What is the initial management of acute myocardial infarction (heart attack) symptoms in women?

Initial Management of Acute Myocardial Infarction in Women

The initial management of acute myocardial infarction in women should include immediate administration of aspirin 162-325 mg (chewed), oxygen if hypoxemic, a 12-lead ECG, sublingual nitroglycerin (unless contraindicated), and prompt reperfusion therapy with primary PCI as the preferred strategy when available within 90 minutes of first medical contact. 1

Recognition of Symptoms in Women

Women often present with different symptoms than men, which can lead to treatment delays:

• Women may experience less typical symptoms including:

  • Shortness of breath
  • Nausea/vomiting
  • Fatigue
  • Palpitations
  • Syncope 2
  • Pain radiating to neck, lower jaw, or left arm 2

• Women tend to present more often with atypical symptoms (up to 30% in some registries) and typically present later than men 2

• It is crucial to maintain a high degree of awareness for MI in women with potential symptoms of ischemia, as women and men receive equal benefit from reperfusion strategies 2

Immediate Actions Upon Symptom Recognition

1. Call emergency services (9-1-1) immediately

   • Patients should not delay seeking medical care 2
   • EMS transport is associated with earlier delivery of reperfusion therapy 2
   • Prehospital ECGs by trained personnel are associated with shorter reperfusion times and lower mortality 2

2. Initial pharmacological interventions:

   • Aspirin 162-325 mg, chewed immediately 1
   • Sublingual nitroglycerin unless systolic BP <90 mmHg or heart rate <50 or >100 bpm 1
   • If symptoms are unimproved or worsen 5 minutes after nitroglycerin, call 9-1-1 immediately 2

Hospital-Based Management

1. Immediate assessment:

   • 12-lead ECG within minutes of arrival 1
   • Continuous cardiac monitoring 1
   • Vital sign monitoring 2
   • Rapid physician evaluation 2

2. Pain management:

   • Morphine sulfate 4-8 mg IV initially, with 2-8 mg IV every 5-15 minutes as needed 1

3. Reperfusion therapy:

   • Primary PCI is preferred when available within 90 minutes of first medical contact 1
   • If PCI is not available within the required timeframe and symptom onset is less than 12 hours, fibrinolytic therapy should be initiated 1
   • The greatest benefit occurs when thrombolysis is initiated within 6 hours of symptom onset 1

4. Additional pharmacotherapy:

   • Beta-blockers: Metoprolol can be administered as three bolus injections of 5 mg IV at approximately 2-minute intervals, followed by oral therapy 3
   • ACE inhibitors: For anterior infarction, heart failure, or ejection fraction <40%, start within 24 hours 1
   • In hemodynamically stable patients, lisinopril can be given 5 mg orally within 24 hours of symptom onset, followed by 5 mg after 24 hours, 10 mg after 48 hours, and then 10 mg daily for at least six weeks 4
   • Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor 1
   • High-intensity statin therapy regardless of baseline cholesterol levels 1

Special Considerations for Women

1. Recognize risk of bleeding:

   • Women have a higher risk of bleeding complications with PCI 2
   • Adjust anticoagulant dosing appropriately

2. Address potential barriers to timely care:

   • Women often delay seeking treatment due to:
     • Attributing symptoms to non-cardiac causes 5, 6
     • Minimizing symptoms 5
     • Knowledge deficit about heart attack symptoms 5
     • Different expectations about what a heart attack should feel like 5

3. Factors that improve timely treatment-seeking in women:

   • Identifying symptoms as cardiac in origin
   • Having a prepared action plan for emergencies
   • Living with someone or contacting others when symptoms occur 6

Common Pitfalls to Avoid

1. Delayed diagnosis due to atypical presentation

   • Women may not present with classic crushing chest pain
   • Maintain high suspicion with any potential ischemic symptoms in women at risk

2. Delayed reperfusion therapy

   • Do not wait for additional tests when STEMI is diagnosed
   • Time to reperfusion is critical for myocardial salvage

3. Underutilization of evidence-based therapies

   • Women should receive the same evidence-based treatments as men, including reperfusion therapy, antiplatelet agents, beta-blockers, and ACE inhibitors 2

4. Inadequate pain control

   • Ensure adequate analgesia with appropriate doses of morphine

By recognizing the unique presentation patterns in women and implementing prompt, evidence-based treatment strategies, healthcare providers can improve outcomes for women experiencing acute myocardial infarction.