After a Heart Attack (Myocardial Infarction)
This leaflet discusses the common advice that applies to most people who have had a heart attack (myocardial infarction). It mainly discusses ways to reduce the risk of having another heart attack or developing further heart problems.
What is a heart attack?
If you have a heart attack, a blood vessel supplying the heart muscle is suddenly blocked. The heart muscle supplied by this blood vessel is called the myocardium. The part of the heart muscle supplied by this artery loses its blood (and oxygen) supply if the vessel is blocked. This part of the heart muscle is at risk of dying unless the blockage is quickly removed. When the heart muscle is damaged it is said to be infarcted. The term myocardial infarction means damaged heart muscle.
A heart attack is usually caused by a blood clot in a heart (coronary) artery, which forms over a fatty deposit known as a patch of atheroma. See separate leaflet called Heart Attack (Myocardial Infarction) for more details.
What can I do to help myself after having a heart attack?
Following a heart attack, 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 support any advice that you may receive.
If you smoke, giving up smoking is the single most effective way to reduce your risk of having a further heart attack. The chemicals in cigarette smoke affect the arteries. If you stop smoking, your risk of a further heart attack is roughly halved (compared to the risk if you continue to smoke). Chest pain called 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. See separate leaflet called Smoking - The Facts for more details about smoking and ways to help you stop.
Changes in diet can make a big difference. Studies suggest that people who eat a healthy diet may halve their chance of a further heart attack compared to those who do not eat healthily.
Good advice is to:
- Eat at least five portions of a variety of fruit and vegetables each day. They are rich in vitamins and minerals. These can be fresh, frozen or dried.
- Limit the amount of saturated fat you eat. It is not just about the total fat content of the diet but also the type of fat in the diet. Try to avoid eating foods that are high in saturated fat. Foods that are high in saturated fat include meat pies, sausages, butter, cream, hard cheese, cakes, biscuits and foods that contain coconut or palm oil. Eating foods that are high in unsaturated fat can help to reduce your cholesterol level. Foods high in unsaturated fat include oily fish (such as herring, mackerel, sardine, salmon), avocados, nuts and seeds and sunflower, rapeseed and olive oil.
- Reduce your salt intake. Many foods contain hidden salt. Lowering your salt intake can reduce your risk of a further heart attack and also of other cardiovascular diseases.
A Mediterranean diet
Eating a Mediterranean-style diet is thought to be one of the best ways to reduce the risk of having a heart attack. This type of diet is, in effect, a summary of the advice above. That is - meals with poultry rather than red meat, lots of wholegrain pasta and breads and plenty of fruit, vegetables, olive oil and oil-rich fish, accompanied by a small glass of wine or beer. See separate leaflet called Health Benefits of the Mediterranean Diet for more details.
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 a heart attack are advised to take a statin medication to lower the cholesterol level. Statins work by reducing the amount of cholesterol that is made in your liver. In general, the lower the cholesterol level, the better. See separate leaflet called Cholesterol for more details.
Some research suggests that drinking a small amount of alcohol may be beneficial for the heart. The exact amount is not clear, but it is a small amount. So, do not exceed the recommended amount of alcohol, as more than the recommended upper limits can be harmful. That is: men should drink no more than 14 units of alcohol per week, no more than four units in any one day and have at least two alcohol-free days a week. Women should drink no more than 14 units of alcohol per week, no more than three units in any one day and have at least two alcohol-free days a week. Pregnant women, and women trying to become pregnant, should not drink alcohol at all. 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. See separate leaflet called Alcohol and Sensible Drinking for more details.
Physical activity and exercise
Normal physical activity and regular exercise are advised for most people who have had a heart attack. You should try to be physically active - for example, take the stairs whenever possible, walk to the shops, and wash your car.
In the past, 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 a heart attack. Physical activity and regular exercise are good for the heart. Indeed, regular exercise is one of the main parts of heart (cardiac) rehabilitation programmes that are popular after having a heart attack (as discussed later). Regular exercise is a major way to reduce the risk of having a further heart attack.
However, before starting regular exercise, discuss it with your doctor. This is because strenuous exercise in certain situations may not be advised. For example, some people with heart valve problems may be advised not to exercise. However, these people are the exception. For most people who have had a heart attack, exercise is beneficial.
After a heart attack it is best to build up your level of activity and exercise gradually. 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; for others, a bit further.
You can then gradually build up the distance of your walking over time. A reasonable goal by about six weeks after having a heart attack is to aim to walk for 20-30 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 they are too frail to exercise.
Regarding 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, the aim is to build up to at least 20-30 minutes of moderate exercise on most days (at least five days per week). This exercise should make you slightly short of breath. See separate leaflet called Physical Activity for Health for more details.
If you are overweight then reducing your weight will reduce your risk of a further heart attack. If you find it difficult to lose weight then see your practice nurse for encouragement and advice.
It is important to 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 mm Hg. If you are being treated for high blood pressure, the usual target is to reduce blood pressure in someone who has had a heart attack to below 130/80 mm Hg. This figure may vary depending on whether you have other conditions - for example, kidney disease.
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. See separate leaflet called High Blood Pressure (Hypertension) for more details.
If you have diabetes then good control of your blood sugar (glucose) level and also your blood pressure will help to reduce the risk of a further heart attack. See separate leaflets called Type 1 Diabetes and Type 2 Diabetes for more details.
What medication is usual following a heart attack?
The following four medicines are commonly prescribed:
- Aspirin. Low-dose aspirin is an antiplatelet medicine. This means it reduces the stickiness of blood, which reduces the risk of blood clots forming. Clopidogrel and ticagrelor are also antiplatelet medicines and help to prevent blood clots. Clopidogrel or ticagrelor can be used together with aspirin.
- A beta-blocker. This slows the heart rate and reduces the risk of abnormal heart rhythms.
- An angiotensin-converting enzyme (ACE) inhibitor. This reduces the risk of developing heart failure and further heart attack.
- A statin. This reduces the cholesterol level (as discussed above).
Although the four medicines above are commonly advised, treatments may vary depending on other factors such as whether you have complications or other diseases. See separate leaflet called Medication after a Heart Attack for more details.
Getting back to normal
After having a heart attack, 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 a heart attack. Regular exercise and getting back to normal are usually advised.
Following a heart attack, most people can go back to work within 2-3 months. However, each person is different. For example, some people who have a small heart attack and feel well go back sooner. On the other hand, some people with ongoing symptoms or complications such as chest pain (called angina) or heart failure may take longer to go back or may not be able to go back to work.
Some people have wrong beliefs about work after a heart attack. For example, some people wrongly believe that work-related stress was the cause of their heart attack and they need to take things easy from now on. However, an increase in activity is often preferable after a heart attack 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. For many people, returning to work is an important part of regaining quality of life.
A possible sensible approach is:
- Discuss with your doctor about when you should return to work.
- Then, a phased return may be best if your employer is agreeable. For example:
- Start with alternate half days and build up to a 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 a heart attack, as the future may be uncertain. However, it is very important that you make such a decision for the right reasons and not based on fear or wrong beliefs about your heart.
Driving and flying
You should not drive for at least four weeks after a heart attack. Then, provided you have made a satisfactory recovery (and your insurance company is notified) you may drive. However, if driving causes angina, you should not drive until the angina is well controlled. PCV and LGV rules are stricter and further assessment is required. It is always sensible to contact the Driver and Vehicle Licensing Agency (DVLA) to be sure.
You can usually fly as a passenger within two to three weeks of a heart attack, as long as you have no complications. This means that, for example:
- You have returned to your usual daily activities.
- Your condition is stable.
- You don't have any symptoms, or your symptoms are controlled.
It is usually sensible to check with your travel operator, airline and travel insurance company before you fly.
Stress, anxiety and relaxation
It is commonly believed that stress can cause a heart attack. However, medical research has failed to show this and the conclusion is that stress does not cause a heart attack. However, being stressed and anxious can make you feel generally unwell in yourself.
Some people have unfounded concerns and wrong beliefs about heart attacks, which can cause symptoms of anxiety. Don't 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).
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.
Some men find that they have problems getting or maintaining an erection (erectile dysfunction) after having a heart attack. These problems can be caused by emotional stress or by medication such as beta-blockers. However, impotence can also have other causes. Speak to your GP who can check what is causing your problems and advise you on treatment. Various treatments (including medication) are now very effective for the treatment of erectile dysfunction. See separate leaflet called Erectile Dysfunction (Impotence) for more details.
Heart (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 a heart attack. 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 a further heart attack and improves general well-being.
Some other general points
- Tell your doctor if you get any chest pain following a heart attack. The chest pain may be due to angina. Angina is a pain in the chest that often comes on when you exercise, such as when walking briskly. It is due to narrowing of the coronary arteries. See separate leaflet called Angina for more details.
- Tell your doctor if you get breathless, become more tired than usual, or notice your feet swelling. 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. See separate leaflet called Heart Failure for more details.
- Depression is common after a heart attack, 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. See separate leaflet called Depression for more details.
Some thoughts to remember:
- Most people who have a heart attack make a full recovery.
- In many cases, only a small part of the heart muscle is 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 a heart attack.
- A heart attack often causes people to review and change their diet and lifestyle. Some people actually become fitter and healthier after they have a heart attack.
- For some people, the biggest cause of disability following a heart attack is not their heart but unfounded worries and anxiety about their heart. Try to learn to positively relax; talk to your doctor if you have any concerns.
Further help & information
Greater London House, 180 Hampstead Road, London, NW1 7AW
Tel: (Heart Helpline) 0300 330 3311, (Admin) 020 7554 0000
7 North Road, Maidenhead, Berkshire, SL6 1PE
Tel: (Helpline) 0845 450 5988, (Office) 01628 777046
Further reading & references
- Myocardial infarction with ST-segment elevation: The acute management of myocardial infarction with ST-segment elevation; NICE Clinical Guideline (July 2013)
- Myocardial infarction: cardiac rehabilitation and prevention of further MI; NICE Clinical Guideline (November 2013)
- MI - secondary prevention; NICE CKS, October 2015 (UK access only)
- Acute coronary syndrome; Scottish Intercollegiate Guidelines Network - SIGN (2016)
- Ticagrelor for the treatment of acute coronary syndromes; NICE Technology Appraisal Guidance, October 2011
- 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation; European Society of Cardiology (August 2015)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Colin Tidy
Dr John Cox