Question

You have just received a new patient admitted through the emergency department. The report you receive from the ED nurse is that Mr. Ramos is a 58 year old obese male with a history of diabetes and hypertension. He is a daily smoker. His wife states he has a high stress job as an executive financial officer. They walk every night for exercise. He doesn’t drink and she states they have tried to control his blood glucose levels but he was diabetic “for many years” before he was finally diagnosed. He arrived to the ED via EMS with crushing chest pain and elevated troponin levels. He was diagnosed with myocardial infarction (MI) and has been stabilized and admitted for evaluation by the cardiology team.

What are the classic physical assessment findings associated with MI? Can you find any information about the differences between the symptoms of MI in men vs. women?

Why did the ED test troponin levels?

Once Mr. Ramos has been treated by the cardiologist and is ready for discharge, what patient education would you give he and Mrs. Ramos about reducing risk factors to prevent potential complications or repeat MI?

Answer 1

The patient’s history is critical in diagnosing myocardial infarction (MI) and sometimes may provide the only clues that lead to the diagnosis in the initial phases of the patient presentation.

Patients with typical acute MI usually present with chest pain and may have prodromal symptoms of fatigue, chest discomfort, or malaise in the days preceding the event; alternatively, typical ST-elevation MI (STEMI) may occur suddenly without warning.

The typical chest pain of acute MI usually is intense and unremitting for 30-60 minutes. It is retrosternal and often radiates up to the neck, shoulder, and jaws, and down to the left arm. The chest pain is usually described as a substernal pressure sensation that is also perceived as squeezing, aching, burning, or even sharp. In some patients, the symptom is epigastric, with a feeling of indigestion or of fullness and gas.

In some cases, patients do not recognize the chest pain, have an unusually high pain threshold, or have a disorder that impairs pain perception and results in a defective anginal warning system (eg, diabetes mellitus). In addition, some patients may have an altered mental status caused by medications or impaired cerebral perfusion. Elderly patients with preexisting altered mental status or dementia may have no recollection of recent symptoms and may have no complaints whatsoever.

MI occurs most often in the early morning hours. Mechanisms that may explain this circadian variation include the morning increase in sympathetic tone leading to increases in blood pressure, heart rate, coronary vascular tone, and myocardial contractility; the morning increase in blood viscosity, coagulability, and platelet aggregability; and the increased morning levels of serum cortisol and plasma catecholamines leading to sympathetic overactivity, thereby resulting in increased myocardial demand.

^{Other symptoms include:}

anxiety,commonly described as a sense of impending doom

• Pain or discomfort in areas of the body, including the arms, left shoulder, back, neck, jaw, or stomach

• Lightheadedness, with or without syncope

• Cough

• Nausea, with or without vomiting

• Profuse sweating

• Shortness of breath

• Wheezing

• Rapid or irregular heart rate

• Fullness, indigestion, or choking.

• Feelings with men, women’s most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.

• Cardiac troponins are regulatory proteins within the myocardium that are released into the circulation when damage to the myocyte has occurred. Therefore, serum troponin is an exquisitely sensitive marker of myocardial injury and is necessary for establishing the diagnosis of MI. High-sensitivity troponin assays are improving the diagnostic accuracy and rapid detection of myocardial infarction. The early identification of MI is vital for the institution of anti-thrombotic therapy to limit myocardial damage and preserve cardiac function. Troponin has both diagnostic and prognostic significance in the setting of acute coronary syndrome (ACS). Increased troponin levels in the absence of ACS should prompt an evaluation for an alternative, non-thrombotic mechanism of troponin elevation and direct management at the underlying cause.

• Patient education

  At home

• Check that you have a list of all the medicines you take. Take your medicines exactly as directed.

• Remember that recovery after a heart attack takes time. Plan to take it easy for at least 4 to 6 weeks while you recover. Then return to normal activity when your doctor says it’s OK.

• Lifestyle changes:These changes will most likely be a combination of diet and exercise.

• Diet:

  You may need to see a registered dietitian for help with these diet changes. These changes may include:

• Cutting back on how much fat and cholesterol you eat

• Cutting back on how much salt (sodium) you eat, especially if you have high blood pressure

• Eating more fresh vegetables and fruits

• Eating lean proteins such as fish, poultry, beans, and peas, and eating less red meat and processed meats

• Using low-fat dairy products

• Using vegetable and nut oils in limited amounts

• Limiting how many sweets and processed foods such as chips, cookies, and baked goods you eat

• Limiting how often you eat out. And when you do eat out, making better food choices.

• Not eating fried or greasy foods, or foods high in saturated fat

• Exercises:Depending on your case, your provider may recommend an exercise program that is best for you. Warm-up 5 to 10 minutes before exercising and cool-down 5 to 10 minutes after exercising.

• The cardiac rehab program:

  Cardiac rehabilitation is a medically supervised program to help people who have heart disease. It's designed to improve heart recovery and your ability to function. It also helps prepare you for activities of daily living. People in this program may have recently had a heart attack or heart surgery. It may ease your symptoms and improve your sense of well-being. Your cardiac rehab program is designed to meet your needs. It's overseen by a cardiac doctor and a team of cardiac health providers. Your program may last from 6 weeks to more than a year.

  The goal of cardiac rehab is to help ease your symptoms and make your heart as healthy as possible. Your program may include:

• Exercise program. This makes you more fit, and helps your heart work better.

• Classes to help you change your lifestyle and habits. For example, classes and support to help you quit smoking. Or you may take a nutrition class to learn how to eat better.

• Stress management. You will learn how to manage stress to lower your anxiety.

• Counseling. This will help you learn about your specific condition and how to live with it.

• Occupational therapy. This is to help you get ready to go back to work or to manage normal activities of daily life.

• A heart attack occurs when a vessel that sends blood to your heart suddenly becomes blocked. This causes your heart not to work as well as it should. Follow these guidelines for home care and lifestyle changes.

• At home

• Check that you have a list of all the medicines you take. Take your medicines exactly as directed. Make sure you've been given instructions about your medicines and how to take them. Make sure you have a pharmacy so you can get the prescription filled. Don’t skip doses. Talk with your healthcare provider if your medicines aren't working for you. Together you can come up with another treatment plan.

• Remember that recovery after a heart attack takes time. Plan to take it easy for at least 4 to 6 weeks while you recover. Then return to normal activity when your doctor says it’s OK.

• Ask your doctor about joining a heart rehab program. This can help strengthen your heart and lungs and give you more energy and confidence.

• Tell your doctor if you are feeling depressed. Feelings of sadness are common after a heart attack. But it's important to speak to someone or seek counseling if you are feeling overwhelmed by these feelings. These feelings most often pass within a month.

• Call 911 right away if you have chest pain or pain that goes to your shoulder, neck, or back. Don't drive yourself to the hospital.

• Ask your family members to learn CPR. This is an important skill that can save lives when it's needed

• Other changes:

• Diet

  Your healthcare provider will tell you what changes you need to make to your diet. You may need to see a registered dietitian for help with these diet changes. These changes may include:

• Cutting back on how much fat and cholesterol you eat

• Cutting back on how much salt (sodium) you eat, especially if you have high blood pressure

• Eating more fresh vegetables and fruits

• Eating lean proteins such as fish, poultry, beans, and peas, and eating less red meat and processed meats

• Using low-fat dairy products

• Using vegetable and nut oils in limited amounts

• Limiting how many sweets and processed foods such as chips, cookies, and baked goods you eat

• Limiting how often you eat out. And when you do eat out, making better food choices.

• Not eating fried or greasy foods, or foods high in saturated fat

• Exercise

  Your healthcare provider may tell you to get more exercise if you haven't been physically active. Depending on your case, your provider may recommend an exercise program that is best for you. Warm-up 5 to 10 minutes before exercising and cool-down 5 to 10 minutes after exercising.

  The cardiac rehab program

  Ask your healthcare provider about a cardiac rehab program. Cardiac rehabilitation is a medically supervised program to help people who have heart disease. It's designed to improve heart recovery and your ability to function. It also helps prepare you for activities of daily living. People in this program may have recently had a heart attack or heart surgery. It may ease your symptoms and improve your sense of well-being. Your cardiac rehab program is designed to meet your needs. It's overseen by a cardiac doctor and a team of cardiac health providers. Your program may last from 6 weeks to more than a year.

  The goal of cardiac rehab is to help ease your symptoms and make your heart as healthy as possible. Your program may include:

• Exercise program. This makes you more fit, and helps your heart work better.

• Classes to help you change your lifestyle and habits. For example, classes and support to help you quit smoking. Or you may take a nutrition class to learn how to eat better.

• Stress management. You will learn how to manage stress to lower your anxiety.

• Counseling. This will help you learn about your specific condition and how to live with it.

• Occupational therapy. This is to help you get ready to go back to work or to manage normal activities of daily living.

• Other changes

  Your healthcare provider may also recommend that you:

• Lose weight. If you are overweight or obese, your provider will work with you to lose extra pounds. Making diet changes and getting more exercise can help. A good goal is to lose your 10% of your body weight in one year.

• Stop smoking. Sign up for a stop-smoking program to make it more likely for you to quit for good. You can join a stop-smoking support group. Or ask your doctor about nicotine replacement products or medicines to help you quit.

• Learn to manage stress. Stress management techniques to help you deal with stress in your home and work life. This will help you feel better emotionally and ease the strain on your heart.

• Control other conditions. If you have diabetes, high blood pressure, kidney disease, or high cholesterol, your provider will work with you to control these diseases. All of these are risk factors for heart attacks.

• Follow-up

  Check that you have the details about all of your medical appointments once you leave the hospital. Or, make a follow-up appointment as directed.

  Lifestyle changes

  Your heart attack might have been caused by cardiovascular disease. Your healthcare provider will work with you to make changes to your lifestyle. This will help the heart disease from getting worse. These changes will most likely be a combination of diet and exercise.