Every year, about 650,000 Americans have H their first heart attack—a temporary interruption in blood flow to the heart that causes permanent damage. Thanks to improvements in emergency and hospital care, more people than ever survive. But what comes next? We asked Paul Kligfield, MD, medical director of the Cardiac Health Center at NewYork-Presbyterian Hospital, for answers to questions cardiologists hear most often.
- What medications should I take to prevent another heart attack?
The American Heart Association and American College of Cardiology recommend that nearly everyone who has had a heart attack take all four of the following types of drugs...
- Blood thinners. These important drugs reduce platelet adhesion, the first step in the formation of blood clots that can block arteries. Low-dose aspirin (81 mg) often is used, but some patients may need a higher dose (325 mg) each day. If you're at higher risk of clotting (after certain kinds of heart attack, for example), your doctor also might prescribe clopidogrel (Plavix).
If your heart attack caused enough damage to continue to reduce heart action or disturb its rhythm, your risk of clots may require a different blood thinner, warfarin (Coumadin), to prevent the kind of blood clots that form within the chambers of the heart.
- Beta-blockers, such as propranolol (Inderal) and atenolol (Tenormin), also are routinely prescribed after heart attacks. These drugs lighten the load on the heart by slowing the pulse and lowering blood pressure.
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) lower blood pressure and seem to have a stabilizing effect on the arteries, allowing blood to flow from the heart more easily.
- Statins, such as lovastatin (Mevacor) and atorvastatin (Lipitor), are powerful cholesterol-lowering drugs. After a heart attack, the acceptable level of LDL cholesterol is lower than before the attack (100 mg/dl, compared to 130 mg/dl), and it appears that bringing it down still lower (to 80 mg/dl or even lower) can cut heart attack risk further. Statin drugs also help keep arteries healthy, perhaps by blocking inflammation.
- Will I be able to be as active as I was before my heart attack?
It depends on how bad the heart attack was, but most people can safely return to their pre-attack activities. One key factor is cardiac rehabilitation—a program of gradually increasing exercise. By helping the heart work more efficiently, this regimen can reduce the risk of future heart attacks, too. I usually start patients on a cardiac rehabilitation program two to four weeks after they leave the hospital.
- What does a cardiac rehabilitation program consist of?
A post-heart attack program usually requires that you exercise three times a week for 12 weeks, following a plan tailored by a cardiologist to your needs and capacities and under the supervision of a nurse. Your heart function will be tracked by electrocardiography to ensure exercise is at a safe level and to spot abnormalities quickly.
With this program, you can increase the level of exercise while keeping it safe. An analysis of 48 clinical trials involving nearly 9,000 patients found that cardiac rehabilitation programs significantly reduce the rate of death from all causes, including heart disease.
- Can I do the program on my own?
After most heart attacks, you can—as long as it's not entirely on your own. Before starting to exercise, have a full examination by your cardiologist, including a stress test, to confirm that it is safe to exercise and to determine the right level. Regular check-ins should guide you in increasing the amount and intensity of exercise as your capacity improves.
Aerobic exercise is best—brisk walking, swimming, riding a stationary exercise bike.
Rule of thumb: A good level of intensity is one that you can sustain comfortably for 30 minutes while being able to talk but not sing. Work out at least three times a week.
You may want to track your pulse rate to make sure it remains at a level your doctor says is safe, possibly with the help of a watchlike heart monitor, available in drugstores and online for between $50 and $100.
- What danger signs should I look for when exercising?
Chest pain or shortness of breath disproportionate to the level of exertion are signals that your heart isn't getting enough oxygen and that you should stop. If these recur or you have unusual fatigue, consult your doctor.
- When is it safe to have sex?
There's no one timetable that is appropriate for every heart patient. Sex makes demands on the heart that are at least as strenuous as walking up stairs, so it's usually okay to have sex once you can climb a flight or two without difficulty.
Aim for 25% to 30% of calories from fat (no more than 7% of that from saturated fat, found in meat, butter, etc), lots of fruits, vegetables and whole grains and other complex carbohydrates. Alcohol in moderation is okay.
Even if you’re taking a statin to reduce cholesterol, diet still counts. It will help the medication work better and even may enable you to cut the dose.
Perhaps the most important thing is to keep calories down enough to maintain a healthy weight. Obesity is associated with worsening heart disease.
- Are there any diseases I should watch out for?
The big two are diabetes and high blood pressure—each substantially increases your risk of having another heart attack. Work with your doctor to keep blood pressure below 130/80.If you have diabetes, use diet and medication, if necessary to control it.
- Is there anything else I should be concerned about?
Depression, which is fairly common after a heart attack, increases the risk of dying from heart disease. Although it hasn't been proven that treating depression reduces this risk, relieving it with medication and/or therapy certainly improves life and makes you better able to take care of your heart.
Signs and symptoms of depression may include irritability, loss of interest in activities that used to interest you and excessive tiredness.