Immediate Management of a Heart Attack

Initial Assessment and Management

The American College of Cardiology recommends that evaluation should ideally be completed within 10 minutes of arrival to the emergency department, with no more than 20 minutes elapsing before assessment 1
A 12-lead ECG should be obtained immediately to identify ST-segment elevation (≥1mV) in contiguous leads or new left bundle branch block, which indicates need for reperfusion therapy 1
Oxygen administration via nasal prongs is recommended, especially for patients who are breathless or have heart failure 2
Sublingual nitroglycerin should be administered unless systolic BP <90mmHg or heart rate <50 or >100bpm 1
Aspirin 160-325mg should be given orally (chewable or water-soluble for faster absorption) 1, 3
Adequate analgesia with intravenous morphine (4-8mg initially with additional 2mg doses at 5-minute intervals until pain relief) or meperidine, with concurrent antiemetics, is essential 1, 2

The American College of Cardiology recommends immediate reperfusion therapy for patients with ST-elevation MI or new LBBB, with greatest benefit when initiated within 6 hours of symptom onset 1
Thrombolytic therapy (fibrinolysis) is most beneficial when given within the first hour (35 lives saved per 1000 patients treated) compared to 7-12 hours (16 lives saved per 1000) 1
Primary percutaneous transluminal coronary angioplasty (PTCA) is an alternative to thrombolysis if performed in a timely fashion by skilled personnel with access to emergency CABG 1, 4

Aspirin reduces mortality in acute MI; a dose of 160-325mg should be given immediately 1, 3
Intravenous opioids (morphine 4-8mg or diamorphine) are essential for pain relief and to reduce sympathetic activation 2
Antiemetics should be administered concurrently with opioids to prevent nausea and vomiting 2
For patients receiving thrombolytic therapy, heparin administration may be beneficial, particularly with tissue plasminogen activator 5

Continuous cardiac monitoring should be established immediately 3
Emergency resuscitation equipment, including a defibrillator, should be immediately available 3
Monitoring for complications including arrhythmias, which are most common in the first 24 hours, is crucial 5
For patients with large anterior MI or LV mural thrombus, early administration of intravenous heparin may reduce stroke risk 5

Elderly patients (>65 years), those with low body weight (<70kg), hypertension, or receiving tissue plasminogen activator have increased risk of intracranial hemorrhage with thrombolytic therapy 1
Time is critical - the "call to needle time" should ideally be no longer than 60 minutes, with 90 minutes as a reasonable target 6
Anxiety is a natural response to heart attack; reassurance is important, and tranquilizers may be considered if necessary 2

Delaying ECG assessment beyond 10 minutes of arrival 1
Withholding aspirin administration while waiting for definitive diagnosis 2
Administering thrombolytics to patients without ST-elevation or with contraindications 1
Failing to provide adequate analgesia, which can increase sympathetic activation and worsen cardiac workload 2
Delaying reperfusion therapy, as benefit is time-dependent with greatest advantage in the first hour after symptom onset 1