Preventing a Second Heart Attack

Heart attacks aren’t as deadly as they used to be. Thanks to advances in emergency treatment, hundreds of thousands of Americans who have had heart attacks survive the experience, some after more than one attack.

If you’re one of those survivors, protecting your heart should be your top priority. One out of four men and one out of three women who live through an attack will die within the following year, most often of cardiac arrest or another heart attack, according to the American Heart Association. By making some healthy lifestyle changes and working closely with your doctor, you can remain a survivor — not a victim.

What can I do to prevent a second heart attack?

Your risk for a second heart attack depends largely on your lifestyle. In other words, prevention is in your hands. Here’s a look at the lifestyle changes that can help keep your heart in working order:

If you smoke, stop. Think of your first heart attack as a very serious wake-up call. Cigarettes damage your arteries, disrupt your heart’s rhythm, and lower your HDL “good” cholesterol. You can cut your risk of another heart attack in half by giving up the habit. You should also avoid secondhand smoke at work and at home.

Eat a heart-healthy diet. Watching your diet, especially your fat intake, has never been more important. By cutting back on fats — particularly saturated fat — you can lower your LDL cholesterol, the artery-clogging substance that sets the stage for a heart attack.

According to the American Heart Association, heart attack survivors should get less than 30 percent of their calories from fat, and less than 7 percent from saturated fat (which is found in animal products). For a typical 2,000-calorie diet, this translates to less than 67 grams of fat (with less than 16 grams of that being saturated fat) every day.

Avoid trans fatty acids. These are found in some margarines, cookies, crackers, fries, donuts, and other snack foods. Some studies suggest that trans fats may actually increase cholesterol levels more than saturated fat! Check labels and avoid foods containing “partially hydrogenated oils” — i.e., trans fat. You should also aim for less than 200 milligrams of cholesterol each day. To reach that goal, have no more than two egg yolks in your diet each week.

While you cut back on fatty foods, you can fill the void with fruits, vegetables, and whole grains. These foods will lower your blood pressure, control your cholesterol, and protect your arteries. For more information on a heart-healthy diet, see Warding Off Heart Disease Through Diet, Reversing Heart Disease Through Diet, and Watching Your Cholesterol. Some researchers, such as Dean Ornish, MD, have found that an extremely low-fat vegetarian diet has actually reversed heart disease by reducing the amount of blockage in the arteries.

Other researchers have found that taking “good fats” such as fish oil supplements containing omega-3 fatty acids — which can help lower cholesterol — is beneficial for the heart. You can also give your heart a boost by adding two fish meals to your diet each week. Cold water fish such as salmon and mackerel are especially rich in omega-3 fatty acids. Finally, substituting olive oil or canola oil for butter, margarine, and corn oil seems to have heart-protective effects as well.

Get regular exercise. Regular workouts strengthen your heart, lower your levels of LDL cholesterol, and boost levels of HDL cholesterol, the “good” cholesterol that helps keep your arteries clear. Exercise also helps ward off depression, a major threat to heart patients. All of this adds up to potent protection. A study published in the journal Circulation found that survivors who increased their activity levels were nearly twice as likely as inactive patients to still be alive seven years after the attack.

The American Heart Association recommends a minimum of 30 minutes of walking or other moderately vigorous exercise at least five times each week, or 20 minutes of vigorous exercise at least three times each week, supplemented by extra activity such as gardening and housework. Any activity is better than nothing. You can give your heart a boost simply by taking the stairs instead of the elevator or doing errands on foot instead of the car.

Not every heart can handle the rigors of exercise. You should have a thorough checkup before starting an exercise program. Your doctor may want to give you a stress test, an exam that monitors your heart while you walk on a treadmill or ride a stationary bicycle. Many patients will be advised to participate in a cardiac rehabilitation program after their first heart attack. This program monitors your heart during exercise training to make sure it’s safe to exercise.

Control your cholesterol. Government health experts recommend keeping your LDL (“bad”) cholesterol under 100 milligrams per deciliter if you have heart disease or diabetes. however, the National Cholesterol Education Program (NCEP) recommends a different treatment option for those people who are at “very high risk” for a heart attack: taking statins or other drugs to get your LDL levels below 70 mg/dL. (You are considered very high risk if you have heart disease plus other risk factors like smoking or diabetes, or if you have been hospitalized for a heart attack.)

After lowering your LDL, your next most important goals are to keep your “good” HDL cholesterol above 40 mg/dL and your overall cholesterol under 200 mg/dL, according to the latest guidelines. (Women should actually keep their HDL cholesterol above 50 mg/dL, according to the American Heart Association.) An additional fat in the blood, triglycerides, ideally should be less than 150 mg/dL.

Watch your weight. Overweight people are especially vulnerable to heart trouble, including heart attacks. Ideally, your body mass index (BMI) should be between 18.5 and 24.9. (To calculate your BMI, see our BMI calculator.) A simpler alternative to the BMI, according to the American Heart Association, is to take your waist measurement. Men should keep theirs to 40 inches or less, women to 35 inches or less. If you’re carrying some extra pounds, your doctor can help you set up an exercise and diet program. And even if you don’t lose much weight, regular workouts and a low-fat diet will go a long way toward preventing another attack.

Reduce your stress. If you’re feeling stressed, depressed, anxious, or angry, your emotional state may be damaging your heart. Many heart programs have shown that incorporating meditation or yoga to reduce stress helps damaged arteries. Developing better social support can also help (see Resurrection and After a Heart Attack: Reaching Out).

Follow a consistent care program. Taking your heart medications on schedule and booking regular doctor visits are also crucial, as is keeping your blood pressure under control. Your goal should be to keep your blood pressure under 140/90 (under 130/80 if you have kidney disease or are diabetic). Regular exercise and eating foods rich in potassium, especially bananas, has been shown to help keep blood pressure in check. If lifestyle changes fail to control your blood pressure, your doctor will likely recommend blood pressure medication.

What can my doctor do to help?

Preventing a second heart attack isn’t just a one-person job. No matter how healthy your lifestyle, you’ll need to work closely with your doctor to give your heart the best possible protection. In addition to providing valuable advice on diet and exercise, your doctor can prescribe medications to ward off another attack.

Here’s a sampling of drugs that may be of help:

Beta blockers. Many heart attack survivors can benefit from these drugs (which include atenolol and metoprolol, among others). Beta blockers lower blood pressure, slow down the heart rate, and increase the heart’s pumping power. In addition, beta blockers may prevent a sudden cardiac arrest. Ideally, patients should start taking the drugs within 24 hours of an attack and stay on them indefinitely. However, you shouldn’t take beta blockers if you have uncontrolled heart failure, a dangerously slow heart beat, dangerously low blood pressure, or active reactive airway disease (asthma).

Cholesterol-lowering drugs. If regular exercise and a healthy diet aren’t enough to bring your cholesterol levels under control, your doctor can prescribe medications to finish the job. As a general rule, any heart attack survivor with an LDL cholesterol level over 100 mg/dL will need drug treatment.

The 2004 NCEP guidelines recommend statins or other cholesterol-lowering drugs for people with an LDL level above 100 mg/dl who are at high risk for a heart attack. (You are at high risk if you have coronary heart disease, diabetes, or multiple risk factors like smoking and high blood pressure.)

If you are at very high risk for a heart attack (which means you have heart disease plus other risk factors like smoking or diabetes, or have been hospitalized for a heart attack), doctors may recommend that you use drug therapy to bring your LDL readings below 70 mg/dL.

The most effective cholesterol medications available today belong to a class called “statins.” These drugs (including simvastatin and lovastatin) can dramatically lower cholesterol levels and come with few side effects, although some patients complain of constipation, stomach pains, and cramps. Recent studies of heart patients have found that statins can lower the risk of fatal heart complications by 20 to 42 percent.

Aspirin. By thinning the blood and preventing blood clots, this humble pain-reliever can make a big difference. In a study of nearly 20,000 heart attack survivors, a daily dose of aspirin cut the risk of a second heart attack by more than 30 percent.

Because regular doses of aspirin can cause stomach problems, you should talk to your doctor before starting an aspirin routine. For most people, a low-to-medium dose (75 to 160 milligrams per day, or the equivalent of one to two baby aspirins) of an enteric coated aspirin provides ample protection with relatively few side effects. In fact, a Duke University review published in 2008 found that a low dose of 50 mg was just as effective as a dose of 325 mg, but with less risk of stomach bleeding.


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