Cardiology - Steps to take for a Healthy Heart - A guide for those who have had a heart attack

The Heart

What is it and what does it do?

The heart is a muscular pump. Its job is to pump blood around the body. The heart pumps about 11 pints of blood every minute. The heart is divided into 2 sides.

The right side of the heart pumps blood that has already been circulated around the body to the lungs, so that the blood can receive a new supply of oxygen. The blood then goes into the left side of the heart where it is pumped around the body again.
 

The coronary arteries

The heart muscle (which is called the myocardium), like all muscles, needs a good supply of blood in order to work effectively. The blood vessels that supply the myocardium are called the coronary arteries. There are 3 main arteries that lie on the surface of the heart. These 3 arteries divide into branches so that every part of the muscle is supplied with oxygen.
 

What is a heart attack?

If the coronary arteries become furred up and narrowed, then the blood supply to the heart muscle is restricted. This narrowing is called atherosclerosis. This can lead to a clot forming in one of the arteries becoming blocked by a blood clot causing part of the heart muscle to be starved of oxygen.

As when other parts of the body are injured, the injured heart will heal, but it needs time to do so and this means lots of rest. A very strong and tough scar will form. In addition to this, the blood supply to the area around the injury will improve as the coronary arteries around the affected area get wider and open up tiny new branches.

What is the difference between a heart attack and angina?

Following a heart attack some people experience symptoms of angina.

Angina occurs when then there is a narrowing in the arteries and the heart muscle requires more oxygen than normal – for example, during exercise – pain or discomfort is felt because the blood supply cannot meet the demand.

The sensation of angina can be difficult to describe but it may be a feeling of tightness or heaviness in the chest, which is sometimes confused with indigestion. Angina symptoms can sometimes spread to the throat, neck, jaws or arms. Angina can be triggered by exercise, emotion or cold/windy weather.

The symptoms of angina can be regarded as a warning to tell you that your heart has reached its maximum workload. The symptoms indicate that you should slow down or stop your exertion.

If it is emotion that has triggered your symptoms, then you should try to relax and remove yourself from the situation.

If you have been prescribed GTN spray you should use this to control your angina symptoms.

During your hospital stay

Initially you will be on bedrest. You may also be attached to a cardiac monitor. This monitor displays the electrical activity of the heart. As you begin to recover, the heart monitor will be removed and you will be encouraged to move around. You may gradually increase the amount of activity you undertake before you are discharged.

If at any time, you experience any of the following symptoms, you MUST inform the nurses or doctors looking after you:

• Chest discomfort
• Palpitations
• Shortness of breath
• Dizziness/nausea
• Extreme fatigue
• Muscle cramps

Whilst you are in hospital you will undergo a number of tests and investigations. These are to help your doctor assess your condition and your progress.

Tests and Investigations

ECG (Electrocardiograph) - This records the electrical activity of the heart. The ECG may become abnormal in people who have had a heart attack.

Echocardiogram - This is an ultrasound scan of the heart. It can give information to help the doctors to assess how well your heart is pumping and how well the valves inside your heart are functioning.

Exercise Tolerance Test - A continuous ECG is taken whilst you are walking on a treadmill. This test helps the doctors to assess your heart condition by showing how well your heart copes with exercise

Angiogram (cardiac catheterisation) - This test is to directly examine the coronary arteries.

Under local anaesthetic, a fine tube (catheter) is introduced into an artery in the groin (occasionally the arm is used) and this tube is gently advanced until it reaches the heart. Special x-ray contrast or dye is then injected down each coronary artery and x-ray films are taken. The dye sometimes causes a hot, flushing sensation which lasts a few seconds. This shows any narrowings or blockages inside the arteries. The test takes between 20 minutes and one hour.

Medication

Usually, after a heart attack, you will be required to take some medication. It is important you have an understanding of the medication you are taking. It is useful to write down a list of the tablets you are taking including the doses. A member of staff will explain all your medication to you and how to take them before you go home. If you are experiencing any problems with your medication at home, you should contact your GP, who is responsible for your care at home.

Listed below are the medications commonly taken after a heart attack:

Aspirin - This makes the blood less sticky and helps to prevent further heart attacks.

Anti-Platelets e.g. Ticagrelor, Clopidogrel, Prasugrel - These work in a similar way to aspirin, and may be given in addition to aspirin, or following angioplasty and stenting.

Beta blockers e.g. Atenolol, Bisoprolol, Metoprolol - These are given to protect your heart after a heart attack. They slow and strengthen the heart rate. You should not stop taking these tablets unless advised to by a doctor.

ACE Inhibitors e.g. Ramipril, Perindopril - ACE inhibitors are given to protect your heart by enabling the heart muscle to work more efficiently, and can prevent your heart from weakening.

Statins e.g. Atorvastatin, Simvastatin - These reduce the level of cholesterol in the blood. They have also been shown to reduce the risk of having a heart attack. They slow down the narrowing of your arteries and reduce the build-up of fatty deposits.
 
GTN – Glyceryl Tri Nitrate - GTN is used to relieve symptoms of angina.  It works by dilating the blood vessels that supply the heart muscle, allowing an increase in oxygen supplying the heart muscle. GTN is taken either as a tablet or a spray under the tongue. It is effective almost immediately. If you have chest pain/tightness:

• Stop what you are doing
• Try not to panic
• Take a GTN tablet/spray under the tongue
• If the symptoms are unrelieved after 5 minutes, repeat as above
• If the symptoms are not relieved after 15 minutes seek medical help
• If the symptoms are severe and you are feeling unwell phone for an ambulance

What causes coronary heart disease?

The fundamental cause of a heart attack is still uncertain. It is known that several factors can contribute towards disease and heart attacks. These are called coronary risk factors. Risk factors are those habits and characteristics that increase the chance of having a heart attack. There are several risk factors, any of which may be relevant to you. Research has shown that the more risk factors you have, the greater your chances of having a heart attack. It is important that you are aware of the risk factors that apply to you and how to reduce them. The coronary risk factors include:-

• Hereditary
• Diabetes
• Cigarette smoking
• High blood pressure
• High levels of blood cholesterol
• Lack of exercise
• Mental stress
• Overweight

Hereditary (Family history)

Whilst you cannot alter your genes and may have inherited a tendency to having a heart attack, prevention is still possible if you take steps to alter the factors that ARE under your control.

Diabetes

If you are diabetic, your risk of having a heart attack is increased. Therefore, it is important to monitor and maintain your blood sugar levels within an acceptable range. There are diabetic nurse specialists available at the hospital who can help and advise you if required.

Cigarette smoking

In general, people who smoke cigarettes have about twice as great a chance of having a heart attack as someone who does not smoke. Carbon monoxide and nicotine are the most important substances in tobacco smoke that affect the heart.
 
Nicotine stimulates the heart to beat faster and also raises blood pressure. Carbon monoxide reduces the bloods capacity to carry oxygen to the heart. Carbon monoxide and nicotine also encourage blood clotting (thrombosis).

People who give up smoking are much less likely to have another heart attack than those who continue to smoke. It is not the case that non-smokers do not suffer from angina or heart attacks, but their chances are less than those who do smoke.

Giving up

Obviously, this is easier said than done. Often the shock of having a heart attack is enough to make someone decide to give up. Giving up smoking whilst in hospital can be fairly easy, problems tend to occur once you are back at home and back into your usual daily routines. There is a smoking cessation adviser available at the hospital who will be able to give you tips and practical advice to help you stop smoking. You may be able to have nicotine replacement e.g. patches to help you to stop. Advice is also available from your practice nurse. The contact telephone number for the smoking cessation team can be found at the end of this leaflet.

High blood pressure (Hypertension)

Blood pressure is the force that moving blood exerts on artery walls. If blood pressure is constantly high, this places a strain on the heart and also causes wear and tear on the walls of the arteries. This makes the arteries more likely to fur up. Some causes of high blood pressure:-

• Smoking
• Stress
• Poor diet
• Excessive alcohol intake
• Lack of exercise
• Being overweight

As many as one in five people in the UK have raised blood pressure but this may be undetected as high blood pressure is often without symptoms. It is important to have your blood pressure checked regularly. Your GP or practice nurse can do this for you once you have been discharged from hospital.

High Cholesterol Levels

Cholesterol is a substance that belongs to a group of fats called lipids and is produced in the liver. The amount of cholesterol in your blood will vary depending on how much you naturally produce and the amount of saturated fat that you eat.

Having a high intake of saturated fat is linked to raised levels of harmful (LDL) cholesterol. People with high levels of LDL cholesterol in their blood are more likely to have a heart attack. If you have a heart problem, you should try to lower your cholesterol level. The aim is to have a total cholesterol reading of below 4 mmol/l.

It is recommended that you have a blood test to check your cholesterol level three months after your heart attack. Your GP/practice nurse can do this for you.

Whether or not you have a high cholesterol level it is still important to follow a diet that is low in saturated fat and based on the Mediterranean style diet. This will help to keep your heart healthy. You will also be prescribed medication to help to lower your blood cholesterol.

What is saturated fat?

Saturated fat is found mainly in fatty processed foods such as pies, pastries, cakes biscuits, chocolates, takeaways and fast foods. It is also found in animal products such as butter, ghee, lard, sausages, beef burgers, full fat milk, cheese, cream and fat on meat and poultry.

Healthy Eating for a Healthy Heart

• Choose heart healthy fats such as olive, rapeseed and sunflower oils and spreads instead of butter, ghee and lard. If you are watching your weight, remember that all fats are high in calories and should be used sparingly
• Choose low fat milk and dairy products such as low-fat cheese and yoghurts
• Trim visible fat and skin off meat and poultry before cooking
• Use cooking methods such as grilling, griddling, baking, steaming or stewing rather than frying
• Look for hidden saturated fat in cakes, biscuits, pastries and ready meals. Compare labels and choose products lower in saturated fat. Foods containing 1.5g or less per 100g are low in saturated fat
• Limit your intake of processed foods, pastries, pies, fried and fast foods and takeaways
• Enjoy a variety of fruit and vegetables. Aim to eat 5 portions a day. Fresh, frozen, tinned and dried all count. They provide vitamins, minerals; fibre and antioxidants that can help to protect your heart. Supplements do not have the same benefit
• Increase your soluble fibre intake. This type of fibre dissolves in water and forms a type of gel that soaks up cholesterol like a sponge and carries it out of the body. Oats, oat bran, fruit and vegetables, vegetable proteins such as beans, pulses including peas, soya, lentils and chickpeas all contain soluble fibre
• Eat less salt. Three-quarters of the salt that we eat is already in our food. Check food labels, avoiding foods that are high in salt such as savoury snacks, crisps, gammon and bacon. Try not to add salt during cooking or at the table. Try using herbs, spices, pepper, garlic, chilli and lemon juice to add flavour

Eating a healthy balanced diet should help to keep your weight under control, but it is important to keep an eye on your portion sizes too. Use a smaller plate or try to change the proportions on your plate so that half of your plate contains vegetables, salad or fruit. If you would like more support with making dietary changes, ask your doctor or a member of the cardiac rehabilitation team to refer you to a Registered Dietitian.

Alcohol

Alcohol can be taken in moderation. The maximum recommended weekly intake of alcohol is:

• 14 units for men
• 14 units for women

1 unit of alcohol =

• ½ pt of ordinary strength beer
• 1 single measure of spirits
• 1 small glass of wine

This should be spread out over the week, try to have no more than 2 – 3 units each day. Try to have 1 or 2 alcohol free days each week.

Exercise

A sedentary lifestyle is associated with heart disease. Undertaking regular exercise reduces the risk of heart attacks and makes your heart stronger. Exercise does not have to be working out in a gym every day. The types of exercises that are recommended are cardio-vascular activities such as brisk walking, cycling or swimming. These exercises should be undertaken five times a week for 20 – 30 minutes, once you have recovered from your heart attack.

The recognised way of measuring whether you are exercising hard enough is to ask yourself if you can sing, whistle or talk. If you can sing or whistle, then you are not working hard enough. If you can talk, you are exercising at the right level. If you cannot talk and you are gasping, then you are working too hard.

When you exercise it is essential that you warm up and cool down, that your breathing is back to normal within 5-10 minutes and that you have recovered within an hour and then just feel pleasantly tired. Obviously, you will not be able to exercise for this amount of time when you first leave hospital. More information is given about gradually increasing the amount of activity you do later in this leaflet.

Stress

A certain amount of stress is part of everyday life. However, being under a continuing high level of stress can contribute to heart disease.  It is important to remember that what is stressful to one person may be stimulating to another.

How does stress affect the heart?

When you are under stress your body produces a chemical substance called adrenaline. Adrenaline makes the heart beat faster and causes your blood pressure to rise. Blood becomes stickier and sugar and fats are released into the blood stream to give you more energy. The high blood pressure can mean more wear and tear on the heart. The increased stickiness of the blood increases the risk of clots forming and blocking the arteries. If the extra sugar and fats are not used up, they are likely to form the fatty deposits that fur up the arteries.

Signs of stress

Stress affects people emotionally and physically. Emotional signs of stress include:

• Anxiety
• Frustration
• Feelings of helplessness
• Lack of concentration
• Irritability

Physical signs of stress include:

• Poor sleep
• Exhaustion
• Dry mouth
• Sweaty palms
• Palpitations
• Over or under eating

What can be done about stress?

In order to cope with stress, you must first recognise what is making you stressed. Some ways of coping with stress are outlined below:

• Learn to accept what you cannot change
• Learn to say no without feeling guilty about it
• Try to anticipate situations you find stressful
• Take regular exercise
• Avoid harmful ways of coping with stress – drinking, smoking
• Learn to relax

Weight

If you are overweight, you are at risk of developing high blood pressure and fat can build up around the heart, making it work harder. It is, therefore, a good idea to keep to a sensible weight. If you need to lose weight, then following a low fat diet and increasing the amount of physical activity you do should result in weight loss. Aim to lose 1-2 lbs per week.

After the heart attack

What now?

Following your heart attack, it is normal to feel anxious about the future. The following advice is to help you gradually return to living a normal life.

Going home - You may have mixed feelings about being discharged from hospital. You may be pleased that you no longer require hospital care, but anxious that the “experts” are no longer on hand.

Your family doctor - Your family doctor will take over your care when you leave hospital. A letter will be sent to your doctor informing him/her about your heart attack, what treatment was given and what medication you have been prescribed.

Medication - You will receive a seven day supply of tablets when you leave hospital. You will need to obtain a further supply of any medications from your family doctor. You should continue to take any medication until you are otherwise instructed either by your own doctor or the hospital doctor.

Outpatient appointment - You will be given an appointment to return to the hospital to the outpatient department to see the consultant or a member of his team. You will be contacted by the Booking and Scheduling Department to arrange this after you have been discharged.

What can I do when I get home?

First week

• Give yourself a few days to settle down to being back at home
• Get up and dressed every day. Continue with any activity that you have been doing in hospital e.g. having a shower
• It is important for you to rest. Do not have too many visitors, as this can be quite tiring
• You may climb the stairs, but avoid unnecessary trips
• Try to get 6 – 8 hours sleep each night. It is a good idea to put your feet up for an hour after lunch

After you have been home for a couple of days you may start to go out for a short walk twice a day. Walk at your normal pace for approximately five to ten minutes.

Second week

• You may increase the amount of walking you are doing, gradually increasing this so that you are walking for 10- 15 minutes by the end of the week
• You may begin light household activities, e.g. washing the dishes, dusting
• Avoid walking immediately after a meal
• It is important to rest when you feel tired

You may be surprised that you still tire easily. There is no need to worry about this, it will improve with time.

Third week

• Increase the amount of walking you are doing so that by the end of this week you are walking for 15 – 20 minutes
• Start to do more around the house
• Go to the shops / supermarket - but have someone else carry the shopping
• Light gardening can be undertaken, weeding, watering plants using a hose
• Resume social activities such as going out for meals

Fourth week

• Continue to increase the amount of walking you are doing. Walk for 20 – 30 minutes twice a day if possible. Do not worry if you are not walking as much as you hoped. The important thing is that you are gradually increasing the amount you are doing
• Increase your household activities – vacuuming one room at a time with rests in between

The important thing to remember with any activity or exercise undertaken after a heart attack is to ensure that it is undertaken gradually and progressively. If you become breathless or experience chest pains/tightness during any activity STOP and REST. Use your GTN spray if you have been prescribed one.

General advice

• Try to walk outside each day (weather permitting)
• Avoid walking against the wind because your heart has to work harder
• Plan your days activities – do not plan to do all your chores in the morning – spread them out through the day
• Try and rest for about half an hour after meals – this gives your heart time to pump the blood to digest your food

Cardiac misconceptions

Cardiac misconceptions are incorrect or muddled beliefs about heart conditions. This can lead people to being over cautious and to respond inappropriately. Many of the problems experienced by people with heart disease are not due to physical illness but due to inaccurate beliefs. What people believe about their illness may affect how they cope with it. Such beliefs stem from those commonly held within society, from friends, family, colleagues – many are old wives tales. e.g.

• Every chest pain is another heart attack
• Once you have had a heart attack you are bound to have another
• People with heart disease should take things easy

Misconceptions have the potential to affect outcome and quality of life. People with a high number of misconceptions often suffer undue fear and anxiety and are less likely to believe that they have any control over their illness. Your rehabilitation team can provide accurate information and advice regarding your condition thereby reducing any fears and anxieties that you have.

Driving

Ordinary driving licence

When you can resume driving depends on the type of heart attack you have had and what treatment you have received. Usually, you are not allowed to drive for 4 weeks following a heart attack. In some cases, it may be possible to drive earlier than 4 weeks, depending on test results and treatments. Please check with your doctor if this applies to you. Before you resume driving it is advisable to have a doctor’s permission to do so. It is not necessary to inform the DVLA; however, you must inform your insurance company, failure to do so may invalidate your policy.

When you do resume driving, it is advisable to avoid motorway driving and rush hour traffic to begin with. If you experience angina symptoms whilst driving, or angina symptoms that occur at rest, you must stop driving. The DVLA should then be notified. You can re-commence driving when satisfactory symptom control is achieved.

Large Goods Vehicles and Public Carrying Vehicles

If you hold one of these licences it is essential that you inform the DVLA of your condition. It is possible to reapply for your licence three months after successful rehabilitation, providing that you undergo an exercise test to prove your fitness to drive. Your doctor will be able to advise you regarding this.

Returning to work

It is usual to be off work for at least 6 weeks. Your doctor will advise you when you can return to work - this will depend on the type of work you do and your progress. You should avoid making a hasty decision about returning to work or changing your job. Discuss your options with your consultant, family doctor and your employers. If a change of employment is suggested, then there are experts at your local job centre who may be able to help you.

Holidays

Before you book your holiday, please make sure that you ask your GP or consultant if they agree that you are fit enough to travel.

Health/travel insurance

If you travel within the British Isles, you do no need any extra health insurance. If you travel within the European Community, you will need a European Health Insurance card (EHIC), which entitles you to reduced cost or sometimes free medical treatment but will not cover your emergency return to the UK. This cover also means that you will have to pay upfront for any costs and claim for reimbursement when you come back. The insurance you get from your travel agent may not cover an existing chronic illness. Shop around for an insurance policy that fits your purse and make sure you read the fine print and what excess you may have to pay.

Travelling by air

Most airlines will let you travel 10 days after a heart attack or coronary angioplasty as long as you do not have any angina symptoms. It is not advisable to fly for 6-8 weeks, although the advice from your consultant may differ from this. Please remember that you may not be able to walk for long distances and carry your suitcases. If you travel for over 2 hours, it may be advisable to wear flight socks to prevent deep vein thrombosis. Whilst in the air, make sure you do the exercises recommended by the flight staff and drink plenty of non-alcoholic/caffeine free drinks, especially if you are on a long flight. High consumption of caffeine and alcohol is not advisable when flying due to the dehydrating effects of these drinks.

If you have a pacemaker or an implantable cardioverter defibrillator, you may need to ask your GP for a certificate of fitness to fly. The metal in a pacemaker can trigger the alarms in some airport security systems and handheld scanners can come very close to your pacemaker and could disrupt its function (very rarely), so it is important to carry your data card and show it to security staff.

Travelling by coach

There is no reason why you should not travel by coach in the UK. Make sure you do not sit for long periods. Do some gentle stretching exercises and ensure that you get off the coach and have a short walk at every stop. Remember that carrying your luggage is not advisable for the first 6 - 10 weeks after a heart attack.

Travelling by car

If you are the driver, please see the information in the driving section. If you are a passenger, it is advisable to stop every hour to hour and a half, walk for 10 minutes or so and then recommence your journey. Avoid long journeys in the first 6 weeks after a heart attack.

During your holiday

Although you do not need to be as strict with your diet and drinking, please do not overindulge. Avoid extremes of temperature, as the cold could bring on an attack of angina and too much heat could dehydrate you and make you feel unwell. Walking in the sunshine is acceptable and good for you in moderation, but do not sit in the direct sun for more than 5 minutes as long exposure could reduce your blood pressure and make you feel dizzy. Swimming is good, again in moderation, but only if you actually swim all year round; if you do not usually go swimming regularly, make sure you do not get over tired. Do not jump/dive into the pool as a sudden difference in temperature can trigger angina symptoms. In hot countries, do as the local people do, make sure you take a “siesta” at the hottest time of the day.

Sexual relationships

After a heart attack questions regarding sexual activity often go unasked and unanswered because of embarrassment. It has been shown that whilst people return to all aspects of normal living after a heart attack, a number of them do not return to their normal sexual activities. Sexual activities may be resumed soon after you have been discharged from hospital, provided that you feel reasonably fit and ready to do so. Obviously you will have fears - will it bring on another heart attack? Will it cause chest pain?

The risk of another heart attack during sexual intercourse is fairly small. Studies have shown that the workload on the heart during sex is about the same as climbing two flights of stairs. If you do develop chest pains during intercourse, stop and use your GTN. If necessary, you can use GTN immediately before intercourse to prevent chest discomfort developing. However, if you take medication for erectile dysfunction, you should avoid using these together. If necessary, you can use GTN immediately before intercourse to prevent chest discomfort developing.

A word of caution is necessary. Studies have shown that extra marital relationships place more strain on the heart. However, in a stable relationship in which the couple are comfortable and familiar with one another, the risk is minimal. During the first few weeks it often happens that the desire for intercourse does not return. The worries that you have may reduce you and your partners desire to make love. This should pass in time as your confidence builds up. If you find you are having problems resuming your sex life, it is important to discuss this with your doctor or nurse. Ignoring the problem can make it worse and lead to stress in your relationship.

Emotions after a heart attack

A heart attack is not just a physical event. It involves changes in emotions as well. It is normal to experience any of the following:

• Irritability
• Difficulty sleeping
• Loss of interest
• Tiredness
• Poor concentration
• Feeling depressed
• Feeling angry
• Anxiety

Your family may experience similar feelings. They may be worried about you and want to protect you from too much stress and activity. Some families become overprotective and sometimes this can lead to frustration. Your family and friends can be more supportive to you if you tell them how you are feeling. Be honest about the way you feel and work together towards your recovery. You should remember that you are not an invalid and that you can return to a normal life.

Cardiac rehabilitation programme

Cardiac rehabilitation programmes are provided to give continuing support for patients recovering from a heart attack. The aim of the programme is to help you to return to a normal life following your heart attack. It helps to improve your confidence and to encourage you to exercise regularly. The programme involves a supervised exercise programme and advice on heart disease, modifying risk factors associated with heart disease, stress, relaxation and medications used in the treatment of heart disease.

Further information is available from the Cardiac Rehabilitation Nurse/Physiotherapist.

Useful telephone numbers

Cardiac Rehabilitation Nurses
Fairfield General Hospital - 0161 778 2450
Royal Oldham Hospital - 0161 627 8339

Local Smoking Cessation numbers:-
Bury Lifestyle services 0161 253 7554
Your Health Oldham 0161 960 0255
Rochdale Living Well services 01706 751190

NHS CHOICES - 0845 606 4647
www.nhs.uk

British Heart Foundation - 0300 330 3311
www.bhf.org.uk

DVLA - 0300 790 6801
www.dvla.gov.uk

HEALTHY EATING - British Dietetic Association
www.bda.uk.com/foodfacts

DIABETES UK - 0345 123 2399
www.diabetes.org.uk

Booking and Scheduling - 0161 778 2233

Counselling Services:-

Bury Talking Therapies - 0161 253 5258
https://www.penninecare.nhs.uk/burytalk

Oldham Talking Therapies - 0161 716 2777
https://www.penninecare.nhs.uk/oldhamtalk

Rochdale Talking Therapies - 01706 751 180
https://www.penninecare.nhs.uk/services/thinking-ahead-heywood-middleton-and-rochdale