Heart Attack and Unstable Angina
Treatment Overview
When a heart attack is in progress, you need to act quickly. Prompt treatment with medicines, angioplasty combined with stenting, or surgery to restore blood flow soon after symptoms first begin can prevent permanent injury to the heart muscle and save your life.
Initial treatment
If you are having a heart attack, the goal of your health care team will be to prevent permanent heart muscle damage by restoring blood flow to your heart as quickly as possible. If you are transported to the hospital in an ambulance, you will be given oxygen therapy and probably nitroglycerin or a pain reliever, such as morphine.
Additionally, aspirin (which is usually chewed on the way to the hospital or in the emergency room), heparin, and other antiplatelet drugs are given to prevent clots from growing. Other medicines will be given initially to decrease your heart's workload, improve its pumping function, and treat life-threatening abnormal heartbeats if they occur.
The time it takes to get to a hospital is critical because angioplasty and/or stenting to open blocked arteries or "clot-busting" thrombolytic medicines to dissolve clots are most effective if used within the first several hours after symptoms start. Thrombolytics are given through an intravenous (IV) line and travel to the coronary arteries where they break up clots.
Numerous studies have shown that percutaneous coronary intervention (angioplasty with or without stenting) saves lives—20 lives for every 1,000 people treated—when compared with treatment with thrombolytics.5 But experts do not know yet how safe the drug-eluting stents are over the long term or how well they work over the long term.
Although angioplasty with or without stenting is usually the preferred treatment, it is not available at all hospitals. As a result, some communities are training paramedics to identify people who have signs of heart attack so that they can be transported directly to a heart center, even if it means bypassing a closer hospital.
If you are treated at a hospital that has proper equipment and staff, you may be taken to the cardiac catheterization lab where your doctor will evaluate your coronary arteries to determine whether angioplasty or coronary artery bypass graft surgery is appropriate.
If angioplasty with or without stenting is not possible, either because of the location of the blockage or because of numerous blockages, emergency coronary artery bypass surgery may be done.
If you are having unstable angina, you most likely will be admitted to the hospital and given medicines, including aspirin, other antiplatelet medicines, and heparin. You will be closely monitored and tested. If chest pain continues after the above treatment and you are at high risk for heart attack, your doctor may decide to perform coronary catheterization and plan for possible angioplasty and stent placement to prevent a heart attack.6
Ongoing treatment
After you have had a heart attack, you will stay in the hospital for at least a few days so your heart rate and rhythm, blood pressure, and medicines can be closely monitored. You will also have several electrocardiograms. This is because after a heart attack you are at high risk of having serious complications, such as life-threatening abnormal heart rhythms and heart failure.
Medicines are started to reduce the risk of developing complications. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers can help prevent heart failure and abnormal heartbeats (arrhythmias), both of which can develop after a heart attack. These medicines also improve your chance of survival after a heart attack.
Cholesterol-lowering medicines called statins are usually given to lower your LDL cholesterol level to less than 100 mg/dL.7 Studies show that taking a cholesterol-lowering medicine substantially decreased the risk of heart attack and stroke over a 5-year period in high-risk individuals, such as those who have had a heart attack.8
Aspirin, other antiplatelet medicines such as clopidogrel (Plavix), or anticoagulants (such as warfarin) may be used after a heart attack. These medicines are used to lower the risk of another heart attack and to prevent blood clots from forming in the heart, which could break loose and travel to the brain, causing a stroke. If you take warfarin (Coumadin), see:
The amount of heart muscle that is permanently damaged may be less than it appears immediately after a heart attack has occurred. Some heart tissue may be "stunned myocardium," or heart muscle that is not able to contract normally at first but is later able to function normally. Your heart's pumping capacity will be closely monitored and your treatment adjusted as needed during this time.
Research highlights the importance of quitting smoking after a heart attack. People who continue to smoke after a heart attack are 1½ times more likely than nonsmokers to have another heart attack. Among those who stop smoking, the risk decreases gradually over 36 months until it becomes the same as the risk for nonsmokers.9
If you smoke, your doctor will strongly advise that you quit and avoid secondhand smoke too. Your doctor may prescribe medicine and therapy to help you do so. Studies show that nicotine replacement therapy, use of the medicine bupropion (such as Zyban or Wellbutrin), and supportive therapy significantly increase long-term success in quitting.10 For more information on how to quit, see the topic Quitting Tobacco Use.
Your doctor may talk to you about other lifestyle changes you may need to make, such as exercising or eating a low-fat diet. You may begin a cardiac rehabilitation program while you're still in the hospital. For more information, see the topic Cardiac Rehabilitation.
Avoid getting sick from the flu. Get a flu shot every year.
Treatment if the condition gets worse
Heart attacks that damage crucial or large areas of the heart tend to cause more complications later. If only a small amount of heart muscle dies, the heart may still function normally after a heart attack.
Scar tissue eventually replaces the areas of heart muscle tissue that are damaged by a heart attack. Scar tissue limits your heart's ability to pump effectively. Damage to the left ventricle can limit the heart's capacity to pump. This damage can lead to heart failure.
If the heart attack damaged the area of your heart that regulates your heart rate, your heart can develop abnormal heart rhythms, called arrhythmias. In this case, you may need a pacemaker, which is a device that stimulates the heart to beat and regulates the heart rate, and possibly medicines to control your heart rhythms.11 Some arrhythmias also increase your risk for stroke.
The chance that these complications will develop depends on the amount of heart tissue affected by a heart attack and whether medicines are given during and after a heart attack to help prevent these complications. Other factors, such as your age and general health, also determine your risk of complications and death.
After a heart attack, you may be a candidate for cardiac rehabilitation to lower your risk of death related to heart disease. Rehabilitation and lifestyle changes are an important part of your recovery after a heart attack. For more information, see the topic Cardiac Rehabilitation.
If you do not participate in a cardiac rehabilitation program, you will still need to learn about necessary lifestyle changes, such as quitting smoking, eating a low-fat diet, and perhaps starting an exercise program.
Palliative care
If your condition gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.
Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.
If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.
For more information, see the topic Palliative Care.
More information
 Go to previous section |  Go to top of page |  Go to next section |
| Author: | Robin Parks, MS | Last Updated: May 14, 2007 |
| Medical Review: | Caroline S. Rhoads, MD - Internal Medicine Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology | |
 | ||
