If you’ve had a heart attack and lived to tell the tale, you’re probably somewhat traumatised, and understandably so. But you’re also not alone.
In September, a study from the American Heart Association (AHA) laid bare the psychological consequences of going through cardiac arrest, revealing that up to 50 per cent of heart attack survivors experience subsequent mental health problems ranging from post-traumatic stress disorder to depression.
The importance of addressing this is increasingly recognised among heart specialists, because people who experience these symptoms on a persistent, ongoing basis are nearly one and a half times more likely to have a second heart attack. In the US, for example, studies show that one in five people who have a heart attack are readmitted to the hospital with a second one within five years.
Many cardiologists believe, however, that with the right proactive steps, a second heart attack is extremely preventable. This is what to do:
Take your medications
Reduces risk by at least 40 per cent
Anyone who has a heart attack is immediately prescribed a cocktail of pills. According to a consultant cardiologist at St Bartholomew’s Hospital, the bare minimum typically comprises of a statin; two blood thinners including aspirin, a beta blocker, an Ace inhibitor (a drug which reduces the activity of enzyme-controlling hormones which can narrow your arteries); and another drug to protect your stomach from the aspirin.
“They might need other drugs if their cholesterol is still not controlled or their blood pressure is still high,” says Riyaz Patel, a consultant cardiologist and clinical academic working at University College London. “But with an uncomplicated heart attack, you’ll still be on five or six drugs, and while you can drop one or two of those after a year, the aspirin and the statin will be lifelong.”
As Patel explains, the blood-thinning aspirin is particularly key, as it’s a way of preventing further artery-blocking blood clots forming in response to arterial plaques, while statins are important to prevent surges in LDL cholesterol from driving the formation of more plaque.
“If you’re a healthy person, you should try and keep your LDL cholesterol under three millimoles per litre, ideally about 2.6,” says Patel. “If you’ve had a heart attack, I want to really crush that cholesterol even lower, down to 1.4. So we’re much more aggressive and intensive in lowering the risk factors that lead to furring up of the arteries.”
The problem is that research suggests that only around 60 per cent of heart attack survivors stick to their medication. Patel says that many stop taking their drugs after around a year, sometimes mistakenly assuming that because their LDL cholesterol appears normal, they no longer need to take statins. Patel says that this is a grave mistake, because having had a heart attack, they are permanently at an elevated risk, and so their LDL cholesterol needs to be greatly suppressed on an ongoing basis for the rest of their life.
Take up all the cardiac rehabilitation on offer
Reduces risk by 26 per cent
According to the British Heart Foundation, cardiac rehabilitation programs are just as vital as taking your medication. One of the most important aspects of them is the tailored exercise sessions, which you can do either in person or at home, and will be varied according to what’s suitable for your heart. Recommended exercise can vary from seated leg lifts and arm circles to increase blood flow, walking down the hallway and gentle marching, before moving on to riding a stationary bike several times per week and jogging.
Research has shown that following exercise-based cardiac rehabilitation for more than three years reduces your risk of dying from a future heart attack or another form of cardiovascular disease by 26 per cent.
Patel says that while it was once assumed that heart attack survivors would need to stay relatively sedentary for the rest of their lives, cardiologists have realised in recent decades that the opposite is the case, and that slowly rebuilding the body’s ability to do exercise, both aerobic exercise like swimming or running as well as strength training, can be hugely beneficial.
“It’s important to start cautiously and under the guidance of a clinician, but even people that have some incurred damage [scarring to the heart known as fibrosis] can do exercise [for example, walking or water aerobics] which is tailored to their needs and condition,” says Patel.
Stop smoking
Reduces risk by 40 per cent
Quitting smoking after a heart attack might sound like the obvious thing to do, but in the grip of nicotine addiction, many people still find it tragically hard to stop. However, as Sindy Jodar, a senior cardiac nurse at the British Heart Foundation, points out, quitting smoking is one of the most impactful steps you can take when it comes to limiting your future risk.
“If you’ve already had a heart attack, it’s important that you stop smoking,” she says. “The chemicals in cigarettes make the walls of arteries sticky, causing fatty material to stick to them and reduce the amount of space that blood has to travel properly through the body, leading to a heart attack or stroke.”
Eat a heart healthy diet
Reduces risk by 25 per cent
Patel points out that a person’s risk of a second heart attack is not only driven by LDL cholesterol, but other harmful biological processes within your blood vessels. For example, the physical trauma of a heart attack will lead to substantial amounts of oxidative stress and inflammation which can play a role in accelerating plaque build-up. This is because plaques are composed not only of cholesterol and other cellular debris, but immune cells. Inflammation in the cells lining blood vessel walls can make it more likely for immune cells to attach, contributing to the formation of plaque.
One of the major lifestyle changes which can make a difference in reducing some of the ongoing oxidative stress and inflammation involves a more Mediterranean-style diet, limiting alcohol, salt, refined carbohydrates and saturated fats, while prioritising whole foods.
“The risk factors associated with cardiovascular disease are reduced with a Mediterranean diet,” says Dell Stanford, a senior dietitian at the British Heart Foundation. “It’s easy to do – make sure you are eating plenty of fruit and vegetables, beans, lentils, wholegrains, fish, nuts and seeds, along with some low-fat dairy and fat from unsaturated sources like olive oil. It’s also important to eat less processed meat, salt and sweet treats.”
Take recommended vaccines
Reduces risk by 20-30 per cent
This might seem like a less obvious step, but people who have already had a heart attack are at a much higher risk from seasonal respiratory infections such as flu and Covid, as well as later-life infections such as shingles. As a result, getting annual Covid boosters and flu jabs is thought to be a key way of lowering your ongoing risk, while studies have shown that shingles vaccination alone can reduce risk of major cardiovascular events by 26 per cent.
“Influenza and infectious diseases in general increase your risk of having a heart attack due to the inflammation triggered by an infection,” says Patel.
Adopt the right mindset
According to Patel, even though someone has already had a heart attack, it doesn’t necessarily mean that a subsequent heart attack or stroke is inevitable. He believes that much comes down to a person’s mindset and how they choose to approach the rest of their life.
“My NHS clinic is full of relatively young people who’ve had heart attacks, and my job is to help them avoid further heart attacks,” he says. “And I see a complete range of patients. There’s those who have flipped their life around 180 degrees, and a year on are running regularly, have lost weight and improved their diet. And then there’s the other end of the spectrum who haven’t made any changes at all, and remain at risk. I say to them, ‘Look, if you continue smoking, what are you expecting?’”
Overall, Patel describes second heart attack prevention as an 80:20 game. “Twenty per cent is us helping patients with medications and all that stuff, but 80 per cent is up to the patient to make those small changes, from a better diet to more exercise and stopping smoking, which can make all the difference.”