Encyclopaedia


Heart attack (Myocardial Infarction - MI)

Introduction

A heart attack is a serious medical emergency in which the supply of blood to the heart is suddenly blocked, usually by a blood clot. The lack of blood to the heart can seriously damage the heart muscles. If left untreated, the muscles will begin to die. The medical term for a heart attack is myocardial infarction.

Symptoms of a heart attack include:

  • chest pain: the chest can feel like it is being pressed or squeezed by a heavy object, and the pain can radiate from the chest to the jaw, neck, arms and back
  • shortness of breath
  • overwhelming feeling of anxiety

Heart attacks and coronary heart disease

Most heart attacks occur in people with coronary heart disease, which is caused by atherosclerosis. Atherosclerosis is a serious condition where the arteries become narrowed and hardened by the build-up of clumps of cholesterol, called plaques.

The two arteries that supply the heart are called the coronary arteries. People with hardened and narrowed coronary arteries are said to have coronary heart disease (CHD).

Risk factors for CHD include:

How common are heart attacks?

Heart attacks are very common and are one of the leading causes of death. Each year in Wales around 7,000 people have a heart attack, and approximately 105,000 people in wales have had a heart attack. Many heart attacks that lead to death are preventable. This is because most of the risk factors that are listed above can also be prevented.

Most heart attacks occur in people who are over 45 years of age. Men are two to three times more likely to have a heart attack than women.

Over the last decade, death rates from heart attacks have fallen. This may be related to an associated decrease in the number of people smoking cigarettes. However, the number of deaths is still higher than in many other western European countries. It is thought that this is because England and Wales has higher rates of obesity, diabetes and physical inactivity (people not exercising enough) than in other countries.

Treatment options for a heart attack can involve using medication to dissolve any blood clots and surgery to widen the coronary artery.

Outlook

The outlook for people who have a heart attack is highly variable and is dependent on two important factors:

  • how quickly they receive treatment after the onset of the heart attack (ideally treatment should begin within 90 minutes of the onset of symptoms)
  • how well they respond to treatment within the first 28 days after the heart attack

Currently, just over half the people who have a heart attack die during the first 28 days after the heart attack. Of these deaths, 75% occur in the first 24 hours and 30% of them occur before the person is admitted to hospital.

If a person survives for 28 days after having a heart attack, their outlook improves dramatically and most people will go on to live for many years.

In those who survive a heart attack, a combination of lifestyle changes and medication is usually recommended to reduce the risk of having another heart attack. See Recovering from a heart attack for more information. 

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Symptoms

If you suspect that you or someone you know is having a heart attack, dial 999 immediately.

The symptoms of a heart attack are:

  • chest pain: the pain is usually located in the centre of your chest and can feel like a sensation of pressure, tightness or squeezing
  • pain in other parts of the body: it can feel as if the pain is travelling from your chest to your arms (usually the left arm is affected but it can affect both arms), jaw, neck, back and abdomen
  • shortness of breath
  • nausea
  • an overwhelming sense of anxiety (similar to having a panic attack)
  • feeling light headed
  • coughing
  • vomiting
  • wheezing

The level of pain can vary significantly from person to person.  For many people, the pain is severe and it has been described as feeling like ‘an elephant was sitting on my chest’. However, this is not always the case. For others, the pain can be minor and is similar to that experienced during indigestion. Also, some women and older people do not experience any chest pain at all.

It is not the level of chest pain that is important in determining whether you are having a heart attack. Instead, it is the overall pattern of symptoms that is important.

The misconception that a heart attack always causes severe chest pain has led to many people dying needlessly.  One American study found that a third of people who had a heart attack did not call an ambulance.

Do not worry if you have any doubts about whether your symptoms indicate that you are having a heart attack. Assume that you are having a heart attack and dial 999 to ask for an ambulance immediately.

Paramedics would much rather be called out to find out that an honest mistake has been made than be called out when it is too late to save a person’s life.

Waiting for the ambulance

If you know that you are not allergic to aspirin and aspirin is easily available, chew (do not swallow) an adult size tablet while you are waiting for the ambulance to arrive. The aspirin will help to thin your blood and restore the blood supply to your heart.

Advice for people with angina

Angina is a syndrome (a collection of symptoms caused by an underlying health condition) that is caused when the supply of oxygen-rich blood to the heart becomes restricted.

People with angina can experience similar symptoms to a heart attack, but they usually pass within a few minutes. However, occasionally people with angina can have a heart attack. It is important to be able to recognise the difference between the symptoms of angina and those of a heart attack.

The best way to do this is to remember that symptoms of angina can be controlled with medication, unlike the symptoms of a heart attack.

If you have angina, you may have been prescribed a medication called glyceryl trinitrate, which is used to provide short-term relief from the symptoms of angina. After taking this medication, your symptoms should improve within five minutes. If the first dose does not work, a second dose can be taken after five minutes, and a third dose after a further five minutes.

If the pain persists despite taking three doses of glyceryl trinitrate over 15 minutes, call 999 and ask for an ambulance. 

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Causes

Like all the other tissues and organs in the body, the heart needs a constant supply of oxygen-rich blood. If the blood supply to the heart is suddenly interrupted, the heart muscles may be damaged and begin to die.

If this is not treated, the heart muscles will experience irreversible damage. If a large portion of the heart is damaged in this way, the heart will stop beating (cardiac arrest), resulting in death.

Coronary heart disease (CHD)

Coronary heart disease (CHD) is the leading cause of heart attacks. CHD is a condition in which the coronary arteries (the major blood vessels that supply the heart with blood) get clogged up with deposits of cholesterol. These deposits are called plaques.

During a heart attack, one of the plaques ruptures (bursts), causing a blood clot to develop at the site of the rupture. The blood clot may then block the supply of blood running through the coronary arteries to the heart, triggering a heart attack.

Risk factors

The risk factors for CHD, many of which are interrelated (related to each other), are outlined below.

Smoking

The toxins that are contained in cigarettes narrow and damage the coronary arteries. This makes people who smoke more vulnerable to CHD. Compared with non-smokers, people who smoke 20 or more cigarettes a day are 60-90% more likely to develop CHD and have a heart attack.

Even small amounts of tobacco can be harmful. If you smoke only one cigarette a day, you are still 30% more likely to develop CHD than a non-smoker.

Diet

If you eat a diet that is high in saturated fat, your blood cholesterol levels will rise. This leads to an increase in your risk of CHD and heart attacks.

Some foods, such as oily fish, can help lower your cholesterol level. See Preventing a heart attack for more information about how diet can influence your heart attack risk.

High blood pressure

Having poorly controlled high blood pressure (hypertension) can weaken the coronary arteries, making them more vulnerable to CHD. The higher your blood pressure, the greater your risk of CHD and heart attacks.

Diabetes

The increased levels of blood glucose associated with type 1 diabetes and type 2 diabetes can damage the coronary arteries, making them more vulnerable to CHD.

It is estimated that people with diabetes are 2-5 times more likely to develop CHD than the general population.

Being overweight or obese

Being overweight or obese does not directly increase your risk of CHD and heart attacks, but leads to related risk factors that do. In particular, people who are overweight or obese:

  • have an increased risk of developing high blood pressure
  • tend to have higher levels of cholesterol as a result of eating a high-fat diet
  • have an increased risk of developing type 2 diabetes

Lack of exercise

Lack of exercise is not directly related to an increased risk of CHD and heart attacks. However, it is linked to an increased risk of being overweight or obese and having high blood pressure (hypertension).

Alcohol

Excessive consumption of alcohol can cause high blood pressure (hypertension) and increased blood cholesterol levels, increasing the risk of developing CHD. Most heavy drinkers also tend to have unhealthy lifestyles, such as smoking, eating a high-fat diet and not exercising enough.

Age and sex

The older you get, the more likely you are to develop some degree of CHD.

Men are 2-3 times more likely to have a heart attack than women. In the past, the increased risk could be explained (to a certain extent) by the fact that more men smoked cigarettes. However, today the number of men and women who smoke is roughly the same, but men are still more at risk of having a heart attack than women.

A number of theories have been suggested to explain this increased risk, such as:

  • higher rates of excessive alcohol consumption in men
  • more men are overweight than women (although obesity levels are roughly the same for both sexes)
  • men may be less effective at coping with stress than women, and increased stress levels may affect their physical wellbeing

Family history

If you have a first-degree relative (a parent, brother or sister) with a history of heart disease, such as angina, heart attack or stroke, you are twice as likely to develop similar problems compared to the general population.

Ethnicity

Rates of high blood pressure and diabetes are higher in people of African and African-Caribbean descent, which means that they also have an increased risk of CHD and heart attacks.

People of South Asian descent (those of Indian, Bangladeshi, Pakistani and Sri Lankan origin) are five times more likely to develop diabetes than the general population. Again, this increases their risk of CHD and heart attacks.

Less common causes

Some less common causes of a heart attack are described below.

Drug misuse

Stimulants, such as cocaine, amphetamines (speed), crack and methamphetamines (crystal meth), can sometimes suddenly cause the coronary arteries to narrow, restricting the blood supply and triggering a heart attack. Heart attacks due to the use of cocaine are one of the most common causes of sudden death in young people.

Lack of oxygen in the blood (hypoxia)

If the levels of oxygen in the blood decrease due to carbon monoxide poisoning or a loss of normal lung function, the heart will receive un-oxygenated blood. This will result in the heart muscles being damaged, triggering a heart attack.

Aneurysm

An aneurysm is a weakness in a blood vessel wall. If the blood vessel wall becomes weakened beyond a certain point, it will no longer be able to withstand the pressure of blood running through it and it will rupture (burst).

Sometimes, an aneurysm can develop inside the coronary arteries, although this is much less common than other types of aneurysm. If a coronary artery aneurysm ruptures, the blood supply to the heart will stop, triggering a heart attack.

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Diagnosis

If a heart attack is suspected, you should be admitted to hospital immediately. You will usually be admitted to an intensive care unit (ICU) so that the diagnosis can be confirmed and treatment can begin.

Electrocardiograph (ECG)

An electrocardiograph (ECG) is an important test in cases of suspected heart attacks. An ECG should be carried out within 10 minutes of being admitted to hospital.

An electrocardiograph (ECG) measures the electrical activity of your heart. Every time your heart beats, it produces tiny electrical signals. An ECG machine records these signals onto paper, allowing your doctor to see how well your heart is functioning.

An ECG is painless and takes about five minutes to perform. During the test, electrodes (flat metal discs) are attached to your arms, legs and chest. Wires from the electrodes are connected to the ECG machine, which records the electrical impulses.

There are two reasons why an ECG is so important:

  • it helps confirm the diagnosis of a heart attack
  • it helps determine what type of heart attack you have had, which will help determine the most effective treatment for you

Types of heart attack

Heart attacks can be classified by a measurement that is known as the ST segment. The ST segment is an electrical measurement that is recorded by an ECG. It corresponds to the level of damage that has been inflicted on the heart. The higher the ST segment, the greater the amount of damage that is likely to have occurred.

There are three main types of heart attack:

  • ST segment elevation myocardial infarction (STEMI)
  • Non-ST segment elevation myocardial infarction (NSTEMI)
  • unstable angina

The three types are described in more detail below.

ST segment elevation myocardial infarction (STEMI)

ST segment elevation myocardial infarction (STEMI) is the most serious type of heart attack. In this type of heart attack, a prolonged interruption to the blood supply, resulting from a total blockage of the coronary artery, causes extensive damage to a large area of the heart. A STEMI is what most people think of when they hear the term heart attack.

Non-ST segment elevation myocardial infarction (NSTEMI)

Non-ST segment elevation myocardial infarction (NSTEMI) is less serious than a STEMI. This is because the supply of blood to the heart is only partially blocked, rather than completely blocked. As a result, a smaller section of the heart is damaged. However, NSTEMI is still regarded as a serious medical emergency.

Unstable angina

Unstable angina is the least serious type of heart attack although, like NSTEMI, it is still regarded as a medical emergency. In unstable angina, the blood supply to the heart is still seriously restricted, but the extent of the damage is much less severe than in cases of STEMI and NSTEMI.

Other tests

A number of other tests can be used to assess the state of your heart and check for related complications. However, because heart attacks are medical emergencies, some of these tests are usually only carried out once your initial treatment has begun and your condition has stabilised.

Blood tests

The damage to your heart that results from a heart attack causes certain enzymes to slowly leak into your blood. Enzymes are special proteins that help regulate the chemical reactions that take place in your body.

If you have had a suspected heart attack, a sample of your blood will be taken so that it can be tested for these heart enzymes. Your enzyme levels will be measured through a series of blood samples that will be taken over the course of a few days. This will allow the level of damage to your heart to be assessed, and it will also help determine how well you are responding to treatment.

Chest X-ray

A chest X-ray can be useful if the diagnosis of a heart attack is uncertain and there are other possible causes of your symptoms, such as a pocket of air trapped between the layers of your lungs (pneumothorax).

A chest X-ray can also be used to check whether any complications have arisen from the heart attack, such as a build-up of fluid inside your lungs (pulmonary oedema).

Echocardiogram

An echocardiogram is similar to an ultrasound scan in that it uses sound waves to build up a picture of the inside of your heart. This can be useful to identify exactly which areas of the heart have been damaged and how this damage has affected your heart’s function.

Coronary angiography

Coronary angiography can help determine whether a blockage or narrowing has occurred in the coronary arteries and, if so, to locate the exact location of the blockage or narrowing.

The test involves inserting a thin tube, known as a catheter, into one of the blood vessels in your groin or arm. The catheter is guided into your caronary arteries using X-rays.

A special fluid, known as a contrast agent, is pumped through the catheter. This fluid shows up on X-rays. Studying how it flows around and through your heart can help locate the site of any blockage or narrowing.

A coronary angiogram is often performed just before surgery because the results can help guide the efforts of the surgeon. See Treating a heart attack for more information.

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Treatment

Cardiopulmonary resuscitation (CPR)

Cardiopulmonary resuscitation (CPR) is a first aid technique that can be used if you think that someone’s heart has stopped beating as the result of a heart attack (cardiac arrest).

Someone may have had a cardiac arrest if:

  • they appear to not be breathing
  • they are not moving
  • they do not respond to any stimulation, such as being touched or spoken to

CPR consists of combining two techniques:

  • chest compressions
  • rescue breathing

Chest compression

To carry out a chest compression, place the heel of your hand at the centre of the person’s chest, in between their nipples. Place your other hand on top of your first hand and interlock your fingers. Using your body weight (not just your arms), press straight down (4-5cm) onto their chest.

Rescue breathing

To carry out rescue breathing, tilt the person’s head back and lift their chin up to open their airways. Pinch their nostrils closed and breathe into their mouth for one second. If their chest rises, give another breath. If their chest does not rise, tilt their head back and lift their chin again, before giving the second breath.

If you have received training in how to give CPR and you feel confident about performing the manoeuvre:

  • give 30 chest compressions
  • followed by two rescue breaths
  • before repeating the cycle

Aim to do the chest compressions at a rate of 100 compressions a minute.

If you have not been trained in CPR, do not attempt to perform rescue breathing because it is possible to damage the person’s airways if it is not performed correctly. Instead, focus on giving 100 chest compressions a minute.

The above advice only applies to adults. For information about how to perform CPR in children, see Birth to Five: how to resuscitate a child (page 36).

Your treatment plan

Your treatment plan will depend on the type of heart attack you have had. For example, if you have had an ST segment elevation myocardial infarction (STEMI), there are two treatment options:

  • a combination of medication to dissolve the blood clot and restore the flow of blood to the heart (this is known as thrombolysis)
  • surgery to widen the carotid artery, which is usually done using a technique called coronary angioplasty

If you have had a non-ST segment elevation myocardial infarction (NSTEMI) or unstable angina, thrombolysis is usually recommended as the first treatment option.

If your symptoms do not improve, a coronary angioplasty can be carried out. These treatment options are discussed in more detail below.

STEMI

As STEMI is the most serious type of heart attack, it is important that it is treated quickly. Therefore, once the diagnosis has been confirmed, an immediate decision has to be made as to whether you are treated with surgery or thrombolysis.

Research has shown that surgery is the most effective treatment for STEMIs. However, a coronary angioplasty is a very complex type of surgery that requires specialist staff and equipment, and not all hospitals have the facilities needed to perform the surgery.

In most cases, surgery would only be the preferred option if it can be carried out within 90 minutes of you being admitted to hospital.

Thrombolysis is usually the preferred option if the facilities for surgery are not available and it would take longer than 90 minutes to transfer you to a hospital where surgery is available. This is because it may be too risky to delay treatment any longer.

Coronary angioplasty

During coronary angioplasty, a tiny wire with a sausage-shaped balloon at the end is put into a large artery in your groin or arm. The wire is passed through your blood vessels and up to your heart, using X-rays to guide it, before being moved into the narrowed section of your coronary artery.

Once in position, the balloon is inflated inside the narrowed part of the artery to open it wide. A stent (flexible metal mesh) is usually inserted into the artery to help keep it open afterwards.

CABG

Sometimes, a coronary angioplasty may not be technically possible if the anatomy of your arteries is different from normal. This may be the case if there are too many narrow sections in your arteries or if there are lots of branches coming off your arteries that are also blocked.

In such circumstances, an alternative surgical procedure, known as a coronary artery bypass graft (CABG), may be considered. CABG involves taking a blood vessel from another part of your body, usually your chest or leg, to use as a graft.

The graft replaces any hardened or narrowed arteries in the heart. A surgeon will attach the new blood vessel to the coronary artery above and below the narrowed area or blockage.

Thrombolysis

Thrombolysis involves giving you injections of a type of medication called thrombolytics. Thrombolytics target and destroy a substance called fibrin. Fibrin is a tough protein that makes up blood clots by acting like a sort of fibre mesh that hardens around the blood.

Thrombolytic medications that are used in the treatment of heart attacks include alteplase and streptokinase.

You may also be given additional blood-thinning medication, such as aspirin or heparin, to prevent further blood clots from developing.

Morphine

Morphine is a painkiller that is usually given to relieve the symptoms of chest pains and to reduce feelings of stress and anxiety.

NSTEMI and unstable angina

In cases of NSTEMI and unstable angina, medication is the first option to dissolve the blood clot and thin the blood to prevent further clotting.

You may also be given an additional medication called glycoprotein IIb/IIIa inhibitors if it is thought that you have an increased risk of experiencing another more serious heart attack.

Glycoprotein IIb/IIIa inhibitors do not break up blood clots in the same way as alteplase and streptokinase, but they prevent blood clots from getting bigger. They are, therefore, an effective method of stopping your symptoms getting worse.

Depending on how serious your symptoms are, how well you respond to treatment and your general state of health, further surgery may be recommended to widen your carotid artery. This will usually be done using a coronary angioplasty.

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Recovery

Recovering from a heart attack can take several months and it is very important not to rush your rehabilitation. During your recovery period, you will receive help and support from a range of healthcare professionals, which may include:

  • nurses
  • physiotherapists
  • dietitians
  • pharmacists
  • exercise specialists

These healthcare professionals will support you physically and mentally to ensure that your recovery is conducted safely and appropriately.

The recovery process will usually take place in several stages. Your recovery will initially begin in hospital, where your condition can be closely monitored and your individual needs for the future can be assessed. After you are discharged, you can continue your recovery at home.

There are two important aims of the recovery process:

  • to reduce your risk of experiencing another heart attack
  • to gradually restore your physical fitness so that you can resume normal activities (known as cardiac rehabilitation)

Reducing the risk

Reducing your risk of having another heart attack involves making lifestyle changes and taking a long-term course of a combination of different medications.

Lifestyle changes

Diet

It is recommended that you eat 2-4 portions of oily fish a week. Oily fish contains a type of fatty acid known as omega-3. Omega-3 can help to lower your cholesterol levels.

Good sources of omega-3 include:

  • herring
  • sardines
  • mackerel
  • salmon
  • trout
  • tuna

If you are unable or unwilling to eat oily fish, your GP may recommend that you take an omega-3 food supplement.

Never take a food supplement without first consulting your GP. Some supplements, such as beta-carotene, could be potentially harmful.

It is also recommended that you eat a Mediterranean-style diet. This means that you should eat more bread, fruit, vegetables and fish and less meat. Replace butter and cheese with products that are based on vegetable and plant oil, such as olive oil.

For more dietary and lifestyle information and advice, see the Q&A section.

Smoking

If you smoke, it is strongly recommended that you quit as soon as possible. The Stop Smoking Wales website can provide you with support and advice. Your GP will also be able to recommend and prescribe medication that can help you give up. See Treatment for quitting smoking for more information.

Alcohol

If you drink alcohol, do not exceed the recommended daily limits (no more than 3-4 units a day for men and 2-3 units a day for women). A unit of alcohol is roughly half a pint of normal strength lager, a small glass of wine or a single measure (25ml) of spirits. Regularly exceeding the recommended alcohol limits will raise your blood pressure and cholesterol level, increasing your risk of having another heart attack.

Avoid binge drinking (drinking more than 3 alcoholic drinks in 1-2 hours). Binge drinking can cause a sudden and large rise in your blood pressure, which could be potentially dangerous.

Research has found that people who have had heart attacks and continue to binge drink are twice as likely to die of a serious health condition, such as another heart attack or stroke, compared with people who moderate their drinking after having a heart attack.

Contact your GP if you find it difficult to moderate your drinking. Counselling services and medications can help you reduce your alcohol intake. See Treatment for alcohol misuse for more information.

Weight management

If you are overweight or obese, it is recommended that you lose weight and then maintain a healthy weight using a combination of exercise and a calorie-controlled diet. See Treatment for obesity for more information.

Regular physical activity

Once you have made a sufficient physical recovery from the effects of the heart attack (see Cardiac rehabilitation, below, for more information about how long this usually takes), it is recommended that you do regular physical activity.

Aim to be physically active for 20-30 minutes a day. The level of activity should be strenuous enough to leave you slightly breathless. Activities that you could incorporate into your exercise programme include:

  • brisk walking
  • cycling
  • climbing stairs

If you find it difficult to achieve 20-30 minutes of activity a day, start at a level that you feel comfortable with (for example, 5-10 minutes of light exercise a day) and gradually increase the duration and intensity of your activity as your fitness begins to improve.

Medication

There are currently four medications that are widely used to reduce the risks of heart attacks. These are:

  • angiotensin-converting enzyme (ACE) inhibitors
  • anti-platelets
  • beta-blockers
  • statins

ACE inhibitors

ACE inhibitors are often used to lower your blood pressure. They block the actions of some of the hormones that help regulate blood pressure. By stopping these hormones from working, the medicine helps reduce the amount of water in your blood and also widens your arteries, both of which will reduce your blood pressure.

ACE inhibitors have been known to reduce the supply of blood to the kidneys, which can reduce their efficiency. Therefore, blood and urine tests may be carried out before you start taking ACE inhibitors to make sure that there are no pre-existing problems with your kidneys. Annual blood and urine tests may then be required if you continue to use ACE inhibitors.

The side effects of ACE inhibitors can include:

  • dizziness
  • tiredness or weakness
  • headaches
  • a persistent, dry cough

Most of these side effects should pass within a few days, although some people continue to have a dry cough.

If they are taken with other forms of medication, including over-the-counter (OTC) medicines, ACE inhibitors can cause unpredictable effects. Therefore, check with your GP or pharmacist before taking anything in combination with ACE inhibitors.

It is usually recommended that you begin taking ACE inhibitors immediately after having a heart attack and, in most cases, continue taking them indefinitely.

Anti-platelets

Anti-platelets are a type of medication that can help prevent blood clots. They work by reducing the 'stickiness' of platelets. Platelets are tiny particles in the blood that help it to clot.

It is usually recommended that you take low-dose aspirin, which has blood-thinning properties as well as being a painkiller.

If testing shows that you have a higher than average risk of having another heart attack, you may be given an additional anti-platelet medication called clopidogrel. Clopidogrel can also be used if you are allergic to aspirin.

Side effects of clopidogrel include:

  • diarrhoea
  • abdominal pain
  • indigestion
  • heartburn

As with ACE inhibitors, treatment with anti-platelets usually begins immediately after a heart attack. The amount of time for which you are prescribed clopidogrel depends on your symptoms. It is usually between 4 weeks and 12 months.

It is usually recommended that you take aspirin indefinitely.

If you are unable to take either aspirin or clopidogrel, you can be prescribed an alternative blood-thinning medication called warfarin. Warfarin is usually prescribed for a maximum of four years.

Excessive bleeding is the most serious side effect of warfarin. Seek immediate medical attention and have an urgent blood test if you experience any of the following side effects:

  • passing blood in your urine or faeces (stools)
  • passing black faeces
  • severe bruising
  • prolonged nosebleeds (that last for longer than 10 minutes)
  • blood in your vomit
  • coughing up blood
  • unusual headaches
  • in women, heavy or increased bleeding during your period or any other bleeding from the vagina

Immediate medical attention must also be sought (or given) if you:

  • are involved in major trauma (an accident)
  • experience a significant blow to the head
  • are unable to stop any bleeding

Beta-blockers

Beta-blockers are a type of medication used to protect the heart from further damage after a heart attack. They help relax the heart’s muscles so that the heart beats slower and the blood pressure level drops, both of which will help reduce the strain on your heart.

It is usually recommended that you begin treatment with beta-blockers as soon as your condition stabilises and continue taking them indefinitely.

Fairly common side effects of beta-blockers include:

  • tiredness
  • cold hands and feet
  • slow heartbeat
  • diarrhoea
  • nausea

Less common side effects include:

  • sleep disturbances
  • nightmares
  • impotence

Beta-blockers can also interact with other medicines, causing possible adverse side effects. Therefore, check with your GP or pharmacist before taking other medicines, including over-the-counter (OTC) medication, in combination with beta-blockers.

Statins

Statins are a type of medication used to lower your blood cholesterol level. This will help prevent further damage to your coronary arteries and should reduce the risk of another heart attack. Statins block the effects of an enzyme in your liver called HMG-CoA reductase, which is used to make cholesterol.

Statins sometimes have mild side effects, including:

  • constipation
  • diarrhoea
  • headaches
  • abdominal pain

Occasionally, statins can cause muscle pain, weakness and tenderness. Contact your GP if you experience these symptoms as your dosage may need to be adjusted.

It is usually recommended that you take statins indefinitely.

Cardiac rehabilitation

Your cardiac rehabilitation programme will begin when you are in hospital. A member of the cardiac rehabilitation team will visit you in hospital and provide you with detailed information about:

  • your state of health and how the heart attack may have affected it
  • the type of treatment that you received
  • what medications you will need to take when you leave hospital
  • what specific risk factors are thought to have contributed to your heart attack
  • what lifestyle changes you can make to address those risk factors

Once you return home from hospital, it is usually recommended that you get plenty of rest and only do light activities, such as climbing up and down the stairs a few times a day or doing some light walking.

Gradually increase the amount of activity that you do each day over several weeks. How quickly you can do this will depend on the condition of your heart and your general state of health. Your care team can provide you with more detailed advice about a recommended plan to increase your levels of activity.

You may also be invited to attend a cardiac rehabilitation programme at your local hospital four to eight weeks after leaving hospital. The programme consists of one- to two-hour exercise sessions, once or twice a week. The type of exercise can vary depending on the programme, but the exercises should mainly be aerobic.

Aerobic exercises are designed to strengthen the heart, improve circulation and lower blood pressure. Examples of aerobic exercises include riding an exercise bike, jogging on a treadmill and swimming.

Returning to work

Most people can return to work after having a heart attack, but how quickly will depend on your health, the state of your heart and the kind of work you do. If your job involves light duties, for example if you work in an office, you should be able to return to work within six weeks. However, if your job involves performing heavy duties, it may be two to four months before you can return to work.

Sex

According to the British Heart Foundation, you should be able to safely have sex once you are fit enough to walk briskly up two flights of stairs without getting chest pains or becoming out of breath. This is usually about four weeks after having a heart attack. Having sex will not put you at further risk of having another heart attack.

Following a heart attack, about 30% of men have erectile dysfunction (difficulty getting or maintaining an erection), which may make having sex difficult. This is most commonly due to anxiety and the emotional stress that is associated with having a heart attack. Less commonly, erectile function is caused by a side effect of the beta-blockers.

If you experience erectile dysfunction, speak to your GP. They may be able to recommend treatment to help with your symptoms. For example, you may be prescribed the impotence medication sildenafil (also known as Viagra).

Driving

If you drive a car or motorcycle and you have a heart attack, you do not have to inform the Driver and Vehicle Licensing Agency (DVLA). However, the DVLA strongly recommends that you stop driving for at least four weeks after a heart attack. After this, you will be able to drive provided you do not have any other condition or complication that would disqualify you from driving.

If you drive a large goods vehicle or passenger carrying vehicle, you must inform the DVLA if you have a heart attack. Your license will be temporarily suspended, for a minimum of six weeks, until you have adequately recovered. Your license will be reissued if you can pass a basic health and fitness test and you do not have any other condition or complication that would disqualify you from driving.

Depression

Having a heart attack can be very frightening and traumatic, and afterwards it is common to have feelings of anxiety. For many people, the emotional stresses can cause them to feel depressed and tearful for the first few weeks after returning home from hospital.

If feelings of depression persist, speak to your GP about how you are feeling because you may have a more serious form of depression. It is important that you seek advice because serious types of depression often do not get better without treatment. Your emotional state could also have an adverse effect on your physical recovery.

Getting help

Everyone who experiences a heart attack will face different problems and challenges, and any guidance or advice that you receive will be tailored to your individual needs.

There are many local and national cardiac support groups where you can meet people who have been through a similar experience.

The British Heart Foundation has a helpline that can give you confidential information about your recovery and advice about how to keep your heart healthy.

Call the helpline on 0300 330 3311 from 9am to 6pm, Monday to Friday.

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Complications

Potential complications arising from a heart attack can vary widely, from mild to life threatening.

Some people experience what is sometimes referred to as a ‘minor’ heart attack (although it is still very serious) with no associated complications. This is also known as an uncomplicated heart attack.

Other people experience a major heart attack, which has a wide range of complications and may require extensive treatment.

Some common complications of a heart attack can include those outlined below.

Arrhythmia

An arrhythmia is an abnormal heartbeat, such a beating too quickly (tachycardia), too slowly (bradycardia) or irregularly (atrial fibrillation).

Arrhythmias can develop after a heart attack as a result of damage to the muscles. The damaged muscles disrupt the electrical signals that are used by the body to control the heart. Some arrhythmias, such as tachycardia, are mild and cause symptoms such as:

  • palpitations (the sensation of your heart racing in your chest or throat)
  • chest pain
  • dizziness
  • light-headedness
  • fatigue (tiredness)
  • breathlessness 

Other arrhythmias can be life threatening, such as:

  • complete heart block, where the electrical signals are unable to travel from one side of your heart to the other so that your heart cannot pump blood properly
  • ventricular arrhythmia, where the heart begins beating faster and faster before going into a kind of spasm, which again means that it is unable to pump blood properly

These life-threatening arrhythmias can be a major cause of death during the 24 hours after a heart attack. However, survival rates have improved significantly since the invention of the portable defibrillator, an external device that delivers an electric shock to the heart and ‘resets’ it to the right rhythm.

Mild arrhythmias can usually be controlled with medication, such as beta-blockers. More troublesome arrhythmias that cause repeated and prolonged symptoms may need to be treated with a pacemaker. A pacemaker is an electric device that is surgically implanted in the chest and is used to help regulate the heartbeat.

Heart failure

Heart failure is a condition where your heart is unable to effectively pump blood around your body. It can develop after a heart attack if the muscles in your heart are extensively damaged, which usually occurs in the left side of the heart (the left ventricle). Symptoms of heart failure include:

  • shortness of breath
  • fatigue
  • swelling in your arms and legs due to a build-up of fluid

Heart failure can be treated with a combination of medications and, in some cases, surgery. See Treatment for heart failure for more information.

Cardiogenic shock

Cardiogenic shock is similar to heart failure but is more serious.  It develops when so much of the heart’s muscles have been damaged that the heart can no longer supply enough blood to maintain many of the functions of the body.

Symptoms of cardiogenic shock include:

  • mental confusion
  • cold hands and feet
  • decreased or no urine output
  • rapid heartbeat and breathing
  • pale skin

Cardiogenic shock can be treated using blood-thinning medication, which makes the blood easier to pump. A type of medication called vasopressors may be used. Vasopressors help constrict (squeeze) the blood vessels, which increases the blood pressure and improves blood circulation.

Once the initial symptoms of cardiogenic shock have been stabilised, surgery may be required to improve the function of the heart. One option is to implant a small pump, known as an intra-aortic balloon pump. This can help improve the flow of blood away from the heart.

Another option is a coronary artery bypass graft.

 

Heart rupture

A heart rupture is a serious and relatively common complication of heart attacks. Heart ruptures occur in around 1 in every 10 cases.

A heart rupture is where the heart's muscles, walls or valves rupture (split apart).  A rupture can occur if the heart is significantly damaged during a heart attack. It usually happens one to five days after a heart attack.

The symptoms of a heart rupture are the same as those of cardiogenic shock. Open heart surgery is usually required to repair the damage to the heart.

The outlook for people who have a heart rupture is not good, and an estimated 50% of people die within five days of the rupture occurring.

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Prevention

The five main risk factors that can lead to a heart attack are:

  • smoking
  • not getting enough exercise (physical inactivity)
  • high blood pressure
  • being overweight or obese
  • high blood cholesterol levels

To reduce your risk of having a heart attack, you should make some changes to your lifestyle.

Give up smoking

Smoking is a major contributor to many serious diseases, such as heart disease, and lung cancer, and it is the biggest cause of death and illness in the UK. Stopping smoking is one of the best ways you can help to prevent a heart attack.

If you decide to stop smoking, your GP will be able to refer you to an NHS Stop Smoking Service, which will provide you with dedicated help and advice on the best ways for you to give up smoking. You can call the NHS Smoking helpline on 0800 169 0 169 who offer free expert advice and encouragement. To find out more information about NHS Stop Smoking Services, see the 'selected links' sections.

If you are committed to giving up smoking, but do not want to be referred to a stop smoking service, your GP should be able to prescribe you medical treatment to help with any withdrawal symptoms you may experience after quitting. See Treatment for quitting smoking for more information about giving up. 

Take regular exercise

If you want to keep your heart healthy, it is very important to take regular exercise. Exercise helps improve your circulation, and helps your heart to work more efficiently.

If you have had a heart attack, see Recovering from a heart attack for advice about exercise. For people without a history of heart disease, 30 minutes of vigorous exercise a day, at least five times a week, is recommended.  The exercise should be strenuous enough to leave your heart beating faster and you should feel slightly out of breath afterwards. Examples of vigorous exercise include going for a brisk walk and walking up a hill.

Diet

For a healthy heart, a low-fat, high-fibre diet, including whole grains and plenty of fresh fruit and vegetables (at least five portions a day), is recommended.  Limit the amount of salt in your diet to no more than 6g (0.2oz) a day. Too much salt will increase your blood pressure. One teaspoonful of salt is equal to about 6g. 

Avoid eating foods that are high in saturated fat because this will increase the cholesterol levels in your body. Foods that are high in saturated fat include:

  • meat pies
  • sausages and fatty cuts of meat
  • butter
  • ghee (a type of butter that is often used in Indian cooking)
  • cream
  • hard cheese
  • cakes and biscuits
  • foods that contain coconut or palm oil

Eating some foods that are high in unsaturated fat can help to decrease your cholesterol level. Foods that are high in unsaturated fat include:

  • oily fish
  • avocados
  • nuts and seeds
  • sunflower
  • rapeseed
  • olive oil

 

Alcohol

Drinking excessive amounts of alcohol will cause your blood pressure to rise, as well as raising the cholesterol levels in your blood. Therefore, sticking to the recommended amounts of alcohol consumption is the best way to ensure that your risk of developing high blood pressure (hypertension) and having a heart attack is reduced.

The recommended daily limits of alcohol consumption are:

  • Men - three to four units of alcohol 
  • Women - two to three units

One unit is approximately equivalent to about half a pint of ordinary strength larger a  small glass of wine or a 25ml pub measure of spirits.

Lose weight

There are many benefits of losing weight. If you can reach the ideal weight for your height, it will help lower your cholesterol levels and your blood pressure. You will also significantly lower your risk of heart disease, as well as increase your life expectancy.

The most successful weight loss programmes include at least 30 minutes of daily exercise, eating smaller portions and only having healthy snacks between meals. A gradual weight loss of around 0.5kg (1.1lb a week is usually recommended.

For more advice, see Treatment for obesity

Other conditions

Several other medical conditions can increase your risk of having a heart attack. Two of the most common conditions are hypertension (high blood pressure) and diabetes.

Keeping these other health conditions under control will help reduce your risk of having a heart attack. This means always remembering to take any medication that you have been prescribed, visiting your GP for regular check-ups, and making sure that your diet is healthy.

See High blood pressure, Type 1 diabetes and Type 2 diabetes for more information about these conditions.

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Q&A

Why should I change my diet after a heart attack?

Making changes to your diet can help reduce the risk of having another heart attack. Other changes to your lifestyle can also help.

What is the Mediterranean diet?

There is evidence to show that eating a Mediterranean-style diet can reduce your risk of another heart attack.

You can make your diet more Mediterranean-style by:

  • eating more bread and pasta,
  • eating more fruit, salad including tomatoes, and vegetables,
  • eating more fish,
  • eating less meat, and
  • choosing products made from vegetable and plant oils, such as olive oil, rather than dairy products, such as butter and cheese.

Oily fish

Oily fish are all rich sources of omega 3 fatty acids, which help prevent heart disease. You should eat 2-4 portions of oily fish a week, such as:

  • herring,
  • sardines,
  • mackerel,
  • salmon,
  • trout, or
  • fresh tuna.

One portion is about 140g, equivalent to a small tin of oily fish or a small fillet of fresh fish.

If you’ve had a heart attack in the last three months and you don’t eat enough oily fish, your GP may offer you a medicine containing omega 3 fish oils, to supplement your diet.

Healthier ways to cook

Don’t fry food or roast food in fat. Instead, choose healthy ways to cook and prepare your food., such as:

  • steaming,
  • poaching,
  • baking,
  • making a casserole,
  • using the microwave, or
  • stir-frying.

Buttery, cheesy or creamy sauces tend to be high in fat. Try adding flavour to your sauces using spices, herbs and lemon juice instead.

Foods to avoid

Avoid foods that contain:

  • a lot of fat, especially saturated fat,
  • salt, and
  • added sugar.

Foods like this include:

  • fried foods,
  • sweets and confectionery,
  • takeaways,
  • processed foods, and
  • pre-packaged foods.

Supplements to avoid

Do not take beta-carotene supplements (beta-carotene is a type of vitamin A). Research has shown that taking these supplements may increase the risk of another heart attack.

You should also be aware that taking vitamin C, vitamin E or folic acid will not help to prevent another heart attack. There is no evidence that taking any of these supplements will have any benefit.

Why should I change my lifestyle after a heart attack?

Making changes to your lifestyle can help you recover from a heart attack. For example, if you smoke, don't take enough exercise or eat unhealthily, this will slow down your recovery. Making lifestyle changes will also help to reduce your risk of another heart attack.

Changing your lifestyle

There is evidence that lifestyle affects your risk of having a heart attack. The changes you make will depend on what your lifestyle is now. Below are some examples:

  • Stop smoking. Smoking increases your risk of having another heart attack and is one of the biggest causes of death and illness in the UK. Speak to your GP or call the free NHS smoking helpline on 0800 169 0 169 for advice and encouragement to help you quit smoking. Treatments are available on the NHS to help you stop.
  • Eat a Mediterranean-style diet. Changing your diet will help to reduce your risk of another heart attack. A Mediterranean diet includes lots of fruit, vegetables, fish, grains and pulses, with a moderate intake of red meat. Foods rich in omega-3 are believed to have an anti-inflammatory effect, which may reduce the pain associated with inflamed joints. Omega-3 is found in oily fish, such as sardines, mackerel and salmon.
  • Drink less alcohol. If you drink alcohol, stay within the recommended maximum limit and don’t drink more than three units of alcohol in one to two hours (binge drink). Men should drink no more than 21 units of alcohol a week or three to four units a day and women no more than 14 units of alcohol a week or two to three units a day.
  • Take regular exercise. Exercise for 20-30 minutes a day. The exercise should make you slightly out of breath but you shouldn’t feel pain or discomfort. If you do, stop and rest immediately. Choose activities that can easily become part of your daily routine, such as walking, swimming and cycling.
  • Check your weight. If you’re overweight, you’re putting extra strain on your heart and increasing your risk of another heart attack. If you need to lose weight, your doctor or nurse can give you advice and support about reaching and maintaining your ideal weight.

What is cardiac rehabilitation?

After your heart attack you'll be given advice and support. You’ll be invited to attend a cardiac rehabilitation programme to help you recover and lead your life as normally as possible. The programme covers exercise, health education and information and stress management.

Depending on your needs, you may see different healthcare professionals, including a:

  • dietitian,
  • physiotherapist,
  • cardiac rehabilitation nurse, or
  • smoking cessation adviser.

Regular exercise can help your heart. Your programme will include supervised exercise sessions. You can get advice about whether you need to increase your activity levels and how to do this safely. This will depend on:

  • how well you have recovered,
  • how physically active you are now,
  • how physically active you used to be, and
  • what type of exercise you enjoy.

You will also be told about when it is safe to resume sexual activity after your heart attack.

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Selected links

NHS Direct Wales Encyclopaedia links

Angina

Atherosclerosis

Heart disease

External links

British Heart Foundation

Lab Tests Online UK: creatine kinase

Lab Tests Online UK: troponin test

Heart Watch Welsh Ambulance Services NHS Trust

Stopping Smoking Stop Smoking Wales  

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.

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