A heart attack is a critical event – the heart muscle isn’t getting enough blood, giving patients symptoms of chest pain and shortness of breath. They can range from small amounts of damage to being life-threatening – so how do we treat heart attacks?

Although the treatment depends a little on the type of heart attack, there are some key principles:

1. Break up the clot that is blocking the blood vessel

• heart attacks are caused by a combination of cholesterol plaque and blood clot blocking the blood vessels that supply the heart muscle (coronary arteries)
• to break up the blood clot (and to stop it forming again), we can give specific medications
• the blood clot is made up of platelets, small particles that clump together quickly to stop bleeding, and the remainder of the clot is a combination of factors that group to strengthen the blood clot
• medications we can give include
  • aspirin
    • aspirin is an anti-platelet agent, and although relatively weak it is the cornerstone of managing and preventing heart attacks
    • we usually continue aspirin lifelong in patients who have had heart attacks
  • stronger anti-platelet
    • there are three types of ‘second anti-platelet’ that we can give, generally for a short period (12 months) after a stent or heart attack
      • ticagrelor
      • prasugrel
      • clopidogrel
    • clopidogrel is slightly older than the above medications, and is generally used in stable patients; for patients presenting with a heart attack, either ticagrelor or prasugrel are given
    • this medication must only be stopped by the cardiologist treating you; stopping these medications at the wrong time can be very dangerous
  • heparin
    • heparin is a blood thinning medication that works on the coagulation factors, proteins that help to strengthen the clot
    • heparin doesn’t specifically break down clot, but stops it getting any bigger so the body can slowly break it down
    • this is temporarily
  • thrombolysis or fibrinolysis
    • this is an powerful injection that breaks down the clot, but carries a significant risk of bleeding because of its strength
    • in an emergency with a severe heart attack in which the clot is not breaking up by itself, and the patient cannot have an emergency angiogram (such as living far away from a cath lab), then thrombolysis is given

2. Fix the narrowing and stabilise the plaque

The cause of a heart attack is an atherosclerotic plaque rupturing, on top of which a blood clot forms. Even after medications are given to break up the blood clot, there is a risk of the clot reforming, and we stabilise that plaque by one of three methods

• medications
  • short term blood thinners to get rid of any clot (see above), followed by statins, a type of cholesterol medication that not only lowers your cholesterol but also stablises the plaque
• stent
  • the process of putting in a stent is called percutaneous coronary intervention, and is done at the time of a coronary angiogram
• coronary artery bypass grafting
  • bypass surgery involves open heart surgery, where a blood vessel is taken from another part of the body (such as the chest, arm or leg) and is used to bypass blood around the blockage
  • this is generally recommended in patients who have many blockages, or if the blockage is in a position that would be too risky to stent

3. Prevent further narrowings from happening, and help the heart to repair the damage

• after a heart attack, the heart muscle can become ‘stunned’ – this means that some heart cells are not dead, but frozen due to the temporary interruption of the blood supply
• to help the heart to recover and reduce the amount of scar, there are a few key medications:
  • angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)
    • these are blood pressure medications that also have a benefit in regard to preventing ‘pathological remodelling’
    • when the heart muscle gets damaged, the body responds with trying to fix things to get the heart working in the short term, however these compensatory mechanisms (remodelling) can be bad in the long term
    • to block these mechanisms, we give medications to prevent this pathological (bad) remodelling
    • lowering the blood pressure also means the heart doesn’t have to work as hard to pump blood out, and allowing the heart to rest after a heart attack is important for recovery
    • examples include perindopril, ramipril, and enalapril
  • beta blockers
    • beta blockers work by reducing the work that the heart has to do
    • they will slow down the heart rate and reduce blood pressure
• in addition to medications, diet focused on reducing salt and fat (as well as overall body fat if the patient is overweight) is critical
• careful exercise can help the heart to slowly improve its reserve, improve the pumping function, and sometimes even encourage new blood vessels to grow
  • the right type of exercise is absolutely critical however, and doing too much too early can be to dangerous
  • it is strongly recommended that patients attend cardiac rehabilitation after a heart attack, which involves education and supervised exercise by trained professionals to help the heart to recover
    • several studies have demonstrated that patients who attend cardiac rehabilitation feel better, have improved cardiac function, and are significantly less likely to die

To summarise:

• medications
  • aspirin lifelong
  • second anti-platelet (ticagrelor, prasugrel or clopidogrel) for a specified duration
  • statins to lower cholesterol AND stabilise the plaques to prevent further heart attacks
  • ACE-inhibitors or ARBs to lower blood pressure and help heart muscle recovery
  • beta blockers to reduce the work of the heart and help heart muscle recovery
• diet
  • low salt
  • low fat
  • weight loss to reduce abdominal fat/waist circumference
• exercise
  • guided therapy through cardiac rehabilitation

 

Not every therapy will be suitable for every person, so there are a large team of people who can help you recover, including your cardiologist, cardiac nurse, physiotherapist, dietitian, and general practitioner.