Heart Attack Bouncing Back

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A manual for heart attack survivors and those who love them

by Suzanne Cambre, RN, BSHA

Barbara Johnston Fletcher, RN, MN, FPCNA, FAHA, FAAN

Julia Ann Purcell, RN, MN, FAAN

This book is to help you learn about your heart. It should not be used to replace any of your doctor’s advice or treatment.

“Here’s to your future good health!”

Most heart attack survivors return to full activity within a matter of weeks. A heart attack is a warning that it’s time to focus on a healthier future. The key is to learn the answers to these questions:

• What happened to my heart?

• What can I do to help my heart heal?

• What can I do to become healthier and not have another heart attack?

This book will answer these questions and help you take charge of your future. Your doctors and nurses can also answer your questions and help you make changes that will lead to a healthier heart.

As you read, keep in mind that you may have a lot of emotions as you recover from your heart attack. You may even wonder if you really had a heart attack. All of this is normal.

What Happened To My Heart?

A heart attack is most often caused by a blood clot. It forms a dam in the stream of blood taking oxygen to your heart muscle.

Right coronary artery

Ask your doctor to show you the artery blockage and the part of your heart that was damaged.

Left anterior descending artery

Circumflex artery

Coronary arteries carry blood and oxygen to your heart muscle. Over time, these arteries can become narrowed by fatty deposits (plaque). This is like rust building up inside a pipe. Inflammation of the artery lining is likely a key part of this process, called coronary artery disease (CAD)*.

When the artery lining is inflamed, splits in the plaque are likely making it easier for blood clots to form. These clots block the flow of blood and oxygen to the heart muscle. Without oxygen, part of the heart is damaged. This is a heart attack, also called a myocardial infarction (MI), a “coronary,” or acute coronary syndrome (ACS).

It’s rare, but sometimes spasm of a heart artery can stop blood flow to part of the heart muscle, causing a heart attack.

An unusual cause of heart attack is Spontaneous Coronary Dissection (SCAD), which is caused by a small tear and blood clot that blocks blood flow to the heart. This is more common in women less than 60 years of age.

spasm

artery blood flow stops

* also called coronary atherosclerosis

Diagnosis and treatment

After hearing your symptoms, your doctor does a physical exam and uses certain tests to tell that you’ve had a heart attack:

blood tests - measure enzymes that go up with heart damage

EKG or ECG (electrocardiogram)can show heart damage or changes in the rhythm or heart rate

MPI (myocardial perfusion imaging) - shows areas of heart muscle not getting good blood flow

Sometimes an ultrasound of the heart (echocardiogram) is done to see how well the damaged heart is squeezing. A chest x-ray is common to see if there is fluid buildup.

Early treatment

The amount of heart damage you have depends on how fast you got treatment. In many cases, early treatment can lessen the amount of damage.

During your hospital stay, the main goals are to prevent further damage and get you on your way to full recovery. Some tests and treatments may be needed right after your heart attack and some later in your recovery.

Drugs

Often heart damage is less if the blocked artery can be opened in the first few hours after symptoms start. A clot-buster drug (thrombolytic) may be used to try and dissolve any blood clot blocking a heart artery. Often heparin is given to reduce the chance of another blood clot.

Other drugs may be given to:

relax the heart arteries and relieve heart attack symptoms

improve blood pressure (or heart rate)

treat abnormal heart rhythms

help the heart muscle squeeze better

Cardiac cath (catheterization)

A cardiac cath is often done in the early stages of a heart attack. It is an x-ray study of the heart arteries. The cath pictures help your doctor decide if a balloon procedure (angioplasty and/or stents) or bypass surgery can reduce the chance of more heart damage and improve long-term survival.

A small catheter (tube) is placed into an artery in your groin (or wrist) and passed along to the heart. When the tube is in place, a liquid contrast is injected*. X-ray moving pictures are made of the heart arteries and chambers. Many times treatment is decided at this point.

* This contrast "dye" may contain iodine. If you have an iodine allergy or are allergic to shellfish, alert your doctor before the cath.

left coronary artery dye

Angioplasty / Stents

Angioplasty is a procedure to open narrowed heart arteries so more blood can get to the heart muscle. Angioplasty or PCI (percutaneous coronary intervention) can be done with one or more of these:

balloon catheter - stretches open a narrowed artery

stent - metal coil that props open a narrowed or collapsed artery

atherectomy - removes layers of fatty plaque

Balloon angioplasty often works to open a blocked artery. Many times a stent is left in place to keep a dilated artery open over time. Either a bare metal stent or a drug-eluting stent (DES) is used, based on which is best for the narrowed artery. DES stents are coated with a drug to help prevent future buildup at the site (restenosis). Blood clots can form in either kind of stent. Anti-platelet drugs like aspirin and/or Plavix®, Effient® or Brilinta® are standard therapy to prevent stent blood clots—for weeks, months or even years. When an artery is not suitable for a stent, other treatments are offered.*

Bypass surgery

Surgery is sometimes done in the early stages of a heart attack to prevent life-threatening damage. A vein from the leg or artery from the chest is used to reroute blood flow around blocked arteries.

If another health care provider tells you to stop your antiplatelet medicine, you should ask your heart doctor before stopping them. This could do more harm than good.

*If you know of any planned surgery within a year of your stent, please let your doctor know. This will help make the decision of what type of stent is used.

artery wall

stent balloon catheter

artery wall stent

Possible problems

Many people have no problems after a heart attack and go home in 3 to 5 days. Others may need to stay in the hospital longer to treat one of these problems:

arrhythmias (dysrhythmias) - changes in the heartbeat

Drugs are often used to prevent or control changes in heart rhythm. Once in a while, a shock must be given to restore a normal beat. Sometimes a pacemaker or implantable cardiac defibrillator (ICD) is needed.

pericarditis - inflammation of the sac around the heart

There may be pain in the chest, neck or shoulder. It may hurt to breathe or move and can feel like another heart attack. Most of the time, anti-inflammatory drugs heal the heart sac quickly.

Possible problems (continued)

heart failure (also called congestive heart failure or CHF) - means the heart is having trouble pumping enough blood

This can lead to extra fluid in the body and in the lungs, often causing shortness of breath and swelling. Drugs are used to make it easier for the heart to fill with blood and help with pumping. Other drugs get rid of the extra fluid (diuretics), replace lost minerals (potassium), and prevent blood clots (blood thinners). Often heart failure improves after a heart attack as healing begins. You will learn to:

eat less salt (sodium)

weigh daily

report rapid weight gain (often fluid)

report any new shortness of breath

Sometimes an intra-aortic balloon pump is needed to treat heart failure. A balloon catheter is guided into the aorta (main blood vessel). This catheter is attached to a pump. Balloon deflation makes it easier for the heart to pump out the blood. Balloon inflation boosts blood flow in the heart arteries. Once heart pumping is better, the balloon catheter is removed.

cardiogenic shock - can happen with severe heart damage. This may include more intense care, special medicines for blood pressure and heart pumping and special mechanical devices.

Hearts do heal

A heart attack is like a quick blow to the heart. The heart can be “stunned” by the lack of blood and oxygen. When the blocked artery can be opened quickly enough, the damaged muscle gains back more of its normal function.

Soon after a heart attack, small arteries (collaterals) near the damaged area begin to expand. They bring blood to the area around the blocked artery. This may help limit the amount of damage. Within a few weeks or months, damaged heart cells are replaced by scar tissue as the heart heals. Common drugs often given to reduce risk of a future heart attack include:

aspirin or an antiplatelet

“statin” and/or other drugs to help keep cholesterol and blood fats in normal range

beta blocker and/or

ACE inhibitor (or ARB)

Sometimes a blood thinner (anticoagulant) may be needed.

expanding arteries (collaterals) damaged area that may recover

scar tissue

The emotional ride

Knowing what to expect after a heart attack can help you, your family and friends deal with the changes.

You may find that your emotions go up and down like a roller coaster the first few days after a heart attack.

Have people around you who care. Talk about what scares you, and ask questions about how you are doing. Holding in emotions only makes them more intense. Let family and friends help you work through them.

Denial

Early denial is very common after a heart attack. Many people have less pain than they thought they would with a heart attack, so they feel their problem is not that serious. You may even have said, “I can’t be having a heart attack.” If you feel this way, you are not alone. When heart attacks are mild, it’s common for people to deny that they even happened. This is risky.

People in denial may start smoking, resume eating high-fat foods, stop doing their exercise and taking their medicines. Going back to bad habits could lead to more heart disease and another heart attack. Your choices in life have a lot to do with your heart’s health.

As you begin to accept that you’ve had a heart attack, ask questions. Find out about your test results and plans for your care. When you know what’s going on, you can choose those habits that will keep you healthy.

Depression

After a heart attack some people become sad or withdrawn. Depression is common. You may not be able to do the things you used to do to cope with hard times (like smoking or eating a bag of fatty potato chips). This can make depression even worse. Give yourself time. Look for new ways to cope:

Talk to a close friend, family member or someone who has had a heart attack*.

Try to start each day with a good outlook. You can start by getting dressed each morning. Don’t stay in your pajamas all day.

Try to be more active. Do some form of exercise each day.

Tell your healthcare team if you still feel sad or depressed beyond the first week or two. If left untreated, depression can affect your recovery.

A heart attack affects you AND the people who care about you. They often have the same fears as you. Keep a sense of humor, and remember that most people return to a full and productive life after a heart attack.

* Mended Hearts Inc. (mendedhearts.org) is an organization of heart attack survivors who are willing to give this support. Ask if they are available in your area.

Fear/Anxiety

It’s OK to be afraid. Fear is a normal emotion after a heart attack. Fear of dying is common. But many fears are based on a lack of information or things you imagine.

Replace your fear of the unknown with facts. Ask your health care team questions about your heart attack and recovery.

You may also be anxious about making changes in your life (job, sex, finances). When you are anxious, you often:

are restless

can’t sleep talk a lot or don’t talk at all

Sometimes, exercise or just keeping busy can ease anxiety. If you are still anxious after you go home from the hospital, ask your healthcare team for help.

Back in the swing

The time it takes to get back to “normal” after a heart attack depends on:

the amount of heart damage

your general health

how active you were before the heart attack

Trying to do too much too soon may put a strain on the heart. Ask what you can do and when.

In the hospital

At first, your activities will be very light to let your heart rest. You will be able to wash, eat and use the toilet by yourself or with help. Soon you can sit in a chair and walk around the room and in the hallways. Ask what you can do and when.

Sometimes a treadmill exercise test is done before you go home. This will help your healthcare team advise you about activities you can do at home.

At home

Most people can return to light activity as soon as they get home from the hospital. When you first get home:

listen to your body

follow the advice you were given eat right

get enough sleep and rest between activities

start a walking program when your healthcare team tells you to (avoid walking in very hot or cold weather)

Don’t lift anything over 10 lbs in the first few weeks.

Avoid things like:

heavy yard work

housecleaning

hobbies or projects that take a lot of energy

working or exercise in very hot or cold weather

Plan to drive, return to work and travel when your healthcare team says it’s ok for each of these.

Sex

Most people can have sex 2 to 3 weeks after a heart attack. Having sex is often compared to the energy of climbing two flights of stairs. When you have enough energy to do this, you most likely have enough energy to start having sex again.

Hints for sex after a heart attack:

Set goals that are easy to reach.

Don’t rush.

Be comfortable and rested.

Avoid being too hot or cold.

Plan sex before or 3-4 hours after a heavy meal.

Avoid alcohol just before sex.

People who use over-the-counter herbals or supplements to enhance sex and those who prefer anal sex should know that both can cause irregular heartbeats. Your doctor may tell you to avoid both until your heart is fully healed.

If sex causes chest discomfort or shortness of breath, stop and wait for another time. Tell your doctor if this happens more than once. Also tell your doctor if you have a lot of skipped heartbeats during or after sex.

Some people take nitroglycerin (NTG) before sex to avoid heart symptoms. But some find that the headache common with NTG is a turnoff to good sex. It may also cause brief loss of erection or a drop in blood pressure.

Do not use nitroglycerin (NTG) for symptoms of angina or heart attack if you have used an erectile dysfunction (ED) drug like Viagra®, Cialis® or Levitra®* or any over-the-counter ED product within the past 24 hours. Instead, go to the nearest ER for treatment. Taking any form of NTG (tablets, patches or sprays) within 24 hours before or after the use of an ED drug may cause a dangerous blood pressure drop. Check with your doctor if you have any questions.

* Prescription ED drugs are Viagra® (sildenafil), Cialis® (tadalafil) and Levitra® (vardenafil). The same NTG precautions also apply to drugs used for lung high blood pressure: Adempas® (riociguat), Revatio® (sildenafil) and Adcirca® (tadalafil).

Cardiac rehabilitation (“rehab”)

After a heart attack, most people can return to full activity in a matter of weeks. Slowly add back bits of your daily routine until you can do all of your normal activity.

A cardiac rehab program can help you get back to full activity. It will help you learn to exercise safely and become stronger. Many people become stronger than they were before their heart attack. It will also teach you how to reduce your risk of future heart problems. It can help you form heart-healthy habits you will keep for life.

Cardiac rehab is a great support system. You can share your feelings and problems with others who have had a heart attack. No one feels embarrassed because everyone is in the same boat. You can also bring family and friends for support. This will ease their minds about how much exercise you can safely do.

Ask your healthcare team about getting into a cardiac rehab program. Most programs are covered by insurance.

See pp. 30-32 for more details on exercise and a sample walk program.

For family and friends

Once your loved one is home, you can help most if you: let them do as much as they can on their own (within their advised activities)

Help, don’t nag. If you find yourself nagging, you may be worried about your loved one. Talk to friends or a member of your healthcare team about your worries. are a good listener

learn CPR* (cardiopulmonary resuscitation)

practice good health habits with your loved one (heart-healthy diet, exercise, stop smoking, etc.)

Take care of your own needs:

eat right and get enough rest

go for a walk with your loved one or do some other exercise each day

let others help you with meals, errands and other jobs

* Call the American Heart Association about CPR classes. You may also order the “Family and Friends™ CPR Anytime™ Personal Learning Kit (cpr.heart.org).

Take Control

Now that you have had a heart attack, it’s important to take steps to prevent any more problems.

Smoking

Smoking rates have dropped a lot in the last 50 years, but millions of Americans continue to smoke. If you are a smoker, cancer and future heart disease are at the top of the list of good reasons to quit. Nicotine (in all its forms) speeds up your heart rate and harms the lining of your arteries. It tightens them so less blood and oxygen get to the heart. Smokers who have CAD are at greater risk for heart attacks and sudden death.* Smokers who quit will have short and long-term benefits to their heart, lungs and blood vessels.

Good news!

After you quit smoking for:

14–90 days your heart attack risk begins to drop and lung function starts to improve

1–9 months coughing and shortness of breath decrease

1 year your risk of coronary heart disease is half that of a smoker

15 years your risk of coronary heart disease is back to that of a non-smoker

* Surgeon General’s Report–"Within 20 Minutes of Quitting"

You can find help to quit smoking! Your healthcare team can give you helpful hints and direct you to a good “stop-smoking” program. There is also stop smoking help at "QuitNow" 800-784-8669. Nicotine replacements include gum or lozenges, nasal sprays or inhalers. Since it can be dangerous to smoke while on these products, talk to your doctor before using any of them. Many people become non-smokers by taking a prescription drug like Chantix® (varenicline) or Wellbutrin®. These drugs block the flow of brain chemicals that make you want to smoke. If you haven’t already, set a date to quit. Then go for it!

E-cigarettes (Vaping)—

Second-hand smoke is harmful, too. Second-hand smoke refers to the inhalation of tobacco smoke from others who are smoking. Avoid the harm of second-hand smoke by staying away from smoke-filled, public places. Try very hard to get family members and close friends who smoke to stop.

High blood pressure (HBP or Hypertension)

High blood pressure causes wear and tear to the blood vessels in your body. If it is not controlled, HBP can lead to stroke, heart failure and kidney disease.

Blood pressure (BP) is recorded as two numbers (like 120 over 80). The top number (systolic pressure) is the peak pressure in the artery when the heart pumps. The bottom number (diastolic pressure) is the pressure in the artery when the heart relaxes between heartbeats.

While a BP goal of 120/80 is considered an ideal goal*, some studies have shown that a BP of less than 140/90 may be ok. People are often given a blood pressure goal of less than 130 and less than 80 if they have high blood pressure and one or more of these: diabetes, heart failure or chronic kidney disease. There is no "one size fits all" for blood pressure. Ask a member of your healthcare team what your BP goal should be.

Seek medical attention if your BP is consistently over 140 (top number) or over 90 ( bottom number.)

If you had HBP before your heart attack, you will likely need a drug for that by the time you return to normal activity. You may be able to keep a lower BP if you lower your salt (sodium) intake, exercise, lose weight and limit alcohol use.

* Source: American Heart Association, Inc.

Heart-healthy diet

Eating a heart-healthy diet means eating foods low in saturated fat and sodium. You should also avoid or cut back on sugaradded beverages and foods. These are the key points:

Eat more fresh fruits, vegetables and whole grains.

Limit the ‘bad’ fats in your diet (saturated fat and trans fats). Eat less red meat and dairy products made with whole milk. Limit fried foods.

Eat up to 6 oz per day of poultry, fish or lean meat. Eat 3.5 oz of oily fish at least twice a week (salmon, trout or herring).

When you do eat red meat, choose loin cuts, round or the lowest percentage of fat in ground meat.

Bake, broil, poach, grill, steam or stir fry (with low-sodium broth). Use small amounts as needed of a mono- or polyunsaturated oil (Ex: canola, olive, peanut, safflower, flax or sunflower).

Avoid saturated fat (fat solid at room temperature) like hard margarine, butter or lard.

Avoid coconut oil as 82% of the fatty acids are saturated fats which increase LDL's.

Avoid foods with trans fats (high-fat baked goods, hard margarines and foods with partially hydrogenated vegetable oils).

Choose fat-free, 1% and low-fat dairy products (milk, cheese, frozen desserts).

Aim to eat less than 2300 mg sodium per day. Avoid pre-packaged/processed foods and fast foods.

Getting started

Ask your healthcare team or a registered dietitian for help in deciding which of these daily calorie options will help you reach and/or maintain your ideal weight:

1,200 calories a day

1,600 calories a day

2,000 calories a day

A structured meal plan like the Dietary Approaches to Stop Hypertension (DASH) diet may help you learn heart-healthy eating. All 3 calorie options in the DASH diet help you take in:

little or no trans fats

less than 5-6% of your daily calories in saturated fat.

Examples:

– 1200 calories/day: up to 9 g (grams) of saturated fat

– 1600 calories/day: up to 11 g of saturated fat

– 2000 calories/day: up to 13 g of saturated fat

Three cups of 2% milk/day = 9 g (grams) of saturated fat! Consider 1% or fat-free as a first step in limiting saturated fat in food and beverage.

Nutrition Facts

16 servings per container

Serving size 1 cup (240mL) of 2% Reduced Fat Milk

When possible, stay with mono- and polyunsaturated fats found in nuts, seeds, fish and vegetable oils.

Lowering blood fats (lipids)

Eating foods high in saturated fat add to the fat and cholesterol made by your body. A blood lipid test (fats) measures total cholesterol, HDL and LDL cholesterol, and triglycerides. Fasting lipid tests are more accurate.

HDL (high density lipoprotein) is the “good cholesterol.” It helps remove “bad cholesterol” from the body. LDL (low density lipoprotein), the “bad cholesterol,” increases plaque. Non-HDL cholesterol is the total cholesterol minus the HDL portion. Blood tests can also measure triglycerides, which if high, can lead to fatty buildup.

* If you are at high risk for heart attack, your goal may be an LDL less than 70 mg/dL and a non-HDL less than 100 mg/dL.

Most people take a drug to keep blood fats normal. If you also avoid foods high in saturated fat, lose weight and exercise, even lower blood lipids are likely. Sometimes fasting triglycerides can become normal. Learn more about healthy foods from a “healthy heart” cookbook.

Lowering sodium

Most of us eat way too much sodium. Aiming for 1500 mg sodium/day gives the least risk of stroke, kidney damage and future heart disease. If you're using the DASH diet, cut down a little more on foods high in sodium.

The CDC Vital Signs (cdc.gov/salt/sources.htm) shows that more than 40% of the sodium we eat comes from these 10 foods:

breads and rolls

chicken cheese

cold cuts/ cured meats

soups

burritos

and tacos

pizza sandwiches

eggs and omelets

snack foods (chips, crackers, popcorn, etc.)

Read nutrition labels carefully to find the lowest sodium in all your favorite foods, especially any of these 10.

Although a food label may say low or reduced sodium, always go by the sodium number on the food label for the serving size you plan to eat. Unless you can find a low-sodium version, many of these products are too high in sodium for a heart-healthy diet:

tomato sauce (& spaghetti sauce, veggie drinks/V8 juice, tomato soup), canned soups and vegetables

frozen dinners, packaged deli meats and snack foods (if food label shows low sodium, check fat content as well)

pre-packaged vegetables (including rice, potatoes) or those with sauces

The sodium content on a food label will include all forms of sodium in that product. Processed or pre-packaged foods, salad dressings and sauces often include sodium preservatives or flavor additives.

Tips to help you limit your sodium:

Season foods with fresh or dried herbs, fruits and vegetables instead of table salt. Use a dash of a low-sodium seasoning if needed.

Avoid high-sodium spices like MSG, teriyaki sauce or soy sauce.

Make your own sauces, salad dressings, vegetable dishes and desserts.

When you eat out, request no salt be added to your meal. Avoid soups, appetizers or casseroles with cheeses and meats. Ask for low-sodium food and any sauces on the side.

Other resources for heart-healthy eating include:

The DASH Diet Action Plan by Marla Heller and www.dashdiet.org

Simple 8 steps of heart-healthy living by the American Heart and Stroke Associations (1-800-242-8721 or mylifecheck.heart.org)

Exercise

Regular exercise can benefit or help control your: heart’s pumping action

oxygen supply (and your muscles’ use of oxygen)

blood fats

mental outlook

high blood pressure

body weight

blood sugar

Studies also show exercise has other beneficial effects to help reduce heart and blood vessel disease.

As you begin a program, choose an exercise you like. Start out with an easy pace. Build up slowly by changing how long, how hard and how often you exercise. Stay at a level that is comfortable for you.

Most people begin to take short walks in the first week after a heart attack. You also get benefit from small amounts of activity or energy you use in your job or with housework.

Some days you may want to exercise slower or easier for a longer time. Other days you may want to exercise a bit faster or harder for less time. Listen to your body, and rest when needed. Rest plays a big part in how the heart heals.

After you are back to normal activity, find a way to make exercise a part of your normal daily routine. You can try:

brisk walking gardening housework

stair climbing swimming dancing

doubles tennis jogging bike riding

aerobic exercise equipment

Think about the things you like to do most. When you are back to normal activity, find a way to make 30-60 minutes of exercise part of your daily routine.

Caution:

Always check with your healthcare team before starting a new exercise program.

A sample walk program

After you leave the hospital, begin with a low level exercise program. You can walk on a flat surface or peddle a stationary bike (with light resistance) for 10 to 15 minutes at a time, 5 to 7 times each week.

After the first week or two of exercise, add 5 minutes each week. Do this until you can exercise for at least 30 minutes a day, without symptoms of dizziness, chest pain, fatigue or shortness of breath. You can then add more time each day, exercise at a harder level or choose to stay at your same level.

Talk with your healthcare team before starting this program.

Exercise should be a part of your daily routine from now on. A good long-term program may be: walking two miles in 30 to 40 minutes, 5 to 7 times each week. Check with your health care team if you wish to increase your pace or distance (or both). Also tell your doctor if you have any:

chest pain

shortness of breath

dizziness

fatigue

palpitations

Weight management and body mass index (BMI) chart

People who are overweight increase their risk of heart disease.

If your BMI score is 18.5-24.9, you are in a healthy weight range; between 25 and 29.9, you are overweight and 30 or higher, you are considered obese.

Get your BMI score*

Your BMI score is:

• Find your height in inches (left side of the chart)

• Move ACROSS that row to your weight (lbs)

• Move UP through the numbers above your weight to see the red number at the top (your BMI)

Example: height of 6 feet (72 inches), weight of 206 lbs = BMI of 28

Weight goal for this person would be 169-177 lbs to get a normal BMI (less than 25).

* A portion of the BMI chart, from the National Heart, Lung and Blood Institute

Your goal is to reach a BMI score of less than 25 and stay there. You may need help from a dietitian. Diets that claim fast weight loss in a short time can make it harder to keep the weight off. Very low-calorie diets (under 1000 calories/day) can be dangerous. Anyone on such a diet should be under a doctor’s care.

The way you “wear” your weight is also a factor. Apple-shaped people (weight around the middle) are more likely to have heart disease than pear-shaped people (weight around the hips).

Men should have a waist less than 40 inches and women less than 35 inches. When measuring, drop down from your “natural” waist to the top of your hip bones.

Caution:

Don’t take diet pills unless your health care team has told you to take them. This includes diet pills sold “over the counter” without a prescription, as well as those sold in health food stores.

The metabolic syndrome

The metabolic syndrome refers to people who have 3 or more of these risk factors for heart disease or stroke:

“waist” measurement (top of hipbones) = more than 35 inches (women) or 40 inches (men)

fasting triglycerides over 150 mg/dL

low HDL cholesterol (less than 40 mg/dL for men and less than 50 mg/dL for women)

blood pressure over 130 (top number)/85 mmHg (bottom number)

fasting blood glucose over 100 mg/dL

Anyone taking drugs for one of the above should count that item as a risk factor whether their current numbers are in the desired range or not. In many cases, people with metabolic syndrome have a hard time using their body’s insulin. Being more active and losing weight will improve all of the above risk factors. Sometimes medicine is also needed.

measure waist at the top of your hipbones

Stress

Stress in your life can increase the risk of a heart attack. Stress causes the body to produce more adrenaline (a hormone that stimulates the heart). This leads to faster or irregular heartbeats as well as higher blood pressure and cholesterol levels. It can also increase the risk of a blood clot. Some people feel the effects of stress on their body more than others.

People who don’t have a healthy outlet for anger may have more heart problems. Education, counseling and learning ways to handle stress improve your emotional well-being. This may lower your chance of another heart attack. Many people find yoga, meditation or exercise helpful.

Your family and friends (and pets in some cases) are very important to your well-being. People who live alone or keep themselves apart from others have a higher death rate after a heart attack. Lean on others for support and fun times, and allow them to lean on you. Regular exercise with a partner or a group of friends can reduce stress and give you support.

Other issues

Aspirin

Your doctor most likely has you on daily aspirin unless there is a reason you should not take aspirin. If not, ask your doctor if aspirin may help you prevent another heart attack. Do not take daily aspirin without first asking your doctor. Often 81 mg of aspirin per day is enough.

Alcohol

A small amount of beer, wine or liquor is OK for most people after a heart attack. Men can usually have 1-2 drinks per day, while women can have 1. One drink is:

one 12 oz beer or

4 oz of wine or

1½ oz of 80 proof liquor (or 1 oz of 100 proof)

Alcohol can help raise HDL (the good cholesterol). However, it can also raise triglycerides and add calories. You may be advised to use other ways to get the same benefits.

People with severe heart weakness (also called heart failure) or a past alcohol problem should not drink any alcohol. Also know that some medicines may interact with alcohol. Follow any instructions about alcohol.

Antioxidants and supplements

Better nutrition can improve cell function over your whole body. Eating foods rich in vitamin C and E, beta-carotene, folate and omega-3 fatty acids is likely the best way to give you more vitamins and nutrients. Omega-3 fatty acids are found in oily fish like salmon, trout and herring.

Vitamin E

Sunflower seeds

Almonds

Spinach and other greens

Sweet potatoes

Broccoli

Tomatoes

Vitamin C

Red and green

sweet peppers

Citrus fruits

Peaches

Strawberries

Sweet potatoes

Beta Carotene

Pumpkin

Sweet potatoes

Spinach and other greens

Carrots

Cantaloupe

Lettuce

Folate

Dried beans/ lentils

Spinach

Broccoli

Lettuce

Corn

Orange juice

Ask your healthcare team before starting any new vitamin or nutrition supplement. Folic acid supplements were made to match the substance folate, found in foods.

Heredity

These problems tend to run in families:

high blood fat levels

high blood pressure

angina or heart attack before the age of 55 diabetes

Now that you’ve had a heart attack, let other members of your family know of their higher risk for heart disease. Teach them what they can do to lower that risk. Make healthy living a family affair.

Estrogen replacement therapy

For many years, it was believed that hormone therapy after menopause (change of life) protected women from heart disease. Studies done on thousands of women suggest that this is not the case. Hormone therapy may even increase the risk of heart disease, stroke and breast cancer. As in all health concerns, you need to discuss this issue with your healthcare team.

Diabetes

Diabetes damages artery walls and can lead to fatty buildup. Since high blood sugar also leads to nerve damage, people with diabetes may not feel symptoms of heart disease. They are more likely to have a “silent” heart attack with symptoms like sweating for no real reason or being dizzy. If you have diabetes, be alert to any symptoms of heart disease, and take fast action.

Besides helping your heart, proper diet and exercise may reduce the need for insulin or pills to keep your fasting blood sugar less than 125 mg/dL and A1C less than 6.5%. There are medicines to help control diabetes (Farxiga®, Jardiance®). In addition to helping diabetes, they may also reduce the risk of another heart attack, heart failure and kidney disease. Ask if these medicines might help you.

Homocysteine

Homocysteine is a substance found in the blood. Studies show too much homocysteine may encourage fatty deposits in blood vessels by damaging the artery lining and promoting blood clots. Persons with high homocysteine levels have more risk of heart disease, stroke and fatty narrowing in the leg/arm arteries. High homocysteine levels can be passed through your genes. Your homocysteine can be checked with a blood test.

C-reactive protein (CRP)

High-sensitivity CRP is measured in a blood test and can show inflammation in the body. CRP cannot diagnose heart disease but research shows it may be a useful screening test for some people.

Medicines

Drugs often used after a heart attack include: Aspirin and/or an anti-platelet drug like Plavix® , Effient®, or Brilinta®– help prevent blood clots.

ACE inhibitors (or ARB's) – help decrease “remodeling” of the heart muscle and improve pumping function. Entresto® is used in chronic heart failure to improve heart function. It is used in place of an ACE or ARB.

Beta-blockers – help prevent or control abnormal heart rhythm and help the heart beat slower and use less oxygen.

Drug(s) to lower the ‘bad’ LDL cholesterol (& total cholesterol and high triglycerides), and increase the ‘good’ HDL cholesterol.

– a “statin” (most common) like Lipitor® (atorvastatin) or Crestor® (rosuvastatin).

– a resin, fibrate, or niacin.

– omega-3 acids in fish oil capsules or the drug Lovaza®.

– an injectable drug ("shot") to lower high LDL's needed in some patients who are on the highest statin therapy and still need lower LDL's (examples are Repatha®, or Praluent®).

* See page 27 for more detail about the blood fats.

Note:

Beta-blockers, ACE inhibitors and ARBs help reduce high blood pressure but do not affect normal blood pressure in most cases.

Doctor:

Nurse: Phone #: Pharmacy: Phone #: My allergies:

Write down important names and numbers: Keep track of medicines you need to take.

Name of medicine

What for How much to take

When to take

How to take (with food, etc.)

Things to watch for

Follow-up

Your doctor may want to check your progress 1 to 4 weeks after you go home from the hospital. In your first follow-up visit, your doctor will:

• check your weight and blood pressure

• make changes in your medicine(s), if needed

• do blood work and EKG testing, if needed

• check to see how you are doing to lessen your risk of heart attack in the future

My next appointment is: _____________________________

Be heart-smart

Taking your medicines and living a heart-healthy lifestyle may prevent further heart problems. But if you do have any of these upper body symptoms, be wise and take fast action:

tightening, pressure, squeezing or aching feeling in the chest or arms

“burning” feeling in the chest that may be confused with indigestion (heartburn) or nausea

sharp, burning or cramping pain or an ache that starts in or spreads to the chest, neck, jaw, throat, shoulder, upper back, arms or wrists

These symptoms may mean angina or heart attack!

Angina

When heart symptoms are brief and go away in a few minutes with rest and/or NTG (nitroglycerin), they are called angina. Angina is a warning sign that the heart doesn’t have enough blood and oxygen to do its work. Often angina occurs during exercise or stress. It can also be caused by spasm of a normal heart artery.

Tell your doctor about:

new angina symptoms in a different area of the upper body

a change in your usual angina pattern

– having symptoms after not having any for a long time

– symptoms coming on more often or during rest or sleep

– more severe symptoms

– symptoms lasting longer at a time

– taking more NTG for relief

Your doctor can give you medicines or treatment for these. This can often prevent another heart attack.

When angina symptoms occur, rest and take 1 NTG tablet or spray under the tongue every 5 minutes (up to 3 times). If the symptoms do not go away within 15 minutes, ACT FAST. You need medical care NOW.

Heart attack

Heart attack symptoms are much like angina but may be more intense. They last longer and do not go away with NTG and rest. Taking fast action will limit the amount of heart damage.

The discomfort of a heart attack can stay in one part of the upper body or move into the back, either arm or the neck and jaw. Symptoms are not always severe and can include:

sweating

dizziness

weakness

skipped heartbeats

nausea/vomiting

shortness of breath

Note:

Women may not feel heart attacks the same way men do. They may have less intense chest pain, more nausea or more weakness.

Elderly people may also have less intense symptoms.

Diabetics may have few or none of the usual heart attack symptoms.

If you think you are having a heart attack, call 9-1-1 (or your local rescue service number*)! Minutes do matter! Emergency Medical Technicians (EMT’s) can start life-saving care and in many cases, alert the hospital before your arrival. While you wait, chew a non-coated aspirin unless you have an allergy to aspirin. If you are alone, unlock your door, and sit or lie down. Loosen any tight clothes and take slow deep breaths. Call and ask someone to come sit with you.

Don’t feel embarrassed if you are not sure whether your symptoms are indigestion, angina or a heart attack. It’s better to be safe than sorry.

If symptoms are not relieved by rest and NTG every 5 minutes X 3, TAKE FAST ACTION. You need medical care NOW.

* If you are in an area without 9-1-1, do as the local emergency rescue personnel advise to get the quickest help for a heart attack. DO NOT drive yourself.

Your heart is in your hands

Now that you’ve read this book, you know what causes a heart attack and how to reduce your chance of having another one. You know the symptoms of CAD and how to respond to them. You are a heart attack survivor. You know firsthand how medical care has gotten you through a hard time. Now it’s up to you to take charge of your future. Remember, your heart is in your hands.

The heart

Your healthcare team may use these when talking with you about your heart.

Front of heart

Right Coronary Artery (RCA)

Posterior Descending Branch

Left Main Coronary Artery

Circumflex Branch

Left Anterior Descending Branch (LAD)

Back of heart

Authors

Suzanne Cambre, RN, BSHA

Cardiology Nurse

Northside Hospital

Atlanta, GA

Barbara Johnston Fletcher, RN, MN, FPCNA, FAHA, FAAN

Brooks College of Health, School of Nursing

Clinical Associate Professor, University of North Florida

Jacksonville, FL (Previous)

Julia Ann Purcell, RN, MN, FAAN

(Author Emerita)

Clinical Nurse Specialist, Cardiology

1968-1996

Emory University Hospital

Atlanta, GA

Reviewers

Gary E. Lane, MD

Assistant Professor of Medicine

Mayo Medical School

Consultant, Cardiovascular Diseases

Mayo Clinic Jacksonville Jacksonville FL

Thanks also to:

Nancy Cronmiller, MMSc, RD, LD, CDE

Stephen D. Clements, Jr., MD

Lori Giles, RN

Randolph P. Martin, MD, FACC

Barbara Riegel, DNSc, RN, CS, FAAN

Linda Shrake, RN

Valorie Sweigart, RN

Johnette Elder

Jim and Carolyn Trobaugh

Carolyn S. Brown, RN, MN, CCRN

Barbara Beier, MS, RD, CDE

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