Heart attack (myocardial infarction): warning signs to recognise and save a life

01Myocardial infarction, an absolute vital emergency#

Myocardial infarction (MI), commonly called "heart attack" or more recently "ST-elevation acute coronary syndrome" (STEMI in international terminology), is one of the most dramatic medical emergencies where every minute literally counts. It is defined as the sudden obstruction of a coronary artery that deprives the heart muscle (myocardium) of oxygen and nutrients. Without rapid restoration of circulation, the myocardial zone deprived of irrigation will progressively necrose definitively in a few hours.

The pathophysiological mechanism is now well understood. In the vast majority of cases, infarction results from the rupture of an unstable atheroma plaque within a coronary artery, followed by clot (thrombus) formation that suddenly obstructs the arterial lumen. This plaque has progressively built up over years through accumulation of cholesterol, inflammatory cells and cellular debris in the arterial wall (atherosclerosis). Several factors precipitate plaque rupture: intense physical effort, major emotional stress, respiratory infection, sometimes no identifiable factor. More rarely, infarction may be caused by coronary spasm (sudden artery constriction), coronary dissection, coronary embolism, or imbalance between oxygen supply and demand (severe anaemia, shock).

In Morocco, myocardial infarction is responsible for approximately 17,000 deaths per year according to Ministry of Health data (2022 report), making it the leading cause of mortality in the country, ahead of strokes, cancers and accidents. Several Moroccan epidemiological specificities deserve highlighting. The average age of occurrence is approximately 57 years, nearly 10 years earlier than in Europe (68 years in France) — a worrying observation explained by less control of risk factors (untreated hypertension, smoking, dyslipidaemias, diabetes epidemic). Men are affected approximately 3 times more than women before age 65, but this difference fades and then reverses after menopause.

In terms of prognosis, approximately 8 to 12% of patients die in the first hours, most often from ventricular fibrillation (lethal rhythm disorder) occurring before emergency arrival. Once admitted alive to hospital, prognosis largely depends on the rapidity of management and the quality of coronary reperfusion. Progress in primary angioplasty has considerably improved prognosis over the last twenty years in countries with an interventional cardiology network. In Morocco, several modern centres now offer this optimal management, but access remains uneven across the territory.

02Recognising typical signs#

The cardinal symptom of infarction is acute chest pain, whose characteristics are relatively stereotypical and must absolutely be recognised by the general public.

The pain is typically located behind the sternum (retrosternal) or more broadly in the chest as a band. It is described as a sensation of oppression, tightness, crushing — patients often use very evocative images: "like a vice squeezing me", "like an elephant sitting on my chest", "I feel like my chest is being crushed". Intensity is generally strong to very strong, often described as the worst pain ever felt. Prolonged duration is a key element of diagnosis: infarction pain typically lasts more than 20 minutes, often 30 to 60 minutes or more, contrary to stable angina which yields in a few minutes at rest. The pain is resistant to rest and does not yield, and contrary to unstable angina, it does not respond to sublingual nitroglycerin intake.

Irradiations are characteristic and largely unrecognised: pain may radiate to the left arm (sometimes also right arm), to the lower jaw (sometimes mistaken for toothache), to the back between shoulder blades, to the left shoulder, more rarely to the epigastrium (upper abdomen) where it can be confused with indigestion. Any chest pain with arm and jaw irradiation is highly evocative of cardiac origin.

Several associated symptoms typically complete the picture and should reinforce suspicion. Sudden and unusual breathlessness (dyspnoea), particularly when occurring at rest or with the slightest effort, may reflect early cardiac decompensation. Profuse cold sweats appear in the majority of cases, giving a pale or even greyish complexion characteristic. Nausea and vomiting are frequent, sometimes prominent, which can lead to confusion with a digestive disorder and delay diagnosis. Palpitations, intense anxiety with sense of impending death are reported by many patients and constitute a major warning signal — the patient "feels" intuitively that something serious is happening. Pallor, malaise, sometimes syncope may occur.

It should be known that not all presentations are typical. Silent infarctions (without perceived pain or with minimal symptoms) represent up to 20% of cases, particularly in diabetic patients (neuropathy attenuating pain perception), elderly subjects, and women. These infarctions often go unnoticed and are only diagnosed retrospectively.

03Atypical symptoms in women#

A capital particularity to know concerns atypical presentations in women, particularly after age 50 and in diabetic women. These atypical presentations explain a diagnostic delay of 30 to 60 minutes on average in women compared to men, with serious prognostic consequences.

In women, several presentations may dominate the picture and mask the diagnosis. Extreme and unusual fatigue, sometimes present several days before acute infarction (prodromal fatigue), often wrongly attributed to overwork or menopause. Upper back pain between shoulder blades or epigastric pain resembling indigestion, without the classic chest band pain. Isolated jaw or neck pain, sometimes wrongly taken for cervical or dental pain. Nausea and indigestion prominent, wrongly suggesting gastroenteritis. Acute anxiety, general malaise difficult to describe but with a feeling that "something is wrong".

The essential message for women and their entourage: any unusual symptom persisting more than 20 minutes, particularly after age 50 or in presence of cardiovascular risk factors, should raise the possibility of infarction and lead to calling 141. Better a call for nothing than an infarction treated late. Several national and international campaigns now raise awareness of these atypical female presentations to reduce diagnostic delay.

04What to do urgently: every minute counts#

The English expression "Time is muscle" perfectly summarises the infarction issue: every minute of delay in coronary reperfusion corresponds to several hours of life lost statistically. The conduct must be known by all.

Step 1 — Immediately call 141 (SAMU in Morocco) or 15 as soon as suspected. Do not procrastinate, do not call your treating doctor, do not consult at the office — infarction is exclusively the responsibility of specialised hospital emergencies. SAMU regulators are trained to quickly recognise infarction suspicion and direct to the appropriate centre equipped for interventional cardiology. Above all, do not drive yourself to hospital or ask a non-medical relative to take you: cardiac arrest can occur at any time in the following hours, and you will be much better cared for in a medicalised ambulance with onboard ECG and defibrillator.

Step 2 — Stay calm and spare your heart. Lie down or sit in a comfortable position, torso slightly raised to facilitate breathing. Do not move, do not climb stairs, do not pack your bag. Physical effort worsens the oxygen deficit of the ischaemic heart.

Step 3 — Loosen clothing at the neck (collar, tie) and waist (belt) to facilitate breathing and circulation.

Step 4 — If you have aspirin available, chew an aspirin tablet of 250 to 500 mg (except in case of known aspirin allergy or formal contraindication). Aspirin prevents clot extension and improves survival chances. Chewing accelerates its absorption compared to simple swallowing.

Step 5 — Eat or drink nothing, even water, while waiting for emergency services. An intervention will probably be necessary on hospital arrival, and the stomach must remain empty in case of anaesthesia or sedation.

Step 6 — Prepare for emergency arrival: unlock the front door so they can enter even if you lose consciousness, make available your recent medical documents (prescriptions, reports) which will help the team.

Step 7 — If you witness cardiac arrest in a relative (sudden loss of consciousness, absence of breathing or abnormal gasp-type breathing), immediately start external cardiac massage. Strongly compress the sternum at 100 to 120 compressions per minute, on the rhythm of the song "Stayin' Alive" by Bee Gees or "La Macarena" — these two songs have precisely the right tempo. Compression depth should be 5 to 6 cm in adults. Do not stop until emergency arrival or if the victim regains consciousness. If an automated external defibrillator (AED) is available (present in some public places in Morocco — airports, large supermarkets, stations), use it following voice instructions — it is designed to be usable by any person.

Several behaviours to avoid: do not drive yourself to hospital (syncope risk at the wheel), do not wait "for it to pass", do not take paracetamol-type analgesics which will have no effect on cardiac pain, do not smoke a cigarette to "calm down" (tobacco dramatically worsens the situation), do not drink alcohol, do not give in to the idea of not bothering emergency services for nothing.

05Hospital treatments#

On hospital arrival, after diagnosis confirmation by ECG (characteristic ST elevation) and troponin dosing (biological marker of myocardial necrosis), management aims for the fastest possible coronary reperfusion.

Primary angioplasty, the reference treatment

Primary angioplasty is the treatment of choice in countries with the necessary technical platforms. This interventional cardiology procedure consists of introducing a catheter through the radial artery (wrist) or femoral (groin) and mounting it to the coronary arteries under radiological control. Once the obstructed artery is identified and crossed by a guide, a balloon is inflated to open the artery, then a stent (small metallic mesh spring, most often drug-eluting to limit restenosis) is deployed to keep the artery open. The procedure lasts about 30 to 60 minutes and allows complete reperfusion in 90-95% of cases, with excellent prognosis provided it is performed early.

The objective set by international recommendations is a delay below 90 minutes between first medical contact and coronary dilatation (door-to-balloon time). In Morocco, several centres practise primary angioplasty 24/7, including CHUs Ibn Rochd in Casablanca, Ibn Sina in Rabat, Hassan II in Fes, Mohammed VI in Marrakech, and several equipped private clinics in major cities (Cardiocheikh, Hôpital Cheikh Khalifa, etc.). Territorial coverage is improving but remains uneven, often justifying medicalised transport to the nearest reference centre.

Intravenous thrombolysis

When primary angioplasty cannot be performed within 2 hours of diagnosis (distant centre, long transport, catheterisation lab unavailability), intravenous thrombolysis by injection of tenecteplase or alteplase is a validated alternative. These drugs dissolve the clot and allow reperfusion in about 60-70% of cases. Thrombolysis is effective especially in the first 3 hours, its efficacy rapidly decreasing beyond. It can be administered in any hospital equipped with emergencies, even in some medicalised ambulances (pre-hospital thrombolysis), making it more accessible than angioplasty. Main risks are haemorrhagic complications (cerebral haemorrhages in approximately 1% of cases).

A combined strategy called "pharmaco-invasive" is often adopted: initial thrombolysis then transfer to an angioplasty centre to evaluate efficacy and complete by coronary dilatation if necessary.

Lifelong post-infarction medications

Beyond the acute phase, basic medical treatment is crucial to prevent recurrences. Several therapeutic classes are systematically prescribed in absence of contraindication. Low-dose aspirin (75 to 100 mg per day) for life to prevent new clot formation. A second antiplatelet (clopidogrel/Plavix, ticagrelor/Brilique, or prasugrel) in association with aspirin for at least 12 months (sometimes more depending on stents placed). A beta-blocker (bisoprolol, metoprolol) which slows heart rate, decreases myocardial oxygen consumption and prevents rhythm disorders. A high-potency statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) to stabilise atheroma plaques and lower LDL below 0.55 g/L (the lowest target). An ACE inhibitor like ramipril or perindopril, or a sartan in case of intolerance, which protects cardiac function and prevents ventricular remodelling. In case of impaired cardiac function, anti-aldosterones (spironolactone, eplerenone) may be added.

Myocardial infarction is recognised as ALD in Morocco, entitling to 100% coverage by CNOPS, CNSS or AMO Tadamon for all care related to coronary pathology, including lifelong medications which can represent several hundred dirhams per month.

06Recovery after infarction#

The post-infarction phase is crucial for functional recovery, recurrence prevention, and return to satisfactory quality of life. Several structured stages are recommended.

Cardiac rehabilitation

Cardiac rehabilitation, ideally started 2 to 4 weeks after infarction, is an essential phase often underused in Morocco. It includes a structured 3 to 6 month programme combining progressive physical retraining under medical supervision (initial stress test then exercise sessions in equipped room with monitoring), therapeutic education on coronary disease and risk factors, psychological support as post-infarction depression affects approximately 30% of patients and significantly worsens prognosis, dietary consultation to adapt diet to cardio-protective regimen, practical advice on returning to work, sexual activity, driving. Benefits of cardiac rehabilitation are demonstrated: 25-30% reduction in cardiovascular mortality, improvement of effort capacity, superior quality of life. Several centres in Morocco now offer this service (CHUs and some specialised private clinics).

Return to daily life

An indicative timeline allows planning progressive resumption of activities. Return to work generally occurs at 4 to 8 weeks depending on the type of profession (earlier for sedentary work, later for physical jobs) and after cardiologist agreement. For very high cardiac strain jobs (lifeguard, heavy goods driver, firefighter), a reorientation may be necessary. Resumption of sexual activity is possible 2 to 4 weeks after a simple uncomplicated infarction, with progressive intensity. Resumption of driving requires a minimum of 4 weeks with cardiologist agreement; heavy goods or public transport driving may be more restrictive. Air travel is allowed 2 weeks after a simple uncomplicated infarction.

Long-term follow-up

Long-term cardiology follow-up is essential for life. A cardiology consultation is recommended 1 to 2 times a year, with clinical evaluation, ECG, sometimes cardiac ultrasound and biological workup. A stress test is generally performed at 1 year then every 2 to 5 years according to clinical context. Coronary angiography of control may be indicated in case of symptom recurrence or signs of ischaemia on non-invasive examinations. Risk factor surveillance is crucial: blood pressure, glycaemia, cholesterol, weight, smoking.

07Prevention: 80 to 90% of infarctions are preventable#

The INTERHEART study published in Lancet in 2004, which analysed 30,000 patients in 52 countries, demonstrated that 9 modifiable risk factors explain 90% of myocardial infarctions worldwide. This extraordinary data means that the vast majority of infarctions are theoretically preventable by better control of these factors. Here are the most effective prevention axes.

Complete smoking cessation is the single most profitable measure. Active smoking multiplies infarction risk by 2 to 3, and quitting progressively restores risk towards a non-smoker over 5 to 10 years. For a patient who has already had an infarction, recurrence risk is halved by quitting smoking. Nicotine substitutes, medications (varenicline, bupropion) and medical support multiply success chances by 5 to 8. In Morocco, several tobacco-cessation consultations exist in public and private sectors.

Strict blood pressure control with a target below 140/90 mmHg, or below 130/80 mmHg in diabetics, is the second major measure. A 10 mmHg systolic reduction decreases infarction risk by approximately 20%.

Cholesterol control by adoption of an adapted diet and, if necessary, statin prescription. The LDL target for secondary prevention after infarction is now below 0.55 g/L (5 mmol/L), which may require therapeutic combinations (high-dose statin + ezetimibe + sometimes PCSK9 inhibitor).

Strict diabetes control with HbA1c target below 7% in the majority of patients, and below 6.5% in young patients without hypoglycaemic risk. Using new cardio-protective antidiabetics (SGLT2i, GLP-1) brings cardiovascular benefit independent of glycaemic control.

Regular physical activity is essential: at least 150 minutes per week of moderate aerobic activity (brisk walking, swimming, cycling), ideally complemented by 2 strength training sessions. Physical activity reduces infarction risk by approximately 25-30% and improves all other risk factors.

A Mediterranean-type diet rich in fruits, vegetables, whole grains, legumes, fish, olive oil, dried fruits, and limited in red meats, processed meats, added sugars and ultra-processed foods. The PREDIMED study demonstrated a 30% reduction in cardiovascular risk with this diet.

Maintaining a healthy weight (BMI between 18.5 and 25, waist circumference below 94 cm in men and 80 cm in women) limits associated risk factors. Stress management by validated techniques (meditation, cardiac coherence, sophrology, physical activity) contributes to prevention. Moderate alcohol consumption (less than 2 glasses per day if you drink, with no obligation to start if you do not drink) does not seem to increase risk.

For at-risk patients, an annual cardiovascular check-up after 40 in men and 50 in women is recommended: blood pressure, fasting glycaemia, lipid panel, ECG, calculation of global cardiovascular risk score (SCORE2 or Framingham). For very high-risk subjects (family history of early infarction, familial hypercholesterolaemia, poorly balanced diabetes), more advanced explorations may be proposed (coronary calcium score on CT scan, carotid ultrasound).

Secondary prevention (after a first infarction) is even more effective than primary prevention: a post-infarction patient who rigorously adopts recommendations can divide their recurrence risk by 2 or 3. This is the best response to give after a cardiac event — transforming this dramatic episode into an opportunity to durably change one's lifestyle.