( By Dr. Natoobhai J.Shah & Dr. Sailesh N. Shah )

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a-Modern Approach In The Treatment Of Heart Attack

For emergency treatment during acute heart pain :

  1. Do not panic
  2. Take rest wherever you are You may either sit down or lie down.
  3. Suck a tablet of glycerin trinitrate
  4. Crush one tablet of aspirin and swallow
  5. Take a prescribed tranquilizer - one or even two tablets.
  6. Immediately go to a neighbouring hospital emergency room. The earlier you reach, the better. " The golden hour " is the first hour. The clot dissolving treatment can be beneficial up to first six hours.
  7. Have courage and confidence. Remember, that many patients who have suffered a heart attack have recovered well enough to live for many more useful and productive years.

During the acute phase of the heart attack, the most important thing is complete physical and mental rest. An oxygen cylinder is usually not necessary. The special drugs used in I.C.C. Unit now a days are :

  1. I/V thrombolytic ( clot dissolving) agent - if the hospital is reached early within first 4 hours of the major chest discomfort. The urokinase or streptokinase is commonly used in our country to dissolve blood cot. The success rate of dissolving the clot is around 50%. The chances are more during the first " golden hour". The earlier the patient presents, the higher the likelihood of success with thrombolysis.

  2. I/V or I/M sedative.

  3. I/V heparin - This is a blood thinner that has been shown to be beneficial during a heart attack or unstable angina.

  4. I/V nitroglycerin drip - This medication dilates the coronary artery and may be beneficial in improving flow.

The main role of the medical team during period of illness would be to closely watch for any complications arising out of heart attack or the thrombolytic therapy if administered in good time. He must treat them if and when they arise. The other drugs which are used with advantage are beta blockers if there is no contraindication. The ace inhibitor drugs have also shown to improve outcome if started early after a heart attack.

Modern Concepts of I.C.C. Units

The maximum damage to the heart muscle occurs during the first six hours of the attack. There are two main types of complications which can arise :

  1. Electrical rhythm disorders of the heart, some of which can be sudden and serious.
  2. Mechanical complications , where the pumping power of the heart becomes defective to lead to congestive left or mixed heart failure or the state of cardiogenic shock.

The first type of complication, namely the electrical complications, can now a days be treated with satisfactory chances of success in a special heart unit called an "intensive coronary care unit " (I.C.C.U.).

The success rate is higher if these complications are recognized immediately and treated promptly. They seem to occur more frequently during the first few hours or during the first few days after a heart attack. Hence, the sooner the patient is shifted to such a unit, the better for him. Should there be a sudden electrical stoppage of the heart, it can be revived if resuscitation is carried out quickly within the first four minutes of its stoppage. An arrested heart cannot be revived effectively after the lapse of the important four minutes. The life-sustaining centres in the brain cannot survive without blood( circulation ) for more than four times. Early recognition and prompt action within seconds is vital. The importance of the mobile cardiac ambulance and I.C.C.U. lies in their ability to provide a prompt response in dealing with an electrical complication. This helps facilitate resuscitation in a patient with sudden death.

The limitation of I.C.C. Units however, still remain. Mechanical complications cannot be combated more effectively in these units and not all cases of sudden electrical arrest can be resuscitated. The average success rate of resuscitation is around 60 per cent.

The main tools for resuscitation are :

  1. External cardiac massage
  2. Cardiac defibrillator
  3. Intracardiac pacemaker
  4. Newer antiarrhythmic drugs
  5. Expert and efficient team of doctors and nurses.

In fact, doctors and nurses form the central pillar of I.C.C. Unit. Modern sophisticated equipment can prove to be quite worthless in the absence of well organized and efficient team of medical personnel.

Nitroglycerin - Its Effectiveness And Method Of Use

  1. A nitroglycerin tablet, when placed under the tongue takes 20 to 30 seconds to dissolve. It can also be crushed and then chewed for immediate effectiveness. It is absorbed directly into the blood stream from oral mucosa.

  2. The action of nitroglycerin is prompt. The relief from chest discomfort is generally obtained within 1 to 5 minutes.

  3. Nitroglycerin should be used immediately and without hesitation at the first hint of chest discomfort.

  4. Nitroglycerin is not habit forming. Patients can take nitroglycerin many times a day.

  5. Patients should carry nitroglycerin at all times.

  6. Nitroglycerin tablets lose their effectiveness within a few months after a bottle is unsealed. In order to retain maximum potency, the tablet should be kept in the original glass bottle with the metal top securely screwed on.

  7. If a single nitroglycerin tablet does not relieve chest discomfort within 2 to 5 minutes, the patient should take a second one. If the discomfort is constant or if the relief is transient and then recurs, a third pill should be taken. If , however, the discomfort is not completely controlled or continues to recur, the patient should take a sedative injection or pill and contact his doctor immediately.

  8. Nitroglycerin is most helpful when taken at the onset of discomfort rather than after discomfort has been present for several minutes.

  9. If the patient knows that a certain level of activity, exertion or excitement is likely to bring on an anginal episode, angina can be prevented by taking a nitroglycerin tablet before exertion.

  10. Nitroglycerine can cause a fall of blood pressure, particularly in elderly persons, which can lead to an occasional fainting spell. An elderly patient is therefore advised to avoid sucking the pill while in a standing position. He should take it while he is sitting with a support or when he is lying down. The symptom of headache that may follow is not harmful. Most of times, it can be controlled by taking simple aspirin or any other pain relieving drug.
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