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KEY POINTS OF HEART ISSUES: WHAT HAPPENS WHEN YOU GO TO THE HOSPITAL?
In any patient with suspected coronary artery disease (hardening of the arteries), the most common reason for seeking urgent medical help is prolonged chest pain, chest tightness, shortness of breath or weakness. These symptoms often result in patients’ going to an emergency room, or consulting with their doctors urgently. The two important questions that the doctors ask themselves are: (1) Are the symptoms due to lack of blood supply to the heart (myocardial ischemia) or some other medical problem?; and (2) Are you having a heart attack?
The first question is important since the presence of myocardial ischemia almost always means that hospitalization is required, often in a coronary care unit, and involves intensive medical therapy (detailed below) and close observation, with continuous monitoring of your electrocardiogram (ECG). It is also crucial for doctors to decide if you are in the throes of a heart attack, since the severity of a heart attack can be markedly reduced by using “clot busters,” technically known as thrombolytic drugs. In heart attack patients who are treated within the first hours after the onset of chest pain or discomfort, these drugs can markedly reduce the risk of death and limit the amount of heart damage that could occur. Currently, the first test used to decide if you are having a heart attack is a simple electrocardiogram (ECG), during which small electrodes are placed on your chest, arms and legs, in order to record the tiny electrical signals coming from your heart. The usual sign on the electrocardiogram of an ongoing heart attack is what is called ST segment elevation; this indicates that you may benefit from clot-busting drugs (unless there is a reason to withhold them, which can occasionally happen). Clot busters are useful for up to six, or even twelve, hours after a heart attack, although their effectiveness diminishes rapidly after the first few hours from the onset of symptoms.
Occasionally, chest pain or chest discomfort suggests symptoms of myocardial ischemia (lack of blood supply to the heart) but the electrocardiogram does not definitively indicate a heart attack. To sort this out, blood will be drawn to be analyzed for myocardial enzymes, which are substances found inside heart muscle cells that are not normally present in the blood but are released into the blood if heart damage occurs. These tests can indicate heart damage as soon as a few hours into a heart attack. After you are evaluated in an emergency room, and an electrocardiogram and blood tests are done, you will usually be sent to a coronary care unit.
Coronary care units were first developed in Toronto, Ontario, in the 1960s, and allow close monitoring of cardiac patients, intensive nursing care and immediate treatment of any complications that may arise. During these early hours, patients are treated with various medications, such as heparin, a blood thinner available intravenously; nitrates, drugs that dilate blood vessels and improve blood supply to the heart; and often beta blockers, drugs that slow the heartbeat and decrease the amount of work the heart has to do. Aspirin is almost always administered, as it prevents blood platelets (small circulating elements in the blood that can stick or clump together and indirectly lead to clotting) from sticking together. During the first few days in the coronary care unit, you will undergo daily electrocardiograms, likely several chest X rays, and receive daily visits from your doctor. You will probably also have an ultrasound of your heart (echocardiogram) in the first few days, and if your chest pain recurs or persists you may undergo an angiogram, an X ray of the blood vessels that supply blood to the heart. (These tests are described in more detail below.) After one to several days in the coronary care unit, depending on whether you have had a heart attack (myocardial infarction) or unstable angina (a “threatened heart attack” but where actual heart muscle damage does not occur), you will be transferred to a regular hospital (“ward”) unit.
Most patients spend a few days to a week in the hospital following an acute cardiac event, unless complications occur or unless a complex procedure or heart surgery is required. Prior to hospital discharge, many patients undergo some form of exercise testing to assess the response of the heart to physical stress. Counseling with respect to long-term changes in diet, activity level, exercise, smoking cessation and other lifestyle changes may occur at this time, or may be deferred until after the early convalescence period is over, generally four to six weeks later.
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