Nothing mild about it

Tuesday, June 3, 2008

Having a mild heart attack is like being a little bit pregnant. Dr. Frasier Crane, Kelsey Grammer’s alter ego, would have appreciated that using euphemisms doesn’t change reality. A heart attack means that part of the heart muscle has lost its blood supply, has died and has been replaced by scar tissue.

And sudden death doesn’t really care if the heart attack was mild or not. The most common reason people die in the midst of a heart attack or myocardial infarction is an electrical short circuit caused by heart muscle that has been irritated.

Classic television: The monitor puts out a high pitched wail. The doc reaches for the paddle. “Everybody clear, I’m read to shock” The patient bucks on the table and the camera zooms onto the monitor screen waiting to see the telltale sign of a regular heart beat.

Injured heart muscle causes injured electrical systems and can lead to ventricular fibrillation, where the heart jiggles instead of beats. No heart beat means no blood to the body, means sudden death.

The heart is a muscle just like any other in the body and has blood vessels that supply it with oxygen and nutrients to function. As opposed to arms and legs that can take a break when they get tired from lifting or running, the heart needs to keep beating.

Emergency departments have special plans to deal with chest pain patients. The patient is descended upon by doctors, nurses and techs. Lots of things happen at the same time until the diagnosis of an acute myocardial infarction is ruled out. Oxygen, monitors, EKGs, IVs, medications, people asking questions to find out what’s going on. Time is muscle. If part of the heart isn’t getting blood supply, that muscle will die and be replaced with scar tissue; end result a life long weaker heart.

There are a couple of key decision points. If the EKG shows a heart attack, then emergency heart catheterization to identify the blocked artery, followed balloon angioplasty and stent to open up the vessels and restore blood supply to the heart muscle. Not all hospitals have that technology available 24 ours a day. Clot busting drugs like TPA can also be used.

But if the EKG is normal, it doesn’t mean that all is well. Heart muscle that is irritated leaks chemicals that can be measured by blood tests. Troponin is the most commonly used chemical measured but there are others as well. The downside to the testing is that it takes awhile for the chemicals to build up. With heart muscle damage, it may take 6-12 hours to be able to measure an abnormal level of troponin in the blood stream .welcome to the limits of technology.

But back to Dr. Crane / Mr. Grammer. It may be that his “mid” heart attack meant that the EKG was normal but he ruled in. that is the blood tests showed chemical evidence of heart muscle damage. The what? Many patients will undergo heart catheterization to see what’s happening with the blood vessels. An echocardiogram may also be done to look at how the heart is beating, whether the walls are squeezing appropriately and how well the heart valves are working. Decisions need to be made whether to treat the patient with just medication or angioplasty and stent or even bypass surgery. It all depends upon the severity of the heart disease.

A heart attack is a big deal. Part of the heart muscle has died and can’t be replaced. Prevention is key by minimizing risk factors by keeping blood pressure, cholesterol and diabetes under control, and avoiding smoking. And one should never ignore chest pain. Delays in diagnosis may lead to a life long weakened heart and even sudden death. Nothing mild about that at all.

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