After a Myocardial Infarction
Advice After Having a Myocardial Infarction (Heart Attack)

What is a myocardial infarction?

Myocardial infarction (MI) means that part of the heart muscle suddenly loses its blood supply. Without prompt treatment, this can lead to damage to the affected part of the heart. An MI is usually caused by a blood clot in a heart (coronary) artery that forms over a patch of atheroma (fatty deposit). Another leaflet called Myocardial Infarction discusses MI in more detail.

What can I do to help after having a myocardial infarction?

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 complement 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 MI 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. Separate leaflets give more details about smoking and ways that help to stop smoking.

Diet
Changes in diet can make a big difference. Studies suggest that people who eat a healthy diet may have up to 50% less chance of a further MI compared to those who do not eat healthily. A separate leaflet called Healthy Eating gives more details. Briefly:

• Eat at least five portions of a variety of fruit and vegetables each day. The exact way in which they protect is not clear. They are rich in vitamins, minerals and other chemicals called anti-oxidants. These are thought to protect against a build up of atheroma.
• Do not each much fat. Sheets that list foods that are low in fat are commonly available (ask your practice nurse for one). Also, it is not just about the total fat content of the diet, but also the type of fat in the diet. Foods that contain fats that are mainly mono and polyunsaturated fatty acids are much preferable to foods with saturated fatty acids and trans fats.
• Eat oil-rich fish such as herring, mackerel, sardines, kippers, pilchards, salmon, trout, anchovies, fresh tuna, (or take fish oil supplements). Studies suggest that eating 2-3 portions of oil-rich fish per week reduces the risk of a further MI. It is probably the omega-3 fatty acids in the fish oil that help. These seem to help reduce the build up of atheroma and may make the blood less likely to clot, and so reduce the risk of having an MI.

So, in practice, a healthy diet briefly means:

• THE BULK OF MOST MEALS should be starch-based foods (such as cereals, wholegrain bread, potatoes, rice, pasta), plus fruit and vegetables.
• NOT MUCH fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use low fat, mono-, or poly-unsaturated spreads.
• Eat oil-rich fish. If you eat meat it is best to eat lean meat or poultry such as chicken.
• If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive oil.

Alcohol
A little alcohol may help. People who drink one glass of wine per day, or about half a pint of beer per day may have less risk of heart disease compared to those who do not drink at all. It is probably the alcohol rather than anything else in the drink that is the active ingredient. Therefore, a small amount of any alcoholic drink is possibly beneficial. The exact way this works is not clear. Alcohol may affect the way atheroma is formed.

However, drinking too much alcohol can be harmful. Men should drink no more than 21 units per week (and no more than four units in any one day). Women should drink no more than 14 units per week (and no more than three units in any one day). 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. A separate leaflet called Alcohol and Sensible Drinking gives more details.

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 pasta and wholegrain breads, and lots of fruit, vegetables, olive oil, oil-rich fish, accompanied by a 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 drug to lower the cholesterol level. There are several statin drugs to chose from. Statins work by reducing the amount of cholesterol that is made in the liver.

In general, the lower the cholesterol level, the better. Your GP or practice nurse will give you a target cholesterol level to aim for. This is usually for your blood cholesterol level to come below 5 mmol/l or to be reduced by 20-25% from your original level, whichever is lower. You need a blood test before starting a statin, and about six weeks later. A blood test every so often may then be advised to keep a check on your cholesterol level. The dose may be increased until your target level is reached. A separate leaflet called Cholesterol gives more details.

Physical activity and exercise
Normal physical activity and regular exercise is advised for most people who have had an MI. In the past, some 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 is 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, get the go-ahead from your doctor. This is because strenuous exercise in certain situations may not be advised. For example, some people with heart valve problems may not be advised to exercise. But these people are the exception, and for most people who have had an MI, exercise is beneficial.

Following an MI, once you get the go-ahead, it is best to gradually build up the level of activity and exercise that you do. 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.

If you feel OK after 1-2 weeks then gradually build up the distance of your walking. A reasonable goal by about six weeks after having an MI is to aim to walk for 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 be too frail to exercise. However, many people who have had an MI can gradually build up the amount of exercise that they can do quite well.

As regards lifting and sudden 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 following an MI the advice about exercise is the same as applies to anyone else to gain health benefits. That is, aim to build up to do at least 30 minutes of moderate exercise on most days (at least five days per week).

• 30 minutes per day is probably the minimum to gain health benefits. However, you do not have to do this all at once. Several short bursts of activity are thought to be equally as good. For example, three 10 minute activities at different times in a day. This may make it easier to fit exercise into a busy schedule. Try to increase the amount to 40-60 minutes per day if you can. For older people, the above recommendations still apply, depending on ability.
• Moderate exercise means that you get warm, mildly out of breath, and mildly sweaty. It does not have to be intense. For example: brisk walking, jogging, swimming, cycling, dancing, badminton, tennis, etc. You can even use normal activities as part of your exercise routine. For example, fairly heavy housework or gardening can make you out of breath and sweaty. Consider a brisk walk to work, or to the shops, instead of using a car or bus, etc. For many people, a daily brisk walk for 30-60 minutes is a realistic goal.
• On most days. You cannot 'store up' the benefits of exercise. You need to do it regularly.

A separate leaflet called Exercise for Health gives more details.

Weight
If you are obese or 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. Separate leaflets called Obesity and Overweight and Weight Reduction - How to Lose Weight give more details.

Blood Pressure
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 mmHg. If you are being treated for high blood pressure, the usual target is to reduce blood pressure to below 140/90. (This figure is controversial as some experts say the target should be to below 140/85 mmHg.) In some cases, your doctor will advise an even lower target. For example, if you have diabetes or certain other conditions.

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. A separate leaflet called High Blood Pressure gives details.

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

What medication is usual following a myocardial infarction?

Medication after an MI is discussed more fully in another leaflet called Medication Following an MI. Briefly, the following four drugs are commonly prescribed.

• Aspirin reduces the 'stickiness' of blood which reduces the risk of blood clots forming. Clopidogrel is an alternative to aspirin which helps to prevent blood clots. It is usually used in people who are not able to take aspirin.
• A beta-blocker slows the heart rate and reduces the risk of abnormal heart rhythms.
• An ACE (angiotensin converting enzyme inhibitor) reduces the risk of developing heart failure and further MI.
• A statin reduces the cholesterol level (as discussed above).

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 is usually advised.

The time it takes to resume normal life after an MI varies from person to person. It is common to feel tired and have some aches and pains for a week or so. As discussed above, you should begin physical activity gently, but gradually increase over 4-6 weeks.

Work issues
About a third of people who have an MI are under 65 and most of these people will have a job at the time of the MI. Following an MI, most people can get back to work within 2-3 months. However, each case is different. For example, some people who have a small MI and feel well get back sooner. On the other hand, some people with ongoing symptoms or complications such as angina or heart failure may take longer to get back, or may not be able to get 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, as explained, 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. There are few jobs that are not possible to do for people who have recovered from an MI. For many people, returning to work is an important part of regaining quality of life.

A sensible approach is possibly:

• Get the go-ahead from your doctor about when you should return to work.
• Then, a phased return to work may be best if your employer is agreeable. For example:
  • start with alternate half days, and build up to your 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 as decision for the right reasons and not based on fear or wrong beliefs about your heart.

Driving and flying issues
You can resume car driving after four weeks provided you have made a satisfactory recovery (and your insurance company is notified). However, if driving causes angina, you should not drive until the angina is well controlled. PSV and HGV rules are stricter and further assessment is required. You can usually resume air travel after six weeks.

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. Dont 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 get a lot of benefit from learning to positively relax. A separate leaflet called Relaxation Exercises may help as it goes through the two main ways to positively relax. That is, muscular exercises and deep breathing exercises. There is also another leaflet called Stress and Tips on How to Avoid It. You can also buy relaxation tapes and CDS to help you learn to relax. Also, tell your doctor if you feel that you have become over anxious as there are other treatments for anxiety that may help.

Sex issues
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.

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 wellbeing.

Some other general points

• 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. A leaflet called Angina gives more details.) Further treatment may be needed.
• Tell your doctor if you get breathless, become more tired than usual, or notice swelling of your feet. 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. A separate leaflet called Heart Failure gives 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.

And 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 was 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. (One example. 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  14 Fitzhardinge Street, London, W1H 4DH
Heart Information Line: 08450 70 80 70. An information service for the public and health professionals on a wide range of issues relating to heart health.
Web: www.bhf.org.uk

© EMIS and PIP 2006   Updated: February 2006   PRODIGY Validated