Heart attack guidance for physicians: When to suspect, how to diagnose, what to do?

Lack of awareness among the first contact physicians is one of the major causes for delay in reperfusion therapy in India. Physicians need not only clear-cut guidance about when to perform an ECG and when to refer a patient but also need to understand the mortality advantage of early intervention as well as medico-legal aspects of this condition.

Cerebrovascular diseases have become number one cause of mortality and morbidity even in developing countries like India. Heart attack or acute myocardial infarction (AMI) represents one of the most disastrous conditions in this area associated with significant morbidity and high mortality. National Intervention Council data shows that most of the coronary interventions in India are in the context of ACS, particularly around acute STEMI, nearly 40% of them performed in the peri-STEMI setting. Since this disease strikes a decade earlier in India it may be particularly devastating in this young productive age group. However, the condition can be totally reversible if diagnosed and treated early, herein the adage is “Time is Muscle.” Thus it is very important for the first contact physicians to suspect it early, confirm by ECG as soon as possible and refer for revascvularization to a higher, better equipped center. Thus the physicians require a clear cut guidance regarding when to suspect a heart attack, how to confirm it and how to proceed when a diagnosis is made. Further, the guideline should be based on evidences obtained from the population of interest reflecting local practice models.

Table 1, Table 2 provide simple guidance on how to suspect and diagnose early treatment steps and when to refer a patient with this condition. This information is also relevant not only clinically but from medico-legal stand-point as well because any delay can worsen prognosis and even culminate in mortality.

Table 1

When to suspect, a heart attack.

Symptoms and Signs3

1. Severe pain, heaviness, uncomfortable pressure or squeezing, generalized in chest, jaw, shoulder, or epigastric lasting for >20 min. 2. Sweating 3. Feeling or inability to take breath 4. Feeling of nausea 5. Light headedness, dizziness, fainting or syncope

Remember if any of these symptoms or signs are present, an ECG is mandatory

ECG

ECG is a mainstay in the initial diagnosis of patients with suspected ACS which will dictate management.4

1. ST segment elevations in leads corresponding to a territory1. - New ST elevation at the J point in two contiguous leads of ≥1 mm (0.1 mV) in all leads other than leads V2-V3 (for V2–V3 ≥ 2 mm may be required). 2. Localization of infarct • Septal: V1 and V2 • Anterior: V3 and V4 • Lateral: V5 and V6 • Antero-septal: V1–V4 • Antero-lateral: V3–V6 • Extensive anterior: V1–V6 • Inferior: II, III, aVF • High Lateral: I, aVL • Posterior: tall R wave and ST depression in V1–V2

2. A new LBBB in a patient with symptoms consistent with MI should be treated like a STEMI

Table 2

Ten Commandments for Physicians after suspecting Heart Attack.

1. Immediate treatment involves giving chewable or sub-lingual 300 mg aspirin. 2. ECG is the key to diagnosis and should be done as early as possible. 3. Acute myocardial infection (AMI) is a medico-legal; emergency. Immediately refer to a higher center if ECG is confirmative or suspected. 4. Opening up of the blocked coronary artery, called reperfusion, is the main-stay of treatment for acute MI; all other treatments are just palliative. 5. Reperfusion should be given in only ST elevation MI 6. Primary PCI (angioplasty) during the course of acute MI saves lives: Refer the patient to a center where PCI facility is available at that point of time. 7. Initial treatment depends on estimated time it will take to reach nearest PCI capable and available center. If it will take less than one hour send to PCI capable center but if it will take more than 1 h, thrombolyse and then send. 8. Thrombolysis can be given by any qualified medical practitioner 9. If a patient is unconscious do immediate cardio-version 10. Begin hands only CPR if patient still unconscious or defibrillator not available. Remember within ten minutes of cardiac arrest at least for the next ten minutes (or till the cardio-version unit arrives) compress the center of the chest continuously and effectively at least with a rate of 10 × 10 = 100 per minute.