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. 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 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 as you recover from the attack and prevent 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, you really need 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.

The first part of of this article covered the medical treatments that are typically offered to people who have had a heart attack. This second part looks at issues related to life and lifestyle after a heart attack.

Life after a Heart Attack

Transitioning Out of the Hospital
You’ve probably heard many, many times that exercise is the core component of cardiac rehabilitation (CR). This is absolutely true. But, in fact, recovery from a heart attack is a multi-part process, and includes nutritional, psychological, and exercise counseling. Your doctor will advise you when to begin new routines, but typically after-care is divided into three phases.

Phase 1: The in-patient phase
While you’re still at the hospital, you’ll learn how to take the medications you've been prescribed, and a set of "survival skills" for the first few weeks after you’re home, such as avoiding driving and heavy labor.

Research has shown there is a 20% reduction in mortality when CR is followed closely.

Phase 2: The out-patient phase
This part makes up the bulk of most patients’ experience and usually consists of 36 outpatient sessions (three per week for 12 weeks). During these sessions, you’ll likely do some supervised exercise, which usually consists of both aerobic exercise and strength training. You’ll also learn about a variety of topics including nutrition, medication use and the common psychological issues that can come up after a heart attack, such as depression and anxiety, as well as coping skills.

Phase 3: The long-term
This phase includes a supervised exercise and education program that is designed to build upon and maintain the achievements of the earlier phases, but carried out over the long term. In most cases, people prefer to exercise independently or in a health club, rather than participate in a formal phase 3 program.

The importance of cardiac rehab (CR) can’t be stressed enough, and there are many studies that speak to this point. We know that if the CR process is begun in-hospital, before discharge, patients are much more likely to continue the routine after they’re back home.

Research has shown there is a 20% reduction in mortality when CR is followed closely. It not only helps the heart recover healthy function, but it also improves a person’s sense of well-being, not to mention one’s cardiac risk factors in the long-run. Despite the known benefits, CR is, unfortunately, often underused.

Patient update: For Sarah, we would recommend evaluation with a physician prior to starting phase 2 of CR, in order to establish that her heart failure is appropriately treated and managed.

Back at Home
Most patients who have had heart attacks without any major complications can resume normal activities, including returning to work, by two weeks. People are usually encouraged to participate in their regular daily activities — known as “activities of daily living,” or ADLs — and other physical activity based on their specific CR plan, which your doctor will discuss with you. Usually, patients can resume driving their cars within a week or two.

Resuming sexual activity is a common concern. Sex requires enough physical exertion that we usually advise patients to abstain for two weeks after a heart attack. After that, the risks of intercourse are lower. But your doctor can give you more personalized advice based on your specific health profile.

Sexual dysfunction can be common after a heart attack. The causes may be psychological or physiological. Sometimes the medications you are taking can lead to sexual dysfunction. Even though it can be uncomfortable to talk about, it’s important to proactively address the problem with your doctor, rather than keep it to yourself.

There can be interactions between certain medications prescribed for erectile dysfunction and nitrates prescribed for heart problems, so it’s especially important to talk with your doctor about appropriate treatments and be clear about the medications you are taking.

Patient Update: We would advise Sarah to abstain from sexual intercourse for a 2-week period. Additional advice would be based on her heart function and general recovery.

Depression can be another common experience after a heart attack. Women and anyone with a prior history of depression are especially at risk of experiencing depression following a heart attack. If you experience sadness that doesn’t seem to be going away after a couple of weeks, speak with your doctor.

Mild symptoms may go away by themselves, but more severe or persistent low feelings should be addressed and treated. Your doctors should ask you questions about your mood and overall mental health, but there is evidence that depression following a heart attack is underdiagnosed. Interestingly, cardiac rehabilitation appears to lessen the risk of depression considerably, which is another good reason to stick with it.

Patient Update: The death of Sarah’s mother from a heart attack at a similar age had an impact on Sarah’s mental health and approach to her illness. We would make sure to follow up with her regularly about her mood, and offer treatment options for managing her depression.

Treatment Only Works If You Stick with It

Unfortunately, in the real world, the number of patients sticking with treatment is too low. One in seven patients, for example, stops their medication within 30 days of having a stent implanted. Other studies have shown similarly low rates of sticking with heart medications after a heart attack.

There are many reasons people stop taking their medications — perhaps unwanted side effects, the cost of the medications, or maybe even indifference or denial of the seriousness of the problem.

It’s very helpful to have a family member present when you’re learning about after-care from your doctors, since family members can be key to helping you stick with the changes you’re trying to make.

We can’t stress enough the importance of cardiac rehabilitation — staying the course has been linked to improved health outcomes and fewer ER visits down the road. It’s the doctor’s duty to make follow-up as easy as possible for the patient. It’s also very helpful to have a family member present when you’re learning about after-care — medications and lifestyle changes — from your doctors, since family members can be key to helping you stick with the changes you’re trying to make.

Again, it’s the doctor’s duty to help you with these issues and arrive at a plan that’s desirable and doable. If you’re feeling reluctant to keep on your CR plan, speak with your doctor, as he or she may be able to offer other options.

A Challenge and An Opportunity

It's true there are many challenges that come with a heart attack, but there is also an opportunity — particularly in terms of living a healthier lifestyle. Having a heart attack is undoubtedly stressful in-and-of itself: The knowledge that one has had a heart attack, which prompts the fear of having another one, can cause some degree of stress. Additionally, people are typically much more attuned to chest sensations, and pains, as a result of a heart attack, which can also create anxiety.

But making the appropriate lifestyle changes can not only reduce your risk of having another heart attack, it can also give you a feeling of empowerment over the situation. For example, quitting smoking, which we did not discuss in detail, can be stressful in the short-term, but it also helps your mental health, improves overall health and reduces your risk of another heart attack.

Again, the right combination of medicationsand lifestyle changes can help lower your chances of having another heart attack. Follow-up care in the form of CR is critical, and can make a big difference in your recovery, and it can also help you ward off depression (but again, if you are feeling ongoing depression, speak with your doctor about different ways to treat it).

Though life after a heart attack may take some getting used to, making the necessary changes will make you much healthier in the long run, and reduce your risk of having another attack in the future.