Importance of Patient Education in the Early Recognition of STEMI

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An acute ST-elevation myocardial infarction (STEMI) continues to be a significant health problem in the United States and throughout the world. Despite this, there has been a steady decline in the mortality rate from STEMI over the last several decades (2).   A STEMI is a high-risk condition in which survival and other clinical outcomes are significantly impacted by reducing the time from vessel occlusion to coronary blood flow restoration (1). Thus, it is crucial for health care providers to educate their patients in recognizing and identifying early symptoms of a STEMI to improve outcomes and mortality.  

Introduction  

An acute ST-elevation myocardial infarction (STEMI) continues to be a significant health problem in the United States and throughout the world. Despite this, there has been a steady decline in the mortality rate from STEMI over the last several decades (2).   A STEMI is a high-risk condition in which survival and other clinical outcomes are significantly impacted by reducing the time from vessel occlusion to coronary blood flow restoration (1). Thus, it is crucial for health care providers to educate their patients in recognizing and identifying early symptoms of a STEMI to improve outcomes and mortality.  

An acute ST-elevation myocardial infarction (STEMI) is when myocardial ischemia results in myocardial injury or necrosis. A STEMI occurs from the occlusion of one or more of the coronary arteries responsible for supplying the heart with blood. The disruption of blood flow is caused by plaque rupture, erosion, fissuring, or dissection of coronary arteries resulting in an obstruction (1). 

Recommendations for Management Prior to Occurrence 

According to the American Heart Association, “One-third of patients who experience STEMI will die within 24 hours of the onset of ischemia, and many survivors will suffer significant morbidity (2).”  

Many patients’ first manifestations of Coronary Heart Disease (CHD) will be sudden death. Clinical studies have shown that modification of risk factors for the development of CHD and STEMI can prevent the development of CHD or reduce the risk of experiencing STEMI in patients who have CHD (2). Healthcare providers should identify patients with risk factors that would contribute to developing a STEMI long-term. 

How to Identify Those at Risk for STEMI 

Being able to identify patients at risk for developing a STEMI as healthcare providers is the first step in the prevention of STEMI. Primary prevention refers to trying to prevent a patient from getting the disease. Secondary prevention refers to detecting disease in the early stages and preventing it from getting worse. Tertiary Prevention refers to improving the quality of life of a patient in reducing the symptoms of the disease that one already has (4).  

Major risk factors for developing CHD (2): 

• Smoking  
• Family history  
• Adverse lipid profiles  
• Elevated blood pressure  

Primary prevention interventions directed toward these risk factors are effective when used correctly. Patients with diagnosed CHD should be identified for secondary prevention and those steps should be implemented accordingly on a patient-by-patient basis. Patients with diabetes and peripheral vascular disease have a baseline risk of STEMI (2).  

A committee from the American Heart Association strongly endorses various public health campaigns that are believed to contribute to the reduction of incidence and fatality in patients with STEMI in the future. These include (2):  

1. Recognition of diabetes mellitus and chronic kidney disease as “risk equivalents” to coronary heart disease and recommends for aggressive attempts to control these risk factors 
2. Recognition of the importance of dyslipidemia as a significant risk factor for coronary heart disease and recommends aggressive attempts at cholesterol reduction and treatment of this issue 
3. Aggressive primary smoking cessation 
4. Patient education regarding the signs and symptoms of MI and appropriate courses of action  
5. Implementation at a professional level of quality assurance projects such as the ACC’s Guidelines Applied in Practice to improve compliance with treatment strategies when caring for patients with MI

Interventions to Reduce Risk  

• According to the American Heart Association, the following are interventions to reduce the risk of the development of a STEMI (2):  
• All patients who smoke should be encouraged to quit and provided with appropriate cessation education. 
• All patients should be instructed to maintain appropriate low-saturated-fat and low-cholesterol diets.  
• Pharmacological intervention with statins should be prescribed to patients when appropriate. 
• Patients with high blood pressure should be treated and maintained. 
• Aspirin prophylaxis can uncommonly result in hemorrhagic complications and should only be used in primary prevention. 

STEMI Classic Symptoms   

• Chest discomfort with OR without radiation to the arm (s), back, neck, jaw, or epigastrium  
• Chest pressure, tightness, or squeezing 
• Shortness of breath  
• Weakness 
• Diaphoresis  
• Nausea  
• Lightheadedness 
• Palpitations  

Men VS. Women 

Men‘s most common heart attack symptom is chest pain (angina) or discomfort. Women are more likely than men to experience other symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain. 

Patient Education for Early Recognition  

It is a crucial element of caring for patients to educate them on their disease process, their risk factors, as well as the common warning signs to watch for in an emergent situation. Patients with symptoms of STEMI should call 9–1–1 immediately.  For patients experiencing a heart attack, every minute counts. EMS can begin treatment upon arrival—up to an hour sooner than if someone travels to the hospital by car (2). 

For patients who have been prescribed nitroglycerine, they should take one nitroglycerine dose sublingually in response to chest/discomfort. If discomfort is unimproved or worsening after 5 minutes, it is recommended the patient or family member call 9–1–1 (2). Morbidity and mortality can be substantially reduced by educating patients, and patients taking action upon recognition of symptoms. 

STEMI Onset 

Prior to evaluation and potentially life-saving treatment, early recognition of symptoms by the patient or close to the patient is the first step that must occur. According to the American Heart Association, “The average patient with STEMI does not seek medical care for approximately 22 hours after system onset (2).“ Below is the algorithm process of a patient experiencing chest pain/discomfort and the appropriate steps to take.

American Heart Association Guidelines for the Management of Patients with non-trauma related STEMI 

Silent, yet Deadly  

Patients who experience STEMI do not always present with chest discomfort. Of the patients diagnosed as having an MI, 33% did not have chest pain upon presentation to the hospital. This group of patients was, on average, seven years older than those who experienced chest pain, and were women with a prior history of heart failure or diabetes (3). According to the American Heart Association, “In the majority of clinical studies that have been examined to date, women have been shown to exhibit more prolonged delayed patterns compared to men often because they do not always perceive themselves to be at risk (2).“  

Based on the REACT research program, patients commonly expect a heart attack to present dramatically with severe, crushing, chest pain without a doubt that something bad was occurring. This contrasts with the actual reported symptoms and experiences of the same patient‘s gradual onset of discomfort with midsternal chest pressure or tightness (2).  Many patients know that chest pain is a bad sign. But they often do not know when to react to that sign and when too long is too late. Patients must know of the other ways that a heart attack can present and know the importance of not delaying seeking help.  

Conclusion 

In conclusion, early identification of risk factions in patients with combined primary and secondary prevention and thorough and explicit patient education and management will significantly improve clinical outcomes of a STEMI event. Because the irreversible damage to the myocardium occurs within the first two hours after coronary occlusion, it is imperative that warning signs are recognized, and the patients seek treatment for reperfusion regardless of the type of intervention -fibrinolysis or percutaneous coronary intervention (PCI) (5).

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