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There’s no such thing as a textbook heart attack

Nurses need to know the truth about myocardial infarction – it could save patients’ lives

Nurses need to know the truth about myocardial infarction – it could save patients’ lives

Picture shows a woman holding her shoulder to ease pain. The article stresses the need to raise awareness about coronary heart disease and heart attack, including gradual onset myocardial infarction, so that people know what symptoms to look out for.
Picture: iStock

There’s a common misconception, fuelled by the media, that a heart attack is always a sudden and quick event – but this isn’t the case.

A gradual-onset myocardial infarction (MI) can happen over the course of several hours or days.

A study published in the European Journal of Cardiovascular Nursing found that 57% of patients reported abrupt symptom onset,  the remaining 43% experienced gradual symptom onset.

Some remain symptom-free until it’s too late

Coronary heart disease, the major cause of heart attacks, which is caused by atherosclerosis in the coronary arteries, takes many years to develop.

Many people remain symptom-free until it’s too late, and they have an acute cardiac event. This can be in the form of acute ST elevation MI (STEMI) or with partial blockage in the form of a non-ST elevation MI (NSTEMI). Both of these are serious and potentially life threatening, and both can present as a gradual-onset heart attack.

‘A person having these gradual-onset symptoms may wait for them to pass and not feel a sense of urgency’

When heart attack symptoms occur out of the blue, patients will experience a crushing pain in the chest which may cause them to collapse dramatically, leading to a 999 call.

For many people the symptoms are less dramatic and can happen on and off, over time.

Symptoms can also be non-specific, such as indigestion, discomfort in other parts of the body, such as the back or shoulder blades, or generally feeling unwell.

Lack of urgency leads to delayed treatment

A person having these gradual-onset symptoms may wait for them to pass and not feel a sense of urgency that prompts them to call for emergency medical assistance. 

In some situations people will seek help but will not call for an ambulance, causing further delay. They may make a GP appointment, ask for a lift to the emergency department or, even worse, drive themselves to hospital.

‘Despite being perceived as a man’s disease, coronary heart disease kills more than twice as many women as breast cancer in the UK every year’

By the time they finally arrive at the emergency department there is irreparable damage to the heart muscle, and emergency procedures such as primary angioplasty often aren’t plausible due to the delay and the effects of myocardial necrosis, as identified on their electrocardiogram (ECG).

Many women think a heart attack won’t happen to them

The narrative that heart attacks only happen to older, overweight men who smoke and eat fast food means that many presume a heart attack can’t happen to them. The truth is that coronary heart disease doesn’t discriminate.

Despite being perceived as a man’s disease, coronary heart disease kills more than twice as many women as breast cancer in the UK every year. 

Women experience inequalities at every stage of diagnosis and treatment, with differences in care contributing to at least 8,200 avoidable deaths in England and Wales in the past decade, according to research funded by the British Heart Foundation.

The incorrect assumption that women having a heart attack will have different symptoms from men can lead to misdiagnosis, delayed treatment and less intensive medical interventions.

‘Women experience inequalities at every stage of diagnosis and treatment’

Research at the University of Edinburgh highlights than men and women actually have the same symptoms for NSTEMI and STEMI – they just differ from person to person.

Men are more likely than women to experience symptoms on exertion, such as physical exercise, and call for help, according to the study in the European Journal of Cardiovascular Nursing.

With gradual-onset heart attack, the lack of an association between exertion and exercise in women may make it even harder for them to identify that something is seriously wrong and increase the risk that they will delay seeking assistance.

Primary care nurses’ role in educating patients

We need to raise awareness about coronary heart disease and heart attack, including gradual-onset MI, so that people are educated about the symptoms to look out for, understand it can happen to them, and most importantly know to call for emergency assistance so that accurate diagnosis and treatment can start as soon as possible.

As nurses, we have a responsibility to educate our patients that there is no such thing as a textbook heart attack.

How to educate patients about heart attack risk

Nurses working in primary care, such as those based in GP surgeries, have a key role in educating patients. People coming to GP surgeries in England should be made aware of the free NHS Health Check for people aged 40-74. Similar arrangements are available in the rest of the UK.

These checks include blood pressure, cholesterol levels, body mass index and diabetes. A conversation should also take place about lifestyle and family history so that the person can be informed of their individual risk of having a heart attack or stroke in the next ten years. Assistance and advice can then be given to reduce the person’s risk factors.

Nurses working in hospitals also have a role in educating people who are admitted via the emergency department or other departments, including coronary care and cardiology wards.


Philippa Hobson is senior cardiac nurse at the British Heart Foundation


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