HEART
April 22, 2014

Life After A Heart Attack, Part 1

Richard Josephson, M.D. and Sri K. Madan Mohan, M.D.
More and more people are surviving heart attacks, but follow-up care is crucial. Know your options.
Dr. Josephson is Professor of Medicine Case Western Reserve University, School of Medicine. Director Cardiac Intensive Care Unit and Director Cardiovascular & Pulmonary Rehabilitation at Harrington Heart & Vascular Institute University Hospitals and Dr. Mohan is Assistant Professor of Medicine, Case Western University School of Medicine and Chief Quality Officer, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH.

In the last few decades, doctors and researchers have made a lot of progress both in preventing and treating heart attacks. Of course, what’s most critical for cardiologists is that a heart attack is recognized when a person has had one, so that healthy heart function can be restored as soon as possible.

Treating the person appropriately — with medication and by recommending the most effective lifestyle changes — is the next step. New medications and lifestyle changes can be hard to stick with, but it’s the doctor’s duty to help you as best he or she can. Follow-up care is critical in guiding the patient's recovery from the attack and preventing another heart attack from occurring.

The goal is not only to avoid having another heart attack in the future, but, hopefully, to get your heart in a state of health that’s better than it’s ever been.

Because heart attack is still a leading cause of death in the U.S., whether you’ve had a heart attack or not, it’s important to make heart health a priority. But if you’ve had a heart attack, it’s especially important to pay attention to your follow-up care. The goal is not only to avoid having another heart attack in the future, but, hopefully, to get your heart in a state of health that’s better than it’s ever been.

This article will cover the most important things to keep in mind when you’re recovering from a heart attack. Part 1 discusses the medical options available to heart patients. Part 2 covers life after a heart attack and discusses how to turn the challenge a heart problem represents into an opportunity for health – making the transition from the hospital back to your regular life. We’ll start with a case study, and return to it throughout our discussion.

Meet Sarah

Sarah is a 64-year-old woman with diabetes, high cholesterol, and rheumatoid arthritis. Her mother died of a heart attack when she was 65 years old. Sarah goes to her doctor having had increasing chest pains for two days, along with what’s known as “rest pain,” or pain in the chest that occurs at rest. She has had five hours of severe unrelenting pain and is found to have a myocardial infarction or heart attack. Her doctor puts in a stent in her right coronary artery, but two days later she is in mild congestive heart failure (CHF).

An echocardiogram shows that she has a reduced “ejection fraction” – that is, the strength of the heart is not normal – because of an abnormality in her heart wall. There are a number of things that Sarah will need to do during her recovery to make sure another heart attack doesn’t strike.

Common Medications After a Heart Attack

Anti-Platelets
There are several medications that are regularly given after a heart attack. Aspirin is the cornerstone of what’s known as antiplatelet therapy, which discourages the blood clots due to platelets in form in the arteries. Studies have shown that aspirin can reduce the death risk following a heart attack by almost 25%. The current recommendations are to take 162-325 mg of aspirin immediately after the heart attack, and then 81-325 mg per day after that — but your doctor will tell you the exact amount you should be taking.

Newer antiplatelet medications, like clopidogrel, prasugrel and ticagrelor, are also used, and can be even more effective than aspirin. These medications, when used in conjunction with aspirin, are referred to as dual antiplatelet therapy (DAPT). However, there can be a risk of hemorrhage associated with some of these medications, so, again, your doctor will make the best recommendation based on your specific situation, age, and risk factors.

Beta Blockers
Beta blockers are another commonly used medicine for managing heart health after a heart attack. This class of drug slows down the heart rate and decreases the force with which it pumps blood, both of which reduce the risk of dying after a heart attack.

Studies on beta blockers have shown that they can significantly lower the mortality risk after a heart attack. And this is particularly true for people at higher risk – that is, those who are older, have chest pain, diabetes, or other existing heart problems. There are some risks associated with beta blockers, particularly if they’re given intravenously (I.V.) immediately following a heart attack, so I.V. use is generally reserved for people with issues, like high blood pressure or continuing chest pain.

Doctors will usually prescribe oral beta blockers as early as possible, starting with a low dose and moving up slowly until the target dose is reached.

Patient update: After careful monitoring, we started Sarah on the beta blocker carvedilol. We will continue to follow up and make sure this medication is the best choice for her.

ACE Inhibitors
Patients who are recovering from heart attack and who have reduced ejection fraction (again, inefficient pumping of the blood) and/or chronic heart failure, may receive an ACE inhibitor. However, your doctor may not want to use an ACE inhibitor if you also suffer from specific allergies, renal (kidney) dysfunction, hyperkalemia (high potassium levels), or low blood pressure.

ACE inhibitors are known to improve remodeling of the heart (that is, the repair of the heart tissue after heart attack), and to help the heart repair itself in other ways. Several studies have shown a reduced mortality risk when patients are given ACE inhibitors after a heart attack,. This is especially true if they’re given within 24 hours of the attack. People with low blood pressure should be watched more closely and the ACE inhibitor dosing monitored carefully, so as to make sure that the patient doesn’t go into shock.

Your doctor will determine the best way to begin the ACE inhibitor, increase its dose, and possibly, switch to a long-acting ACE inhibitor while you are still at the hospital.

Statin Therapy
Starting patients on statins – cholesterol-lowering drugs – is a good idea. In most cases, a patient’s blood fats will be measured in the first 24 hours, or even the first few days, after a heart attack.

Studies have shown that “intensive” statin therapy is more effective in reducing the risk of another heart attack, compared to less intense therapy. Some have questioned the use of statins for people who have low LDL cholesterol levels, but studies have found that they can significantly reduce mortality and other health problems. When statins are started before discharge from the hospital, they seem to have the greatest effect on heart health, and the current recommendations reflect this finding.

Update: For Sarah, we decide to start her on atorvastatin at 80 mg daily and will monitor for side effects (like muscular problems).

Spironolactone and Eplerenone
Sometimes a medication called spironolactone is prescribed in addition to other treatments. One of the ways spironolactone works is by blocking the action of aldosterone. Aldosterone raises blood pressure, thereby making spironolactone a blood pressure-lowering medication. Studies have shown that the medication can decrease hospitalizations due to chronic heart disease, as well as the risk of death.

Usually spironolactone is started in the hospital, and can be increased once the patient is back at home. Kidney function and electrolytes can be affected by the medication, so it’s important for your doctor to keep monitoring both.

As there are potential drug interactions, your doctor has to carefully choose the sequence to begin medications, if more than one is to be used. Because in most cases the target dose of a given drug is not reached until after the patient has been home, it’s especially important to continue your after-care and regular follow-ups with your doctor.

Eplerenone works in a manner similar to spironolactone.

Defibrillators and Pacemakers

Implantable cardiac defibrillators (ICDs) offer a clear benefit for people with ischemic cardiomyopathy — that is, a weakened heart muscle. However, doctors are more likely to wait for a little while (about 40 days) before considering this option. An externally wearable ICD “jacket” is also available and effective. But since the exact benefit is not yet precisely known because this device is still being studied, your doctor will determine whether it is appropriate to offer it.

Cardiac resynchronization therapy — done using a special pacemaker — may also be used in patients with different types of heart problems. Studies have shown that resynchronisation can reduce morbidity (heart-related health problems) and mortality. These devices are typically implanted once patients are stabilized on a medication regime for at least several weeks after their heart attack.

Next time: Life After A Heart Attack — Coming home, coping with concerns, sex and the value of family support.

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