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Heart Attack Symptoms and Warning Signs

A blockage in the heart's arteries may reduce or completely cut off the blood supply to a portion of the heart.
This can cause a blood clot to form and totally stop blood flow in a coronary artery, resulting in a heart attack
(also called an acute myocardial infarction or MI).

Irreversible injury to the heart muscle usually occurs if medical help is not received promptly. Unfortunately, it
is common for people to dismiss heart attack symptoms.

What are the warning signs of a heart attack?

The American Heart Association and other medical experts say the body likely will send one or more of
these warning signals of a heart attack:

           Uncomfortable pressure, fullness, squeezing or pain in the centre of the chest lasting more than
            a few minutes.
           Pain spreading to the shoulders, neck or arms. The pain may be mild to intense. It may feel like
            pressure, tightness, burning, or heavy weight. It may be located in the chest, upper abdomen,
            neck, jaw, or inside the arms or shoulders.
           Chest discomfort with light-headedness, fainting, sweating, nausea or shortness of breath.
           Anxiety, nervousness and/or cold, sweaty skin.
           Paleness or pallor. Increased or irregular heart rate.
           Feeling of impending doom.

Not all of these signs occur in every attack. Sometimes they go away and return. If some occur, get help fast.
IF YOU NOTICE ONE OR MORE OF THESE SIGNS IN YOURSELF OR OTHERS, DON'T WAIT. CALL
EMERGENCY MEDICAL SERVICES (9-1-1) RIGHT AWAY! In the event of cardiopulmonary arrest (no
breathing or pulse), call 9-1-1 and begin cardiopulmonary resuscitation (CPR) immediately.

How does the doctor know if I've had a heart attack?

The actual diagnosis of a heart attack must be made by a doctor who has studied the results of several tests.
The doctor may:

           Review the patient's complete medical history.
           Give a physical examination.
           Use an electrocardiogram (or EKG) to discover any abnormalities caused by damage to the
            heart.
           Use a blood test to detect abnormal levels of certain enzymes in the bloodstream.

What does heart-related chest pain feel like?

By William R. Ladd, M.D., Director of Nuclear Cardiology, Cardiovascular Institute of the South

If you suffer chest pain, particularly while exercising, you will almost certainly wonder whether it might be
heart-related - and well you should. Heart muscle pain - angina - is likely to be the first warning of blocked
coronary arteries, the cause of most heart attacks.

While there are no infallible guidelines about whether a chest pain is heart-related, it generally takes a
particular form. Heart discomfort is rarely a sharp, stabbing pain. The textbook description of angina is a
feeling of heaviness, pressure, tightness or aching in the chest, usually accompanied by shortness of breath.
The pain generally goes away when you stop exerting yourself, and it frequently isn't especially severe,
which is, perhaps, unfortunate.

Even a heart attack may not be unbearably painful at first, permitting its victim to delay seeking treatment for
as much as four to six hours after its onset. By then, the heart may have suffered irreversible damage. It is
not unknown for patients to drive themselves to emergency rooms with what proved to be very serious and
even fatal heart attacks.

Angina is a protest from the heart muscle that it isn't getting enough oxygen because of diminished blood
supply. A heart attack is simply the most extreme state of oxygen deprivation, in which whole regions of
heart muscle cells begin to die for lack of oxygen. If the blockage in the arteries serving the heart muscle can
be cleared quickly enough - within the first few hours of the onset of the attack - the permanent damage can
be held to a minimum.

That's why it is so vital to seek medical attention quickly if you feel the sort of pressing pain or heaviness
described above. There is a 90 percent probability that pain of this type is angina. And even if it goes away,
the artery blockages that caused it are still there and will grow progressively worse.

Ignoring this sort of pain because it is not unbearable or because it goes away is the worst thing you can do.
It is the only warning you are likely to get of a potentially lethal condition. Heed it! Consult a cardiologist
immediately.

You can have a heart attack without knowing it

By William R. Condos, Jr., M.D., Medical Director, Cardiovascular Institute of the South/Lake Charles

The nation's longest-running heart study suggests that about one heart attack in four produces no symptoms
- or at least none that the victim associates with a heart problem.

These so-called "silent heart attacks," however, are only the most extreme case of a still more prevalent
condition called "silent ischemia" - a chronic shortage of oxygen - and nutrient-bearing blood to a portion of
the heart. Both conditions put their victims at significant risk.

The cause of ischemia, silent or otherwise, is almost always atherosclerosis - the progressive narrowing of
the heart's arteries from accumulations of cholesterol plaque. In most instances, this reduction in blood
supply generates a protest from the heart - the crushing pain called angina. But in perhaps 25 to 30 percent
of heart attack victims, there were no previous symptoms of these gradually developing blockages. The
Framingham Heart Study, which followed 4,000 Massachusetts men for more than 40 years, found that 25
percent of their subjects' heart attacks go unnoticed until their annual EKGs detect their after-effects.

The absence of pain, however, doesn't mean an absence of damage. The heart has a built-in reserve
capacity, allowing it to suffer a certain amount of scarring and weakening from a heart attack and continue to
meet the body's needs. But further ischemia or another heart attack, even a mild to moderate one, may
prove fatal because that reserve capacity is no longer there. Even those who survive another heart attack
are at increased risk of becoming cardiac cripples, disabled by congestive heart failure or arrhythmias
heartbeat irregularities.

There is no way of predicting absolutely who is a candidate for silent ischemia, but statistically, the greater
the number of risk factors for coronary artery disease that you have, the more likely you are to be a
candidate. Those risk factors include some you can't control - your age, sex and genetic predisposition to
atherosclerosis - and those you can influence, like diabetes, high blood pressure, high blood cholesterol,
smoking, lack of exercise and obesity.

As a rule of thumb, I would urge you to undergo a screening for silent ischemia if you have any three of
these factors working against you - a man over age 50 who smokes, or a post-menopausal woman with a
ten-year history of diabetes and chronic unfavourable blood cholesterol levels, for instance.

The screening for undetected ischemia is a medical history and physical examination and a cardiac stress
test - a workout on a treadmill while your heart function is monitored.

It's a simple, painless and inexpensive way to learn whether the beating of your heart is accompanied by the
inaudible ticking of an atherosclerosis time bomb that could kill you.

Last Updated: September 2, 2001
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Why do you need bypass surgery?

If you are suffering chest pain or other symptoms that may indicate a cardiovascular problem, your doctor will
likely want you to undergo an angiogram (cardiac catheterization) to see if your coronary arteries are blocked
by plaque. A blockage can cause a decrease in the supply of blood and oxygen to the heart, and over time
can lead to debilitating chest pain or a heart attack.

If angioplasty proves unsuccessful, the position of the blockage is too difficult to access by angioplasty, or
you have severe blockages in multiple major vessels, your doctor may recommend that you undergo
coronary artery bypass graft (CABG) surgery.

Bypass surgery has been performed for nearly 30 years. Cardiovascular surgeons have received extensive
training on bypass techniques. More than 500,000 bypass procedures are performed each year in the United
States, making it the most frequently performed major surgery in the country.

What happens during bypass surgery?

Bypass surgery is a major operation that usually lasts between two and six hours. Pre-operative medications
are often administered by mouth, muscular or subcutaneous injection, or IV. You will receive general
anesthesia and be completely asleep.

During bypass surgery, the chest bone is separated, and the ribs are spread apart to allow visible and
physical access to the heart. In most instances, blood circulation and breathing functions will be taken over
by a heart-lung machine. The cardiac surgeon uses a piece of vein or artery to form a bypass to enable
blood to go around the blockage. Several blockages can be bypassed during surgery.

What is a graft?

A graft is a blood vessel that has been created to bypass a blocked artery. It is usually taken from the
internal mammary artery in the chest, the saphenous veins from the leg, or in rare instances from the radial
artery in the arm. The graft is attached above and below the area in the artery where there is a blockage, so
that the blood can use the new, unblocked path to flow freely to the heart.

From stress tests, angiograms and intravascular ultrasounds, your doctor is able to determine exactly how
much of the heart structure needs repair. Some patients undergo double, triple or even quadruple bypasses,
based on their specific needs.

Doctors have found that grafts are most successful when attached to major coronary arteries rather than
smaller arterial branches. Doctors have also found better results for bypass surgery when there are discrete,
localized blockages rather than a buildup of plaque throughout an artery.

Will my heart be stopped?

In some cases, your blood circulation and breathing functions will be carried out by a heart-lung machine
during surgery, also known as cardiopulmonary bypass. However, more coronary artery bypass surgeries
are being done while the heart is still beating (called the off-pump technique). Doctors say the beating heart
approach reduces the risk of neurologic injury, stroke and other complications associated with the heart-lung
machine, and leads to a shorter hospital stay for patients.

Are there any transfusions involved? Should I bank my own blood?

Ordinarily, as with any serious heart surgery, blood transfusions are necessary during bypass surgery. The
blood used for your surgery will be matched by type and Rh factor, and provided by a local blood bank.

You may be familiar with the case of Arthur Ashe, a well-known tennis player and activist who ultimately died
of AIDS-related pneumonia. He acquired the AIDS virus from a transfusion received during a bypass
procedure performed in 1983. Although this kind of oversight was devastating, the national blood banks have
advanced a great deal in the past 20 years, and blood is screened much more carefully for contamination,
including AIDS and other infectious diseases.

Unless your surgery is scheduled to be performed in less than 72 hours, and if your doctor gives you
permission, arrangements can be made for banking your own blood for surgery. You also may have family or
friends with a compatible blood type donate blood for your surgery. The hospital, the Red Cross or blood
bank can provide family members and friends with necessary information about blood donation for your
surgery.

Bypass procedures have been performed without transfusion. Some patients, such as Jehovah's Witnesses,
are restricted from using another person's blood. Studies have shown that bypass procedures can be
performed "bloodlessly," although these operations have had a higher rate of mortality.

What is minimally invasive bypass surgery?

Minimally invasive coronary artery bypass surgery (MIDCAB) involves a significantly smaller incision – only
three inches – instead of splitting your sternum with a six- to eight-inch incision.

An artery that supplies blood to chest muscles is grafted to the left anterior descending artery (an important
artery located close to the chest wall). Your heart continues to beat during the surgery, instead of being
attached to a heart-lung machine. You may be given a drug to reduce your heartbeat.

Surgeons can also use a slightly different approach by making small incisions in your chest and viewing the
surgery on video monitors. For this procedure, called port-access coronary bypass surgery, your heart is
attached to a heart-lung machine.

Doctors are also exploring the use of robotics and telecommunications to perform minimally invasive
surgeries, or to provide assistance to fellow surgeons, at remote locations.

The number of minimally invasive coronary bypass surgeries is rising, and now represents about 10 to 20
percent of all bypass operations performed annually. Compared to a traditional bypass surgery, minimally
invasive bypass surgery is cheaper, shorter and less painful, requires fewer blood transfusions and reduces
your recovery time. Hospital stays for MIDCAB patients can be three to four days, instead of five to six days
for a traditional bypass.

However, this type of surgery is only for certain patients with one or two blocked arteries, and the long-term
results have not been determined.

What are the risks?

The current success rate for bypass surgery is 95 to 98 percent, meaning that between 2 and 5 percent of all
patients have complications, including death. The survival rate has improved over time.

As with any surgical procedure, there are risks of infection and heavy bleeding. There also are risks
associated with anesthesia. These can include adverse reactions to medication and breathing problems.
Postoperative pneumonia and wound infection also are common complications arising from open-heart
surgery.

How successful is bypass surgery? Can I expect to live a long life?

Studies have shown in 80 to 95 percent of patients, bypasses made with segments of the mammary artery
still performed efficiently 10 years after surgery. Two-thirds to 75 percent of patients who received grafts from
leg veins still had satisfactorily unrestricted blood flow after 10 years.

Remember that even if your graft becomes blocked, you may not need additional bypass surgery. However,
you may be a candidate for balloon angioplasty and insertion of a stent.
Where will the surgery take place, and how can I prepare for it?

The surgery will be performed in a hospital operating room.

Some individuals are unaware of the extent to which their arteries are clogged until they have a heart attack.
In cases such as these, a cardiologist or emergency room doctor will probably quickly determine whether
bypass surgery can be successful. There might be little time to discuss options or extensively educate you or
your family.

Ideally, you have discussed your health history with a cardiologist. You may have been treated with
cholesterol lowering or blood pressure-lowering medications for some time. However, because of chest pain
or test results from a stress test, it is evident to your doctor that bypass surgery is a necessary step. If you
need additional input from your doctor, or perhaps a second opinion, it is in your best interest to get it as
quickly as possible. In most cases, advanced coronary artery disease should be treated as soon as possible,
to avoid further damage to the heart.

How long is the surgery?

Typically, traditional bypass surgery takes between two and six hours, depending on the number of
bypasses to be performed. Minimally invasive bypass surgery usually takes two to three hours.

Will I be awake?

No. You will be under general anaesthesia throughout the procedure.

Where will my family be?

Because the surgery must be performed in a sterile environment, family members are encouraged to remain
close by in a hospital waiting room.

Where will I go directly after surgery?

Patients are typically observed for 24 to 36 hours in the cardiac intensive care unit (CICU). The CICU has
limited visitation hours.

What is it like in the CICU? How will I feel after the surgery?

When you first wake up in the CICU, you will be groggy or slightly disoriented. This is normal. You will still
have a tube in your mouth, connecting you to breathing monitors and apparatus. Until you are able to
breathe on your own, you will have difficulty talking (because of the tube) and will be unable to eat.

There are numerous monitors and machines in the CICU; it is not as quiet or cosy as a normal hospital room.
Nurses will be watching your vital signs (temperature, pulse, breathing) constantly to make sure that you are
recovering as expected. You may find your hands strapped down so that you cannot disconnect any of the
monitoring wires. Once your condition has stabilized (approximately 24 to 36 hours), you will be moved to a
regular hospital room, where you can have more frequent visitors and rest more peacefully.

How long will I be in the hospital?

The overall hospital stay, including both the CICU and a regular hospital room, is generally between five and
six days if you undergo a traditional bypass surgery. You could be in the hospital for less time – three to four
days – following minimally invasive surgery.

Will I have a special rehabilitation program?

Your doctor will place you on a specialized postoperative rehabilitation and prevention program, which
usually includes supervised exercise, dietary and lifestyle changes. You should be careful to protect the area
around the leg or arm from which the vein was harvested. This may take a few months to return to normal.
Will I be in pain after the procedure?

You will receive medications in order to cope with the immediate surgical recovery. However, your doctor
should talk to you about the difference between pain from the incision versus pain due to low blood supply to
the heart muscle following surgery. If you have any questions about chest pain, contact your doctor. Even if
you have had prior surgeries, be aware that bypass patients undergo a more painful recovery than do other
surgery patients.

When can I walk?

You will be encouraged to walk before you leave the hospital.

When can I drive?

Patients are generally able to drive approximately three weeks after surgery.

When can I resume sexual activity?

In most cases, sexual activity can be resumed approximately four weeks after surgery. Your doctor may give
you an indicator, such as being able to climb two flights of stairs without stopping, before you resume sexual
activity.

When will I be able to return to work?

Depending on the amount of physical exertion required for your job, you will likely be able to work within 12
weeks, and possibly even sooner.

Sources

Minimally Invasive Heart Surgery. American Heart Association Web site, 2000.

Coronary Artery Disease Treatment – Surgery. Cleveland Clinic Heart Center Web site, April 2001.

Minimally Invasive Direct Coronary Artery Bypass, MIDCAB. Brown University Division of Biology and
Medicine Web site.

Mack MJ, MD. Minimally Invasive and Robotic Surgery. Journal of the American Medical Association ,
February 2001:568-572.

Baumgartner WA, MD. What's New in Cardiac Surgery. Journal of the American College of Surgeons .
March 2001:345-355.

Mayo Clinic Health Letter , May 1994.

Dr. David Allie, M.D., Cardiovascular Institute of the South;

HealthAnswers (Orbis-AHCN); Ask the Doctor, Infinity Heart Institute;

Virtual Hospital, Iowa CHAMPS;

Dean Santerre, Anatomy of the Human Heart;

Dr. Joseph Galichia, Heart Homepage.
Heart Attack, Part One: A Patient Guide


Introduction

The Heart Attack Patient Guide is a simple explanation of what a person is likely to experience when having
a heart attack. The guide describes how a person is treated immediately during the attack, upon arrival at the
hospital, to months and years later. The first part of the guide discusses the basics of heart function, heart
attack symptoms, emergency care, medications, tests and treatments performed in the hospital. The second
part is a comprehensive guide that covers short-term recovery in the cardiac care unit of the hospital,
including details about bypass and angioplasty recovery, discharge from the hospital, cardiac rehabilitation,
exercise, long-term recovery, medication, depression, and lifestyle modification.

I. Heart function

The heart works like a large pump and consists of a bag comprised of muscle with blood vessels leading in
and out. The blood flows from your lungs, where it picks up oxygen, into your heart and gets pumped out to
the rest of your body. Once the blood has delivered its oxygen to the tissues, it returns to your heart and gets
pumped back out to the lungs.

Blood flow during a heart attack

The heart requires oxygen to function properly. The blood inside your heart does not supply oxygen to the
heart muscle. Special blood vessels on the outside of the heart, called coronary arteries, feed the heart
muscle. Three major vessels and many smaller vessels do this job. When one or more of the major vessels
is obstructed (usually due to blood clot formation in the blood vessel lumen), blood cannot reach the heart
muscle beneath the block, restricting the supply of oxygen to the heart. Within 20 minutes of not receiving
blood and oxygen, the heart muscle begins to die, leading to a heart attack. A heart attack results in the loss
of function or contractility of the damaged portion of the heart.

Symptoms of a heart attack

The symptoms of a heart attack can be greatly varied. Some heart attacks are blatantly obvious, with
affected people describing an intense, vice-like squeezing chest pressure or a feeling of a heavy weight
having been placed on their chest. Other heart attacks are much more subtle, often beginning slowly as a
mild chest discomfort or dull ache. Some individuals may report a stabbing, knifelike, or burning sensation.
The pain is usually prolonged and typically lasts for at least 30 minutes. The pain, however, may also greatly
fluctuate in intensity during the period of a heart attack, and at times, appear to nearly completely dissipate.
The intensity of heart attack-related chest pain does not usually alter with changes in body position. Even
rest will not typically relieve this type of chest pain. Finally, some patients may not experience any chest
pain.

Some patients describe pain radiating down the arms (usually the left arm) with a tingling sensation in the
wrists, hands, and fingers. Others report pain in the shoulders, neck, and jaw. The pain can also radiate to
the teeth and back. Additional symptoms include indigestion, nausea, vomiting, palpitations, cold
perspiration, weakness, dizziness, cough, fainting, dry mouth, anxiety, or a sense of impending doom.

In general, men and women experience the same symptoms of a heart attack. Although many heart attack
victims report some form of chest pain, others may report none at all. While individuals who are elderly or
have diabetes are generally at highest risk for experiencing no chest pain during a heart attack (this is known
as a silent heart attack), all persons should recognize this risk. In particular, individuals with unexplainable
new onset indigestion, nausea, or shortness of breath should consider seeking prompt medical attention.

Finally, acute heart attack is a major cause of sudden death in adults and may occur with absolutely no
warning signs at all.
II. Emergency Care

Prehospital care for heart attacks

If you are experiencing chest discomfort and any of the aforementioned symptoms, you or someone close to
you should call an ambulance immediately. Use 911 or your local emergency number. If you are not sure if
you are having a heart attack, call your doctor immediately. There is a strong tendency to deny the possibility
of a heart attack. Denial and delaying medical treatment can cost you your life. Research shows that one in
three people die from a heart attack within the first few hours of experiencing chest pain. Making the decision
to get to a hospital as early as possible is often the single most important factor in determining your
likelihood of survival.

If your doctor has previously prescribed nitroglycerin tablets for you, put one under your tongue when the
symptoms begin and repeat at five-minute intervals for a total of three doses. If the symptoms have not
disappeared within 15 minutes, call an ambulance immediately. Do not take nitroglycerin tablets unless
directed by a doctor. In patients with a condition known as aortic stenosis, taking nitroglycerin tablets can
precipitate death. If you do have this condition, clearly understand from your doctor how you should respond
in the event that you do develop worrisome chest pain.

As soon as you think you are having a heart attack, take one aspirin, unless you have a specific allergy to it
or a condition that makes taking aspirin highly risky. While perhaps the most inexpensive of all heart attack
related therapies, aspirin is also one of the most effective.

Unlike a heart attack, if you believe you are having a stroke, aspirin may not be beneficial and may even
prove harmful. This is because not all strokes are due to blood clots. Some are due to bleeding. Aspirin may
worsen a stroke if, in fact, it is due to bleeding.

If you are with someone whose heart has stopped beating, call 911 or your local emergency number.
Administer cardiopulmonary resuscitation (CPR) immediately. CPR will supply oxygen to parts of the body
until the ambulance arrives. It is important to have a family member or caretaker trained in CPR, especially
when there is diagnosed heart disease in the family. Local community centres and hospitals can provide
information on CPR training.

In the emergency department

Treatment goals at the emergency department (emergency room) are to decrease the demands on your
heart and prevent and treat complications. An IV (intravenous catheter) will be placed in a vein. This is
usually the best way to administer fluids and medications. Even if blood levels of oxygen are normal, oxygen
is generally administered to decrease the workload of the heart and make oxygen readily available to the
body. A urinary catheter might be inserted to help monitor the input and output of fluid from the body.

Your doctor will use the following information to determine the severity of your condition and treatment of
choice: previous medical history, physical examination, an electrocardiogram (ECG or EKG), and the level of
pertinent chemicals in your blood.

Physicians will want to know what type of chest pain you may have experienced previously. They will also
want to know whether you have had a heart attack in the past, surgeries, and if you take any medications. (It
is useful if a family member has knowledge of medication dosages.) This information will help physicians
determine whether the pain you are feeling is due to a heart attack.

If you are having a heart attack, a rapid pulse, changes in blood pressure, crackles in lungs, and abnormal
heart sounds might be found on physical examination. The ECG (or EKG) is a test that records the electrical
rhythm of your heart. Wires (or leads) are attached to the chest, arms, and legs using pads with gel or tape.
This procedure is not painful. Specific changes in the ECG alert the physician that a heart attack is occurring.
EKG monitoring is generally started immediately since life threatening dysrhythmias (defective rhythm) are
the leading cause of death during the first several hours following an acute heart attack.

Blood tests provide an indication of heart muscle damage. When some of the heart muscle dies, the dead
cells release chemicals into the blood. One chemical that is routinely evaluated is creatinine phosphokinase
(CPK), specifically the MB isoform. Another set of chemicals belong to the troponin family of proteins
(troponin I and troponin T). All of these chemicals have high specificity for heart muscle and when they are
significantly elevated, confirm a heart attack diagnosis. The CPK MB and troponins provide important
information about the extent and severity of your heart attack, when your heart attack might have occurred,
and your prognosis.

Heart Attack Medicines

If ECG results determine that you are having a heart attack, your doctor will try to use medications to help
the heart. Several of these drugs are specifically designed to prevent further blood vessel obstruction
(aspirin, heparin, low-molecular weight heparin, glycoproteins 2b/3a inhibitors, and clopidogrel). Others, such
as oxygen and beta blockers, improve oxygen utilization by the heart and decrease the heart's workload.
Nitrogylcerin and morphine decrease chest pain and reduce heart strain. If you have an arrhythmia during
the course of your heart attack, you may also be placed on an antiarrhythmic (other than beta blockers which
are, by themselves, effective antiarrhythmics). Diuretics such as lasix may be prescribed if you have fluid
accumulation in your lungs. Cholesterol-lowering agents such as statins and antihypertensive, anti-
remodelling agents such as angiotensin-converting enzyme inhibitors (ACE inhibitors) are important
adjunctive therapies that may also be used early in the course of your therapy.

If your doctor finds enough convincing evidence that you are having a heart attack, then you will be
prescribed some form of reperfusion therapy. Reperfusion therapy refers to using intravenous medication
(thrombolytics), a percutaneous catheterization-based technique (angioplasty), or surgery to re-establish
blood flow to an occluded artery. The decision to receive one of these therapies is dependent upon a number
of important factors including how long ago your heart attack started, the severity and instability of your heart
attack, and the available resources and experience of the cardiovascular specialists at the hospital where
you are being treated. Each of these therapies has their own unique advantages and disadvantages that will
be discussed with you during the very initial phases of your hospitalization. If the caring emergency team has
decided during your en route trip to the hospital that you will receive thrombolytics, you may be started on
such medication in the ambulance. Along with reperfusion therapy, heparin and/or 2b/3a inhibitors may be
prescribed to reduce the clotting tendency of your blood.

III. Tests and Treatments for heart attack

The following tests and treatments are usually not performed in the emergency room. Patients are usually
admitted at this point.

Cardiac catheterization

Your physician may request a cardiac catheterization. A thin catheter (plastic tube) is inserted through a vein
or artery in the arm or leg and is guided into the coronary arteries of the heart. This test can accurately
measure how much oxygen is in your blood, your blood pressure, and can provide information about
functioning of the heart muscles, valves and arteries. A skilled doctor usually injects dye through the catheter
into the origins of the coronary arteries and identifies arterial obstructions by observing dye flow.

Angioplasty

As briefly mentioned, your doctor may decide to treat you with angioplasty to establish reperfusion when
he/she feels that thrombolytic therapy is either not primarily indicated or was ineffective in relieving your
heart attack symptoms. Angioplasty can be performed during a cardiac catheterization. The technique
consists of a small balloon being placed at the site of the coronary blockage and blown up with air. This
causes the material forming the blockage to be compressed along the wall of the vessel. The inflated balloon
can also cause the vessel to stretch, making it wider so more blood can flow through. It can also cause
cracks in the blockage that will allow more blood to flow through.

You will be mildly sedated during angioplasty, and most people report feeling only minor discomfort. Like a
catheterization, your doctor will inject dye into your arteries that will allow him/her to monitor your blood flow
and determine the site(s) of blockage. The tube carrying the balloon, regarded as the catheter, is inserted at
the site of artery access, usually in the groin area. The catheter is moved along the artery until it reaches the
blockage. The balloon is then inflated for a period of a few seconds to a few minutes and then deflated.
Blood flow is monitored to ensure adequate reperfusion or restoration of blood flow. Sometimes the balloon
will be reinflated at the same site or at another site.
Usually a stent is placed at the site of the balloon. A stent is a rigid tube which prevents the vessel from
collapsing or a blood clot from forming at the site of the blockage. Great advances in stent technology have
led to markedly improved outcomes for people who undergo angioplasty at the time of their heart attack, or
shortly thereafter.

Bypass surgery

If angioplasty proves unsuccessful, the position of the block is too difficult to access by angioplasty, or you
have severe blockages in multiple major vessels, the doctors may recommend bypass surgery. In this
procedure, a piece of vein taken from the leg or an artery taken from the chest is used to form a bypass
conduit to enable blood to go around the blockage. Several blocks can be bypassed at the time of surgery.

Bypass surgery is a major operation. If you undergo this operation, you will receive general anaesthesia, and
thus be completely asleep during the surgery. Pre-operative medications are often administered to bypass
patients by mouth, muscular or subcutaneous injection, or IV. During bypass surgery, the chest bone is
separated, and the ribs are spread apart to allow visible and physical access to the heart. During surgery,
blood circulation and breathing functions will be taken over by a heart-lung machine. The operation usually
lasts between two and six hours. A bypass graft is performed to reroute blood flow around the blockage.
Veins used in bypass surgery are usually taken from one of the legs or an artery is usually taken from the
chest wall (internal mammary artery), or forearm (radial artery) to complete the graft.

A newer technique, minimally invasive bypass surgery, requires a much smaller incision in the chest (only
three inches) instead of sawing through the chest bone. An artery from the chest is used to bypass the
blockage. While fewer patients are candidates for this type of surgery, the technique is less painful and leads
to a shorter hospital stay than the usual bypass surgery.
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. The second part 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)

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). Within the first day of your CCU stay, you may be ordered not to
receive anything to eat by mouth (i.e., made fasting) or placed on a clear liquid diet. The reason for these
dietary restrictions is to reduce the risk of vomiting and nausea after the heart attack. More importantly, you
must be made fasting 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, 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
particular groups of 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 and progress.

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 an 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. A s 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-vascularise (or open) clogged arteries are bypass surgery
and angioplasty. Bypass surgery is an invasive procedure, often performed when patients cannot be treated
with angioplasty.

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 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 oedema (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 to two weeks of surgery, depending on a patient's progress.

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.

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, anaemia), cholesterol
levels, PT (protimes) 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 annually or biannually. 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 it can sometimes be
overlooked by physicians, 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.

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. And doctors have encouraged
resumption of sexual activity anywhere from one day to eight weeks after returning home from the hospital.
For your emotional reassurance, speak with your doctor regarding concerns you have about physical and
sexual activity.

After two to four months, most heart attack patients can return to their jobs. 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 counselling.

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.

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 comorbidities or 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 in June 1998 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. 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
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.