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         Heart attack

What is a heart attack?
Your heart is a powerful muscular pump that drives blood around your body. To keep your heart healthy, the heart muscle needs to get a constant supply of oxygen-containing blood from the coronary arteries. If one of the coronary arteries becomes blocked – for example, by a blood clot – part of your heart muscle may be starved of oxygen and may become permanently damaged. This is what happens if you have a heart attack.

The symptoms of a heart attack
The symptoms of a heart attack can range from a severe pain in the centre of the chest, to having mild chest discomfort that makes you feel generally unwell. The pain often feels like a heaviness or tightness which may also spread to the arms, neck, jaw, back or stomach.

Or it may affect only the neck, jaw, arms or stomach. Someone who is having a heart attack may also sweat, feel light-headed, feel sick, or be short of breath. In some cases, people mistake the pain of a heart attack for indigestion. A heart attack may also cause the rhythm of the heart to be disturbed.

However, sometimes a heart attack is ‘silent’ and produces little discomfort. For example, in some people the discomfort is so mild that they never report it to their doctor. You may not even know you have had a heart attack until you have a medical test for something else later on, or a routine medical examination reveals that you have had a heart attack. A heart attack is sometimes called a coronary thrombosis or myocardial infarction.

What is acute coronary syndrome?
When someone has a persistent chest pain or chest discomfort which seems to be coming from the heart, it is sometimes difficult for the doctors and nurses to tell whether the person is having a heart attack or an episode of unstable angina. If this happens, your doctor may tell you that you have acute coronary syndrome. ‘Syndrome’ means a set of symptoms that occur together, and ‘coronary’ means to do with the coronary arteries.

So, acute coronary syndrome is a general term that describes a heart attack or unstable angina.

What is a cardiac arrest?
During a heart attack, there may be disturbances in the heart rhythm. The most serious form of this is called ventricular fibrillation. This is when the electrical activity of the heart becomes so chaotic that the heart stops pumping and quivers or ‘fibrillates’ instead. This is acardiac arrest. It can sometimes be corrected by giving a large electric shock through the chest wall, using a device called a defibrillator. This is often successful in restoring a normal heartbeat and afterwards the person can do just as well as if they had not had the cardiac arrest.

If a person has a cardiac arrest, they lose consciousness almost at once. There are also no other signs of life such as breathing. This is the most extreme emergency. Unless someone starts cardiopulmonary resuscitation (CPR) within three to four minutes, the person may suffer permanent damage to the brain and other organs.

CPR means:
rescue breathing (inflating the lungs by using mouth-to-mouth resuscitation), and
chest compression (pumping the heart by external cardiac massage), to keep the breathing and circulation going until the ambulance arrives.

Tests
ECG
The doctors and nurses will look for specific changes on your ECG. They are mainly looking for one of two types of changes:
changes which show that a blood clot has suddenly and completely blocked one of the coronary arteries, or
changes which show that a blood clot is partly blocking one of the coronary arteries.

Blood tests
If you have acute coronary syndrome, the most important blood tests you will have are troponin tests and cardiac enzyme tests. These tests can tell whether or not your heart muscle has been damaged and, if so, how severe that damage is.

Troponin test
This test measures the level of troponins in the blood. Troponins are a type of protein. They are normally found within the heart muscle cells but not in the blood. If the heart is damaged – for example, by a heart attack – troponins leak into the blood where they can be detected, within 12 hours, by a simple blood test. In some hospitals, troponin tests are used instead of cardiac enzyme tests.

Often if you are admitted to hospital with chest pains, the troponin test can help doctors to decide whether you are having a heart attack. If the troponin test is positive, it confirms that there has been damage to the heart muscle. If it is negative, it means that the heart muscle was not damaged.

You may have more than one troponin test, especially if your first test is negative. This is because it takes some time for the troponin to be released into the bloodstream.

The results of your troponin tests will also help the doctors to decide what treatments you will need and whether or not you need further tests.

The treatment you are likely to have
The treatment you are likely to have depends on the results of the ECG you have while you are having chest pain and the overall assessment that the doctors and nurses carry out.

Thrombolysis
Thrombolysis is a treatment that helps to dissolve the clot that is blocking the artery, and helps to restore the blood supply to the heart muscle. It involves injecting a thrombolytic drug such as streptokinase or tenecteplase into the bloodstream. Ideally the injection should be given as soon as possible. That’s why, if you think you may be having a heart attack, it is important to call ambulance immediately, so that the blood supply to your heart muscle can be restored as quickly as possible.
If you have thrombolysis, you may need to stay in hospital for several days, so that the doctors can check your progress.

Coronary angioplasty with stent
Coronary angioplasty with stent is a treatment to widen the narrowed artery. When angioplasty is done as an emergency like this, it is called primary angioplasty. The technique is the same as a coronary angioplasty which is done as a planned procedure.

If you have a coronary angioplasty, you may be discharged from hospital about two or three days after having the procedure.

Other treatments you may have
Whether you have had thrombolysis or coronary angioplasty, the doctors or nurses may also give you a combination of drugs which could include:
nitrates
beta-blockers, or
ACE inhibitors.
The ambulance staff or hospital doctors will already have given you aspirin. Some people may also be given a drug to help make their blood thinner and reduce the risk of blood clots.

This combination of either thrombolyis or coronary angioplasty and other drugs will help to:
improve the blood supply through your coronary artery
ease your chest pain, and
reduce the risk of ongoing damage to your heart muscle.

If you have had a troponin test, it may be some hours before the doctor gets the results. If your doctor tells you that the result is positive, this confi rms that your heart muscle has been damaged.

What happens to my heart after a heart attack?
After a heart attack, your body will replace the area of the heart muscle that was damaged with scar tissue. This takes from a few days to a few months. Within two or three months, the hearts of many heart attack patients are working just as well as they were before their heart attack. However, sometimes a heart attack can cause more severe damage to the heart, with the result that the pumping action of the heart is not as good as before. This can lead to breathlessness, tiredness and swollen ankles. The term used to describe this condition is heart failure.

Also, some people continue to experience angina (heaviness or tightness in the chest when they exercise) because there is still narrowing of the coronary arteries. If you have any of these symptoms, tell your doctor.

Feelings and relationships
Fears and changing emotions are normal after a heart attack. After your heart attack you may feel:
frightened that you may have another heart attack
afraid of dying, or
worried that you won't be able to do as much.

All this is normal and is often associated with changing emotions, such as feeling depressed or bad-tempered. These changing emotions can strain even the closest relationships. Both partners may experience feelings of anger or guilt. Bottling up these feelings can lead to resentment and difficulties in the relationship. It is important to talk about these feelings. You can solve many problems by talking about them.

‘Will it happen again?’
Many people wonder if they will have another heart attack. Having one heart attack increases the risk of having another. However, if you take the medicines your doctors have prescribed for you and if you follow a healthy lifestyle, you can dramatically reduce that risk. Many people find that going on a cardiac rehabilitation programme gives them – and their partners – confidence and support to work out ways of having a healthier lifestyle.

‘I’m afraid to do too much in case it brings on another
heart attack.’

It’s natural to feel a bit nervous about exercising after your heart attack. However, the heart is a muscle and, like any other muscle in the body, it needs exercise to keep it in tip-top condition. While you are in hospital, the medical team, nurse and physiotherapist will advise you about how much, and what type of, physical activity is suitable for you.

At the beginning they will advise you to do gentle activity. You will then be asked gradually to increase the intensity of your exercise as you become stronger and more confident.

The advice they give you about physical activity may be different to the advice given to other people who have had heart attacks. This is because everyone is different. Follow the advice carefully. After you have left hospital it is important to continue this at home. Pace yourself as you did in hospital, increasing the amount as you progress.

Facing the future
After your heart attack, and during your hospital stay and your recovery at home, you will have the chance to think about your lifestyle. There may be some areas which you will want to change, to reduce the risk of another heart attack.

The first few days
For the first two or three days at home, it is best to take things easy. Do about the same amount of moving around and exercise indoors as you did in your last few days in hospital. Make sure you have enough rest. However, each day try to get up, wash and dress and do some light household activities such as making drinks and light snacks, going up and down stairs a few times a day, and doing some gentle walking.

The first few weeks after a heart attack

Getting active again
Gradually increase the amount of physical activity you do as the weeks go by. Aim to do a little bit more each day, if you can. Don’t be afraid to go upstairs or out of the house. Many people find that they tire easily in the early stages after a heart attack. This is normal and will pass as your strength and confidence return. Walking is an ideal form of exercise during the early weeks after a heart attack. If the weather is OK, go out with a friend or relative for a short walk, ideally somewhere fairly flat. Getting into the fresh air and doing your deep breathing exercises will help you get better and will help lift your spirits. But avoid walking outdoors when it is either very hot or very cold. Instead, try walking on the spot or up and down the hallway at home for the same length of time, or do some walking in your local shopping centre or supermarket. Gradually increase the amount of walking you do over the first two or three weeks. After two or three weeks you should be able to walk longer distances. If you get symptoms such as angina or breathlessness, it is important to stop and rest. You may be given a GTN spray or tablets to carry with you. It is important to keep the spray or tablets with you and use them as prescribed.  Different people will be able to do different amounts of exercise. So, it is important to talk to your cardiologist, GP or rehabilitation nurse about how much exercise you can do and when it is advisable for you to start doing more strenuous activities. Swimming is usually fine, as long as the pool is reasonably warm and you’re used to swimming. It is not a good idea to take up swimming for the first time after a heart attack. It is also OK to use an exercise bike. Jogging is usually quite harmless except for people with serious heart disease.

Housework
Start doing light work in the house as soon as you feel fit and able – for example, washing up and dusting. After a few weeks, you may feel well enough to do other housework such as hoovering and carrying the laundry. You can do light gardening, but avoid digging and heavy lifting.

Return to work
Most people will be able to go back to their previous job after a heart attack. This may be as early as six weeks after your heart attack if your work is not too physically demanding, or if it only involves light duties. For other people, returning to work depends on the nature of your job, so talk to your doctor or one of the staff at the cardiac rehabilitation programme about this. You may need to get a certificate, signed by a doctor or a nurse, to confirm that you have been in hospital.

Talk to your employers too. They may be willing to give you lighter work for a while when you first go back. Most large organisations have an occupational health service which may be able to recommend lighter work or a staged return to work.

Sex
People with heart disease and their partners are often understandably anxious about how sex may affect the heart. However, most people can return to their sex life after a heart attack. Like any other physical activity, having sex can increase the heart rate and blood pressure.

This increases the work of the heart and, in people with coronary heart disease, can lead to breathlessness or chest pain. However, sex is just as safe as other equally energetic forms of physical activity or exercise. It is usually safe to have sex if you can climb two flights of stairs briskly without getting chest pain or becoming breathless. If you have had a heart attack, you can safely start having sex again two or three weeks after the attack, as long as your recovery is not complicated. The stairs test is a useful guide. If you tend to have angina attacks brought on by physical exertion, here are some helpful suggestions.

Avoid having sex after a heavy meal.
Keep the bedroom warm and avoid cold sheets.
Don’t have too much alcohol before sex.
Choose a relaxing atmosphere.
• Get into a comfortable position. Your partner may take the more active role.
• Keep your GTN spray at the bedside just in case you need it.

Remember also that there are alternatives to intercourse for giving and receiving pleasure. Touching and caressing may be a useful start to increase confidence. Some medicines – such as regular beta-blockers and calcium antagonists – improve the amount of exercise or activity you can do, and can help relieve symptoms that can be brought on by sex.

Loss of sex drive is not uncommon after illness. Some men may experience impotence after a heart attack. This may be the result of the emotional stress you are feeling. However, occasionally it can also be the result of drug treatment, including beta-blockers which can affect your sex drive. It may also be the result of diabetes or cardiovascular disease. Impotence is a very common problem, so if you are having difficulties, talk to your doctor about it.

Looking after the carer
Often the person who has had the heart attack does very well in the early stages, but the partner or person caring for them gets very tired and run down. If you are looking after someone who has had a heart attack, try to take a rest yourself while the person you’re caring for is resting, and to get a good night’s sleep. Don’t try to do too much for the person. This is tiring and stressful for both of you and in the end will not help either of you. Try to control how many visitors you have and how long they stay for. It can be exhausting to have too many visitors. Make sure you have time to yourself.

 
      Doctor Tips
Angina is an uncomfortable feeling or pain in the chest.
   
It usually feels like a heaviness or tightness.
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