Heart Attack : FAQs
Myocardial infarction (mi): Heart attack 

What is the treatment given?
Heart attack is a medical emergency that must be quickly addressed by conventional medicine. Alternative medicine cannot compete with standard drug and surgical therapy during the emergency and follow-up phases of heart attack. However, alternative medicine can make valuable contributions to prevention and recovery.

Heart attack victims are usually hospitalised in special coronary care units (CCU) for at least 36 hours. The immediate goal of treatment is to quickly open the blocked artery and restore blood flow to the heart muscle; a process called "reperfusion." Once the artery is open, the heart attack is generally halted and the patient becomes pain free. Early reperfusion minimises the extent of heart muscle damage and preserves the pumping function of the heart. Delay in establishing reperfusion can result in irreversible death to the heart muscle cells and reduced pumping force of the remaining heart muscle. The amount and health of the remaining heart muscle is the major determinant of the future quality of life and longevity for a patient after a heart attack. Optimal benefit is obtained if reperfusion can be established in the first 4- 6 hours of a heart attack.

In the acute phase the following treatment may be given:-

Clot dissolving medicines (thrombolytic agents) such as tissue plasminogen activator (TPA) or streptokinase given intravenously can successfully open up to 80% of acutely occluded coronary arteries. The earlier these agents are administered, the better the success at opening the artery, and the more effective the preservation of heart muscle. If thrombolytic administration is given too late (more than 6 hours after the onset of the heart attack), most of the muscle damage may have already occurred.

Emergency angioplasty (to relieve the blocked artery) and possibly surgery might be performed to remove a clot, reopen a clogged artery, or bypass blocked arteries.

An anti-coagulant, heparin, is given intravenously in the hospital as a blood-thinning agent to prevent blood clots and to maintain an open artery during the initial 24-72 hours of the heart attack.

The most direct method of opening a blocked artery, provided the hospital has a cardiac catheterisation facility, is to perform an immediate coronary angiogram and PTCA (percutaneous transluminal coronary angioplasty). Under x-ray guidance, a tiny plastic catheter with a balloon at the end is advanced over a fine guide wire to the blockage site and inflated, thus pushing the clot and plaque out of the way. PTCA can be effective in opening up to 95% of arteries, usually within 60 minutes. In addition, the angiogram allows evaluation of the status of the other coronary arteries, so that long- term treatment plans may be formulated. Recently, it has been demonstrated that the placement of a coronary stent (a tiny hollow cylinder) at the time of PTCA results in even better long term outcomes, with a lower recurrence rate and lower risk of repeat heart attack. These results may be further enhanced by the addition of newer super aspirins (potent blood thinners that work to antagonize the blood-clotting effects of platelets in the blood and in the cholesterol plaque), which are given at the time of PTCA or coronary stenting.

In some patients, PTCA can be technically difficult or dangerous to perform. In others, PTCA and thrombolytic medications may fail to achieve reperfusion or maintain open arteries. These patients may be considered for coronary artery bypass graft (CABG) surgery.

Nitroglycerin, a vasodilator (blood vessel dilator), which opens the blood vessel by relaxing the muscular wall of the blood vessel, is given intravenously in an emergency and later as skin patches to prevent blood vessel spasm and to minimise the size of the heart attack.

While hospitalized, heart attack patients are hooked to ECG machines for constant monitoring, in case heart rhythm abnormalities develop. If the heart starts beating too fast or too slow, various medications may be given. Some patients may be fitted with pacemakers. If a patient experiences a dangerous arrhythmia known as ventricular fibrillation, an electric shock to the chest is administered. Patients who show signs of congestive heart failure are given a variety of medications to decrease strain on the heart and to encourage the heart to beat more forcefully.

After the acute attack is controlled the following drugs are often used in combination or alone:-

Aspirin- a daily low dose of aspirin (81-325 mg) taken on a lifelong basis decreases repeat heart attacks significantly. For those patients allergic to aspirin, ticlopidine may be substituted. Anti-platelet agents, like aspirin, reduce the tendency of platelets (a type of blood cells that play a role in the normal clotting mechanism) in the blood to clump and clot. Aspirin is given to patients with a heart attack, unless there is a history of significant intolerance to aspirin. These agents work in conjunction with the above-mentioned reperfusion therapies (like surgery and angioplasty) to decrease the possibility of recurrent closure of the artery and improve the chances of survival.

Beta-blockers- the use of beta-blockers such as metoprolol and atenelol significantly increase the survival in a person who has had a heart attack. Long-term administration of these agents following a heart attack has been shown to improve survival and reduce the risk of future heart attacks.

ACE Inhibitors- ACE (angiotensin converting enzyme) inhibitors, another class of drugs, are often given orally after a large heart attack to improve the heart muscle healing process. Examples of ACE inhibitors include captopril, enalapril and lisinopril. These medications reduce the stress load to the heart, thereby helping the damaged heart muscle to recover.

Calcium Channel Blockers- these drugs are used as a substitute for beta-blockers in-patients who suffer from angina (heart pain) after a heart attack or in those who have slow heart rates.

People recovering from a heart attack are urged to get back on their feet as quickly as possible, which reduces the chances of blood clots forming in the deep veins of the legs; the clots could travel through the circulatory system and lodge in the lung, creating a blockage. Gentle exercise is recommended, but nothing that requires significant exertion.

Post surgical management (after a bypass surgery)

After the surgery, the patient will awaken in the cardiovascular intensive care unit with: -

An oxygen mask,
One or two chest tubes to collect and drain any blood from the chest, and/or
EKG leads affixed to the chest to monitor the heart rhythm, and/or 

Intravenous tubing to inject fluids, antibiotics and medications into the patient, and to monitor his venous pressure. If needed, there will be an additional line that holds a pacemaker wire.

An arterial line, which is a catheter inserted into one of the arteries, usually in the wrist. This line will monitor the patientís blood pressure.

After the patient's cardiac status is stabilised:-
The patient is often shifted to a post-operative ward, and his EKG continuously monitored.
The patient will be encouraged to first sit up in a chair, and then attempt to walk around the room.
Pain control, including oral painkillers will be provided.
The patient may be given oxygen and intravenous fluids.

On successive days following the surgery:-
The patient will be put on oral medications.
The patient will be motivated to increase walking, as this will facilitate a speedy recovery.
The patient may still be kept on intravenous fluids.
The patientís diet will gradually be advanced.

Once the patient is walking around, is in no great pain or distress, and his heart rhythm is stable, he is ready to be discharged. In some cases, a Cardiac Rehabilitation Clinic may plan the patientís care so as to enable him to make a smooth transition from hospital to home.

Your doctor/cardiologist is an important member of your healthcare team. He helps you receive the best possible care before, during and after hospitalisation. You should feel free to discuss any queries you may have with your doctor.


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