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Risk-Reducing Steps to Take After a First Heart Attack

August 28, 2000|JONATHAN FIELDING and VALERIE ULENE | Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles

Although many people think of a heart attack as a fatal event, the statistics paint a much brighter picture. Of the 1.5 million Americans who suffer heart attacks each year, nearly a million recover, thanks to medical advances that have dramatically improved the survival rate.

But survivors of a first heart attack (even those who have undergone coronary artery bypass surgery or angioplasty) face another problem: a very high risk of suffering another heart attack--about seven times higher than individuals who have never had a heart attack.

Fortunately, there are many ways to reduce that risk.

Low-dose aspirin is recommended for most people after a heart attack and has been shown to reduce the risk of another episode by as much as 30%. Aspirin helps by interfering with the formation of blood clots that could plug up a narrowed coronary artery and block the delivery of oxygen to the heart.

However, only half of those who should be taking aspirin actually do so. Some people don't take it because they are allergic to it, or they have a medical problem, such as a bleeding ulcer, that could be aggravated by aspirin (other medications can be substituted in these cases); others don't take it because their physician fails to prescribe it. But experts believe that many people simply don't appreciate the life-saving value of this inexpensive over-the-counter drug.

Beta-blockers, a type of medication frequently prescribed to lower blood pressure, are also recommended for most people after a heart attack. These drugs slow the heart rate and decrease the amount of oxygen that the heart requires to function (a heart attack occurs when the heart needs more oxygen than it is receiving).

They can pose problems for some people. For example, beta-blockers can aggravate breathing problems in people with asthma and raise blood sugar levels in diabetics. Some physicians will not prescribe them for people with these disorders. However, many experts argue that the use of beta-blockers should be considered even in these groups, provided that individuals are carefully monitored.

The risk of another heart attack and the risk of dying from heart disease can also be lowered significantly by reducing elevated cholesterol levels. The goal for people who have suffered heart attacks is to get their level of LDL-cholesterol, the so-called bad cholesterol, to 100 milligrams per deciliter or less. (In men and women who have never had a heart attack and are not considered to be at high risk of suffering one, an LDL level up to 160 milligrams per deciliter is often considered acceptable.)

In almost all cases, the first step toward cholesterol reduction should be changing the diet. Cholesterol-lowering medications are typically only prescribed if cholesterol levels cannot be lowered sufficiently with dietary changes alone. Just as high levels of LDL cholesterol can increase heart attack risk, so can low levels of HDL cholesterol (the so-called good cholesterol). About 25% of people suffering heart attacks will have normal total cholesterol levels but low HDL levels (less than 35 milligrams per deciliter). Lifestyle changes such as exercise, smoking cessation and weight loss, which can help raise HDL levels, are also recommended for these individuals. People who continue to smoke place themselves at much higher risk of another heart attack, because smoking promotes continued narrowing of the coronary arteries and can trigger spasms in these blood vessels.

In spite of this, many smokers don't quit after suffering heart attacks. Most people continue to smoke because they are unable to overcome their addiction to nicotine. Nicotine replacement therapy, with nicotine gum or patches, as well as a medication called bupropion (Zyban) can significantly improve quit rates, and be safely used in most people after a heart attack.

Although many people are afraid to exercise after a heart attack, it is an important part of the recovery process. Vigorous activity is usually discouraged while the heart muscle is still healing, but an exercise program can often be safely initiated within several weeks.

Anyone who has suffered a heart attack should consider participating in a formal cardiac rehabilitation program at a local hospital, medical center or community facility such as the YMCA. These programs provide expert advice and support on exercise, nutrition and stress management, and can help take fear out of the recovery process. People who participate in formal cardiac "rehab" programs have a lower risk of experiencing another heart attack and a better quality of life during recovery. In spite of this, only about 15% of heart attack survivors participate in these programs.

Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. They can be reached by e-mail at Their column appears the second and fourth Mondays of the month.

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