future myocardial infarction.

Secondary prevention

Patients are usually commenced on several long-term medications post-MI, with the aim of preventing secondary cardiovascular events such as further myocardial infarctions or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:

Antiplatelet therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of thrombus formation. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and aspirin may further reduce risk of cardiovascular events, however the risk of hemorrhage is increased.

â-Blocker therapy such as bisoprolol or metoprolol should be commenced. These have been particularly beneficial in high-risk patients such as those with left ventricular dysfunction (LVD) and/or continuing cardiac ischaemia. â-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.

ACE inhibitor therapy should be commenced 24 ' 48 hours post-MI in hemodynamically-stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by ECG), tachycardia, and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling post-MI.

Statin therapy has been shown to reduce mortality and morbidity post-MI, irrespective of the patient's cholesterol level.
The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.

Patients' blood pressure is also treated to target, and lifestyle changes are suggested, chiefly smoking cessation, regular aerobic exercise, a sensible diet, and limitation of alcohol intake.

Source http://www.wikipedia.org

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