Treatment and recovery after a heart attack

As soon as you arrive at the hospital with a heart attack, specific protocols are initiated. The priority is to determine what is happening and, when an artery is blocked, restore blood flow as quickly as possible to save heart muscle.

Initial emergency care focuses on stabilizing you.

The emergency team will check your vital signs, provide oxygen if needed, give medications for pain relief and order blood work. When a heart attack is suspected, the cardiology team is consulted about the next steps.

You may hear a lot of unfamiliar terminology during this process. Here is what some of it actually means.

Doing an electrocardiogram to figure out what is happening

Your evaluation may begin before you even reach the hospital. Paramedics will assess your symptoms and vital signs and may perform an electrocardiogram (ECG). An ECG involves placing small stickers called electrodes on your chest and limbs to record the heart's electrical activity. It does not hurt, and it does not send electricity into your body. Certain ECG changes can indicate that a coronary artery may be seriously or completely blocked and that you need treatment urgently. Once you arrive at the hospital, the emergency and cardiology teams may perform additional ECGs and a blood test measuring troponin. Troponin is a protein found inside heart muscle cells. When heart muscle becomes injured, troponin is released into your bloodstream. Together, your symptoms, ECGs, blood tests and other investigations help your healthcare team determine whether you are having a heart attack and what treatment you need.

Opening the blocked artery

STEMI (ST-elevation myocardial infarction) and NSTEMI (non-ST-elevation myocardial infarction) are two types of heart attack. The names describe ECG findings, rather than precisely measuring how blocked an artery is. Both involve heart muscle injury, detected through troponin blood tests. A STEMI usually signals an acutely blocked artery and requires urgent treatment; an NSTEMI is also serious and may need an invasive procedure.

If doctors determine that a coronary artery needs to be reopened urgently, you may be taken to a specialized hospital room called the Cardiac Catheterization Laboratory or the “Cath Lab.” It is a specialized procedure room equipped with X-ray imaging and everything the cardiology team needs to treat artery blockages. A cath lab may look somewhat like an operating room, but PCI is generally not open-heart surgery. A STEMI usually requires immediate reperfusion treatment. An NSTEMI may also require angiography and PCI, depending on risk and clinical findings.

Your healthcare team may include:

• an interventional cardiologist (a heart doctor specially trained to perform procedures inside the coronary arteries)
• specialized nurses
• cardiovascular/cath-lab technologists
• other healthcare professionals involved in your monitoring, medications and care

Additionally, you are usually awake, but you will receive local anesthetic to numb the area where the catheter enters, and medications may be given to help you relax and remain comfortable.

Finding the artery blockage, in the Cath lab

Before doctors can treat a blockage, they need to see exactly where it is. This is done with coronary angiography, sometimes simply called an angiogram. Instead of making a large incision in the chest, the cardiologist inserts a very thin, flexible tube called a catheter into an artery, most commonly through the wrist, and sometimes through the groin. The catheter is carefully guided through the blood vessels toward the heart. Contrast dye is then injected into the coronary arteries while X-ray images are taken. The dye makes the blood vessels visible on the screen, allowing the cardiologist to see:

• Where is the blockage?
• How severe is it?
• Are other coronary arteries narrowed too?

You may briefly feel warmth when contrast is injected, but you generally cannot feel the catheter moving through your blood vessels.

Reopening the artery

If the cardiologist identifies a blockage that should be treated immediately, they can often treat it during the same procedure. This treatment is called Percutaneous Coronary Intervention (PCI). PCI is a minimally invasive procedure used to reopen a narrowed or blocked coronary artery. A very small balloon is guided to the blockage through the catheter and then is briefly inflated, which helps open the narrowed area and restore blood flow. This part is called angioplasty.

Not every hospital has a cardiac catheterization laboratory available around the clock. For certain types of heart attacks caused by an acutely blocked coronary artery, if PCI cannot be performed quickly enough, doctors may sometimes use a medication called a fibrinolytic or thrombolytic. It is often referred to as a “clot-busting” medication. Rather than mechanically opening the artery with a catheter and balloon, this medication helps the body break down the blood clot that is blocking the artery. The medical team decides whether this treatment is appropriate based on factors such as the type of heart attack, how long symptoms have been present, how quickly PCI can be accessed and whether the person has conditions that make clot-dissolving medication unsafe. Clot-dissolving treatment may be used for eligible patients with STEMI when timely PCI is unavailable; it is not a treatment for NSTEMI.

Putting in a stent to keep the artery open

Opening up the artery is a great start to protect the heart, but to keep it open long-term, a stent is commonly placed during PCI. A stent is a tiny expandable mesh tube, and it is positioned inside the narrowed portion of the coronary artery and expanded. The balloon and catheter are then removed, while the stent remains permanently inside the artery to help keep blood flowing. Most modern coronary stents are coated with medication that slowly releases into the surrounding tissue to reduce the chance of the artery narrowing again. A stent treats a particular narrowing, but it does not remove atherosclerosis in other arteries or eliminate future heart attack risk. A stent can also become obstructed again.

Sometimes doctors discover that there are multiple severe blockages, that an important artery is affected in a particular way, or that the anatomy of the coronary arteries makes PCI less suitable. In these cases, doctors may recommend Coronary Artery Bypass Grafting (CABG). This is heart surgery and takes place in an operating room.

Your healthcare team may include:

• A cardiac surgeon
• Anesthesiologist
• Operating room nurses
• Perfusionists
• Respiratory therapists

Instead of opening the blockage itself, the surgeon uses healthy blood vessels taken from elsewhere in the body to create a new route around the blocked coronary artery. Think of a blocked road: PCI reopens the road, whereas bypass surgery builds another route around it. Each has its own advantages depending on various factors, such as timing and patient profile.