Lifestyle changes after a heart attack

Many people feel scared, confused and overwhelmed after a heart attack, which can be a life-changing event. Prevention of another heart attack and cardiac rehabilitation should be a priority to speed recovery and to improve quality of life.

Did you know?


According to the World Health Organization (WHO), 80% of cardiovascular diseases like heart attacks and strokes are preventable.1


Four out of five people who die from cardiovascular disease (CVD) are killed by a heart attack or a stroke, and one third of these deaths occur in people under 70 years of age.2, 3


In Australia, coronary heart disease is the leading cause of death for males and the second most common cause for females, after dementia and Alzheimer’s disease.4


Every 90 minutes, someone in New Zealand dies prematurely from heart disease. Many of these deaths are preventable.5  


After a heart attack, only about 30% of Australian patients are referred to cardiac rehab, and only 28% of those referred actually attend.6  

The Facts:


Cardiac rehabilitation programs

  • Cardiac rehab programs were developed to provide a personalised approach to preventing a second heart attack or other heart diseases, and are the most cost-effective means of improving a patient’s outcomes.7
  • They can be delivered by phone, online or face-to-face, either in hospital or in the community.
  • Following an initial medical evaluation of physical, mental and emotional health, a cardiac rehab program is developed. This incorporates goal-setting, supervised exercise, education about self-management and optimising risk factors, and psychological support, in addition to support from other patients.
  • This integrated approach addresses not only the physical effects, but also the psychological effects of having a heart attack. As a result, death and disability, hospital admissions and cardiac risk factors are lowered, while quality of life can be improved to the point where the patient is able to return to work and normal life.7

Who should participate?

  • Cardiac rehab following a cardiac event occurs a few days after hospital discharge.7 Evidence from the US indicates that the following conditions respond to cardiac rehab8, 9:
    • Stable angina (chest pain)
    • Recent myocardial infarction (heart attack)
    • Heart failure
    • Recent coronary artery bypass surgery (CABG)

What are the benefits?

  • Cardiac rehab has been shown to reduce the frequency of hospital readmissions by 40% and death from a second heart attack by 25%.10
  • Cardiac rehab saves lives and reduces healthcare costs because it11-16:
    • Reduces mortality
    • Accelerates recovery
    • Improves clinical outcomes (e.g. cholesterol, blood pressure)
    • Improves behavioural outcomes (e.g. exercise tolerance, quit smoking)
    • Reduces repeat cardiovascular events and hospital readmissions
    • Strengthens adherence to medication, and
    • Enhances mental health and quality of life
  • One in two people are unable to return to their original work capacity, and one in four don’t return to work at all.17 Cardiac rehab supports people as they strive to return to a productive life and stay out of hospital.

How does it work?

Cardiac rehab programs are delivered by a dedicated team, including doctors, nurses, exercise specialists, therapists, nutritionists and counsellors. Programs typically include the following core components:18

  • Foundations of cardiac rehab:
    • Initial assessment and goal setting: Information is collected and assessments are made in the following areas:
      • Exercise capacity to evaluate the risk of cardiovascular complications from a training program.
      • Lifestyle risk factors (physical activity, diet, smoking, alcohol)
      • Psychosocial health (depression, anxiety)
      • Medications
      • Adiposity (waist circumference)
      • Medical risk factors (blood pressure, lipids, blood glucose)
      • Quality of life
      • Return to activities of daily living
    • Heart education and self-management: In order to develop problem-solving skills to manage their condition, patients are educated in cardiovascular anatomy and disease.
  • Developing knowledge of heart health:
    • Exercise training
      • Usually tailored to individual needs, exercise is supervised and may include aerobic and resistance training with progressive intensity.
      • Formal sessions include at least 30 minutes of aerobic activity – longer if combined with resistance training, balance training or stretching. This occurs 1-3 times per week, but activity on most days is recommended.
    • Healthy eating and weight management
      • A dietician provides education and assistance to adopt a healthy diet and reduce weight. This includes:
        • Serving sizes, number of serves and meal planning
        • Whole plant foods, lean meat and low-fat dairy options
        • Healthy whole-fat foods and oils
        • Herbs and spices to replace salt
        • Water as the fluid of choice.
      • Patients are referred to expert weight loss programs where needed.
    • Quit smoking and alcohol reduction
    • Education and review of medications
      • Discuss commonly prescribed medications, their benefits, side effects and use.
      • Emphasise the importance of taking medications and consulting a GP before changing or stopping medications.
    • Management of medical risk factors
      • Patients are educated and provided with support to reduce the most common risks of high blood pressure, high cholesterol and type 2 diabetes.
  • Psychosocial health
    • Depression, anxiety and denial are common in patients following a heart attack.20, 21 In fact, one in five heart attack patients also suffer major depression, increasing their risk of death and further cardiac events.19
    • Cardiac rehab programs address psychosocial wellbeing by:
      • Discussing typical emotional responses to a cardiac event.
      • Identifying and broadening social support available to patients.
      • Helping patients to recognise signs and symptoms of depression and other mood disorders, and know where to seek help.
  • Life beyond cardiac rehab
    • Participants are helped to return to activities of daily living, such as:
      • Driving
      • Sexual intimacy
      • Work – by addressing barriers and developing strategies for a graded approach.
      • CPR training
    • Reassessment and completion of rehab includes:
      • Reviewing participant’s goals
      • Providing a discharge summary for GP and cardiologist

When should I join Cardiac rehab?

  • The first visit to an outpatient cardiac rehab program can occur a few days after hospitalisation, in the case of an uncomplicated heart attack or revascularisation surgery.
  • More complicated cases involving coronary artery bypass grafting (CABG) or complex hospital courses will typically start later.20
  • Early enrolment improves subsequent attendance and outcomes.21-23 Delaying cardiac rehab by more than 30 days has been linked to decreased improvement in exercise performance.24

Home-based programs

  • Home-based cardiac rehab is increasingly recommended.25-27 It is similarly effective in improving clinical outcomes and health-related quality-of-life in patients with heart failure, or after heart attacks or revascularisation.28 Local availability and patient preference may guide this choice.

What can we do about it?


If you or a loved one have just experienced a heart attack, the following recommendations should be followed to reduce the risk of having a second cardiac event.

  • Attend cardiac rehab. If none was provided at hospital discharge, it is important to follow-up with the discharge team.
  • Know your medications and take them as directed.
  • Attend all follow-up appointments. It is important to attend these appointments so your doctor can monitor your condition and recovery.
  • Seek support. Loved ones and others who have experienced a heart attack can help you overcome the fear and anxiety that patients commonly feel.
  • Change your lifestyle. Following a lifestyle that promotes physical and mental health is vital to manage risk factors and reduce your risk of further cardiac events:
    • Follow a healthy plant-based diet
    • Drink water rather than sugary drinks or fruit juices
    • Lose any excess weight
    • Maintain recommended levels of physical activity
    • Manage your stress
    • Stop smoking
  • Find support to safely return to work after injury. Different states and countries have different programs to help people to return to work if a heart attack has largely been related to stress or demands at work. Links have been provided below to find information on how to access work support in Australia and New Zealand:

REFERENCES:
 

  1. World Health Organization. Cardiovascular Diseases: Avoiding Heart Attacks and Strokes. Q&A detail [Internet]. 2015. Accessed [cited 2020 Nov 19]. Available from: https://www.who.int/news-room/q-a-detail/what-can-i-do-to-avoid-a-heart-attack-or-a-stroke 10
  2. World Health Organization. Hearts: Technical package for cardiovascular disease management in primary health care. Geneva, Switzerland: World Health Organization; 2016. [cited 2020 Jul 22]. Available from: https://www.who.int/cardiovascular_diseases/hearts/Hearts_package.pdf 11.
  3. World Health Organization. Global Health Estimates 2018: Disease burden by Cause, Sex, by Country and Region, 2000-2016: World Health Organization; 2018 [cited 2020 Sep 22]. Available from: https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html 12.
  4. Australian Insitute of Health and Welfare. Australia's health 2018. Canberra: Australian Insitute of Health and Welfare; 2018. [cited 2020 Jul 22]. Available from: https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contents 13.
  5. New Zealand Ministry of Health. Annual Data Explorer 2018/19. New Zealand Health Survey; 2019. [cited 2020 May 7]. Available from: https://www.health.govt.nz/publication/annual-update-key-results-2018-19-new-zealand-health-survey 14.
  6. Astley CM, Chew DP, Keech W, Nicholls S, Beltrame J, Horsfall M, et al. The Impact of Cardiac Rehabilitation and Secondary Prevention Programs on 12-Month Clinical Outcomes: A Linked Data Analysis. Heart Lung Circ. 2020 Mar;29(3):475-82. doi:10.1016/j.hlc.2019.03.015
  7. Heart Foundation. Cardiac rehabilitation information for health professionals [Internet]. Heart Foundation;  [cited 2020 Sep 22]. Available from: https://www.heartfoundation.org.au/recovery-and-support/cardiac-rehabilitation-for-health-professionals 15.
  8. Arena R, Williams M, Forman DE, Cahalin LP, Coke L, Myers J, et al. Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association. Circulation. 2012 Mar 13;125(10):1321-9. doi:10.1161/CIR.0b013e318246b1e5
  9. Balady GJ, Ades PA, Bittner VA, Franklin BA, Gordon NF, Thomas RJ, et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 2011 Dec 20;124(25):2951-60. doi:10.1161/CIR.0b013e31823b21e2
  10. De Gruyter E, Ford G, Stavreski B. Economic and Social Impact of Increasing Uptake of Cardiac Rehabilitation Services--A Cost Benefit Analysis. Heart Lung Circ. 2016 Feb;25(2):175-83. doi:10.1016/j.hlc.2015.08.007
  11. Briffa TG, Kinsman L, Maiorana AJ, Zecchin R, Redfern J, Davidson PM, et al. An integrated and coordinated approach to preventing recurrent coronary heart disease events in Australia. Med J Aust. 2009 Jun 15;190(12):683-6. doi:10.5694/j.1326-5377.2009.tb02636.x
  12. Thomas E, Lotfaliany M, Grace SL, Oldenburg B, Taylor CB, Hare DL, et al. Effect of cardiac rehabilitation on 24-month all-cause hospital readmissions: A prospective cohort study. Eur J Cardiovasc Nurs. 2019 Mar;18(3):234-44. doi:10.1177/1474515118820176
  13. Dunlay SM, Pack QR, Thomas RJ, Killian JM, Roger VL. Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. Am J Med. 2014 Jun;127(6):538-46. doi:10.1016/j.amjmed.2014.02.008
  14. Peersen K, Munkhaugen J, Gullestad L, Liodden T, Moum T, Dammen T, et al. The role of cardiac rehabilitation in secondary prevention after coronary events. Eur J Prev Cardiol. 2017 Sep;24(13):1360-8. doi:10.1177/2047487317719355
  15. Griffo R, Ambrosetti M, Tramarin R, Fattirolli F, Temporelli PL, Vestri AR, et al. Effective secondary prevention through cardiac rehabilitation after coronary revascularization and predictors of poor adherence to lifestyle modification and medication. Results of the ICAROS Survey. Int J Cardiol. 2013 Aug 20;167(4):1390-5. doi:10.1016/j.ijcard.2012.04.069
  16. Kraal JJ, Peek N, Van den Akker-Van Marle ME, Kemps HM. Effects of home-based training with telemonitoring guidance in low to moderate risk patients entering cardiac rehabilitation: short-term results of the FIT@Home study. Eur J Prev Cardiol. 2014 Nov;21(2 Suppl):26-31. doi:10.1177/2047487314552606
  17. Heart Foundation. Cardiac Rehabilitation Factsheet: Heart Foundation;  [cited 2020 Sep 23]. Available from: https://www.heartfoundation.org.au/getmedia/946216ec-af94-4e4d-a32a-d5923fee8dee/HF-Cardiac_Rehab_Factsheet_WEBHR.pdf 16.
  18. Heart Foundation. A Pathway to Cardiac Recovery - Standardised program content for Phase II Cardiac Rehabilitation: Heart Foundation; 2019 [cited 2020 Sep 22]. Available from: https://www.heartfoundation.org.au/getmedia/c77bac1d-4de5-4000-8e4c-0ecb1365f1b2/A_Pathway_to_Phase_II_Cardiac_Recovery_(Full_Resource).pdf 17
  19. Richards SH, Anderson L, Jenkinson CE, Whalley B, Rees K, Davies P, et al. Psychological interventions for coronary heart disease. Cochrane Database Syst Rev. 2017 Apr 28;4(4):Cd002902. doi:10.1002/14651858.CD002902.pub4
  20. Practitioners TRACoG. Exercise based rehabilitation for Coronary heart disease. 2016 Aug [cited May 7 2020]. In: Handbooko of Non-Drug Interventions (HANDI) [Internet]. The Royal Australian College of General Practitioners, [cited May 7 2020]. Available from: https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/handi-interventions/cardiovascular/exercise-based-rehabilitation-for-coronary-heart-d 18.
  21. Zullo MD, Jackson LW, Whalen CC, Dolansky MA. Evaluation of the recommended core components of cardiac rehabilitation practice: an opportunity for quality improvement. J Cardiopulm Rehabil Prev. 2012 Jan-Feb;32(1):32-40. doi:10.1097/HCR.0b013e31823be0e2
  22. Russell KL, Holloway TM, Brum M, Caruso V, Chessex C, Grace SL. Cardiac rehabilitation wait times: effect on enrollment. J Cardiopulm Rehabil Prev. 2011 Nov-Dec;31(6):373-7. doi:10.1097/HCR.0b013e318228a32f
  23. Pack QR, Mansour M, Barboza JS, Hibner BA, Mahan MG, Ehrman JK, et al. An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial. Circulation. 2013 Jan 22;127(3):349-55. doi:10.1161/CIRCULATIONAHA.112.121996
  24. Johnson DA, Sacrinty MT, Gomadam PS, Mehta HJ, Brady MM, Douglas CJ, et al. Effect of early enrollment on outcomes in cardiac rehabilitation. Am J Cardiol. 2014 Dec 15;114(12):1908-11. doi:10.1016/j.amjcard.2014.09.036
  25. Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, et al. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation. 2019 May 13;140(1):e69-e89. doi:doi:10.1161/CIR.0000000000000663
  26. Salvi D, Ottaviano M, Muuraiskangas S, Martinez-Romero A, Vera-Munoz C, Triantafyllidis A, et al. An m-Health system for education and motivation in cardiac rehabilitation: the experience of HeartCycle guided exercise. J Telemed Telecare. 2018 May;24(4):303-16. doi:10.1177/1357633X17697501
  27. Sunamura M, Ter Hoeve N, van den Berg-Emons RJG, Boersma E, van Domburg RT, Geleijnse ML. Cardiac rehabilitation in patients with acute coronary syndrome with primary percutaneous coronary intervention is associated with improved 10-year survival. Eur Heart J Qual Care Clin Outcomes. 2018 Jul 1;4(3):168-72. doi:10.1093/ehjqcco/qcy001
  28. Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. 2017.

Summary:

Going through a heart attack can be physically and emotionally challenging. Cardiac rehab programs have been designed to give all the support patients need for a speedier recovery, so if you or a loved one have had an event, make sure you attend and reap the benefits.

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Dr. Luiz Fernando SellaMD, MPH
Author
Medical Doctor at the Federal University of Santa Catarina, Brazil, a Certified Lifestyle Medicine Physician and Health and Wellness Coach.

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