Heart Attack Prevention
An ounce of prevention
There is now overwhelming evidence that control of blood pressure, smoking cessation, and aggressive lowering of lipids will have major preventive benefits. Perhaps the most compelling evidence has accumulated in the area of lipid lowering. Treatment with statins has dramatically changed the cardiology landscape. These agents dramatically lower LDL (bad) cholesterol. They also have a variety of other beneficial actions including an anti-inflammatory effect.
Preventive measures, especially risk factor modification, have had a significant impact on the rate of heart attacks. Coronary mortality has declined about 20% during the past two decades. Contributing to this decline is a greater awareness of healthy diet and lifestyles.
When a heart attack strikes
It is the patients job to seek medical attention as soon as possible after symptoms occur. Classic symptoms of discomfort, pressure, or heaviness over the upper chest may be absent. Instead, shortness of breath, sweating, weakness or lightheadedness may be the only signs.
On presentation to a medical facility, symptoms are reviewed, vital signs are taken, and a focused examination is performed. An intravenous line is inserted, blood tests are drawn, and oxygen is administered. An electrocardiogram (EKG) is quickly obtained. The next phase of treatment depends on the EKG findings. If the typical EKG changes of an acute myocardial infarction (heart attack) are present, the medical team will swing into action.
Opening the artery
The overriding aim is to restore blood flow in the blocked artery as soon as possible. This will limit damage to the heart muscle and avoid complications. Other treatments are designed to decrease the workload of the heart to minimize its oxygen demand. After protecting the heart with a beta-blocker (to lower pulse and blood pressure), a concerted effort is focused on dealing with the offending clot.
All available weapons are brought into the therapeutic arena. Aspirin will be given wiithout delay. This old remedy has potent inhibitory effects on platelet clumping. Even by itself, aspirin can decrease heart attack mortality by 20%. Another platelet inhibitor,
clopidogrel (Plavix) is also routinely administered.
The assault on the clotting mechanism will be expanded with heparin or one of its low-molecular weight derivatives. These agents interfere with the synthesis of fibrin, the reinforcing protein in clot formation. With a simultaneous attack on platelet aggregation, and clotting proteins, coronary blood flow will sometimes be restored. Often, however, additional measures will be necessary. It is at this point that subsequent treatment will be determined by the available facilities.
Clot-busters in the community
Heart attack patients in community hospitals without angioplasty laboratories who have not responded to the above treatments, will now receive intravenous therapy with powerful clot-busters known as thrombolytic agents. Numerous studies have documented the effectiveness of these agents in opening arteries clogged with a blood clot. The majority of patients will obtain prompt restoration of coronary blood flow with alleviation of symptoms and reversal of EKG changes.
Thrombolytic agents, originally introduced in the mid-1980s dramatically improved the prognosis of heart attack victims. Mortality was reduced by about 40%. For the first time, doctors had the ability to actively alter the course of the disease. Several drawbacks, however, became evident with the thrombolytic approach. Some patients did not achieve clot resolution. Also, a small percentage of patients experience significant bleeding. The most serious is cerebral hemorrhage, a complication occurring in fewer than 1% of patients. Other patients are not candidates for this treatment because of bleeding problems, recent surgery, or history of stroke.
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