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After a Myocardial Infarction

This leaflet discusses the common advice that applies to most people who have had a myocardial infarction (heart attack). It mainly discusses ways to reduce the risk of having another myocardial infarction (MI) or developing further heart problems.

What is a myocardial infarction?

If you have an MI (heart attack), a blood vessel supplying the heart muscle is suddenly blocked. The heart muscle supplied by this blood vessel is called the myocardium. The part of the heart muscle supplied by this artery loses its blood (and oxygen) supply if the vessel is blocked. This part of the heart muscle is at risk of dying unless the blockage is quickly removed. When the heart muscle is damaged it is said to be infarcted. The term myocardial infarction means damaged heart muscle. An MI is usually caused by a blood clot in a coronary (heart) artery, which forms over a patch of atheroma (fatty deposit). See separate leaflet called Myocardial Infarction (Heart Attack) which discusses MI in more detail.

What can I do to help myself after having a heart attack?

Following an MI, there are things that you can do to reduce the risk of further heart problems. Everyone is different and individual circumstances will vary. You should discuss with a doctor or nurse what is best for you. This leaflet aims to support any advice that you may receive.

Smoking
If you smoke, giving up smoking is the single most effective way to reduce your risk of having a further MI. The chemicals in cigarette smoke affect the arteries. If you stop smoking, your risk of a further heart attack is roughly halved (compared to the risk if you continue to smoke). Angina is also more likely to develop in smokers. If you find it hard to give up smoking then seek help from your doctor, practice nurse or pharmacist. They can give help and can advise on the use of nicotine replacement therapy (nicotine gum, etc) or other treatments that can help you to stop smoking. See separate leaflet called Smoking - The Facts for more details about smoking and ways that help you to stop smoking.

Diet
Changes in diet can make a big difference. Studies suggest that people who eat a healthy diet may halve their chance of a further heart attack compared to those who do not eat healthily. See separate leaflet called Healthy Eating for more details. Good advice is to: Eat at least five portions of a variety of fruit and vegetables each day. They are rich in vitamins and minerals. These can be fresh, frozen or dried.

Page 2 of 7 Limit the amount of saturated fat you eat. It is not just about the total fat content of the diet, but also the type of fat in the diet. Try to avoid eating foods that are high in saturated fat. Foods that are high in saturated fat include meat pies, sausages, butter, cream, hard cheese, cakes, biscuits and foods that contain coconut or palm oil. Eating foods that are high in unsaturated fat can help to reduce your cholesterol level. Foods high in unsaturated fat include oily fish (such as herring, mackerel, sardine, salmon), avocados, nuts and seeds, sunflower, rapeseed and olive oil. Reduce you salt intake. Many foods contain hidden salt. Lowering your salt intake can reduce your risk of another MI and also other cardiovascular diseases.

A Mediterranean diet
Eating a Mediterranean-style diet is thought to be one of the best ways to reduce the risk of having an MI. This type of diet is, in effect, a summary of the advice above. That is - meals with poultry rather than red meat, lots of wholegrain pasta and breads and plenty of fruit, vegetables, olive oil, oil-rich fish, accompanied by a small glass of wine or beer.

Cholesterol
Cholesterol is involved in the formation of atheroma. Eating a healthy diet (described above) will help to lower cholesterol. In addition, most people who have an MI are advised to take a statin medication to lower the cholesterol level. Statins work by reducing the amount of cholesterol that is made in your liver. In general, the lower the cholesterol level, the better. See separate leaflet called Cholesterol for more details.

Alcohol
Some research suggests that drinking a small amount of alcohol may be beneficial for the heart. The exact amount is not clear, but it is a small amount. So, do not exceed the recommended amount of alcohol as more than the recommended upper limits can be harmful. That is: men should drink no more than 21 units of alcohol per week, no more than four units in any one day, and have at least two alcohol-free days a week. Women should drink no more than 14 units of alcohol per week, no more than three units in any one day, and have at least two alcohol-free days a week. Pregnant women, and women trying to become pregnant, should not drink alcohol at all. One unit is in about half a pint of normal strength beer, or two thirds of a small glass of wine, or one small pub measure of spirits. See separate leaflet called Alcohol and Sensible Drinking for more details.

Physical activity and exercise

Page 3 of 7 Normal physical activity and regular exercise are advised for most people who have had an MI. You should try to be physically active - for example, take the stairs whenever possible, walk to the shops, and wash your car.

In the past, people thought that exercise "put a strain on the heart" and was bad. However, quite the opposite is true for most people who recover from an MI. Physical activity and regular exercise are good for the heart. Indeed, regular exercise is one of the main parts of cardiac (heart) rehabilitation programmes that are popular after having an MI (as discussed later). Regular exercise is a major way to reduce the risk of having a further MI. However, before starting regular exercise, discuss it with your doctor. This is because strenuous exercise in certain situations may not be advised. For example, some people with heart valve problems may be advised not to exercise. However, these people are the exception. For most people who have had an MI, exercise is beneficial. After an MI it is best to build up your level of activity and exercise gradually. For the first week or so, try simply to go for a short walk each day. Everyone is different and the length of the walk depends on how fit you were to start with. For some people, at first it may simply be a walk to the end of the garden and back, for others a walk to the end of the road and for others a bit further. You can then gradually build up the distance of your walking over time. A reasonable goal by about six weeks after having an MI is to aim to walk for 20-30 minutes each day. However, the amount of exercise that some people can do will be limited because of other medical problems. For example, some people develop angina which may limit the intensity of exercise that can be done. Others have other unrelated medical problems that limit exercise ability, or they are too frail to exercise. Regarding bursts of strenuous effort. As a rule, normal manual work is fine. However, you should not do anything that makes you need to hold your breath. For example, lifting very heavy objects when you would need to 'grit your teeth' and hold your breath. In most cases, after about 6-8 weeks, the aim is to build up to at least 20-30 minutes of moderate exercise on most days (at least five days per week). This exercise should make you slightly short of breath. See separate leaflet called Physical Activity for Health for more details.

Weight
If you are overweight then reducing your weight will reduce your risk of a future MI. If you find it difficult to lose weight then see your practice nurse for encouragement and advice. See separate leaflets called Obesity and Overweight in Adults and Weight Reduction - How to Lose Weight for more details.

Blood pressure
It is important to have your blood pressure checked regularly. High blood pressure is a major risk factor for heart disease. Normal blood pressure is less than 140/90 mm Hg. If you are being treated for high blood pressure, the usual target is to reduce blood pressure in someone who has had an MI to below 130/80 mm Hg. This figure may vary depending on whether you have other conditions - for example, kidney disease. Lifestyle factors can help to lower blood pressure, such as eating a healthy diet, exercise, losing weight if you are overweight and not eating much salt. Medication is advised if your blood pressure remains persistently high. See separate leaflet called High Blood Pressure (Hypertension) for more details.

Diabetes
If you have diabetes then good control of your blood sugar level and also your blood pressure will help to reduce the risk of a further MI. See separate leaflets called Type 1 Diabetes and Type 2 Diabetes for more details.

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What medication is usual following a myocardial infarction?

Medication after an MI is discussed more fully in another separate leaflet called Medication after a Myocardial Infarction. Briefly, the following four medicines are commonly prescribed: Aspirin. This reduces the stickiness of blood, which reduces the risk of blood clots forming. Clopidogrel or ticagrelor are alternatives to aspirin and help to prevent blood clots. They are usually used in people who are not able to take aspirin. They may be given with aspirin in some cases. A beta-blocker. This slows the heart rate and reduces the risk of abnormal heart rhythms. An angiotensin-converting enzyme (ACE) inhibitor. This reduces the risk of developing heart failure and further MI. A statin. This reduces the cholesterol level (as discussed above). Although the four medicines above are commonly advised, treatments may vary depending on other factors such as whether you have complications or other diseases.

Getting back to normal

After having an MI, it is natural to wonder if there are any dos and don'ts. In the past, well-meaning (but bad) advice to "rest and take it easy from now on" caused some people to become over-anxious about their hearts. Some people gave up their jobs, hobbies and any activity that caused exertion, for fear of straining the heart. However, quite the opposite is true for most people who recover from an MI. Regular exercise and getting back to normal are usually advised.

Work issues
Following an MI, most people can go back to work within 2-3 months. However, each person is different. For example, some people who have a small MI and feel well go back sooner. On the other hand, some people with ongoing symptoms or complications such as angina or heart failure may take longer to go back or may not be able to go back to work. Some people have wrong beliefs about work after an MI. For example, some people wrongly believe that work-related stress was the cause of their MI and they need to take things easy from now on. However, an increase in activity is often preferable after an MI rather than taking it easy. Some people believe that a physical job will be ruled out. Again, this is usually not the case, provided that you feel well in yourself. Indeed, physical jobs are often better for the heart than office jobs. For many people, returning to work is an important part of regaining quality of life. A possible sensible approach is: Discuss with your doctor about when you should return to work. Then, a phased return may be best if your employer is agreeable. For example: Start with alternate half days, and build up to a normal routine over 2-3 weeks. Start with light or less challenging duties at first. Include additional rest periods if tiredness is a problem. Understandably, some people consider early retirement following an MI, as the future may be uncertain. However, it is very important that you make such a decision for the right reasons and not based on fear or wrong beliefs about your heart.

Driving and flying

Page 5 of 7 You should not drive for at least four weeks after an MI. Then, provided you have made a satisfactory recovery (and your insurance company is notified) you may drive. However, if driving causes angina, you should not drive until the angina is well-controlled. PCV and LGV rules are stricter and further assessment is required. It is always sensible to contact the Driver and Vehicle Licensing Agency (DVLA) to be sure.

You can usually fly as a passenger within two to three weeks of an MI, as long as you have no complications. This means that, for example: You have returned to your usual daily activities. Your condition is stable. You don't have any symptoms, or your symptoms are controlled. It is usually sensible to check with your travel operator, airline and travel insurance company before you fly.

Stress, anxiety and relaxation

It is commonly believed that stress can cause an MI. However, medical research has failed to show this and the conclusion is that stress does not cause an MI. However, being stressed and anxious can make you feel generally unwell in yourself. Some people have unfounded concerns and wrong beliefs about MI, which can cause symptoms of anxiety. Don't be afraid of talking to your doctor if you have concerns about your health. Alternatively, ring the helpline of the British Heart Foundation for advice (see below). They will give correct up-to-date advice (which may be very different to the old wives tales that sometimes get passed around). Many people who become anxious benefit from learning to positively relax. See separate leaflet called Relaxation Exercises which may help. It explains two main ways to positively relax - that is, muscular exercises and deep breathing exercises. There is also another separate leaflet called Stress and Tips on How to Avoid It. You can also buy relaxation tapes and CDs to help you to learn to relax. Also, you should tell your doctor if you feel that you have become over-anxious, as there are other treatments for anxiety that may help.

Sex
Some people worry about resuming sex. For a few weeks it is probably best avoided. If you are able to walk without discomfort then a return to sexual relationships should not cause any problems. If sex causes angina (chest pains) then tell your doctor. Some men find that they have problems getting or maintaining an erection (erectile dysfunction) after having an MI. These problems can be caused by emotional stress or by medication such as beta-blockers. However, impotence can also have other causes. Speak to your GP who can check what is causing your problems and advise you on treatment. Various treatments (including medication) are now very effective for the treatment of erectile dysfunction.

Cardiac rehabilitation
You may be advised to attend a cardiac rehabilitation programme. Not every area has this facility, but these courses are becoming more widely available on the NHS. They are staffed by nurses, physiotherapists, and other health professionals. They aim to provide advice and help on exercise, diet, stress, and getting back to work and normal life following an MI. It is also useful to mix with others who are going through the same experience. Studies have shown that cardiac rehabilitation helps to reduce the risk of having another MI and improves general well-being.

Immunisation
You should have the annual influenza jab and be immunised against the pneumococcal bacterium.

Some other general points

Page 6 of 7 Tell your doctor if you get angina following an MI. Angina is a pain in the chest that comes on when you exercise, such as when walking briskly. It is due to narrowing of the coronary arteries. See separate leaflet called Angina for more details. Further treatment may be needed. Tell your doctor if you get breathless, become more tired than usual, or notice your feet swelling. These symptoms may indicate a degree of heart failure (the heart muscle not pumping as well as normal). This can often be helped with medication. See separate leaflet called Heart Failure for more details. Depression is common after an MI, often made worse by unfounded concerns. Again, tell your doctor if you think you are depressed. Treatment for depression often works well and can improve your quality of life.

Some thoughts to remember: Most people who have an MI make a full recovery. In many cases, only a small part of the heart muscle is damaged. The rest of the heart muscle remains undamaged and, in many cases, easily manages to do the work needed. Most people who have a job should be able to get back to work and do their normal job after having an MI. An MI often causes people to review and change their diet and lifestyle. Some people actually become fitter and healthier after they have an MI. A gradual increase in physical activity is good for the heart after an MI. The famous explorer Sir Ranulph Fiennes had an MI in 2003 and even had a cardiac arrest. Just a few months later he was training for seven marathons in seven continents in seven days. Perhaps this is a bit excessive but it shows it can be done. For some people, the biggest cause of disability following an MI is not their heart, but unfounded worries and anxiety about their heart. Try to learn to positively relax, and talk to your doctor if you have any concerns.

Further sources of information and help

British Heart Foundation
Greater London House, 180 Hampstead Road, London, NW1 7AW Tel (Heart Help Line): 0300 330 3311 Web: www.bhf.org.uk

HEART UK (the Hyperlipidaemia Education and Atherosclerosis Research Trust UK)

7 North Road, Maidenhead, Berkshire SL6 1PE Tel (Helpline): 0845 450 5988 Web: www.heartuk.org.uk

British Cardiac Patients Association

15 Abbey Road, Bingham, Notts, NG13 8EE Tel (Helpline): 01223 846845 Web: www.bcpa.co.uk

Further reading & references

Secondary prevention in primary and secondary care for patients following a myocardial infarction, NICE Clinical Guideline (2007) Management of acute myocardial infarction in patients presenting with persistant ST-segment elevation, European Society of Cardiology (November 2008) Management of Acute Coronary Syndromes (ACS) in patients presenting without persistent ST-segment elevation, European Society of Cardiology (2011) Acute coronary syndromes - ticagrelor, NICE Technology Appraisal Guideline (October 2011) Myocardial infarction - secondary prevention, Prodigy (December 2007) Alcohol Advice, Dept of Health, 14 February 2012 The evidence base for alcohol guidelines, Royal College of Physicians (2011) Murphy AW, Cupples ME, Smith SM, et al; Effect of tailored practice and patient care plans on secondary prevention of BMJ. 2009 Oct 29;339:b4220. doi: 10.1136/bmj.b4220. Original Author: Dr Tim Kenny Last Checked: 14/06/2012 Current Version: Dr Hayley Willacy Document ID: 4545 Version: 41 Peer Reviewer: Dr John Cox EMIS

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