“I feel like I am having a heart attack!” These words must be taken very seriously by any emergency room staff. Failure to follow proper procedures can result in a patient being sent home only to experience a sudden and fatal event. Too often heart attacks are missed by hospital emergency room staff because it did not present in a classic or usual fashion and the staff fails to follow protocol. I have seen emergency room doctors broom a patient out of their emergency room in less than an hour. The patient goes home and dies.
Heart attacks can strike patients under 50–even if they appear to be in the best of shape. The symptoms may be quite variable. A normal EKG does not rule out a heart attack. Heart attacks happen to men and women but will often present with different symptoms.
Myocardial infarction, commonly called a heart attack occurs when there is a blockage in a vessel which runs along the outside of the heart which supplies blood to the heart muscle. Typically, plaque has built up in one or more of these vessels to the extent that a piece of plaque that breaks off the vessel wall can block that artery and cause a damn which will block a supply of blood carrying oxygen to the muscle downstream. There are four major cardiac vessels which supply the heart muscle, and the extent of the heart attack is determined by the location and extent of the blockages.
Good emergency rooms approach patients who are suspected in having a heart attack in a stepwise fashion–following a written protocol. Usually, the first step is giving the patient an aspirin when they present to triage. An EKG should be performed promptly. This may show signs of a heart attack. But, if it is negative, that is not the end of the evaluation. Cardiac enzymes (markers) will elevate if the patient is suffering from a lack of adequate oxygen to the heart muscle. The most common marker is Troponin and will typically elevate within several hours of the onset of ischemia (low or lack of oxygen supply to a portion of the heart muscle). Typical protocol is to draw blood as soon as possible to determine whether the Troponin level is elevated. If the first draw is negative, it will be repeated approximately six hours later because the patient may have presented so soon after onset of ischemia that it will take time for the enzymes to become elevated. During the interim, the patient may be given nitroglycerin to help relieve the pain and the patient’s vitals will be continuously monitored (EKG, blood pressure, pulse and oxygen status).
Even when all of the testing fails to finds evidence of a heart attack, the patient may still have a life threatening problem and a good physician will recommend that the patient undergo treadmill testing (a stress echo with or without radioisotope evaluation injection before discharge. Referral to a cardiologist for follow-up is a must.