The Modern Management of Heart Attacks

A heart attack, or myocardial infarction, is an interruption of the arterial blood flow to the heart. Untreated, it will lead to the death of part of the muscle of the heart. The heart is supplied by blood from two smallish arteries, the coronary arteries; a blockage in one of these is a heart attack. The blockage is caused by a clot or ‘thrombus’ forming on a ‘plaque’ of cholesterol in the artery. Symptoms are classically pain in the centre of the chest, perhaps radiating to the left arm or to the jaw; other symptoms include a ‘stomach ache’ or heartburn, or just a feeling of being unwell.

In the past, treatment was simple; the patient was put to bed, given a hefty dose of a painkiller such as heroin, and rested for several weeks. That has all now gone.

The principles of the modern management of a heart attack are early diagnosis; chemical dissolution of the clot; and ‘opening up’ any underlying narrowing of the artery. If there are irregularities of the heart’s action, treatment may be needed; depending on the problem, drugs, the use of an external defibrillator, or internal ‘pacing’ may be required.

The diagnosis, as always, is made from the clinical history, and confirmed by examination and special tests. There may be changes on the electrical tracing of the heart’s rhythm, the ECG. A chemical marker in the blood, a troponin, is a very sensitive test.

If the diagnosis is confirmed, the clot should be dissolved using enzymatic means (‘clotbusters’); the original treatment was streptokinase, but more modern versions are now available. It is given intravenously.

An x-ray examination of the heart’s arteries using a radio-opaque dye may show an underlying blockage or blockages. A fine tube can be passed into the artery, and a balloon attached to it can be blown up, to widen or ‘dilate’ the artery. A ‘stent’, a fine metallic meshwork, looking remarkably like the expanded metal used by builders, can be inserted in the expectation that it will hold the artery open. If there are multiple blockages, a coronary artery by-pass graft operation may be necessary.

When the acute episode has passed, cardiac rehabilitation begins. This includes ‘lifestyle’ advice, exercise, advice about flying, and usually a ‘cocktail’ of drugs designed to prevent, as far as possible, a recurrence, and to prevent complications.

Note: as a distinctly retired surgeon, I’m not in an ideal place to discuss the minutiae of modern management; the above is very much a synopsis, and one produced at very short notice.

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  • Ernekid

    I wish Peter a speedy recovery.

    Is there any word on who will take over as First Minister now that Robinson has taken ill?

  • Jag

    Presumably Arlene again?

  • Jag

    Has Peter had a confirmed heart attack then?

    I recall Tony Blair being admitted to hospital in 2004 with heart arythmia, details here http://news.bbc.co.uk/2/hi/health/3205978.stm

    Heart issues all seem to be serious, some more serious than others.

    Will Peter’s absence suspend the High Noon showdown on welfare reform?

  • Catcher in the Rye

    Thoughts with Peter Robinson and hoping he makes a speedy recovery and is back at work soon.

    I also appreciated the medical information. Always good to have an explanation from someone with first hand knowledge of the condition.

  • Kevin Breslin

    I’d imagine so, not sure who’d fill in on finance. In my opinion though, junior ministers for OFMDFM should fill in, they do nothing anyway so throw them in at the deep end.

  • Turgon

    I am afraid Korhomme is simply incorrect here. The modern treatment is not “clot busters” but rather Primary PCI for what are called STEMIs. It was rolled out in NI in 2013 (quite a few years after it was in GB). Here is the press release about it.

    Other heart attacks, NSTEMIs, may also benefit from PCI (not primary) but “clot busters” are not used for them either.

    Sometimes it is better to stop, look at the evidence and then comment rather than rush to be the first out especially when one claims authority in a field. Though some may understand the difference between a surgeon and a cardiologist not all the general public will. It is behovent on people with special knowledge not to stray outside that field of knowledge lest they accidentally mislead the public.

    Here is a BBC article from 2008 about it and here from the same year is the BBC reporting the plan to roll it out to England and Wales. I think it was rolled out in Scotland about the same time but am not sure. To be fair we were only 5 years behind.

  • chrisjones2

    Yeah…Finance isn’t that important at the moment

  • Korhomme

    STEMI is an acronym for ‘ST elevated myocardial infarction’. ST elevation refers to ECG changes. When these aren’t seen, it’s NSTEMI.

    The press release refers to patients in the very greater Belfast catchment area; services in other areas were to be ‘rolled out’.

    The treatment only applies to very recent myocardial infarctions.

    I specifically included a note about my knowledge. If a more competent authority posts here, I will delete this post.

  • Pete

    Given RVH has said that Robinson has undergone a procedure, I suspect he’s had PCI.

  • submariner

    Turgon clot busters are still given especially if the patient does not have ready access to PCI. It is true that PCI is the preferred avenue for treatment but to say that clot busters are no longer used is wrong http://www.nhs.uk/Conditions/Heart-attack/Pages/Treatment.aspx I believe Peter Robinson was treated at the Ulster prior to being moved to the Royal and im sure clot busters may have been given prior to him going for PCI

  • Korhomme

    Tony Blair’s problem was quite different. Contractions of the heart muscle begin in the atria, the chambers which receive blood from the great veins. The blood is forced into the ventricles, from where it is discharged either into the lungs in the pulmonary circulation, or into the aorta, for distribution throughout the body. Contractions should spread as a ‘wave’ from the atria to the ventricles; occasionally, there are abnormal or ‘aberrant’ conduction pathways which cause the ventricles to beat fast and irregularly. The treatment is to destroy or ‘ablate’ these.

  • Ciaran

    That’s him finished unless he wants to end up in a box. Some nuts will be wondering did it have anything to do with him going inside a Roman Catholic chapel.

  • puffen

    In normal circumstances,STEMIs are usually first diagnosed by Amb crews, who after consultation with the Cath Lab, take the patient directly to the Cath Lab this is irrespective of where in the province, the patient is, I suspect in this case the ED in the Ulster Hospital made the diagnoses, as the First Minister was a “walk in”.

  • chrisjones2

    I don’t like Robinson’s politics but hold no grudge against anyone and hope he fully recovers

  • Turgon

    The service has been rolled out with Altnagelvin offering the service to the west of Northern Ireland. Since Mr. Robinson lives in the Belfast area he would not have had “clot busting” drugs if he had had an STEMI. Had he had a NSTEMI he would not have had them either.

    Medicine moves on an the views of a retired doctor from a different speciality rapidly become hopelessly out of date: as you have demonstrated rather effectively. Your view is not the “modern management of heart attacks” but rather 1990s / early 2000s management of heart attacks. I have indeed demonstrated a more competent authority (see the enclosed links from DoHPSS websites). If that is inadequate see pages 2580-2581 of the European Society of Cardiology Guidelines: I hope you regard that as a competent authority.

    Remember also that if one publishes stating that one is a doctor the GMC requires that one identifies oneself by name (point 17 here).

  • Korhomme

    Perhaps you would write a short post instead, remembering to use language accessible to a layperson.

    I’m well aware of the views of the GMC. They will have no interest in what I write.

  • Granni Trixie

    Forget the put-downs Korhomme – sharing your knowledge is appreciated by most of us,I’m sure.

  • Turgon

    Absolutely not. I would rather you corrected your post to remove the thing about clot busting drugs as it obsolete in an NI context.

  • Korhomme

    Thank you, Granni, for that.

  • Kevin Breslin

    As interesting as this is, what kind of political debate can be made from it?
    Should Transforming your Care look at smartphone technology, wearable EEG kits for out of hospital treatments?
    What can we do to ensure there’s more paediatric heart specialists at a time of Higher Education cuts?
    Does genetic markers in families that have a high occurance of CHD make their blood a donation risk through epigenetics?

  • Korhomme

    Why will you not write about how treatment is supposed to be delivered in N Ireland? Note that my post does not refer to any specific geographical area.

  • Turgon

    I think these sort of articles are highly problematic when someone famous is ill. It feels a bit like ambulance chasing. I would rather people thoughts and prayers were with Mr. Robinson and the other people who no doubt have had similar problems recently. Not everyone may agree with that but I just find such articles a bit unseemly.

    If I were a doctor I would have to state that to establish the authoritative nature of my views. That would as per the GMC guidelines require me to give my name.

    If I were some other sort of expert I would have to explain who I am in order to establish my authority on this subject.

    I have simply provided links to websites which explain what happens generally and what is being done in NI. If one reads the links one can establish it.

  • Jag

    No word at all from the DUP, there’s not been a press statement since last Friday, amazing.

    Today is a big day. The welfare reform debate will not be resolved today with the petition of concerns. Arlene says the direct consequence of what she claims is an external deadline is she will not be able to finalise a budget which is required by this coming Friday. After that happens, GB takes over. Serious stuff.

    This is my 1-minute visualisation of the the six-month unwinding of the Stormont House Agreement, we’ve been flying through the air and fountains for the past six months, this is now what’s about to happen.

  • Starviking

    In the US, self-administration of Aspirin is recommened to lower the probability of clot formation.

  • Mister_Joe

    If you experience symptoms of a heart attack, take an aspirin (ASA) and get thee to a hospital immediately. The staff there would much prefer a false alarm than someone who tries to ignore the potential problem and there are lots of dead people who might have survived. I’m a bit of an expert having survived 6 heart attacks.