A heart attack occurs
when blood flow to the heart is blocked. Without blood and the oxygen it
carries, part of the heart starts to die. A heart attack doesn't have to be
deadly. Quick treatment can restore blood flow to the heart and save your
life.
Your doctor might call a heart attack a myocardial
infarction, or MI.
What is angina, and why is unstable angina a concern?
Angina (say "ANN-juh-nuh" or "ann-JY-nuh") is a type of chest pain or
discomfort that occurs when there is not enough blood flow to the heart. Angina
can be dangerous, so it is important to pay attention to chest pain, know what
is typical for you, learn how to control it, and understand when you need to
get treatment.
There are two types of angina:
Stable angina is chest pain that has a typical
pattern. It happens when your heart is working harder and needs more oxygen,
such as during exercise. The pain goes away when you rest.
Unstable angina is chest pain that is unexpected, and
resting or taking nitroglycerin may not help. Your doctor will probably
diagnose unstable angina if you are having chest pain for the first time or if
your pain is getting worse, lasting longer, happening more often, or happening
at rest.
Unstable angina is a warning sign that a heart attack may
happen soon, so it requires treatment right away. But if you have any type of
chest pain, see your doctor.
What causes a heart attack?
Heart attacks happen
when blood flow to the heart is blocked. This usually occurs because fatty
deposits called
plaque have built up inside the
coronary arteries, which supply blood to the heart. If a plaque breaks open, the
body tries to fix it by forming a clot around it. The clot can block the
artery, preventing the flow of blood and oxygen to the heart. See a picture of
how plaque causes a heart attack.
This process of plaque buildup in
the coronary arteries is called coronary artery disease, or CAD. In many
people, plaque begins to form in childhood and gradually builds up over a
lifetime. Plaque deposits may limit blood flow to the heart and cause angina.
But too often, a heart attack is the first sign of CAD.
Things
like intense exercise, sudden strong emotion, or illegal drug use (such as a
stimulant, like cocaine) can trigger a heart attack. But in many cases, there
is no clear reason why heart attacks occur when they do.
What are the symptoms?
The most common symptom of
a heart attack is severe chest pain.
Many people describe the pain as discomfort, pressure,
squeezing, or heaviness in the chest.
People often put their fist to their chest when they describe
the pain.
The pain may spread down the left shoulder and arm and to
other areas, such as the back, jaw, neck, or right arm.
Many people also have at least one other symptom, such
as:
Pain in the upper belly, often mistaken for heartburn.
Sweating.
Nausea and vomiting.
Trouble breathing.
A feeling that their heart is racing or pounding (palpitations).
Feeling weak or very tired.
Feeling dizzy or fainting.
Not everyone has the classic symptom of severe chest pain
during a heart attack. Women, older adults, and people with diabetes are less
likely to have severe chest pain and more likely to have shortness of breath,
dizziness, weakness or fainting, and belly pain.
What should you do if you think you are having a heart attack?
If you have symptoms of a heart attack, act fast. Quick
treatment could save your life.
If you are having chest pain and
your doctor has prescribed nitroglycerin for angina:
Take 1 dose of nitroglycerin and wait 5 minutes.
If the chest pain doesn't improve or it gets worse,
call 911 or other emergency services. Describe your symptoms, and say that you
could be having a heart attack.
Stay on the phone. The emergency operator will tell you what
to do.
If you are having chest pain and you do not have nitroglycerin:
Call 911 or other emergency services now. Describe your symptoms, and say that you could
be having a heart attack.
Stay on the phone. The emergency operator will tell you what
to do.
After you call for help, chew 1 regular-strength aspirin.
Aspirin helps keep blood from clotting, so it may help you survive a heart
attack.
The best choice is to go to the hospital in an ambulance.
The paramedics can begin lifesaving treatments even before you arrive at the
hospital. If you cannot reach emergency services, have someone drive you to the
hospital right away. Do not drive yourself unless you have absolutely no other
choice.
If you think you are having unstable angina but you are
not sure, follow the steps listed above. Unstable angina can lead to a heart
attack or death, so you need to have it checked right away.
How is a heart attack treated?
If you go to the
hospital in an ambulance, treatment will be started right away to restore blood
flow and limit damage to the heart. You may be given medicines, including:
Aspirin (if you have not already taken some) and other
medicines to prevent blood clots.
Medicines that break up blood clots (thrombolytics). To work,
these must be given within a few hours of the start of the heart attack.
Medicines to decrease the heart's workload, ease pain, and
treat abnormal heart rhythms, which can be life-threatening.
At the hospital, you will have tests, such as:
Electrocardiogram (EKG or ECG). An EKG can detect
signs of poor blood flow, heart muscle damage, abnormal heartbeats, and other
heart problems.
Blood tests, including tests to see whether cardiac
enzymes are high. Having these enzymes in the blood is
usually a sign that the heart has been damaged.
If these tests show that you may be having a heart
attack, you may have a
cardiac catheterization. For this test, the doctor
puts a thin, flexible tube (called a catheter) through an artery in the groin
or arm and carefully guides it into the heart. (See a picture of
catheter placement.) A dye is injected that makes the coronary arteries show up
on a computer screen. The doctor then can see if the coronary arteries are
blocked and how your heart is working.
If cardiac catheterization
shows that an artery is blocked, the doctor may do
angioplasty right away. The doctor guides the catheter
into the narrowed artery, and a small balloon at the end of it is inflated.
This widens the artery to help restore blood flow. Often a small wire-mesh tube
called a
stent is placed to keep the artery open. See a picture
of angioplasty with stent placement.
Angioplasty, with or without a stent, is the preferred treatment for a
heart attack. But if angioplasty is not available or cannot be done for some
reason, 'clot-busting' thrombolytic medicines may be used. Or the doctor may do
emergency
bypass surgery to redirect blood around the blocked
artery.
After these treatments, medicines are given to prevent clots,
reduce the heart's workload, and lower cholesterol. These can help prevent
another heart attack and heart failure. Most people who have had a heart attack
take these and sometimes other medicines for the rest of their lives.
After you have had a heart attack, the chance that you will have another
one is higher. Taking part in a
cardiac rehab program helps lower this risk. A cardiac
rehab program is designed for you and supervised by doctors and other
specialists. It can help you learn how to eat a balanced diet and exercise
safely to reduce your risk of more heart problems.
It is common to
feel worried and afraid after a heart attack. But if you are feeling very sad
or hopeless, ask your doctor about treatment. Getting treatment for depression
may help you recover from a heart attack.
Can you prevent a heart attack?
Heart attacks are
usually the result of heart disease, so taking steps to delay or reverse
coronary artery disease can help prevent a heart attack. Heart disease is the
number one killer of both men and women in the United States, so these steps
are important for everyone.
To improve your heart health:
Don't smoke, and avoid secondhand smoke. Quitting smoking can
quickly reduce the risk of another heart attack or death.
Eat a heart-healthy diet that includes plenty of fish, fruits,
vegetables, beans, high-fiber grains and breads, and olive oil.
Get regular exercise on most, preferably all, days of the
week. Your doctor can suggest a safe level of exercise for you.
Control your cholesterol and blood pressure.
If you have diabetes, keep your blood sugar as close to normal
as possible.
Lower your stress level. Stress can damage your heart.
The major cause of
unstable angina and
heart attack is
coronary artery disease (CAD). Coronary artery disease
occurs when
plaque builds up over years inside your coronary
arteries and reduces blood flow to the heart muscle. In many people, coronary
artery disease begins in adolescence and gradually develops over a
lifetime.
Plaques are deposits of
cholesterol, calcium, and other substances that are
covered by a fibrous cap. If a sudden surge in blood pressure occurs, if the
artery suddenly constricts, or if other factors such as inflammation are
present, the fibrous cap can tear or rupture. The body tries to repair the
tear, much as it might stop bleeding from a cut on the skin, by forming a blood
clot over it. The blood clot can completely block blood flow through the
coronary artery to the heart muscle and cause a heart attack. See a picture of
how plaque causes a heart attack.
Newly formed plaques are most at
risk for rupture. The fibrous caps on newly formed plaques tend to be more
unstable and more prone to tearing than the thicker fibrous caps on plaques
that have been present for a long period of time.
But plaque is
not always the cause of a heart attack. In rare cases, the coronary artery
spasms and contracts, obstructing blood flow and causing chest pain. If severe,
the spasm can completely block blood flow and cause a heart attack. Most of the
time in these cases, atherosclerosis is also involved, although sometimes the
arteries are clear. Cocaine, cold weather, emotional stress, and other factors
can cause these spasms. But in many other cases, it is not known what triggers
the spasm.
A blood clot that forms over a ruptured plaque may not
completely block the artery but may block blood flow enough to cause unstable
angina. Unstable angina is a sign that a heart attack may soon follow, because
the blood clot can quickly grow and block the artery. If the blood clot
dissolves, and an immediate heart attack is avoided, the body will try over
time to repair the tear on the surface of the plaque. But this newly repaired
plaque can also be very unstable. It is more likely to rupture again, putting
you at even greater risk of a heart attack.
Heart attack triggers
In most cases, there are no
clear reasons why heart attacks occur when they do. But sometimes your body
releases adrenaline and other hormones into the bloodstream in response to
intense emotions such as anger, fear, and the "fight or flight" impulse. Heavy
physical exercise, emotional stress, lack of sleep, and overeating can also
trigger this response. Adrenaline increases blood pressure and heart rate and
can cause coronary arteries to constrict, which may cause an unstable plaque to
rupture.
Nicotine, which is found in tobacco products, and
cocaine can cause similar responses.
The most common symptom of a
heart attack is severe chest pain, although this sensation is not always present. In one study of
people treated for a heart attack, almost half of them came to the emergency
room because they had symptoms other than chest pain. These symptoms included
shortness of breath, dizziness, weakness or fainting, and abdominal
pain.1Women, older adults, and people with
diabetes are less likely to have chest pain during a
heart attack and more likely to have other symptoms.
It is
possible to have a "silent heart attack" without any symptoms, but this is
rare. Most people have chest pain and at least one other symptom, such
as:
A feeling of choking or a "tight throat," a lump in the throat,
or a need to keep swallowing.
A cold sweat.
Nausea.
A sense of impending doom.
Difficulty breathing or breathlessness.
Palpitations, or feeling your heart beat rapidly or
irregularly. (Palpitations are very common and are usually harmless in a
healthy heart, but they may signal
coronary artery disease if brought on by
exertion.)
Numbness or discomfort in either arm or hand.
Weakness.
People who are having a heart attack
often describe their chest pain in various ways. The pain:
May feel like pressure, heaviness, weight, tightness, squeezing,
discomfort, burning, a sharp ache (less common), or a dull ache. People often
put their fist to their chest when describing the pain.
May radiate from the chest down the left shoulder and arm (the
most common site) and also to other areas, including the left shoulder, middle
of the back, upper portion of the abdomen, right arm, neck, and jaw. See a
picture of the
areas where you might have pain during a heart attack.
May be diffuse-the exact location of the pain is usually
difficult to point out.
Is not made worse by taking a deep breath or pressing on the
chest.
Usually begins at a low level, then gradually increases over
several minutes to a peak. The discomfort may come and go. Chest pain that
reaches its maximum intensity within seconds may represent another serious
problem, such as an
aortic aneurysm.
Women are more likely to have symptoms such as shortness of
breath, heartburn, nausea, jaw pain, back pain, or fatigue.
Call 911 or your local emergency services if:
Your chest pain gets worse or lasts more than 5 minutes,
especially if you are short of breath or feel weak, nauseated, or
lightheaded.
Your chest pain doesn't improve or gets worse within 5 minutes
after taking 1 dose of nitroglycerin.
It may not always be possible to tell the difference
between
unstable angina and a heart attack. Often the symptoms
are similar. Both conditions require immediate emergency care.
People who have unstable angina often describe
their pain as:
Starting within the past 2 months and becoming more
severe.
Limiting their physical activity.
Suddenly becoming more frequent, severe, or longer-lasting or
being brought on by less exertion than before.
Occurring at rest with no obvious exertion or stress-it may wake
the person up.
Not responding to rest or nitroglycerin.
The symptoms of stable angina are different from those of
unstable angina. Stable angina occurs at predictable times with a specific
amount of exertion or activity and may continue without much change for years.
It is relieved by rest or nitrates (nitroglycerin) and usually lasts less than
5 minutes.
Use the
heart attack risk calculator to estimate your risk of having a heart attack
over 10 years. This tool is designed to estimate risk in adults age 20 and
older who do not have heart disease or diabetes.
Even if you
already have coronary artery disease or have had a heart attack, you can still
lower your risk of another heart attack. To lower your risk:
Stop smoking. Quitting smoking is probably the most important step to
decrease your chance of a heart attack. Avoid secondhand smoke too.
Reduce high cholesterol. High cholesterol can lead to
a buildup of cholesterol inside your arteries.
Lower high blood pressure. High blood pressure damages
the coronary arteries and increases the heart's workload.
Manage diabetes. People who have diabetes develop
hardening and narrowing of the arteries more frequently and at a younger age
than those not affected by diabetes. Keeping blood sugar at normal levels can
slow this development.
Stay at a healthy weight. Weight loss frequently
improves blood pressure and cholesterol levels and may also help control
diabetes.
Be physically active. Regular exercise can help reduce
your risk of heart attack by helping you to control cholesterol and blood
pressure, regulate blood sugar (important for people with diabetes), and lose
weight. Try to do activities that raise your heart rate. Exercise for at least
30 minutes on most, preferably all, days of the week.
Manage depression and emotions. Treating depression
and treating anger problems are important steps in improving cardiac and
overall health and quality of life.
Reduce stress. Stress causes increased blood pressure
and heart rate and causes your arteries to narrow, increasing your risk for
heart attack.
Your age and gender. The number of people affected by heart
disease increases with age in men after age 45 and in women after age 55. Also,
men and
women have different risk factors.
Elevated
homocysteine levels and mutations of a specific gene (MTHFR) may also indicate an increased risk of heart attack, although
more study is needed to fully understand their role in heart disease. Tests for
these factors may be indicated for some people, such as those who have had a
heart attack at a young age, but are not recommended for the general
population.
Elevated levels of
C-reactive protein (CRP), a substance found in blood
that indicates inflammation, may better predict your risk for having a heart
attack than cholesterol levels. Two studies on CRP levels and statin treatment
show that testing CRP levels may help predict heart attack risk even when a
person has a normal or low level of LDL cholesterol. The studies suggest that
testing people for both C-reactive protein and cholesterol levels could prevent
more heart attacks by identifying who is at risk.2, 3
Tests for C-reactive protein are now available in many hospitals.
If you have any CAD risk factors, ask your doctor if CRP testing would be
helpful in guiding your treatment.
Most
nonsteroidal anti-inflammatory drugs (NSAIDs), which
are used to relieve pain and fever and reduce swelling and inflammation, may
increase the risk of heart attack. This risk is greater if you take NSAIDs at
higher doses or for long periods of time. People who are older than 65 or who
have existing heart, stomach, or intestinal disease are more likely to have
problems.
Aspirin, unlike other NSAIDs, has been shown to reduce
the risk of heart attack and stroke. But it also carries the risks of serious
stomach and intestinal bleeding as well as skin reactions. Regular use of other
NSAIDs, such as ibuprofen, may make aspirin less effective in preventing heart
attack and stroke.
When to Call a Doctor
Call 911 or other emergency services immediately if you have any of the following symptoms
of a heart attack:
You have chest pain that has not improved or that gets worse
within 5 minutes after taking 1 dose of nitroglycerin and/or resting. After you
call 911 , continue to stay on the phone
with the emergency operator. He or she will give you further instructions. See
how to take nitroglycerin.
You have chest pain or discomfort that is crushing or squeezing,
feels like pressure on the chest, and gets worse or lasts more than 5 minutes,
especially if it occurs with any of the following symptoms:
Sweating
Shortness of breath
Nausea or vomiting
Pain that spreads from the chest to the neck, the jaw, or one
or both shoulders or arms
Women are more likely to have symptoms such as shortness of
breath, heartburn, nausea, jaw pain, back pain, or fatigue.
After
you call 911 or other emergency services,
you should chew 1 regular-strengthaspirin (325 mg)
unless you cannot take aspirin because of allergy or some other reason. By
calling 911 and taking an ambulance to the
hospital, you may be able to start treatment before you arrive at the hospital.
If any complications occur along the way, ambulance personnel are trained to
evaluate and treat them.
If an ambulance is not readily
available, have someone else drive you to the emergency room. Do not drive
yourself to the hospital.
If you witness a person become
unconscious, call 911 or other emergency
services and start CPR (cardiopulmonary resuscitation). The emergency operator
can coach you on how to perform CPR. To learn more about CPR, see the
Rescue Breathing and Cardiopulmonary Resuscitation (CPR) section of the topic
Dealing With Emergencies.
Never wait if you have symptoms of a heart attack. Many people
are unsure if they are having a
heart attack and take a "wait and see" approach. Heart
attack symptoms can vary. People often discount their symptoms if they do not
fit into the expected "extreme chest pain" scenario. Some people are
embarrassed or don't want to bother others by calling for help if they think it
may not be a heart attack. Even if you're not sure it's a heart attack, you
should still have it checked out. Rapid treatment can save your life.
After you
call 911 for a
heart attack, paramedics will quickly assess your
heart rate, blood pressure, and breathing rate and place electrodes on your
chest for an
electrocardiogram (EKG, ECG). An electrocardiogram is
a graphic record of the heart's electrical activity as it contracts and relaxes.
The ECG's jagged-line image appears on a portable monitor, and in some areas
this image can be transmitted to the hospital emergency room so a doctor there
can assess your condition before you arrive.
When you arrive at
the hospital, the emergency room doctor will take your history and perform a
physical exam, and a more complete ECG will be done. An ECG can detect signs of
insufficient blood flow, heart muscle damage, abnormal heartbeats, and other
heart problems. A technician will draw blood to test for
cardiac enzymes, which are released into the
bloodstream when heart cells die. The presence of the protein troponin in the
blood usually means that there has been heart damage.
Results of
these tests are usually available quickly. If your tests show that you are at
risk of having or are having a
heart attack, your doctor will probably recommend that
you have
cardiac catheterization. During a cardiac
catheterization, a fine tube (called a catheter) is threaded through an artery
in your arm or leg and up into the heart. Then a dye that contains iodine is
injected, which makes the coronary arteries visible on a digital X-ray screen.
The doctor can then see whether your coronary arteries are blocked and how your
heart functions.
If your tests do not clearly indicate a
heart attack or unstable angina and you do not have other high-risk indicators
(such as a previous heart attack), you will probably have other tests, such as
a myocardial perfusion scan, also called single photon emission computed
tomography or
SPECT imaging. SPECT is a noninvasive imaging scan that is often done while
you are in the emergency department to help determine whether you are at risk
of heart attack.4
If your SPECT test is abnormal, you are considered at high risk
and may need cardiac catheterization.
If your tests do not
indicate a heart attack but your doctor thinks you have unstable angina and may
be in danger of having a heart attack, you will be admitted to the
hospital.
Testing after a heart attack
From 2 to 3 days
after a heart attack or after being admitted to the hospital for unstable
angina, you may have additional tests to assess how well your heart is working
and to determine whether undamaged areas of the heart are still receiving
adequate blood flow.
These tests may include:
Echocardiogram (echo). An echo is an
ultrasound exam used to evaluate the size, thickness, shape, and movement of
the heart muscle. It also evaluates blood flow and the heart valves.
Stress electrocardiogram (such as
treadmill testing). A stress test compares your ECG while you rest to your ECG
after your heart has been stressed, either through physical exercise (treadmill
or bike) or by using a medicine. A stress test can detect ischemia, which is
reduced blood flow to the heart muscle.
Stress echocardiogram. A stress
echocardiogram can determine whether you may have reduced blood flow to the
heart.
Cardiac perfusion scan. A thallium scan
or technetium scan (also called a sestamibi scan) is a test used to estimate
the amount of blood reaching the heart muscle during rest and exercise.
Angiogram. In this test, a dye
(contrast material) is injected into the coronary arteries to evaluate your
heart and coronary arteries.
When a
heart attack is in progress, you need to act quickly.
Prompt treatment with medicines, angioplasty combined with stenting, or surgery
to restore blood flow soon after symptoms first begin can prevent permanent
injury to the heart muscle and save your life.
Initial treatment
If you are having a
heart attack, the goal of your health care team will
be to prevent permanent heart muscle damage by restoring blood flow to your
heart as quickly as possible. If you are transported to the hospital in an
ambulance, you will be given
oxygen therapy and probably
nitroglycerin or a pain reliever, such as
morphine.
Additionally,
aspirin (which is usually chewed on the way to the
hospital or in the emergency room),
heparin, and
other antiplatelet drugs are given to prevent clots
from growing. Other medicines will be given initially to decrease your heart's
workload, improve its pumping function, and treat life-threatening abnormal
heartbeats if they occur.
The time it takes to get to a hospital
is critical because
angioplasty and/or stenting to open blocked arteries
or "clot-busting"
thrombolytic medicines to dissolve clots are most
effective if used within the first several hours after symptoms start.
Thrombolytics are given through an
intravenous (IV) line and travel to the coronary
arteries where they break up clots.
Numerous studies have shown
that percutaneous coronary intervention (angioplasty
with or without
stenting) saves lives-20 lives for every 1,000 people
treated-when compared with treatment with thrombolytics.5 But experts do not know yet how safe the
drug-eluting stents are over the long term or how well
they work over the long term.
Although angioplasty with or without
stenting is usually the preferred treatment, it is not available at all
hospitals. As a result, some communities are training paramedics to identify
people who have signs of heart attack so that they can be transported directly
to a heart center, even if it means bypassing a closer hospital.
If you are treated at a hospital that has proper equipment and staff, you
may be taken to the
cardiac catheterization lab where your doctor will
evaluate your coronary arteries to determine whether angioplasty or
coronary artery bypass graft surgery is
appropriate.
If angioplasty with or without stenting is not
possible, either because of the location of the blockage or because of numerous
blockages, emergency coronary artery bypass surgery may be done.
If you are having unstable angina, you
most likely will be admitted to the hospital and given medicines, including
aspirin, other antiplatelet medicines, and heparin. You will be closely
monitored and tested. If chest pain continues after the above treatment and you
are at high risk for heart attack, your doctor may decide to perform coronary
catheterization and plan for possible angioplasty and stent placement to
prevent a heart attack.6
Ongoing treatment
After you have had a
heart attack, you will stay in the hospital for at
least a few days so your heart rate and rhythm, blood pressure, and medicines
can be closely monitored. You will also have several
electrocardiograms. This is because after a heart
attack you are at high risk of having serious complications, such as
life-threatening
abnormal heart rhythms and
heart failure.
Cholesterol-lowering medicines called
statins are usually given to lower your LDL
cholesterol level to less than 100 mg/dL.7 Studies
show that taking a cholesterol-lowering medicine substantially decreased the
risk of heart attack and stroke over a 5-year period in high-risk individuals,
such as those who have had a heart attack.8
Aspirin, other
antiplatelet medicines such as clopidogrel (Plavix),
or anticoagulants (such as warfarin) may be used after a
heart attack. These medicines are used to lower the risk of another heart
attack and to prevent blood clots from forming in the heart, which could break
loose and travel to the brain, causing a
stroke. If you take warfarin (Coumadin), see:
The amount of heart muscle that is permanently damaged
may be less than it appears immediately after a heart attack has occurred. Some
heart tissue may be "stunned myocardium," or heart muscle that is not able to
contract normally at first but is later able to function normally. Your heart's
pumping capacity will be closely monitored and your treatment adjusted as
needed during this time.
Research highlights the importance of
quitting smoking after a heart attack. People who continue to smoke after a
heart attack are 1½ times more likely than nonsmokers to have another heart
attack. Among those who stop smoking, the risk decreases gradually over 36
months until it becomes the same as the risk for nonsmokers.9
If you smoke, your doctor will strongly advise
that you quit and avoid secondhand smoke too. Your doctor may prescribe
medicine and therapy to help you do so. Studies show that
nicotine replacement therapy, use of the medicine
bupropion (such as Zyban or Wellbutrin), and
supportive therapy significantly increase long-term success in
quitting.10 For more information on how to quit, see
the topic
Quitting Tobacco Use.
Your doctor may talk to you about other lifestyle
changes you may need to make, such as exercising or eating a
low-fat diet. You may begin a
cardiac rehabilitation program while you're still in
the hospital. For more information, see the topic
Cardiac Rehabilitation.
Avoid getting
sick from the
flu. Get a flu shot every year.
Treatment if the condition gets worse
Heart attacks
that damage crucial or large areas of the heart tend to cause more
complications later. If only a small amount of heart muscle dies, the heart may
still function normally after a heart attack.
Scar tissue
eventually replaces the areas of heart muscle tissue that are damaged by a
heart attack. Scar tissue limits your heart's ability to pump effectively.
Damage to the
left ventricle can limit the heart's capacity to pump.
This damage can lead to
heart failure.
If the heart attack
damaged the area of your heart that regulates your heart rate, your heart can
develop abnormal heart rhythms, called
arrhythmias. In this case, you may need a
pacemaker, which is a device that stimulates the heart
to beat and regulates the heart rate, and possibly medicines to control your
heart rhythms. Some arrhythmias also increase your risk for
stroke.
The chance that these
complications will develop depends on the amount of heart tissue affected by a
heart attack and whether medicines are given during and after a heart attack to
help prevent these complications. Other factors, such as your age and general
health, also determine your risk of complications and death.
After
a heart attack, you may be a candidate for
cardiac rehabilitation to lower your risk of death
related to heart disease. Rehabilitation and lifestyle changes are an important
part of your recovery after a heart attack. For more information, see the topic
Cardiac Rehabilitation.
If you do not
participate in a cardiac rehabilitation program, you will still need to learn
about necessary lifestyle changes, such as quitting smoking, eating a low-fat
diet, and perhaps starting an exercise program.
Palliative care
If your condition gets worse, you
may want to think about
palliative care. Palliative care is a kind of care for
people who have illnesses that do not go away and often get worse over time. It
is different than care to cure your illness, called curative treatment.
Palliative care focuses on improving your quality of life-not just in your
body, but also in your mind and spirit. Some people combine palliative care
with curative care.
Palliative care may help you manage symptoms
or side effects from treatment. It could also help you cope with your feelings
about living with a long-term illness, make future plans around your medical
care, or help your family better understand your illness and how to support
you.
If you are interested in palliative care, talk to your
doctor. He or she may be able to manage your care or refer you to a doctor who
specializes in this type of care.
The percentage of Americans who have a
heart attack, as well as the number of resulting
deaths, has continued to decrease since the 1970s. This decline is mainly
attributed to the steps people are taking to prevent
coronary artery disease (CAD) and heart attack,
including lowering blood pressure and cholesterol and changing diet and
exercise habits.11
The most important
lifestyle changes that you can make are to quit smoking and to exercise on
most, preferably all, days of the week. Eating a balanced diet that is low in
saturated fats and rich in fruits and vegetables is also advised.
Having high cholesterol increases
your risk of coronary artery disease. If diet and exercise are not effective in
lowering your cholesterol to a safe level, your doctor will probably prescribe
a statin, a cholesterol-lowering medicine. These
medicines have been proven effective in treating high cholesterol, and now
doctors are beginning to prescribe them for people with lower cholesterol
levels. Recent studies show that the use of cholesterol-lowering drugs can also
help people with normal to moderately high levels of cholesterol. In these
people, cholesterol-lowering drugs combined with lifestyle changes may slow the
development of
atherosclerosis and lower the risk of heart attack or
death.
Aspirin
Aspirin may reduce the risk of
developing blood clots that can lead to a heart attack in people with known CAD
and in people with multiple risk factors for CAD, such as
diabetes,
high blood pressure, and
high cholesterol. There are some risks associated with
aspirin therapy that you should discuss with your doctor before you begin this
type of treatment. If you cannot take aspirin, your doctor may prescribe
another
antiplatelet medicine, such as clopidogrel (Plavix).
For more information, see:
Taking
estrogen with or without
progestin does not prevent coronary artery disease. In
fact, if you are 10 or more years past
menopause, taking
hormone therapy may raise your risk of coronary artery
disease.13
Talk to your doctor about your
risks with hormone therapy. And carefully weigh the
benefits against the risks of taking it. If you need
relief for symptoms of menopause, hormone therapy is one choice you can think
about. But there are other types of treatment for problems like hot flashes and
sleep problems. For more information, see the topic
Menopause and Perimenopause.
Ongoing Concerns
After you've had a
heart attack, your biggest concern will probably be
that you could have another one. Taking your medicines as directed will be an
important part of preventing another heart attack. Medicines commonly
prescribed after a heart attack include drugs to:
Your doctor will
want to closely monitor you after a heart attack. Be sure to keep all your
appointments. Tell your doctor about any changes in your condition, such as
changes in chest pain, weight gain or loss, shortness of breath with or without
exercise, and feelings of depression.
About half of all people who
have a heart attack will experience a serious complication. The kinds of
complications you may have depend upon the location and extent of the heart
muscle damage. The most common complications are:
Abnormal heart rhythms, called
arrhythmias. These include life-threatening
ventricular tachycardia, which is a rapid heart rate, and
atrial fibrillation, a type of irregular
heartbeat.
Heart failure, which can be short-term or can become a
lifelong condition.
Managing angina
You should notify your doctor
about any chest pain or discomfort (angina) you
have after a heart attack, because it will probably be treated more
aggressively and may indicate that you are at risk for another heart attack.
Many people have stable angina, which is predictable and diminishes after
taking
nitroglycerin (a medicine to control angina) and
resting.
Nitroglycerin is often prescribed to be taken on an
as-needed basis for angina. In most cases, you may take 1 nitroglycerin tablet
or 1 dose if you use the spray form. If after 5 minutes the chest pain doesn't
improve or gets worse, call 911 or other emergency services immediately. Continue to stay on the phone with the
emergency operator-he or she will give you further instructions.
See
how to use and store nitroglycerin. Keep nitroglycerin with you at all
times. Some doctors recommend that you use it before you exercise or exert
yourself, to prevent an angina attack.
Coming home after a heart
attack may be unsettling. Your hospital stay may have seemed too short. You may
be nervous about being home without medical oversight after being so closely
attended to in the hospital. But you have undergone tests that tell your doctor
that it is safe for you to return home. Also, to reduce your risk of having
another
heart attack, your doctor may recommend that
you:
Quit smoking and avoid secondhand smoke. Quitting smoking may be
the most important step you can take to reduce your risk. Evidence suggests
that people with
coronary artery disease who stop smoking rapidly
reduce their risk of recurrent heart attack or death. Check with your doctor
about using nicotine replacement therapy.
Nicotine replacement therapy, use of the medicine
bupropion (such as
Zyban or Wellbutrin), and supportive therapy
significantly increase long-term success in quitting.10
For more information, see the topic
Quitting Tobacco Use.
Be physically active. Talk with your doctor about
exercising safely and about enrolling in a cardiac rehabilitation program.
Regular exercise can help reduce your risk of another heart attack by helping
you control cholesterol and blood pressure, regulate blood sugar (important for
people with diabetes), and lose weight. See the Cardiac Rehabilitation
topic.
Take an
aspirin every day. If you have a stent, you may also
take an
antiplatelet medicine, such as clopidogrel (Plavix).
Lower your cholesterol by taking medicines such as statins or
other lipid-lowering medicines.14 Several studies have
shown that lowering cholesterol can reduce the risk for another heart
attack.
Control your blood pressure by taking medicines as directed by
your health professional. Some nutrients in the diet can affect blood pressure.
See nutrition for hypertension (including the DASH diet)
for more information about this eating plan, which has been proven to lower
blood pressure.
Keep your blood sugar under control if you have diabetes. Studies
have found that having high blood sugar over a long period of time is linked
with developing heart disease.15 One way to check
whether your blood sugar is under control is to have a simple blood test
(called a
hemoglobin A1c test) every 2 to 3 months. The American
Diabetes Association and the American Heart Association recommend that people
with diabetes have an HA1c level of less than 7%.16
Follow a
heart-healthy diet. A heart-healthy diet includes
eating more fish. You may also follow the
Mediterranean diet. A heart-healthy diet may help you
lose weight, lower your blood pressure, and reduce your cholesterol. Studies
show that people who follow these dietary practices may live longer.14 For more information, see:
Reduce stress. Some evidence suggests that stress
management may decrease rates of heart attack or death in people with coronary
artery disease.14
Participate in a
cardiac rehabilitation program. You will learn how to
exercise safely, change habits that put you at risk for another heart attack,
and deal with stress and emotional issues. Studies have found that cardiac
rehab reduces your risk of having another heart attack.14 Try to do activities that raise your heart rate. Exercise for
at least 30 minutes on most, preferably all, days of the week.
Avoid getting sick from the
flu. Get a flu shot every year.
If you drink alcohol, drink moderately (1
alcoholic drink per day for women or 2 drinks per day for men). Drinking alcohol
moderately may lower your risk of
complications after a heart attack.17 Drinking alcohol moderately, along with living a healthy
lifestyle, may lower your risk for a heart attack.18
Although studies show that wine may be beneficial, the American Heart
Association (AHA) states that the link between wine and reduced coronary artery
disease has not been proven. The AHA urges individuals to talk to their doctors
about the benefits and risks of drinking alcoholic beverages.19
Confide in loved ones. Having a heart attack is scary, and
depression afterward is common. Asking for and receiving support from friends
and relatives can help you avoid depression. If you continue to have the
"blues" after your heart attack, talk to your doctor about counseling and
medicine for depression. A study showed that people who received treatment for
depression recovered better after a heart attack than those who did not.
(However, long-term survival was not affected.)20
Before you start an exercise program or do any strenuous
exercise, your doctor can do pre-exercise testing to determine your risk for
heart attack. For more information, see the following:
One common myth is that resuming sex after a heart attack
can cause another heart attack, stroke, or sudden death. According to the
American Heart Association, people who have had heart attacks can
resume sexual activity after a heart attack as soon as
they feel ready for it. Talk with your doctor if you have any concerns.
Most often the underlying cause of a heart attack is
coronary artery disease (CAD). Understanding what CAD
is and how to treat it may help prevent a future heart attack. For more
information, see the topic
Coronary Artery Disease.
Certain medicines can help keep blood from clotting, reduce the
risk that unstable angina may develop into a
heart attack, and decrease your chance of dying. These
include:
Anticoagulants, such as heparin, enoxaparin (Lovenox),
dalteparin (Fragmin), and bivalirudin (Angiomax). Some anticoagulants, such as
bivalirudin, are only used in the hospital.
Medicines that decrease the heart's workload, improve
blood flow to the heart, and relieve chest pain are usually given to people
with
unstable angina who are at risk of heart attack. These
medicines include:
Oxygen therapy,
nitrates (such as nitroglycerin), and
beta-blockers work to decrease the workload on the
heart, thereby decreasing the amount of oxygen needed and possibly saving heart
muscle.
Medicines after a heart attack
After a heart
attack, your doctor may give you medicines to prevent
heart failure and prevent or reduce the risk of
irregular heartbeats (arrhythmias), both of which can happen
after a heart attack. These medicines include:
ACE inhibitors, which lower blood pressure and lower
the heart's workload.
Beta-blockers, which improve blood flow to the heart
and lower the heart's workload.
Your doctor may also give you medicines to prevent blood
clots from forming and causing a stroke or another heart attack. These
medicines include:
Nitrates may be used to control remaining angina
symptoms.
What to Think About
Do not substitute
nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen (Advil, for example) or naproxen (such as Aleve), for aspirin.
Although NSAIDS relieve pain and inflammation much like aspirin does, they may
increase your risk for a heart attack or stroke.
If you had
angioplasty and got a
stent, you will take antiplatelet medicines to help
prevent another heart attack or a stroke. You will probably take aspirin plus
another antiplatelet such as clopidogrel (Plavix). If you get a drug-eluting
stent, you will probably take both of these medicines for at least one year. If
you get a bare metal stent, you will take both medicines for at least one month
but maybe up to one year. Then, you will likely take daily aspirin long-term.
If you have a high risk of bleeding, your doctor may shorten the time you take
these medicines.
On rare occasions,
coronary artery bypass graft surgery (CABG) is done on
an emergency basis to treat a
heart attack. Coronary artery bypass grafting, also
called bypass surgery or "cabbage," may be needed when a heart attack cannot be
safely and effectively treated with medicine or angioplasty. For example,
bypass surgery may be done when there are blockages in the coronary arteries
that cannot be reached during
angioplasty or if angioplasty was tried but did not
sufficiently widen the blood vessel.
Also, bypass surgery is often
recommended in people with
diabetes. Studies show that bypass surgery reduces the
rate of death in people who have diabetes and heart attack when compared with
angioplasty or
thrombolytic therapy.21
What to Think About
If muscles holding the heart
valve in proper position were damaged by the heart attack, heart valve repair
or replacement may be done at the same time as a coronary artery bypass.
After a heart attack, or after you have had angioplasty or bypass
surgery, you may be encouraged to participate in a
cardiac rehabilitation program to help lower your risk
of death related to heart disease. For more information, see the topic
Cardiac Rehabilitation.
In the past decade,
angioplasty, also known as percutaneous coronary
intervention (PCI), has become a common procedure in large medical centers in
the United States. Angioplasty is done during
cardiac catheterization or coronary angiogram.
During a cardiac catheterization, a tiny tube (called a catheter) is
threaded through an artery of an arm or leg up into the heart and a dye that
contains iodine is then injected through the catheter. The dye makes the
coronary arteries visible on a digital X-ray screen. The doctor can then see on
a TV screen whether your coronary arteries are blocked and how your heart is
beating. If an artery appears blocked,
angioplasty with or without stent placement may be
done during the catheterization to open the blockage.
Studies
show that angioplasty with stent placement, compared with angioplasty only,
reduces the chance that the artery will renarrow and possibly reduces the risk
of death.14 (See a picture of
stent placement). Angioplasty with stent placement is less invasive and
expensive than bypass surgery and is the preferred treatment for most people
with a
heart attack.
In some cases a heart
attack causes enough muscle damage that your heart's pumping capacity is
decreased. In this case, your doctor may recommend placement of a type of
pacemaker called an
implantable cardioverter-defibrillator (ICD),
especially if you have life-threatening abnormal heart rhythms.
Even with stents, an artery
can renarrow after angioplasty, although recent innovations are improving the
long-term success of this procedure.
Drug-eluting stents are coated with medicines that
prevent the artery from renarrowing. Experts do not know yet how safe the
drug-eluting stents are over the long term or how well they work over the long
term.
Although studies are not conclusive, folate therapy (taking a
combination of folic acid, vitamin B6, and vitamin B12) may be harmful after
stent placement and probably should be avoided.22
Instead, try to get enough vitamin B by eating a balanced diet.
End-of-Life Decisions
Although treatment for a
heart attack is increasingly successful at prolonging
life and reducing complications and hospitalization, a heart attack can lead to
progressive, fatal conditions, such as
heart failure and abnormal heart rhythms (arrhythmias).
Many important end-of-life decisions can be made while you are active and able
to communicate your wishes.
When you are diagnosed with a heart
attack, your doctor will discuss treatment options with you. Your doctor may
talk to you about your desire to be revived (resuscitated) if your heart stops
pumping and you are unable to breathe on your own. You may want to learn more
about aggressive life-sustaining medical treatment and whether it is right for
you. For more information, see:
Many other decisions about end-of-life issues, such as
writing a living will and estate planning, can be made in advance, leaving
valuable time that can be spent with loved ones and on other important matters.
For more information, see the topics
Care at the End of Life and
Writing an Advance Directive.
Other Places To Get Help
Online Resource
NIHSeniorHealth
National Institutes of Health
Web Address:
http://NIHSeniorHealth.gov
This Web site for older adults offers aging-related health
information. The site was developed by the National Institute on Aging (NIA)
and the National Library of Medicine (NLM), both part of the National
Institutes of Health (NIH). NIHSeniorHealth features up-to-date health
information from Institutes and Centers at NIH. In addition, the American
Geriatrics Society provides independent review of some of the material found on
this Web site. The Web site's senior-friendly features include large print,
simple navigation, and short, easy-to-read segments of information. A visitor
to this Web site can click special buttons to hear the text aloud, make the
text larger, or turn on higher contrast for easier viewing.
Organizations
American Heart Association (AHA)
7272 Greenville Avenue
Dallas, TX 75231
Phone:
1-800-AHA-USA1 (1-800-242-8721)
Web Address:
www.americanheart.org
Call the American Heart Association (AHA) to find your
nearest local or state AHA group. AHA can provide brochures and information
about support groups and community programs, including Mended Hearts, a
nationwide organization whose members visit people with heart problems and
provide information and support. AHA's Web site also has information on
physical activity, diet, and various heart-related conditions.
National Heart, Lung, and Blood Institute
(NHLBI)
P.O. Box 30105
Bethesda, MD 20824-0105
Phone:
(301) 592-8573
Fax:
(240) 629-3246
TDD:
(240) 629-3255
E-mail:
nhlbiinfo@nhlbi.nih.gov
Web Address:
www.nhlbi.nih.gov
The U.S. National Heart, Lung, and Blood Institute (NHLBI)
information center offers information and publications about preventing and
treating heart, lung, and blood diseases.
WomenHeart: The National Coalition for Women With Heart
Disease
818 18th Street NW
Suite 930
Washington, DC 20006
Phone:
(202) 728-7199
Fax:
(202) 728-7238
Web Address:
www.womenheart.org
WomenHeart: The National Coalition for Women with Heart Disease is
a nonprofit organization dedicated to reducing heart disease, death, and
disability among women. The coalition also sponsors a network of support
groups, a bulletin board, a newsletter, and other services.
Gupta M, et al. (2002). Presenting complaint among
patients with myocardial infarction who present to an urban, public hospital
emergency department. Annals of Emergency Medicine,
40(2): 180-186.
Nissen SE, et al. (2005). Statin therapy, LDL
cholesterol, C-reactive protein, and coronary artery disease. New England Journal of Medicine, 352(1): 29-38.
Ridker PM, et al. (2005). C-reactive protein levels
and outcomes after statin therapy. New England Journal of Medicine, 352(1): 20-28.
Klocke FJ, et al. (2003). ACC/AHA/ASNC guidelines for
the clinical use of cardiac radionuclide imaging-Executive Summary. A report of
the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation, 108(11): 1404-1418.
Available online:
http://circ.ahajournals.org/content/vol108/issue11/index.shtml.
Grines CL, et al. (2003). Fibrinolytic therapy: Is it
a treatment of the past? Circulation, 107(20):
2538-2542.
American College of Cardiology (ACC) and American
Heart Association (AHA) (2002). Guideline update for the management of patients
with unstable angina and non-ST-segment elevation myocardial infarction.
Report of the ACC/AHA Task Force on Practice Guidelines.
Available online: http://www.acc.org/clinical/topic/topic.htm#guidelines.
Grundy SM, et al. (2004). Implications of recent
clinical trials of the National Cholesterol Education Program Adult Treatment
Panel III Guidelines. Circulation, 110(2): 227-239.
[Erratum in Circulation, 110(6): 763.]
Heart Protection Study Collaborative Group (2002).
MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in
20,536 high-risk individuals: A randomised placebo-controlled trial.
Lancet, 360(9326): 7-22.
Rea TD, et al. (2002). Smoking status and risk for
recurrent coronary events after myocardial infarction. Annals of Internal Medicine, 137(6): 494-500.
Silagy C, et al. (2006). Nicotine replacement therapy
for smoking cessation. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.
Topol EJ, Van De Werf FJ (2002). Acute myocardial
infarction early diagnosis and management. In EJ Topol, ed., Textbook of Cardiovascular Medicine, 2nd ed., pp. 385-419.
Philadelphia: Lippincott Williams and Wilkins.
Grundy S, et al. (2002). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (NIH Publication No. 02-5215). Bethesda, MD: National
Institutes of Health. Also available online:
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf.
Rossouw JE, et al. (2007). Postmenopausal hormone
therapy and risk of cardiovascular disease by age and years since menopause.
JAMA, 297(13): 1465-1477.
Gami A (2006). Secondary prevention of ischaemic
cardiac events, search date July 2004. Online version of Clinical Evidence (15): 1-31.
Selvin E, et al. (2004). Meta-analysis: Glycosylated
hemoglobin and cardiovascular disease in diabetes mellitus. Annals of Internal Medicine, 141(6): 421-431.
American Diabetes Association (2006). Standards of
medical care in diabetes. Clinical Practice Recommendations 2005.
Diabetes Care, 29(Suppl 1): S3-S42.
De Lorgeril M, et al. (2002). Wine drinking and risks
of cardiovascular complications after recent acute myocardial infarction.
Circulation, 106(12): 1465-1469.
Mukamal KJ, et al. (2006). Alcohol consumption and
risk for coronary heart disease in men with healthy lifestyles. Archives of Internal Medicine, 166(19): 2145-2150.
Goldberg IJ, et al. (2001). Wine and your heart: A
science advisory for healthcare professionals from the Nutrition Committee,
Council on Epidemiology and Prevention, and Council on Cardiovascular Nursing
of the American Heart Association. Circulation, 103(3):
472-475.
Berkman LF, et al. (2003). Effects of treating
depression and low perceived social support on clinical events after myocardial
infarction: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD)
Randomized Trial. JAMA, 289(23): 3106-3116.
Aronson D, Rayfield EJ (2002). Diabetes. In EJ Topol,
ed., Textbook of Cardiovascular Medicine, 2nd ed., pp.
139-170. Philadelphia: Lippincott Williams and Wilkins.
Lange H, et al. (2004). Folate therapy and in-stent
restenosis after coronary stenting. New England Journal of Medicine, 350(26): 2673-2681.
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American Heart Association and American College of
Cardiology (2006). AHA/ACC guidelines for secondary prevention for patients
with coronary and other atherosclerotic vascular disease: 2006 update.
Circulation, 113(19): 2363-2372. [Erratum in
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Antman EM, et al. (2007). 2007 focused update of the
ACC/AHA 2004 guidelines for the management of patients with ST-elevation
myocardial infarction: A report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. Circulation, 117(2): 296-329. Originally published online
December 10, 2007 (doi:10.1161/circulationaha.107.188209).
Epstein AE, et al. (2008). ACC/AHA/HRS 2008 Guidelines
for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the
American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002
Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia
Devices): Developed in Collaboration With the American Association for Thoracic
Surgery and Society of Thoracic Surgeons. Circulation,
117(21): e350-e408.
Hirsch J, et al. (2008). Executive summary: American
College of Chest Physicians evidence-based clinical practice guidelines (8th
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ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: A
report of the American College of Cardiology/American Heart Association Task
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Credits
Author
Robin Parks, MS
Editor
Kathleen M. Ariss, MS
Associate Editor
Pat Truman, MATC
Primary Medical Reviewer
Caroline S. Rhoads, MD - Internal Medicine
Specialist Medical Reviewer
Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
This information does not replace the advice of a doctor. Healthwise disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.
Gupta M, et al. (2002). Presenting complaint among
patients with myocardial infarction who present to an urban, public hospital
emergency department. Annals of Emergency Medicine,
40(2): 180-186.
Nissen SE, et al. (2005). Statin therapy, LDL
cholesterol, C-reactive protein, and coronary artery disease. New England Journal of Medicine, 352(1): 29-38.
Ridker PM, et al. (2005). C-reactive protein levels
and outcomes after statin therapy. New England Journal of Medicine, 352(1): 20-28.
Klocke FJ, et al. (2003). ACC/AHA/ASNC guidelines for
the clinical use of cardiac radionuclide imaging-Executive Summary. A report of
the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation, 108(11): 1404-1418.
Available online:
http://circ.ahajournals.org/content/vol108/issue11/index.shtml.
Grines CL, et al. (2003). Fibrinolytic therapy: Is it
a treatment of the past? Circulation, 107(20):
2538-2542.
American College of Cardiology (ACC) and American
Heart Association (AHA) (2002). Guideline update for the management of patients
with unstable angina and non-ST-segment elevation myocardial infarction.
Report of the ACC/AHA Task Force on Practice Guidelines.
Available online: http://www.acc.org/clinical/topic/topic.htm#guidelines.
Grundy SM, et al. (2004). Implications of recent
clinical trials of the National Cholesterol Education Program Adult Treatment
Panel III Guidelines. Circulation, 110(2): 227-239.
[Erratum in Circulation, 110(6): 763.]
Heart Protection Study Collaborative Group (2002).
MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in
20,536 high-risk individuals: A randomised placebo-controlled trial.
Lancet, 360(9326): 7-22.
Rea TD, et al. (2002). Smoking status and risk for
recurrent coronary events after myocardial infarction. Annals of Internal Medicine, 137(6): 494-500.
Silagy C, et al. (2006). Nicotine replacement therapy
for smoking cessation. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.
Topol EJ, Van De Werf FJ (2002). Acute myocardial
infarction early diagnosis and management. In EJ Topol, ed., Textbook of Cardiovascular Medicine, 2nd ed., pp. 385-419.
Philadelphia: Lippincott Williams and Wilkins.
Grundy S, et al. (2002). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (NIH Publication No. 02-5215). Bethesda, MD: National
Institutes of Health. Also available online:
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf.
Rossouw JE, et al. (2007). Postmenopausal hormone
therapy and risk of cardiovascular disease by age and years since menopause.
JAMA, 297(13): 1465-1477.
Gami A (2006). Secondary prevention of ischaemic
cardiac events, search date July 2004. Online version of Clinical Evidence (15): 1-31.
Selvin E, et al. (2004). Meta-analysis: Glycosylated
hemoglobin and cardiovascular disease in diabetes mellitus. Annals of Internal Medicine, 141(6): 421-431.
American Diabetes Association (2006). Standards of
medical care in diabetes. Clinical Practice Recommendations 2005.
Diabetes Care, 29(Suppl 1): S3-S42.
De Lorgeril M, et al. (2002). Wine drinking and risks
of cardiovascular complications after recent acute myocardial infarction.
Circulation, 106(12): 1465-1469.
Mukamal KJ, et al. (2006). Alcohol consumption and
risk for coronary heart disease in men with healthy lifestyles. Archives of Internal Medicine, 166(19): 2145-2150.
Goldberg IJ, et al. (2001). Wine and your heart: A
science advisory for healthcare professionals from the Nutrition Committee,
Council on Epidemiology and Prevention, and Council on Cardiovascular Nursing
of the American Heart Association. Circulation, 103(3):
472-475.
Berkman LF, et al. (2003). Effects of treating
depression and low perceived social support on clinical events after myocardial
infarction: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD)
Randomized Trial. JAMA, 289(23): 3106-3116.
Aronson D, Rayfield EJ (2002). Diabetes. In EJ Topol,
ed., Textbook of Cardiovascular Medicine, 2nd ed., pp.
139-170. Philadelphia: Lippincott Williams and Wilkins.
Lange H, et al. (2004). Folate therapy and in-stent
restenosis after coronary stenting. New England Journal of Medicine, 350(26): 2673-2681.
