Patient information: Heart attack recovery

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".) 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 every day. Some of these medications can help you to live longer while others help to prevent or treat recurrent symptoms, like 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".)

• Clopidogrel (Plavix®) is given to people who have had a stent placed (to open a blocked artery), and may be used in some other situations as well. Clopidogrel is usually taken for at least one year, and may be recommended indefinitely.

• A beta blocker is a medication that lowers your blood pressure and decreases your heart's demand for oxygen. If you cannot tolerate a beta blocker, another medicine may be used in it's place.
• Nitrates are a medication that widen (dilate) coronary blood vessels, bringing more blood to the heart muscle. Nitrates also decrease the blood pressure and reduce the amount of blood returning to the heart, which decreases the heart's demand for oxygen. Nitrates are often given to treat or prevent further episodes of chest pain. Nitrates are available in short-acting forms (nitroglycerin) and long-acting preparations (isosorbide mononitrate or dinitrate). (See "Patient information: Angina treatment — medical therapy".)

• An ACE inhibitor can lower blood pressure and limit the size or damaging effects of the heart attack; it may also help prevent heart failure and future heart attacks.
• A statin is a medication that helps to lower your cholesterol levels. Statins are sometimes recommended after a heart attack, even if your cholesterol levels are "normal". (See "Patient information: High cholesterol and lipids (hyperlipidemia)".)

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 rehabiliation. 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.

Heart healthy diet — 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".)

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 varenicline (Chantix®) or bupropion (Zyban®, Wellbutrin®). (See "Patient information: Smoking cessation".)

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".)

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

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".)

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".)

WHEN IS SEX SAFE?

An important issue for many people who have had a heart attack is knowing when it's 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 sildenafil (Viagra®), tadalafil (Cialis) or vardenafil (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".)

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".)

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. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

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

Professional Level Information:
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: Risk factor reduction
Sexual activity in patients with heart disease

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• 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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