Heart attack

A heart attack happens when one of the arteries feeding the heart is blocked by a clot. The patch of muscle that depended on it is left without oxygen and begins to die, at first reversibly and then for good. That is why time decides everything here: an artery opened within the first hours leaves the heart almost undamaged, while muscle that has spent half a day without blood never recovers. Half of those hours are usually spent at home, lying down, waiting to see whether it passes off by itself.

What it feels like

The classic picture is this: behind the breastbone comes pressure, heaviness, burning or a squeezing sensation, as though a slab had been laid on the chest. The pain often spreads to the left arm, but it may go to both arms, to the jaw, the neck, between the shoulder blades or to the upper abdomen. With it come cold sweat, light-headedness, breathlessness, nausea, weakness and a sense of dread that has no cause. All of it lasts more than a few minutes and does not settle with rest.

The danger lies elsewhere: the classic picture may not appear at all.

• The pain can be mild and taken for heartburn, indigestion or a pulled muscle.
• In women it is more often not the pain that comes to the fore but breathlessness, nausea, light-headedness, pain in the back or jaw and a draining tiredness in the days beforehand.
• In people with diabetes and in older people a heart attack sometimes passes almost without pain: all that remains is sudden breathlessness, weakness, confusion or a faint.

Anyone who already has angina needs to feel the difference. Angina is predictable: it comes on with exertion — a hill, cold weather, a heavy meal, an upset — lasts a few minutes and goes as soon as you stop or take glyceryl trinitrate. A heart attack also comes at rest, often at night, lasts longer, hurts more, brings sweating and light-headedness with it, and the tablet or spray does not take it away. There is also a warning sign of its own: attacks that have suddenly become more frequent, that come on with less effort, or that appear at rest for the first time. That is unstable angina, and it needs sorting out within hours rather than at an appointment next month.

What to do in the first minutes

• Call an ambulance (in Europe, the single number 112). Do not wait for things to become clearer and do not ring relatives first.
• Stop whatever you are doing, sit or half-lie down, loosen tight clothing. Walking about and going down stairs are out.
• Do not drive and do not ask to be taken in a private car: the heart can stop on the way, and an ambulance crew is equipped for that while a passenger is not.
• If there is no allergy to aspirin and the call handler confirms it, chew an ordinary aspirin tablet rather than an enteric-coated one: chewed, it works faster and holds back the growth of the clot. The call handler will tell you the dose.
• If your doctor has prescribed glyceryl trinitrate, take it sitting down. If nothing has happened after five minutes, take a second dose; if that fails too, call the ambulance without waiting for a third.
• Get your list of medicines ready and open the front door.

Cardiac arrest is a separate matter. Sometimes a heart attack disturbs the rhythm so badly that the heart stops pumping: the person collapses, does not respond and is not breathing normally (occasional gasps count as no breathing). Then it is a matter of minutes. Call an ambulance, lay the person on their back on a firm surface and press with the heel of your hand on the centre of the breastbone to a depth of five to six centimetres, at a rate of about a hundred and twenty compressions a minute, without stopping. If somebody else is there, send them for an automated external defibrillator: these devices hang in shopping centres, stations and gyms, they talk you through every step and decide for themselves whether a shock is needed.

Why the artery blocks

Behind a heart attack there is usually atherosclerosis. Over years a plaque of cholesterol and other substances builds up in the wall of a coronary artery, and while it is growing the person may feel nothing. The heart attack begins at the moment the cap of the plaque tears: the body reads the tear as a wound and seals it with a clot, and the clot blocks the vessel. The process is speeded up by smoking, high blood pressure, raised cholesterol, diabetes, excess weight, inactivity, family history and long-term stress, and together these do not add up so much as multiply.

But there are other mechanisms that are hardly ever suspected:

• spontaneous tearing of the wall of a coronary artery, a rare cause but a characteristic one in young women, including during pregnancy and shortly after birth, and often with not a single conventional risk factor;
• spasm of a coronary artery, among other things after cocaine and amphetamines;
• a clot arriving from elsewhere, for instance from the chambers of the heart in atrial fibrillation;
• a sharp fall in blood oxygen from severe anaemia, major blood loss or carbon monoxide poisoning.

Youth and good fitness therefore do not rule the diagnosis out.

What happens in hospital

The first thing done is an electrocardiogram, which by standard should be recorded within minutes of arrival. It settles the key question: is there elevation of the ST segment, the sign of a completely blocked artery? At the same time blood is taken for troponin, a protein released from dying heart cells, and the test is repeated some hours later.

From there two paths open. In a heart attack with ST elevation the artery is opened immediately, usually by a percutaneous procedure: a catheter is passed to the heart through a vessel in the wrist or the groin, a balloon is inflated at the blockage and a stent is left in place, a small mesh tube that holds the channel open. If no such hospital is within reach, a clot-dissolving drug is given first. In a heart attack without ST elevation and in unstable angina treatment starts with medicines, and the timing of coronary angiography is set by how ill the patient is; when several arteries are affected at once, bypass surgery is sometimes offered instead of stents.

The first days are spent under observation, and with good reason: that is when most complications appear — disturbances of rhythm, heart failure where a large area of muscle has been lost, inflammation of the sac around the heart, and the rare but extremely dangerous rupture of a wall or a valve. All of these are treated the more successfully the sooner they are spotted, and that is the point of the ward even once someone feels well.

Medicines after a heart attack

You leave hospital with a handful of drugs, and nearly every one of them is prescribed for the long term. It is worth understanding what each is for: a great many people abandon treatment within the first year simply because nothing hurts any more.

• Antiplatelet drugs stop platelets sticking together. For a while two are usually taken at once, after which one remains. The side effect is easier bleeding, so black stools, blood in the urine or in vomit and unusual bruising are reported to the doctor straight away.
• Statins lower cholesterol and, more importantly, stabilise the plaques; they are prescribed even when cholesterol is normal. Muscle aching and weakness are a reason to discuss the dose or a switch with your doctor, not to stop on your own.
• Beta blockers slow the pulse and take load off the heart. They must not be stopped abruptly: there can be a rebound.
• ACE inhibitors or angiotensin receptor blockers lower blood pressure and protect the heart muscle from remodelling after the attack. A dry cough on an ACE inhibitor is a common reason for switching.

None of these is stopped on your own initiative, even when you feel perfectly well. Before any operation, dental work included, the doctor must be told about blood-thinning medicines, and any new drug, over-the-counter painkillers and supplements included, is worth asking about first: some combinations are dangerous.

Getting life back

Recovery takes weeks and months, and the main tool is cardiac rehabilitation: measured, supervised exercise, education, work on diet and support with anxiety. People who complete it return to hospital less often and live longer. Ask about the programme when you are discharged, because it is frequently not offered as a matter of course.

• Exercise. Start with walking on the flat and build up gradually. The rule of thumb is simple: during exertion you should still be able to talk.
• Work. Most people go back; how soon depends on the size of the attack and on whether the job is desk-based or physically heavy.
• Driving. After an uncomplicated heart attack people usually return to the wheel within a few weeks, but the rules for professional drivers are stricter and differ from country to country, so the interval is checked with a doctor.
• Sex. It is no more of a strain than climbing two flights of stairs. A common problem is erectile dysfunction, from anxiety or as an effect of the medication; it can be dealt with, but the drugs that treat it are incompatible with nitrates, so it is settled with a doctor.
• Mood. Low spirits, anxiety and fear of a repeat are so common that they count as part of the picture rather than as weakness. If they have not eased after a month, say so: depression holds back physical recovery too.

Do not put off seeing a doctor if increasing breathlessness appears, or swelling of the legs, a sharp gain in weight over a few days, palpitations or blackouts. And chest pain resembling the original is once again a reason to call an ambulance.

Reducing the risk of a second attack

• Smoking. Stopping does more than any single drug, and the risk starts falling within the first months. There are medicines and support programmes, and asking for help is wiser than relying on willpower alone.
• Blood pressure and cholesterol. Keep them at the target your doctor sets and check them regularly rather than by how you feel: neither of them hurts.
• Food. The Mediterranean pattern — vegetables, fruit, wholegrains, pulses, nuts, fish, olive oil — is the best studied. Less processed meat, fewer sugary drinks, less shop-bought cake and pastry, less salt. Supplements, omega-3 included, do not replace food and have not proved their worth after a heart attack.
• Movement. The benchmark for most people is around two and a half hours of moderate activity a week; after a heart attack the plan is agreed with a doctor.
• Weight and diabetes. Losing even a few kilograms improves blood pressure and blood sugar, and glucose control after a heart attack matters no less than everything else.
• Alcohol. The less the better: the idea that moderate amounts protect the heart has not held up, and drinking heavily in one go is particularly dangerous because it disturbs the rhythm and pushes blood pressure up.
• Vaccination. Annual flu vaccination is recommended to people with heart disease for a reason: influenza raises the risk of cardiac events appreciably.

Online consultation

The attack itself is treated in hospital, but a great deal remains around it that is convenient to sort out remotely. A doctor will go through your discharge summary and explain what its wording means, help you arrange the medicines into a routine you can realistically keep to, discuss side effects, look at your cholesterol results and advise on how to build up exertion and diet and when to go back to work. Acute chest pain is not assessed remotely: with that, an ambulance is called at once.

This material is for information only and does not replace medical advice.