HEART ATTACK

HEART ATTACK

Also called myocardial infarction.

What is it?

Myocardial infarction takes place when the blood supply to a part of the cardiac muscle is reduced or cut altogether. This happens when a coronary artery is either contracted or partially or totally obstructed.

With total or partial suppression of blood supply to the heart muscle, it sustains an irreversible injury, and, on stopping working, leads what´s been left of the heart to sudden death, late death or heart failure with outcomes ranging from severe limitations in physical activity to total recovery.

Myocardial infarction is the most common death cause in the USA.

Myocardial infarction may also occur to people who have normal coronary arteries. This happens when the coronaries present a spasm, contracting itself violently and also producing a partial or total deficit of blood supply to the heart muscle irrigated by the constricted vessel.

This kind of spasm can also occur in vessels already compromised by atherosclerosis.

Learn more about atherosclerosis on this site.

Chest angina

Angina presents in two forms: stable and unstable.

Both unstable and stable angina have manifestations or symptoms similar to those of myocardial infarction. They may evolve to myocardial infarction when untreated.

Stable chest angina is differentiated from infarction by some of the characteristics below:
 

	Pain duration – generally this is of short duration, if it lasts more than 15 minutes, it´s probably an infarction.
	Pain appears with effort and disappears when this stops, with rest..
	Parallel manifestations usually aren´t as intense as in an infarction.
	The retrosternal crushing pain disappears with the use of sublingual nitro-derived pills. If pain doesn´t cease, it´s probably an infarction.

The symptoms of stable angina range from one person to another, but, in a same individual, they´re usually similar, and the triggering factors are well known, such as making efforts, walking in the cold wind, climbing stairs, sexual activity, etc.

The symptoms of unstable angina usually appear at rest while getting up in the morning and their appearance is sudden, with pain and moderate to severe discomfort, rapidly evolving to a stage in which there is an increase in discomfort and pain, both in its intensity and severity.

Warning! Chest angina can be considered a friendly pain, an unpleasant manifestation which, however, warns something wrong and worrisome may be happening to your heart, leading the affected person to seek medical help before the disease becomes worse.

Warning signs

The most common ones are:
 

	Pressure and discomfort, crushing pain at the center of the chest that lasts more than a few minutes or that is intermittent.
	Pain at the center of the chest that radiates to shoulders, jaws, neck, and arms, more frequently to the left arm..
	Discomfort in the chest with lightheadedness, sensation of faintness, sweating, and shortness of air.

The least common are:
 

	Dull, atypical pain in the pit of stomach, chest or belly.
	Nausea and vomiting without chest pain..
	Shortness of breath or difficulty breathing, even without chest pain..
	Unexplained anxiety, weakness or fatigue..
	Palpitations, cold sweat, or paleness, sometimes intermittent..

Trivia

In men, precordial pain is the most frequent symptom, while in women excessive tiredness and fatigue are the most commonly found symptoms.

Women more often experience nausea, pain in the epigastrium or in the back, neck or jaw.

Many times symptoms other than pain have been experienced long before the infarction occurs.

The intensity of the infarction pain ranges a lot from one patient to another. Pain isn´t necessarily intense.

Pain usually radiates to the left arm, but in 15% of the ones affected it radiates to the right arm.

Many symptoms of coronary disease are ignored by patients as well as by physicians. There are silent infarctions that are revealed by the electrocardiogram or other exams during a routine check-up.

Require of your doctor an investigation into the cause of your symptoms, especially if you belong to a risk group.

The part of the heart that suffers necrosis, dies, as a result of an infarction, is no longer viable and won´t spawn symptoms such as pain. Therefore, as long as the patient feels pain, there is still remaining viable heart tissue that can recover on its own or with suitable treatment. The sooner the compromised tissue is treated, the greater the chances for recovery are.

If this happens, if you observe one or more of the above manifestations, don´t wait, go to or call an emergency service at once.

50% of the people that die from an infarction do so within the first hours and don´t receive medical assistance in the due course.

Prognosis for myocardial infarction

The prognosis with regard to life quality and survival after a myocardial infarction depends on the severity, extension of the infarction and other diseases that accompany the patient.

Around 1 million and a half people suffer an infarction in the USA per year. In the past years, the incidence of infarction has increased in women; conversely, survival has increased due to more effective means of treatment.

In the short run, the prognosis is worse for elderly people, diabetics, heart failure and renal failure patients.

The most frequent cause of death in infarcted people is the shock that takes place in 7% of the cases. Shock incidence hasn´t dropped in the last years.

Blockade of the ventricular auricle is frequent and can be treated with pacemakers.

In the long run, the prognosis, both for survival time and for life quality, also depends on the severity of the infarction and the preventive measures taken.

There are no tests to prevent when a new attack will occur, it is admitted that up to 30% of further fatal attacks and heart surgeries can be avoided with the adoption of healthy lifestyle and treatment compliance.

The physicians know that 66% of the patients don´t change their lifestyle and don´t follow medical prescriptions and advice to prevent a new infarction.

Brain attack

Also called brain ischemia, brain thrombosis, brain embolism or brain hemorrhage, depending on the type of underlying disease.

In a brain attack, a decrease in blood supply to a brain region occurs, or an embolism obstructs an artery, or, yet, there´s formation of a thrombus, or a vessel has a spasm or disrupts. All of these scenarios reduce or impede the passage of blood and are the motives of a brain attack.

Brain attacks can be deadly, but total recovery may also occur, with palsy or other rather extensive, transient or lasting manifestations of decrease in brain function, with recovery ranging from partial to total.

Brain attack is the third most frequent cause of death in the USA.

Most common signs and symptoms  
 

	Falling asleep suddenly, or weakness in the face, arm, leg, especially if it´s on one side of the body only.
	Sudden confusion.
	Sudden difficulty understanding or speaking.
	Sudden sight difficulty in one or both eyes.
	Sudden difficulty walking, sudden dizziness, loss of balance or coordination,
	Severe headache by unknown cause.

Seek a doctor or a medical emergency service at once if you present one or more of these manifestations.

Diagnosis of coronary disorders

For the diagnosis of coronary disorders, there are several methods available for the doctor to determine how ill your coronaries are. Some are performed in the medical office, others in specialized services or in a hospital.

Anamnesis and clinical exam

Anamnesis is what the disease history reported by the patient or their family members is called. The information collected by the doctor may suggest, with lower or higher certainty, a diagnosis.

As a second step, the doctor carries out what is called clinical examination. The findings from this evaluation, plus the data from the disease history, allow the doctor to raise a diagnostic hypothesis or even arrive at a diagnosis.

To confirm the diagnosis, your doctor will ask supplementary exams that, in case of heart disease, are the following.

Electrocardiogram

The electrocardiogram performed at rest is useful to diagnose arrhythmia, enlargement of cavities, conduction disorders, manifestations suggestive of perfusion disorders, metabolic disorders or medication-induced disorders.

If the patient´s clinical history is suggestive of ischemic heart disease, and if the electrocardiogram at rest is normal, the investigation must go on.

It´s a test to ascertain the heart´s tolerance to effort. It is performed with the patient pedaling a stationary bike or walking on a treadmill, while the doctor observes or records the electrocardiogram.

Another possibility for testing the heart capacity is the one performed by administering a radioactive substance that fixes itself to the heart muscle.

If there are regions in the heart less irrigated by blood, there will be a poorer fixation of the radioisotope in those areas. Via this test we can see how the heart moves and how the blood is distributed through the heart muscle. We can observe how the heart behaves at rest and under exertion.

Exertion Test

If the person has other diseases and isn´t able to perform the exercise test, the test may be carried out with a drug that activates their heart and dilates the coronary arteries. An electrocardiography made during the test provides the same information as a test done with a treadmill or bike.

These stress tests show how the heart´s working, but fail to show the precise site at the heart where the disease is located, which is the blocked artery and what the degree of obstruction is.

In order to elucidate this doubt we resort to cardiac catheterism.

Cardiac catheterism

Cardiac catheterism, angiography or cinecoronariography are related terms, though they don´t mean the same thing.

Via cinecoronariography we can analyze the coronary arteries.

For the test execution, a catheter is introduced through an artery of an arm or leg and is directed to the heart where, by injection of a contrast into the heart cavities, we can analyze the heart cavities and valves. By injecting a contrast into the opening orifices of the coronaries, we can assess their state.

Doppler/Echocardiogram

By means of this exam information is collected on the anatomy and function of the heart. For the diagnosis of ischemic disease this exam has no greater utility.

Tomography Angiography

By means of this examination it is possible to perform a 3-D investigation of the heart vessels and obtain a good information on circulatory deficiencies.

What we can expect of these tests

Stress tests allow your health care provider to know how much of your heart is in danger or how much it´s been destroyed. They show the place and degree of obstruction of an artery and the number of vessels affected. All of these data are important for the doctor to be able to make a prognosis based on experience. Another result from these exams is the fact that they allow to guide the treatment.

Basically, the treatments of coronary disorders are of 3 types:  
 

	Medical Treatment
	Angioplasty
	Bypass surgery

Medical treatment

Medical treatment is made up of medications, dietary measures, and sociohygienic measures.

Medications – your doctor will decide which one is best indicated for your case. Medications have side effects that can even aggravate a clinical state. There exist drugs that are contraindicated for some people and not for others, and drugs that compete among one another, having their utilization changed in view of medicines taken for other diseases. Hear from your doctor what medication is the most convenient for your case.

Medical treatment is recommended for the following cases:  
 

	Obstruction of only one artery.
	Less severe obstructions.
	For the patient not to have very frequent angina crises.
	For patients that were hospitalized in crisis and responded well to treatment and to rest in the course of hospitalization.

The most used medications are aspirin, nitro-derived agents and beta-blockers.

Use medications only under medical guidance. An wrongly indicated or misused medication can even cause death to whom receives it.

Angioplasty

Like in catheterism, a catheter is introduced through the coronary to the place where the obstruction lies. In the narrowed site, a small balloon is inflated and the constricted part is dilated. Later the balloon is removed, and we evaluate if the blood flow has been partially or completely resumed.

We can also leave a stent in the place of obstruction, the stent is a small metal spring that is contracted and introduced to the constricted part. Once placed at the right site, the contraction of the spring is released, the spring dilates and widens the constricted area of the artery along with it.

Benefits of angioplasty  
 

	Angina relief
	Allows an increase in physical activity free of angina.
	Allows to resume normal activities.
	Lower medication consumption.
	Less fear.

Potential risks of angioplasty  
 

	Aggravation of angina
	Requiring emergency bypass surgery. This happens to 2-5% of the cases.
	Myocardial infarction during the procedure.
	Artery lesion.
	Reobstruction of the vessel that has been dilated. This occurs in about 40% of the cases at six months of the procedure, necessitating new angioplasty or surgery.
	Death during the procedure.

Revascularization surgery

The revascularization surgery uses a vein from the leg or a chest artery to unite the aorta to a point beyond that in which the coronary is obstructed, in order to allow the blood to pass.

Angioplasty is indicated for patients with severe obstructions, mainly those of the main left coronary artery, or in multiple obstructions. It may constitute an emergency procedure when accidents occur in the course of an angioplasty. Another indication for bypass placement is when the patients don´t get better with clinical treatment.

The Coronary bypass surgery provides an optimal blood supply to previously poorly perfused regions.

Potential benefits from bypass surgery  
 

	Prolongs life.
	Relief of symptoms.
	Increases physical activity.
	Allows returning to previous activities.
	Reduces medication consumption.
	Reduces fear and anxiety.

Potential risks for bypass surgery  
 

	Bleeding, which may entail a new surgery.
	Infections.
	Stroke.
	Formation of clots and embolus.
	Failure of organs such as kidneys, liver, and lungs.
	Myocardial infarction.
	Death.

What´s better – angioplasty or surgery?

It falls to your doctor to decide on this.

The two procedures have the same purpose.

Both can improve your heart function.

	Being less invasive than surgery.
	Shorter hospitalization time
	Lower cost.
	Allowing an earlier return to activities.

What to do after angioplasty or bypass surgery?

The two procedures don´t cure the underlying disease, atherosclerosis.

The two procedures aim at improving the perfusion of ischemic regions of the heart. Not always is this improvement complete.

Follow the recommended precautions to manage the risk factors of atherosclerosis.  
 

	Listen to your doctor, follow his/her advice.
	Take the medications on a regular basis.
	Go on a diet and work out according to medical advice.
	Change your lifestyle, correcting what´s been wrong.
	Understand your illness, search for information from your doctor, ask him/her what worries you.
	Avoid getting information from lay magazines or lay people. Even the ones that have been there and done that are not reliable sources.
	Your illness may be different from other people´s, though the symptoms and diagnoses are similar.
	Return to your doctor whenever you have doubts.
	Don´t hide the symptoms, behavior alterations, change of medications that have occurred. Communicate with your doctor.
	Don´t diagnose by yourself. If something different happens, ask your doctor whether it is significant or not.