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Myocardial infarction and unstable angina

Myocardial infarction (or heart attack) occurs from the blockage of one or several coronary
arteries. Coronary arteries supply the heart with oxygenated blood. Artery blockage occurs when an
atheromatous plaque within the artery ruptures and forms a thrombus (blood clot) around it.
Atheromatous plaques and thrombus will obstruct the blood flow to myocardial cells, depriving
them of oxygen and nutrients. Without blood supply, heart muscle cells die. If the heart is affected
during a large area of myocardium, it can cause death. Myocardial infarction requires immediate therapy
to restore the blood flow.
Angina is a type of chest pain that occurs when the myocardial blood flow is not enough, most
commonly occurs by decreasing the size of blood vessels (coronary arteries). Stable angina appears after
a certain effort or after a physical activity.
Unstable angina appears as:
- a change in expression of stable angina
- a chest pain that occurs in rest or in a minor exercise, chest pain can be severe and last longer or does
not respond to administration of nitroglycerin;
- the occurrence of angina in a person who had not such events in history.
Because unstable angina can progress to heart attack, it requires immediate treatment.
Chest pain is not present in all cases. In a recent study of 700 patients treated for myocardial
infarction, 47% were presented to the emergency room for other symptoms than chest pain. These
symptoms were: dyspnea (breathing impaired), dizziness, fatigue, weakness or abdominal pain. Women,
diabetics or the elderly were feeling retrosternal pain in a lesser percent and more frequently than other
symptoms.

Protocol for myocardial infarction


If a person suspects a heart attack and was prescribed nitroglycerin, it is advisable to administer a
nitroglycerin pill. After 5 minutes, if the pain does not respond or it is getting worse, call the emergency
services.
If there is a heart attack or unstable angina and weren`t prescribed nitroglycerin, present to the
emergency room or call the ambulance. It is important to start treatment quickly.
If you cant call the ambulance, present to the emergency room. It is not advisable to drive the
car in this state, except if there are no other alternatives. Do not wait to see if the symptoms will pass,
because this option can be fatal.
Each year about 40% of myocardial infarctions are fatal, and of which more than half of deaths
occur in the emergency room or before reaching the hospital.

After you call the ambulance, chew an aspirin. A recent study showed that those who were taking
aspirin during a heart attack, after another month had a lower risk of dying because of complications due
to attack or stroke than those not taking aspirin.
Unstable angina can lead to heart attack or cardiac arrest (heart stopping). In case of suspicion of
unstable angina there are recommended the same measures as for myocardial infarction.

Causes
The main cause of both, unstable angina and myocardial infarction, is coronary artery disease.
Coronary heart disease occurs when atheromatous plaques appear along the internal walls of the
coronary arteries and thus reduces blood flow to the heart. The majority of coronary heart disease begins
in adolescence and develops over the years.
Elevated cholesterol, hypertension, smoking and damaged arteries contribute to plaque
formation. The process of forming plates is called atherosclerosis. Are plaque deposits of cholesterol,
calcium and other substances covered by a fibrous capsule? If you experience a sudden disturbance in
blood pressure, the artery will contract suddenly but if other factors are present (as inflammation),
fibrous capsule of the plaque may break or crack.
The body will try to repair that crack in the same way as a skin lesion will repair by forming a
thrombus on the surface of the capsule. Formed thrombus may completely obstruct the artery, blocking
blood flow to heart muscle and thus cause heart attacks. Newly formed plaque has the highest risk of
rupture. Fibrous capsule of a newly formed plaque is more likely to break or crack (more unstable) than
an older thicker capsule plaque.
Plaques are not always a reason for myocardial infarction. In some cases, rarely, coronary spasm
and contracture, can completely obstruct blood flow and cause heart attacks. Most often, in these cases,
all atherosclerosis is involved, but there are cases in which other factors produce spasm. Cocaine, cold
weather, emotional stress can cause episodes of arterial spasm. In many other cases it is unknown the
cause of these spasms.
Thrombus formed on a ruptured or fissured plaque, may not be large enough to block the artery
completely, but can decrease blood flow in that artery vascular territory, causing unstable angina.
Unstable angina may be a sign that would follow a heart attack, because that thrombus may grow in size
and completely artery obstruction. If the thrombus is dissolved, a heart attack will soon be avoided and
the body will try over time to repair the damaged capsule plaque. Also, a freshly repaired plaque can be
unstable. The probability of rupture is high again, making it an important risk factor for a new heart
attack.

Precipitating factors
In many cases it is not known certainly which are the causes of a heart attack.
Sometimes the body releases adrenaline and other hormones into the bloodstream in response to
some intense emotions like anger, fear.
Physical exertion, emotional stress, sleep deprivation and overnutrition can also be precipitating
factors. Adrenaline increases heart rate and blood pressure and coronary spasm can cause things that can
cause the rupture of unstable plaques.
Cocaine and nicotine, which can be found in tobacco products, can produce similar effects.

Symptoms
Most common symptom of heart attack is severe chest pain, although this feeling is not always
present.
In some cases, silent myocardial infarction occurs without symptoms, but this is rare.
Most people with retrosternal pain and heart attacks have at least one of the following symptoms:
- Shortness of breath, throat foreign body and always feel the need to swallow;
- Cold sweats;
- nausea;
- Sensation of imminent death;
- Shortness of breath or inability to breathe;
- Palpitations or feeling that the heart beats rapidly and irregularly (palpitations are a common symptom
in healthy people too, but they can signal a coronary artery disease);
- Numbness or discomfort in the hand or arm.
People who have had myocardial infarction described the chest pain in several ways.
Pain can be described in the following forms:
- Feeling of pressure, weight, pressing, squeezing, discomfort, burning, sharp pain (less common) or
confusing pain, people usually put his fist on his chest when asked to describe the pain;
- Can radiate from the chest in the left shoulder and left hand (most common site of irradiation) or in
other regions, including the back, upper abdomen and right hand;
- Can be scattered, the exact location of pain is usually difficult to determine;
- Does not improve by a forced breath or chest tightness;
- Usually starts with a low intensity and increases in intensity over several minutes to a maximum.
Discomfort may be intermittent. Chest pain that reaches maximum intensity within seconds can be a
sign of another disease, aneurysm of aorta.
Indicated call to emergency services when:
- Chest pain worsens or does not disappear during 5 minutes, especially if associated with impaired
breathing, nausea or impaired consciousness;
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- Chest pain does not improve or worsens within a 5 minutes after administration of netroglicerina.
The difference between unstable angina and myocardial infarction may not be always easy. The
symptoms are often similar. Both conditions require emergency treatment.
People who have unstable angina pain were described with the following characteristics:
- Debut in the last two months and rising over time;
- Frequency of pain of 3 or more times per day;
- Suddenly increases its intensity, becomes more frequent, lasts longer and is caused by a lower activity
than in the past;
- Occurs when resting, without being precipitated by exercise or stress, may awaken the person from
sleep;
- Does not respond to nitroglycerin.
Stable angina symptoms are different from those of unstable angina. Stable angina occurs in a
predictable time after a particular exercise or activity and may have the same character over a long
period of time, even years. Pain is relieved by rest or nitroglycerin administration and lasts at least 20-30
minutes.

Risk Factors
Coronary heart disease is the leading cause of myocardial infarction in all nearly cases. Therefore
the more risk factors there are for coronary artery disease, the greater will be the risk of unstable angina
or myocardial infarction. Smoking, diabetes, high cholesterol, hypertension and a family history of heart
disease are important factors for coronary artery disease.
Even if coronary disease is already present or there is a history of myocardial infarction the risk of
developing a heart attack can be diminished.
To reduce risks are indicated:
- Stop smoking: Stopping smoking is probably the most important step to decrease the risk of a heart
attack;
- Reduction of serum cholesterol: high cholesterol can cause cholesterol to build structures inside
arteries;
- Reduce blood pressure: high blood pressure increases the labor damaging of the coronary arteries, thus
the hearts need for blood will increase and the arteries already damaged can not provide more blood
- Diabetes treatment: people with diabetes develop a thickening of arteries and a decrease in size more
frequently and at a younger age than those without diabetes; keeping blood glucose (blood glucose
value) within normal limits slows these processes;
- Maintaining an optimal weight: weight loss improves blood pressure and serum cholesterol levels and
may also help control diabetes;
- Regular physical activity: regular exercise reduces the risk of heart attack by helping control serum
cholesterol, blood pressure, regulates blood sugar levels (important in people with diabetes) and
supports weight loss;
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- Treatment of depression and emotion control: treatment of depression and emotional disorders are
important steps in improving cardiac function and quality of life;
- Reduce stress: in periods stressfull periods blood pressure increases along with the heart rate, which
can cause narrowing of arterial size and increased risk of heart attack;
- Assessing the effects of birth control pills and hormone therapy: hormone replacement therapy
(estrogen and progesterone) increase the risk of heart disease, birth control pills increase the risk of heart
disease if the woman is over the age of 35 years old and is a smoker;
- Daily administration of aspirin (to indicate call your doctor before starting aspirin no contraindications
to aspirin).
Some risk factors cant be controlled. They are:
- Family history (family members who have had the disease) of heart disease, particularly if the disease
occurred in men younger than 55 years and women under 65;
- Age and sex: the number of people affected by heart disease increases with age after 45 years, in men,
and 55, in women; also men and women have different risk factors.
Levels of homocysteine and a specific gene mutation may also increase the risk of heart attack,
although more studies are needed to fully understand the role of these factors in heart disease. Some
tests, to highlight these risk factors, may be necessary in some people, especially those who had a heart
attack at young age, but are not recommended for daily use.
High levels of C-reactive protein, a substance found in blood that indicates inflammation, may
have a greater predictive value for heart attack than cholesterol levels. Two studies based on C-reactive
protein levels and treatment with statins, have shown that C-reactive protein levels may predict risk of
heart attack, even when the person has normal or low levels of LDL-cholesterol. Studies have shown
that both C-reactive protein test and cholesterol can prevent a greater extent in heart attacks.

Call a Doctor
Emergency presentation to the doctor is indicated when one of the following signs of heart attack
are present:
- Chest pain that does not improve or gets worse within 5 minutes after administration of nitroglycerin
and / or rest; after his rescue call it will also be given a nitroglycerin; if it does not reduce chest pain in 5
minutes is will be given one more nitroglycerin (can manage up to three doses of nitroglycerin to 5
minutes or up to 3 doses in 15 minutes); after he called emergency call will continue to receive
instructions from the controller;
- Chest pain or discomfort that is annoying and appears as a feeling of pressure on the chest that gets
worse or lasts more than five minutes, especially if associated with:
- sweating;
- Breathing disorders;
- Nausea or vomiting;
- Pain that radiates to the neck, jaw, in one or both shoulders or arms;
- dizziness;
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- Irregular pulse, fast.


After you call the ambulance is advisable to chew an aspirin, unless the cases when the aspirin is
contraindicated, for example, allergies to aspirin or gastric ulcer.
In that they go by ambulance to the hospital, treatment will begin again during the road and the
ambulance staff is trained for providing first aid, evaluation and treatment if complications arise.
If a person becomes unconscious will call the emergency and begin CPR. The operator from
performing emergency number can guide resuscitation.
Never expect if a heart attack is suspected. Many people are unsure whether it is or not heart
attack and wait for some time.
Heart attack symptoms can be variable. Usually symptoms do not count unless you enter the
scenario "extreme pain". Some people feel embarrassed or do not want to bother with that call for help,
if they believe they would have a heart attack. Even if symptoms do not definitely indicate a heart
attack, it is very important to consult your doctor.
Rapid treatment can save lives.

Investigations
Evaluation of emergency heart attack
In the ambulance, doctor or nurse will assess heart rate, blood pressure, respiratory rate and will
place electrodes on the chest to perform an ECG (electrocardiography). ECG is a graphic recording of
electrical activity of the heart and contraction and relaxation.
After reaching the emergency room, the doctor will make history, will perform a physical exam
and will make another ECG. ECG can detect heart disorders, signs of circulatory failure, heart muscle
damage, abnormal heart beating.
A nurse will harvest blood and there will be conducted blood tests for cardiac enzymes, that are
released into the blood when heart cells are injured. Troponima enzyme present in blood, usually shows
a cardiac lesion.
The test results are quickly available. If tests indicate high risk of heart attack or stroke in
evolution, the patient will be transferred in cardiac catheterization laboratory.
Cardiac catheterization involves inserting a fine tube through an artery in the arm or leg to the
heart. Iodine is then injected, which will make possible to visualize coronary arteries on a screen. The
doctor will see if the arteries are blocked and how the heart works.
If an artery appears blocked, angioplasty will be an installation of a stent, a process which
unlocks the blocked artery. This procedure can be performed during catheterisation or may indicate
coronary bypass performed by a cardiovascular surgeon.
If the tests do not clearly indicate a heart attack or unstable angina and are not present other
indicators of risk (such as another heart attack in history) will probably make another investigation, the
scan myocardial infused (SPECT). SPECT is a noninvasive imaging investigation and can be performed
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since the emergency room to assess whether the risk of heart attack is high. If the SPECT test is
abnormal, the patient will be considered high risk and will require cardiac catheterization.
If the test does not indicate a heart attack, but the doctor thinks it is an unstable angina, the
patient will be hospitalized for monitoring.

Investigations conducted after heart attack


After 2-3 days of hospitalization after heart attack or hospitalized for unstable angina, further
investigation will be conducted to assess how well the heart works and to determine whether unaffected
heart areas are suitable infusioned.
These tests include:
- Cardiac ultrasound: this is an investigation that evaluates the size, thickness, shape and movement of
the heart muscles; it also assesses the flow of blood and heart valves;
- Stress Electrocardiogram: a stress test will compare the ECG during the rest period with the one after
stressing the heart, either through physical activity (biking or climbing stairs) or by using drugs; a stress
test will detect ischemia,which represents the reducing of the blood flow to the myocardium;
- Stress echocardiography: it determines whether there is reduced blood flow to the heart;
- Heart perfusion scan: scanning with thallium or technetium is used to estimate the amount of blood
reaching the myocardium at rest and after exercise;
- Angiogram: This test involves injecting a contrast agent in order to assess coronary heart and coronary
arteries.

Treatment
In case of a heart attack in progress, it is necessary to intervene immediately.
Prompt treatment with drugs, angioplasty combined with stents installation or surgical
procedures to restore blood flow after the onset of symptoms, may prevent permanent damage to the
myocardium and may save your life.

Initial treatment
The goal of therapy during a heart attack is to prevent permanent damage by restoring blood flow
to heart muscles as quickly as possible. During transport to hospital by ambulance will be given oxygen,
nitroglycerin and probably a strong painkiller like morphine. In addition may be given aspirin, heparin
or other antiplatelet agents to prevent the increase in size of thrombi. Other drugs may be administered
to reduce cardiac labor, improve heart pump function and prevent abnormal heart rhythms that can be
fatal.

Time until reaching the hospital is very important, because angioplasty and / or the assembly of
stents to open blocked arteries and thrombolysis lumen which dissolve thrombi are more effective in the
early hours of the onset of symptoms. Thrombolytics are administered intravenously and will flow
through blood to the level of the coronary arteries where they will dissolve the thrombi.
Numerous studies have shown that angioplasty with or without a stent installation, save about 20
lives for every 1,000 patients treated, compared to treatment with thrombolytics. Although angioplasty
with or without a stent mounting is the preferred therapeutic procedure, it is not available in all hospitals
and needs to be done in the first 12 hours after the onset of symptoms. It is therefore important that the
ambulance personnel to recognize a heart attack and transport the patient to the nearest center that has
the means to intervene in these cases, even if it will go to the nearest hospital.
If the treatment is done in a hospital that has the necessary facilities for such cases, the patient
will undergo a cardiac catheterization and angioplasty indicate determine whether or coronary bypass
surgery. If angioplasty with or without stent mounting is not possible, either because the location of the
blockage or due to a larger number of blocks, will help you do a surgery and coronary bypass.
In the case of unstable angina, treatment consists of hospitalization and administration of aspirin,
heparin or other antiplatelet agents (drugs that prevent formation of thrombi). The patient will be closely
monitored and will perform various tests. If symptoms do not resolve after initial treatment and the risk
of heart attack is considered high, there will be a coronary catheterization and angioplasty probably
install a stent to prevent heart attack.

Ongoing treatment
After a heart attack patient will be hospitalized for at least several days, they will be monitored:
heart rate, blood pressure, effects of drugs. Shall be made in this period several EKG's
(electrocardiografii). Monitoring after heart attack is necessary because during the next attack are
common complications, such as potentially fatal arrhythmias or heart failure.
Medicines used to prevent complications agents will be administered fairly quickly after heart
attack. Angiotensin inhibitors and beta-blockers can prevent heart failure and arrhythmias (abnormal
heart beats). Drugs that lower cholesterol levels (statins) are given for lowering the LDL-cholesterol (a
formation of atherogenic cholesterol) below 70 milligrams / deciliter or lower amount.
A recent study on a large number of patients, demonstrated that administration of drugs that
lower cholesterol levels, reduce the risk of heart attack in a period of five years in people at high risk, eg
those who have had a heart attack in history.
Aspirin and other antiplatelet drugs such as clopidogrel or ticlopidine can be administered after a
heart attack. These drugs reduce the risk of a heart attack and prevent the formation of thrombi in the
cavities of the heart, the clot can break off and can get into the brain causing a stroke.
The proportion of irreversibly damaged heart tissue may be lower than expected after a heart
attack. Certain portions of the myocardium may be affected temporarily, they will not shrink, but in time
they can resume function. Heart pump function will be closely monitored and treatment will be adjusted
as needed during this period.
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Recent studies have demonstrated the importance of quitting smoking after a heart attack. People
who continue to smoke have a risk 1.5 times higher to develop a new heart attack than those who do not
smoke. In people who quit smoking after a heart attack, the risk gradually decreases in the next 36
months, until it becomes equal to that of non-smokers.
If people smoke, the doctor will recommend stopping smoking and in some cases may
recommend certain medications or therapies to facilitate this. Studies have shown that nicotine
replacement therapy with another substance such as bupropion and supportive therapies to stop smoking
increased long-term rate.
Your doctor may indicate some changes in lifestyle, such as performing physical activity or
dietary changes.

Treatment if the condition gets worse


Heart attack that damaged a large portion of the myocardium is likely to give higher late
complications than a heart attack with minimal damage. If only a small part of the myocardium is
affected (muscle death), the heart will continue to operate normally after a heart attack.
Scars will replace damaged myocardial areas while following a heart attack. Scars will limit the
ability of the heart to work effectively as a pump. Injuries in the left ventricular pump function alters
heart. In this case will receive angiotensin inhibitors or beta-blockers to prevent heart failure.
If the stroke affects the area which is responsible of the heart rate (responsible for initiating and
conducting the electrical impulses of the heart), will produce arrhythmias. In this case you may need to
install a pacemaker, a device that will stimulate the heart and will adjust the rate or administration of
drugs that regulate heart rate. Arrhythmias may increase the risk of stroke.
Laughter of developing these complications depends on the damaged myocardial tissue during
heart attack and taking drugs to prevent them. Other factors such as age and health, can also influence
the risk of complications or death.
After a heart attack it is indicated for patients to participate in a rehabilitation program to reduce
death risks due to heart disease. Rehabilitation and lifestyle changes are an important part of recovery
after a heart attack.

Medications
Unstable angina medications
Some drug agents prevent thrombus formation, reduce the risk of unstable angina to heart attack
to evolve and reduce the death risk. These agents are aspirin and other antiplatelet agents (clopidogrel or
ticlopidine).

Aspirin
Mode of action
Aspirin takes effect rapidly (approximately in 15 minutes) and prevents thrombus formation,
reduces the risk of heart attack or stroke. All types of aspirin are equally effective.
Indications
Aspirin may be given:
- During a heart attack, in which case it will be chewed (do not swallow it entirely);
- In people with stable angina;
- The treatment of unstable angina;
- In people with heart disease to reduce the risk of heart attack;
- In people older than 50 years, healthy, but have one or more risk factors for cardiovascular disease;
- After bypass or angioplasty surgery;
- To people who have had a stroke, a transient ischemic attack or had undergone a surgery to prevent a
stroke (carotid endarterectomy).
Effectiveness
Studies have shown that people who have an increased risk of coronary artery disease or who
already have coronary heart disease benefit most from this therapy. A recent study showed that in people
older than 65 years, with heart failure and coronary heart disease, death rate is significantly lower if
aspirin is taken regularly.
Aspirin may reduce symptoms in unstable angina.
In people with low risk of cardiovascular disease, the benefits of aspirin therapy may be
exceeded by the increased risk of bleeding present in this therapy.
Side effects
Side effects of aspirin include:
- Gastritis (inflammation of the gastric mucosa)
- Gastrointestinal bleeding
- Allergic reactions
- Increased frequency of hematomas (blood clots) and bleeding in the brain or other internal organs.
Note!
Some doctors believe that people who have one or more risk factors for coronary artery disease
should take aspirin every day. Others believe that taking daily aspirin for a long time increases the risk
of disease or stomach bleeding, if hypertension is associated and it is not treated.
Experts recommend the administration of the 75-160 mg of aspirin per day. Aspirin tablets on the
market are 500 mg. It is advisable to call your doctor before starting daily aspirin administration.
Because aspirin reduces the ability to form blood clots, its administration can be discontinued at
least 5 days before surgery or dental procedure that involves bleeding.
Recently studies have been conducted to determine whether administration of nesteriodiene
inflammatory (eg ibuprofen) in some way interfere with aspirin's ability to prevent heart attack. Studies
have had mixed results, not drawn any conclusion. Today doctors recommend administration of aspirin
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at least 2 hours before taking non-steroidal anti-inflammatory to reduce the likelihood that the two drug
agents to interact.
Other antiplatelet
Examples of platelet aggregation:
- Clopidogrel (Plavix)
- Ticlopidine (Ticlid).
Mode of action
These drugs agents work in several ways to prevent formation of thrombi (blood clots).
Indications
Antiplatelet medication is used in people with unstable angina or heart attack and those with
angina who underwent angioplasty.
Ticlopidine and clopidogrel are administered to people who cant take aspirin or for whom
aspirin is not sufficient to prevent thrombus formation. These drugs are administrated at least for a
month, in some cases even more, after mounting stents on coronary arteries. These drugs are used in
combination with aspirin to prevent clots in arteries that have stents.
Effectiveness
Ticlopidine or clopidogrel reduce the risk of a heart attack or stroke than aspirin alone more
effective in people with coronary artery disease. A recent study showed that taking aspirin in
combination with copidogrel in patients with unstable angina or heart attack, reduces the risk of death,
the occurrence of another heart attack or stroke in 20% of cases.
If that is administered after angioplasty, a recent study showed that clopidogrel administration
before surgery and continuing for another eight months, reduced the risk of death or another heart attack
in about a third of the patients, compared with administration on a shorter period (4 weeks).
Side effects
Side effects of platelet aggregation are:
- Intracerebral hemorrhage or other organs;
- Bleeding of the stomach or intestines;
- Bruises that appear frequently;
- Gastric irritation;
- Allergic reactions;
- Thrombocytopenia (low platelet count), low number of white blood cells (neutropenia), low number of
red blood cells (anemia).

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Note!
All agencies with a role antiplatelet drug increases the risk of bleeding.

Anticoagulants
- Heparin
- Enoxaparin (Levenox)
- Deltaparin (Fragmin).
Nitrates (nitroglycerin)
Some medicinal agents that reduce cardiac labor, improve blood flow to the heart and relieve
chest pain are given to individuals with unstable angina who are at risk of heart attack. These drugs
include nitrates (nitroglycerin).
Examples of nitrates:
- Nitroglycerin
- Isosorbit dinitrate
- Isosorbine moninitrat.
Nitrates are in the form of pills or spray that is sublingual sprayed. They can also take the form
of patches or paste that is applied to the skin. In emergencies, such as during a heart attack nitrates will
be administered intravenously.
Mode of action
Nitrates dilate coronary arteries, increase blood flow, relieve pain and reduce labor chest heart.
Indications
Nitrates prevent and treat angina. They can be used:
- During episodes of angina
- Before activities that can cause angina (sexual activity or climbing stairs)
- In long-term administration to prevent angina that occurs in daily activities.
Forms of sublingual administration are useful to treat episodes of angina. Pills or patches that
have long action are used to prevent retrosternal pain occurred during the daily activities.
Effectiveness
Nitrates are useful in relieving the retrosternal pain, but don`t reduce the risk of death in patients
with heart attack.
Advantages of nitroglycerin
- Act fast
- Is easily managed, either sublingually or intravenously
- The effects disappear within 24 hours.
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Side effects
Side effects of nitrates are:
- Feeling a pulsation or congestion in the head (the most common adverse effect) or headache
- Sudden drop in blood pressure that can cause a feeling of dizziness
- Sublingual burning (in sublingual administration).
Note!
Different types of nitrates are often given in combinations. Tablets, patches or paste can be
managed with sublingual nitroglycerin to relieve and prevent angina. Some people develop a tolerance
to nitrates when they are administered consistently and over a long period of time. Tolerance occurs
when drugs lose their effectiveness and seems to have no effect. Your doctor may indicate a time of
nitroglycerin administration, for example it would be administered 12-18 hours and 6-12 hours will not
be covered to prevent the nitroglycerin tolerance.
If the patient continues to have episodes of angina despite the medication (beta-blockers or
calcium channel blockers), at the treatment it will be added long lasting nitroglycerin.
Even if the pain releases after the administration of nitroglycerin, the patient will have to go to
the doctor. If angina episodes are becoming more frequent and last longer, it is necessary to call your
doctor to adjust medication.
If nitroglycerin compounds are old or almost at the end of validity, it is probably that they have
not an adequate effect. Tablets should be changed at every 3-6 months.
Potency enhancement drugs are contraindicated (Viagra) in people who are under the
administration of nitroglycerin. The combination of these two substances can cause a sudden drop in
blood pressure, sometimes life-threatening. In case the potency enhancement substances were
administered and an episode of angina occurs, it is indicated to consult a doctor and to mention the
substances administered, to prevent making a nitrate therapy.
Beta-blockers
Examples of beta-blockers:
- Atenolol
- Metoprolol
- acebutolol
- Carvedilol
- Labetalol
- propranolol
- Timolol
- Penbutolol
- Pindolol.
Mode of action
The body responds to stress after a heart attack or unstable angina by increasing heart rate and
blood pressure. Beta-blockers slow the heart rate and reduce labor.
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Indications
Beta-blockers reduce heart rate, blood pressure and heart labor. If heart labor is low, myocardium
will require less oxygen to function. Beta-blockers are used in combination with other medications to
treat heart attack in progress.
Effectiveness
Beta-blockers given within hours of the onset of a heart attack reduce the risk of death and
recurrence of the attack.
Side effects
Adverse effects of beta-blockers are:
- Fatigue, dizziness and insomnia feeling
- Impotence (erectile disorder)
- Decrease blood flow to the hands and feet, which will cause a sensation of cold at these levels and
increased pain in the calf muscle during physical activity (intermittent claudication).
In people with diabetes, beta-blockers may increase blood sugar. They can also cover the
symptoms of hypoglycemia, such as the change in pulse.
Note!
Beta-blockers administered during and after a heart attack appear to reduce the risk of death.
Studies have shown that beta-blockers should be administered at least 6 months after a heart attack, in
order to have maximum benefits.
Administration of beta-blockers can interfere with other diseases. For example: asthma, heart
failure, diabetes and certain types of arrhythmias.
Administration of beta-blockers should be interrupted if these conditions will get worse or if
side effects occur and they can not be controlled. In case of food allergies, medications or insect bites,
concomitant administration of beta-blockers may worsen symptoms of these allergies and these will be
harder to treat.
Dizziness are more common in the early beta-blocker therapy or when doses increased. This
symptom can also be increased in combination with alcohol or after spending a long time in hot water. It
is indicated that the rise from a lying position to make slow. If disorders continues take a medical advice.
Do not suddenly stop taking beta-blockers. The risk of heart attack increases if beta-blockers are
stopped suddenly.
Beta-blockers tend to diminish blood flow to the hands and feet, and so they will be more
sensitive to low temperatures. It is advisable to take several precautions such as thick dressing and avoid
spending a long period in cold weather.

Other therapeutic agents

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In some cases, can be used other therapeutic agents:


- Inhibitors of glycoprotein IIb / IIIa, which helps prevent thrombus formation in people with high risk
of heart attack or requiring angioplasty
- Calcium channel blockers, which are given in cases where beta blockers are contraindicated
- Angiotensin converting enzyme inhibitors, used to control blood pressure and reduce heart labor.

Therapeutic agents used in heart attack


Therapeutic agents used during heart attacks acts to restore blood flow more quickly and to
reduce heart labor.
To unblock arteries are used:
- Aspirin and other antiplatelet
- Anticoagulantii (heparin)
- Inhibitors of glycoprotein IIb / IIIa (where angioplasty is needed)
- Thrombolytics.
Thrombolytics dissolve thrombi and other agents prevent their growth.
Oxygen, nitrates and beta-blockers act by decreasing heart labor and thus reduce the cantity of
oxygen needed myocardium.

Therapeutic agents used after heart attack


After heart attack, the administration of ACE inhibitors and beta-blockers prevent the heart
failure and arrhythmias, which can occur after a heart attack.
Anticoagulants, along with aspirin and other antiplatelet agents may be used after stroke to
prevent thrombus formation in the heart cavities and stroke.
Beta-blockers, ACE inhibitors and drugs, that lower the cholesterol levels (statins), are important
in preventing a heart attack.
After installing a stent to dilate an artery, the doctor will indicate the administration of
clopidogrel. This drug prevents stent blockage due to a clot.
Nitrates can be used to control symptoms of angina Rasta.
Note!
Aspirin does not replace other NSAIDs such as ibuprofen or naproxen. Although NSAIDs relieve
pain and inflammation like the aspirin, they may increase the risk of heart attack or stroke.
COX-2 enzyme inhibitors (cyclooxygenase), such as rofecoxib and valdecoxib were withdrawn
from use because studies have shown that they increase the risk of heart attack, stroke and severe
gastrointestinal bleedings. Celecoxib it is still in use, but it's still studying its side effects.

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Surgery
In some occasions, surgical procedures involving coronary artery bypass is performed in
conditions of emergency treatment for heart attack. The coronary bypass is performed when the heart
attack can be effectively treated by drug therapy or angioplasty procedures.
For example, you will perform coronary bypass if the blockage is at the level of an artery that
can not be addressed by angioplasty or in cases where angioplasty was performed, but results were not
satisfactory.
Also bypass procedures are recommended in patients with diabetes. Studies have shown that
coronary bypass reduces death rate in patients with diabetes and heart attack, compared to those treated
with angioplasty or thrombolytic therapy.
Note!
In cases where after the heart attack was affected also the heart valves muscles (muscles that
keep the valves in position), will make repairations or replacements of the valves during surgery for
coronary bypass.

Other treatments
In the last decade, angioplasty, which is also called percutaneous coronary intervention, has
become the most appropriate therapeutic procedure to treat heart attacks. Angioplasty is done during
cardiac catheterisation or coronary angiogram.
Studies have shown that angioplasty with a stent assembly, reduces the risk of recurrence of
artery narrowing and perhaps reduce the risk of death, compared to angioplasty without stent assembly.
Angioplasty with stent installing process is a less invasive procedure than bypass surgery and is the
preferred therapy for most patients with heart attack.
In some cases a heart attack cause damage to large areas of the myocardium, so that will be
affected the ability of the heart pump. For these cases we recommend to place a pacemaker (device that
stimulates the heart), this therapeutic procedure is recommended especially in patients with abnormal
heart rhythm.
Note!
Even after stents installation, the diameter of coronary arteries can narrow, although the materials
and methods used in the last period increased long-term success rate of angioplasty with stent mounting.
Although study results are inconclusive, it is assumed that treatment with folate (folic acid
combinations, vitamin B6 and vitamin B12) is harmful after installing the stents, and probably will be
avoided. Instead of taking nutritional supplements containing vitamins B, it must be chosen a proper diet
which contain optimal amounts of these vitamins.

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Mortality after heart attack


Although treatment of heart attack rate is becoming more successful in prolonging life and
reducing complications, there are cases in which stroke can cause fatal progressive disease like heart
failure or arrhythmias. Decisions regarding the fatal situations should be taken since the time the person
is active and able to communicate with others.
After diagnosis of a heart attack your doctor will determine the possible treatment options.
Cardiovascular resuscitation will be taken if it is the case or it will be useing aggressive methods to
maintain vital functions.
The decisions regarding a fatal situation must be taken before the begining of the situations that
can affect life, as for example the writing of the will.

Prophylaxis
The number of heart attacks decreased in the recent years, as the number of deaths from heart
attacks. This is largely due to measures taken to prevent coronary disease population, such as
diminishing blood pressure, serum cholesterol, dietary changes and new habits including physical
activity.
The most important measures to be taken are stopping smoking and regular physical activity
performance. It also recommended a diet rich in fruits and vegetables and low in saturated fat.
Lifestyle changes involve:
- Stop smoking
- Control of serum cholesterol
- Control blood pressure
- Physical activity
- Methods of relaxation and reducing stress
- Methods of therapy of depression and anger.
Some doctors recommend a diet that includes vitamins such as B6, B12 and folic acid. These
vitamins reduce homocysteine serum levels (those with elevated homocysteine levels have an increased
risk of heart attack). It hasn`t been certainly demonstrated if vitamin B supplements prevent heart attack.
Most doctors recommend that vitamin B should be taken from food and not as dietary supplements.
Cholesterol
Elevated serum cholesterol levels increase the risk of coronary heart disease. If the diet and the
exercise will not achieve an optimal level of serum cholesterol, your doctor will prescribe statins, which
lower the cholesterol level. These drugs have proven their efficacy in treating elevated cholesterol levels,
and are currently widely prescribed by doctors worldwide.
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Recent studies have shown that these drugs may be beneficial in people with normal or
moderately elevated levels of serum cholesterol. To these people, medicinal agents decrease serum
cholesterol levels in combination with lifestyle changes, slow process of atherosclerosis and reduce the
risk of heart attack and death.

Aspirin
Aspirin therapy reduces the risk of thrombus formation that can cause a heart attack in people
with coronary artery disease or those with multiple risk factors for coronary artery disease (diabetes,
hypertension, elevated serum cholesterol levels). Before starting therapy with aspirin, consult a doctor
because there are some risks of this therapy. If aspirin is contraindicated, the doctor may prescribe
another antiplatelet medicine, such as clopidogrel Plavix.
Hormone therapy subtitutie
It was once considered that hormone subtitutive therapy (estrogen and progesterone) decreases
the risk of heart disease. Now the opposite has been demonstrated. The risk of heart attack doubles in the
first year of hormone replacement therapy and risk at 6 years is about 24% higher than in women who
are not subject to hormonal therapy subtitutive.
Although the total risk of hormone therapy is not very high, doctors don`t recommend its
continuation for a period longer than a few years and then will be given hormones only if needed, during
the menopause (hot flashes, feeling for sudden heating and night sweats).
It is assumed that hormone replacement therapy also increases the risk of breast cancer,
dementia or other health problems, but also has benefits.
Precautions
After a heart attack, the biggest concern is the possible appearance of a new attack. Correct use
of medications can have an important role in preventing a heart attack. Prescribed drug agents after a
heart attack include substances with role in:
- Prevention of thrombus formation
- decreased cardiac labor
- Improving the pump function of heart
- Lowering serum cholesterol
- Treat arrhythmias
- Lower blood pressure
After the heart attack it is important to closely observ the patient. Visits to the doctor must be
taken. It is important to inform your doctor about the changes that appears in the patient's symptoms
(retrosternal pain, dyspnea, depression and loss or gain weight).
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About half of patients who had a heart attack will develop a serious complication. The
compilation type depends on the location and extension of myocardial injury.

The most common complications are:


- Arrhythmias (abnormal heart rhythms): can be ventricular tachycardia (rapid heart rate) and atrial
fibrillation (irregular heartbeat)
- Heart failure, which can be temporary or may be permanent.
Angina therapy
If after a heart attack occur chest pain episodes or discomfort (angina), call immediate a doctor,
because you may need aggressive treatment. These episodes may indicate a new heart attack. Stable
angina diminished under nitroglycerin treatment and at rest.
It is recommended to always have on hand nitroglycerin tablets. Some doctors recommend
taking nitroglycerin before physical activity to prevent episodes of angina.

Lifestyle after heart attack


Some people seem restless after discharge, and time spent in hospital may be too short. This
anxiety may be caused by lack of supervision by trained personnel. Investigations carried out before
leaving the hospital were the doctor who indicated that he was sure that the patient can continue a
normal life.
To reduce the risk of a heart attack your doctor may recommend:
- Stop smoking, may be the most important step in reducing the risk, there is evidence that people with
coronary disease who do not smoke, reduces the risk of recurrent heart attack or death
- Daily administration of aspirin or antiplatelet medication another if aspirin is contraindicated
- Lowering serum cholesterol levels with drugs such as statins or other drugs that lower serum
cholesterol level
- Control blood pressure with prescription drugs, certain nutrients in the diet can influence blood
pressure
- Diet that includes fish in large quantity, the fish diets may be useful in weight loss, decreased blood
pressure and cholesterol
- Reduce stress: there is evidence that reducing stress can influence the rate of heart attacks or deaths
caused by heart attack in people with coronary artery disease
- Participation in cardiac rehabilitation programs, the patient is taught in these programs to change habits
that increase heart attack risk, manage stressful situations or strong emotions
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- Drinking alcohol in moderation (1-2 glasses of wine a day maximum), decreases the risk of
complications from a heart attack, in a recent study, middle-aged men, alcohol consumption in amounts
moderate to significant reductions in complications associated with a period of four years, some
associates say that is not proven link between wine consumption and reduce the severity of coronary
artery disease
- Affection to loved ones, a person who had a heart attack may be scared, and depression can be
common in these individuals. Support loved ones can avoid depression. If the emotional state does not
improve after stroke is important to call your doctor about it. A recent study showed that people who
have been treated for depression after heart attack had a better recovery than those who were not treated
(long-term survival but not affected).
Before beginning physical activity after a heart attack is indicated for the doctor to perform
certain tests to determine the risk of a heart attack.
One of the most common myths that refer to sexual activity would cause a heart attack, a stroke
or death. According to medical recommendations sexual activity can be resumed whenever the patient
feels able to do so.

Medical specialists recommend


- Emergency doctor: will assess and treat stroke in the emergency room
- Cardiologist: for outpatient treatment
- Cardiovascular surgeon: If you require surgery.

Evolution and healing heart


In ordinary cases, when blood flow that remaines in coronary arteries is good, healing begins
quickly. The portion of heart muscle that has suffered permanent damage will be replaced by a scar.
Myocardial infarction can leave some sequelae, which are variable and depend on:
infarct size;
if it is a first heart attack or a relapse;
status of completely coronary artery.
Sequelae may be minimal in the following cases: many patients agree to stop smoking, to
exercise, lose weight, and after a few months after stroke recover very well.
There is also possibility of sequelae:
heart failure that causes difficulty breathing;
persistence of angina pectoris;
the occurrence of cardiac arrhythmias.
These problems must be identified as quickly as possible - their appearance after a heart attack
must guide you to your cardiologist doctor! Depending on the results, it will adapt the treatment.
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Convalescence and rehabilitation


Each person recovering from acute myocardial infarction has two main purposes:
developing a recovery plan for its capacity to live a life as close to normal;
Control risk factors that can reduce stroke recurrence.
In the absence of complications, patients should not stay in bed more than 12 hours. Daily
activity should be resumed gradually, individually, depending on overall condition, age and physical
ability of the patient.
Stage 1 (days 1-2)
During the first day the patient stay in bed, being able to feed themselves using a table-support.
He will receive full support for toilet. With help, will perform passive movements of the arms and legs.
In the next day, the patient may sit on the bed or a chair for 1-2 hours a day. He (she) is able to
actively move hands / feet for 5-10 minutes a day.
Stage 2 (days 3-4)
Patient may make its toilet and may dreesed-up, but keeping the sitting position. You can sit on a
chair or sofa as often as desired, and can walk through the room.
On the fourth day, the patient can take a shower or sitting upright (use a chair to reduce anxiety
and fear of falling). Rides of 50-100 m under surveillance several times a day.
Stage 3 (days 5-7)
Patient may walk about 100 m 3 times a day. You can shave or wash the head (activities
involving lifting arms overhead). It can climb / descend stairs under surveillance.
Usually best results are obtained when the recovery program involves more people. Family
should be understanding and to actively participate in the patient program. But overly protective family
or those who are having too high expectations of rapid recovery may delay its progress. The doctor is
showing gradual increase in activity, exercise and treatment.

Discharge
Discharge time varies depending on the patient's condition, the types of treatments. Before
discharge, patients receive clear recommendations about treatment, diet and physical activity allowed.
Some of the activities that were previously possible may be limited after stroke. However, for most
patients is possible adaptations, and so you could resume an active life satisfactorily, including resume
services, where appropriate.

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Recommendations at discharge
Initially, it is important to avoid physical exertion, lifting, to rest several times a day. Over time
you can do more activities, and depending on how you support them.
You should avoid any activity that will produce anginal chest pain!
It is important to always have on hand nitroglycerin tablets, which use them if necessary.
A long-term plan will include ways to reduce risk factors that could lead to recurrence of
myocardial infarction.
It is essential to stopping smoking! In patients who do not smoke, over the coming years
significantly decreases the risk of heart disease.
Proper diet is also important. It includes decreased intake of fat and cholesterol. First you have
reduced fat intake from meat and dairy. Adding fruits and vegetables to food is good. In some cases,
lower blood cholesterol requires the use of drugs. In hypertensive patients, should be reduced while the
use of salt.
Exercise and physical activity in general is an extremely important factor for recovery from
myocardial infarction. It is important to ask your doctor about the level of exercise that you can achieve.
You will be linked with cardiac rehabilitation specialists who will guide this. Under their supervision,
the cardiac rehabilitation department, your physical activity will be monitored and guided to a better
physical recovery. Discuss this with your doctor without your inhibitions.
Sexual activity may be resumed only after a stress test at the hospital. It is considered that sexual
activity can be resumed when the patient can climb two floors with no problems.
Other key measures to be taken to decrease cardiovascular risk in the future are: control of
hypertension, diabetes and dyslipidemia (if present), weight control and avoiding stress. After a heart
attack or angina condition is not enough to take drugs. They can be ineffective if not fight against risk
factors: obesity, smoking, diabetes mellitus, hypertension, dyslipidemia, sedentary!
Drug treatment you will receive at discharge should be followed long term. It will contain
several classes of essential medicines, which should not be interrupted without the doctor.
Any adjustment of dose or dosage regimen should be made only with the doctor!

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Contents
Myocardial infarction and unstable angina...................................................1
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Protocol for myocardial infarction.................................................................1


Causes..........................................................................................................2
Symptoms.....................................................................................................3
Risk Factors...................................................................................................4
Call a Doctor.................................................................................................5
Investigations...............................................................................................6
Evaluation of emergency heart attack.......................................................6
Investigations conducted after heart attack..............................................7
Treatment.....................................................................................................7
Initial treatment.........................................................................................7
Ongoing treatment.....................................................................................8
Treatment if the condition gets worse........................................................9
Medications................................................................................................9
Therapeutic agents used after heart attack.............................................15
Surgery....................................................................................................16
Other treatments.....................................................................................16
Mortality after heart attack......................................................................17
Prophylaxis.................................................................................................17
Lifestyle after heart attack.........................................................................19
Medical specialists recommend..................................................................20
Evolution and healing heart........................................................................20
Convalescence and rehabilitation............................................................21
Discharge.................................................................................................21

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