Dr. David L. Brown, of Medical City Dallas Hospital and Baylor Regional Medical Center at Plano, discusses types of heart attack.
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In the movies, when someone has a heart attack, that person clutches his chest or arm and falls to the ground. Some people have exactly that experience. But it’s also important to know that
- Not all heart attacks have the same symptoms or severity, and
- Heart disease is the number one cause of death for women as well as men.
If you’ve had a heart attack, you know firsthand that Hollywood misses a lot of the details, including the hard physical and emotional work it takes to recover afterward.
Ultimately, the seriousness of the heart attack is judged by the amount of heart muscle that is permanently damaged. Your cardiologist will assess this damage through use of echocardiography, which is an ultrasound of the heart. Treatment of a heart attack will depend on the type and severity of the heart attack.
Several types of heart attacks are discussed below, as well as non-heart-related sources of chest pain. Remember, if you are experiencing symptoms of a heart attack, dial 911. Just because heartburn, for example, can produce some of the same symptoms doesn’t mean you should assume it is the less serious cause rather than the more serious condition. Every minute you delay if it is a heart attack could result in permanent heart muscle damage or increased risk of death.
STEMI Heart Attacks
An ST-segment elevation myocardial infarction (STEMI) is a serious form of heart attack in which a coronary artery is completely blocked and a large part of the heart muscle is unable to receive blood. “ST segment elevation” refers to a pattern that shows up on an electrocardiogram (EKG).
This type of heart attack requires immediate, emergency revascularization which restores blood flow through the artery. This revascularization is achieved either with drugs in the form of thrombolytics (clot busters), which are given intravenously, or mechanically with angioplasty – a treatment using thin, flexible tubes called catheters to open the closed artery.
These catheters are positioned at the beginning of the coronary arteries (the arteries of the heart), and contrast dye is injected through them to enable the interventional cardiologist to gather images of any blockage in the coronary arteries. Very thin wires (guidewires) are then advanced beyond the blockage and the clot is sucked out and/or a small balloon is opened to push the blockage out of the way. A stent– a metal, mesh tube – is often inserted at the same time to permanently prop the cleared artery open to allow blood to flow through.
NSTEMI Heart Attacks
A non-ST segment elevation myocardial infarction (NSTEMI) is a type of heart attack that does not show a change in the ST segment elevation on an electrocardiogram and that results in less damage to the patient’s heart. However, these patients will test positively for a protein called troponin in their blood that is released from the heart muscle when it is damaged. In NSTEMI heart attacks, it is likely that any coronary artery blockages are partial or temporary.
Treatment for an NSTEMI heart attack consists of medication and evaluation for whether a blockage is present that should be treated with medication only, cleared through angioplasty or treated with cardiac bypass graft surgery.
Coronary Artery Spasm
A coronary artery spasm is when the artery wall tightens and blood flow through the artery is restricted – potentially leading to chest pain, or blood flow is cut off all together – causing a heart attack. Coronary artery spasm comes and goes. Because there may not be a build-up of plaque or a blood clot in the artery, a coronary artery spasm may not be discovered by an imaging test called an angiogram that is typically performed to check arteries for blockages.
Treatment for a coronary artery spasm consists of medications such as nitrates and calcium channel blockers.
Demand ischemia is another type of heart attack for which blockages in the arteries may not be present. It occurs when a patient’s heart needs more oxygen than is available in the body’s supply. It may occur in patients with infection, anemia, or tachyarrhythmias (abnormally fast heart rates). Blood tests will show the presence of enzymes that indicate damage to the heart muscle.
Cardiac Arrest (not a heart attack)
In cardiac arrest, a person’s heart stops beating. Cardiac arrest is not the same thing as a heart attack, but it is worth discussing alongside heart attack. Cardiac arrest can occur due to a heart attack, but cardiac arrest can also occur as a primary event. In other words, cardiac arrest can also occur for other reasons besides a blockage in the artery. These other reasons include electrolyte disturbances, such as low or high potassium or low magnesium, congenital abnormalities, or poor pumping function of the heart.
In a heart attack, a person’s heart keeps beating. A heart attack can cause life-threatening arrhythmias (abnormal heart rhythms), like ventricular tachycardia (VT) or ventricular fibrillation (VF). These arrhythmias result in cardiac arrest within a few minutes because the heart is not pumping blood to the lungs to pick up vital oxygen that circulates back to the heart and to the body.
Seconds count in treating both heart attack and cardiac arrest. With cardiac arrest, the odds of survival go down by about 10 percent for every minute until the person is resuscitated. After 10 minutes the risk of permanent brain injury is very high.
Initial treatment will consist of cardiopulmonary resuscitation (CPR) and defibrillation – delivery of an electrical shock to restore the heart’s rhythm. For people who are resuscitated and have a heartbeat but do not regain consciousness, hypothermia protocols are sometimes used, where the body is cooled for 24 hours then gradually warmed. This has been shown to improve the odds of a good neurological outcome for those patients.
Non-Heart-Attack Sources of Chest Pain
There are many medical conditions that can mimic a heart attack. Some of these are a sign of something urgent, and others are not. Remember, if you are experiencing symptoms of a heart attack, dial 911. A few possible non-heart-attack causes of chest pain are described below. Your physician can help you identify the cause of any chest pain.
Angina is chest pain caused by a lack of blood flow to the heart due to narrowed or blocked heart arteries. Most commonly it is the result of coronary artery disease (CAD). Angina occurs when the heart is not getting as much blood and oxygen as it needs to pump. Angina that occurs with increasing frequency, with decreasing levels of physical activity, at rest or that is not relieved with rest is called unstable angina. Unstable angina requires immediate attention because it can be the first sign of a heart attack. In unstable angina, blood work that assesses for damage to the heart muscle is negative, indicating no heart attack (yet). Generally, at rest, there is still some blood flow beyond a severe blockage, and so there has not been damage to the heart.
Angina that occurs with exercise and is relieved with rest is called stable angina. In stable angina, the stimulus that causes the chest pain is relatively stable and reproducible. For instance, a patient with stable angina may report that he or she gets chest pressure with walking ten minutes on the treadmill, that the chest pressure is relieved with rest, and that the symptoms have been relatively stable for the past several months. Additionally, the patient may report that he or she can easily do some activities at home, such as walking one mile slowly, but that increasing the level of exercise by walking faster brings on chest pain.
The chest pain is a sign that blood flow to the heart is being restricted by build-up of plaque (a fatty substance) in the coronary arteries that supply blood to the heart. While a patient with stable angina is not likely to be at immediate risk for a heart attack, the condition does need to be treated. Medications and lifestyle changes will be part of treatment. If the angina is very painful, the patient may consider angioplasty to reopen the narrowed arteries or cardiac bypass graft surgery to reroute blood flow around the blocked blood vessels.
Broken Heart Syndrome (Takotsubo Syndrome)
Now, physicians know that there is something behind the folk idea of a broken heart. Occasionally, a person may arrive in the emergency room with the symptoms of a heart attack, including the presence of cardiac enzymes in the blood that indicate damage to the heart muscle, as well as abnormalities on an electrocardiogram (EKG). However, no blockages will be discovered in the arteries that supply blood to the heart. Instead, in these patients, the heart’s main pumping chamber, the left ventricle, contracts in an unusual pattern. With contraction, this ventricle will be shaped like a fishing pot used to trap octopuses, the tako-tsubo pot – an observation made by the Japanese physicians who were the first to identify the syndrome. In other words, the bottom of the heart does not squeeze well (akin to the base of the pot) while the top part of the heart does squeeze well (akin to the neck of the pot).
While takotsubo syndrome is not well understood, researchers think the left ventricle may be “stunned” and unable to function because of a surge of stress hormones after the patient experiences a severe emotional or physical trauma, such as a death of a loved one or an automobile accident. The syndrome usually resolves quickly and without lasting damage to the heart, but it can, in very rare cases, be fatal. If you experience signs of a heart attack, dial 911 right away.
Esophageal Spasm, Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease (GERD) is a condition in which you have chronic heartburn. Esophageal spasm is when your esophagus, the pipe that carries food from your mouth to your stomach, strongly contracts. Either of these conditions can cause chest pain and can be hard to distinguish from a heart attack since the esophagus runs directly behind the heart within the chest. If the symptoms you experience are unusual for you, sudden, and severe, don’t be embarrassed to seek immediate medical attention. It is better to seek treatment and find out you have heartburn than to ignore a potentially fatal heart attack.
Pulmonary Embolism (blood clot in the lung)
Some forms of chest pain may originate from your lungs, rather than your heart. One lung problem, pulmonary embolism, can mimic a heart attack and is equally serious. A pulmonary embolism is a blood clot in an artery in the lungs. This clot cuts off blood flow, and the lung tissue begins to die. A pulmonary embolism is a life-threatening medical emergency that requires immediate treatment.
Aortic Dissection (tear in the wall of the aorta)
The aorta is the main artery that brings blood from the heart to the rest of the body. The wall of the aorta is made of three different layers. If there is a tear in the innermost layer, blood pumped from the heart may push under this flap and separate one layer from another. This separation causes a tearing chest pain that sometimes goes to the back. This tear in the aorta can extend up to the carotid arteries to the brain, back to the coronary arteries of the heart, or down to the arteries of the legs. Aortic dissection may cause stroke, heart attack and death. It is a life-threatening medical emergency that requires immediate treatment.
Sometimes chest pain may be something as simple as a pulled chest muscle. Inflammation in the cartilage that connects the ribs to the breastbone can also feel like a heart attack. If you have sudden chest pain that is causing you concern, you should seek immediate medical treatment to rule out a serious condition.