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What Is MONA and Is It Still Used During a Heart Attack

Medically reviewed by Uzochukwu Ibe, MD, MPH — By Daniel Yetman on October 21, 2022MONA is a mnemonic that was taught to medical professionals, such as doctors, nurses, and emergency medical technicians (EMTs), for the initial management of a suspected heart attack. It stands for:morphineoxygen therapynitratesaspirin MONA is no longer taught to new health professionals. Emerging research, including reviews of studies, suggests that MONA isn’t as effective as previously thought. Of the four MONA treatments for heart attack, only aspirin is still routinely recommended by the American Heart Association (AHA) and the American College of Cardiology (ACC). Read on to learn more about MONA, including why it’s no longer taught and what medical associations now recommend.

What is MONA

MONA was a mnemonic taught to emergency room personnel and EMTs for the initial treatment of acute coronary syndrome. Acute coronary syndrome is a group of conditions characterized by lack of blood flow to the heart. These conditions include:Unstable angina: Unstable angina is characterized by reduced blood flow to your heart that puts you at risk of a heart attack.ST-segment elevation myocardial infarction (STEMI): STEMI, or a classic heart attack, is caused by a complete obstruction of your coronary artery.Non-ST segment elevation myocardial infarction (NSTEMI): NSTEMI is usually a less damaging type of heart attack caused by a partial obstruction of the coronary artery. The goals of MONA were to:reduce symptomsprevent or limit heart damageimprove outcomes The MONA mnemonic wasn’t intended to specify what order treatment should be administered but simply provided an easy way to remember the components.

MONA treatments

The four treatments that made up MONA include:Morphine: Morphine is an opioid pain medication that’s given to reduce pain associated with a heart attack. Its use for heart attacks dates back to at least the 1930s.Oxygen therapy: Oxygen therapy is when medical professionals give you extra oxygen through a mask or tube to increase oxygen levels in your blood. It has been used to treat heart attacks since about 1900.Nitrates: Nitrates are medications that help relax your arteries to increase blood flow to your heart. Nitrates have been used to treat cardiovascular disease since the late 1800s.Aspirin: Aspirin is administered after a heart attack to help thin your blood and reduce blood clots that may be contributing to a blockage. Aspirin’s blood-thinning effects have been recognized since the 1960s. Over the past 100 years, the risk of in-hospital death after a heart attack has decreased by about 90%. However, some parts of the MONA treatment may be associated with poorer outcomes. For example, in a 2015 study, researchers compared the outcomes of people with STEMI (a classic heart attack), without low blood oxygen levels, who either received 8 liters per minute of oxygen or no oxygen. The researchers found that administering oxygen was associated with more heart damage at 6 months.

Why is MONA no longer used for heart attacks

In a 2015 review of studies, researchers found evidence that the routine use of morphine, oxygen therapy, and nitrates isn’t supported. They concluded that MONA should be reconsidered as a teaching aid. In a 2018 review, researchers concluded that MONA should be viewed as obsolete. It’s now thought that strictly following MONA might do more harm than good because it doesn’t include the use of potentially beneficial drugs. Of the four steps, only aspirin is still routinely recommended as an initial heart attack treatment by the AHA and ACC. The other treatments are still recommended in specific situations. Here’s a summary of what research has found about each MONA treatment and the recommendations of the AHA and ACC:TreatmentFindingsAHA/ACC recommendationsMorphine– No benefit for decreasing death rate
– Associated with higher death rate in people with NSTEMI
– Perhaps more heart damage in people with STEMI– NSTEMI: moderate recommendation
– STEMI: drug of choice for pain reliefOxygen therapy– No benefit for decreasing death rate
– Associated with higher risk of recurrent heart attack or major arrhythmias– NSTEMI: strongly recommended when oxygen saturation is under 90%
– STEMI: may be used if oxygen saturation is under 90%Nitrates– No benefit for decreasing death rate– NSTEMI: strongly recommended for persistent lack of blood flow (ischemia), heart failure, or high blood pressureAspirin– Associated with improved death rate– Strongly recommended for NSTEMI and STEMI

What s replaced MONA for heart attack

The AHA and ACC still strongly recommend the use of aspirin in initial heart attack treatment, except for anyone who’s not able to take it safely. Many different medications are under investigation for the initial treatment of heart attacks.

THROMBINS2

In a 2015 study, researchers proposed a new mnemonic, known as THROMBINS2, to include a wider range of current treatment options, which includes:thienopyridines, including prasugrel and clopidogrelheparin, including enoxaparinrenin-angiotensin system blockersoxygen therapymorphinebeta-blockersinvasive surgery to widen the blocked coronary arterynitroglycerinstatins and salicylate (aspirin) This expanded list of treatments is now part of current heart attack management.

What are the symptoms of a heart attack

The Centers for Disease Control and Prevention recommends calling 911 or local emergency services immediately if you or somebody you’re with develops symptoms of a heart attack. The primary symptoms include:chest painshortness of breathweaknesslightheadedness or faintness that may cause a cold sweatpain in your jaw, neck, or backpain in one or both of your arms or shouldersnausea and vomiting After calling 911, the Red Cross recommends:being prepared to administer CPR or an automated external defibrillator if the person stops breathing and becomes unresponsivehelping the person into a comfortable position and loosening tight clothinggetting the person’s medication if they have medication prescribed for chest painreassuring and monitoring them until the ambulance arrivesoffering aspirin if the person is responsive, able to chew, and doesn’t have a medical condition that prevents them from receiving aspirin safely

The bottom line

MONA is a mnemonic that used to be taught to new medical professionals to help them memorize how to treat heart attacks. New research has made MONA outdated, however. Of the four MONA treatments, current guidelines only recommend routine administration of aspirin. The other three treatments are still administered in specific situations. It’s important to call 911 any time you suspect you or somebody you’re with is having a heart attack. The sooner treatment is started, the lower the chances of having severe complications. Last medically reviewed on October 21, 2022

How we vetted this article

SourcesHistoryHealthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.Bonin M, et al. (2018). Effect and safety of morphine use in acute anterior ST-segment elevation myocardial infarction.
ahajournals.org/doi/10.1161/JAHA.117.006833Divakaran S, et al. (2017). The role of nitroglycerin and other nitrogen oxides in cardiovascular therapeutics.
ncbi.nlm.nih.gov/pmc/articles/PMC5687289/Gouda P, et al. (2015). The demise of morphine oxygen nitroglycerin aspirin (MONA).
onlinecjc.ca/article/S0828-282X(15)01566-4/fulltextHeart attack symptoms, risk, and recovery. (2022).
cdc.gov/heartdisease/heart_attack.htmJneid H, et al. (2017). 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non–ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.
ahajournals.org/doi/10.1161/HCQ.0000000000000032Kline KP, et al. (2015). Historical perspective and contemporary management of acute coronary syndromes: From MONA to THROMBINS2.
pubmed.ncbi.nlm.nih.gov/26457728/Layne K, et al. (2017). Antiplatelet therapy in acute coronary syndrome.
ncbi.nlm.nih.gov/pmc/articles/PMC6206448/McCarthy CP, et al. (2017). Time-honored treatments for the initial management of acute coronary syndromes: Challenging the status quo.
sciencedirect.com/science/article/abs/pii/S1050173817300555?via%3DihubNunes de Alencar Neto J. Morphine, oxygen, nitrates, and mortality reducing pharmacological treatment for acute coronary syndrome: An evidence-based review. (2018).
ncbi.nlm.nih.gov/pmc/articles/PMC5866121/Petrovic L, et al. (2022). Selecting a treatment modality in acute coronary syndrome.
ncbi.nlm.nih.gov/books/NBK544273/Responding to emergencies. (n.d.).
redcross.org/content/dam/redcross/training-services/course-fact-sheets/RTE-IM-Sample.pdfOur experts continually monitor the health and wellness space, and we update our articles when new information becomes available. Current Version Oct 21, 2022 By Daniel Yetman Edited By Rosalie Rung Medically Reviewed By Uzochukwu Ibe, MD, MPH Copy Edited By Brennan Doherty Share this articleMedically reviewed by Uzochukwu Ibe, MD, MPH — By Daniel Yetman on October 21, 2022

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