Heart Attack, Part Two: A Patient Guide

Introduction

The Heart Attack Patient Guide describes what you are likely to experience when having a heart attack, as well as your recovery and treatment. This guide describes the various stages of recovery, from the first few days in the cardiac care unit to months and years later. Details about bypass and angioplasty recovery, discharge from the hospital, cardiac rehabilitation, exercise, long-term recovery, medication, depression, and lifestyle modifications are included. Part One of the guide reviews basics of heart function, heart attack symptoms, emergency care, medications, tests, and treatments performed in the hospital.

I. Recovery

The cardiac care unit (CCU) or medical intensive care unit (MICU)

If you have had or are suspected of having a heart attack, you will usually be taken from the emergency room (ER) to the cardiac care unit (CCU) or medical intensive care unit (MICU). Within the first day of your CCU stay, you may not receive anything to eat by mouth (i.e., made fasting) or be placed on a clear liquid diet. The reason for these dietary restrictions is to reduce the risk of vomiting after the heart attack and to empty the upper gastrointestinal tract prior to the performance of any urgent invasive cardiac procedures (i.e., cardiac catheterization). Once it is deemed safe for you to resume eating solid food, you will be prescribed a diet that is low in saturated fats, cholesterol, and sodium (and processed sugars, if diabetes is present). Diets might consist of fish or lean chicken (protein), fruits and vegetables (fiber and carbohydrates, antioxidants), and breads and light pastas (carbohydrates). Bananas, orange juice, and grapefruit juice might be used because they serve as plentiful sources of potassium and magnesium and are low in sodium.

Anxiety is common during the first 24 to 48 hours and may be treated with benzodiazepines (e.g., lorazepam or oxazepam), low-dose narcotics (e.g., morphine), or haloperidol. While these medications overall are very safe, each has its own set of side effects or adverse reactions that could occasionally dissuade its use in individual patients. You may become temporarily confused and disoriented to time (termed delirium, or ICU psychosis) in the CCU because you are receiving multiple new medications, severely sleep-deprived, or unaccustomed to your new surrounding. Patients with multiple complex medical problems and the elderly are at greatest risk for this condition. Fortunately, ICU psychosis is usually tempered with medications (e.g. haloperidol), discontinuation of problematic medications, or discharge from the CCU to a quieter floor. You may also be given sleeping pills to maintain as normal a day-night schedule as possible. Stool softeners are used to prevent constipation and straining.

In the absence of complications, patients who have had a heart attack are not confined to bed for more than 12 hours. You can participate in progressive daily activity depending on your vital signs (blood pressure and heart rate), age, and physical capacity. The following stages are used as general guidelines for activity following a heart attack. Actual practice may vary significantly from these guidelines, depending on your health status, the therapies performed and progress. Due to reperfusion therapies whether with intravenous medicines or the use of angioplasties and stents, and improvements in the anesthesia used for coronary artery bypass surgery, it is common for patients to leave the hospital, if they are stable, within just a few days.

Stage one (days 1 and 2)

During the first day, you may use a bedpan or bedside commode. You may feed yourself from a tray with arm and back support. Complete assistance will be given for bathing. The nurse will move your arms and legs to assess range of motion. You may be asked to push your foot against a footboard as a first step in active motion. You are encouraged to concentrate on relaxing and taking deep breaths.

On the second day, with back support, you may partially bathe your upper body. You should try to move from the bed to the chair for one to two hours per day. You should actively move your arms and legs five to 10 times during the day.

Stage two (days 2 through 4)

You may bathe, groom and dress yourself either sitting on the bed or in a chair. You may transfer from the bed to a chair as often as desired and may walk around the room for increasing periods of time. Walking can help alleviate constipation.

On the fourth day, you may shower or stand by the sink to bathe. Using a shower chair helps guard against falling and anxiety. You may dress in your own clothes. Supervised walks outside the room (100 to 600 feet) should occur several times per day.

During stage two, you may be transferred to an intermediate coronary care unit where you will continue to be treated with in-hospital rehabilitation and participate in educational programs to learn how to maintain a healthy heart.

Stage three (days 3 through 7)

You may walk up to 600 feet three times per day. You may shampoo your hair, expanding your activity to moving your arms above your head. You may begin supervised stair climbing. It is also possible that, prior to discharge, you will be given an exercise tolerance test.

Discharge

Discharge times vary with each patient. If you were treated with bypass surgery and have no subsequent complications, you may be safely discharged in fewer than five days. Discharge is more common, however, five to six days after admission. Most complications that prevent early discharge happen within the first day or two of admission.

If you have complications, discharge is deferred until your condition is stable for several days and it is clear that you are responding appropriately to necessary medications.

Prior to discharge, you will be given detailed instructions about activities in which you can engage. They should initially avoid lifting and rest several times per day. You should be given nitroglycerin tablets and should be instructed in their use and the use of any other medications. As time progresses, you should resume more activities. Any activity, including sexual activity, that causes chest pain should be avoided until appropriate medical follow-up and a possible standard exercise stress test.

II. Short-term recovery

In at least one-third of cases, the first sign of heart disease is a heart attack. Recovery will vary based on the type of treatment you receive at the hospital and your overall health, age and medical history.

Doctors will try to open clogged coronary arteries to prevent another heart attack for many heart attack patients. Two common surgical techniques to re-vascularize (or open) clogged arteries are bypass surgery and angioplasty. Bypass surgery is an invasive procedure, often performed when patients cannot be treated with angioplasty. (For a description of bypass and angioplasty procedures, refer to Heart Attack, Part I: A Patient Guide.)

Bypass recovery

After undergoing bypass surgery, you will be taken to a surgical intensive care unit (SICU) for postoperative recovery. The first few days of recovery from bypass surgery are the most critical. Doctors will watch for complications from the bypass.

For the first 24 hours, catheters, IVs, and other monitors used for the surgery will remain inserted and the doctors and nurses will closely watch all vital signs. A breathing tube, if still inserted, will prevent speaking during this period. Your hands might be restrained to prevent the dislodgement of tubes, wires, and monitors. Physical activity is limited. Eating will not occur for at least the first day and usually resume after the gastrointestinal tract begins to resume normal activity (indicated by the passing of gas and toleration of oral fluids). A physical therapist will encourage small movements. Walking does not usually begin until the second or third day.

A pillow will usually be given to lessen pain from incisions when coughing, transferring or walking. You will be instructed to use an incentive spirometer (a device that is used to encourage you to take deep breaths) and to cough after the breathing tube is removed to help with lung expansion and to prevent pulmonary (lung) complications.

You will have a large vertical incision line that extends the length of your chest, and an incision from the graft site (usually on your leg). Generally, a pressure dressing will be in place over the chest incision for the first 24 hours after the operation. The incision will have staples and internal or external sutures. Postoperative care and the removal of sutures or staples is determined by your physician and hospital protocol. On the day of operation, exercises will be performed on the affected limb to decrease edema (swelling), stiffness and other postoperative complications.

On the second day after surgery, you will be able to sit up in bed. The third day, you will be encouraged to move to a chair for brief sitting and walking about the room. If recovery is as expected, catheters and IVs will be removed. You will also be encouraged to eat a very basic diet and to resume use of the toilet. IVs will not be removed until fluids are tolerated by mouth.

At this point, you will most likely be moved to another part of the hospital for general recovery. You will be allowed to shower, and most physicians will permit wetting the incision. Blood pressure and temperature will continue to be monitored, and increased activity will be encouraged. Walking is recommended to augment normal gastrointestinal tract activity and reduce constipation. Hospital discharge may occur sometime within one week of surgery, depending on a patient's progress and their prior condition. (See Bypass Surgery: A Patient Guide for detailed information about bypass surgery.)

Angioplasty recovery

Because it is less invasive, angioplasty patients will experience a much quicker recovery than bypass patients. If you are treated with angioplasty, with or without the insertion of a stent, you will be closely monitored, and possibly discharged within 24 to 48 hours of the procedure. (See Angioplasty: A Patient Guide for detailed information about angioplasty.)

Getting the information you need

A social worker is usually involved in discharge planning to check for family support, financial resources for medications, transport for follow-up appointments, and details such as architectural barriers in the home. Sometimes home health care is prescribed if additional instruction is needed for IV therapy, central line care or for bandaging incisions. Home health care is usually scheduled before you are discharged.

Before you leave the hospital, a doctor will discuss the critical issues of your recovery. You should consider having a spouse, friend, or relative take notes for you because the information provided can be overwhelming. Your spouse, friend, or relative can play a significant role in recovery.

Your doctor will likely give you information to read. It is important to fully understand your condition and feel comfortable asking questions prior to your hospital discharge and realize that you can always telephone your doctor or the hospital if you have additional questions at any time.

III. Rehabilitation and long-term recovery

If you have heart disease and have experienced a heart attack, try to view it as a wake-up call, not a death sentence. Patients who see their illness as an opportunity to modify lifestyle and bad habits can live with the changes for a long time.

Some of the most important things your doctor will discuss with you are the following lifestyle changes: diet; exercise; medication; blood pressure, diabetes, and cholesterol control; smoking cessation; and stress management. These topics also will be discussed during the series of doctor visits you will have throughout the first year following your heart attack.

Doctor visits

You can expect to see your doctor within the first month after leaving the hospital and again at two- to four-month intervals for the first year following your heart attack. The doctor will conduct a physical exam, check incisions and perform blood tests that might include: chemistries (if on diuretics and/or electrolyte supplements, kidney function, diabetes control), CBC (for inflammatory responses, anemia), cholesterol levels, INR (prothrombin time or pro time is now called INR) if on coumadin, digoxin levels if on digoxin, and liver function tests (to evaluate if any medication liver-related side effects).

The doctor will also perform an electrocardiogram (ECG or EKG) to measure your heart's electric impulses, and repeat the ECG on a regular basis. It is common to perform an exercise tolerance test about two or three months after discharge from the hospital and to repeat this if symptoms recur. This will be a good chance to show just how much you have progressed. It is also common to recheck an echocardiogram in the first few months after discharge from the hospital. After that, you can expect to visit your cardiologist every four to six months for the rest of your life.

Depression

Anxiety, depression, or a combination of both can accompany a heart attack. Because physicians can sometimes overlook it, family members should be especially careful to watch for signs of excessive worry and/or depression. Heart attack patients often feel that a part of them has died and they are mourning both its loss and the loss of their former life. People often expect their lives to be changed immeasurably - and for the worse - after a heart attack. Not knowing what to expect can create anxiety. This also might be your first serious hospitalization or illness. Feelings of fragility and vulnerability might be difficult to accept. Support groups for you and your family members, as well as patient education programs, are available to help manage this transition. Families often feel more comfortable if they are educated about what to do in emergencies and first responder courses are available all over the country through the Red Cross.

Even after having resumed full strength (determined by stress tests at your doctor's office), you and your family members often feel hesitant to resume physical activities. Patients often wonder when it is safe to resume sexual activity. Generally, normal activities can be resumed over time. Depending upon you condition resumption of sexual activity anywhere from one day to eight weeks after returning home from the hospital can be anticipated. For your emotional reassurance, speak with your doctor regarding any concerns you have about physical and sexual activity.

After two to four months, most heart attack patients can return to their jobs (this is dependant upon our condition and the requirements of the job). Some people can return to work in less time. Job-related stress, however, must be considered when returning to work.

Lifestyle modifications

Diet. Heart attack patients must restrict their fat and cholesterol consumption. People with high blood pressure must restrict salt, and people with diabetes must monitor sugar intake. Your physician can recommend a book that defines heart-healthy dietary guidelines, or provide you with a list of items to avoid. Some doctors refer patients to a nutritionist for dietary counseling.

Above all, saturated fats from meats and dairy products should be limited. More fruits and vegetables should be added to your diet. While dietary changes are difficult to initiate, you can adjust well to your new diet and learn to enjoy healthier eating.

Family members should support you in all aspects of your new habits. Studies show that family support can help heart disease patients achieve and maintain a healthy lifestyle, and thereby reduce future, recurrent heart attack risk. This is especially true with smokers. Smokers who do not quit have triple the risk of death in the following year than those who do quit.

Exercise. Exercise and increased physical activity is important in recovering from a heart attack. Studies show a sedentary lifestyle contributes to heart disease. Recovery also is quicker for patients who were active before their heart attack. Before leaving the hospital, you will be monitored to make sure you can function with limited physical activity. When you return to visit your doctor (anywhere from one to six weeks after you return home), you will likely be given another stress test to ensure your safe return to normal physical activity.

Cardiac rehabilitation. Many hospitals that perform bypass surgery have cardiac rehabilitation programs or can refer you to a conveniently located program. As part of cardiac rehabilitation, patients treated with bypass surgery usually attend monitored exercise programs. This is especially important for high-risk patients and those with other diseases.

In cardiac rehabilitation, you are monitored with machines and supervised by trained medical personnel. In addition to helping you improve physical strength, cardiac rehabilitation can improve your outlook and provide needed support to make important lifestyle changes.

It is important to ask your physician when you can begin an exercise program so that you can exercise safely. Your doctor will tell you what your target and maximum heart rate should be when exercising.

According to national guidelines issued by the American Heart Association, the American College of Sports Medicine and the International Health, Racquet and Sports Clubs Association, persons with heart disease should choose a facility that employs a nurse and other health/fitness instructors trained to recommend and supervise exercise regimens. (See HeartInfo article: Health Clubs Should Screen for Heart Disease) Consider using a supervised rehabilitation exercise program for the first few months following surgery. You can move to a local gym or YMCA to continue your cardiovascular training after discussing your health with your doctor.

After receiving approval for an exercise regimen from your doctor, begin your exercise program. Warm up slowly before participating in vigorous aerobic activity, and allow three to five minutes to cool down. When you feel your heart racing or you get tired too quickly, stop and rest. Remember to monitor your heart rate so it does not pass the training zone determined by your doctor. Patients often find that within four months of having a heart attack, their level of physical activity will be as good or better than it was before the heart attack.

Medication. Some of the medications your doctor prescribes might be taken only for the first few weeks or months after your heart attack. Some of these medications might be warfarin (for blood thinning), amiodarone (for arrhythmias), Lasix or other diuretics, potassium supplements, and beta-blockers. Others, such as cholesterol-lowering drugs, ACE inhibitors, and aspirin, will be taken for the remainder of your life.

Because you will likely take several medications in combination, your doctor might need to test various strengths and combinations before determining the optimum drug therapy for you. If there are any medications that cause disturbing side effects, discuss them with your doctor immediately. Do not discontinue any medication without first discussing it with your doctor. Some medications, such as certain hypertension medicines, must be gradually lessened to prevent dangerous complications.

Stop smoking. Smoking cessation is one of the most important steps heart attack patients can take to prolong their lives. By stopping smoking, you greatly reduce your risk of suffering further heart damage. Ask your doctor about ways to stop smoking, such as programs and/or medications. Many local hospitals offer smoking cessation classes that are helpful for people needing support when quitting.

Smoking cessation should begin immediately at the time of your heart attack. Medications such as bupropion, varenecline or numerous formulations of nicotine replacement can be started in the hospital if pharmacologic assistance to quit is necessary. Research shows smokers are more successful at cessation when supported by their doctors, family members, friends and co-workers. Because second-hand smoke is also conclusively harmful, the entire family benefits when a smoker stops smoking. Family member who smoke are exposing the patient to second hand smoke. It would be helpful to limit this exposure.