Types of Heart Attacks

Dr. David L. Brown, of Medical City Dallas Hospital and Baylor Regional
Medical Center at Plano, discusses types of heart attack.
In the movies, when someone has a heart attack, that person clutches his che
st or arm and falls to the ground. Some people have exactly that experience. But
its also important to know that
Not all heart attacks have the same symptoms or severity, and
Heart disease is the number one cause of death for women as well as men.
If youve had a heart attack, you know firsthand that Hollywood misses a lot o
f the details, including the hard physical and emotional work it takes to recove
r afterward.
Ultimately, the seriousness of the heart attack is judged by the amount of h
eart muscle that is permanently damaged. Your cardiologist will assess this dama
ge through use of echocardiography, which is an ultrasound of the heart. Treatme
nt of a heart attack will depend on the type and severity of the heart attack.
Several types of heart attacks are discussed below, as well as non-heart-rel
ated sources of chest pain. Remember, if you are experiencing symptoms of a hear
t attack, dial 911. Just because heartburn, for example, can produce some of the
same symptoms doesnt mean you should assume it is the less serious cause rather
than the more serious condition. Every minute you delay if it is a heart attack
could result in permanent heart muscle damage or increased risk of death.
STEMI Heart Attacks
Inferior MIAn ST-segment elevation myocardial infarction (STEMI) is a seriou
s form of heart attack in which a coronary artery is completely blocked and a la
rge part of the heart muscle is unable to receive blood. ST segment elevation refe
rs to a pattern that shows up on an electrocardiogram (EKG).
This type of heart attack requires immediate, emergency revascularization wh
ich restores blood flow through the artery. This revascularization is achieved e
ither with drugs in the form of thrombolytics (clot busters), which are given in
travenously, or mechanically with angioplasty a treatment using thin, flexible t
ubes called catheters to open the closed artery.
These catheters are positioned at the beginning of the coronary arteries (th
e arteries of the heart), and contrast dye is injected through them to enable th
e interventional cardiologist to gather images of any blockage in the coronary a
rteries. Very thin wires (guidewires) are then advanced beyond the blockage and
the clot is sucked out and/or a small balloon is opened to push the blockage out
of the way. A stent a metal, mesh tube is often inserted at the same time to per
manently prop the cleared artery open to allow blood to flow through.
NSTEMI Heart Attacks
A non-ST segment elevation myocardial infarction (NSTEMI) is a type of heart
attack that does not show a change in the ST segment elevation on an electrocar
diogram and that results in less damage to the patients heart. However, these pat
ients will test positively for a protein called troponin in their blood that is
released from the heart muscle when it is damaged. In NSTEMI heart attacks, it i
s likely that any coronary artery blockages are partial or temporary.
Treatment for an NSTEMI heart attack consists of medication and evaluation f
or whether a blockage is present that should be treated with medication only, cl
eared through angioplasty or treated with cardiac bypass graft surgery.
Coronary Artery Spasm
A coronary artery spasm is when the artery wall tightens and blood flow thro
ugh the artery is restricted potentially leading to chest pain, or blood flow is
cut off all together causing a heart attack. Coronary artery spasm comes and go
es. Because there may not be a build-up of plaque or a blood clot in the artery,
a coronary artery spasm may not be discovered by an imaging test called an angi
ogram that is typically performed to check arteries for blockages.
Treatment for a coronary artery spasm consists of medications such as nitrat
es and calcium channel blockers.
Demand Ischemia
Demand ischemia is another type of heart attack for which blockages in the a
rteries may not be present. It occurs when a patients heart needs more oxygen tha
n is available in the bodys supply. It may occur in patients with infection, anem
ia, or tachyarrhythmias (abnormally fast heart rates). Blood tests will show the
presence of enzymes that indicate damage to the heart muscle.
Cardiac Arrest (not a heart attack)
In cardiac arrest, a persons heart stops beating. Cardiac arrest is not the s
ame thing as a heart attack, but it is worth discussing alongside heart attack.
Cardiac arrest can occur due to a heart attack, but cardiac arrest can also occu
r as a primary event. In other words, cardiac arrest can also occur for other re
asons besides a blockage in the artery. These other reasons include electrolyte
disturbances, such as low or high potassium or low magnesium, congenital abnorma
lities, or poor pumping function of the heart.
In a heart attack, a persons heart keeps beating. A heart attack can cause li
fe-threatening arrhythmias (abnormal heart rhythms), like ventricular tachycardi
a (VT) or ventricular fibrillation (VF). These arrhythmias result in cardiac arr
est within a few minutes because the heart is not pumping blood to the lungs to
pick up vital oxygen that circulates back to the heart and to the body.
Seconds count in treating both heart attack and cardiac arrest. With cardiac
arrest, the odds of survival go down by about 10 percent for every minute until
the person is resuscitated. After 10 minutes the risk of permanent brain injury
is very high.
Initial treatment will consist of cardiopulmonary resuscitation (CPR) and de
fibrillation delivery of an electrical shock to restore the hearts rhythm. For pe
ople who are resuscitated and have a heartbeat but do not regain consciousness,
hypothermia protocols are sometimes used, where the body is cooled for 24 hours
then gradually warmed. This has been shown to improve the odds of a good neurolo
gical outcome for those patients.
Non-Heart-Attack Sources of Chest Pain
There are many medical conditions that can mimic a heart attack. Some of the
se are a sign of something urgent, and others are not. Remember, if you are expe
riencing symptoms of a heart attack, dial 911. A few possible non-heart-attack c
auses of chest pain are described below. Your physician can help you identify th
e cause of any chest pain.
Unstable Angina
Angina is chest pain caused by a lack of blood flow to the heart due to narr
owed or blocked heart arteries. Most commonly it is the result of coronary arter
y disease (CAD). Angina occurs when the heart is not getting as much blood and o
xygen as it needs to pump. Angina that occurs with increasing frequency, with de
creasing levels of physical activity, at rest or that is not relieved with rest
is called unstable angina. Unstable angina requires immediate attention because
it can be the first sign of a heart attack. In unstable angina, blood work that
assesses for damage to the heart muscle is negative, indicating no heart attack
(yet). Generally, at rest, there is still some blood flow beyond a severe blocka
ge, and so there has not been damage to the heart.
Stable Angina
Angina that occurs with exercise and is relieved with rest is called stable
angina. In stable angina, the stimulus that causes the chest pain is relatively
stable and reproducible. For instance, a patient with stable angina may report t
hat he or she gets chest pressure with walking ten minutes on the treadmill, tha
t the chest pressure is relieved with rest, and that the symptoms have been rela
tively stable for the past several months. Additionally, the patient may report
that he or she can easily do some activities at home, such as walking one mile s
lowly, but that increasing the level of exercise by walking faster brings on che
st pain.
The chest pain is a sign that blood flow to the heart is being restricted by
build-up of plaque (a fatty substance) in the coronary arteries that supply blo
od to the heart. While a patient with stable angina is not likely to be at immed
iate risk for a heart attack, the condition does need to be treated. Medications
and lifestyle changes will be part of treatment. If the angina is very painful,
the patient may consider angioplasty to reopen the narrowed arteries or cardiac
bypass graft surgery to reroute blood flow around the blocked blood vessels.
Broken Heart Syndrome (Takotsubo Syndrome)
TAKOTSUBO
Now, physicians know that there is something behind the folk idea of a broke
n heart. Occasionally, a person may arrive in the emergency room with the sympto
ms of a heart attack, including the presence of cardiac enzymes in the blood tha
t indicate damage to the heart muscle, as well as abnormalities on an electrocar
diogram (EKG). However, no blockages will be discovered in the arteries that sup
ply blood to the heart. Instead, in these patients, the hearts main pumping chamb
er, the left ventricle, contracts in an unusual pattern. With contraction, this
ventricle will be shaped like a fishing pot used to trap octopuses, the tako-tsu
bo pot an observation made by the Japanese physicians who were the first to iden
tify the syndrome. In other words, the bottom of the heart does not squeeze well
(akin to the base of the pot) while the top part of the heart does squeeze well
(akin to the neck of the pot).The Japanese octopus traps after which Takotsubo
Syndrome is named.
While takotsubo syndrome is not well understood, researchers think the left
ventricle may be stunned and unable to function because of a surge of stress hormo
nes after the patient experiences a severe emotional or physical trauma, such as
a death of a loved one or an automobile accident. The syndrome usually resolves
quickly and without lasting damage to the heart, but it can, in very rare cases
, be fatal. If you experience signs of a heart attack, dial 911 right away.
Esophageal Spasm, Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease (GERD) is a condition in which you have chro
nic heartburn. Esophageal spasm is when your esophagus, the pipe that carries fo
od from your mouth to your stomach, strongly contracts. Either of these conditio
ns can cause chest pain and can be hard to distinguish from a heart attack since
the esophagus runs directly behind the heart within the chest. If the symptoms
you experience are unusual for you, sudden, and severe, dont be embarrassed to se
ek immediate medical attention. It is better to seek treatment and find out you
have heartburn than to ignore a potentially fatal heart attack.
Pulmonary Embolism (blood clot in the lung)
Some forms of chest pain may originate from your lungs, rather than your hea
rt. One lung problem, pulmonary embolism, can mimic a heart attack and is equall
y serious. A pulmonary embolism is a blood clot in an artery in the lungs. This
clot cuts off blood flow, and the lung tissue begins to die. A pulmonary embolis
m is a life-threatening medical emergency that requires immediate treatment.
Aortic Dissection (tear in the wall of the aorta)
The aorta is the main artery that brings blood from the heart to the rest of
the body. The wall of the aorta is made of three different layers. If there is
a tear in the innermost layer, blood pumped from the heart may push under this f
lap and separate one layer from another. This separation causes a tearing chest
pain that sometimes goes to the back. This tear in the aorta can extend up to th
e carotid arteries to the brain, back to the coronary arteries of the heart, or
down to the arteries of the legs. Aortic dissection may cause stroke, heart atta
ck and death. It is a life-threatening medical emergency that requires immediate
treatment.
Musculoskeletal Pain
Sometimes chest pain may be something as simple as a pulled chest muscle. In
flammation in the cartilage that connects the ribs to the breastbone can also fe
el like a heart attack. If you have sudden chest pain that is causing you concer
n, you should seek immediate medical treatment to rule out a serious condition.
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