About heart attack

A heart attack usually occurs when a blood clot blocks the flow of blood through a coronary artery — a blood vessel that feeds blood to a part of the heart muscle. Interrupted blood flow to your heart can damage or destroy a part of the heart muscle.

Years ago, a heart attack was often fatal. Thanks to better awareness of heart attack signs and symptoms and improved treatments, most people who have a heart attack now survive.

Your overall lifestyle — what you eat, how often you exercise and the way you deal with stress — plays a role in your recovery from a heart attack. In addition, a healthy lifestyle can help you prevent a first or subsequent heart attack by controlling risk factors that contribute to the narrowing of the coronary arteries that supply blood to your heart.

Symptoms

Common signs and symptoms of a heart attack include:

  • Pressure, fullness or a squeezing pain in the center of your chest that lasts for more than a few minutes
  • Pain extending beyond your chest to your shoulder, arm, back, or even to your teeth and jaw
  • Increasing episodes of chest pain
  • Prolonged pain in the upper abdomen
  • Shortness of breath
  • Sweating
  • Impending sense of doom
  • Fainting
  • Nausea and vomiting

Signs and symptoms of a heart attack in women may be different or less noticeable than heart attack symptoms in men. In addition to the symptoms above, heart attack symptoms in women can include:

  • Abdominal pain or “heartburn”
  • Clammy skin
  • Lightheadedness or dizziness
  • Unusual or unexplained fatigue

Not all people who have heart attacks experience the same ones or experience them to the same degree. Many heart attacks aren’t as dramatic as the ones you’ve seen on TV. Some people have no symptoms at all. Still, the more signs and symptoms you have, the greater the likelihood that you may be having a heart attack.

A heart attack can occur anytime — at work or play, while you’re resting, or while you’re in motion. Some heart attacks strike suddenly, but many people who experience a heart attack have warning signs and symptoms hours, days or weeks in advance. The earliest predictor of an attack may be recurrent chest pain (angina) that’s triggered by exertion and relieved by rest. Angina is caused by temporary, insufficient blood flow to the heart, also known as “cardiac ischemia.”

Causes

The medical term for a heart attack is “myocardial infarction.” “Myo” refers to “muscle;” “cardio” refers to “heart;” “infarct” refers to “death of tissue from lack of oxygen.” Like any muscle, the heart needs a steady supply of blood. Without blood, heart cells are injured, causing pain or pressure. If blood flow isn’t restored, heart cells can die and scar tissue can form, replacing working heart tissue. The lack of blood flow to the heart also may trigger irregular heart rhythms that can be fatal.

A heart attack occurs when one or more of the arteries supplying your heart with oxygen-rich blood become blocked. These arteries are called coronary arteries and encircle your heart like a crown. Over time, a coronary artery can become narrowed from the buildup of cholesterol. This buildup — collectively known as plaques — in arteries throughout the body is called atherosclerosis.

During a heart attack, one of these plaques can rupture and a blood clot forms on the site of the rupture. If the clot is large enough, it can block the flow of blood through the artery. When your coronary arteries have narrowed due to atherosclerosis, the condition is known as coronary artery disease. Coronary artery disease is the major underlying cause of heart attacks.

An uncommon cause of a heart attack is a spasm of a coronary artery that shuts down blood flow to part of the heart muscle. Drugs, such as cocaine, can cause such a life-threatening spasm.

A heart attack is the end of a process that typically evolves over several hours. With each passing minute, more heart tissue is deprived of blood and deteriorates or dies. However, if blood flow can be restored in time, damage to the heart can be limited or prevented.

Risk factors

Certain factors, called coronary risk factors, increase your risk of a heart attack. These factors contribute to the unwanted buildup of deposits (atherosclerosis) that narrows arteries throughout your body, including arteries to your heart. Coronary risk factors include:

  • Tobacco smoke. Smoking and long-term exposure to secondhand smoke damage the interior walls of arteries — including arteries to your heart — allowing deposits of cholesterol and other substances to collect and hamper blood flow. Smoking also increases the risk of deadly blood clots forming and causing a heart attack.
  • High blood pressure. Blood pressure is determined by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. Over time, high blood pressure can damage arteries that feed your heart by accelerating atherosclerosis. The risk of high blood pressure increases as you age, but the main culprits for most Americans are eating a diet too high in salt and being overweight. High blood pressure can also be an inherited problem.
  • High blood cholesterol or triglyceride levels. Cholesterol is a major part of the deposits that can narrow arteries throughout your body, including those that supply your heart. A high level of the wrong kind of cholesterol in your blood increases your risk of a heart attack. Low-density lipoprotein (LDL) cholesterol (the “bad” cholesterol) is most likely to narrow arteries. A high LDL level is undesirable and is often a byproduct of a diet high in saturated fats and cholesterol. A high level of triglycerides, a type of blood fat related to your diet, also is undesirable. However, a high level of high-density lipoprotein (HDL) cholesterol (the “good” cholesterol), which helps the body clean up excess cholesterol, is desirable and lowers your risk of heart attack.
  • Lack of physical activity. An inactive lifestyle contributes to high blood cholesterol levels and obesity. Conversely, people who get regular aerobic exercise have better cardiovascular fitness, which decreases their overall risk of heart attack. Exercise is also beneficial in lowering high blood pressure.
  • Obesity. Obese people have a high proportion of body fat (a body mass index of 30 or higher). Obesity raises the risk of heart disease because it’s associated with high blood cholesterol levels, high blood pressure and diabetes.
  • Diabetes. Diabetes is the inability of your body to adequately produce or respond to insulin properly. Insulin, a hormone secreted by your pancreas, allows your body to use glucose, which is a form of sugar from foods. Diabetes can occur in childhood, but it appears more often in middle age and among overweight people. Diabetes greatly increases your risk of a heart attack.
  • Stress. You may respond to stress in ways that can increase your risk of a heart attack. If you’re under stress, you may overeat or smoke from nervous tension. Too much stress, as well as anger, can also raise your blood pressure.
  • Alcohol. Consumed in moderation, alcohol helps raise HDL levels — the “good” cholesterol — and can have a protective effect against heart attack. Men should have no more than two drinks a day, and women should have no more than one. Excessive drinking can raise your blood pressure and triglyceride levels, increasing your risk of heart attack.
  • Family history of heart attack. If your siblings, parents or grandparents have had early heart attacks, you may be at risk, too. Your family may have a genetic condition that raises unwanted blood cholesterol levels. High blood pressure also can run in families.
  • Homocysteine, C-reactive protein and fibrinogen. People who have higher blood levels of homocysteine, C-reactive protein and fibrinogen appear to have an increased risk of heart disease. Some research suggests homocysteine levels can be reduced with folic acid supplements and a healthy diet. Fibrinogen and C-reactive protein levels may be reduced by modifying other risk factors for heart disease, such as quitting smoking, lowering cholesterol and exercising.

You can modify or eliminate many of these risk factors to reduce your chances of having a first or second heart attack. However, you can’t change some risk factors, such as heredity and gender. Men are generally at greater risk than are women of heart attacks. However, the risk for women increases sometime after menopause, usually after age 55. If your father had heart disease before 55 or your mother had heart trouble before 65, your risk of developing heart disease is greater.

Diagnosis

Ideally, your doctor should screen you during regular physical exams for risk factors that can lead to a heart attack.

If you’re having a heart attack or suspect you’re having one, screening and diagnosis will likely happen in an emergency setting. You’ll be asked to describe your symptoms and will have your blood pressure, pulse and temperature checked. You’ll be hooked up to a heart monitor and will almost immediately start to have tests done to determine if you are indeed having a heart attack. The medical staff will listen to your heart and lung sounds with a stethoscope. You’ll be asked about your health history and the history of heart disease in your family. The tests your doctors order will help determine whether your signs and symptoms, such as chest pain, signal a heart attack or another condition. These tests include:

  • Electrocardiogram (ECG). This is the first test done to diagnose a heart attack. It’s often done while you are being asked questions about your symptoms. This test records the electrical activity of your heart via electrodes attached to your skin. Impulses are recorded as “waves” displayed on a monitor or printed on paper. Because injured heart muscle doesn’t conduct electrical impulses normally, the ECG may show that a heart attack has occurred or is in progress.
  • Blood tests. Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Emergency room doctors will take samples of your blood to test for the presence of these enzymes.

Additional tests
If you’ve had a heart attack or one is occurring, doctors will take immediate steps to treat your condition. You may also undergo these additional tests:

  • Chest X-ray. An X-ray image of your chest allows your doctor to check the size and shape of your heart and its blood vessels.
  • Nuclear scan. This test helps identify blood flow problems to your heart. Small amounts of radioactive material, such as thallium, are injected into your bloodstream. Special cameras can detect the radioactive material as it flows through your heart and lungs. Areas of reduced blood flow to the heart muscle — through which less of the radioactive material flows — appear as dark spots on the scan.
  • Echocardiogram. This test uses sound waves to produce an image of your heart. During an echocardiogram, sound waves are directed at your heart from a transducer, a wand-like device, held on your chest. The sound waves bounce off your heart and are reflected back through your chest wall and processed electronically to provide video images of your heart. An echocardiogram can help identify whether an area of your heart has been damaged by a heart attack and isn’t pumping normally or at peak capacity.
  • Coronary catheterization (angiogram). This test can show if your coronary arteries are narrowed or blocked. A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter) that’s fed through an artery, usually in your leg, to the arteries in your heart. As the dye fills your arteries, the arteries become visible on X-ray, revealing areas of blockage. Additionally, while the catheter is in position, your doctor may treat the blockage by performing an angioplasty, also known as coronary artery balloon dilation, balloon angioplasty and percutaneous coronary intervention. Angioplasty uses tiny balloons threaded through a blood vessel and into a coronary artery to widen the blocked area. In most cases, a mesh tube (stent) is also placed inside the artery to hold it open more widely and prevent re-narrowing in the future.

In the days or weeks following your heart attack, you may also undergo a stress test. Stress tests measure how your heart and blood vessels respond to exertion. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Or you may receive a drug intravenously that stimulates your heart similar to exercise. Stress tests help doctors determine the best long-term treatment for you.

Complications

Heart attack complications are often related to the damage sustained by your heart during a heart attack. This damage can lead to the following conditions:

  • Abnormal heart rhythms (arrhythmias). If your heart muscle is damaged from a heart attack, electrical “short circuits” can develop resulting in abnormal heart rhythms, some of which can be serious, even fatal.
  • Heart failure. The amount of damaged tissue in your heart may be so extensive that the remaining heart muscle can’t do an adequate job of pumping blood out of your heart. This decreases blood flow to tissues and organs throughout your body and may produce shortness of breath, fatigue, and swelling in your ankles and feet. Heart failure may be a temporary problem that remedies itself after your heart, which has been stunned by a heart attack, recovers over a few days to weeks. However, it can also be a chronic condition resulting from extensive and permanent damage to your heart following your heart attack.
  • Heart rupture. Areas of heart muscle weakened by a heart attack can rupture, leaving a hole in part of the heart. This rupture is often rapidly fatal.
  • Valve problems. Heart valves damaged during a heart attack may develop severe, life-threatening leakage problems.

Treatment

During a heart attack, act immediately. Take these steps:

  • Call for emergency medical help. If you even suspect you’re having a heart attack, don’t hesitate. Immediately call 911 or your local emergency number. If you don’t have access to emergency medical services, have someone drive you to the nearest hospital. Drive yourself only as a last resort, if there are absolutely no other options. Driving yourself puts you and others at risk if your condition suddenly worsens.
  • Take nitroglycerin. If your doctor has prescribed nitroglycerin, take as instructed while awaiting the arrival of emergency medical personnel.

If you encounter someone who is unconscious from a presumed heart attack, call for emergency medical help and, if you have received training in emergency procedures, begin cardiopulmonary resuscitation (CPR). This helps deliver oxygen to the body and brain. If you’re not trained in emergency procedures, doctors recommend skipping mouth-to-mouth rescue breathing and proceeding directly to chest compression. Do chest compressions at a rate of 100 a minute.

In the initial minutes, a heart attack can also trigger ventricular fibrillation, a condition in which the heart quivers uselessly. Without immediate treatment, ventricular fibrillation leads to sudden death. The timely use of an automatic external defibrillator (AED) that shocks the heart back into a normal rhythm can provide emergency treatment before a person suffering a heart attack reaches the hospital.

Once you reach a hospital emergency room and it’s clear you’re having a heart attack, you may be treated with medications, undergo an invasive procedure or both — depending on the severity of your condition and the amount of damage to your heart.

Medications
With each passing minute after a heart attack, more tissue is deprived of oxygen and deteriorates or dies. The main way to prevent progressive damage is to restore blood flow quickly.

Medications given to treat a heart attack include:

  • Aspirin. You may be given aspirin by emergency medical personnel soon after they arrive or as soon as you get to the hospital. Aspirin inhibits blood clotting, thus helping maintain blood flow through a narrowed artery. Take an aspirin yourself while waiting for help to arrive only if your doctor has previously recommended that you do so if you have symptoms of a heart attack.
  • Thrombolytics. These drugs, also called clot-busters, help dissolve a blood clot that’s blocking blood flow to your heart. The earlier you receive a thrombolytic drug following a heart attack, the greater the chance you will survive and lessen the damage to your heart.
  • Superaspirins. Doctors in the emergency room may give you other drugs which are somewhat similar to aspirin to help prevent new clots from forming. These include medications such as clopidogrel (Plavix) and others called platelet IIb/IIIa receptor blockers.
  • Other blood-thinning medications. You’ll likely be given other medications, such as heparin, to make your blood less “sticky” and less likely to form more dangerous clots. Heparin is given intravenously or by an injection under your skin and is usually used during the first few days after a heart attack.
  • Pain relievers. If your chest pain or associated pain is great, you may receive a pain reliever, such as morphine, to alleviate your discomfort.
  • Nitroglycerin. This medication, used to treat chest pain (angina), temporarily opens arterial blood vessels, improving blood flow to and from your heart.
  • Beta blockers. These medications help relax your heart muscle, slow your heartbeat and decrease blood pressure making your heart’s job easier. Beta blockers can limit the amount of heart muscle damage and prevent future heart attacks.
  • Cholesterol-lowering medications. Examples include statins, niacin, fibrates and bile acid sequestrants. These drugs help lower levels of unwanted blood cholesterol and may be helpful if given soon after a heart attack to improve survival.

Surgical and other procedures
In addition to medications, you may undergo one of the following procedures to treat your heart attack:

  • Coronary angioplasty and stenting. Emergency angioplasty opens blocked coronary arteries, letting blood flow more freely to your heart. Doctors insert a long, thin tube (catheter) that’s passed through an artery, usually in your leg, to a blocked artery in your heart. This catheter is equipped with a special balloon tip. Once in position, the balloon tip is briefly inflated to open up a blocked coronary artery. At the same time, a metal mesh stent may be inserted into the artery to keep it open long term, restoring blood flow to the heart. Depending on your condition, you doctor may opt to place a stent coated with a slow-releasing medication to help keep your artery open.Coronary angioplasty is done at the same time as a coronary catheterization (angiogram), a procedure that doctors do first to locate narrowed arteries to the heart. When getting an angioplasty for heart attack treatment, the sooner the better. If an angioplasty is performed days or weeks after you’ve been stabilized with a completely blocked artery, there may not be any benefit.
  • Coronary artery bypass surgery. In rare cases, doctors may perform emergency bypass surgery at the time of a heart attack. Bypass surgery involves sewing veins or arteries in place at a site beyond a blocked or narrowed coronary artery (bypassing the narrowed section), restoring blood flow to the heart. Or your doctor may suggest that you have this procedure after your heart has had time to recover from your heart attack.

Once blood flow to your heart is restored and your condition is stable following your heart attack, you may be hospitalized for observation. Because physical exertion and emotional upset place stress on your heart, be sure to rest. Visitors are usually limited to family members and close friends.

Rehabilitation
The goal of emergency treatment of a heart attack is to restore blood flow and save heart tissue. The purpose of subsequent treatment is to promote healing of your heart and prevent another heart attack.

Some hospitals offer cardiac rehabilitation programs that may start while you’re in the hospital and, depending on the severity of your attack, continue for weeks to months after you return home. Cardiac rehabilitation programs generally focus on three main areas — medications, lifestyle changes and emotional issues.

Prevention

It’s never too late to take steps to prevent a heart attack — even if you’ve already had one. Drug therapy has become an increasingly important part of reducing the risk of a second heart attack and helping a damaged heart function better. Lifestyle factors also play a critical role in heart attack prevention and recovery.

Medications
Doctors typically prescribe drug therapy for people who’ve had a heart attack or who are at high risk of having one. Medications that help the heart function more effectively or reduce heart attack risk may include:

  • Blood-thinning medications. Aspirin makes your blood less “sticky” and likely to clot. Doctors recommend a daily aspirin for most people who’ve had a heart attack. Your doctor may, in some cases, prescribe a stronger blood thinner than aspirin.Doctors may prescribe aspirin and an anti-clotting drug such as clopidogrel (Plavix) for people undergoing an angioplasty or stent procedure to open narrowed coronary arteries, both before and after the procedure.If you’re taking aspirin to help prevent a heart attack, be aware that taking the painkiller ibuprofen (Advil, Motrin, others) at the same time may increase the risk of gastrointestinal problems and may interfere with the heart benefits of aspirin. If you need to take a pain-relieving medication for a condition such as arthritis, discuss with your doctor which is best for you.
  • Beta blockers. These drugs lower your heart rate and blood pressure, reducing demand on your heart and helping to prevent further heart attacks. Many patients will need to take beta blockers for the rest of their lives following a heart attack.
  • Angiotensin-converting enzyme (ACE) inhibitors. Doctors prescribe ACE inhibitors for most patients after heart attacks, especially for those who have had a moderate to severe heart attack that has reduced the heart’s pumping capacity. These drugs allow blood to flow from your heart more easily, prevent some of the complications of heart attacks, and make a second heart attack less likely.
  • Cholesterol-lowering medications. A variety of medications, including statins, niacin, fibrates and bile acid sequestrants, can help lower your levels of unwanted blood cholesterol. The majority of people who’ve had a heart attack take cholesterol-lowering medications — drugs that help lower the risk of a second heart attack. These medications can help prevent future heart attacks even if your cholesterol was not very high at the time of the heart attack.

Lifestyle
How you live your life can largely affect the health of your heart. Taking the following steps can help you not only prevent but also recover from a heart attack:

  • Don’t smoke. If you smoke, the single most important thing you can do to improve your heart’s health is to stop. It’s very hard to stop smoking by yourself, so ask your doctor to prescribe a treatment plan to help you kick the habit.
  • Check your cholesterol. Have your blood cholesterol levels checked regularly, through a blood test at your doctor’s office. If “bad” cholesterol levels are undesirably high, your doctor can prescribe changes to your diet and medications to help lower the numbers and protect your cardiovascular health.
  • Get regular medical checkups. Some of the major risk factors for heart attack — high blood cholesterol, high blood pressure and diabetes — cause no symptoms in their early stages. Your doctor can perform tests to check that you’re free of these conditions. If a problem exists, you and your doctor can manage it early to prevent complications that can lead to a heart attack.
  • Control your blood pressure. Have your blood pressure checked every two years. Your doctor may recommend more frequent measurement if you have high blood pressure or a history of coronary artery disease.
  • Exercise regularly. Years ago, doctors forbade exercise following a heart attack for fear it would cause another. But regular exercise helps improve heart muscle function following a heart attack. Exercise is now a major component of a cardiac rehabilitation program. Exercise helps prevent a heart attack by helping you to achieve and maintain a healthy weight and control diabetes, elevated cholesterol and high blood pressure. Exercise doesn’t have to be vigorous. For example, walking 30 minutes a day, five days a week can improve your health.
  • Maintain a healthy weight. Excess weight strains your heart and can contribute to high cholesterol, high blood pressure and diabetes. Losing weight can lower your risk of heart disease.
  • Eat a heart-healthy diet. Too much saturated fat and cholesterol in your diet can narrow arteries to your heart. If you’ve had a heart attack, limit fat and cholesterol — and sodium. A diet high in sodium can raise your blood pressure. Follow your doctor’s and dietitian’s advice on eating a heart-healthy diet. Prepare heart-healthy meals together as a family. Fish is part of a heart-healthy diet. It contains omega-3 fatty acids, which help improve blood cholesterol levels and prevent blood clots. Eat plenty of fruits and vegetables. Fruits and vegetables contain antioxidants — nutrients that help prevent everyday wear and tear on your coronary arteries.
  • Manage stress. To reduce your risk of a heart attack, reduce stress in your day-to-day activities. Rethink workaholic habits and find healthy ways to minimize or deal with stressful events in your life.
  • Consume alcohol in moderation. Drinking more than one to two alcoholic drinks a day raises blood pressure, so cut back on your drinking if necessary. From a heart-healthy standpoint, one to two drinks daily is fine for men, and women can have one alcoholic beverage a day. One drink is equivalent to 12 ounces of beer, 4 ounces of wine or 1.5 ounces of an 80-proof liquor.

Coping skills

Having a heart attack is a scary experience. Even if your doctor says you’re OK, you may still be afraid. How will this affect your life? Will you be able to get back to work or resume activities you enjoy? Even more frightening — will it happen again?

Fear is just one of the many emotions you and your family must deal with. Other emotions that can be particularly difficult to cope with after a heart attack may include:

  • Anger. You may be angry and wonder: “Why did I have to have a heart attack, and why now?” It’s normal to feel some resentment after a heart attack.
  • Guilt. Family members may feel scared at first and then guilty about your heart attack. Some may even feel that they’re somehow responsible for doing something that gave you a heart attack.
  • Depression. Depression is common after a heart attack. You may feel that you can no longer do things you used to do — that you’re not the same person you were before the heart attack.

These feelings are common, and openly discussing them with your doctor, a family member or a friend may help you better cope. You need to take care of yourself mentally as well as physically after a heart attack. Exercising and participating in cardiac rehabilitation sessions with other people who are recovering from a heart attack may help you work through these feelings.

Sex after a heart attack
Many people worry that sex after a heart attack will be too strenuous on their hearts. However, most people can safely return to sexual activity after recovering from a heart attack. Each person has a different timeline, depending on his or her level of physical comfort, psychological readiness and previous sexual activity.

The demands sexual intercourse places on your heart approximate those of taking a brisk walk, scrubbing a floor, or climbing one or two flights of stairs. In a way, sexual activity parallels any other physical exertion — your heart rate, breathing rate and blood pressure level increase. Ask your doctor when it’s safe to resume sexual activity. With time, you’ll likely be able to resume your normal sexual patterns.

Some heart medications, such as beta blockers, may affect sexual function. However, sexual dysfunction following a heart attack is more often due to depression or anxiety than to medications. If you’re having problems with sexual dysfunction, talk to your doctor. He or she may be able to help you pinpoint the problem and seek the appropriate treatment.

You and your family may have a lot of questions and concerns following your heart attack. If so, it might be helpful to talk to others who are experiencing some of the same things as you and your family. Many cardiac rehabilitation programs offer counseling services and support groups for heart attack survivors.

Surviving a heart attack doesn’t mean that life as you knew it is over. On the contrary, most people lead full, active lives after a heart attack. But it may mean making some positive changes in your daily habits, being patient as you recover and adopting a can-do attitude.