As a nurse, no matter your specialty, you need to be able to recognize signs and symptoms of a heart attack.

Whether you call for help or push the patient to the cath lab, you need to know when to be worried and what to do.

Saddle up, because I am about to go over the deets of an ST-Elevated Myocardial Infarction (AKA STEMI), Non ST-Elevated MI (AKA NSTEMI), and unstable angina.

What is a Acute Coronary Syndrome?

Wait.

I thought we were talking about heart attacks?

We are. Stay with me.

Acute Coronary Syndrome, or ACS, is the presentation of a patient having an acute myocardial infarction (heart attack). So it’s kinda like the signs and symptoms of an MI but actually is an MI, not just the signs and symptoms. For the sake of simplicity, we will use the words acute coronary syndrome and myocardial infarction synonymously.

There are 3 types of ACS:

1. Unstable Angina

2. Non-ST Elevated MI (NSTEMI)

3. ST Elevated MI (STEMI)

When someone says they are having chest pain, you should assume they are having an MI. Then, work quickly to investigate, hopefully eliminating all 3 types of ACS as causing factors.

A STEMI is found by looking at an ECG, a NON-STEMI is a heart attack that is found after getting some lab results but has a normal ECG and unstable angina has normal lab results and a normal ECG. All three have similar presentations of signs and symptoms.

What are the signs and symptoms of a heart attack?

A patient having a myocardial infarction may have one or more of the following signs or symptoms:

• Pain, squeezing, pressure and/or tightness in:

  • Chest

  • Arm

  • Neck

  • Jaw

  • Shoulder

  • Epigastric area

Anginal Equivalents: Signs and symptoms that may seem to be from another issue. For example: Shortness of breath, you tend to think about lungs and less about the heart, but shortness of breath is an anginal equivalent that could be a warning sign of a heart attack.

Examples of Anginal Equivalents:

• Diaphoresis

• Shortness of breath/Difficulty in breathing

• Nausea

• Lightheadedness/Dizziness

• Fatigue

• Syncope or near syncope

If you have a patient who is complaining of new onset chest pain or they suddenly became short of breath, grab an EKG/ECG. You never know when someone could all of a sudden be having a heart attack. Some nurses may argue that you should consider risk factors, but I say better safe than sorry. Plus, I have had some patients surprise me that did not have any risk factors.

How is a heart attack diagnosed?

Because all three types of MI’s have the exact same symptoms, it is impossible to know which MI a patient is having without an EKG/ECG and some lab work.  

Another test that will be ordered for a patient having signs and symptoms of an MI is a chest x-ray.

What are the nursing interventions for unstable angina?

Nursing interventions for unstable angina is an area nurses can shine in, because it involves a lot of preventative care.

The goals/interventions are to:

1. Decrease oxygen demand of the heart

2. Monitor for EKG/ECG changes

3. Monitor hemodynamics

You should encourage the patient to rest so the heart's oxygen demand is decreased. The nurse will also monitor oxygen saturation (applying oxygen when appropriate) and for ekg changes.

Diagnostically speaking, a stress test might be ordered or a PCI could be performed but this is unlikely.

What should you do if your patient is having an NSTEMI?

The patient should be placed on a heparin drip to thin the blood and re-perfuse the heart. You should keep them on the cardiac monitor and watch for any EKG/ECG changes. These patients will be followed by a cardiology team and eventually weaned to oral anticoagulants such as warfarin or subcutaneous anticoagulant medications such as Lovenox.

What does a STEMI look like?

When reading a 12 lead ECG, you will need to note at least 1 mm of ST elevations in 2 or more different leads in order to declare the patient having a STEMI. The ST wave is on the same isometric line. Each little box of the ECG paper is 1mm.

Each lead has a different view of the heart, thus knowing which leads view certain parts of the heart help you know where the Myocardial Infarction is happening. There is a Mnemonic that can help you remember the locations.

LISA-Lo

• L-Lateral
  • Lead I & AVL
  • Left Circumflex Artery
• I-Inferior
  • Lead II, III & AVF
  • Right Coronary Artery
• S-Septal
  • Lead V1 & V2
  • Left Anterior Descending Artery
• A-Anterior
  • Lead V3 & V4
  • Left Anterior Descending Artery
• Lo-Lower lateral
  • Lead V5 & V6
  • Left Circumflex Artery

Below is a chart that helps you visualize this Mnemonic.

Some people say that an anterior STEMI looks like a row of tombstones. I agree, however, it is important to note that they also can be subtle and not so obvious in other leads and locations so don’t just memorize what they look like tombstones. The key is to measure the elevation of the ST wave from the isometric line.

What should you do if your patient is having a STEMI?

Freak out.

...Kidding...

Stay calm but be diligent and quick. Activate the cath lab or your hospitals STEMI protocol. Every facility is different on the steps to activation, so know your facilities policies and procedures. Once Cath Lab is activated, be ready to transport the patient.  

Get a portable monitor and an AED to take the patient to the Cath Lab. Make sure you have a full oxygen tank and NC readily available as well.

Before leaving your location, make sure the patient has at least one large bore IV placed. The best scenario is having two large bore IV’s. Blood work should also be drawn and sent for this patient. You do not need to wait for any results of the blood work to take the patient to the cath lab. But in the event that the patient turns from having a STEMI to having a dysrhythmia or arrest, you will have access to administer drugs following your ACLS guidelines.

So to recap: A STEMI is one of the three types of myocardial infarctions. The signs and symptoms are the same, you can tell the difference by an ECG. You treat the STEMI with a cardiac cath and the MONA mnemonic. You should be prepared for cardiac arrest so have your crash cart ready. And finally, time is tissue, so move fast to save as much of the heart tissue as possible.

…...

Check out this article on the ‘Ten Commandments’ of a STEMI.

How do I care long term for a patient who had a heart attack?

Medications are the most important part of managing a post heart attack patient. It frequently can be the reason that a patient will return with signs or symptoms of another heart attack or heart failure. The medications that are commonly used are:

• Baby Aspirin

  • Thins the blood to prevent clots

  • Chewable aspirin is the gold standard because it is absorbed quicker and has shown to be the only factor that decreases mortality rate

• Beta Blockers

  • Block the effects of adrenaline, reducing the heart rate and blood pressure. This helps keep the heart perfused and not stressed

  • Medication names end in -olol

  • Examples:

    • Atenolol (Tenormin)

    • Metoprolol (Lopressor)

    • Propranolol (Inderal)

• Ace Inhibitors

  • Ace stands for Angiotensin Converting Enzyme

    • This enzyme constricts the blood vessels causing vasoconstriction

    • ACE Inhibitors block this action, thus causing vasodilation

  • Medication name ends in -pril

  • Examples:

    • Lisinopril (Zestril)

    • Ramipril (Altace)

    • Captopril (Capoten)

• Statins

  • Decreases lipids in the patient's vasculature by reducing the amount of lipids the liver makes

  • Also called HMG-CoA reductase inhibitor

  • Examples:

    • Atorvastatin (Lipitor)

    • Pravastatin (Pravachol)

    • Simvastatin (Zocor)

Diet, exercise, and mental/emotional stress need to address for these patients to improve their quality of life as well as decrease their risks of having another heart attack. Depending on the patient's ability, they may be able to modify these as an outpatient but could potentially need to go to a cardiac rehab.

Educate the patient on the importance of being seen by a medical professional immediately if they experience any signs or symptoms of a heart attack, not just chest pain.

Nursing Tidbits

So to recap:

• There are 3 types of MI

  • Unstable Angina

  • Non-STEMI

  • STEMI

• All three have the same presenting symptoms

• You should always error on the side of caution and get an EKG/ECG

• You should get your BLS (and preferred ACLS) even if you aren’t required to because it is important to know what to look out for and what is supposed to happen with the patient.

• Remember to stay calm but work quickly and diligently.

   

This Post was written by my colleague, Susan Dupont, RN (aka the BossRN).

Susan DuPont of BossRN is a full-time bedside emergency room nurse in a level one trauma center. In her spare time, she likes to fish, hunt, and travel.

Disclaimer: This material should be used to supplement your understanding of the cardiovascular system. Any use of the information given in this post series is at your own risk and should be verified prior to making it a part of your nursing practice. There may be affiliate links associated with some products but we promise that we will never recommend anything that we don’t use ourselves.