Heart Mnemonics: MONA-BASH + POND – What to do 1st when your patient has a “broken heart”…

By Molly Lewis

When a patient presents with something as life-threatening as a heart attack or acute heart failure, the urgency can cloud decision-making. Use these mnemonics to quickly recall the initial steps of management, keeping in mind that treatment must be tailored to the individual patient based on the latest clinical guidelines and evidence.

For a suspected heart attack (myocardial infarction/MI), students were traditionally taught to remember MONA:

• Morphine: for pain relief and to reduce the cardiac workload, though its use has become more cautious over the years.
• Oxygen: for hypoxic patients, with an oxygen saturation < 90% or in respiratory distress.
• Nitroglycerin: for vasodilation and to reduce oxygen demand, with contraindications in certain conditions.
• Anti-platelet drugs: aspirin and ADP receptors to inhibit platelet aggregation, a key treatment for acute MI.

This mnemonic can be expanded to MONA-BASH to include other initial treatments and considerations:

• Beta-blockers: to reduce myocardial O2 demand by slowing the heart rate, used cautiously in the acute setting depending on the patient’s hemodynamic status.
• ACE inhibitors: to reduce vascular resistance and manage blood pressure, typically started within the first 24 hours after an MI in patients without hypotension.
• Statins: to lower cholesterol levels and stabilize plaque, recommended to be initiated early in patients with acute coronary syndrome.
• Heparin (or other anticoagulants): to prevent further thrombosis. The choice between unfractionated heparin, low molecular weight heparin, or direct oral anticoagulants depends on the clinical scenario and guidelines.

This rule isn’t true for all heart attacks. For example, in a pure right ventricular infarction, it’s best to avoid vasodilators like nitroglycerin (NG), since you want to maintain venous return. The weakened right ventricle needs enough blood coming into it that at least some of it will make it out of the RV, into the LV, and out to the tissues! Also, it’s best to avoid NG in patients who are in cardiogenic shock (i.e. are hypotensive).

There are other important urgent treatment strategies for MI’s, but…for most heart attacks, MONA-BASH is an excellent 1^st step treatment strategy.

For acute heart failure / a CHF exacerbation (i.e. a patient presenting with acute pulmonary edema), remember POND:

• Positioning (upright) and non-invasive Positive Pressure Ventilation: elevate the head of the bed to improve breathing and reduce pulmonary congestion. Noninvasive positive-pressure ventilation, such as CPAP or BiPAP can be used for patients with respiratory distress by improving oxygenation and reducing the work of breathing.
• Oxygen: used to address hypoxia, a common issue in acute heart failure.
• Nitrates: for vasodilation to reduce the preload and afterload, improving cardiac output
• Diuretics: loop diuretics like furosemide are used to reduce fluid overload and relieve symptoms of pulmonary edema.

While there are some similarities to the 1^st steps of treatment of acute heart failure and treating an MI, it’s important to understand the differences.  Of course, the cause of the patient’s acute heart failure could be an MI, in which case you could use both treatment strategies!

Now that your patient is stabilized using MONA-BASH or POND, you can take a minute to catch your breath and plan the strategy for the rest of his or her treatment!

Bonus fact:

Why use morphine to treat a heart attack?

It causes venodilation! This reduces preload and therefore decreases the myocardial oxygen demand. Plus, it relieves the pain and anxiety involved in an acute MI. Helping the patient relax reduces catecholamine release, which leads to a slower heart rate, further decreasing the amount of oxygen needed by the heart. So, its calming ability makes it especially useful in a patient who is restless and short of breath.