Treatment of an acute heart attack (myocardial infarction, MI) must be prompt and comprehensive. Medical therapy is used to stabilize the cardiovascular system and prevent or minimize long-term complications. This may include angioplasty and the use of thrombolytics or other priority medications for a heart attack.
Heart attacks need to be urgently treated because blockage of coronary arteries that supply blood to the heart causes an area of the heart muscle to begin to die—and longer blood flow insufficiency means more damage.
Call 911 immediately if you are having signs of a heart attack. Do not drive yourself to the hospital. You could lose consciousness while driving and get into an accident.
The first few hours after a heart attack are critical. Getting medical help as rapidly as possible is essential to preventing cardiac arrest, preserving heart muscle, and preventing further blood clots from forming. National guidelines recommend that the affected coronary artery be opened within 90 minutes for the best outcome.
If you arrive at the hospital with a possible heart attack, medical personnel will immediately check your vital signs (pulse and blood pressure) and prepare to deal with any apparent life-threatening conditions, such as ventricular fibrillation.
An electrocardiogram (ECG) and cardiac enzyme testing will also be performed. High-sensitivity cardiac troponin levels will likely be checked—they are the preferred biomarker fot myocardial injury (cardiac cell damage).
Treatment is started once a heart attack is suspected.
This can include:
- Aspirin is given to prevent further blood clotting
- Oxygen therapy
- Nitroglycerine to improve blood flow
- Chest pain treatment
Your healthcare team will also determine which type of heart attack has occurred:
- An ST-segment elevation myocardial infarction (STEMI), is when the ST-segment on the ECG is elevated, usually due to a complete blockage in a single coronary artery, known as the "culprit" vessel.
- A non-ST-segment elevation myocardial infarction (NSTEMI), when there is no ST-segment elevation on the ECG, and the blocked artery is likely to be one of several blockages, known as diffuse coronary artery disease or from intermittent blockage of a severely narrowed vessel.
Based on the diagnosis, the medical team will start treatment to restore blood flow through the blocked or partially blocked blood vessels. This may include a procedure or medications.
In the event of a STEMI or NSTEMI, immediate steps must be taken to unblock the artery, get blood flowing through it again as quickly as possible, and prevent damage.
One main treatment is a non-surgical procedure called coronary angioplasty, also called percutaneous coronary intervention (PCI). A thin tube with a balloon is threaded through a blood vessel to the blocked artery. The balloon is then inflated to push the clot against the artery wall to restore blood flow. A stent may be placed to keep the blood vessel open after the procedure.
With partially blocked blood vessels, PCI can also be beneficial, depending on the level of severity. About 32% to 40% of patients with NSTE acute coronary syndromes will have a PCI done at the hospital.
Coronary artery bypass grafting (CABG) may be considered for patients who are not candidates for PCI or who have cardiogenic shock. During this surgery, a healthy vein in your body is removed from elsewhere In the body and then re-connected in the affected area to bypass the blocked section and restore blood flow to the heart.
There are many medications that can be used during and immediately after a heart attack to stop the event and help prevent further damage to the heart.
This approach to treating an acute heart attack involves using medication to break up a blood clot. These powerful drugs, also known as thrombolytics or fibrinolytic agents, are only given in the event of a STEMI.7 They are given intravenously and nicknamed "clot busters" because they do just that—dissolve blood clots that are in the process of forming.
Thrombolytic therapy is most likely to be used for STEMI patients if angioplasty can't be performed or isn't a safe option. The best results are obtained if the medication is given as soon as possible after chest pain occurs, usually in less than 12 hours.
Tissue plasminogen activator (tPA) is the type of thrombolytic most often used to break up a blood clot during a heart attack.
The major side effect of thrombolytic therapy is bleeding, making it unsafe for patients at high risk of this complication, such as those who've had recent surgery, have a history of stroke due to brain hemorrhage, or have very high blood pressure.
Aspirin is the most commonly used antiplatelet. It reduces the stickiness of platelets, thereby making it difficult for blood clots to form or get bigger.
Heart attack patients are often treated with dual antiplatelet therapy, meaning that two types of antiplatelet agents are taken to prevent blood clotting. In addition to aspirin, your healthcare provider would prescribe a P2Y inhibitor such as clopidogrel, prasugrel, or ticagrelor.
You should discuss with your healthcare provider whether dual antiplatelet therapy is the right treatment for you.
Anticoagulants slow down your body’s ability to make clots. Given within the first 24 hours of an acute heart attack, these blood thinners help prevent clotting in your arteries and may lower the risk of long-term mortality.11
These drugs include:
- Coumadin (warfarin)
- Eliquis (apixaban)
- Xarelto (rivaroxaban)
Eliquis, Xarelto, and like drugs are sometimes referred to as novel oral anticoagulants (NOACs).How NOACs Stack Up to Traditional Blood Thinners
Beta-blockers significantly improve the survival of patients with MIs. These drugs are typically recommended beginning on the first day after a heart attack.
According to the American Heart Association, the beta-blockers most often prescribed after a heart attack are:12
- Lopressor, Toprol XL (metoprolol)
- Corgard (nadolol)
- Inderal (propranolol)
- Sectral (acebutolol)
- Tenormin (atenolol)
- Kerlone (betaxolol)
- Ziac (bisoprolol/hydrochlorothiazide)
- Zebeta (Bisoprolol)
- Betapace (sotalol)
Angiotensin-Converting Enzyme (ACE) Inhibitors
These drugs expand blood vessels and allow blood to flow more easily. ACE inhibitors have been shown to significantly improve the outcome of patients who have significant heart attacks or signs of heart failure, although they also can be beneficial in patients with less severe heart attacks.
ACE inhibitors are usually started during the first 24 hours after a heart attack.
- Lotensin (benazepril)
- Vasotec (enalapril)
- Altace (ramipril)
Statins appear to improve survival after a heart attack regardless of cholesterol levels, probably by reducing inflammation or stabilizing coronary artery plaques in some other way.
Most often, statins should be started before a heart attack patient leaves the hospital. Sometimes it's beneficial to begin them even sooner.
The primary statins are:
- Lipitor (atorvastatin)
- Lescol (fluvastatin)
- Mevacor (lovastatin)
- Livalo (pitavastatin)
- Pravachol (pravastatin)
- Zocor (simvastatin)
- Crestor (rosuvastatin)