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Coronary thrombosis (heart attack)
Reviewed by Dr Neal Uren, consultant cardiologist and Dr Patrick Davey, cardiologist
How is a coronary thrombosis treated?
On arrival at the hospital, one 300mg tablet of aspirin (acetylsalicylic acid) is given to the patient if they have not already taken one. This prevents platelets (small blood cells) from adhering to each other in the clot.
Thrombosis-dissolving (thrombolytic) treatment is usually given, administered directly into a forearm vein. An alternative is emergency dilatation (enlarging) of the occluded coronary artery using a balloon, a procedure known as coronary angioplasty. This is generally only done in specialist centres but should be considered if the patient cannot receive a thrombolytic medicine for medical reasons or if the patient has a sustained low blood pressure (cardiogenic shock).
It is important to receive treatment as soon as possible after the symptoms begin. The earlier it is given the better the result.
Which medication is used afterwards?
Nitrates
Beta-blockers
Calcium-channel blockers
Nicorandil (potassium channel activator)
ACE inhibitors
Diuretics
Cholesterol-reducing medicine (eg statins)
What examinations may be performed following a thrombosis?
Echocardiography
Coronary artery examination (coronary arteriography)
Outlook for the future
Small injuries will often not be noticed afterwards.
Larger damaged areas can reduce the functional level in the long term, reducing the amount of physical work the patient is able to do and increase the likelihood of heart failure. An echocardiogram of the heart before discharge can show the doctor how extensive the damage is.
Immediately following a coronary thrombosis some patients feel tired and need much more sleep.
Mental consequences
Patients suffering from depression should speak about it to their family, good friends and GP. They will need help getting through this difficult period.
What can be done to prevent further attacks in the future?
Take regular exercise
Eat a healthy diet
Nitrates are drugs which act by expanding the arteries. Quick-acting glyceryl trinitrate tablets or spray may be prescribed for the treatment of chest pain episodes. Long-acting oral nitrate, such as isosorbide mononitrate, helps prevent attacks of angina and is useful for shortening the duration of any such attacks.
Among other effects, beta-blockers such as atenolol block the action of the adrenaline hormone on the heart and, therefore, blood pressure is lowered as the heart beats more slowly. This reduces the workload on the heart and increases flow of blood in the coronary arteries. In selected patients beta blockers reduce mortality rates and the rate of repeated heart attacks.
Calcium-channel blockers
reduce the muscle tension in the arteries, expanding them and so allowing a larger blood flow. Furthermore, they slightly relax the heart muscle, reducing the need for oxygen. There are different types of calcium-channel blockers available, which have different effects on the heart rate, the coronary arteries, the heart muscle and the circulation. These medicines are not routinely used early after a coronary thrombosis, but may be used for angina management in the long term.
Nicorandil
reduces the muscular tension in the coronary arteries and dilates (enlarges) the vessels accordingly. This improves blood flow to the heart. It also dilates blood vessels elsewhere in the body, which reduces the amount of work the heart has to do to pump blood around the body.
ACE inhibitors such as lisinopril
prevent the formation of a hormone (angiotensin-II), which makes the blood vessels contract and may increase the thickening of heart muscle away from the heart attack area. They lower the pressure in the veins, decreasing the workload for the heart. This may be a very helpful medicine in improving the function of the heart and in preventing late complications after a heart attack. A doctor is very likely to prescribe a medicine from this class, unless the patient has a persistently low blood pressure.
Diuretics are medicines that help the body secrete superfluous fluids and salt, which reduces blood pressure (this may be helpful if heart failure occurs). Diuretics can have different effects in the kidneys and can be divided into thiazides, loop diuretics, potassium sparing diuretics and a combination of these. Often, oral potassium is added, as the kidneys discharge lots of potassium when treated with diuretic medication.
If blood cholesterol levels are too high, these medicines can aid the lowering of natural cholesterol production in the liver. Statins such as simvastatin
inhibit an enzyme called HMG-CoA reductase and thereby reduce the production of cholesterol (cholesterol stimulates the development of atherosclerotic plaques and increases plaque instability).
Ultrasound scan of the heart, which shows the doctor how well the heart pumps, and to how great an extent the heart has been injured by the thrombosis.
Consists of an injection of a contrast medium in the coronary arteries. It reveals stenoses (narrowing) or occlusion (blockage) in the coronary arteries which may require treatment.
Depression can sometimes follow a coronary thrombosis with a feeling of being physically tired. Many people are afraid of having a relapse which might affect their general mood. This occurs particularly where the hospital doesn't arrange an exercise rehabilitation programme.
Twenty minutes of exercise three times a week, eg on an exercise bicycle or walking will help to significantly reduce a raised cholesterol level and lessen cardiovascular risk.
Eat only oily fish or chicken and reduce consumption of red meat. All food should be grilled and none should be fried. You should aim to eat five servings of vegetables or fruit per day.
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