Although there is some overlap, care provided to a heart attack patient can be divided into three settings:
- Prehospital (outside the hospital and in the hospital emergency department)
- Hospital (inpatient care, including the coronary care unit)
- Convalescent (recovery and rehabilitation)
Care provided in the prehospital and hospital settings focuses on:
- Relief of distress, including chest pain and anxiety
- Limiting the size of the heart attack (i.e., the area of heart muscle that dies)
- Reducing the work of the heart
- Preventing and treating complications of a heart attack
Since not everyone who comes to the hospital with chest pain has had a heart attack, it's important to establish an accurate diagnosis quickly. This is done based on information obtained from the personal health history, physical examination, and diagnostic tests.
In contrast, convalescent care, including cardiac rehabilitation, focuses more on restoring the ability of an individual to function normally, or as close to normally as possible, following a heart attack. This care usually begins during the hospital stay and continues after the person has returned home.
Prehospital And Emergency Department Care
Prehospital care refers to care provided outside the hospital and in a hospital emergency department by early-responder rescuers, such as police, firefighters, and paramedics, as well as emergency personnel. The focus of this care is rapid intervention and may include
- defibrillation to restore normal heart rhythm
- thrombolytic drugs to dissolve the blood clot
Because 50 to 60 percent of deaths from a heart attack occur within the first several hours, prompt treatment is essential.
Clot-dissolving (thrombolytic) drugs are used to break up a blood clot in a
- Reduce the size of the heart attack
- Improve heart function
- Reduce the risk of death
Although the cause of the chest pain is not always clear, someone with severe chest pain is treated as though they have suffered a heart attack until proven otherwise. More tests are done once the patient reaches the hospital.
At The Hospital
Once at the hospital, the following are begun to help in the rapid assessment of the individual and the provision of early treatment.
- Placement of an intravenous (IV) line: This involves placing a small tube or catheter into a vein to permit the IV administration of fluids and medications.
- Beginning continuous electrocardiographic (ECG) monitoring: This permits continuous monitoring of the heart's electrical system to screen for abnormal heart rhythms called arrhythmias.
- Obtaining a 12-lead electrocardiogram: A 12-lead electrocardiogram (ECG) will also be obtained upon arrival at the emergency room followed by sequential (repeat) ECGs for monitoring and diagnostic purposes.
- Administration of medication to dilate (widen)
arteries, if appropriate: Nitroglycerin can be used to relieve pain and improve blood flow if the blood pressure and heart rate are stable. Nitroglycerin will also relieve coronary artery spasm, which causes four percent of acute heart attacks.
- Provide adequate pain relief. If pain is not sufficiently relieved with nitroglycerin (or nitroglycerin administration is not appropriate), morphine is used to relieve pain.
- Administer oxygen through a face mask or nasal tubes.
- Stabilize blood pressure and heart rhythm: If necessary, intravenous (IV) fluids or medications can be given to prevent or treat abnormal heart rhythms, low blood pressure, or other complications.
- Draw blood to determine cardiac enzymes: This involves obtaining a blood sample to look for increased levels of certain cardiac enzymes, which indicate the presence of damage to heart muscle.
- Administer aspirin, if appropriate. Aspirin prevents blood clot formation and should be started in the emergency department and continued indefinitely, barring any contraindications.
- Evaluate and administer thrombolytic drugs or clot busters, if appropriate. Thrombolytic drugs can break down or lyse a blood clot blocking a coronary artery and allow blood flow to a region of heart muscle to be restored. This can reduce and even prevent muscle damage and improve outcomes.
- Evaluate for signs of complications from heart attack. Physical examination and diagnostic tests will help detect evidence of any complications.
In addition to the events, the emergency doctor also evaluates the individual to help make a diagnosis and determine appropriate treatment. This involves obtaining a brief personal health history and performing a physical examination.
The patient or a family member is asked about
- The location of the pain. Where did the pain start? Has it spread to other areas?
- The character or quality of the pain. Is the pain dull or sharp? Is the pain steady or intermittent?
- The intensity of the pain. How severe is the pain? How would you rate it on a scale of 1 to 10, with 10 being the most severe pain you have ever experienced?
- The duration of the pain. How long has the pain lasted?
- The frequency of the pain. Has the pain occurred before and if so, when and how often?
- Other factors. What were you doing when the pain started? Does anything make the pain better or worse?
The doctor also asks about:
- Previous and current health problems
- Risk factors
- Past history of heart disease
- Habits, including use of cigarettes, alcohol, or "recreational" drugs
- Current medications (prescription drugs, over-the-counter drugs, and herbal remedies)
- Allergies (especially to medications)
- Past and current health problems of family members
These questions are directed at identifying specific risk factors for coronary artery disease and help distinguish between a heart attack and some other condition.
Not everyone who goes to the emergency room with chest pain is admitted to the hospital. But if there is a reasonable chance that the pain is due to a heart attack or other serious condition, the person is admitted.
Depending on the level of care needed, he or she may go to
- The coronary care unit (CCU)
- Another unit with a monitored bed that has the capability for continuous ECG monitoring, often called a "step-down unit."
The step-down unit is more appropriate for lower-risk patients who may not have had a heart attack. Patients can be transferred between locations as needed.