After a Heart Attack: What Happens Now? (Part One)
This year about 660,000 people in the U.S. will have a first heart attack. About 85 percent of those who experience a heart attack this year will survive. Many of them will be forever changed in one way or another by the experience.
Given the seriousness of a heart attack, it’s expected that survivors experience psychological effects. Depression is common; fear and anxiety of another MI may also come into play. At the same time, some may experience a new lease on life, having ‘dodged a bullet.’ We’ll explore this topic in detail later in this series. If you’re looking for support from heart attack survivors or family caregivers, try visiting our online Support Network for patients and families.
Dr. John Osborne
Recovery is usually determined by how severe the heart attack is. In the simplest cases, only one coronary vessel is blocked, and it is treated quickly so there’s minimal damage to the heart muscle. “If the heart function is normal, those patients can really be discharged from the hospital pretty quickly,” said John Osborne, a cardiologist at State of the Heart Cardiology in Dallas.
When there is more damage, either because the patient doesn’t get to the hospital quickly enough or because there are more arteries involved, it’s more complicated. “In these cases, the patient will normally stay in the hospital longer as we’re assessing heart function and identifying the right medication to help heal the heart,” he said.
The most severe level occurs when the patient has multiple blockages and needs bypass surgery. “In that case, their hospitalization and recovery are going to be much more complicated,” he said.
Once the emergency is over and the survivor is discharged, treatment will almost always involve medications and lifestyle changes to slow the progression of atherosclerosis and reduce the risk of developing blood clots. In most cases, cardiac rehab is also prescribed.
Lifestyle changes start with eliminating tobacco. “I always tell patients, I don’t care whether you smoke it, chew it, snort it, inject it, rub it on your skin or use it as a colonic, the use of any kind of tobacco has to stop. That’s mandatory,” Osborne said.
Choosing a heart-healthy diet is equally important.
The American Heart Association recommends a diet that limits saturated and trans fats, sodium, added sugars and red meat. A healthy eating plan should include fruits and vegetables, whole-grains, low-fat dairy products, skinless poultry, fish, legumes (dried beans and peas), non-tropical vegetable oils and unsalted nuts and seeds.
It is important for MI survivors to complete inpatient and outpatient cardiac rehab. Cardiac rehab has been shown to lower mortality in patients who have a heart attack. “I like to get patients started right away,” Osborne said. “If they’re in pretty good health, I really encourage them to start as soon as possible. Patients who have bypass surgery will have to wait a little bit longer. But usually I like to have them start within the first couple of weeks after surgery.”
After rehab, being physically active most days of the week is essential. If you need to lower your cholesterol or blood pressure, aim for 40 minutes of moderate-to-vigorous physical activity three to four times per week.
Medication is an important part of post-MI treatment. “Generally, anybody that comes in with a heart attack due to atherosclerosis should get some kind of cholesterol-lowering medication,” Osborne said. MI survivors should also take a baby aspirin every day, and if they’ve had a stent, they need an additional anticoagulant or antiplatelet medication to prevent clots from forming within the stent.
Because most survivors have high blood pressure, they will usually be on at least one medication to control it. But even without hypertension, after a MI, medications that lower blood pressure, such as ACEI and beta blockers, may be recommended due to the damage to the heart.
“There are a lot of different parts to recovery, but when you add them all up, it translates to large reductions in both complications and mortalities,” Osborne said.
AVOIDING ANOTHER MI AND READMISSION
Nobody wants a second MI or another hospital stay, but about 18 percent of survivors are readmitted. Survivors can certainly improve their chances of recovery and avoid readmissions by taking the recommended actions of their medical team seriously and sticking to them.
An important step is to make — and keep — a followup appointment with the cardiologist. “I usually like to see them within the week after being discharged to make sure they’re tolerating all their medications,” Osborne said. Often patients are going from no medication to having a regimen of six or more. “I think psychologically that’s a blow as well because it makes people think they’re really sick. But that may be what it takes in order to minimize the risk of recurring problems.”
Patients should come to their follow-up appointments armed with questions. Osborne expects them to talk about any symptoms they are having so the doctor can either reassure them it’s nothing serious, or so the doctor can be aware of the situation and monitor it. Are there any side effects from medications? Anticoagulants and antiplatelet drugs can cause bleeding, and blood in the stool can be a symptom. Is there increased shortness of breath and swelling in the ankles? “Those are some of the things that your doctor needs to be aware of,” Osborne said. “I love it when patients volunteer information and ask questions about those issues.”
After so traumatic an incident, often including having chest pain, MI survivors may become acutely concerned with any pain in their chest. Most chest pain does not indicate a MI, but the question is how to know if that chest pain is another heart attack or heartburn or something else. “I tell my patients that another heart attack will feel similar to the first one,” Osborne said. “If it feels very different — if it’s a sharp pain, if it’s focal, if it’s transient, lasting only seconds, that’s not the heart. Heart pain would be heaviness, tightness, pressure, burning, an ache that’s more diffused and that typically lasts minutes or longer, and gets worse with exertion and better with rest.”
First Steps for Best Recovery After a Heart Attack
- Make and keep a follow-up appointment
- Understand your medications and take them as directed
- Participate in cardiac rehabilitation
- Get the emotional and social support you need
Make changes that support your health:
- Stop using tobacco
- Maintain a heart-healthy diet
- Control blood pressure
- Manage your cholesterol
- Be physically active
- Reach and maintain a healthy weight
- Control diabetes if you have it
Many MI survivors remain under a doctor’s care, taking medicine and living with dietary and exercise prescriptions for the rest of their lives. Stress management, which may also include use of medications and/or counseling, is also an important component of follow-up care. Not following the doctor’s guidance is a huge problem.
At first glance, adherence to the medical regimen seems to be a patient problem. But there are many barriers to following doctors’ orders. Some of them external and some internal.
MEDICATION REGIMENS AND COSTS
MI survivors generally have to take multiple medications, particularly if they have other conditions such as atherosclerosis, high blood pressure or diabetes, which often contributed to the heart attack. The more complicated the drug or lifestyle prescription, the easier it is too miss doses, miss refills or just simply be overwhelmed.
Solutions: Create a medication map. A medication map is a schedule covering the whole day that plots when you take what medicine, the dose and any other instructions, such as whether or not to take with food. It organizes all your medication in one place so you see at a glance what, when and how much
Schedule a “brown bag” session with your doctor or pharmacist. Put all your prescription and nonprescription medications in a bag and take them to your doctor’s office or pharmacy. They may find overlapping or duplicate prescriptions from different doctors. This would also be a good time to make a medication map. Periodic medication reviews allow you to ask if simpler, less expensive or otherwise better alternatives are available.
Prescriptions can be expensive, and even patients with good insurance may find that their out-of-pocket costs are more than they can afford. Patients on fixed incomes may think they have to choose between their prescriptions and other necessities. In an effort to stretch their medicine, they may reduce the amount they take or the frequency, hoping it will still be effective. But a medicine not taken as directed can’t work as expected. If you’re having challenges affording your prescriptions, speak to your healthcare team about it, they may be able to help you chose medications that are affordable and within your health plan. You may also want to see Managing Prescription Costs, from Stroke Connection magazine for several ways to save costs.
For many people, taking a prescription reminds them that they are sick, and they prefer not to be reminded. Or they may not feel better or even feel worse taking blood pressure medication, so they figure ‘why bother?’
Solutions: Though MI survivors may find these prescriptions difficult to accept, much less embrace, the medicines and lifestyle recommendations from the doctor are designed to reduce the risk of another life-threatening event. Talking with a professional counselor may also help with moving beyond feelings of denial. Enlisting the support of family and friends to help keep on track with meds and to encourage and participate in healthy behaviors, like eating right and making time for physical activity, can be helpful for all involved.
THOUGHT PROCESS CHALLENGES
Seniors with high blood pressure or diabetes must monitor those conditions closely. If they’re also experiencing dementia or memory loss, it can interfere with their ability to keep track of these conditions.
Solutions: Thought process challenges may be difficult to compensate for. Medication maps (see above) and simplified drug regimens are helpful. Family support is important, but professional caregiving services may be necessary in dealing with this barrier. Caregiver creativity can help. For instance, they may mask the medication by putting it in food or drink. For patients who do well with a smartphone or tablet device, there are also apps that can alert a patient at the right time with the name of the medicine and instructions for using it
LACK OF KNOWLEDGE
Some survivors don’t understand the underlying condition that may have caused the MI and aren’t ready for the amount and complexity of information that comes with their diagnosis. That information is often given at hospital discharge, a time when patients may find it hard to focus on what is being said.
Solutions: Ask someone on your healthcare team, whether it’s your doctor, nurse practitioner or a clinical nurse specialist about anything and everything that you’re not sure you understand. Ask if they have any printed material for patients that explains your condition(s) or a list of credible, layperson-friendly websites you can visit. The American Heart Association’s website is a great place to start. If you have more questions after exploring print materials or the internet, write them down and discuss them with your healthcare provider. If you are unsure about medication, ask questions of your nurse, doctor or pharmacist.
LIFE GETS BUSY AND OTHER PRIORITIES ARISE
It seems like taking a few pills every day would be easy to do, but sometimes things that should be easy simply aren’t, especially if there are no immediate repercussions for not taking medicine, eating the wrong foods, or not exercising. At first your medication may be the highest priority, but as you get further from the event, other priorities pop up and demand attention. A prescription bottle gets pushed behind something else, and without a symptom to signal that something is wrong, might be forgotten for days or weeks.
Solutions: You can’t make something a habit until you’ve made it a priority, so make taking your medicine as important as brushing your teeth. Most people don’t wait until someone tells them they have bad breath before using a toothbrush. Don’t wait for your body to tell you that you need to take your medication. Making a written commitment can help. If yours is a complicated treatment plan, ask your doctor, nurse practitioner or a clinical nurse specialist if it can be simplified. Use a weekly pill box where a week’s worth of pills can be allotted. Cue pill taking with some other activity, like eating. Find a smartphone app that lets you schedule automatic reminders. Ask your family to help you remember.
FEAR & SIDE EFFECTS
Some people fear being defined by their condition, and taking medicine reminds them of it. Others are simply afraid to put foreign substances into their bodies, fearing there will be unknown consequences or that they will become addicted.
Solutions: Many fears are unfounded. Talk with your healthcare provider about any fears or concerns; they may have information that will put you at ease. If you experience side effects, report them and talk with the doctor about other possible ways of taking the medicine (with food? change frequency or dosage?).
There have been great advances in cardiac care. “The cocktail of medications we have now are a great advance and cardiac rehab is a tremendous tool,” Osborne said. “I think it’s the collection of all of these advances that have translated to a really dramatic reduction in the mortality from heart attacks.”
If you or someone you care about has had a heart attack, be sure to see our companion to this article A Heart Attack Survivor Shares What She Has Learned featuring Traci Joyce.