heart attack

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n.
Sudden interruption or insufficiency of the supply of blood to the heart, typically resulting from occlusion or obstruction of a coronary artery and often characterized by severe chest pain. Also called myocardial infarction.

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Definition

A heart attack is the death of, or damage to, part of the heart muscle because its blood supply is severely reduced or stopped.

Description

Heart attack is the leading cause of death in the United States. Approximately every 29 seconds one American will have a heart attack, and once a minute one American will die from a heart attack. More than 1.5 million Americans suffer a heart attack every year, and almost half a million die, according to the American Heart Association. Most heart attacks are the end result of years of silent but progressive coronary artery disease, which can be prevented in many people. A heart attack is often the first symptom of coronary artery disease. According to the American Heart Association, 63% of women and 48% of men who died suddenly of coronary artery disease had no previous symptoms. Heart attacks are also called myocardial infarctions (MIs).

A heart attack occurs when one or more of the coronary arteries that supply blood to the heart are completely blocked and blood to the heart muscle is cut off. The blockage is usually caused by atherosclerosis, the buildup of plaque in the artery walls, and/or by a blood clot in a coronary artery. Sometimes, a healthy or atherosclerotic coronary artery has a spasm and the blood flow to part of the heart decreases or stops. Why this happens is unclear, but it can result in a heart attack.

About half of all heart attack victims wait at least two hours before seeking help. This increases their chance of sudden death or being disabled. The longer the artery remains blocked during a heart attack, the more damage will be done to the heart. That is why it is important to recognize the signs of a heart attack and seek prompt medical attention at the nearest hospital with 24-hour emergency cardiac care.

About one fifth of all heart attacks are silent, that is, the victim does not know one has occurred. Although the victim feels no pain, silent heart attacks can still damage the heart.

The outcome of a heart attack also depends on where the blockage is, whether the heart rhythm is disturbed, and whether another coronary artery supplies blood to that part of the heart. Blockages in the left coronary artery are usually more serious than in the right coronary artery. Blockages that cause an arrhythmia, an irregular heartbeat, can cause sudden death.

Causes & Symptoms

Heart attacks are generally caused by severe coronary artery disease. Most heart attacks are caused by blood clots that form on atherosclerotic plaque. This blocks a coronary artery from supplying oxygen-rich blood to part of the heart. A number of factors increase the risk of developing coronary artery disease.

Major risk factors significantly increase the risk of coronary artery disease. Those that cannot be changed are:

• Heredity. People whose parents have coronary artery disease are more likely to develop it as well. African Americans are also at increased risk, due to their higher rate of severe hypertension than whites.
• Gender. Men under the age of 60 years of age are more likely to have heart attacks than women of the same age.
• Age. Men over the age of 45 and women over the age of 55 are considered at risk. Older people (those over 65) are more likely to die of a heart attack. Older women are twice as likely to die within a few weeks of a heart attack than men. This may be because of other co-existing medical problems.

Major risk factors that can be changed are:

• Smoking. Smoking greatly increases both the chance of developing coronary artery disease and the change of dying from it. Smokers have two to four times the risk of non-smokers of sudden cardiac death and are more than twice as likely to have a heart attack. They are also more likely to die within an hour of a heart attack.
• High cholesterol. Cholesterol is a soft, waxy substance that is produced by the body, as well as obtained from eating foods such as meat, eggs, and other animal products. Cholesterol level is affected by age, sex, heredity, and diet. Risk of developing coronary artery disease increases as blood cholesterol levels increase. Total cholesterol of 240 mg/dL and over poses a high risk, and 200–239 mg/dL a borderline high risk. In LDL cholesterol, high risk starts at 130–159 mg/dL, depending on other risk factors. HDL (healthy cholesterol) can lower or raise the coronary risk also.
• High blood pressure. High blood pressure makes the heart work harder, and over time, weakens it. It increases the risk of heart attack, stroke, kidney failure, and congestive heart failure. A blood pressure of 140 over 90 or above is considered high. As the numbers increase, high blood pressure goes from Stage 1 (mild) to Stage 4 (very severe). When combined with obesity, smoking, high cholesterol, or diabetes, the risk of heart attack or stroke increases several times.
• Lack of physical activity. This increases the risk of coronary artery disease. Even modest physical activity is beneficial if done regularly.
• Use of certain drugs or supplements. Extreme caution is advised in the use of the herbal supplement ephedra. The supplement, which was marketed for weight loss and to improve athletic performance, was found to contribute to heart attack, seizure, stoke and death. In April 2003, the U.S. Food and Drug Administration (FDA) investigating controlling or banning the substance. While it was once believed that hormone replacement therapy (HRT) helped prevent heart disease in women, a large clinical trial called the Women's Health Initiative found the opposite to be true. In 2003, the FDA began requiring manufacturers of HRT to place warnings on the box listing adverse effects of estrogen, including increased risk of heart attack, stroke and blood clots. The labels also must mention that HRT should not be used as a preventive medicine for heart disease.

Contributing Risk Factors

Contributing risk factors have been linked to coronary artery disease, but their significance and prevalence are not known yet. Contributing risk factors are:

• Diabetes mellitus. The risk of developing coronary artery disease is seriously increased for diabetics. More than 80% of diabetics die of some type of heart or blood vessel disease.
• Obesity. Excess weight increases the strain on the heart, increases blood pressure and blood cholesterol, and increases the risk of developing coronary artery disease, even if no other risk factors are present. In fact, new research in 2002 shows that losing weight also reduces inflammation of the arteries in obese women, which is a risk factor equal to that of high cholesterol.
• Stress and anger. Some scientists believe that stress and anger can contribute to the development of coronary artery disease. Stress increases the heart rate and blood pressure, and can injure the lining of the arteries.

More than 60% of heart attack victims experience symptoms before the heart attack occurs. These sometimes occur days or weeks before the heart attack. Sometimes, people do not recognize the symptoms of a heart attack or are in denial that they are having one. Symptoms are:

• Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest. This lasts more than a few minutes, or may go away and return.
• Pain that spreads to the shoulders, neck, or arms.
• Chest discomfort accompanied by lightheadedness, fainting, sweating, nausea, or shortness of breath.

All of these symptoms do not occur with every heart attack. Sometimes, symptoms disappear and then reappear. A person with any of these symptoms should immediately call an emergency rescue service or be driven to the nearest hospital emergency room.

Diagnosis

Experienced emergency care personnel can usually diagnose a heart attack simply by looking at the patient. To confirm this diagnosis, they talk with the patient, check heart rate and blood pressure, perform an electrocardiogram, and take a blood sample. The electrocardiogram shows which coronary artery is blocked. Electrodes covered with conductive jelly are placed on the patient's chest, arms, and legs. They send impulses of the heart's activity through an oscilloscope (a monitor) to a recorder, which traces them on paper. The blood test shows the leak of enzymes or other biochemical markers from damaged cells in the heart muscle. In 2003, the FDA cleared a new test for ruling out heart attacks in people who come to emergency rooms with severe chest pains. It is the first new blood test for evaluation of heart attacks since 1994 and is used along with an electrocardiogram.

Treatment

Heart attacks are treated with cardiopulmonary resuscitation (CPR) when necessary to start and keep the patient breathing and his heart beating. Upon arrival at the hospital, the patient is closely monitored. An electrical-shock device called a defibrillator may be used to restore a normal rhythm if the heartbeat is fluttering uncontrollably. Oxygen is often used to ease the heart's workload or to help a victim of a severe heart attack breathe easier. If oxygen is used within hours of the heart attack, it may help limit damage to the heart.

Alternative therapies aim at preventing the progression of heart disease that leads to a heart attack. Changes in lifestyle can also prevent second heart attacks.

Herbal medicine offers a variety of remedies that may have a beneficial effect on coronary artery disease. Oats (Avena sativa), garlic (Allium sativum), and guggul (Commiphora mukul) may help reduce cholesterol; linden (Tilia europaea) and hawthorn (Crataegus spp.) are sometimes recommended to control high blood pressure, a risk factor for heart disease. Tea (Camellia sinensis), especially green tea, is high in antioxidants, which studies have shown may have a preventative effect against atherosclerosis. A 2003 study found that black tea may reduce the risk of a heart attack by as much as 43% and that black tea's protective effects are even greater in women than in men.

Nutritional therapies have been shown to prevent coronary artery disease and stop, or even reverse, the progression of atherosclerosis. A low-fat, high-fiber diet is often recommended. It is essential to reduce the amount of meat and animal products consumed, as they are high in saturated fats. Whole grains, fresh fruits and vegetables, legumes, and nuts are recommended. Vitamin and mineral supplements that reduce, reverse, or protect against coronary artery disease include chromium; calcium and magnesium; B complex vitamins; the antioxidant vitamins B and E; L-carnitine; and zinc. These protective effects even work in the elderly, according to a 2003 report. A study revealed that those age 65 and older who ate the most cereal and bread fiber were 21% less likely to develop heart disease than those who ate the least. They also were less likely to have a heart attack or stroke.

Yoga and other bodywork, massage, relaxation therapies, aromatherapy, and music therapy may also help by reducing stress and promoting physical and mental wellbeing. A 1996 study in the United Kingdom found that participants who practiced t'ai chi had a resulting lowering in blood pressure. By evoking the body's relaxation response through meditation and deep breathing, blood pressure, metabolic rate, and hearth rate can all be reduced.

Allopathic Treatment

Additional treatment after a heart attack can include close monitoring, electric shock, drug therapy, re-vascularization procedures, percutaneous transluminal coronary angioplasty and coronary artery bypass surgery.

Drugs to stabilize the patient and limit damage to the heart include thrombolytics, aspirin, anticoagulants, painkillers and tranquilizers, beta-blockers, ace-inhibitors, nitrates, rhythm-stabilizing drugs, and diuretics. Thrombolytic drugs that break up blood clots and enable oxygen-rich blood to flow through the blocked artery increase the patient's chance of survival if given as soon as possible after the heart attack. These include anisoylated plasminogen streptokinase activator complex (APSAC) or anistreplase (Eminase), recombinant tissue-type plasminogen activator (r-tPA, Retevase, or Activase), and streptokinase (Streptase, Kabikinase).

To prevent additional heart attacks, aspirin and an anticoagulant drug often follow the thrombolytic drug. These prevent new blood clots from forming and existing blood clots from growing. Anticoagulant drugs help prevent the blood from clotting. The most common anticoagulants are heparin and warfarin. Heparin is given intravenously while the patient is in the hospital; warfarin, taken orally, is often given later. Aspirin helps to prevent the dissolved blood clots from reforming.

To relieve pain, a nitroglycerine tablet taken under the tongue may be given. If the pain continues, morphine sulfate may be prescribed. Tranquilizers such as diazepam (Valium) and alprazolam (Ativan) may be prescribed to lessen the trauma of a heart attack.

Percutaneous transluminal coronary angioplasty and coronary artery bypass surgery are invasive revascularization procedures which open blocked coronary arteries and improve blood flow. They are usually performed only on patients for whom clot-dissolving drugs do not work, or who have poor exercise stress tests, poor left ventricular function, or ischemia. Generally, angioplasty is performed before coronary artery bypass surgery.

Percutaneous transluminal coronary angioplasty, usually called coronary angioplasty, is a non-surgical procedure in which a catheter (a tiny plastic tube) tipped with a balloon is threaded from a blood vessel in the thigh or arm into the blocked artery. The balloon is inflated and compresses the plaque to enlarge the blood vessel and open the blocked artery. The balloon is then deflated and the catheter is removed. Coronary angioplasty is successful about 90% of the time. For one third of patients, the artery narrows again within six months after the procedure. The procedure can be repeated. It is less invasive and less expensive than coronary artery bypass surgery.

In coronary artery bypass surgery, called bypass surgery, a detour is built around the coronary artery blockage with a healthy leg or chest wall artery or vein. The healthy vein then supplies oxygen-rich blood to the heart. Bypass surgery is major surgery appropriate for patients with blockages in two or three major coronary arteries or severely narrowed left main coronary arteries, as well as those who have not responded to other treatments. About 70% of patients who have bypass surgery experience full relief from angina; about 20% experience partial relief. Long term, symptoms recur in only about three or four percent of patients per year. Five years after bypass surgery, survival expectancy is 90%, at 10 years it is about 80%, at 15 years it is about 55%, and at 20 years it is about 40%.

Expected Results

The aftermath of a heart attack is often severe. Twothirds of heart attack patients never recover fully. Within one year, 27% of men and 44% of women die. Within six years, 23% of men and 31% of women have another heart attack, 13% of men and 6% of women experience sudden death, and about 20% have heart failure. People who survive a heart attack have a chance of sudden death that is four to six times greater than others and a chance of illness and death that is two to nine times greater. Older women are more likely than men to die within a few weeks of a heart attack.

New statistics released in early 2002 revealed that about half of all deaths from heart disease happen before the patient can get to the hospital. Women were slightly more likely than men to die quickly after cardiac arrest and the risk of dying quickly from heart disease increased with age, to 61% of those over age 85. The study authors said that improved prevention and recognition of the warning symptoms of heart attack could lower the number of sudden deaths.

Prevention

Many heart attacks can be prevented through a healthy lifestyle, which can reduce the risk of developing coronary artery disease. For patients who have already had a heart attack, a healthy lifestyle and carefully following doctor's orders can prevent another heart attack. A heart healthy lifestyle includes eating right, regular exercise, maintaining a healthy weight, no smoking, moderate drinking, no illegal drugs, controlling hypertension, and managing stress.

A healthy diet includes a variety of foods that are low in fat (especially saturated fat), low in cholesterol, and high in fiber; plenty of fruits and vegetables; and limited sodium. Saturated fat raises cholesterol, and, in excessive amounts, it increases the amount of the proteins in blood that form blood clots. Polyunsaturated and monounsaturated fats are relatively good for the heart.

Fat should comprise no more than 30 percent of total daily calories. In 2002, new evidence suggested that a diet rich in lutein, the pigment found in dark green leafy vegetables, helps artery walls fight plaque and lessens risk of heart attack.

Cholesterol should be limited to about 300 mg per day. Many popular lipid-lowering drugs can reduce LDL-cholesterol by an average of 25–30% when combined with a low-fat, low-cholesterol diet. Soluble fiber can also help lower cholesterol. Fruits and vegetables are rich in fiber, vitamins, and minerals, and they are low calorie and nearly fat free. Vitamin C and beta-carotene, found in many fruits and vegetables, keep LDL-cholesterol from turning into a form that damages coronary arteries. Excess sodium can increase the risk of high blood pressure, and daily intake should be limited to 2,400 mg—about the amount in a teaspoon of salt.

Regular aerobic exercise can lower blood pressure, help control weight, and increase HDL ("good") cholesterol. Moderate intensity aerobic exercise lasting about 30 minutes four or more times per week is recommended for maximum heart health, according to the Centers for Disease Control and Prevention and the American College of Sports Medicine. Three 10-minute exercise periods are also beneficial. Aerobic exercise—activities such as walking, jogging, and cycling—uses the large muscle groups and forces the body to use oxygen more efficiently. It can also include everyday activities such as active gardening, climbing stairs, or brisk housework.

Maintaining a desirable body weight is also important. About one quarter of all Americans are overweight, and nearly one-tenth are obese, according to the Surgeon General's Report on Nutrition and Health. People who are 20% or more over their ideal body weight have an increased risk of developing coronary artery disease. Losing weight can help reduce total and LDL cholesterol, reduce triglycerides, and boost relative levels of HDL cholesterol.

Smoking has many adverse effects on the heart. It increases the heart rate, constricts major arteries, and can create irregular heartbeats. It also raises blood pressure, contributes to the development of plaque, increases the formation of blood clots, and causes blood platelets to cluster and impede blood flow. Heart damage caused by smoking can be repaired by quitting—even heavy smokers can return to heart health. Several studies have shown that ex-smokers face the same risk of heart disease as non-smokers within five to 10 years of quitting.

Drinking should be done in moderation. Modest consumption of alcohol can actually protect against coronary artery disease. This is believed to be because alcohol raises HDL ("good") cholesterol levels in some patients. The American Heart Association defines moderate consumption as one ounce of alcohol per day—roughly one cocktail, one 8-ounce glass of wine, or two 12-ounce glasses of beer. Excessive drinking is always bad for the heart. It usually raises blood pressure, and can poison the heart and cause abnormal heart rhythms or even heart failure. Illegal drugs, like cocaine, can seriously harm the heart and should never be used.

High blood pressure, one of the most common and serious risk factors for coronary artery disease, can be completely controlled through lifestyle changes and medication. People with moderate hypertension may be able to control it through lifestyle changes and medication.

Stress management means controlling mental and physical reactions to life's irritations and challenges. Techniques for controlling stress include thinking positively, getting enough sleep, exercising, and practicing relaxation techniques.

Daily aspirin therapy has been proven to help prevent blood clots associated with atherosclerosis. It can also prevent heart attacks from recurring, prevent heart attacks from being fatal, and lower the risk of strokes. Surprisingly, a 2002 study found that aspirin therapy is underused by people at risk for heart attacks. Patients should consult their doctors before taking aspirin regularly.

Resources

Books

American Heart Association. 2000 Heart and Stroke Statistical Update. Dallas, TX: American Heart Association, 1999.

DeBakey, Michael E., and Antonio M. Gotto Jr. The New Living Heart. Holbrook, MA: Adams Media Corporation, 1997.

Notelovitz, Morris, and Diana Tonnessen. The Essential Heart Book for Women. New York: St. Martin's Press, 1996.

Periodicals

"Aspirin Underused to Prevent Heart Attacks, Strokes." Diabetes Week (January 28, 2002): 15.

Cerrato, Paul L. "Tea Consumption May Benefit Heart and Bone." Contemporary OB/GYN (January 2003):101.

"Drugs or Angioplasty After a Heart Attack?" Harvard Health Letter 22, no. 10 (August 1997): 8.

Evans, Julie, et al. "Popeye's Favorite for Strong-to-the-Finish Arteries." Prevention (January 2002): 108.

"First New Blood Test to Evaluate Heart Attacks." Biomedical Market Newsletter (January-February 2003):42.

"How Weight Loss May Protect Your Heart" Environmental Nutrition (March 2002): 1.

Kirn, Timothy F. "FDA Probes Ephedra, Proposes Warning Label (Risk of Heart Attack, Seizure, Stroke)." Clinical Psychiatry News (April 2003):49.

Marble, Michelle. "FDA Urged to Expand Uses for Aspirin, Benefits for Women." Women's Health Weekly (February 10, 1997).

"More on Anger and Heart Disease." Harvard Heart Letter. (May 1997): 6-7.

Mozaffarian, Dariush, et al. "Cereal, Fruit, and Vegetable Fiber Intake and the Risk of Cardiovascular Disease in Elderly Individuals." JAMA (April 2, 2003):1659.

Stephenson, Joan. "FDA Orders Estrogen Safety Warnings: Agency Offers Guidance for HRT Use." JAMA (February 5, 2003):537.

"Too Many Patients Never Make it to the Hospital Alive" Medical Letter on the CDC & FDA (March 31, 2002): 7.

Organizations

American Heart Association. National Center. 7272 Greenville Avenue, Dallas, TX 75231-4596. (800) AHA-USA1. http://www.americanheart.org

National Heart, Lung, and Blood Institute Information Center. P.O. Box 30105, Bethesda, MD 20824-0105. http://www.nhlbi.gov/nhlbi/nhbli.htm.

Texas Heart Institute Heart Information Service. P.O. Box 20345, Houston, TX 77225-0345. 1-800-292-2221. http://www.tmc.edu/thi/his.html.

[Article by: Paula Ford-Martin; Teresa G. Odle]

An episode of heart failure or the stopping of normal heart function; a coronary thrombosis. Symptoms of a heart attack include pain and pressure in the chest, which often spread to the shoulder, arm, and neck. Today, physicians tend to define heart attack in terms of muscle damage to the heart caused by oxygen deprivation.

Rocktron Heart Attack