Therapy of a heart attack

Order of therapy

The Sequence of therapeutic interventions In the case of an acute heart attack (myocardial infarction), the following procedure should be followed:

• General measures (securing life)
• Reperfusion therapy (reopening closed Coronary arteries)
• Coronary re-thrombosis prophylaxis
• Therapy of complications

A further distinction is made between measures in the Pre-hospitalization phasei.e. the time before the patient arrives at the hospital, and the Hospital phasewhere the patient is in the hospital.

The general measures ideally take place during the pre-hospitalization phase, i.e. before the hospital.

Illustration of a heart attack

Heart attack (HI)
Myocardial infarction (MI)

1. Healthy coronary artery
   (Coronary artery)
   Coronary artery
2. Occluded artery
   Atherosclerotic plaque
   with blood clot (Thrombus)
3. Fat deposits (plaque)
4. Blood clot -
   thrombus
5. Healthy muscle tissue
6. Coronary artery right -
   Coronary artery dextra
7. Pericardium -
   Pericardium
8. Left coronary artery -
   Left coronary artery
9. Destroyed muscle tissue
   (Infarct area with cell death)
   Typical areas of pain in a heart attack:
   Woman - chest, upper abdomen, neck,
   Lower jaw, spine, back,
   NAN rule (nose - arm - navel)
   Man - chest, stomach,
   Emanation in the arm and shoulder,
   Lower jaw, back

An overview of allhe images by Dr-Gumpert can be found at: medical illustrations

Treatment after a heart attack

In the acute situation of a myocardial infarction, vasodilating medication (for example the nitro spray) and oxygen are administered first. As a result, the heart muscle cells are better supplied again. Painkillers should also be given. Then it is important to remove or widen the narrowed point in the coronary vessels. This is usually done through a stent or a bypass. Depending on the long-term consequences, different drugs are then administered. Blood thinners are designed to prevent blood clots from forming in the event of cardiac arrhythmias. There are also drugs that prevent these arrhythmias. Using a pacemaker also helps. If the heart is so damaged that it could stop by itself, it makes sense to install a defibrillator. If heart failure occurs as a result of a heart attack, cardiac glycosides (digitalis) are usually prescribed. Diuretics (water tablets) are also helpful as they relieve the heart. Depending on the disease underlying the infarction, this can also be treated. Antihypertensive drugs make sense when blood pressure values ​​are too high. Statins bring blood lipids back into balance.

Immediate therapy / acute therapy

At the slightest suspicion of a heart attack is one immediate admission to the clinic with the emergency ambulance under medical care and then hospitalized necessary. The aim of the immediate transport to the hospital is to initiate a Reperfusion therapy within 12 hours of the onset of the infarction, so that the Heart muscle damage can be contained as much as possible by the infarction.

The faster the locked Coronary artery is reopened and blood circulation is restored, the less Heart muscle tissue dies and the fewer complications arise from the heart attack. The motto of acute heart attack therapy is: "time is muscle" (Time are muscle cells).

Certain initial measures must be taken immediately. The person concerned should be with raised upper body be stored and oxygen should be fed through a nasogastric tube to provide oxygen to the damaged heart. Consistent monitoring of the Heart rate, of Heart rhythm, of the Oxygen saturation and des Blood pressure via a monitor or a electrocardiogram (EKG) is required. It may be necessary to use electrical surges (Defibrillation) to be life threatening Cardiac arrhythmias or to treat ventricular fibrillation.

A heart attack is severe in most cases Paincaused by pain medication (Analgesics) should also be breastfed as acute therapy. For this mostly opiate about the vein given. Also be Sedativese.g. Benzodiazepines (sedatives) administered, which dampen states of agitation (e.g. fear, restlessness). Nitrates (e.g. Nitroglycerin) are given to relieve the heart, and they also have a beneficial effect on heart attack pain. Early administration of beta blockers (e.g. Esmolol) can prevent cardiac arrhythmias and left heart failure (the most common complications after a heart attack). In addition, the Heart work (Heart rate) Beta blockers slowed down. This leads to a reduction in the heart's need for oxygen and thus the extent to which the heart muscle is damaged by the heart attack. The instant gift of Acetylsalicylic acid (ASS) also showed in when a heart attack was suspectedi Studies show a death rate reduction of over 20 percent. But not only Acetylsalicylic acid is used to prevent re-formation of a thrombus (Blood clots), but also the drugs heparin and prasugrel or ticagrelor.

The growth of an existing thrombus causing the patient's discomfort may result from the use of Heparin be contained. It enhances the effects of what is present in the blood Antithrombin IIIwhich inhibits blood clotting by preventing the dissolution (Fibrinolysis) of a platelet aggregate.

If the Blood pressure if you have a heart attack is low or the suspicion of one Right heart attack administration of fluids through the vein is also part of acute therapy. In some cases it is necessary to take medication against nausea and Vomit (Antiemetics) (e.g. metoclopramide).

Drug therapy for dissolution (Lysis) of the blood clot should be started as early as possible in an acute heart attack. The lysis therapy is less effective the longer ago the heart attack occurred. This Lysis drugs inhibit the body's own Blood clotting throughout the body and can therefore lead to heavy bleeding (e.g. from a previously unrecognized Gastric ulcer). Therefore, after a Lysis therapy be closely monitored.

Reperfusion therapy

If the heart attack is certain and it takes a long time to transport the patient to the hospital, a Thrombolytic therapy be initiated by the emergency doctor (for thrombolytic therapy see below). It is also important to treat complications that arise during the transport to the hospital and to follow up further measures in the clinic.
Once the patient is in the hospital, they begin Hospital phase interventions.
The general measures that have already started are carried out under intensive medical circulatory monitoring and in Readiness for resuscitation (Readiness for resuscitation) continued.

A rapid reperfusion therapy to reopen the vessels has top priority:

The conservative therapy approach for heart attacks represents the Thrombolystherapy Here, activators of fibrinolysis are given by infusion:

The Medication

• Streptokinase
• Alteplase (r-t-PA) or
• Reteplase (r-PA)

cause blood clots to dissolve (thrombolysis). One speaks of a systemic lysis, since the necessary medication is over the vein administered and reach the coronary arteries via the blood vessel system.

The requirements for this therapy are:

• a recent heart attack that started no more than 6 hours ago
• visible changes in the EKG such as
• the absence of contraindications (contraindications) to treatment.

An accompanying Heparin therapy, which also serves to dissolve the thrombus, improves the result of the lysis.
In approximately 70-85% of the treated cases, reopening of the vessel is observed within 90 minutes after the infusion. Fibrinolysis can reduce mortality within the first 35 days after the acute infarction by 50%.

Physical (clinical) criteria for successful revascularization are the disappearance of the chest pain and a normalization of the ST segment in the ECGwhich was previously increased by the infarct. These clinical signs are indirect criteria for monitoring the success of the therapy. Coronary angiography (visualization of the patency of the coronary arteries) provides direct evidence of the success of the therapy.

In 20-25% of the cases, the coronary vessel is closed again after the lysis therapy. Therefore, after completing this therapy, all patients should be transferred to a cardiology center, where a coronary angiography is performed to check the vascular status. A possibly necessary reopening of the resealed vessel can be connected immediately if necessary.

Contraindications that speak against lysis therapy are:

• Gastric ulcer and Intestinal ulcer (ulcer)
• Fundus bleeding
• acute headache
• Medical history of bleeding disorders
• a stroke less than 6 months ago (apoplex) and
• an operation less than 1-2 weeks prior or an accident.

If these diseases or conditions are present, no fibrinolytic therapy should be carried out because a life-threatening bleeding complication must be expected.

Medication after a heart attack

After a heart attack, it is necessary to start drug therapy to prevent another heart attack. The basic drugs for the treatment are so-called platelet aggregation inhibitors, which prevent the clumping of blood platelets (Platelets) and thus prevent a new blood clot from triggering another heart attack. Well-known representatives of this group of drugs are, for example, acetylsalicylic acid (ASS), Clopidogrel, prasugrel, ticagrelor, abciximab or tirofiban. Side effects of these drugs are an increased risk of bleeding in the gastrointestinal tract if taken continuously and profuse bleeding from even minor injuries is possible.

Another group of drugs called anticoagulants (Anticoagulants) are used in the therapy of a heart attack, especially if the left ventricle is affected or atrial fibrillation has remained. Anticoagulants such as phenprocoumon (Marcumar®), Warfarin, dabigatran or rivaroxaban reduce the ability of the blood to clot. During treatment with anticoagulants, regular blood tests must be carried out to ensure that the blood coagulation factors are ideal. The side effects are bleeding from the nose and gums, and if taken continuously there is a risk of osteoporosis (bone loss).

Drugs that lower blood pressure are also used in heart attack therapy. These include beta blockers, ACE inhibitors, and angiotensin receptor blockers. Beta blockers are used to prevent another heart attack or the occurrence of ventricular fibrillation. Beta blockers such as atenolol, bisoprolol, metoprolol or propanolol slow down the pulse, which means that the heart uses less oxygen and blood pressure drops. Beta blockers can also cause undesirable side effects, such as a disruption of the conduction of the heart, the heart conduction can be critically lowered and beta blockers may have a narrowing effect on the bronchi. For this reason, people with severe heart failure or allergic bronchial asthma should not be treated with beta blockers. ACE inhibitors also lower blood pressure, and they also have a positive effect on the growth of blood vessel wall and heart muscle cells after a heart attack. If, in addition to a heart attack, there is diabetes mellitus or cardiac insufficiency, ACE inhibitors such as captopril, enalapril or ramipril are the drugs of first choice. The most common side effect of ACE inhibitors is an excruciating urge to cough, which in some cases leads to discontinuation of the medication or to a switch to angiotensin receptor blockers (very similar effects to ACE inhibitors).

Statins also play a role in the therapy of myocardial infarction. Statins inhibit the production of cholesterol in the liver and thus reduce the concentration of excess cholesterol in the body that is deposited on the walls of the blood vessels and blocks them. This mechanism is considered to be the main cause of heart attacks. Side effects of statins include gastrointestinal complaints, liver damage and muscle pain as well as psychological side effects (such as aggressiveness, memory loss and lack of concentration), which is why careful medical supervision is necessary when taking statins.

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Cardiac catheter

The gold standard of myocardial infarction treatment is percutaneous transluminal coronary angiography (PTCA) / percutaneous coronary intervention (PCI), a treatment with a catheter.
Studies show that this therapy option has better results with regard to the patient's recovery from myocardial infarction and survival after a heart attack than pure thrombolysis therapy (dissolving the plug that closes the coronary artery), which is why PTCA is preferable to lysis.

However, if the technical possibilities (cardiac catheter laboratory) to carry out a catheter intervention on site are not available and the transport of the patient to the nearest cardiac center is associated with a very long journey, immediate lysis therapy is the therapy of choice.

Acute PTCA with or without stenting is indicated for patients who have suffered a heart attack with or without ECG changes and for patients with unstable angina pectoris. All three groups benefit from coronary intervention.

It is absolutely necessary to carry out a PTCA even after a lysis therapy, since 20% of all patients successfully treated with thrombolysis without any further invasive measures, i.e. without PTCA, have another heart attack over 4-8 weeks.

Further information on this topic can be found at: Cardiac catheter

Stent

In the case of an acute myocardial infarction, it is desirable to have a cardiac catheter examination carried out on the person concerned within the first 60 to 90 minutes after the heart attack. The primary percutaneous coronary intervention (PCI) is not only helpful in making a diagnosis, the catheter is also used for the therapy of myocardial infarction by clearing the blocked coronary arteries again.

After a local anesthetic, a very thin plastic tube is pushed through an artery towards the heart via a small puncture site in the groin area or on the arm. A stent (small tube with a lattice structure, usually made of metal) can be inserted into the vessel with this catheter in order to prevent the vessel from being closed again. At the tip of the catheter there is an externally inflatable balloon on which the stent lies tightly folded. As soon as the catheter has been advanced to the narrowed point of the coronary artery, the balloon is inflated, thereby widening the narrowed point. At the same time the metal mesh of the stent unfolds. The pressure of the balloon presses the stent against the vessel wall and remains there as a stabilizing element on the widened vessel wall. In order to prevent the stent from being recognized by the organism as a foreign body and thereby promoting a new clogging of the arteries, stents that continuously release drugs and deliver into the blood (so-called "drug eluting stent"). As a result, the risk that the stent-enlarged vessel sections will grow closed again has decreased to less than ten percent. The placement of a stent is successful in 95 percent of the cases, the probability of a renewed closure is particularly given within the first six months. In this case, however, a new stent can usually be deployed.

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Bypass surgery

In a bypass operation, a diversion is built in, so to speak, for a blocked coronary artery. For this, one usually uses a body's own blood vessel (for example from the lower leg). This is connected to the main artery and connected to the coronary artery behind the constriction. This allows the blood to flow past the blocked area and supply the tissue behind with nutrients. Bypass surgery is usually done with the chest open. A skin incision is made and then the bony chest is opened so that the surgeon can get to the heart. The operation is often performed on the heart-lung machine. In this case, the machine can take over the pumping function of the heart for a certain period of time. The heart itself can be immobilized with medication for so long. This makes an operation much easier and increases the accuracy. Without a heart-lung machine, the bypass is first attached to the affected coronary artery. The main artery of the body is then partially closed with a clamp. In this way, the bypass can be connected to the main artery without blood oozing out of the hole with each heartbeat. After the vessel has been sewn on successfully, the clamp is removed again. Depending on the surgical technique, bypass surgery takes three to eight hours. It is always performed under general anesthesia.

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Long term therapy

An accompanying long-term anticoagulant therapy should be done that counteracts platelet clumping. Suitable drugs are Acetylsalicylic acid (e.g. Aspirin ®) such as Clopidogrel (e.g. Plavix ®), which belong to the group of platelet aggregation inhibitors, i.e. the clumping, which should prevent platelets from clumping. The mortality of patients in the first year after the heart attack is reduced by 15% under these therapeutic measures, the risk of a new heart attack by 30%.
If there are blood clots (thrombi) in the left ventricle that have been confirmed by echocardiography (heart echo / cardiac ultrasound), drug therapy is indicated, which counteracts the coagulation-promoting substances in the blood plasma. Serve for this Coumarins (Group of anticoagulants (anti-coagulants), Marcumar®), which are used for at least three months. The risk of the thrombi loosening from the ventricle and floating into the cerebral arteries with subsequent stroke is reduced by taking coumarin.

Duration of therapy

There are many different ways to treat a heart attack. Depending on the type, size and complications of the infarct, different therapies are combined. The acute therapy, which usually takes place in the ambulance, consists of oxygen, vasodilating drugs and painkillers. Then the cause of the heart attack should be eliminated as quickly as possible in a hospital. This is usually in a blocked coronary artery. The previously disturbed blood flow is ensured again through a bypass operation or the insertion of a stent (a wire mesh that holds the vessel open). These operations are now routine treatments and usually only last 30 minutes (stent operation) to 8 hours (bypass operation). Depending on the long-term complications that occur, this can be followed by drug treatments lasting years to life. For cardiac arrhythmias, blood thinners and drugs that maintain the correct rhythm should usually be taken for life. Alternatively, a pacemaker can be used. This gives the heart a fixed heart rate through electrical impulses. If heart failure occurs, this must also be treated with medication for life.

Therapy of a silent heart attack

The silent heart attack is treated like any normal heart attack. Only the administration of painkillers can usually be saved, since a silent heart attack is characterized by the absence of the otherwise typical pain. While the heart attack is taking place and immediately afterwards, the therapy initially consists of administering oxygen and elevating the upper body. Due to the raised upper body, not too much blood flows back to the heart, so that this is somewhat relieved. Nitrates, or vasodilators, are given either into the vein or as a spray onto the tongue. Blood thinners should also be given. As with a "normal" heart attack, the constriction in the blood vessel should be removed in the next hospital. This is usually done with a stent. Alternatively, bypass surgery can be considered. Since silent heart attacks are often based on a non-cardiac (i.e. not originating from the heart) disease such as diabetes mellitus (diabetes), this should primarily be treated. This can prevent further long-term damage or a new heart attack. Also complications such as cardiac arrhythmias and a Heart failure (Heart failure) should be treated with medication and carefully monitored in the following years.

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How can you prevent another heart attack?

In order to prevent another heart attack, one should above all treat the existing underlying disease. These are often heart conditions, but high blood pressure can also be diabetes ("Diabetes") or an imbalance in blood lipid levels. All of these diseases can be adjusted with medication. It is also advisable to take part in a rehabilitation program after a heart attack. Training courses on all aspects of cardiovascular health take place here. In addition, you learn to slowly and carefully relieve your own body after a heart attack. Physical activity and training in particular prevent another heart attack in the long term. A balanced diet is also helpful.

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Guidelines

Medical guidelines are systematically developed Decision-making assistance about the appropriate medical procedure for special health problems and provide a Guidance in terms of the Treatment of diseases The current guidelines are provided by the German Society for cardiology-, Heart and Circulatory Research e.V. published and distinguish one in therapy Heart attack between infarctions with certain characteristics on the electrocardiogram (with a ST segment elevation, STEMI) and without (without ST elevation, NSTEMI). The heart attack with changes in the EKG (STEMI) is the more serious event, as it is usually caused by a complete closure of a Coronary artery is caused.

The guidelines state that the first therapeutic goal in this type of heart attack is the most possible early reopening of the closed vessel, either mechanically using a Catheter or medicinal (Fibrinolysis). The method of choice for an acute STEMI is this Restoration of blood circulation of the heart muscle means Cardiac catheter (PCI, percutaneous coronary intervention). The use of so-called Drug-eluting stents (Drug-eluting stents) recommended unless the patient is at increased risk of bleeding from other medical conditions. In this case, pure metal stents should continue to be preferred. According to the guideline, the earlier this treatment is, the greater the chances that that will heart the Heart attack survives with little damage. The guideline on myocardial infarction also differentiates between the various Types of catheter therapy. The catheter access via the Arm artery should be preferred, but only if the attending physician has sufficient experience with this approach. The rate of Complications and Bleeding are at the entrance at the Arm decreased compared to the catheter access via the Leg artery.

One way of Heart attack therapy About special catheters is also mentioned in the guidelines. The Thrombi (Blood plug that closes the vessel, which leads to the heart attack) can be sucked off immediately via special catheters. After a successful revival after a Cardiac arrest is the recommendation of the guideline To cool affected persons (therapeutic hypothermia). Newly included in the guidelines Medication are two Antiplatelet drugs (Prasugrel and Ticagrelor), these inhibit the clumping of blood platelets and are often called "blood thinner"The two new drugs are intended to give the older one Drug clopidogrel be preferred in the future.

Also a recommendation regarding the Lifestyle change can be found in the guidelines. Especially that Smoke should be given up immediately by people who are at increased risk of heart attack.