Myocardial infarction

Signs and Symptoms

• Squeezing pain, heaviness, tightness, pressure in center of chest
• Pain that spreads to your back, left arm, jaw, neck
• Shortness of breath
• Dizziness, weakness
• Nausea, vomiting
• Irregular heartbeat
• Sweating
• Feeling of doom

Women may experience different symptoms than men. In women, along with chest pain, symptoms can include:

• Heartburn or pain in the abdomen
• Unusual fatigue
• Clammy skin

Causes

Heart attacks happen when an artery supplying your heart with blood becomes blocked. Without blood, the heart does not get enough oxygen and cells in the heart start to die.

The most common cause of blocked arteries is atherosclerosis. No one knows the exact cause of atherosclerosis. But most researchers believe it begins with an injury to the innermost layer of the artery, known as the endothelium. The following factors are thought to contribute to the damage:

• High blood pressure
• Elevated LDL (bad) cholesterol
• An accumulation of homocysteine (an amino acid produced by the human body, thought to be a risk factor for heart disease, stroke, osteoporosis, diabetes, and dementia)
• Smoking
• Diabetes
• Inflammation

Once the artery is damaged, blood cells called platelets build up at the site to repair the injury. Over time, fats, cholesterol, and other substances also accumulate, which thickens and hardens the artery wall. The amount of blood that flows through the artery dwindles, and oxygen supply to organs also decreases. Blood clots may also form, blocking the artery.

Rarely, a spasm in a coronary artery (one that supplies blood to the heart) stops blood flow and can cause a heart attack.

Risk Factors

The following risk factors increase your chances of developing atherosclerosis:

• Age
• Gender (men are at higher risk than women)
• Smoking
• High-fat diet
• High LDL (bad) cholesterol and triglycerides (fats in the blood)
• Lack of exercise
• Being overweight or obese
• Family history of heart attack
• Diabetes
• High blood pressure
• Stress
• History of mental illness

Also, people who have elevated homocysteine, C-reactive protein (CRP), and fibrinogen levels seem to have an increased risk of heart attack. These are markers of inflammation. But researchers are not sure whether they contribute to heart disease or occur when you have heart disease. High homocysteine can be treated with folic acid. More research in these areas is underway.

Diagnosis

If you think you are having a heart attack, call 911 immediately. Treating a heart attack quickly can save your life, while delay can be fatal. In the emergency room, a doctor will ask you about your symptoms and perform a physical examination. The doctor will immediately run tests to determine your heart function. They may include:

• Electrocardiogram (ECG). The first test done to check for a heart attack. You may be hooked up to a monitor even as the doctor is asking you questions. An ECG measures electrical activity of your heart.
• Blood tests. Your doctor may look for certain enzymes that are released into your blood when you have a heart attack.

Other tests include:

• Chest x-ray
• Echocardiogram (uses sound waves to take a picture of your heart)
• Coronary catheterization or angiogram (uses a liquid dye inserted through a catheter to see whether your arteries are blocked)
• Stress test (involves walking on a treadmill while hooked up to an ECG machine to see how your heart responds to exercise)

Preventive Care

You can reduce your risk of heart attack by:

• Stopping smoking.
• Exercising (such as walking, biking, or swimming) for at least 30 minutes 5 days per week. If you haven't exercised much in the past, walking is a great way to start. If you have any heart risk factors, you should get an okay from your health care provider before starting an exercise program.
• Reducing stress and learning stress-reduction techniques such as deep breathing and meditation. Practicing yoga and tai chi, two forms of exercise that emphasize stretching, breathing, and meditating, can also help you reduce your stress level.
• Eating a diet low in saturated fat and rich in fruits, vegetables, and whole grains.
• Losing weight or maintaining a proper weight.

If you have high cholesterol, diabetes, or high blood pressure, follow your doctor's instructions to keep these risk factors under control. You may need medications in addition to lifestyle changes. If you do not have heart disease, or have not had a heart attack despite these risk factors, aggressive control can help prevent a heart attack. And, if you already have heart disease, aggressive control of these risk factors can prevent further heart attacks or other heart-related problems.

Treatment Approach

The goal when treating a heart attack is to restore blood flow to the affected area of the heart immediately, to preserve as much heart muscle and heart function as possible. If your doctor has prescribed nitroglycerin, take it while you are waiting for emergency medical personnel to arrive. Once at the hospital, your doctor may use drug therapy, angioplasty (using one of several methods to clear the blocked blood vessel, such as inflating a balloon inside it or holding it open with a device called a stent), and surgery.

Once you have been treated for a heart attack, making changes in your lifestyle (especially in your diet and exercise habits), and taking medications as prescribed are very important for avoiding recurrent heart attacks and even death. Although certain herbal remedies, as well as relaxation techniques may also be used, they should never be used alone to treat a heart attack. A heart attack always requires emergency medical attention.

Lifestyle

Making lifestyle changes can improve many risk factors for heart disease, including high cholesterol, high blood pressure, extra weight, high homocysteine, and elevated C-reactive protein. Cardiac rehabilitation programs generally involve teaching you about diet, physical activity, and relaxation techniques. To keep your risk factors low, you will need to follow the healthy habits taught in cardiac rehab, such as exercise and eating properly, for the rest of your life.

Medications

When you arrive at the hospital, you will likely be given medication to help your body cope with, or ward off, damage from the heart attack, including:

• Aspirin. Helps stop blood from clotting. You may be given aspirin in the ambulance or as soon as you get to the hospital. Aspirin should be continued indefinitely at a dose of 81 mg per day, or as directed by your physician.
• Nitroglycerin. Helps dilate (widen) blood vessels. You may be given nitroglycerin in the ambulance or as soon as you get to the hospital.
• Pain reliever. Helps relieve pain and is often given intravenously (IV).
• Thrombolytics. Work to break up clots. They are most effective when taken within 2 hours of the heart attack, and are not given after 12 hours have elapsed. These drugs may be given with other anticoagulants (blood thinners).
• Anticoagulants (blood thinners). Make your blood less likely to form clots. Heparin is often given by injection while you are in the hospital.

After you recover, other drugs are used to lower your risk of having another heart attack. They include:

ACE inhibitors. Widen blood vessels and make it easier for your heart to pump blood. Side effects can include chronic cough. ACE inhibitors include:

• Benazepril (Lotensin)
• Captopril (Capoten)
• Fosinopril (Monopril)
• Lisinopril (Zestril)
• Enlapril (Vasotec)

Beta-blockers. Slows heart rate, thus lowering blood pressure. These drugs include:

• Acebutolol (Sectral)
• Atenolol (Tenormin)
• Bisoprolol (Zebeta)
• Carteolol (Cartrol)
• Metoprolol (Toprol XL)
• Nadolol (Corgard)
• Propranolol (Inderal)

Statins. Help lower cholesterol. People who are pregnant or have liver disease should not take statins. They include:

• Lovastatin (Mevacor)
• Simvastatin (Zocor)
• Pravastatin (Pravachol)
• Atorvastatin (Lipitor)
• Fluvastatin (Lescol)
• Rosuvastatin (Crestor)

Niacin (nicotinic acid). In prescription form, is sometimes used to lower cholesterol. Dietary supplements of niacin should not be used instead of prescription niacin, as it can cause side effects. Take niacin for high cholesterol only with your doctor's supervision.

Bile acid sequestrants. Lowers cholesterol; people who have high levels of triglycerides (fats in the blood) should not take bile acid sequestrants. These drugs include:

• Cholestyramine (Questran)
• Colestipol (Colestid)
• Colesevelam (Welchol)

Fibric acid derivatives. Lower triglycerides and moderately lower LDL cholesterol. They include Gemfibrozil (Lopid).

Anticoagulants (blood thinners). Help keep clots from forming. Your doctor may prescribe aspirin, warfarin (Coumadin), or Clopidogrel (Plavix).

Surgical Treatments

Percutaneous coronary intervention (PCI). In primary PCI, the doctor performs a coronary angiogram (injecting dye into the arteries) to see where the artery is blocked. The doctor then performs balloon angioplasty (widening an artery with a balloon), often with stent placement, to keep the artery open.

Coronary artery bypass graft (CABG). This surgery bypasses the blocked arteries by using a graft of another blood vessel (usually from your arm or leg) to restore blood flow to the heart.

Nutrition and Dietary Supplements

Healthy eating habits can help reduce high cholesterol, high blood pressure, and excess weight, three of the major risk factors for heart disease. The American Heart Association (AHA) has developed dietary guidelines that help lower fat and cholesterol intake and reduce the risk of heart disease and heart attack. The AHA does not recommend very low fat diets, because new research shows that "good" fats, such as those found in olive oil and avocadoes, are good for your heart.

Fad diets are popular, but they may not help you lose weight and keep it off. In some cases, they may not even be healthy. Any healthy diet will include a variety of foods. If a diet bans an entire food group (such as carbohydrates), it is probably not healthy.

The AHA recommends the following for healthy eating:

• Grains: 6 to 8 servings per day (half of those servings should be whole grains)
• Vegetables: 3 to 5 servings per day
• Fruits: 4 to 5 servings per day
• Fat-free or low-fat dairy: 2 to 3 servings per day
• Lean meat, poultry, and seafood: 3 to 6 oz. per day (about the size of a deck of cards)
• Fats and oils: 2 to 3 tbsp. per day (use unsaturated fats such as olive oil or canola oil)
• Nuts, seeds, legumes: 3 to 5 servings per week
• Sweets, sugars: 5 or fewer servings per week (the fewer, the better)

In addition, the AHA also recommends eating 2 servings of fatty fish (such as salmon or lake trout) per week; holding sodium (salt, including salt already added to food) to 2,400 mg per day or less; and limiting alcohol intake to one drink a day for women and two for men.

Diets for People with High Blood Pressure

People with high blood pressure especially need to lower the amount of sodium in their diet. The DASH diet (Dietary Approaches to Stop Hypertension) emphasizes a diet rich in fruits, vegetables, and low-fat or nonfat dairy products that provide high intake of potassium, magnesium, and calcium sources. Sodium intake should be between 1,500 to 2,400 mg per day (the lower, the better). Weight loss, regular exercise, and limiting alcohol are also very important factors for lowering blood pressure.

Mediterranean Diet

The Mediterranean Style Diet concentrates on whole grains, fresh fruits and vegetables, fish, olive oil, and moderate wine consumption. The Mediterranean Style Diet is not low fat; it is low in saturated fat, but high in monounsaturated fat. It appears to be heart healthy: In a long-term study of 423 people who had a heart attack, those who followed a Mediterranean Style Diet had a 50 to 70% lower risk of recurrent heart disease compared with people who received no special dietary counseling.

Vitamins and Supplements

Some supplements may help lower your risk factors for heart attacks, such as high blood pressure or high cholesterol. Most do not work as well as prescription medications. But some can be used along with prescription medications in your treatment. If you have had a heart attack, or are at high risk of having one, ask your doctor before taking any supplements. Your physician should manage your heart disease, and you should not take supplements without your physician's approval. Many supplements can have negative interactions with medications used to treat heart disease.

• B vitamins. Folic acid, vitamin B6, and vitamin B12 help the body break down homocysteine, an amino acid that has been linked to increased risk of heart disease and stroke. Researchers believe that homocysteine may also contribute to atherosclerosis by damaging artery walls, making it easier for blood clots to form, but so far they haven't found a definite link. Researchers also do not yet know whether taking B vitamins reduces the risk of atherosclerosis or heart attack, nor do they know how much might have an effect. Talk to your doctor about checking your homocysteine levels and whether you should take a B complex vitamin supplement. In the meantime, be sure to get enough B vitamins through your diet by eating fruits and leafy green vegetables every day.
• Vitamin D. Studies show that lower levels of vitamin D are associated with higher risk of myocardial infarction and premature death. Dose recommendations for vitamin D vary greatly between physicians. Your physician may do blood work to monitor your vitamin D levels and determine the appropriate dose for your needs.
• Omega-3 fatty acids. There is good evidence that omega-3 fatty acids (known as EPA and DHA) found in fish oil can help treat atherosclerosis by preventing the development of plaque and blood clots. Omega-3s can also help prevent heart disease, lower blood pressure, and reduce the level of triglycerides (fats) in the blood. The AHA recommends that people eat at least 2 servings of fatty fish (such as salmon) per week. For people who have had a heart attack, several studies show that eating fish or taking fish oil reduces the risk of both fatal and nonfatal heart attacks, as well as lowers your risk of death from any cause. Because fish oil at high doses can increase the risk of bleeding, talk to your doctor before taking a high dose (more than 1 g per day), especially if you already take blood-thinning medication.
• Beta-sitosterol. A plant sterol, a chemical found in plants that can stop cholesterol from being absorbed by the intestines. A number of well-designed scientific studies have shown that beta-sitosterol does lower LDL (bad) cholesterol levels in the body. Beta-sitosterol may lower the amount of vitamin E and beta-carotene absorbed by the body, so you may want to ask your doctor if you need to take extra E or carotene.
• Policosanol. A mix of waxy alcohols usually derived from sugar cane and yams. Several studies have indicated it may lower LDL (bad) cholesterol and possibly even raise HDL (good) cholesterol. One study found that policosanol was equivalent to fluvastatin (Lescol) and simvastatin (Zocor) in lowering cholesterol levels. It may also help stop blood clots from forming. However, almost all the studies have been conducted in Cuba by a research group that uses a proprietary form of policosanol, and is funded by the manufacturer. So it is hard to evaluate the evidence. Policosanol may increase the risk of bleeding, and it should not be taken by people who also take blood-thinning medications.
• Coenzyme Q10 (CoQ10). Researchers believe that CoQ10 may help stop blood clots from forming and boost levels of antioxidants. One study found that people who received daily CoQ10 supplements within 3 days of a heart attack were much less likely to experience another heart attack and chest pain. They were also less likely to die from heart disease than those who did not receive the supplements. Statins, drugs that lower cholesterol, can actually interfere with the body's natural ability to make CoQ10, so your doctor may recommend taking a CoQ10 supplement. Still, more research is needed to say whether CoQ10 has any role in preventing or treating atherosclerosis. CoQ10 may interact with blood-thinning medications, such as warfarin (Coumadin), and others since CoQ10 helps blood clot it may make these medications less effective.
• Psyllium. This fiber helps lower cholesterol levels and blood sugar levels. If you take medicine for diabetes or have digestive problems, talk to your health care provider before taking psyllium. Always take your medications at least a few hours away fro when you take psyllium.
• L-carnitine. Studies suggest that people who take L-carnitine (an amino acid) soon after a heart attack may be less likely to have a subsequent heart attack, die of heart disease, experience chest pain and abnormal heart rhythms, or develop heart failure. (Heart failure occurs when the heart can't pump blood properly and blood backs up into the lungs and legs.) Studies also suggest that people with heart disease who take carnitine may be better able to exercise. Most studies used a special form of carnitine called propionyl-L-carnitine. L-carnitine can interact with certain medications, including thyroid and blood-thinning medications such as warfarin (Coumadin). Talk to your provider about whether L-carnitine is right for you.

Herbs

Herbs should not be used in place of emergency medical attention for a heart attack, nor should they be used by themselves to lower your risk of heart attack after you have had one. However, certain herbs can be used along with prescription medications in your treatment, although many can interact with a variety of medications. The herbs below have the potential to interact with several different medications. It is critical that you consult your physician before adding any herbs to your regimen. If you have had a heart attack, or are at high risk of having one, ask your doctor before taking any herbs.

• Hawthorn (Crataegus monogyna). Hawthorn contains the polyphenols rutin and quercetin, and was used traditionally to treat cardiovascular diseases. Animal and laboratory studies show that hawthorn has antioxidant properties that help protect against the formation of plaques and may help lower high cholesterol and high blood pressure. Talk to your doctor before taking hawthorn, as it can interact with other drugs taken for heart disease and high blood pressure.
• Garlic (Allium sativum). Studies show that fresh garlic and garlic supplements may lower cholesterol levels, prevent blood clots, and destroy plaque. However, other studies show mixed evidence. In one study, people who had a previous heart attack and then took a garlic oil extract for 3 years had fewer second heart attacks and a 50% reduction in death rate than those who did not take garlic. Garlic can increase the risk of bleeding. Garlic can interact with a number of medications, including some of those used to treat HIV/AIDS. You should not take garlic if you are also taking blood-thinning medication.
• Bilberry (Vaccinium myrtillus) and other flavonoids. A close relative of the cranberry, bilberry fruits contain flavonoid compounds called anthocyanidins. Flavonoids are plant pigments that have antioxidant properties. Researchers think they may help prevent several illnesses, including heart disease and diabetes. Bilberry has been used traditionally to treat heart disease. But only animal and test tube studies have been done. Animal studies have found that anthocyanidins and other flavonoids may strengthen blood vessels, improve circulation, and prevent LDL (bad) cholesterol from being damaged (which may cause blood clots to form in arteries). Bilberry may have a blood-thinning effect and therefore can increase the risk of bleeding in people taking blood-thinning medications such as warfarin (Coumadin) and others. Talk to your health care provider.
• Green tea (Camellia sinensis). Population studies suggest that regularly drinking green tea may reduce the risk of heart attack from atherosclerosis. It also may help you lower lose weight and your cholesterol levels. More research is needed to know for sure. Avoid caffeinated varieties.
• Kudzu (Pueraria lobata). Kudzu has been used traditionally to treat heart disease, including heart attack and congestive heart failure. A few studies suggest it may help relieve angina, but the studies were of poor quality. More research is needed to know whether kudzu has any benefit for heart disease. Kudzu might slow blood clotting, so people with bleeding disorders or who take blood-thinning medications, such as warfarin (Coumadin), should use caution. Talk to your doctor.

Homeopathy

Homeopathy should not be used instead of immediate medical attention for a heart attack. However, homeopathy may be used to help reduce the risk of heart disease. Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate therapy to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account your constitutional type. In homeopathic terms, a person's constitution is their physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for you as an individual.

Acupuncture

Acupuncture may be helpful in reducing some risk factors for heart disease. Some studies show that it can help people who want to stop smoking, and it may help some people lose weight and lower their blood pressure.

Massage and Physical Therapy

Although few studies have examined the effectiveness of massage therapy for heart disease, massage has a relaxing effect and can reduce stress-related hormone levels. Lowering stress hormone levels can lower cholesterol and blood pressure, reducing your risk of heart disease. In addition, relaxation techniques may help you make lifestyle changes such as eating healthy, quitting smoking, and exercising. At least one study found that massage can lower blood pressure.

Other Considerations

Prognosis and Complications

After a heart attack, a person's prognosis depends on how damaged the heart is. If the person is alive 2 hours after an attack, he or she has a good chance for survival, but may experience complications such as:

• Irregular heart rhythm, called an arrhythmia
• Heart failure
• Shock
• Infarct extension (extension of the amount of affected heart tissue) or recurrent heart attack(s)
• Pericarditis (infection around the lining of the heart)
• Pulmonary embolism (blood clot in the lungs)
• Complications from treatment (for example, thrombolytic agents increases the risk of bleeding)

However, the good news is that heart attacks are not always disabling, especially when there are no complications. In fact, a full recovery is possible that allows you to do all the things you used to do, including sexual activity. Going through cardiac rehabilitation and committing to positive lifestyle changes can improve your chances of recovery.

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