Recognizing a Heart Attack: Classical and Atypical Symptoms of Acute Coronary Syndrome

The prognosis is poor when a patient with ST-elevation MI cannot be thrombolyzed because of a contraindication. Ideally these patients should be sent for primary angioplasty; if that is also unavailable, they should be managed medically in an ICU with aspirin, clopidogrel or ticagrelor, statins, beta blockers, ACE inhibitors, nitrates and heparin or low molecular weight heparin, using whatever resources are available. Outcomes can be described as roughly 50/50: some patients respond well to this treatment, while others deteriorate and need referral to a higher-level facility.

Management of aortic dissection depends on which part of the aorta is involved. If the dissection involves the ascending aorta or the arch, it needs surgical management. If it involves the descending thoracic aorta or the descending abdominal aorta, percutaneous repair of the aneurysm is possible instead.

Once symptoms begin, the earliest ST elevation can appear on ECG within 15 to 30 minutes. This ST elevation persists if there is complete occlusion of the artery, and can still be present up to 48 hours later. If blood flow is restored spontaneously, whether from medicines or other reasons, the ST elevation resolves; otherwise it persists until the artery is reopened.

Mortality in ST-elevation MI can be quite high if the patient is not treated properly, up to 30 to 50%, which is why adequate and timely treatment matters so much. Cardiac echo, alongside ECG and cardiac enzymes, is very important and can pick up early signs of heart damage; it is now one of the first-line investigations at tertiary care hospitals in suspected cases.

Cardiac echo is important and is now done routinely, alongside cardiac enzymes and ECG, in suspected cases of heart attack at every tertiary care hospital where it is available. In summary, once ischemic heart disease is confirmed, every patient is loaded with aspirin (325 mg) along with clopidogrel (300 mg), prasugrel (60 mg) or ticagrelor (180 mg), a statin (atorvastatin or rosuvastatin, 40 to 80 mg), a beta blocker if blood pressure and heart rate allow, and glyceryl trinitrate for pain relief alongside oxygen. From there, ST-elevation MI patients receive heparin ahead of primary angioplasty, or are thrombolyzed if angioplasty is unavailable; non-ST-elevation MI and unstable angina patients are managed medically with low molecular weight heparin or fondaparinux instead of thrombolysis, and are escalated to coronary angiography and angioplasty or bypass surgery if they are high-risk or not improving.

No. Diabetic patients and women frequently present atypically, with dizziness, fatigue, jaw pain, neck pain, upper back pain, palpitations or epigastric discomfort instead of classic chest pain.

Long-standing diabetes can blunt the nerve signals that normally produce chest pain, so the heart attack can present with vague symptoms like fatigue or upper back pain instead.