Cardiac Emergencies: Protect the Most Important Muscle

When a loved one suffers a heart attack or experiences a heart-related emergency, every minute counts. Learn what happens during a heart attack, and how local cardiac teams respond when every minute counts.

Heart disease is the No. 1 cause of death in the United States, for both men and women. That fact really hits home when a family member, friend or colleague is diagnosed with heart disease or rushed to the hospital with the agonizing symptoms of a heart attack.

Just as a finely-tuned engine is dependent upon smoothly-operating valves, so, too, is the heart, and valve disease affects patients of all ages. “Usually, the first thing we notice is a heart murmur,” says Dr. Fernando Lamounier, a Cardiac Surgery Associates’ surgeon practicing at Centegra Hospital, McHenry. “Symptoms can also include shortness of breath, intolerance to exercise, palpitations, dizziness and even sudden death. Unfortunately, sudden death can be the first symptom.”

Lamounier explains that physicians listen closely for murmurs and, when one is heard, take steps to evaluate how seriously the heart is affected. They use echocardiograms to determine which valves are malfunctioning and whether there are any structural problems.

“Depending on the outcome of the echocardiogram, we may decide to proceed with surgery,” says Lamounier. “An angiogram should be performed to rule out blockages in the heart vessels before surgery can proceed.”

Open-heart surgery begins by hooking up the patient to a bypass or heart-lung machine. Then, surgeons stop the heart, repair or replace the faulty valve, and restart the heart. Patients usually stay in the hospital for three to seven days and resume normal life in about four weeks.

“A number of different factors can cause valve disease,” says Lamounier. “Rarely, it can be an inherited trait. More often, it’s the result of an unhealthy lifestyle. For example, heart attacks can cause valve disease, and conversely, valve disease can lead to heart attacks. If a patient doesn’t take good care of his or her teeth, dental work can free bacteria that migrates into the bloodstream and settles around the heart, causing infections. Some medications can cause valve disease, too.”

Changes in lifestyle can lower risk. “Controlling high blood pressure, enjoying a vegetarian diet, appropriate exercise – all those things that help to keep a heart healthy will also help patients to avoid valve disease,” says Lamounier.

Open-heart operations, such as this one at Centegra Health System, Crystal Lake, repair faulty heart valves.
“Not everyone knows there’s a difference between cardiologists and cardiac surgeons,” he adds. “Cardiologists are trained in treating hearts with medications and doing some procedures like stenting. As a cardiac surgeon, I took a different pathway, first trained as a general surgeon and then taking a fellowship to specialize in cardiothoracic surgery. Cardiologists and heart surgeons should work closely together to help patients achieve the best possible outcomes.”

When heart disease leads to heart attacks, swift intervention is vital. As a board-certified emergency medicine specialist at Delnor Hospital, Geneva, Dr. Arnold del Mundo is the first to see patients experiencing such symptoms. The trouble is that some patients exhibit classic symptoms, while others present with lesser-known problems, says del Mundo. On rare occasions, no warning signs are visible.

“Tightness or heaviness in the chest area; a burning sensation with exertion; radiating pain in the neck, jaw or arm; sweating; nausea; heart palpitations or racing pulses may all be indicators that the patient is on the verge of a heart attack,” he says. “But patients with diabetes might not feel any pain. Other patients may come in with symptoms of indigestion, being winded for no discernible reason, or shortness of breath. It’s my job to evaluate all the symptoms and determine what’s happening.”

When a patient shows a possible cardiac emergency, nurses initiate chest pain protocols which include obtaining initial vital signs, doing an electrocardiogram (EKG), placing the patient on supplemental oxygen, starting an IV and drawing blood samples. If del Mundo determines that a patient is having a heart attack, he calls a “cardiac alert,” which pages the interventional cardiologist and mobilizes the cardiac catheterization team.

“When the pain eases, we know we’re helping the heart to work better,” says del Mundo. “An angiogram is performed, to identify any blockage in the patient’s arteries. If there is a blockage, the interventional cardiologist can open it up and allow blood flow to the area of the heart muscle. The sooner we do this, the better, because we can prevent any muscle damage that could occur. We automatically give aspirin to patients with cardiac symptoms.”

Delnor Hospital has cardiologists available for around-the-clock emergency catheterization as the first line of therapy.

“If the patient comes with chest pain and doesn’t meet criteria for emergent cardiac catheterization, I’ll evaluate him or her for other etiologies [causes] of chest pain and may admit him or her for further testing, such as an exercise or chemical stress test,” says del Mundo. “We can check for significant blockages or other conditions.”

Patients who have heart attacks with no warning symptoms may have experienced a plaque rupture from the lining of a coronary vessel, says del Mundo. Platelets then clot on the rupture, blocking blood flow to the heart muscle and causing a heart attack. In any case, the most important thing anyone can do is to get medical help as quickly as possible.

“The sooner the better,” says del Mundo. “Within a window of time, we can do something to not only save the patient but also limit long-term damage to the heart muscle. Daily in the ER, we see patients with chest pain. While it might be related to muscular or skeletal problems, or even severe heartburn, it’s much better to be safe than sorry.”

When potential heart attack patients arrive by ambulance at Provena Saint Joseph Hospital, Elgin, they’ve already been assessed and treated by emergency responders, says Dr. James Burks, an interventional cardiologist.

“Our initial code cardiac team has already been called in,” says Burks. “The ambulance has radioed symptoms and electronically sent a ribbon-strip EKG. They’ve also started an IV with appropriate medications.”

The code cardiac team includes an interventional cardiologist, at least two nurses, one scrub nurse and one radiology technician. The team assembles day or night. While an assessment is conducted in the ER, part of the team gets equipment up and running in the cath lab.

The rush to unblock the artery begins with a tiny, catheter-guided wire inserted through an incision in the groin. The wire is worked through the blockage and a balloon is fed through.

“We inflate the balloon to the equivalent of six atmospheres [of pressure] for 15 to 20 seconds,” says Burks. “When the balloon is deflated, the blood flow is restored and the patient’s pain eases. It also stops the clock on damage to the heart muscle.”
The balloon is pulled back and a repeat angiogram performed. This helps Burks to decide the proper length and diameter of stent needed to maintain the re-opened artery.

Inside the cath lab at Provena Saint Joseph Hospital, Elgin.
“We place the stent over the balloon and re-insert it into the blocked area,” says Burks. “The balloon is re-inflated, pushing the stent tight against the artery’s walls, which holds the artery open and ensures adequate blood flow.”
While stents are most commonly used in emergency procedures, they also can be inserted after a patient presents with abnormalities during stress tests.

“Therapeutic angioplasty, for what we call plain old blocked arteries, worked well in the past, but there was a 35- to 45-percent chance of re-blockage,” says Burks. “This was the result of recoil in the artery – which is similar to a rubber band – and the presence of scar tissue.”

Bare metal stents were used previously to hold the arteries open, resulting in a 20- to 25-percent drop in vessel stricture, a good improvement. However, the latest advancement uses dissolving stents, mesh coated with medications, which reduce scarring. The coating also reduces recoiling and lowers the risk of new blockage.

“We work hard and fast,” says Burks. “The average intervention nationwide is 90 minutes. At Saint Joseph Hospital, we’ve cut it to less than 20 minutes in some cases, with an average of between 45 and 60 minutes, significantly better than the national average.”

Heart attacks aren’t the only heart conditions that bring people to the emergency room.

Atrial fibrillation (A-fib) is one of the more common heart conditions that ER doctors diagnose. As director of invasive cardiology and the cardiology catheterization laboratory at Advocate Good Shepherd Hospital, Barrington, Dr. Douglas Tomasian describes common symptoms of A-fib as a rapid heart rate or palpitations combined with shortness of breath.

“Patients may say that their chest feels tight,” he says. “They may also feel light-headed, or even pass out. A-fib can also be diagnosed when patients have no obvious symptoms, but the condition shows up on a routine EKG.”

Several conditions can influence the development of A-fib, including valve disease, heart failure and blocked arteries. A-fib also may be triggered by conditions such as lung or thyroid disease. Most often, A-fib is considered to be its own cardiac condition, and is very common among patients reaching retirement age.

“When patients present with A-fib, we generally first work to improve their symptoms by controlling their heart rates with medications, and we administer anticoagulants in patients at risk for strokes,” says Tomasian. “In A-fib, the most serious complication is a higher risk of stroke. This is due to the fact that, in this condition, patients may form blood clots in the heart which may then embolize to the brain, causing a stroke.”

Attempting to normalize the patient’s heart rhythm is often the next step, using specialized medications or electrical cardioversion, done under sedation. Despite these measures, the arrhythmia of A-fib will recur in many patients. Tomasian says that in certain patients, a minimally-invasive procedure known as an electrophysiology ablation may restore a normal rhythm and prevent recurrences of A-fib.

“The procedure is done utilizing catheters in the heart that can pinpoint the exact place in the heart where the arrhythmia originates,” says Tomasian. “Then, using specialized ablation catheters, a small scar is created on the inside of the heart to isolate the area from which the A-fib originates. This can effectively restore a normal rhythm and prevent recurrence of A-fib.”

After treatment, patients stay at Good Shepherd Hospital overnight for observation. In most cases, patients are back to normal activities in a couple of days, often with much more energy. Follow-up and outpatient monitoring are required, but in many cases there is no further need for hospitalization.

A nurse at Advocate Good Shepherd Hospital in Barrington evaluates a patient for unusual heart rhythms.
Tomasian emphasizes that A-fib is a common cardiac problem that may cause symptoms and serious complications, such as stroke. It’s often a recurrent problem that requires management through medication and cardiac follow-up. New technologies, such as catheter-based or minimally-invasive electrophysiology ablation procedures, have become a popular treatment option.

Newly-diagnosed patients and their families are confronted with a bewildering barrage of heart-related medical terms.

“Basically, heart disease is an umbrella term, with many different conditions underneath,” says Kara Aalfs, manager of the Heart & Vascular Center at Sherman Hospital, Elgin. “Heart failure, a term used widely in the media, was formerly called congestive heart failure. Simply put, heart failure means the heart muscle has become weakened and is no longer effective or efficient at pumping blood through the body. This happens for a number of reasons.”

Aalfs lists viruses, drugs and alcohol, hypertension, abnormal heart valves, coronary artery disease, uncontrolled cholesterol, unhealthy diet, kidney disease, irregular heartbeat and diabetes among potential causes. A coronary attack (heart attack) may also cause heart failure.

“Your heart muscle needs oxygen to survive,” says Aalfs. “A coronary attack occurs when the oxygenated blood flow to the heart is reduced or blocked completely. This can happen when coronary arteries build up with plaque caused by fat, cholesterol and other substances, a process called atherosclerosis. When part of the plaque in the coronary artery breaks, a blood clot can form around the plaque. This blood clot – thrombosis – can reduce or block blood flow to the heart muscle. When the heart muscle is damaged from lack of oxygen, it’s called a heart attack, or myocardial infarction.”

Peripheral vascular disease (PVD) is the narrowing of blood vessels “caused by fatty buildups – atherosclerosis – in the inner walls of the arteries which can in turn block normal blood flow,” says Aalfs. “Patients may experience fatigue, cramping, pain or discomfort in the legs when walking.”

Good health practices go a long way toward preventing heart disease, but it’s not possible to avoid factors such as aging, viruses and inherited tendencies. When a heart attack occurs or heart disease is diagnosed, it’s reassuring to know that swift, quality care is available throughout our region. ❚