Do you want to learn more about heart attack?

Introduction

Graphic illustration about AMI explained by Idorsia

“When I had my first heart attack, I felt really down and not sure how to go forward. I was fit and couldn’t understand why it happened.”

- Patient

A heart attack is life-threatening and should be treated as a medical emergency. Anyone who thinks they – or another person – are having a heart attack should call the emergency medical services immediately and ask for an ambulance. Any delay can dramatically reduce the chance of survival and increase the risk of permanent heart damage.

In fact, one of the key reasons for patients failing to receive prompt treatment is patient delay in seeking medical help. Timely treatment for a heart attack can be very effective and survival rates are improving. However, more than 15% of people who suffer a heart attack die before they arrive in hospital. When a heart attack strikes, every minute counts!

Understanding a heart attack

Heart attack explained by Idorsia

“I was sent home from work - despite reassuring them I was just feeling a little unwell. As I was traveling home, my temperature rose and the chest pain and numbness in my arm worsened so I diverted to my local hospital where they confirmed I’d had a heart attack.”

- Patient

Most often a heart attack (myocardial infarction) happens when one of the coronary arteries that normally delivers oxygen-rich blood from the heart, through the coronary arteries, to the heart muscle (also called myocardium) becomes partially or fully blocked, usually as a result of a blood clot. This reduces or cuts off the blood flow to that part of the heart muscle and it begins to die due to a shortage of oxygen.

A heart attack requires immediate emergency treatment as any delay can result in permanent damage to the heart muscle, or even death of the patient. The concept of ‘time is muscle’, outlined more than 50 years ago, refers to the fact that the first hour following a heart attack is vital to prevent further damage to the heart muscle.

There are different types of heart attack and a number of different medical terms are used.

  • + Medical terminology

    Acute coronary syndrome (ACS) is a general term which includes:

    • Myocardial Infarction (MI) or Acute Myocardial Infarction (AMI) is the most commonly used medical term for a heart attack.

    Other terms are also used for specific types of heart attack:

    • ST segment elevation myocardial infarction (STEMI) is the most serious type of heart attack, where there is a complete interruption to the blood supply and extensive damage to the heart muscle.
    • non-ST segment elevation myocardial infarction (NSTEMI) is usually when the blood flow to the heart muscle is only partially blocked and a smaller section of the heart muscle is affected.
    • Unstable angina (chest pain caused by reduced blood flow to the heart muscle) is the least serious type of ACS. Although the blood supply to the heart muscle is still seriously restricted, there is no permanent damage and the heart muscle is preserved.
  • + Risk factors for a heart attack

    A heart attack is usually caused by coronary heart disease (CHD). The risk of developing CHD is increased by a number of factors, some of which are modifiable (can be changed) and some of which are non-modifiable (can’t be changed).

    Modifiable risk factors, which can be addressed or controlled through lifestyle changes and medication:

    • Diabetes
    • High blood pressure
    • High cholesterol
    • Being overweight or obese
    • Smoking
    • Excessive alcohol consumption
    • Inactivity

    Non-modifiable risks are:

    • Age: the risk of having a heart attack increases with age. The majority of people who die of CHD are 65 or older.
    • Gender: men have a greater risk of heart attack than women in younger years, women’s hormones may offer some protection in the pre-menopause, but the risk post menopause is comparable to that of men.
  • + Family history

    There may be a family history of cardiovascular diseases if:

    • Your father or brother was under the age of 55 when they were diagnosed with cardiovascular disease, or
    • Your mother or sister was under the age of 65 when they were diagnosed with cardiovascular disease

    People with a family history should have regular heart checks and are encouraged to adopt positive lifestyle choices to reduce their risk of having a heart attack.

Symptoms of a heart attack

It is important to be aware of all the possible symptoms of a heart attack and to know what to do in the case of a suspected heart attack. Prompt treatment reduces the risk of complications, disability and death.

Most people think of chest pain as a key symptom of a heart attack. In fact, the warning symptoms of a heart attack can vary. It is possible to have a heart attack without experiencing chest pain.

Heart attack symptoms can be sudden and intense and cause sudden death. However, in other instances heart attacks are not always painful, but can start with mild symptoms that develop gradually and symptoms are sometimes mistaken for less serious issues such as indigestion.

Symptoms can vary from men to women. Women may not suffer the ‘classic’ chest pain and be more likely to experience some of the less common symptoms such as breathlessness, nausea/vomiting and back or jaw pain. Many women still regard heart attack as a ‘male’ disease and do not recognise the symptoms, which can lead to delays in seeking medical help. This can have a major impact on survival.

People who have had a previous heart attack may experience different or less/more severe symptoms if they have a second heart attack. For this reason, it is important for heart attack survivors and their loved ones to be aware of the range of possible symptoms of heart attack.

Key facts

  • Heart attacks are not always painful and do not always cause chest pain
  • Symptoms can vary and can come on suddenly or slowly
  • Men and women may experience different symptoms
  • Symptoms of a second heart attack may be different from those of a first attack
  • Emergency medical help should be called at the first sign of a suspected heart attack

What to do if you think you (or somebody else) are having a heart attack

  • The first priority is to immediately call the emergency medical services and explain all the symptoms that are being experienced. Highlight that you suspect a heart attack.
  • Open tight-clothing, sit in a comfortable position (do not lie down) and try to rest calm while waiting for the emergency services to arrive. This helps to avoid any unnecessary strain on the heart.
  • If the person experiencing a heart attack is unconscious, try to measure their pulse on their wrist or neck. If you don't feel any heartbeat, begin with cardiopulmonary resuscitation (CPR) and / or follow the device instructions if an automated external defibrillator (AED) is available.

What happens to the heart after a heart attack?

After a heart attack, the heart develops scar tissue as part of the healing process. Areas of scar tissue do not perform as effectively as healthy muscle tissue. The size and location of the scar tissue will affect how efficiently the heart pumps and the damage may result in the heart being weakened.

The healing process usually takes about 8 weeks. The recovery period will be significantly longer for patients with complex conditions or who have undergone major surgery.

  • + Potential complications

    Even if treatment is delivered promptly, complications can occur in the aftermath of heart attack and these may require extensive treatment. Complications can occur immediately after an attack or may develop in the longer term and include:

    • Recurrent heart attack: Having one heart attack increases the risk of having a second attack
    • Heart failure: the heart muscle is unable to pump enough blood through the heart to meet the body’s need for blood and oxygen. It can result in an enlarged heart and shortness of breath. A common symptom of heart failure is edema, an accumulation of fluid that causes swelling in the legs and ankles, or in the lungs (pulmonary edema)
    • Arrhythmias: abnormal heart rhythms or electrical ‘short-circuits’ that result in abnormal heartbeats (slow, fast or irregular heartbeat)
    • Cardiogenic shock: this is similar to heart failure but more serious. It occurs when the heart muscle is so severely damaged that it can no longer pump enough blood to maintain the body’s function

What is the outlook for people with heart attack?

The outlook for a person who has had a heart attack depends on how quickly they are able to access appropriate treatment and the degree of damage to the heart muscle. Without treatment, heart attacks can be fatal but with prompt, effective treatment, the majority of patients survive and, in many cases, go on to enjoy a good quality of life.

Treatment has improved dramatically. If we take Australia for example, in 2000, 10.6% of those admitted to hospital with an AMI died within 30 days. By 2012, this mortality rate had dropped to 4.5%. However, the majority of heart attack survivors will need to take medication for the rest of their lives as high blood pressure or cholesterol and adapting lifestyle through a healthy diet and exercise.

Having one heart attack increases the risk of having a second attack: according to the American Heart Association around 20% of patients aged 45 or above who have suffered a heart attack will have another heart attack within five years of their first. This is why it is so important for heart attack survivors to be aware of all the possible symptoms of heart attack and to act immediately if a heart attack is suspected.

Diagnosis and management of heart attack

Graphic illustration about diagnosis and treatment of heart attack by Idorsia

“When I had my second heart attack, I knew straight away I was in trouble again. This time the ambulance was called immediately. I’d learnt my lesson to act quickly – it’s better to be sure.”

- Patient

When somebody has a heart attack, time is of the essence to prevent permanent damage to the heart muscle (the ‘Time is Muscle’ principle). This means it is vital to gain an accurate diagnosis as soon as possible.

The emergency services attending a patient will ask a number of questions regarding type and duration of symptoms, previous medical history and potential immediate risk factors in order to build up a medical profile. They may also perform some initial tests and provide pain relief, if this is needed. If a heart attack is suspected or confirmed, the patient will be transferred to hospital.

  • + What tests are used to diagnose a heart attack?

    Following a clinical examination of the patient, a variety of tests may be used to confirm a heart attack diagnosis and to determine the severity of the damage to the heart.

    • Electrocardiogram (ECG): This is a test that measures the electrical activity of the heartbeat. It can be carried out at a patient’s home or wherever they are situated, or it will be performed as soon as a patient reaches hospital. In some cases, this will be sufficient to diagnose a heart attack. If the results are inconclusive, additional tests will be carried out.
    • Echocardiogram: A test that uses high frequency sound waves (ultrasound) to create pictures of the structure of the heart and its pumping action.
    • Blood tests: are carried out to detect signs of whether a patient has suffered a heart attack, such as a protein called troponin which leaks into the bloodstream from the damaged heart.
    • Angiogram (or coronary angiography): to see the precise location and extent of the blockages in the coronary arteries. This will help to determine the best treatment strategy. Following a local anesthetic, a catheter (a thin, flexible tube) is passed into an artery (usually from the wrist) and directed into the heart. A dye is flushed through to show up any narrowed areas or blockages in the artery and a series of X-ray images is taken.

What treatments are available for heart attack and to reduce the risk of recurrence?

It is vital to start treatment as soon as possible after a heart attack to resume blood flow to the damaged part of the heart muscle and to prevent further damage. The specific treatment will depend on the type of heart attack and how quickly blood flow was returned to the blocked artery. Most patients will be given a combination of drugs following an attack to break down blood clots and reduce the risk of further clots forming. Today, it is common that invasive treatment such as stents or angioplasty (see Procedures used to treat heart attack) is used to improve the blood supply to the heart muscle as fast as possible.

  • + Procedures used to treat heart attack

    Common procedures include:

    • Primary percutaneous coronary intervention (PCI), is a procedure to mechanically widen narrowed parts of the coronary artery that caused the heart attack. It is complex and requires specialist staff and equipment, which is not available in all hospitals.
    • In most cases, a stent (a small stainless-steel mesh) is placed inside the artery and is left in position to keep the artery open.
    • Bypass surgery: For patients with lesions which cannot be managed by PCI and stent, a cardiac surgery, known as coronary artery bypass graft (CABG) surgery, is needed. In this procedure, one or more blood vessels are grafted between the aorta (the main blood vessel leaving the heart) and the coronary artery. The aim is to re-route blood around the clogged artery to improve the supply of blood and oxygen to the heart. This is a complex procedure which can only be managed in experienced cardiac surgery department and therefore may not be available in all hospitals.
  • + Medication to treat symptoms or reduce the risk of recurrence

    Some medicines will be given in hospital as soon as possible after a heart attack and in many cases a combination of drugs will be prescribed. Many patients will need to continue taking some or all of this medication for the rest of their lives and it is important to continue taking the drugs when feeling healthy and well. Key options are:

    • Pain relief: patients experiencing pain will be offered pain relief, which may be delivered intravenously (in liquid form into a vein), a spray used under the tongue or in tablet form out of hospital.
    • Antiplatelet and anticoagulants (blood-thinning) agents: to reduce the risk of further blood clots forming and recurrent heart attacks, particularly if one or several stents have been but in place.
    • Clot-busting medication: delivered via injection to destroy the tough protein that makes up blood clots and limits the extent of the heart attack.
    • ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) to relax and widen the blood vessels. This lowers blood pressure and improves blood flow to the heart and prevent risk of recurrent heart attack.
    • Beta-blockers: to slow the heart beat and reduce strain on the heart. This in turn prevents recurrent heart attacks.
    • Statins: to reduce the level of cholesterol, reduce the risk of fatty build-up in the arteries and reduce the risk of recurrent heart attacks.
  • + Devices to manage complications of recurrent heart attacks

    Most common devices are:

    • Implantable Cardioverter Defibrillator (ICD): a battery-powered device placed under the skin that keeps track of heart rhythm. If an abnormal heart rhythm preceding cardiac arrest is detected the device will deliver an electric shock through thin wires to the heart to restore a normal heartbeat.
    • Pacemaker: a small battery-operated device that helps the heart beat in a regular rhythm.
  • + Healthcare professionals involved in the management of heart attack

    The main physician for patients who suffer a heart attack will be a cardiologist (heart specialist) but a range of other healthcare professionals may be involved in the care of heart attack patients, including:

    • Emergency physicians
    • General practitioners
    • Nurses and nurse specialists
    • Thoracic surgeons
    • Rehabilitation specialists
    • Dietitians
    • Psychologists

What is cardiac rehabilitation?

The term ‘cardiac rehabilitation’ refers to support and information designed to support heart attack survivors in their recovery and allow them to return to maximum health as quickly as possible. Part of rehabilitation is also education on reducing the risk of having another heart attack. In some countries, when heart attack patients leave hospital, they are referred to a formal cardiac rehabilitation service. It offers advice and information on a range of health education topics such as keeping active, healthy eating, stopping smoking and maintain a healthy weight. The aim is to address any “modifiable” risk factors that may have contributed to a patient’s heart attack and may lead to a second heart attack. This also allows a phased return to exercise, starting gradually and building up over the weeks and months.

In other countries no formal rehabilitation programs are available. However, all heart attack survivors should focus on maintaining a healthy lifestyle and minimising modifiable risk factors such as high blood pressure and obesity. Patient support groups can be a useful source of information on these topics.

Burden of heart attack

Graphic illustration about burden of heart attack by Idorsia

“When I was informed it was a heart attack, I was emotionally scared and confused. I immediately felt life would never be the same. It suddenly felt like I wasn’t young anymore and that I was nearer to reaching death, through life expectancy alone.”

- Patient

The experience of having survived a heart attack can have a profound impact on many aspects of everyday life from studying, employment or exercising to personal and sexual relationships and social activities. Many heart attack survivors struggle to come to terms with what has happened to them and find it difficult to face the future with confidence.

  • + Work and employment
    • Patients who have suffered a heart attack may not be able to return to work immediately or at all, if the job requires strenuous activity. The length of time needed off work will depend on the amount of damage caused by the heart attack. The healthcare team will advise on the best way forward.
    • Inability to work or reduced working hours will have a financial impact on a heart attack survivor and their family and can also damage self-esteem and confidence levels. The person who has suffered a heart attack may feel they are a burden on loved ones.
  • + Driving
    • Heart attack survivors are not usually allowed to drive immediately after an attack and in some countries, must declare it to their local vehicle licensing agency. The cardiac team will provide guidance on when it is safe to resume driving. This will depend on the treatment undergone and the stability of the condition.
  • + The emotional impact of heart attack
    • A heart attack is a frightening and life-changing experience that can have a severe emotional impact.
    • Fear of a second attack is common and this can lead to anxiety and uncertainty about the future. Often a period of re-adjustment is needed before patients can begin to return to normal.
    • In the US, major depression occurs in about 20% of patients after they have a heart attack, and 65% experience at least 1 symptom of depression.
    • One in eight heart attack survivors suffer post-traumatic stress disorder (PTSD) and survivors with PTSD have double the risk of having another cardiac event or of dying within one to three years, compared with survivors without PTSD.
    • Fatigue is common following a heart attack and this can make it difficult to enjoy social or leisure activities.
    • In some cases, surviving a heart attack can have a more positive impact, by prompting the patient to re-appraise the way they live and to adopt a healthier lifestyle. Some people regard a heart attack as a ‘wake-up call’.
  • + Friends and family
    • Heart attack survivors often need practical assistance when they return home from hospital, as well as on-going emotional support.
    • Caring for someone who has had a heart attack can be physically and emotionally draining. In the UK two in five family members live in constant fear of their loved one having another heart attack.
    • Everyone is different: some patients want to be treated as normal rather than being ‘fussed over’ while others may welcome additional care and support.

Practical guidance on life after heart attack

Graphic illustration about practical guidance on life after heart attack by Idorsia

“I was instructed to stay off work and to not exert myself for 7 weeks, but I felt totally useless. As soon as I was allowed, I started adding activity back into my day – the whole time I couldn’t wait to return to my usual routine of work and regular cycle rides.”

- Patient

Patients who have suffered a heart attack will usually need to take medication indefinitely to reduce the risk of a further attack, but there is also a great deal they can do themselves to minimize any risk factors associated with their condition.

  • + Making positive lifestyle changes

    Lifestyle changes can be an important factor in reducing the risk of a recurrence. Often specific tailored advice on these measures is provided as part of cardiac rehabilitation support. Key areas to focus on are:

    • Smoking: this is a key factor in heart health so giving up smoking is one of the most important changes a heart attack patient can make. It is also important to avoid ‘second-hand’ smoke by avoiding smoky atmospheres
    • Keeping physically active: like any muscle the heart needs physical activity to keep it in good condition. Patients will often be given a program of phased return to exercise, starting slowly and gradually building up the level of activity. Adults should aim to do at least 150 minutes of moderate-intensity aerobic activity (such as cycling or fast walking) every week
    • Maintaining a healthy weight and body shape: obesity and being overweight are key modifiable risk factors
    • Following a healthy, balanced diet: the emphasis should be on foods that are low in saturated fat and sodium (salt) and high in fiber, with at least five portions of fruit and vegetables a day
    • Keeping cholesterol and blood pressure under control: these are important risk factors and should be checked regularly and medication taken if prescribed
    • Keeping blood glucose levels under control: patients with diabetes should monitor their blood sugar levels regularly
    • Taking medication as prescribed, even when feeling fit and healthy
    • Keeping alcohol intake to within guidelines
  • + Being open with family and friends
    • Suffering a heart attack is a frightening experience and It can be difficult to cope with the fear of a recurrence. This is particularly true in the early stages of the recovery period when patients leave the ‘secure’ environment of a hospital.
    • It is natural to feel vulnerable and anxious initially and it is best to share these feelings with family and friends rather than shutting them out. Loved ones are usually only too happy to offer support.
    • If feelings of anxiety or depression persist, it is worth talking to a doctor or other healthcare professional about ways of managing these feelings. In some cases, medication will be prescribed.
    • People who have had a heart attack sometimes find it difficult to be honest about negative feelings and are reluctant to worry family and friends. It can sometimes be easier to talk to a counsellor or independent third party.
    • It can be daunting to make major lifestyle changes such as giving up smoking, but a great deal of advice and support is available. It is also helpful to break goals into smaller segments and to tackle one element at a time.
  • + Managing the impact on sexual relationships
    • People who have had a heart attack may be concerned about resuming sexual relationships as they fear putting a strain on their heart, but in most cases, this will not present a problem. The healthcare team can advise on this.
    • Some patients experience loss of sex drive or experience sexual dysfunction, either due to the stress associated with a heart attack or as a result of medicines such as beta blockers. These problems are often temporary but on-going issues should be discussed with a healthcare professional.
    • Changes in self-esteem or loss of confidence can also impact on personal relationships. Being open and honest will reassure partners and help to maintain a sense of intimacy.
  • + Becoming informed
    • Many heart attack survivors find it helpful to arm themselves with as much information as possible. This can help them to feel more in control.
    • It is important to keep on top of treatments and to be clear about dosage, instructions about when to take medicines and side effects. Medication should be continued even when patients are feeling well.
    • It is important to learn about the lifestyle changes that can make a difference to the risk of a recurrence. The cardiac rehabilitation team and patient support groups can be very helpful in this respect.
    • It is vital to be aware of the symptoms of a heart attack. No two heart attacks are the same and a patient who experienced specific symptoms during a first heart attack may experience different ones if they have a recurrence. This is important not only for the heart attack survivor, but also for family and friends.
    • Patient support organizations are a good source of information and support on a variety of topics from treatments to benefits and social services.
    • Some people find it helpful to attend support group meetings or to join online forums to communicate with other people who share similar experiences.

Getting support

  • + Joining a patient association

    There are many patient associations that are dedicated to helping patients and their families to live well after heart attack, through providing detailed information, practical advice, and valuable support.

    The American Heart Association (AHA) has offices across the US, as well as International activities and events: www.heart.org.