Patient information: Heart attack recovery (Beyond the Basics)

HEART ATTACK OVERVIEW

Recovering from a heart attack can be a long process, requiring you to make big changes in your life. You may need to change how you eat, begin a new exercise program, take new medicines, and visit your doctor on a regular basis. However, these treatments can help to lower your risk of having another heart attack, reduce your risk of death from heart disease, and often increase your ability to exercise and be active.

This article will review the steps involved in recovering from a heart attack. An overview of heart attack treatment is available separately. (See "Patient information: Heart attack (Beyond the Basics)".) More detailed information about cardiac rehabilitation is available by subscription. (See "Cardiac rehabilitation: Exercise training and secondary prevention of coronary heart disease in older adults" and "Efficacy of cardiac rehabilitation in patients with coronary heart disease".)

CARE AT HOME AFTER A HEART ATTACK

Discharge from the hospital — Most people can go home after about three to five days in the hospital. In some cases, the hospital stay could be longer (for example, if you have surgery). If you develop complications, you will not go home until your condition is stable.

Before leaving the hospital, it is important for you and your family to understand the discharge plan. Make sure all your questions are answered and get written directions for taking all medicines (new and old). After a heart attack, it is common to start new medicines and stop or adjust the doses of old medicines.

Medications — Most people who have had a heart attack are sent home with prescriptions for several medications. It is important to take each of these drugs exactly as directed. Some of these medications can help you to live longer while others help to prevent or treat recurrent symptoms, such as chest pain.

• Aspirin helps prevent future blood clots and decreases the risk of death after a heart attack. (See "Patient information: Aspirin and cardiovascular disease (Beyond the Basics)".)
• Clopidogrel (brand name: Plavix) and similar medications such as ticagrelor (brand name: Brilinta) or prasugrel (brand name: Effient) are given to people who have had a stent placed or received clot-busting drugs to open a blocked artery. These drugs are given with aspirin to prevent platelets from clumping inside arteries that feed the heart and can prevent re-blockage. DO NOT STOP THIS KIND OF MEDICINE WITHOUT FIRST CHECKING WITH YOUR HEART DOCTOR.
• A beta-blocker (example: metoprolol [brand names: Lopressor, Toprol-XL]) is a medication that protects your heart from stress and can prevent future heart attacks. It can slow your heart rate. It can take weeks for your body to get used to a beta-blocker. The dose may need to be changed a few times as your body adjusts.
• Nitrates (examples: isosorbide dinitrate [brand name: Isordil], nitroglycerin patch or pills) are medicines that widen (dilate) coronary blood vessels, bringing more blood to the heart muscle, and are used to treat or prevent chest pain. Nitrates should be taken exactly as prescribed by the doctor. (See "Patient information: Angina treatment — medical therapy (Beyond the Basics)".)
• An ACE inhibitor (example: lisinopril [brand name: Zestril) can help your heart work better after a heart attack and decrease the amount of damage from a heart attack; it may also help prevent heart failure and future heart attacks. ACE inhibitors also lower blood pressure.
• A statin (examples: atorvastatin [brand name: Lipitor], pravastatin [brand name: Pravachol]) is a medication that helps to lower bad cholesterol levels and can help prevent another heart attack or stroke. Because statins help stabilize fatty deposits inside the arteries that can cause heart attacks, they are often given in high doses after a heart attack, even if your cholesterol levels are normal or low. (See "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)

Medicines after a heart attack are important. To help you take them correctly, keep a current list of their names and how many times per day you take them. An example of such a list can be found at http://www.fda.gov/Drugs/ResourcesForYou/ucm079489.htm.

Some people have difficulty taking medicines several times per day. If this becomes a problem, ask your doctor or pharmacist if there are ways to reduce the number of times per day you take pills. The cost of medicines can also be a problem. There may be ways to lower costs. (See "Patient information: Reducing the costs of medicines (Beyond the Basics)".)

For more detailed information about your medicines, ask your doctor or nurse for information from Lexicomp, available through UpToDate. The Lexicomp hand-outs explain how to use and store your medicines. They also list possible side effects and warn you if your medicines should not be taken with certain other medicines or foods.

CARDIAC REHABILITATION AFTER HEART ATTACK

People who have had a heart attack are encouraged to participate in a structured cardiac rehabilitation (cardiac rehab) program. The program can improve your heart's ability to function, lower your heart rate, and reduce your risk of dying or developing complications from heart disease.

There are three parts to cardiac rehabilitation:

• Exercise
• Reduce risk factors
• Deal with stress, anxiety, and depression

You are most likely to benefit if you participate in all three parts of rehabilitation. However, if you cannot participate in all, you can still benefit by participating in one or two components.

Exercise — Exercise is known to improve cardiovascular health. Although nearly everyone can exercise safely after a heart attack, the intensity and duration of exercise depends upon the severity of your heart disease. Therefore, the first step in an exercise program is to determine your risk of complications from exercise. This is usually done by performing an exercise test on a treadmill.

During cardiac rehabilitation, a trained clinician will work with you and your doctor to develop an exercise program that is safe; this program will consider your fitness level, heart health, any physical limitations, the amount, intensity and duration of exercise needed to improve heart health, and the need for supervision. (See "Components of cardiac rehabilitation and exercise prescription".)

The exercise should use large muscle groups and include aerobic exercise. Walking, jogging, swimming, cycling, rowing, and stair climbing are some examples. You can also build exercise into your daily routine by taking a brisk walk or playing with children or grandchildren. Over time, most people can gradually increase the intensity of exercise in their workout.

The recommended frequency of exercise is three to five times a week. Each session should include the following:

• 5- to 10-minute warm-up phase
• Conditioning phase of at least 20 minutes
• 5- to 10-minute cool-down phase

Eliminating the warm-up or cool-down phase can increase your risk of heart-related complications.

Reduce risk factors — A number of factors increase your risk of developing heart disease and having a heart attack. Reducing or eliminating these risk factors can be helpful, even if you already have heart disease or had a heart attack.

Stop smoking — Cigarette smoking markedly increases your risk of coronary heart disease and heart attack, and stopping smoking can rapidly reduce these risks. One year after stopping smoking, the risk of dying from coronary heart disease is reduced by about one-half, and the risk continues to decline with time. In some studies, the risk of heart attack was reduced to the rate of nonsmokers within two years of quitting smoking.

Cardiac rehabilitation programs can recommend a treatment to help stop smoking, such as group programs, nicotine patches, gum, or nasal spray, or a prescription medication such as bupropion (brand names: Zyban®, Wellbutrin®). (See "Patient information: Quitting smoking (Beyond the Basics)".)

Treat high blood pressure — Medicines to control high blood pressure are often recommended after a heart attack. It is important to take these medications exactly as prescribed. (See "Patient information: High blood pressure treatment in adults (Beyond the Basics)".)

Treat high cholesterol — Medicine to lower blood cholesterol levels is also recommended after a heart attack. (See 'Medications' above and "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)

Manage diabetes — People with diabetes are at an increased risk of developing complications after a heart attack. Tight control of your blood sugar can help to reduce the risk of these and other types of complications. Tight control can be achieved by losing weight, managing your diet, exercising, monitoring blood sugar levels regularly, and taking oral medications (for people with type 2 diabetes) or insulin (for people with type 1 and sometimes type 2 diabetes). (See "Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)".)

Dietary counseling — Diet counseling is helpful for people who need to lose weight or reduce cholesterol levels. A registered dietitian is the best person to consult about foods that are helpful, appropriate portion sizes, total calorie recommendations, and realistic ways to change bad eating habits. Most cardiac rehab programs have a dietitian who is knowledgeable and experienced in advising people who are recovering from a heart attack. (See "Patient information: Diet and health (Beyond the Basics)".)

Psychosocial treatment — Feelings of depression, anxiety, and denial are common after a heart attack, occurring in up to 20 percent of people. Depression can make it hard to exercise, decrease energy levels, cause fatigue, and reduce your quality of life and sense of well being. Women, and in particular younger women, are at an especially high risk for depression after heart attack.

These symptoms often translate into problems within the family, marriage, and the workplace. Individual or group therapy, and sometimes treatment with an antidepressant medication, can be beneficial. Many cardiac rehabilitation programs have trained personnel, including psychologists, psychiatrists, and social workers to help manage these issues. Getting treatment for depression and anxiety can improve your long term outlook and general sense of well being. (See "Patient information: Depression treatment options for adults (Beyond the Basics)".)

WHEN IS SEX SAFE?

An important issue for many people who have had a heart attack is knowing when it is safe to have sex. In the first two weeks after an uncomplicated heart attack, most people are at high risk of heart-related problems during sex. However, this risk becomes much smaller at six weeks after the heart attack.

If you had complications with your heart attack, such as recurrent chest pain, abnormal heart rhythms (arrhythmias), or heart failure, you are at intermediate to high risk of heart-related problems during sex. People in these risk groups need further evaluation and/or treatment before attempting to have sex. A cardiologist or internal medicine specialist can help to determine when sex is safe.

Sexual problems — Sexual problems after a heart attack are common, occurring in one-half to three-quarters of patients. Both men and women may have less sex or feel less satisfied with sexual activity after heart attack. A variety of factors may contribute, including side effects of drugs (such as beta blockers), depression, and fears about triggering a new heart attack or dying. Since sexual activity is a type of physical activity, exercise testing can be used to determine if you are at risk of heart problems related to sex.

Treatment for men — For many men with erectile dysfunction, medications such as sildenafil (brand name: Viagra), tadalafil (brand name: Cialis) or vardenafil (brand name: Levitra) are highly effective. If used appropriately, these drugs appear to be well tolerated and safe, even after a heart attack. (See "Patient information: Sexual problems in men (Beyond the Basics)".)

There is one important exception: none of the medications for erectile dysfunction should be used if you take nitrates (such as nitroglycerin or isosorbide) on a regular basis or even occasionally for chest pain. This combination of medications can cause a life-threatening drop in blood pressure.

Thus, if you develop chest pain after taking Viagra, Cialis or Levitra, you should not take nitrates. Instead, you should call for emergency medical services (available in the United States and Canada by calling 911).

Treatment for women — Unfortunately, medications for erectile dysfunction are not usually helpful for women who develop sexual problems after a heart attack. Other treatments are available for women. (See "Patient information: Sexual problems in women (Beyond the Basics)".)

FOLLOW-UP CARE AFTER HEART ATTACK

Following your healthcare provider's advice and participating in a cardiac rehabilitation program are the best ways to recover from a heart attack. In addition, it is important to schedule and attend periodic visits with your internal medicine provider and/or cardiac specialist (cardiologist).

Follow-up care is very important; people who have had one heart attack have a significantly increased risk of more cardiac events, including chest pain, another heart attack, heart failure, and an increased risk of dying. The risk of these problems can be reduced by following recommendations for rehabilitation, follow up visits, and treatments. Over time, the treatment plan may change as your heart health improves or other medical problems develop.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Heart attack (The Basics)
Patient information: Heart attack recovery (The Basics)
Patient information: Sex as you get older (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Heart attack (Beyond the Basics)
Patient information: Aspirin and cardiovascular disease (Beyond the Basics)
Patient information: Angina treatment — medical therapy (Beyond the Basics)
Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)
Patient information: Diet and health (Beyond the Basics)
Patient information: Quitting smoking (Beyond the Basics)
Patient information: High blood pressure treatment in adults (Beyond the Basics)
Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)
Patient information: Depression treatment options for adults (Beyond the Basics)
Patient information: Sexual problems in men (Beyond the Basics)
Patient information: Sexual problems in women (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cardiac rehabilitation: Exercise training and secondary prevention of coronary heart disease in older adults
Components of cardiac rehabilitation and exercise prescription
Efficacy of cardiac rehabilitation in patients with coronary heart disease
Exercise assessment and measurement of exercise capacity in patients with coronary heart disease
Rehabilitation after cardiac transplantation
Secondary prevention of cardiovascular disease
Sexual activity in patients with heart disease

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

     (www.nhlbi.nih.gov)

• American Heart Association

     (www.americanheart.org)

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