What is the immediate management of a heart attack?

Immediate Management of a Heart Attack

The immediate management of a heart attack requires rapid assessment and intervention with oxygen, aspirin (160-325mg), sublingual nitroglycerin (if systolic BP >90mmHg and heart rate between 50-100bpm), and adequate analgesia (morphine or meperidine), followed by prompt reperfusion therapy for eligible patients within 90 minutes of first medical contact. 1

Initial Assessment and Management

• Evaluation should ideally be completed within 10 minutes of arrival to the emergency department, with no more than 20 minutes elapsing before assessment 1
• Immediately obtain a 12-lead ECG to identify ST-segment elevation (≥1mV) in contiguous leads or new left bundle branch block, which indicates need for reperfusion therapy 1
• Initial interventions should include:
  • Oxygen administration via nasal prongs, especially for patients who are breathless or have heart failure 1
  • Sublingual nitroglycerin unless systolic BP <90mmHg or heart rate <50 or >100bpm 1
  • Aspirin 160-325mg orally (chewable or water-soluble for faster absorption) 1
  • Adequate analgesia with intravenous morphine (4-8mg initially with additional 2mg doses at 5-minute intervals until pain relief) or meperidine, with concurrent antiemetics 1

Reperfusion Therapy

• For patients with ST-elevation MI or new LBBB, immediate reperfusion therapy is indicated, with greatest benefit when initiated within 6 hours of symptom onset 1
• Options for reperfusion include:
  • Thrombolytic therapy (fibrinolysis): Most beneficial when given within the first hour (35 lives saved per 1000 patients treated) compared to 7-12 hours (16 lives saved per 1000) 1
  • Primary percutaneous transluminal coronary angioplasty (PTCA): Alternative to thrombolysis if performed in a timely fashion by skilled personnel with access to emergency CABG 1
• Patients without ST-segment elevation should not receive thrombolytic therapy 1

Medication Administration

• Aspirin reduces mortality in acute MI; a dose of 160-325mg should be given immediately 1, 2
• Intravenous opioids (morphine 4-8mg or diamorphine) are essential for pain relief and to reduce sympathetic activation 1
• Antiemetics should be administered concurrently with opioids to prevent nausea and vomiting 1
• For patients receiving thrombolytic therapy, heparin administration may be beneficial, particularly with tissue plasminogen activator 1
• Clopidogrel has shown benefit in reducing cardiovascular death, MI, and stroke in ACS patients when added to aspirin 3

Monitoring and Further Care

• Continuous cardiac monitoring should be established immediately 1
• Have emergency resuscitation equipment, including a defibrillator, immediately available 1
• Monitor for complications including arrhythmias, which are most common in the first 24 hours 1
• For patients with large anterior MI or LV mural thrombus, early administration of intravenous heparin may reduce stroke risk 1

Special Considerations

• Elderly patients (>65 years), those with low body weight (<70kg), hypertension, or receiving tissue plasminogen activator have increased risk of intracranial hemorrhage with thrombolytic therapy 1
• Time is critical - the "call to needle time" should ideally be no longer than 60 minutes, with 90 minutes as a reasonable target 1
• Anxiety is a natural response to heart attack; reassurance is important, and tranquilizers may be considered if necessary 1

Common Pitfalls to Avoid

• Delaying ECG assessment beyond 10 minutes of arrival 1
• Withholding aspirin administration while waiting for definitive diagnosis 1
• Administering thrombolytics to patients without ST-elevation or with contraindications 1
• Failing to provide adequate analgesia, which can increase sympathetic activation and worsen cardiac workload 1
• Delaying reperfusion therapy, as benefit is time-dependent with greatest advantage in the first hour after symptom onset 1