Is the heart not getting enough blood? Let's learn about NSTEMI (Non-ST-Elevation Myocardial Infarction)

Do you sometimes feel a little tightness in your chest, a strange feeling, or a little difficulty breathing? Some people think that it might be due to gastritis. But it's not always like that. It could also be a heart problem. Today we're going to talk about a type of heart attack like that, which is a condition called NSTEMI.

What is NSTEMI? Simply put...

NSTEMI is a type of heart attack. This is when a part of your heart doesn't get enough oxygen. Just think, just like every other part of our body, the heart needs oxygen from the blood to function. It's when that oxygen supply is interrupted that the problems begin.

It gets its name because, like the other major type of heart attack, STEMI, there is no obvious, major change in the electrical activity of the heart that shows up on an ECG. However, it is still a very dangerous, life-threatening medical emergency . So if you or someone you know is experiencing symptoms of a heart attack, it is essential to go to the hospital or call an ambulance immediately. Delaying treatment can cause permanent heart damage or even death.

Why is this called NSTEMI?

In medical terms, a heart attack is called ``Myocardial Infarction''. ``Infarction'' means that a part of the body loses blood flow and that part begins to die. ``Myocardial'' means something related to the heart muscle. So, when the heart muscle does not get enough blood, that part begins to malfunction.

The electrical activity of our heart can be easily seen with a test called an ``Electrocardiogram'' or ``ECG''. You may have seen it, a test that involves attaching small sensors to various parts of the body. This shows the electrical waveform of the heart on a piece of paper or on a monitor. There are different parts of this waveform, which are named with letters like P, Q, R, S, T.

In STEMI heart attacks, the part of this waveform called the ``ST segment'' rises above normal levels. This clearly identifies it as STEMI. STEMI usually occurs when a major coronary artery that supplies blood to the heart is completely blocked.

However, in NSTEMI, there is no significant elevation of the `(ST segment)`. Sometimes, small changes can be seen on the `ECG`, but it is not as clear as in STEMI. Therefore, other tests, especially blood tests, are very important to diagnose NSTEMI. In this, there is a partial blockage of a coronary artery, not a complete blockage, or a blockage of a small vein that branches off a main artery.

Who is more likely to develop NSTEMI? (Risk factors)

There are several risk factors that can contribute to heart disease. Some of them we can control, but some we cannot change.

Things we can change:

These are things related to our lifestyle.

• Smoking and tobacco use: This is one of the main enemies of the heart.
• Diet: What we eat and drink, especially foods high in salt (which can raise blood pressure), sugar (which can contribute to diabetes), and oil/fat (which can contribute to cholesterol).
• Lack of physical activity: That means lack of exercise.
• Illegal drug use: Especially stimulants, such as amphetamines and cocaine, which affect the heart.

Things we cannot change:

• Age: The risk of developing heart disease increases with age.
• Gender: Men are more likely to develop heart disease than women. The risk increases for men after age 45, while for women the risk increases after age 50 (or after menopause).
• Family history: If your father or brother had heart disease or a heart attack before the age of 55, or your mother or sister had a heart attack before the age of 65, you are also at higher risk.
• Congenital or genetic conditions: Some genetic diseases or congenital conditions can also increase the risk of heart disease.

How common is NSTEMI?

Actually, NSTEMI, which belongs to the group of heart diseases called `(Acute Coronary Syndrome)`, is a condition that is commonly seen all over the world, including in our country Sri Lanka. According to American statistics, only 70% of the patients diagnosed with `(Acute Coronary Syndrome)` are NSTEMI patients. That means we need to be concerned about this.

What happens before and during an NSTEMI?

NSTEMI is one condition in a broader category called ``Acute Coronary Syndrome.'' Other conditions in this category include STEMI and ``Unstable Angina'' (unstable angina - chest pain that occurs even at rest, but is not as severe as a heart attack).

When the heart does not receive the necessary blood supply, a condition called ``Ischemia'' occurs. Simply put, the part of the heart that is deprived of blood begins to die. Unlike other muscles, heart muscle cells cannot regenerate once they die. This means that if blood flow is not restored quickly, the damage is permanent.

There can be several direct and indirect causes for NSTEMI.

Causes that directly reduce blood supply to the heart:

• Plaque buildup: These are waxy deposits made from cholesterol in our blood. Just as a clogged drain reduces the flow of water, plaque can block the arteries that carry blood to the heart. Sometimes, when a plaque ruptures, a blood clot forms on top of it, blocking the artery further or completely within minutes or hours.
• Vasospasm: Our blood vessels have a layer of smooth muscle inside that controls the widening and narrowing of the vessels. Just like a muscle twitching in a leg, this layer of muscle in the arteries of the heart can suddenly tighten and contract. This is called vasospasm. This can cause blood flow to become blocked and lead to a heart attack. However, this is rare.
• Coronary Embolism: This is when a blood clot that has formed elsewhere gets stuck in an artery in the heart. This is also a very rare condition.

Damage or injury to the heart:

Even though the heart is safe inside our chest cavity, it can sometimes get damaged.

• Myocarditis: This is inflammation of the heart muscle. It often occurs when a viral infection affects the heart muscle.
• Toxins: Some toxins can damage the heart muscle and cause a heart attack. An example is `(Carbon Monoxide)` poisoning.
• `Cardiac Contusion`: This is a bruised heart. This can happen in a major accident, such as a car accident. This is also rare.

Indirect reasons:

This means that the heart has to work harder, therefore requiring more oxygen, but is deprived of that much oxygen supply.

• Severe high blood pressure (`Malignant Hypertension` or `Hypertensive Emergency`) or very low blood pressure (`Hypotension`): When the pressure is too low, the heart has to work harder to pump blood. When the pressure is too high, the heart has to work harder due to the resistance in the blood vessels. In both cases, the heart needs more oxygen.
• Tachycardia: When the heart beats too fast, it doesn't pump blood properly. The heart muscle also needs more oxygen to work at that speed.
• Aortic Stenosis: This is a narrowing of the main valve that carries blood out of the heart (aortic valve). When this becomes severe, the heart has to work harder to pump blood through the narrowed valve.
• Pulmonary Embolism: This occurs when a blood clot gets stuck in a blood vessel leading to the lungs. This blocks the oxygen-rich blood from reaching the lungs and returning to the heart.

What are the symptoms of an NSTEMI?

A person with a heart attack may experience symptoms like these:

• Chest pain or discomfort (Angina): This is the main symptom. It can feel like your chest is tightening, heavy, or constricted.
• Difficulty breathing: It may feel like you are having difficulty breathing or suffocating.
• Nausea, stomach upset: Some people may experience stomach pain or gastritis.
• Palpitations: You may feel a strange sensation as if your heart is beating rapidly, skipping beats, or stopping suddenly.
• Dizziness (vertigo), fainting, and feeling like you're losing your mind.

Important: These symptoms do not occur in the same way for everyone. Some people may experience only one symptom, while others may experience several. The intensity of the pain can also vary.

Symptoms that are especially felt by women:

Although women can also experience the symptoms mentioned above, they are more likely to mistake the discomfort in the middle of their chest for gastritis. They also report more symptoms such as:

• Excessive fatigue, shortness of breath, or insomnia that precedes a heart attack.
• Pain spreading to the jaw, neck, shoulders, arms (especially the left arm), mid-back, or abdomen.
• Nausea and vomiting.

How to recognize this condition?

A doctor diagnoses an NSTEMI by combining several tests and information from the patient. In NSTEMI, the symptoms and ECG changes are not as clear as in STEMI, so it is important to look at all of these together.

First, the doctor will examine you, listen to your heart and lungs, and check your blood pressure. Then, they will ask about your "medical history," such as your lifestyle, family history, and medications you take.

Tests used to diagnose NSTEMI:

• Electrocardiogram (ECG or EKG): This is the first and most important test to diagnose a heart attack. As mentioned earlier, in STEMI, the ST segment is elevated. While there is no such dramatic change in NSTEMI, the following changes may be seen (but not always):
• `(Transient ST-elevation)`: The `(ST segment)` rises for a while and then returns to normal.
• `(ST-depression)`: The `(ST segment)` goes below normal.
• `(New T-wave inversions)`: The `(T-wave)` (a wave that is normally curved upwards) on the `ECG` appears to be curved downwards.
• Blood tests: When heart muscle cells are damaged, a chemical called `(Troponin)` (Troponin) is released into the blood. Measuring the level of `(Troponin)` in the blood is the most reliable way to diagnose any heart attack (including NSTEMI). However, it can take several hours (usually less than 6 hours) for the `(Troponin)` level in the blood to reach a testable level, so this test may need to be done several times.
• Imaging tests: If other tests are inconclusive, these types of imaging tests can also help.
• Echocardiography: This is an ultrasound scan of the heart. It is very useful in emergency rooms because it can be performed at the bedside.
• Computed Tomography (CT) scan: This uses X-rays to create three-dimensional (3D) images of the heart. This is sometimes done by injecting a special liquid called a contrast dye. This can then clearly show plaque deposits and blockages in the arteries of the heart.
• Magnetic Resonance Imaging (MRI): Uses a strong magnetic field to produce very clear images of the heart.

What are the treatments for NSTEMI?

Treating any heart attack is a race against time. The faster blood flow is restored to the blocked blood vessel, the less damage will be done to the heart.

• Oxygen: If the oxygen level in the blood is low, oxygen is given.
• Percutaneous Coronary Intervention (PCI): This is what many people call a "stent." In this procedure, a cardiologist inserts a small tube (catheter) through a major vein in your arm or leg and threads it into the blocked artery in your heart. Then, a small balloon at the end of the tube is inflated to widen the blocked area. Often, a stent (a mesh-like device) is inserted to keep the widened area from closing again. The sooner this is done, the better the results.
• Medications: There are several types of medications given to someone with a heart attack (some are given even before the diagnosis is confirmed).
• Aspirin or other antiplatelet medications: These stop platelets in the blood from clumping together and forming blood clots. This stops the clot from getting worse.
• Anticoagulants: These also prevent blood clotting, but in a different way.
• Angiotensin-Converting Enzyme (ACE) inhibitors: These medications block the production of a protein that increases blood pressure. This lowers blood pressure. They are more likely to be given to people with heart failure, high blood pressure, kidney problems, or diabetes.
• Beta-blockers: These slow the heart rate and reduce the force with which the heart pumps. This reduces the amount of oxygen the heart needs because the workload on the heart is reduced. However, these may not be suitable for people with low blood pressure, heart failure, or certain heart rhythm disorders (arrhythmias).
• Nitroglycerin: This medicine works by widening blood vessels and improving blood flow. Therefore, it is very effective for chest pain.
• Statins: These lower blood cholesterol levels and reduce the risk of plaque buildup in the coronary arteries.
• Coronary Artery Bypass Grafting (CABG): Sometimes, if more than one artery in your heart is severely blocked, surgery may be the best option. This is called "bypass surgery" (or "open-heart surgery"). In this procedure, the surgeon takes a blood vessel from another part of your body (such as your leg or the inside of your chest) and grafts it to create a new path around the blocked artery in your heart. The blood can then "bypass" the blocked area.

Can we prevent a heart attack?

Yes, there are many things we can do to prevent a heart attack, or at least delay it. One of the most important things is to see your family doctor at least once a year for a complete medical checkup (`checkup` / `wellness visit`).

Many diseases, such as high blood pressure and diabetes, do not show symptoms until they are very advanced. But even before symptoms appear, these conditions continue to damage the heart and coronary arteries, greatly increasing the risk of heart attack. However, these conditions can be easily identified early with simple tests done during an annual check-up. If there is any such problem, your doctor will give you the necessary advice and guidance.

Some of the best things you can do to prevent a heart attack are:

• Maintaining a healthy weight.
• Eating a balanced diet (your doctor can recommend a diet that suits you, for example, the Mediterranean diet).
• Being physically active (at least 150 minutes of moderate-intensity exercise per week).
• Keep your existing medical conditions (such as blood pressure, diabetes, cholesterol) under control. If you are taking medication for them, take them exactly as prescribed by your doctor.
• If you use tobacco (including cigarettes, beedis, cigars, and vaping), quitting is very important to prevent a heart attack.

Unfortunately, some people still have a heart attack, especially those who are at higher risk due to family history or other medical conditions. However, by following the above steps, you can delay the onset of a heart attack or reduce its severity if you do have one. Also, staying healthy can make it easier to recover from a heart attack.

How long will I have to stay in the hospital?

The length of time you will stay in the hospital depends on several factors. These include the severity of your heart attack, your general health, and the type of treatment you received. You may typically stay for two to seven days. Treatments such as PCI (insertion of a stent) may take less time, and surgeries may take longer.

When will you feel better?

Your symptoms should start to improve as you receive treatment. Many people feel a little tired and weak after a heart attack, but this will go away in a few days. Your doctor will advise you on how much rest you need and what you can do to help you recover.

What is the outlook after an NSTEMI?

How you will feel after an NSTEMI depends on several factors. The severity of the heart attack and your overall health will play a big role. Your doctor can best explain what to expect, what to watch out for, and what to avoid.

What else can you expect after an NSTEMI?

If you have had a heart attack once, your chances of having another one increase. Therefore, regular medical follow-up care and preventive measures are very important to prevent another heart attack. Your doctor may suggest things like:

• Repeat medical tests and `(imaging)` tests: Monitoring how your heart is working is one of the most important ways to prevent another heart attack.
• Cardiac Rehabilitation: These are programs that help you improve your health through physical activity, supervised by doctors. Specialists in various fields, such as dietitians and exercise instructors, help you.

When can normal activities resume?

When you can return to work, drive, or exercise normally will vary depending on your health. Your doctor can give you the best advice. Talk to him or her about your goals and when you can start doing things. It's best to start gradually, as he or she suggests.

How to take care of your health after a heart attack?

Much of what was said earlier under "Prevention" also applies to taking care of your health after a heart attack. It's important to eat a good diet, exercise regularly , maintain a healthy weight, take the right medications for other illnesses, and see your doctor on time.

When should you call the doctor?

Your doctor will advise you on what problems to expect, what to be concerned about, and when to talk to him or her. Also, if you develop new symptoms or if an existing symptom changes (especially if it comes on suddenly or starts to interfere with your daily activities), talk to your doctor.

When should you go to the hospital or emergency room?

If you suddenly have heart-related symptoms again, or if your symptoms become unexpectedly severe, you should go to the hospital immediately. The main symptoms that indicate the need for emergency medical treatment are:

• Chest pain (Angina) or pain that spreads to nearby areas of the body (neck, jaw, back, arms, shoulders, or stomach).
• Difficulty breathing or shortness of breath.
• Excessive sweating.
• Palpitations.
• Nausea or vomiting.
• Dizziness (vertigo), fainting, or loss of consciousness.

If I need emergency treatment, should I drive to the hospital alone?

Absolutely not! If you think you are having a heart attack, driving yourself to the hospital could be a danger not only to yourself but also to others on the road. Therefore, call 1990 (Suvaseriya) or another ambulance service immediately. There are several advantages to going by ambulance:

* Ambulance personnel can assess your condition and begin treating your symptoms on the way to the hospital. The information they collect helps save valuable time for doctors at the hospital making diagnoses.

* If you lose consciousness on the way, you will not be in danger or harmed by others because you are traveling in an ambulance.

* Ambulance personnel can take you directly to the Emergency Room (ER). If you go alone, there may be a delay as you enter through the lobby.

The symptoms of a heart attack can be a frightening, confusing experience. Fortunately, with the advancement of medical science, the diagnosis and treatment of heart attacks have improved greatly. Treatment options, medications, and scientific understanding of the heart are constantly advancing. That means your chances of a good outcome are always increasing. If you or a loved one are experiencing symptoms of a heart attack, please seek medical help immediately without delay.

The most important things to remember (Take-Home Message)

Dear friends, I have to tell you that NSTEMI is a serious type of heart attack that we should not take lightly.

• If you experience symptoms like chest pain or difficulty breathing, don't just assume it's "gastric." See a doctor immediately.
• Making simple lifestyle changes (eating well, exercising, and avoiding smoking) can greatly reduce this risk.
• The most important thing is to listen to what the doctors say, get the tests done, take the medications as prescribed, and try to live a healthy life. Your heart is worth it!

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