Cardiology

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 schedules.”

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 triglycerides;
• 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.”

Dietary changes

Patients are often confused about what to eat after they have an MI, Collins said.

“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 preferences.

“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 fat;
• 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 be plant-based.”

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.

Exercise recommendations

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 life.”

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 and dyslipidemia.

“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

GISSI-Prevenzione Investigators. Lancet. 1999;354:447-455.

Lichtenstein A. Circulation. 2006;114:82-96.

Salisbury A. Am J Cardiol. 2011;doi:10.1016/j.amjcard.2010.12.005.

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