After an MI, most patients are advised by their cardiologists regarding
the different lifestyle changes they should make to prevent another MI.
The experience of having an MI has changed considerably in the United
States, according to Richard E. Collins, MD, cardiologist and director
of wellness and prevention at South Denver Heart Center in Littleton, Colo.
“In 1955, when President Eisenhower had an MI on Sept. 23, he did
not return back to work until Nov. 11, after at least a month of bed
rest,” Collins told Cardiology Today. “That used to be the standard
of care. Now, people go to the hospital, receive a stent and are in the
hospital for only 2 days. It’s just a minor interruption to their
According to Collins, there has been a drop in mortality after an MI.
The average hospital mortality after an MI is just 15.8%, a big reduction from
the 30% to 40% mortality seen in the 1970s.
“When an event like an MI happens, there is an awakening in
patients, who rebound and say ‘I’d better start taking care of
myself,’” Collins said.
In 2006, the American Heart Association released an updated scientific
statement on diet and lifestyle recommendations to prevent CVD. The
recommendations are as follows:
- Consume an overall healthy diet;
- Aim for a healthy body weight;
- Aim for recommended levels of LDL and HDL cholesterol and
- Aim for a normal BP;
- Aim for a normal blood glucose level;
- Be physically active;
- Avoid use of and exposure to tobacco products.
“Many of the risk factors that led patients to their MI are
treatable with lifestyle changes, in addition to pharmacologic therapy,”
said Vera A. Bittner, MD, MSPH, professor of medicine and section head
of preventive cardiology at the University of Alabama at Birmingham. “That
puts the patient in control of their own destiny to some degree, but it also
means that they have to actively participate in their treatment.”
Patients are often confused about what to eat after they have an MI,
“This is the first thing they will consider when they arrive home
after an MI,” he said. “They will go into their kitchen and say,
‘What do we do next?’ Then they start to consult the diet books. We
as cardiologists have made a mistake by talking in the negative, as in
don’t eat this, can’t do that. Pretty soon, the patient is saying,
‘Well, what can I eat?’”
According to Bittner, dietary recommendations after an MI should be
individualized because people have different baseline diets and different
“We tend to follow the ‘TLC’ [Therapeutic Lifestyle
Change] diet that is recommended by the Adult Treatment Panel III of the
National Heart, Lung, and Blood Institute,” Bittner said. “We also
recommend salt restriction, especially in patients with hypertension.”
The TLC diet includes the following recommendations, including consumption of:
- Less than 7% of the day’s total calories from saturated
- 25% to 35% of the day’s total calories from fat;
- Less than 200 mg of dietary cholesterol a day;
- Limit sodium intake to 2,400 mg a day; and
- Just enough calories to achieve or maintain a healthy weight and
reduce blood cholesterol levels.
After an MI, Collins said he recommends that patients reduce their
intake of fat and cut back on “inflammatory foods,” which are foods
that are high in fat, not cardioprotective and high in cholesterol. A diet of
“anti-inflammatory foods” includes more of a plant-based,
Mediterranean-style diet, which helps expand and dilate the arteries.
“Eat good quality fresh food, smaller portions and mostly plants,
which is the basis of a Mediterranean diet,” he said. “I’m not
saying that people should be vegetarians, but the majority of the diet should
Collins also said he recommends that patients get a higher amount of
fiber because it helps to bind up cholesterol, and to add plant sterols for the
blockage of cholesterol uptake.
In a 1999 study published in The Lancet, researchers of the
GISSI-Prevenzione trial in Italy analyzed the effect of omega-3 fatty acids in
MI survivors. They found that supplementation with the omega-3 fatty acids
lowered the risk for death, non-fatal MI and stroke. Fish oils contain the key
fatty acids eicosapentaenoic acid and docosahexaenoic acid. Collins recommends
that his patients consume at least 1 g of fish oils per day.
According to the 2006 AHA scientific statement on diet and lifestyle
recommendations, physical activity is an important component to maintaining CV
fitness in adults. But after an MI, a patient’s path to regular physical
activity should be individualized.
“Within a week or two of an MI, I recommend that patients undergo
cardiac rehabilitation,” said Michael H. Davidson, MD, clinical
professor and director of preventive cardiology at University of Chicago
Pritzker School of Medicine. “It has been shown that starting exercise
under supervision is a lot more effective. There is good documentation that
these programs result in improved cardiac function and improved quality of
According to Davidson, cardiac rehabilitation programs typically run for
12 weeks, three times a week, in a cardiac rehabilitation center. The benefit
of cardiac rehabilitation is that it is designed specifically for the patient.
Bittner added that ideally, “all patients should attend cardiac
rehabilitation programs after an MI, which provides individualized exercise
prescriptions tailored to age, physical fitness, preferences and comorbidities,
like arthritis and prior stroke.”
Adhering to changes
According to an AHA scientific statement, even modest sustained
lifestyle changes can substantially reduce CVD morbidity and mortality.
However, although interventions to change dietary patterns, encourage weight
loss and encourage more physical activity initially start off well, these
changes are often not carried out as long-term behavioral maintenance.
In a recent study published in the American Journal of
Cardiology, for example, researchers analyzed patients’ fast food
consumption 6 months after treatment for MI. They found that among the 2,481
patients enrolled, 503 of these (20%) reported frequent fast food intake after
their MI. Factors that were independently associated with fast food intake
included male gender, white race, lack of college education, current employment
“I have some patients who made rather dramatic lifestyle changes
and are now in better overall health after their MI than they were
before,” Bittner said. “There are, unfortunately, many patients who
do not attempt lifestyle changes, and many who attempt them are not able to
sustain them. It takes support at all levels: workplace, home, friends and
family, and physician reinforcement.”
Aside from dietary and exercise changes, one of the key changes that
patients should make after an MI is stress management.
“When we look at the people who survive the longest after an MI, we
find that the more they practiced yoga or did other stress management
technique, the better their arteries,” Collins said. “Stress
management is almost more important than exercise and diet. Stress is
definitely a killer; there is no question about it.”
Bittner said people can learn how to cope with stress.
“Many cardiac rehabilitation programs provide coping classes or
collaborate with a clinical psychologist to help patients deal with stress and
deal with their illness,” she said. – by Emily Schafer
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Lichtenstein A. Circulation. 2006;114:82-96.
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