Transcription:
Management of Heart Attacks (With Emergency Cardiac Intervention)

Melanie Cole (Host): Heart attacks caused by a blood clot that blocks one of the coronary arteries can be fatal. Prompt treatment is crucial. Here to talk about the management of heart attacks with emergency cardiac intervention is Dr. Kenneth Miller. He’s a cardiologist with Summit Medical Group. Welcome to the show, Dr. Miller. Tell us about some signs of an impending cardiac arrest, and give us the differences also with women and men when they are experiencing these symptoms.

Dr. Kenneth Miller (Guest): Sure. The classic symptom of a heart attack or an impending heart attack is discomfort in the chest. It often travels to the left arm, to the jaw, or to the upper back. Occasionally, the discomfort can just involve the jaw or the arm or the back and not the chest. Sometimes it can involve the upper abdomen. Other times, symptoms could be more atypical, such as shortness of breath, nausea or vomiting, or just the feeling of fatigue, or even a feeling of impending doom. Most people have symptoms that are fairly typical, but there’s a significant minority of patients that have relatively atypical symptoms. And women are more likely to have atypical symptoms than men. Diabetic patients are more likely to have atypical symptoms. A good rule of thumb is that if you’re feeling some sensation in your chest or thereabouts, or any of the other places I mentioned that you’ve never felt before, it’s a good time to be concerned and seek medical attention, often promptly. Some associated symptoms, one that I didn’t mention is sweating. If you’re sweating along with those other symptoms that I mentioned for no apparent reason, that is a suggestion that something could be wrong and you need medical attention.

Melanie: Dr. Miller, would there be symptoms two weeks before, three weeks before, anything that would send them to the doctor to see you before the actual arrest takes place?

Dr. Miller: Absolutely. Unfortunately, probably about 50 percent of patients who have heart attacks have no warning symptoms, or at least no warning symptoms that they have recognized as such. But the other half of patients will have warning symptoms. That can often be similar but more transient discomfort or any of the other symptoms that I mentioned. One sort of scenario that should really alert somebody is if they’re having any symptoms with activity. Previously, well-tolerated levels of activities, such as walking to the subway, doing housework, walking up and down stairs, if you are developing symptoms of chest discomfort, more breathlessness than usual or the arm, jaw, upper back scenario, and that’s happening with predictable levels of activity, and especially gradually decreasing levels of activity, that is a red flag, and it really warrants prompt evaluation. It’s much better to be cared for before the heart attack happens than during the heart attack.

Melanie: Absolutely. If we’re experiencing any of these symptoms, 911 the first call. If you were alone in experiencing these symptoms, calling 911 right away, what is it you do? Take it from there. We’ve called 911, whether it’s a loved one’s called or we have called ourselves, what happens next?

Dr. Miller: Somebody is experiencing symptoms like that and in other words, not just you’ve walked up the steps, you have a little twinge and you’ve gotten better. In other words, you’re sitting there watching TV, your chest starts to hurt, it’s not going away, you’re sweating. You call 911. An ambulance with trained personnel arrives, and you’re evaluated rapidly with history—in other words, eliciting the symptoms and examination, and most importantly, an electrocardiogram. The patient is then transported rapidly to the nearest facility. Often, the electrocardiogram can be transmitted to the emergency room physician so the tracing can be reviewed even before the patient arrives. That can speed the system that leads to the most effective care.

Melanie: Is it reversible in some victims if it’s treated within a few minutes? Is this something that you can sort of stop in its tracks? And then tell us what treatment, once they get to the emergency room and see a cardiologist such as yourself, then what happens?

Dr. Miller: Absolutely. That is one of the major advances in cardiology in the last 15, 20 years. Basically, when a patient arrives, the electrocardiogram is done. And again, it’s a combination of the electrocardiogram and the examination, the symptom complex. The emergency room physician determines that this is highly likely to be a heart attack. What a heart attack is is a sudden occlusion of a coronary artery with a blood clot. That occlusion results in a loss of blood flow to the heart muscle and injury often irreversible to the heart muscle if it is not reversed. The best acute treatment for that situation is to open up that artery as fast as possible. The first way that was done probably 25, 30 years ago, was with certain blood clot busting medication—streptokinase, tissue plasmagen activator, and medications such as that. Around the same time that those drugs were being developed, coronary angioplasty was developed. Eventually, the technology is converged, and people realized that the best way to open up an artery during a heart attack was directly with a balloon and now with a stent. Because of the availability of that technology, the knowledge that opening the artery promptly is the best way to treat these patients, that has become the treatment of choice for patients acutely having a heart attack.
When they arrive at the emergency room, and the determination is made rapidly that they have that problem, there is a process in place at hospitals that have this service. The operators are called, and they know to call the cardiologist on call. It’s a sort of procedure. That’s one of those things that I do. I’m on call for this, probably on the average 15 to 20 days a month. I’m on call for this a lot. I get called, and I’m immediately available. I come in. The staff that works in the facility that this is done comes in. Technologists, nurses, and anesthesiologists come in. Even if it’s a hospital without cardiac surgery, an ambulance crew comes in case the patient needs to be emergently transferred to another hospital. Very rapidly, I see the patient, speak to them, find out crucial information that needs to be attained before the procedure; brief examination, and then off to the cath lab, put on the table, sedated by the anesthesiologist, and then the procedure ensues to open the artery. The goal and the standard that facilities like this work by is that less than 90 minutes should have lapsed between when the patient comes through the door to the hospital until the first balloon inflation. The 90-minute door to balloon time, that’s sort of gospel in this endeavor.

Melanie: After the angioplasty, Dr. Miller, what is the post care? Back in the days, you’d lay in bed after a heart attack for a long time. Now, you get up right away, even the day of, and get them up. What about post care? What is your best advice for listeners post-cardiac arrest?

Dr. Miller: Again, this is not a cardiac arrest. This is a heart attack. A cardiac arrest sometimes complicates a heart attack. Some small subset of patients with heart attacks may present with a cardiac arrest. But most heart attacks are not cardiac arrest. There are other reasons to have a cardiac arrest besides heart attacks, but post heart attack, the patient, again, they have the stent put in, they are transferred to the intensive care unit. If everything is fine, they are monitored there for about 24 hours. There is certain testing done—usually an ultrasound on the heart to look at the heart muscle. The patient’s rhythm is monitored to make sure that there are no rhythm disturbances that could lead to a cardiac arrest. Blood work is obtained to make sure that there were no other associated symptoms; the cholesterol levels are measured. The patient is generally treated with certain medications that improve their prognosis as time goes on. There are several medications that are used. One class are certain blood thinners, aspirin, and medications like aspirin, which inhibit the platelets in the body, which are little blood cells that promote blood clotting. Patients are put on aspirin as well as one of several other anti-platelet drugs which are stronger. And those are standard therapy after a stent is put in. It prevents the stent from clotting off. Generally, most patients are put on cholesterol medications. And actually, by recent guidelines, even if the cholesterol isn’t elevated, everybody with coronary disease gets a statin drug. That is the current guideline. They may be put on other medications such as beta-blockers, which reduce the adrenaline input to the heart, and a class of medication called ACE inhibitors, angio-converting enzyme inhibitors, which also are plaque fighters. They improve the prognosis after a heart attack, as do beta blockers, and they allow the heart muscle to contract with less resistance. Those classes of medications are given because they improve the prognosis after heart attacks. Meaning, there have been studies done and event rates are reduced—events being death, recurrent heart attack, or need for further procedures. Most patients are put on these medications because they are greatly beneficial. Patients are referred to cardiac rehabilitation to get a jumpstart into an exercise program. Generally, if everything goes well, the patient will go home in about three days and subsequently followed in the office. Because I’ve been doing these emergency procedures for many years, if you look at my office roster on any given day, there’s always several patients that I met in this emergency setting. Basically, what you do is you monitor them for the problems. You monitor the effects of the medication. At intervals, you may reassess them with stress testing to see if any further blockages have developed. You may assess them with an ultrasound of the heart to look at the heart muscle. Some patients who’ve had a heart attack, if they’ve had a certain amount of damage more than moderate, may require a defibrillator placed to prevent them from succumbing to a cardiac arrest.
Even though we put these stents in, unfortunately not everybody ends up with a normalized heart muscle. Some patients still end up with weak heart muscle despite what you’ve done. It may have been much weaker if you would not put the stent in, but in certain situations, you need to check the heart muscle at three months to see if a defibrillator is needed. And then, on an ongoing basis, when a patient is stable, they’re seen, generally every six months, check cholesterol levels, check any potential side effects of the medication. Lifestyle change is one of the most important things is for patients to stop smoking. Smoking is the most hideous thing you’d do for your health. Everybody knows that, but unless you sort of do this every day, you can’t imagine how true it is. Every effort needs to be made for the patient to stop smoking. Unfortunately, despite heroic efforts, many patients cannot stop smoking. It is incredibly addictive and it’s very difficult to get patients to stop smoking. I would say we’re probably successful about 50 percent of the time. It should be better, but I think it’s the nature of the beast.
Patients are encouraged to lose weight and to exercise regularly. That, I think, we’re a lot more successful with. Of course, maintaining a healthy diet—low fat, high fiber, high fruits and vegetables, whole grain—that sort of thing.

Melanie: Thank you so much, Dr. Miller, for such great information. For more information, you can go to summitmedicalgroup.com. You’re listening to SMG Radio. I’m Melanie Cole. Thanks for listening.