Coronary Artery Disease/Myocardial Infarction

Your heart is an organ made up of muscle tissue that requires oxygen and blood to fuel its actions. The special blood vessels that feed the heart are called coronary arteries. They are so named because these vessels "crown" the heart. Coronary artery disease is a process of narrowing that occurs over time in these important vessels. This build-up of fats and plaques in arteries can exist and grow without any symptoms. Angina is a common warning sign of coronary artery disease.

What is angina?
Angina is described as a transient pain or discomfort due to a temporary imbalance between the demand for oxygen by the heart muscle and the ability of the coronary arteries to supply enough blood to meet that demand. Often angina is experienced during exertion which increases heart rate and blood pressure. As the narrowing in these blood vessels increase, the amount of exertion needed to cause anginal pain decreases. With severe coronary artery disease, angina can occur at rest. Symptoms of angina can be midsternal chest pain that is described as crushing, pressing, constricting, oppressing or heavy. It may radiate to one or both (more often the left) shoulders and/or arms. Neck, jaw, back and epigastric pain without midsternal chest pain can also be angina. It is a steady discomfort, most commonly lasting 2-15 minutes. It is usually relieved with rest and/or nitroglycerin tablets under the tongue or in spray form.

Heart attack (or myocardial infarction) occurs
when the demand of the heart muscle far exceeds the supply. It usually results from severe narrowing or complete blockage of a coronary artery and results in death of the heart muscle cells supplied by that vessel. Often the narrowing causes slowed blood flow through the artery which leads to the formation of a clot. This clot completely blocks the artery and a heart attack occurs. If this occurrence is caught early, "clot busting" drugs and "ballooning open the arteries" are common treatments to interrupt a heart attack. The usual symptom of an attack is the pressure or pain described above. Other associated symptoms include sweating, clamminess, lightheadedness, nausea, vomiting and shortness of breath. If this type of discomfort lasts for 2 minutes or more, emergency action should be initiated.

• Recognize the signals
• Stop activity and sit or lie down
• If pain persists for 2 minutes (unless otherwise instructed for known heart patients) or more dial 911 or go to the nearest hospital
• Do not drive!

The exception would be with a known heart patient with instructions from his physician to take nitroglycerin first.

Nitroglycerin acts by 1) dilating the coronary arteries and increasing the blood flow to the heart and 2) lowering blood pressure to allow the heart to work less hard. Since this drug lowers blood pressure, it should be given while the victim is lying or sitting. It usually produces a stinging sensation under the tongue and may cause a headache. Nitro may be inactivated by age and light. It is best to keep a fresh supply in a dark place and carry a few tablets in a small dark bottle. Even in known heart patients, if typical symptoms persist despite rest and nitro, an emergency plan should be followed.

At the hospital, the doctor may order ECGs and oxygen. Blood will be drawn to determine if any heart muscle damage has occurred. An IV will be started in order to infuse needed medications to either thin the blood, stabilize the heart or dilate the arteries. A cardiac catheterization may be recommended to actually visualize the vessels and pumping action of the heart.

Increasing knowledge about how hearts heal and more effective early treatment have shortened the length of enforced bed rest and quiet previously recommended following a heart attack. In the usual case where the remaining flow is good (or returned through angioplasty or bypass surgery), the healing process starts promptly. The portion of the heart muscle that is damaged is replaced by scar tissue. During this healing time, depending on your personal rate of recovery, the doctor will prescribe increasing activity. You will be able to walk to the bathroom, bathe and brush your teeth shortly after you transfer out of the intensive care unit. PCE's (progressive cardiac exercises) will also be started at this time. These exercises advance from low level activity and walking in the room to walking in the hallway and climbing the stairs should not be done for one hour after meals and isometric exercises are not done because of the increased workload they place on the heart. Exercises in the hospital are done while the patient is monitored, and blood pressure and heart rate are checked before and after activity. These exercises can be continued at home upon discharge. Check your radial pulse before and after walking or exercising. Check with your doctor or nurse for the limit your pulse can go up during exercise depending on the type of medication you are on. Please refer to exercise information materials for more specific exercise description.

Unacceptable sensations during exercise include chest pain, weakness, dizziness, indigestion, clamminess, and shortness of breath. If any of these symptoms occur, sit down and rest. Take medication if your doctor has prescribed it. If symptoms persist, go directly to the hospital, preferably via ambulance. Your return to work will depend on the amount of heart damage, recovery, complications, rehabilitation, type of job, financial situation and sick leave allowed. It is a decision ultimately made by the physician and can vary from several weeks to several months. Lifting is usually restricted to items less than 15 pounds for at least a month. Driving can usually be resumed within several weeks after discharge, but check with your doctor. Cardiac rehabilitation after a heart attack will be discussed with you and dietary instructions will be given. We hope to get you and your heart on the road to health!