Heart attack recovery

Psychological issues

Depression affects one in four people after a heart attack. It’s critical to address any depression – it won’t just go away on its own and it can make it harder for you to make any necessary lifestyle changes or follow your doctor’s advice on particular treatments. Without specific help, those who become depressed don’t recover as well as they might.

If you take part in a cardiac rehabilitation programme, it will be able to offer treatments ranging from medication to group therapy and stress management (stress and anger may contribute to a heart attack by producing changes in your body that increase your risk of blood clots).

Heart attack recovery

Back to normal

In uncomplicated cases, you should be back to your normal routine after six to 12 weeks.

• Work – exactly when you return depends on your job and how serious the heart attack was. Take it in stages and rest when you feel tired. Some very physical jobs may be beyond your ability at first.
• Driving – avoid long journeys and stressful driving situations, such as in a city or in the rush hour.
• Sex – many people worry that sexual activity may be too strenuous after a heart attack, but research shows these fears are generally unfounded. Like all exercise, take it slowly at first.

Cardiac Rehabilitation

Conclusion

Cardiac rehabilitation is an important component of the current multidisciplinary approach to the management of the patients with various presentations of coronary heart disease. Cardiac rehabilitation involves exercise training, education, counseling regarding risk reduction and lifestyle modification, and, frequently, behavior interventions.

The goals of cardiac rehabilitation services are to improve the physiologic and psychosocial condition of patients. Physiologic benefits include the improvement of exercise capacity and the reduction of risk factors (eg, cessation of smoking and lowering of lipid levels, body weight, blood pressure, blood glucose), with the exercise component provided through rehabilitation possibly reducing the progression of atherosclerosis. Psychological improvements include the reduction of depression, anxiety, and stress. All of these improvements enable the patient to acquire and maintain functional independence and to return to satisfactory and appropriate activity that benefits the patient and society.

For excellent patient education resources, visit eMedicine’s Public Health Center. Also, see eMedicine’s patient education articles Chest Pain, Coronary Heart Disease, Heart Attack, Walking for Fitness, and Resistance Training.

Cardiac Rehabilitation

Cardiac rehabilitation aims to reverse limitations experienced by patients who have suffered the adverse pathophysiologic and psychological consequences of cardiac events.

Cardiovascular disorders are the leading cause of mortality and morbidity in the industrialized world, accounting for almost 50% of all deaths annually. The survivors constitute an additional reservoir of cardiovascular disease morbidity. In the United States alone, over 14 million persons suffer from some form of coronary artery disease (CAD) or its complications, including congestive heart failure (CHF), angina, and arrhythmias. Of this number, approximately 1 million survivors of acute myocardial infarction (MI), as well as the more than 300,000 patients who undergo coronary bypass surgery annually, are candidates for cardiac rehabilitation.

The image below depicts cardiac rehabilitation after bypass surgery.

Phase 1: A patient walking in the hallway with a physical therapist following bypass surgery.

Traditionally, cardiac rehabilitation has been provided to somewhat lower-risk patients who could exercise without getting into trouble. However, astonishingly rapid evolution in the management of CAD has now changed the demographics of the patients who can be candidates for rehabilitation training. Currently, about 400,000 patients who undergo coronary angioplasty each year make up a subgroup that could benefit from cardiac rehabilitation. Furthermore, approximately 4.7 million patients with CHF are also eligible for a slightly modified program of rehabilitation, as are the ever-increasing number of patients who have undergone heart transplantation.[1]

This review addresses the objectives, indications, program components, exercise training, monitoring, benefits, risks, safety issues, outcome measures, and cost-effectiveness of cardiac rehabilitation.

Objectives
The identification of the patients at risk for a cardiac event’s recurrence (ie, risk stratification) is central to formulating an appropriate medical, rehabilitative, and surgical strategy to prevent such a recurrence. Patients who are at low or moderate risk typically undergo early rehabilitation. The major goals of a cardiac rehabilitation program are:

Curtail the pathophysiologic and psychosocial effects of heart disease
Limit the risk for reinfarction or sudden death
Relieve cardiac symptoms
Retard or reverse atherosclerosis by instituting programs for exercise training, education, counseling, and risk factor alteration
Reintegrate heart disease patients into successful functional status in their families and in society
Cardiac rehabilitation programs have been consistently shown to improve objective measures of exercise tolerance and psychosocial well being without increasing the risk of significant complications.

Utilization
The Agency for Health Care Policy and Research (AHCPR); the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), and the National Heart, Lung and Blood Institute (NHLBI) have recognized the wide variation in awareness and understanding of the role of cardiac rehabilitation among physicians, ancillary health care providers, third-party payers, and patients with heart disease.

In the past, it was found that only 11% of patients participated in such programs following an acute coronary event. However, there is evidence that participation has increased. Approximately 38% of US patients and 32% of Canadian patients with acute MI who were involved in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) trial were enrolled in cardiac rehabilitation programs.

Outcome Measures
Current cardiac care has already reduced early acute coronary mortality so much so that further exercise training, as an “isolated” intervention, may not be able to cause significant reduction in the morbidity and mortality.[2] Nonetheless, exercise training has the potential to act as a catalyst for promoting other aspects of rehabilitation, including risk factor modification through therapeutic lifestyle changes (TLC) and optimization of psychosocial support. Therefore, the outcome measures of cardiac rehabilitation now include improvement in quality of life (QOL), such as the patient’s perception of physical improvement, satisfaction with risk factor alteration, psychosocial adjustments in interpersonal roles, and potential for advancement at work commensurate with the patient’s skills (rather than simply return to work).[3, 4]

Similarly, among patients who are elderly, such outcome measures may include the achievement of functional independence, the prevention of premature disability, and a reduction in the need for custodial care.[5, 6, 7, 8] Despite limited data, older male and female patients in observational studies have shown improvement in their exercise tolerance comparable to that of younger patients participating in equivalent exercise programs. In addition, the safety of exercise within cardiac rehabilitation programs, as studied in over 4,500 patients, is well accepted and established.

Cardiac rehabilitation services are, therefore, an effective and safe intervention. These services are undoubtedly an essential component of the contemporary treatment of patients with multiple presentations of coronary heart disease and heart failure.

Related eMedicine topics:

Angina Pectoris (Cardiology)
Angina Pectoris (Emergency Medicine)
Complications of Myocardial Infarction
Myocardial Infarction (Cardiology)
Myocardial Infarction (Emergency Medicine)
Myocardial Infarction in Childhood
Unstable Angina
Vascular Diseases and Rehabilitation

Rheumatoid Arthritis Pictures Slideshow

There is no known cure for rheumatoid arthritis; however, early medical intervention has been shown to be important in improving outcomes.

How Is Rheumatoid Arthritis Treated?

There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as seen on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.

Women’s Health Pictures Slideshow: 18 Embarrassing Beauty Questions and Answers

Aren’t I Too Young to Go Gray?

If you haven’t reached 40 and more than half of your hair is white, you’re “going gray” prematurely. In some cases, this can be a sign of a thyroid or pigment disorder. But most often, you can thank your parents for the early gray genes. Fortunately, premature graying does not mean that your body is aging more quickly than anyone else’s.

Women’s Health Pictures Slideshow: 18 Embarrassing Beauty Questions and Answers

Why Do I Blush So Often?

Most people blush on occasion, especially when feeling shy or embarrassed. But when patches of red pop up randomly on the cheeks, forehead, or chin, rosacea may be to blame. This chronic skin condition is treated with pills and/or creams. Frequent blushing along with a pounding heart during social situations can be a sign of social anxiety disorder.

Teenage health campaigns ‘reduce adult heart risks

Health campaigns targeted at teens could help reduce their risk of heart problems as adults, a study suggests.

Smoking can have a big impact on general health and cholesterol levels in later life

Concerns have been raised that warning signs like high cholesterol are being seen in the young, laying the foundation for future health problems.

But the study of more than 500 people found those with high cholesterol at 15 could normalise it by their mid-30s.

The Australian research is published in Archives of Pediatrics and Adolescent Medicine.

Participants in the Australian study had levels of cholesterol and other blood fats measured in 1985 when they were aged 9, 12 or 15.

They were measured again between 2004 and 2006, an average of 20 years later.

High risk levels in this study were defined as a total cholesterol level of 240 miligrams per deciliter or higher (6.2mmol/l).

The average total cholesterol level in the UK is 5.5mmol/l for men and 5.6mmol/l for women.

Height, weight, waist circumference, skin-fold thickness, smoking habits and cardio-respiratory fitness were also measured in the study.

Good and bad

Of those participants who had high-risk cholesterol levels in their youth, those who stopped smoking or lost weight became low-risk in adulthood, while those who increased their body weight or who started smoking were more likely to maintain those high-risk levels 20 years later.

Costan Magnussen, lead study author from the University of Tasmania, said their findings were important.

“They suggest that beneficial changes in modifiable risk factors in the time between youth and adulthood have the potential to shift those with high-risk blood lipid and lipoprotein levels in youth to low-risk levels in adulthood,” he said.

He added that prevention programmes targeted at the young could also benefit those who develop bad habits as they get older.

Dr John Coleman, chairman of the Association for Young People’s Health, said: “This reseach gives a very clear example of why we need to invest more in adolescent health and make it a higher priority.

“It is clear that young people’s lifestyle choices have a long term impact on their health and it is cost effective and sensible to work with them to encourage healthy habits.”

Mike Knaptonof the Brtish Heart Foundation said: “All teenagers can do something to improve their cholesterol.

“We should all be eating five portions of fruit and veg a day. And, most importantly, the message is don’t smoke.”

Heart patients not getting ‘most appropriate’ drugs

More than half of heart patients in Scotland at high risk of stroke are not receiving the most appropriate treatment, according to a new report.

The report reviewed cardiology services across Scotland

Scrutiny body Healthcare Improvement Scotland has published the “most comprehensive picture yet” of cardiology services across the country.

It found 53% of patients who should be getting a blood thinning drug were not.

Meanwhile low-risk patients are being given more powerful medication when they should just be taking aspirin.

The report paints an in-depth picture of the strengths and weaknesses of heart disease services in Scotland, and includes detailed plans for how improvements to services can be made.

Cardiovascular disease is the leading cause of death in the UK and coronary heart disease results in nearly 10,000 deaths every year in Scotland.

The report raised concerns about treatments prescribed to people with atrial fibrillation, a common heart rhythm disorder with a high risk of stroke.

While nearly 80% of people with this diagnosis receive some form of blood-thinning drug, less than half (47%) of higher risk patients are receiving the most appropriate treatment, Warfarin.

At the same time 31% of low-risk patients, who should be treated with aspirin alone, are receiving a blood-thinning drug which exposes them unnecessarily to a higher risk of bleeding complications.

Vital services

Dr Martin Denvir, clinical lead for the heart disease improvement programme, said: “Within three years of starting this improvement programme we are now publishing a groundbreaking report which sets out in detail just what has been achieved in Scotland – and what is still to be done.

“This is the most comprehensive picture yet of heart disease services in Scotland.

“The journey towards perfect care for all patients is by no means over, but our findings clearly identify what is already being done well, what needs improvement and how we can measure our improvement and progress towards best quality of care.”

The report also found that although all health boards have risk assessment programmes in place to identify people at high risk of heart disease and stroke, these programmes are not provided comprehensively for all high-risk groups in the general population.

It also said the Scottish Ambulance Service provides a well-trained and rapid response to emergency calls and reaches 71% of patients with suspected heart disease within eight minutes.

The report makes a number of key recommendations to improve patient care, including a review of the prescribing of blood-thinning drugs.

It said patients at low risk of stroke should not routinely be prescribed Warfarin.

Andy Carver from the British Heart Foundation (BHF) welcomed the report and said: “It is an important step in improving the accountability of NHS boards for the delivery of vital services for heart patients.

“We will continue to watch closely and help ensure that these standards are implemented to help people prevent heart disease and make sure services for heart patients are the best possible in all parts of the country.”

Chest Heart & Stroke Scotland’s chief executive David Clark said “We recognise that there has been real progress as a result of the Heart Disease Improvement Programme and that Scotland has some world-class centres for the treatment of heart disease.

“However, we also have to recognise that there is some way to go until every patient has the correct treatment every time.”

Perimenopause: Help for Haywire Hormones

Perimenopause symptoms are different for every woman—get the relief you need with these customizable tips

4. Poor Sleep

Try This: Many perimenopausal symptoms are interrelated: Hot flashes rob you of sleep, so by minimizing them, you start the morning feeling more refreshed. Also pay attention to what you put in your body—and not just in the evenings. Some OTC meds contain stimulants such as caffeine, and nicotine disrupts sleep too. Also, limit yourself to a glass (or less) of adult beverages at night: “Alcohol helps you fall asleep, but it prevents the deeper stages needed for proper rest,” says Dr. Pinkerton. Melatonin, bright light therapy, or valerian supplements may also improve sleep. Exercise earlier in the day and avoid heavy meals at night.

Then This: If tossing and turning is a nightly affair, it could be sleep apnea. Although men are more prone to the problem, a woman’s risk rises around the time of menopause. “It’s important to speak to your doctor to rule that out,” says Dr. Pinkerton. If that’s not the cause, low-dose antidepressants or antianxiety medications can help normalize sleeping patterns without becoming addictive. Prescription sleeping aids, such as Ambien, are a big gun that should be fired with caution. “I don’t recommend using it more often than every three days,” says Pinkerton. “When you are under stress or grieving, it’s a fine short-term option. But if you need to use it every day, talk to your doctor about switching to a new medication or another option.”

Perimenopause: Help for Haywire Hormones

Perimenopause symptoms are different for every woman—get the relief you need with these customizable tips

2. Mood Swings

Try This: The holy trinity of healthy lifestyle changes: good nutrition, adequate sleep, and regular exercise. A recent study in the journal Menopause found that perimenopausal women who exercise have a better sense of self-worth and well-being overall. You may also want to try St. John’s wort supplements—women between the ages of 43 and 65 who took one 900 mg tablet three times a day for 12 weeks reported a significant improvement in menopause-related psychological symptoms, found German researchers.

Then This: If your behavior is Exorcist-worthy, consider taking a low-dose oral contraceptive with a shortened placebo week to lessen your exposure to mood-altering spikes in estrogen. Other underlying medical issues, such as thyroid imbalances, may also be a factor. Keep in mind, too, that some of the common stressors in midlife—aging parents, kids in college, marital issues—could be the source of any emotional unease. “Don’t blame perimenopause for everything that’s wrong in your life,” says Judi Chervenak, MD, associate clinical professor of obstetrics and gynecology at Montefiore Medical Center. “You need to investigate the root cause of the problem.”

28 Days to a Healthier Heart

Lower heart disease risk by 92% with a simple change each day

Heart Health Day 23: Do Something Sweet for Your Partner

There’s a lot of proof that marriage buffers you against heart disease, but that may be true only if you’re happily coupled, says Agatston. One study in the Annals of Behavioral Medicine found that spouses who reported a lot of negative encounters with their partner had blood pressure that was, on average, 5 points higher than that of single people. The emotional stress of a difficult marriage typically causes adrenaline levels in the blood to spike, raising blood pressure; it can also cause blood vessels to spasm.

To make sure your marriage doesn’t go on autopilot, forge little ways to stay connected all the time. If you do something nice today (like paying an unexpected compliment or taking on a chore he normally handles) chances are he’ll reciprocate soon, which helps bolster your bond.

Feel closer in 5 minutes with these fast relationship-boosters

28 Days to a Healthier Heart

Lower heart disease risk by 92% with a simple change each day

Heart Health Day 21: Stay Connected to Loved Ones

Strong ties to family, friends, and community reduce anxiety and fight depression — two factors that increase your risk of a heart attack. Make a lunch date with a friend you’ve been playing phone tag with, dedicate at least 1 night a week for a sit-down family dinner, or plan to visit your place of worship. Resolve to do one of these things every day (yes, jetting off a quick thinking-of-you e-mail counts).

Signs of Heart Attack

When to Seek Medical Care

Call your health care provider if you have these symptoms, which are warning signs of a heart attack.

• Chest pain or pressure or feeling of indigestion on exertion
• Shoulder or arm pain, left or right or both, during physical or stressful activity
• Jaw pain
• Unexplained shortness of breath (while at rest or comes on suddenly)
• Unexplained nausea, vomiting, or sweating
• Fainting spell
• Palpitations (awareness of rapid or pounding heartbeat)
• Dizziness

If these symptoms do not go away in 5 minutes, call 911 immediately for emergency medical transport to a hospital. Do not try to drive yourself.

Each year, thousands of Americans die because they did not seek medical attention in time.

• It is good to be cautious and go to the hospital.
• This may mean the difference between life and death.
• Don’t worry about “wasting everyone’s time.” You aren’t.
• If you are not having a heart attack, that’s fine. You may be able to receive treatment for whatever is causing your symptoms.

Strong Emotion Can Impact The Heart

A recent study confirmed that grief over losing a loved one increases heart attack risk. According to the study reported on in Cardiology Today: risk for a myocardial infarction (MI) “appears to increase in the days and weeks after the death of a significant person in one’s life.”

“Strong emotion can impact the heart,” explains Leo Pozuelo, MD, section head of Consultation Psychiatry in the Cleveland Clinic Heart and Vascular Institute. “This study also points out that grief can be especially detrimental to patients with heart disease.”

Knowing this behooves all healthcare providers, caretakers and those people suffering a loss to realize that they are in a period of risk following the death of a loved one.

As part of this multicenter study on “Determinants of Myocardial Infarction Onset,” the researchers looked at charts and interviewed patients in the hospital who suffered a heart attack during a five year period from 1989 to 1994.

They questioned patients about the circumstances surrounding their heart attack. They talked with people who had lost someone recently and others who had lost a loved one within the six months prior to the MI. According to study results: “the incidence rate of acute MI onset was elevated more than 21-fold within 24 hours of the death of a significant person and declined steadily on each subsequent day.” *

“Having good support, minimizing isolation and keeping up with wellness techniques can help patients weather the loss of loved ones on an emotional level,” Dr. Pozuelo stresses. “It may be advantageous to one’s heart health to keep up with these healthy coping behaviors.”

Murray Mittleman, MD, DrPH, preventive cardiologist and epidemiologist at Harvard Medical School’s Beth Israel Deaconess Medical Center, noted that “These results require confirmation in prospective studies.”

* It’s important to note that the study data were collected before common use of statins. Future research could examine whether the risk is lessened with the regular use of statins