Heart Attack

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Follow-up Treatment

Patients who suffer a heart attack are admitted to a cardiac care unit (CCU), usually for the first several days. In the CCU, the patient's heart rate, blood pressure, and heart rhythm are carefully monitored. Patients also are carefully monitored for recurring chest pain and shortness of breath.

Blood tests usually are performed every 8 hours for the first 24 hours to help assess the amount of heart damage. If intravenous unfractionated heparin is administered, regular blood tests are used to determine if the blood is "thinned" to the correct degree.

During the first several days, an echocardiogram (cardiac echo) may be used to assess the size and function of the heart and to determine if heart valves have become leaky or narrowed (stenotic).

For several days after a heart attack, most medications are administered intravenously. After a few days, most medications can be taken orally.

Studies have shown that acute and long-term aspirin therapy can decrease the chances of recurrent heart attack and death. Therefore, patients are often treated indefinitely with aspirin. In most cases, a 325 mg enteric-coated aspirin is prescribed. The enteric coating decreases the risk for stomach irritation.

According to the U.S. Food and Drug Administration (FDA), the pain reliever ibuprofen can interfere with the benefits of aspirin therapy. Patients who are on aspirin therapy should speak with a health care provider for information about taking ibuprofen.

Studies have shown that some patients are resistant to the effects of aspirin therapy. Regular blood tests may be performed to monitor the patient's response; the results of these tests can be used to adjust the aspirin dosage or change the medication.

A medication called clopedigrol (Plavix®) is an alternative to aspirin therapy. Clopedigrol decreases the "stickiness" of platelets to a greater degree than aspirin therapy.

In a study in which clopedigrol therapy was compared to aspirin therapy in patients with coronary heart disease, clopedigrol proved slightly more effective in decreasing future heart attacks and had a slightly lower incidence of stomach irritation and bleeding. These benefits are weighed against the higher cost of this medication. Current studies are assessing the potential benefits of therapy combining aspirin and clopedigrol.

The usual dose of clopedigrol is one 75 mg tablet daily. Side effects include abdominal pain, constipation, and nausea.

Angiotensin converting enzyme (ACE) inhibitors, which often are used to treat high blood pressure, may be administered for approximately 6 weeks following a heart attack. These medications may help the heart "heal," improving function (ejection fraction) and decreasing risk for heart failure, recurrent heart attack, and death. ACE inhibitors provide the greatest benefit in patients who have had a severe heart attack, those who experience heart failure, and those with long-term moderately or severely reduced heart function (i.e., those with ejection fractions less than about 40%).

ACE inhibitors include the following:

• Benazepril (Lotensin®)
  
• Captopril (Capoten®)
  
• Enalapril (Vasotec®)
  
• Fosinopril (Monopril®)
  
• Lisinopril (Prinivil®, Zestril®)
  
• Quinapril (Accupril®)
  
• Ramipril (Altace®)
  
• Trandolapril (Mavik®)
  

These medications are usually tolerated well, but there are potential side effects. Approximately 10% of patients develop a chronic nonproductive cough. Rarely, ACE inhibitors produce a sudden swelling of the lips, face, and cheek areas in an allergic reaction that can occur at any time during therapy. If an allergic reaction occurs, medical attention should be sought immediately. Because ACE inhibitors can affect kidney function and raise the potassium level, physicians monitor these during the first few weeks of treatment.

Angiotensin receptor blockers (ARBs) are similar to ACE inhibitors and also may be used to treat high blood pressure. These medications have been shown to help the heart to "heal" after a heart attack and may benefit patients with lower than normal heart function.

ARBs include candesartan (Atacand®), eprosartan (Tevetan®), and irbesartan (Avapro®). Side effects include cough, dizziness, low blood pressure, and headache.

Tests

Before heart attack patients are discharged from the hospital, a stress test and/or a cardiac catheterization usually is performed. The primary purpose of a stress test is to determine if one or more of the coronary arteries has a significant blockage that is likely to cause problems in the near future. If a blockage is indicated by a stress test, cardiac catheterization is performed to obtain images of the coronary arteries.

Several types of "stress tests" may be used. In some cases, a patient simply walks on a treadmill while connected to an electrocardiogram. In other cases, a drug is infused into the bloodstream to increase the heart rate or to affect the flow of blood within the heart and an echocardiogram is used to obtain images of the heart.

Nuclear stress test involves injecting a radioactive substance into a vein and using a special camera to obtain images of the heart during rest and immediately following exercise on a treadmill. The radioactive substance is absorbed by normal heart tissue and following exercise, areas of diminished blood flow appear as relative "cold spots" on the images.

In some cases, the physician will omit the stress test and proceed directly to cardiac catheterization, which produces images of the coronary arteries and enables the physician to assess heart damage. In this procedure, a special catheter is inserted into the left ventricle, usually through the femoral artery in the groin. Iodine-based dye (contrast agent) is then injected through the catheter into the left ventricle, and images are taken of ventricle function. The infusion of dye typically produces a characteristic "hot flash" sensation throughout the body that lasts 10 to 15 seconds.

The advantage of first undergoing a stress test is that it may indicate that cardiac catheterization is unnecessary. The advantage of proceeding directly to cardiac catheterization is that it can determine the degree of blockage quickly and accurately and allow for prompt treatment.

The decision to perform a stress test first depends on many factors. In most cases, elderly patients and those in poor health may not be good candidates for cardiac catheterization and should be assessed via stress test first. Patients who have significant complications from a heart attack and those who have recurrent chest pain despite medical therapy usually require cardiac catheterization.

Resuming sexual relations

Many heart attack patients are concerned about resuming sexual relations. Some patients worry they are not healthy enough and that sexual activity will put too much strain on the heart or cause another heart attack. Partners of heart attack patients often worry about these issues even more so than the patient. As a result of these concerns, many couples are reluctant to resume sexual activity.

Most patients are safely able to resume sexual relations at some point after a heart attack. The strain on the heart during sexual intercourse is about the same as from walking up two flights of stairs. However, specific recommendations for resuming sexual relations depend on a number of factors, including the severity of the heart attack and the degree of residual heart function. The decision to resume sexual relations should be discussed with a physician.

Some men and women become depressed after a heart attack, which can interfere with sexual drive and performance. In addition, men who are taking beta-blockers may experience erectile dysfunction. Abrupt discontinuation of these medications is dangerous and discontinuation should be discussed with a physician.

Long-Term Treatment

The goals of long-term treatment are to facilitate healing within the heart, to make it easier for the heart to function effectively, and to decrease the risk for future heart attacks. Medications may include aspirin and beta-blockers, and ACE inhibitors.

Patients who have had a heart attack should not smoke. Smoking cessation substantially reduces the risk for heart attack. Within one year of quitting, heart attack risk decreases by about 50%; and within 5 to 10 years of quitting, the risk is about the same as for anyone who is the same age and has never smoked.

Support groups, behavior modification, relaxation techniques, hypnosis, acupuncture, and drug therapy (e.g., bupropion or Zyban®) may be helpful while quitting. A recent study suggests that a combination of bupropion (Zyban®) and a nicotine patch may also be helpful.

Cholesterol reduction therapy has been proven to decrease the risk for future heart attacks and strokes and to decrease the need for coronary angioplasty or bypass surgery. The primary goal of treatment is to reduce the level of "bad" (LDL) cholesterol to less than 100 mg/dL.

Medications called statins often are used to lower cholesterol. They include atorvastatin (Lipitor®), cerivastatin (Baycol®), fluvastatin (Lescol®), lovastatin (Mevacor®), pravastatin (Pravachol®), and simvastatin (Zocor®). These medications effectively lower LDL cholesterol levels and usually are well tolerated. Rare side effects include liver inflammation and muscle pain and inflammation. Patients taking these medications also must follow a low-cholesterol diet.

People who are physically active and exercise regularly have a lower risk for coronary heart disease than those who have inactive, sedentary lifestyles. Regular exercise can improve levels of "good" (HDL) cholesterol, can help control diabetes, can lead to modest reductions in blood pressure, and can reduce the risk for future heart attacks.

Heart attack patients must consult a physician for help devising an exercise program before beginning to exercise. Cardiac rehabilitation programs are available at many hospitals and community centers.

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