Your heart, your recovery care record

What to expect after your discharge from hospital

On Discharge from Hospital you should have:

• Your Heart, Your Recovery Care Record
• Community cardiac rehabilitation nurse contact numbers
• Discharge letter (provided by nursing staff. A copy of this will also be sent to your GP). Your GP will be informed of your diagnosis, treatment, medication changes and any further tests or treatments required. You do not need to contact your GP unless you have any concerns.
• 28 Days supply of your medications (Your GP will update your repeat prescription on receiving a copy of your discharge letter, ready for when you next need to get a repeat prescription)
• Within seven days a community cardiac rehabilitation nurse will contact you by telephone.
• They will discuss how you have been feeling since your discharge home and explain how community cardiac services can support you in your recovery
• You can use this as an opportunity to ask questions or voice any concerns you may have had
• During this phone call, the nurse will arrange an appointment with you
• Within four weeks you will have a clinic or home visit with your community cardiac rehabilitation nurse
• You may have your blood pressure and heart rate checked and medications will be discussed
• Reassurance, advice and support can be offered as well as discussion around making positive lifestyle changes
• Your cardiac nurse may also discuss our six week education and exercise programme run in some local leisure centres around Leeds which will be available to you where appropriate
• Within 6-8 weeks you may have started your cardiac rehabilitation programme at the local leisure centre and be well underway to recovery
• If you have not attended the cardiac rehabilitation programme, your cardiac rehabilitation nurse is likely to have been keeping regular contact with you and you may now be reaching a point where you no longer need our services
• Within 2-3 months you will have an OP appointment
• If you are not contacted by the community cardiac rehabilitation nurses within seven working days of being discharged from hospital or if you have any concerns once home, please make contact on the numbers below
• Monday to Friday 8.30am-4.30pm (0113) 843 4200
• If you need help for minor accidents or unexpected health problems outside these working hours or over bank holidays, please call 0345 605 9999 (West Yorkshire ‘Out of hours service’) or 111 (for urgent medical help that’s not an emergency).
• If you feel very unwell or are experiencing chest pains which are not resolving please do not hesitate to call 999 and get emergency help

Foreword by Consultant Cardiologist

Coronary heart disease can often come as a shock and many people have concerns about their recovery and what the future will hold. Fortunately, the outlook for people with heart disease is now excellent and most people return to normal activities and lead a full and active life.

Cardiac rehabilitation is very effective in ensuring a satisfactory recovery and is tailored to your specific needs. By focussing on risk factors, physical activity and lifestyle factors cardiac rehabilitation is proven to improve both survival and quality of life.

As a cardiologist who treats many patients with coronary heart disease I have no doubt that cardiac rehabilitation is every bit as important as stents, surgery or tablets. I thoroughly recommend this page to you and your family. Enjoy reading it and make the most of your cardiac rehabilitation.

Prof Stephen Wheatcroft

Part 1: Your recovery

What is cardiac rehabilitation?

Cardiac rehabilitation provides people with information, support and advice to reduce and to cope with the causes of coronary heart disease (CHD).

It aims to provide information to allow people to make choices and take control of their health. The cardiac rehabilitation team aims to respect the wishes of individuals and offer support. It believes that individuals need to move at their own pace towards their own goals.

Research has shown that cardiac rehabilitation is an effective way for you to take control of your health and well-being. It is an ongoing part of your treatment, which your cardiology consultant strongly advises you to attend.

Cardiac rehabilitation nurses provide support and individualised advice for patients and their families following discharge from hospital.

Cardiac rehabilitation provides health, education and exercise programmes for patients with CHD. If you are unable to exercise, you can be followed up by your cardiac rehabilitation nurse who will either see you during your stay in hospital, or contact you following discharge from hospital.

Cardiac rehabilitation:

• Helps you through your recovery
• Provides information and help to make lifestyle changes that can result in a healthier heart

The heart and coronary arteries

The heart is a powerful muscle which pumps blood around your body. This muscle needs a supply of nutrients (food) and oxygen in order to keep healthy and work properly. The heart muscle gets its own blood supply from arteries known as the coronary arteries.

There are two main coronary arteries; the left and the right. The left one divides into two main branches which then divide further. The right one also further divides, so that all of the heart has a blood supply.

The heart and coronary arteries

Coronary heart disease

The arteries supplying the heart can become diseased by a condition known as atherosclerosis (this is also known as hardening of the arteries, plaque build-up and furring up of the arteries). Atherosclerosis is caused by the build up of fatty deposits inside the artery. These deposits narrow the artery, therefore not enough blood may reach the heart muscle, causing chest discomfort or pain and possible shortness of breath. Coronary heart disease (CHD) can lead to angina and heart attack. We will discuss the causes of CHD later on the page.

The coronary arteries

What is angina?

Angina is pain or discomfort in your chest, which is usually caused by CHD. Some people feel the pain in their arm, neck, stomach or jaw.

Angina often occurs when you are:

• Exerting yourself
• Eating a heavy meal
• Emotionally stressed
• Exposed to cold

Plaque deposits restricting blood flow

CHD can reach a point where the blood supply to your heart muscle is not enough even while you rest. Symptoms of angina such as chest pain can then occur while you are sitting in a chair or lying down. By making some small lifestyle changes you can help to prevent or lower the risk of this happening.

Chest pain management

If you get pain or discomfort in your chest, follow the ‘10-minute rule’. This chest pain may not be from your heart. However, it is very important that you get it checked out as soon as possible.

If the GTN relieves the pain, then wait until another time to finish what you were doing. If the same activity causes angina again, then try taking the GTN before starting the activity, to prevent the pain developing in the first place.

It is important that you carry your GTN spray with you all the time. You should check the expiry date on the spray and get a new one from your GP or pharmacist if your spray goes past the expiry date.

If you have not been prescribed GTN and you develop chest pain rest for 15 minutes and if you have no relief then dial 999 to call an ambulance. If the pain goes off then wait until another time to complete the task you were doing.

Let your GP or cardiac rehabilitation nurse know how often you have angina and which activities bring it on. Even if the GTN spray gives complete relief, you should let your doctor know if your angina:

• Happens with little or no exertion
• Lasts longer each time
• Requires more GTN than you would normally use (you may want to keep a diary of this to show your doctor)

Your medication may need to be changed or altered or you may need more medical tests.

Also let your doctor know if you have any of the following:

• Increased shortness of breath
• Unusual tiredness
• Swollen feet or ankles
• Fainting
• Palpitations

You may need some further investigations.

What is a heart attack?

A heart attack occurs when the blood supply to the heart muscle is blocked for a longer period of time (due to one or more blocked coronary arteries).

This can result in some permanent damage to the heart muscle beyond the area of blockage. Symptoms of a heart attack usually last longer than 30 minutes and are not relieved by rest or medication, such as GTN spray. A heart attack may be the first sign of CHD.

If you have these symptoms and they are not relieved by rest or medication such as GTN spray it is very important that you dial 999 and get an ambulance to hospital. It is often possible to treat a heart attack by unblocking the artery with an angioplasty & stent. If this is done quickly and the blood supply restored then the damage to the heart muscle (the heart attack) can be reduced.

How the heart muscle heals

The heart begins to heal during the first few weeks after a heart attack.

Information on medicines

After your diagnosis of angina or heart attack, you will have been asked to take several medicines. It is important to realise that some of these medicines may not make you feel any better, but they can lower the chances of you having another heart attack or getting symptoms of angina.

This section provides information on some of the most commonly used medicines in patients who have had angina or a heart attack. It is not a comprehensive list, so if you need more information, please discuss with your GP, community pharmacist, or nurse.

Usually you will have been asked to take two types of antiplatelet drugs; aspirin and a second antiplatelet (clopidogrel, prasugrel or ticagrelor), a beta-blocker, a statin, and an ACE inhibitor, unless your doctor decides that they are not suitable for you. If you are unsure why you were not prescribed one of these medicines, please discuss it with your doctor, nurse or pharmacist.

Antiplatelets

Examples: Aspirin, Clopidogrel, Prasugrel, Ticagrelor.

Proton pump inhibitors

Examples: Lansoprazole, Omeprazole, Esomeprazole, Rabeprazole, Pantoprazole

Beta-blockers

Examples: Atenolol, Bisoprolol, Metoprolol, Carvedilol, Nebivolol

Ace Inhibitors

Examples: Ramipril, Perindopril, Lisinopril, Captopril, Enalapril, Quinapril.

Cholesterol (Lipid)-Lowering Drugs (‘Statins’)

Examples: Atorvastatin, Simvastatin, Rosuvastatin, Fluvastatin, Pravastatin.

Icoaspent Ethyl

Other medications for the heart

All the medicines mentioned so far are used to try to prevent further heart problems and improve your symptoms. Sometimes after a heart attack the heart muscle can be weakened, this can be referred to as heart failure. Some patients may be prescribed a medicine called eplerenone. This medicine reduces the risk of worsening of heart failure. You also may be prescribed medicines to control your chest pain symptoms such as nitrates, nicorandil, ivabradine, calcium channel blockers (e.g. amlodipine, diltiazem) and ranolazine. We will only be providing information about nitrates. However, full information about these medicines can be found in the information leaflets that you get from your pharmacist. For further advice please speak to your pharmacist, nurse or doctor.

Nitrates

Examples: Isosorbide Mononitrate, Isosorbide Dinitrate, Glyceryl Trinitrate (GTN Tablets or Spray)

Ask your nurse or pharmacist for a GTN card – it is a good reminder to carry with you in your wallet.

Commonly asked questions about medicines

Part 2: Risk factors

Risk factors for heart disease

There are a number of factors that can contribute to the development of Coronary Heart Disease (CHD) and therefore increase your risk of having a heart attack or developing angina. These factors are known as risk factors for CHD. They can be divided into being ‘modifiable’ or ‘non-modifiable’.

• Modifiable risk factors: factors that may increase your risk of CHD which can be changed to reduce the risk of future problems. These will be discussed in detail over the following sections.
• Non-Modifiable risk factors: factors that may increase your risk of developing CHD which cannot be changed.

Fortunately, you can control many of the modifiable risk factors that contribute to the narrowing of the coronary arteries. Your cardiac rehabilitation nurse can help you set realistic, achievable goals to reduce the risk factors that apply to you.

Smoking

Stopping smoking is the single most important thing you can do to improve your health.

From the minute you stop smoking there are health benefits.

To find out more, ask the ward staff, your cardiac rehabilitation nurse or your pharmacist.

Nicotine replacement therapy (NRT)

Nicotine Replacement Therapy (NRT) replaces a small amount of the nicotine that you used to get from cigarettes. It is the addictive nature of nicotine that makes it hard for many people to quit. NRT provides you with some help with the addiction and allows you to deal with the habit side of smoking first. Remember you are four times more likely to quit for good using a combination of medication and specialist support.

Your cardiac rehab nurse or Stop Smoking advisor can advise you on which types of NRT would be most suitable for you and which products can be combined to achieve the best outcomes.

The use of medications to stop smoking

There are two medications that can also be considered to help you stop smoking; these should only be considered under advice from a specialist who can prescribe, such as the Stop Smoking advisor or your GP. Using medications such as those listed below can double your chances of stopping smoking. However, they can have side effects and may not be recommended in certain health conditions.

The use of e-cigarettes to stop smoking

• Electronic Cigarettes or Vaporisers do not contain tobacco; they create vapour from liquid nicotine. E-cigarettes are not licenced for use as Nicotine Replacement Therapy (NRT) at present.
• Public Health England state that e-cigarettes are at least 95% less harmful than smoking.
• E-cigarettes are the most popular quit smoking aid and when combined with specialist stop smoking support can be the most effective way to quit smoking for good.

High blood pressure

Blood pressure is the force that circulating blood puts on the artery walls. When blood pressure is high, there is more pressure on the artery wall than usual. Some people have high blood pressure and do not know they have it. This extra pressure damages the smooth lining of the arteries and makes it easier for cholesterol and fat to build up along the artery walls. As the arteries become clogged with these fatty layers (atherosclerosis), less blood gets through. This causes the heart to beat harder as it tries to pump blood through narrowed arteries. If untreated, high blood pressure may in time damage the heart, brain and kidneys. It is a leading cause of heart attacks and strokes, heart or kidney failure.

The exact cause of high blood pressure is not fully known for many people. High blood pressure can be lowered with medication.

Cholesterol

Cholesterol and triglycerides are fatty chemicals in the blood. There are two main types of cholesterol; LDL ‘bad cholesterol’ which carries cholesterol from the liver to the rest of the body, and HDL ‘good cholesterol’ which returns excess cholesterol to the liver.

While foods with plant stanols and sterols are thought to reduce the absorption of cholesterol from the gut (British nutritional foundation), they do not provide sufficient reduction in cholesterol and should not replace the medicines prescribed to lower cholesterol. They can be taken alongside the cholesterol-lowering medicines that you were prescribed. Plant stanols and sterols are usually added to particular spreads and yoghurts and they are also found naturally in nuts and seeds and some fruits and veg.

If you have high levels of cholesterol and triglycerides, your risk of CHD is greater.

High levels of LDL cholesterol stick to the walls of your arteries and make plaque. This plaque blocks the arteries, interfering with the blood flow which can make a heart attack more likely.

The treatment for high cholesterol is now as routine as that of other common conditions. Treating raised blood cholesterol is a positive way you can do something to avoid future heart problems. The next section provides information about diet which can help you to control your blood cholesterol levels.

The aim of your cholesterol lowering medication is to reduce the level of bad cholesterol (LDL-cholesterol) as much as possible. The National Institute for Health and Care Excellence (NICE) recommends that LDL-cholesterol is 2.0mmol/L or lower in people with heart disease. However, many people may benefit from a lower LDL-cholesterol target. For example, the Joint British Societies recommend a target of 1.8mmol/L or lower and the European Society of Cardiology recommend a target of 1.4 mmol/L or lower. Your cardiology team will advise and help to agree a personalised target for you.

It is recommended that once starting cholesterol-lowering medications, you have your cholesterol checked after three months and then at least yearly, unless advised otherwise. This can be carried out by your local GP practice.

Cholesterol:

Diet: Getting the balance right

Overall dietary balance is important. No single food contains all the essential nutrients the body needs to be healthy and function efficiently. A balanced diet should include a variety of foods.

The following illustration represents each of the five food groups and gives a guide to the proportions of food we need to achieve a balanced diet.

Adapted from The Eatwell Guide as per crown copyright protection.

Five easy ways to five a day

Check this website for further examples
(https://www.bhf.org.uk/informationsupport/support/healthy-living/healthy-eating/recipe-finder)

Cardioprotective diets

Cardioprotective diets generally follow the Eatwell Guide principles and are linked with a healthier heart. One example would be a Mediterranean style of eating. This is one well known whole dietary approach that may suit you.

Be mindful that other dietary approaches may work better for you, but the most important thing is to think of your diet as a whole. Continue with any cardiac beneficial, whole dietary approaches that suit you.

Fat

A cardio protective style of eating is not necessarily low in fat, but the type of fat is important. There are two groups of fats: saturated and unsaturated. Healthy fats are better than very low fat. The cardio protective diet is more beneficial than a very low fat diet in prevention of CVD. If you need to reduce your weight, then you need to eat less fat of any kind and this should be a small proportion of your overall diet. Replacing saturated with unsaturated fat is better than replacing it with carbohydrates or protein.

Salt

Most of us consume more salt than we need. High salt intakes can contribute to high blood pressure and fluid retention. Gradually reduce the amount of salt you add to foods – in cooking and at the table to allow you to adapt to the change in taste. Use other means of seasoning such as pepper, herbs, spices and lemon juice to flavour foods. Pre-prepared foods, sauces and soups can contain lots of salt – check the labels and try lower salt varieties, or prepare foods yourself without adding salt if possible.

Foods high in sugars

These foods should be eaten in small quantities. They provide excess calories and can contribute to weight gain. It is important to limit the amount of ‘free sugars’ in the diet. Too much free sugar can raise your triglycerides (fatty chemicals in the blood). Free sugar includes sugar added to food and drinks (either at home or during manufacturing) and sugar naturally found in foods like honey, agave syrup or fruit juice. Adults can have up to 30g of ‘free sugars’ a day. The sugar found naturally in whole fruits and vegetable is not free sugar and does not need to be included in this amount. There is advice on how to cut down on sugar on the NHS live well website. This group includes biscuits, cakes, ice cream, sweets, chocolate and fizzy or sweetened drinks.

How do I understand food labels?

Nutrition labels can help you choose between products and keep a check on the amount of foods you are eating that are high in fat, saturated fat, sugar and salt.

Packaging often shows foods in ‘traffic light’ colours, so that you can see at a glance if they are high (red), medium (amber) or low (green) in fats, sugar or salt. For a healthier choice, try to choose products that have more greens and ambers than reds.

If you have a smart phone you can download the food4life food scanner App. You can scan product bar codes to check levels of sugar, saturated fat, salt and calorie content of the item. This will allow you to make an informed choice about your purchase (or product at home).

Being overweight

If you are overweight, then aiming to reduce your weight by 10% is beneficial.

For example, if you are 18 stone, aim for 16 stone or if you are 14 stone aim for 13 stone. This will reduce the strain on your heart and will help lower your blood pressure. If you follow the dietary advice to reduce fat intake, your weight should come down. Waist size is an indicator for heart disease risk. 37 inches for a man and 31.5 inches for a woman is the top end of waist measurement that is considered healthy (BNF).

You can reduce your energy intake by changing the snacks you eat, (e.g crisps, cakes, biscuits) to the fruits and vegetables suggested. Do not forget that all alcoholic drinks contain calories.

Be careful when choosing low fat foods as some can still be high in calories due to the amount of sugar in the foods e.g fruit juices, reduced calorie biscuits and low fat yoghurts.

You may notice that you tend to eat more when you are feeling worried, low in mood or bored. If this happens to you, try and find an activity or hobby that will take your mind off food or have a glass of water or no added sugar squash instead.

Keeping a diary of what you eat and drink can also help you to find ways in which you can reduce the amount of energy you eat. The support of your friends and family is also important to help you to keep motivated.

See the following website for further details: https://www.nhs.uk/better-health/lose-weight/

BMI Chart

There are also tools and information on the British Heart Foundation website that can help you to build healthier eating habits into everyday life (for example Heart Matter Healthy Recipe Finder).

Diabetes

What is diabetes?

Diabetes is a condition which occurs when either the body does not produce enough insulin or the insulin that is produced by the pancreas does not work properly. This means that the glucose (sugar) cannot enter the cells in the body where it would normally be converted into energy. It therefore stays in the blood stream, causing the level of glucose to be too high.

Diabetes can occur at any age. The most common is called Type 2 which mainly affects those people over 40 years of age. Type 2 diabetes is strongly linked with being inactive, over-weight and often has a link with family history.

It can also happen more commonly in certain populations, for example those with South Asian and African-Caribbean origins.

The risk of developing Type 2 diabetes can be reduced by taking regular exercise and maintaining a healthy weight.

Type 1 diabetes occurs when the pancreas is unable to produce any insulin and is usually diagnosed in young people or children. We do not know at present what causes this.

Testing for diabetes

Diabetes is usually diagnosed though a blood test called HbA1c. This is a measure of average blood sugar levels over the last few weeks. An HbA1c level of 48mmol/mol indicates diabetes.

A level between 41-47mmol/mol indicates ‘pre-diabetes’. We routinely check HbA1c levels on people admitted to hospital with a heart attack. The results can sometimes take 2-3 days to come through. We will advise you if your HbA1c level is abnormal.

If you have diabetes, you should have been advised of your personal target level for HbA1c by your diabetes nurse, pharmacist or doctor.

What effect does diabetes have on the heart?

People with Type 2 diabetes often have high triglyceride levels and low levels of HDL cholesterol (the protective type of cholesterol).

High glucose levels can affect the nerves to the heart, so dangerous symptoms are not felt in the usual way (for example, people with diabetes may not feel any pain with a heart attack which can lead to difficulty and delay in the diagnosis of heart problems).

What can I do about diabetes?

Diabetes cannot be cured, but it can be managed and controlled. The two main aims of diabetes management are to resolve the symptoms of diabetes and prevent the health problems associated with this condition.

Glucose levels can be improved by following a healthy diet, being physically active and taking the medications prescribed. Keeping to a recommended weight is also beneficial.

What are the health risks associated with having diabetes and what can be done to keep healthy?

People with diabetes have a higher chance of developing high blood pressure, circulation problems, nerve damage, damage to the kidneys and the eyes. The risks are particularly high in someone who is also overweight, who smokes and is not physically active.

It is important to attend regular check-ups, where blood glucose, blood pressure, kidney function, eyes and feet are monitored and overall diabetes control can be assessed. Further information about diabetes is available on request.

Can medications for diabetes protect the heart?

Certain medications for type 2 diabetes also have protective effects on the heart.

Metformin is effective for blood sugar control and slightly reduces the risk of heart attacks when taken in the long term.

SGLT2 inhibitors (for example empagliflozin, dapagliflozin, canagliflozin) reduce the risk of heart problems (such as heart failure) and protect the kidneys.

GLP-1 receptor agonists, (for example semuglutide (Ozempic), dulaglutide (Trulicity) and liraglutide (Victoza) which are usually given by injection, reduce the risk of heart attacks, promote weight loss and protect the kidneys.

After a heart attack, the cardiology team, diabetes team or your practice nurse or GP will advise on your suitability for these medications.

You may be invited to attend a ‘Cardiometabolic’ clinic, when we can advise on recovery from a heart attack and management of diabetes.

What about pre-diabetes?

People with pre-diabetes are at increased risk of developing diabetes in future. This risk can be reduced by lifestyle changes such as weight loss and regular physical exercise. Participation in the NHS National Diabetes Prevention Programme can be very helpful. You can ask to be referred by your GP, or can refer yourself. Please ask your cardiac rehabilitation nurse for more details.

Alcohol

Drinking more than the recommended amount of alcohol can have a harmful effect on your heart and general health. It can cause abnormal heart rhythms, high blood pressure, damage to your heart muscle and other diseases such as stroke, liver problems and some cancers.

Alcohol is also high in calories so it can lead to weight gain. (See drinkaware.co.uk to check calorific value of alcoholic drinks.) It also lowers your inhibitions which might mean you find it harder to stick to your healthy eating plans when you have been drinking. If you are trying to lose weight, cut down on alcohol.

Most people don’t drink alcohol every day – but if you do, try having some days off – aim for at least two alcohol free days a week. Just make sure you don’t increase the amount you drink on the other days.

Drinking large amounts of alcohol in one go can cause damage to your heart muscle so avoid drinking 6 or more units in a day on a regular basis.

Your GP can help to support you in reducing your alcohol consumption if you decide you would like to do this. If you are a dependent drinker, please seek medical advice before you stop drinking suddenly.

You can find more information at www.drinkaware.co.uk

Alcohol units

Ensure you check the strength of what you are drinking, as this will affect the units, particularly if you are drinking stronger ales or lagers.

Consider the measures you pour when you are drinking at home, as these tend to be more generous than standard pub measures.

If you require further information or support with reducing your alcohol intake, please seek advice from your cardiac nurse or GP.

Physical activity

If you have recently had a heart attack or been admitted to hospital with angina, physical activity will play an important part in your recovery.

It is natural to be concerned about what you can and cannot do safely. Your cardiac rehabilitation team will help you build up your physical activity level.

The benefits of physical activity

People with coronary heart disease can benefit from regular moderate intensity physical activity. Not everyone will get the same benefits, but most of the benefits listed below can come from regular physical activity.

Regular light to moderate physical activity will help you to stay healthy and reduce your chance of future heart problems.

Aim to build up gradually to at least 30 minutes of moderate intensity physical activity on most days of the week. This can be broken down into 10 minute sections.

Everyday activity

This section is designed to help you return to everyday life after you come home from hospital. It is a guide only and you must remember that everybody recovers at different rates and has different levels of fitness. As with everything, you should start gently and build up gradually.

How much you feel able or want to do will depend on your usual daily routine. You may find it useful to break down a task into more manageable chunks, giving yourself time to rest. If you experience any pain or discomfort STOP doing the task.

While you are exercising or active – a ‘normal’ level of breathlessness when active is still being able to carry out a conversation while you are active.

Individual advice and guidance on work and leisure activities can be sought from the cardiac rehabilitation team.

First week at home

This is the first week of recovery after your stay in hospital. Take things slowly and rest if you need to.

You could start with everyday activities such as walking around the house/garden. You can start stage one of the walking programme. See below. Climbing stairs, building up your activities gradually.

After first week you can start to do some light gardening & light housework.

This can be built up gradually over the next 4 weeks. Concentrate mainly on following the walking program.

Walking guidelines after you leave hospital

During your first week at home you may start the walking programme. Start by walking outdoors for five minutes at an easy stroll. Avoid it if you feel tired or unwell or if the weather is very bad. Take your GTN spray with you if you have one. You may want someone to go with you to start with to increase your confidence.

How you feel is the best guide to what the safe level of physical activity is for you. Start by walking on the flat and avoid hills at first. Always walk at a comfortable pace for you.

Walking programme instructions

• Start at stage one of the walking guidelines and remain at each stage for at least two consecutive days or up to several days depending on how you feel.
• Only move onto the next stage when you feel comfortable with the current stage. As you progress it may take longer before you move onto the next stage.
• If you are unwell, do not do the activity. You may need to drop back a stage or two when you feel well enough to resume the activity.

Walking programme

Warm up and cool down

It is very important that you include a warm up and a cool down into your activity. The warm up prepares the body for the activity ahead. It should be a gradual build-up of movements before you start the main part of your programme. It will increase your heart rate and breathing rate.

The cool down should be a gradual decrease of movement at the end of your activity. It will bring down your heart rate and breathing rate and return your body to its pre- activity condition.

What about hobbies and sports?

After a heart attack you may take up a hobby or sport such as cycling, swimming, tennis, golf or bowls or any other activity. You will need to build up to the activity gradually. The ACPICR (Association of Chartered Physiotherapists in Cardiac Rehabilitation) has information leaflets on a number of activities. These are available at http://acpicr.com. Alternatively you can contact your cardiac rehabilitation team if you require more advice.

The type of straining that you get from lifting heavy weights and other strenuous activities and sports can raise your blood pressure and should be avoided in the early stages after a heart attack. Gradually building up resistance training with weights can be part of your healthy physical activity programme.

For further information about sports or strenuous exercise seek advice from your cardiac rehabilitation team.

Things to remember

Cardiac rehabilitation

Cardiac rehabilitation, sometimes called cardiac rehab, helps you to recover and get back to as full a life as possible. It is an individualised programme of support built around your personal circumstances and needs. It involves supervised and independent exercise or activity sessions. You will be able to access cardiac rehab through a variety of different ways such as attending in person at a leisure or community centre or within your home environment. This may include video calls, websites, mobile apps or telephone support.

Cardiac rehab is a vital part of your recovery, so consider it as important as taking your medication. No matter your age, gender, ethnicity or level of fitness you can benefit from cardiac rehab.

A member of the Cardiac Rehab team will contact you to discuss the right programme for you.

Exercise for life!

It is important that you choose a physical activity that you enjoy, so you will be more likely to continue with it. Involve your family and friends in the activities.

Any extra activity you can add into your life will significantly benefit your health.

Why not try?

• Walking to work
• Parking the car further away from the shops
• Getting off the bus one or two stops earlier
• Use the stairs instead of the lift or escalators.

Breathlessness

Is it common to become breathless when walking or doing tasks?

It is quite normal to breathe a bit harder than normal when you are physically active. If you get breathless when physically active, pacing your activities or resting usually helps. Sometimes people find they get very worried about breathing a bit harder than usual. This worry can lead to the body becoming tenser which may make relaxed breathing more difficult. Recognising when breathing harder is normal and learning how to relax can both be of help if you think this applies to you.

How do I know when I should ask for help?

Everyone gets a bit breathless at times if they have to do something they’re not used to and find it a bit of a challenge. However, if you find that you are experiencing any of the following, please seek help:

• The breathlessness comes on suddenly
• Is different from normal
• Does not go with rest
• Comes on when you are not active
• Or, if you find that you are gradually getting more breathless over a few days.

Part 3: everyday life

Your emotional recovery

It is commonly believed that stress and worries can lead to a person having a heart attack. However, there is actually little good scientific evidence to support this. It is true that people who are under high levels of stress are likely to smoke or drink more, both of which contribute to risk, but stress itself is not believed to be problematic.

For most people, having a heart attack or bad angina attack comes as quite a shock and people experience a variety of feelings and emotions. It is also normal to become more aware of your heartbeat or to feel twinges in your chest. It can take time to come to terms with what has happened. It is important to remember that there is no right or wrong way to feel. You might find that talking things over with family or friends is helpful.

Anxious feelings

Some people feel very anxious or nervous and you may find that you have good and bad days. This can result in you feeling tearful and a bit down, or getting more angry or irritated with things that you had been able to cope with before. These feelings are all perfectly normal and usually pass with time. Some people talk about having vivid dreams or nightmares after the heart attack. This too is quite normal and usually passes in time.

It is also common for partners and family members to try to over-protect people who have had heart problems. It is natural for those who are close to you to feel worried and want to help, but it is easy to become over-protective and try to wrap someone in cotton wool.

Relaxation or meditation

It is common to have difficulties sleeping after heart problems and to feel more tired than normal. This usually improves over time, but relaxation or meditation can be of help. Relaxation CDs designed specifically for people with heart problems are available. Ask your cardiac rehabilitation nurse.

Pacing yourself

As part of your recovery, it is important to get back to doing things that you enjoyed before. The rate at which different people are able to do this will vary. Some people say that they have lost confidence or trust in their body.

This can take time to re-build. Speak to your cardiac specialist as to how much you should be doing and how soon you should be doing it.

For some people, the worry caused by having heart problems stops them from activities they previously enjoyed, even after they have been told that they can do them. If you find yourself doing this, here is some advice you might find useful.

• Set yourself a target. For example, some people want to get back to doing the gardening or jobs around the house. Break the target down into smaller chunks; you may decide that weeding a whole flowerbed would be too much. Think about how much you might be able to do without becoming tired. If this is five minutes of light weeding, have a go. Be prepared to stop if it gets too much. If you found it easy, think about doing a bit more next time, e.g. 10 minutes. However, make sure you do not do more than you had planned to do on one day as rushing into things can make you feel more tired

• You may be worried about going out alone straight away. Try going somewhere nearby with someone else the first time. When you feel okay about doing this, go some of the way on your own, then gradually do more to build up your confidence.

How about the future?

For some people, recovering from heart problems can be the start of some positive changes. Many people become a lot fitter and may take up new activities such as swimming or walking.

Others realise the importance that some things – and some people – have to them and are determined to make time for themselves to do things they enjoy.

Worrying will not bring on heart problems, but people often realise that they would like to be less stressed and do something about it. Many people get a real sense of achievement from giving up smoking or doing something else to feel healthier.

How can the cardiac rehabilitation team help me?

Having experienced heart problems, it is important that you feel supported in regaining your confidence. There may be a lot of information to remember when you first come out of hospital. This might include advice about stopping smoking, changing your diet and becoming more active therefore assisting your physical recovery .We can also support you with any ongoing symptoms and give you education on new medications you may have been prescribed. Your cardiac rehabilitation nurse can help you in all these areas, so please talk to them if you have any worries.

You may be invited to attend an exercise and health education programme where you will receive further support and advice from the members of the team. The talk by the mental health practitioner covers the emotional side of heart problems in more detail. If you do find that your worries are getting in the way of your recovery, your nurse may talk with you about whether you would like to see the mental health practitioner or your cardiologist can refer you to the clinical psychologist.

Information for spouses, partners and family

If someone close to you has had a heart attack or is diagnosed with angina you may find this very upsetting. This is entirely normal and reading through this page may be helpful as it will give you more information about what to expect.

You may find yourself doing a lot of worrying, particularly when the person you are caring for first comes out of hospital. This is quite normal and usually improves with time. It might be tempting to want to do everything for them.

This is generally unhelpful, as it can lead to both of you feeling stressed. You may also start to feel a bit resentful. It is important that the person you are caring for gradually begins doing things they have been told are appropriate, in order to build up their strength again. Try to encourage them to stick to the goals as discussed by the cardiac rehabilitation team.

You can play an important role in the person’s recovery, but it can also be very tiring. Sometimes carers can start to feel run down, perhaps because they are not sleeping as well or are feeling worried, particularly at night. It is important that you also take time to look after yourself. Try to take a rest when you can. It may also help to talk to a close friend, your doctor or someone from the cardiac rehabilitation team.

Driving

Here are some common questions and answers about driving after a heart attack or angina. This is only a guide and assumes no other disqualifying conditions. For more detailed information, please ask your cardiac rehabilitation nurse.

I have had a heart attack. Will I be allowed to drive and do I need to inform the DVLA?

The Driver and Vehicle Licensing Agency (DVLA) is the government department responsible for deciding whether a licence holder may drive a motor vehicle. Many conditions may stop a person from driving either permanently or temporarily.

Usually, you should be able to drive a private car four weeks after having a heart attack, unless you have any other disqualifying condition.

You do not need to inform the DVLA unless you are a heavy good vehicle (HGV) or public service vehicle (PSV) driver. You should however inform your insurance company. If you do not, your insurance may not be valid. It is also a good idea to have someone with you (who is insured to drive your car) the first time you drive and to go on a short journey. It is also important to remember you are not exempt from wearing a seat belt because you have had a heart attack.

I have been told I have angina. Can I still drive?

You may recommence driving when your symptoms are under control. That is, you can predict when you are likely to have an angina attack and they are infrequent. Driving must cease when symptoms occur at rest, with emotion or at the wheel.

What about the driving I do for my job?

If you are a HGV (heavy goods vehicle) or PSV (public service vehicle) driver, there are special requirements for getting re-licensed when you have had a heart attack. You can get details of these from the DVLA.

Before you can drive again, you need to wait at least six weeks and have an exercise ECG or other functional test. It may take time before you get the appointment for the exercise ECG. It is important that the results of this test show no significant changes to your heart rhythm, that you had no chest pain during the test and that your blood pressure did not drop after the test.

If you have angina, you can be re-licensed once you have had at least six weeks with no pain, providing you have had a successful exercise ECG and other functional test requirements and you have no other disqualifying conditions.

If you are a taxi driver and you have had a heart attack you will need to inform the local council that you are licensed with. They will send you a form to for your GP to fill in. You will not be able to drive a taxi again until the form has been assessed by the council taxi licensing office.

For further information, please contact:

Drivers Medical Group, DVLA, Swansea, SA99 1TU
Tel: 0300 790 6806
Website: www.gov.uk/government/organisations/driver-and-vehicle-licensing-agency

Flying advice

When can I fly after a heart attack?

Most airlines will not allow flying in the first week after your heart attack.

Flying should normally be delayed for four weeks, for short distance flights, after which the risks of problems related to the heart attack are lower.

This delay period may need to be extended if you had any complications after your heart attack.

In some circumstances you may be able to fly after 7-10 days however you must discuss this with your doctor.

If you are planning on travelling on a long distance flight, it is advised that it may be better to wait for 12 weeks.

If you have a holiday planned, please discuss this with your doctor. It may also be helpful to consider where you are going, the length of time you will be travelling and the provision of medical services once you arrive at your destination. Your doctor may suggest further restrictions if you are going to a remote location, or not in easy reach of medical care.

Can I fly if I have angina?

Flying should not be a problem as long as your condition is ‘stable’, and attacks are infrequent. However, if you find it difficult to predict when you will have an angina attack, you should seek the advice of your GP. Generally,

if you can climb a flight of stairs whilst holding a conversation and without stopping and you do not have significant symptoms, you should be well enough to fly.

If you have frequent angina, or your symptoms are ‘unstable’ (pain at rest), it is recommended that you do not fly. You should avoid holidays at high altitudes, especially if your angina is brought on easily, or if you suffer from breathlessness.

What if I am waiting for an angioplasty/stent insertion?

Flying may not be advisable while waiting for your angioplasty. Please discuss this with your doctor.

Is there anything I should do during the flight?

If you have a long flight (over two hours), it is best to walk in the aisle at regular intervals so that you reduce the risk of a venous thrombosis (blood clot) in the legs. If it is difficult to walk in the aisle, you could move your feet for several minutes every half an hour to prevent sluggish circulation in the legs.

It is best to avoid alcohol and limit drinks containing caffeine (tea, coffee and cola). Drink plenty of water to avoid dehydration, which is especially common during night flights.

What about insurance cover?

The NHS does not pay for treatment whilst you are out of the UK. You will need to take out travel insurance and let them know that you have had a heart attack. You can arrange this through your travel agent or insurance broker.

Travelling abroad without insurance cover is unwise and potentially hazardous. Insurance cover should not be a problem with stable conditions, although an increased premium is possible. You will need to shop around for the best deal. Make sure you read the small print to ensure your condition is covered. Please ask your cardiac rehabilitation nurse if you require a list of sympathetic insurance companies.

For further information or advice please see:

Website: www.caa.co.uk/passengers-and-public/

Returning to work

Many people have questions about going back to work. The following gives some general advice.

I had a heart attack. How soon can I return to work?

Going back to work is often a major concern if you are recovering from a heart attack or an acute cardiac illness. Between 62% and 92% of people who worked before their heart attack are likely to return to work. You are likely to be fit for light work in about four to six weeks. If your job is more physically demanding, you may need about 12 weeks. If you have had a heart attack and are looking for a new job, your cardiologist may be able to give you a fitness report that you can use to reassure prospective employers of your ability to work.

Will I be able to do as much as before?

You might be able to discuss with your employer ways in which you can modify your work to avoid the heaviest jobs. If your organization has an occupational health service, you will be able to talk to someone about your heart attack and your return to work. They might be able to suggest way of modifying your role while you recover, like returning to work in phases.

Exercise and health education cardiac rehabilitation programmes have increased the number of people successfully returning to work. Many people find that full recovery from a heart attack makes them more conscientious in their work than before. But even if you have fully recovered, you might be at the age where early retirement is an option.

How do I get a fit note?

Please ask your ward nurse about a fit note before leaving hospital or you can get it from your GP.

Does cardiac illness affect my status as an employee?

You might be worried that your job will be downgraded or that your promotion prospects will be affected by your illness. The Disability Discrimination Act makes it unlawful for employers to discriminate against employees on the grounds of a declared disability, unless they can show it would be unreasonable to make the necessary modifications to allow you to return to work.

For further information on your rights or if you feel you are being discriminated against, contact the:

Resuming sexual activities

Many people who have had a heart attack or angina fear it will put a stop to their sex lives. This need not be the case. Most people who have had a heart attack or angina are able to resume normal sexual activity with no problems.

After you have been discharged from hospital, you are advised to gradually increase your daily exercise as you gain strength and confidence, pacing yourself, as you feel most comfortable. This applies to all your activities, including sexual intercourse.

Many people have concerns about having sex after a heart attack. Some frequently asked questions include the following:

I don’t feel like having sex. Is this normal?

It is very common for people who have heart problems to experience a temporary loss of sex drive. This is normal and will return, given time. Many people and their partners feel anxious and frightened about having sex after heart problems. If, after reading this page, you are still experiencing anxieties and concerns, then contact your cardiac rehabilitation nurse for further advice and support.

How demanding is sex on the heart?

Having sex can increase the heart rate and blood pressure. The maximum heart rate with sexual activity is approximately 120 beats per minute. This is similar to climbing two flights of stairs or walking about 300 yards on the level. If sex does bring on angina, taking a GTN spray or tablet, beforehand, will usually prevent chest pain or discomfort.

When can I resume sexual intercourse?

Sexual activity can begin once modest levels of activity become part of your normal lifestyle. If you have made a good recovery after your heart attack, it is safe to resume sexual activity when you feel ready, usually after about four weeks. The risk of you having another heart attack is very small, but is slightly higher than for someone who has never had a heart problem. If you are physically active, the chance of sex bringing on another heart attack is only 2.5 in a million.

I am unable to maintain an erection. Why?

Erection problems were once thought to be caused most commonly by psychological or emotional reasons, such as the breakdown of a relationship, worries about work or just general stress. We now recognize that physical ailments, such as heart disease, high blood pressure or diabetes, can also cause erection problems. Men with heart disease, high blood pressure or narrowed arteries may notice a slow but continuing change in being able to achieve or maintain an erection. The same process, which can cause heart disease and linked conditions, also affects the penis. When arteries in the general circulation become blocked, blood flow, which is necessary for an erection, is restricted to the penis as well.

I am being treated for heart disease, and have erection problems. Is my medication to blame?

You may have noticed erection problems starting around the same time as your doctor prescribed treatment for a heart condition or high blood pressure. Certain medication can affect the ability to get or keep an erection (see the section on Medicine Treatment for more information). Your doctor can review whether there is a strong link between medication for

your heart condition and erection problems. Usually, changing your regular medication will not be the answer to improving your erections. Only your doctor can advise you on this. It is critical that you do not stop taking or change your medication without your doctor’s advice.

Is it safe to take medications for erection problems along with other medications?

You may have been prescribed with sildenafil (Viagra®), vardenafil (Levitra®) or tadalafil (Cialis®) for erection problems. Do not take these within six weeks of your heart attack. These are not safe to take if you have been prescribed nitrates (e.g. GTN spray or isosorbide mononitrate), nicorandil, nebivolol or doxazosin. Before taking Viagra® following a heart attack, consult your doctor to make sure it is still safe to do so. Always see your doctor rather than self-prescribing or obtaining them from another source.

Useful Addresses:

Part 4:

Additional information

Further investigations

During your hospital stay, your doctor may suggest that you have some tests or investigations. These investigations may occur during your stay in hospital or be carried out as an outpatient.

These tests are very useful for helping to diagnose heart disease and assessing the condition of your heart. The following is a list of common investigations.

A coronary stent

Glossary of terms

Further contacts

Health advice

Advice

Alcohol/drug misuse

Anxiety & Depression

Bereavement

Carers

Disability

Driving

Exercise

Information

Medication

Older people

PALS

Voluntary services/networks in Leeds

If you’re looking for support/assistance on discharge there is a vast amount available. You can get assistance with practical tasks such as shopping and gardening, assistance with checking benefits and completing the forms, social groups and drop-in centres to name a few.

These services are available through three main networks that can be accessed by telephone or on-line. They are:-

Community Cardiac Rehabilitation Teams Contact Numbers

Medication

You may find it useful to record information on your medication. In the PDF at the top of this page there is a section (on page 96), where you can use to fill out any information you have on your medication.

Personal Progress Section

You may find it useful to record and monitor your progress, blood pressures, cholesterol tests, weight, and medication on the charts (on page 98 of the PDF at the top of this page). Speak to your cardiac rehabilitation nurse if you need help or have any concerns.

Goals for a healthy heart

Stop Smoking
There are no safe limits

Control Blood Pressure (BP)
Aim for BP below 140/90* or 130/80 for people with diabetes.

Increase Physical Activity
Aim for 20-30 minutes of moderate intensity exercise most days.

Maintain Healthy Weight
Aim for BMI less than 25 or waist circumference less than 94cm – Men 80cm – Women

Eat Healthy Balanced Diet
Eat a Mediterranean style diet.

Drink Sensibly
Keep your alcohol intake to no more than 14 units per week split over at least 3 days.

Reduce your cholesterol
Aim for a total cholesterol less than 4mmol/L and an LDL cholesterol below 1.8mmol/L

*Please note, this target may differ depending on your health conditions.