​                         Professor Francisco Leyva-León

What is a heart attack?

​A heart attack (myocardial infarction, MI) is due to blockage of a coronary artery. Typically, it is due to rupture and haemorrhage of an atherosclerotic plaque within the inner lining of an artery. It is the end-product of years of accumulation of abnormal cells and lipids within the artery wall (atherosclerosis). Once the artery ruptures, a clot forms over it and this blocks the artery.​ It is a serious condition, because it leads to permanent damage (death) of the heart muscle.

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Symptoms of a heart attack

​Typically, the pain of a heart attack is a severe pain, felt in the centre of the chest. It may be associated with sweating, clamminess, vomiting, a racing heart, lightheadedness or fainting. You should seek emergency help. Remember every minute counts.



Investigation

There is very little time for medical and paramedical staff to make the diagnosis. The ECG will confirm it in most cases. If you have called the ambulance, the paramedics will do an ECG and communicate the findings to  the cardiologists in the local hospital, who will decide whether the type of heart attack you have can be treated with emergency angioplasty (primary PCI). 



Immediate treatment

The standard treatment for someone with an ST-segment elevation myocardial infarction (STEMI), is 'primary' angioplasty (PPCI). By the time you get to hospital and you have the right type of heart attack (ST-segment elevation myocardial infarction, STEMI) the cardiology team will be waiting for you. An emergency angioplasty will be undertaken. In the UK, this emergency treatment is delivered in NHS hospitals, not private hospitals. If circumstances are such that early (<2 hrs) PPCI is not possible, patients may be treated with a clot-busting drug (thrombolytic). Sometimes, PPCI can be combined with a thrombolytic drug.



After the MI

​You will be kept in hospital for 3-5 days, provided you have not developed complications.



Investigations after an MI

The following investigations may be performed:

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• Angiogram: If this was not undertaken at the time of the MI, it may be undertaken at follow-up.  coronary arteries

• Echocardiogram: to check the function of the heart

• Lipid levels

• Glucose levels, to exclude diabetes

• ECG (heart trace) - this, plus the echocardiogram, will be central in deciding whether you need an implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy (CRT).



​Drugs after an MI

The choice of treatment depends on the individual characteristics and circumstances of the patient, but all patients should be on the following drugs:
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• Aspirin makes blood less sticky and reduces the likelihood of developing heart attacks and angina.

• Clopidogrel/prasugrel are alternatives if you develop side-effects to aspirin, such as indigestion. You may need to take both aspirin and clopidogrel or prasugrel for a year after an MI or angioplasty.

• Beta-blockers, such as atenolol and metoprolol relieve angina by reducing the heart rate. They also reduce the likelihood of developing heart attacks and angina.

• Statins, such as simvastatin, pravastatin, rosuvastatin and atorvastatin reduce blood cholesterol levels and slow down arteriosclerosis, reducing the likelihood of developing heart attacks and angina. The ideal total cholesterol in patients with coronary disease level is below 4 mmol/L. The 'bad' cholesterol (low-density lipoprotein [LDL] cholesterol) should be below 2 mmol/L. If you have coronary disease, make a point of remembering your cholesterol level.



• ACE inhibitors: These drugs (eg. ramipril, perindopril), which are normally used to treat blood pressure, also reduce the risk of a heart attack.

Cardiac devices after an MI

If the function of the heart has been severely affected by a heart attack, the risk of death from a rhythm abnormality may be significant. If the pumping action of the heart is poor (left ventricular ejection fraction of less than 30%), an implantable cardioverter defibrillator (ICD) may be required. You will need to discuss this with the cardiologist. If you are breathless and your ejection fraction is less than 35%, cardiac resychronisation therapy (CRT) may be an option.



Here is how you can help reduce the risks of further problems:



• Stop smoking

• Take all the prescribed drugs

• Keep blood pressure in target: less than 130/80 mmHg.​

• Keep total cholesterol to less than 4 mmol/L  and LDL cholesterol to less than 2 mmol/L

• Complete rehabilitation programme and exercise regularly

• Attend revision every 6 months, to check blood pressure, lipid levels and need to change medications.



Rehabilitation

You will automatically be contacted for rehabilitation either before or after discharge from hospital. This consists of a variable period of time of exercise rehabilitation, aimed to get you back to your normal daily activities.



MI links:

https://my.clevelandclinic.org/health/diseases/16818-heart-attack-myocardial-infarction