Dr. Ashok Seth
FRCP(LOND), FRCP(EDIN), FRCP(IREL), FACC, FSCAI, DSc (HONORIS CAUSA),
AWARDED 'PADMA SHRI' President, Caridological Society of India-Delhi Branch

A heart attack is a 'feared' disease, which often strikes without a warning and leaves dreadful consequences - both physical and psychological. However, a heart attack does not have to be a death sentence. It can be the beginning of a new and even more productive life if unhealthy lifestyle practices can be substituted with healthier ones along with the development of a positive attitude towards life.

A heart attack occurs when a clot in a coronary artery blocks the supply of blood and oxygen to an area of the heart muscle. While it seems to occur suddenly and often without warning, the process underlying the event has been probably going on for many years. It occurs when a clot in a coronary artery blocks the supply of blood and oxygen to an area of the heart muscle. The scientific term for a heart attack is "Myocardial Infarction myocardial infarction."

The factors that may lead to a heart attack include cholesterol deposition in the artery wall, high blood pressure, diabetes, sedentary lifestyle, obesity, family history of the problem, stress and smoking which damages the lining of the arteries, promotes the clotting of blood, lowers the level of "good" cholesterol in the blood, and spurs the contractions of the blood vessels, tending to keep them closed.

After a heart attack we have noticed two broad reactions: Some people learn to value life more, while some others develop an ongoing fear of another attack. It is a fact, that about ten per cent of those who have a heart attack will experience another one within a year. This risk, however, gradually drops to three to four per cent, every year... (this statistic needs to be confirmed)

In order to prevent a second heart attack, some leading heart centers prescribe a rehabilitation programme, which includes making changes in one's life style. At Max, Heart and Vascular Institute, New Delhi we offer rehabilitation guidance, which not only treats the patient medically, but takes care of both - the mind and body, since they are, after all, one. I really believe in that it is equally important to know who the patient is and what makes him tick rather than what just what the disease is. In fact, it is a well-established fact that 50 percent of cardiac problems stem from physiological reasons and 50 per cent lie elsewhere, including the mind.

Rehabilitation (More can be put in if you want...)

Recovery begins only 48 hours after a heart attack. Within a few days, the tissues of the heart begin to heal and, if there are no complications, you may be discharged from hospital after five to seven days.

As the weeks pass, the damaged muscle is replaced by scar tissue. During this period, one should be careful to increase physical activity levels only gradually.

Exercise helps to speed recovery. A gradual increase in exercise helps the heart to get back in shape and adapt to any scars left behind. It also improves general well being and encourages good quality and regular sleep. It helps test out the heart so the patient and doctor become aware of any residual problems, such as angina or breathlessness.

In uncomplicated cases, you should be back to your normal routine after 4-6 weeks.

Exactly when you return to work depends on your job and how serious the heart attack was. Take it in stages and rest when you feel tired. Some physically strenuous work may be avoided in the immediate post-recovery period.

Avoid long journeys and stressful driving situations, such as in a city or in the rush hour, for at least 4 weeks.

Many people worry that sexual activity may be too strenuous after a heart attack. But research shows these fears are generally unfounded. Like all exercise, take it slowly at first, especially for the first 4 weeks.

In order to eliminate the risk of repeated attacks, one has to stick to the medication prescribed by the treating cardiologist and bring meaningful and committed changes in one's lifestyle.

Making healthy lifestyle choices would include taking care of the major risk factors, which lead to heart problems. These include:

• Family history
• Diet - balanced meal, what we eat and adherence to meal timings
• Any substance abuse e.g. cigarettes, alcohol, panmasala
• Exercise whether regularly followed or not
• Stress

Of these, family history is non-modifiable and coronary artery disease is known to have a strong genetic component. A family history, having a first-degree family member (parent or sibling) with the disease predisposes a person towards a cardiac problem. As they say, history can repeat itself and if we want a history different from that of our parents or grandparents, we need to change our history by living and thinking differently from the way they did. The risks lie essentially in our lifestyle and our belief system. For example, a basic belief that could either motivate us to continue with our lifestyles or adopt a change would be: Is health wealth or is wealth health.

Belief system would also take into account priorities such as am I living for my children. And living for my children would include the concomitant worrying for my children and forgetting ourselves in the process. Then where do we end up: worrying ourselves sick about the children and the future and ending up in hospital. So what are we really achieving distress and chaos both for the children and ourselves. What we need to understand is that our first responsibility is to ourselves only if we are mentally and physically well can we do something for others.

Cardiac problems, both in women and men, can beprevented and even reversed in most people by making comprehensive lifestyle changes. These include effective stress management techniques, moderate exercise, group support, and a low-fat nutritious diet. Most people experience substantial improvements in weight, cholesterol, blood pressure, vitality, and quality of life, once they follow this regimen.

Giving up smoking is the single most effective way of reducing cardiac risks by almost half. A heart attack is a powerful motivation to stop smoking - 50 per cent of those who try at this time succeed. It is important to monitor one's blood pressure regularly.

Emotional stress plays an important role in just about all illnesses, both directly and indirectly. Thus, stress management is an important part of what I recommend. Professional help from a psychologist as well as learning relaxation techniques such as yoga, meditation etc, are known to be effective in dealing with stress, anger, frustrations, all triggers for potential heart attacks.

Medication/Drug Therapy: to be included

The medications after heart attack are given for two purposes:

1. Improving the tissue healing and decreasing long-term complications after a heart attack.

For control of the risk factors leading to a heart attack.

1. Certain medications medication which improves the healing of the heart muscle after a heart attack and thereby improve the prognosis include Beta Belablockers, ACE-inhibitors, Spironolactone diuretic and, then in some cases, nitrates. Your cardiologist These will prescribe these be prescribed by your cardiologist in the appropriate tolerated doses.
2. For control of these factors leading to heart attack.

Risk factor control to prevent future heart attacks is achieved by decreasing cholesterol levels (the target values for CAD patients: Cholesterol. < 200mg/dl; HDL Cholesterol. > 40mg/dl; LDL Cholesterol < 70 mg/dl; Triglycerides <150 mg/dl Cholesterol).. For achieving these desirable ranges, this statins may be needed,; good diabetic control is necessary and medication for diabetes need to be adjusted accordingly. Blood thinners like aspirin and/or Clopidogrel help to prevent future heart attacks attack and are given to in all patients unless there are contra indications.

A constant monitoring is kept on symptoms of chest pain on exertionexhaustion, heart function by Echo Doppler and regular ECG at follow up. An exercise test or on Exercise Thallium Scan is usually done between 4-6 weeks to see the progress. In many cases, either based on symptom

Psychological Issues post Heart Attack

In fact the toughest problem that we often encounter that even if physically the incident and the interventions are left behind, mentally, the patients it still with the trauma. According to the August issue of the Harvard Heart Letter, Post-traumatic stress disorder (PTSD) is often noticed after a heart attack, a stroke, or heart surgery. It not only causes emotional and psychological distress, it may also slow recovery and hasten the progression of heart disease.

Max Heart and Vascular Institute, is one of the few hospitals in India where psychological counseling is done at every stage of a patient's journey through the hospital. Handling anxiety regarding hospitalization, stress management, post-surgery depression, de-addiction as well as motivating the patient to adopt and sustain healthier lifestyle options are part of the regular protocol. We also ensure that the caregivers are also counseled on how to cope with the stress they themselves undergo because ofas well as the cardiac patients.

A special problem of heart-related PTSD is that the trauma comes from within. Sufferers are constantly on the alert for signs of an impending heart attack, such as a racing heart or shortness of breath. The trouble is, these are also normal responses to physical activity or stress.

Some people with heart-related PTSD go to great lengths to avoid these reminders they stop climbing stairs, making love, or doing other activities that make the heart beat faster. Some also stop taking medications that remind them of the heart attack.

Psychological counselling has an important role to play here. Treating PTSD starts with talk therapy that aims to help a person come to terms with a traumatic event by conjuring up memories of it in a safe situation. Reconnecting with people, interests, and activities also helps is another goal of therapy.

Depression affects one in four people after a heart attack. It is It's critical to address any depression you may be suffering - it won't just go away on its own and it can make it more difficult harder for you to make any necessary lifestyle changes or follow the treating doctor's advice, on particular treatments. Without specific help, those who become depressed don't recover as well as they might. Some may otherwise. Some such patients also benefit from anti-depressants.

Anxiety about leading a "normal" life, after an attack is also an important concern of patients.

If you take part in a cardiac rehabilitation programme, they'll be able to offer treatments ranging from medication to group therapy and stress management (stress and anger may contribute to a heart attack by producing changes in they our body that increase the your risk for blood clots).

Symptoms of a heart attack

The classic symptoms of a heart attack include: Pain in the chest, neck, jaws, back, shoulders, or arms. The pain may be severe, or moderate in intensity. The pain may be described as "crushing", "heavy" or "pressure-like". These same sensations can occur in the other locations just mentioned.

This pain can be accompanied with intense sweating, a key sign that a heart attack is occurring.

Shortness of breath, nausea, or vomiting are also common.

There is, often, a distinct feeling that something is really wrong. The pain does not always involve the left arm. It could be the right or both or no pain in the arms at all.

Have taken it from a website, can be modified if thought appropriate Management Plan Post heart attack

• Angioplasty, surgery or just medication: The fact that someone has had a heart attack is no absolute indication that they require one of these invasive therapies (called "revascularization procedures").
  Some factors that favor the need and benefit of a
  revascularization procedure include:
• The continued recurrence of chest pain after the heart attack has initially "completed".
• Evidence that there is still muscle in the distribution of the diseased artery, which is at risk of dying if the vessel, should totally occlude again. That is, it is suspected that although the artery did close at the time of the heart attack, it reopened enough to let some blood through and "salvage" some of the muscle in its distribution.
• Moderate, but not minimal or huge amounts of muscle damage.
• The vessel causing the heart attack being large with more than minor but less than total blockage. Some factors, which would tend to favor a "less aggressive" approach (that is, treat with medicine alone) include:
  Atotally blocked vessel. Quite simply, this vessel cannot get any worse. A100% blockage is less of a threat in most cases than those that are blocked from 90-99%, which have a high
• Incidence of, repeat closure and another heart attack.
• A blockage of less than 50-70%.
• Vessels where there is a lot of blockage, but where it appears that all of the damage has already been done. For example, if all of the muscle in the distribution of an artery has died, there is no need to bypass that vessel, since it will only supply a scar. Remember, it is the muscle that's important - the only point of an artery is as a conduitto that muscle.

It is also not unusual to find out that other heart arteries have blockage, and this will also influence whether bypass or balloon procedures are required.