Page 1

The Heart Manual Post Myocardial Infarction (Post MI) Edition

Put your heart attack behind you with this six-week programme for healthy living

How to use the Manual Part 1:

Your Heart Attack: the Facts (pages 9–16) This section is for you to read while you are recovering. It is labelled like this:

Starting your recovery

It tells you the plain facts about your heart attack. You should read this section first, and you might want to come back to it a few times during your recovery. If you live with someone, get them to read this section, too. It can help them just as much as it helps you. You should also listen to the ‘Questions and Answers’ CD.

Part 2:

The Weekly Programme (pages 17–132) This part consists of six weekly sections. The weeks are clearly labelled like this:



Each weekly section has important information to help you to recover, and an exercise programme to help you back to fitness in easy stages. Every day: ■ follow your plan morning and evening as advised by your facilitator

Part 3:

Each time mark your activities in the charts provided

practise relaxation by listening to tracks 1 and 2 on the relaxation CD.

Facts and Advice to Help Your Recovery (pages 133–171) This part provides extra information about your recovery, medicines and other things you might want to know. You can read it right through or dip into it to answer your questions. 7

The Heart Manual: Post MI Edition Not just a book This Manual isn’t just a textbook of information. It is a proven rehabilitation tool – an important part of your treatment which has been demonstrated to help many people in the first weeks after a heart attack. It is designed for you to use as you wish and for you to adapt to your needs, with regular support. This Manual has been given to you by a healthcare worker (usually a nurse) who has been specially trained to work with patients using the Manual. We call this person a facilitator. During the first 6 weeks at home, you will be contacted by another facilitator. He or she can discuss with you how you are getting on with the Manual, answer any questions you may have, and discuss future contact dates and times. You might like to write down the names of your facilitators here: Hospital facilitator

Facilitators r us

Name Contact phone number Community (home) facilitator Name Contact phone number

Important message If you know someone else who has had a heart attack, please do not show them this Manual or the CDs. Do not advise them to do any of the exercises or give them advice from the Manual. You may be very tempted to help them, but please don’t. Instead of helping them you may harm them. This is very important because they may have a different or much more serious kind of heart condition. Your advice may be wrong for them and you may cause them harm. There is no way that you can guess about this. This Manual is only suitable for people who have been advised to use it by trained healthcare staff. None of the advice in this Manual is intended to replace any advice that you are given by your doctor. 8

Part 1 Your Heart Attack: the Facts


Starting your recovery

Recovering You and your heart attack

The first section of this Manual gives you the plain straightforward facts about your heart attack and answers some of the first questions that people usually ask. We suggest that you read through this section while you are still in hospital. If you live with someone, they should read it, too. If you don’t receive the Manual until you are back home, read this first section now, and then move straight on to Part 2 (page 21) and start the weekly programme. But please remember not to show it to anyone else who has had a heart attack. This is because: ■ their heart attack may have been caused in a different way ■ they may have a much more serious problem than yours ■ the advice may be wrong for them. Only a healthcare professional can decide this.

What is a heart attack? Many people believe that a heart attack occurs because the heart is ‘worn out’ or has ‘packed up.’ This is completely untrue. The fact that you have had a heart attack doesn’t mean that your heart is worn out or that you are ‘finished.’ Your heart is a muscle which pumps blood around your body. Like all muscles, it has its own blood supply through arteries which run over its surface. These are called coronary arteries. Heart attack

If one of these arteries becomes blocked suddenly, part of the heart muscle will be starved of blood and will become damaged. Doctors call this a myocardial infarction. Most people call it a heart attack.


Part 2 The Weekly Programme


Why is exercise so important? Exercise can:



■ help to prevent more heart problems in future ■ help increase the blood flow to the heart muscle, ■ reduce stress, make you feel happier and help you to sleep better ■ help to reduce your blood pressure ■ help you to lose weight – but you must change your eating habits as well ■ help to lower your cholesterol level ■ help to reduce angina and breathlessness ■ reduce aches and pains from joints and muscles. Below are some of the activities that people who have had a heart attack have taken up. Tick any that you think might interest you. Add any others that you think you might like to try. But only think about them this week – we don’t suggest you try them until later on in the programme, when you are feeling better.

Playing darts in the pub may be enjoyable and is therefore good for you, but it doesn’t count as exercise!

❑ ❑ ❑ ❑

Hill walking Jogging Bowling Cycling

❑ ❑ ❑ ❑

Swimming Badminton Football Dancing

❑ ❑ ❑ ❑

Exercise classes ........... ........... ...........

Remember that if your exercise does not make you slightly out of breath, it won’t make you fitter. This is why you may not be as fit as you think even if you have an active lifestyle.

Exercise/Activity Plan On page 40 of the manual you will find advice about how to start your walking plan. On pages 169-171 you will find a set of five exercises and some stretches Read the instructions carefully and if there’s anything you don’t understand, ask your facilitator about it. You should do your exercise/activity plan regularly. A walking and exercise record in each weekly section of the manual will help you to decide if it is time to do a little more. The plan is in four stages.


Stage 1

Week 1

Getting started on your plan

Stage 2

Week 2 onwards

Gradually building up your plan

Stage 3

Week 5 onwards

Thinking about lifelong exercise/activity

Stage 4

Week 6 onwards

Regular lifelong exercise/activity




What can relaxation do for me? It has been proved to help people to recover from a heart attack. It is the first step in learning to control stress. Relaxation has many benefits ❑ ❑ ❑ ❑

for health, as well as helping you to: reduce stress cope with problems increase your feeling of being in control lower your blood pressure and heart rate.

It takes time. At first it may seem that very little is happening – but stick with it! Relaxation can also: ❑ reduce pain ❑ help you to get good refreshing sleep ❑ help you to cope better with work ❑ help to reduce tension ❑ help you to stop smoking if you are a smoker ❑ help if you have given up smoking and feel tense ❑ reduce fears and anxieties ❑ help you to keep calm in difficult situations ❑ help with sport – many top sportsmen and women employ psychologists to teach them relaxation; it improves their control, their concentration and their stamina ❑ reduce angina.

How long does it take? It takes most people about 12–16 weeks to get the full benefit of relaxation

To start with, you should practise for 20 minutes twice a day. Eventually it will become quite natural – you will be able to do it whenever, or wherever, you want. It’s like learning any new skill – for example, driving, swimming, playing snooker or knitting – it takes time to get good at it. In time, you will be able to relax quickly, anywhere, without using the relaxation CD.


It’s a mistake to be impatient – you can’t relax if you are trying to force it to happen. People who practise get good at it.




Last week you were listening to two different ways of relaxing on the relaxation CD. This week, please go on listening at least once a day to whichever method you find best. If you like them both, listen to them both. To get the full benefits you should go on listening regularly for at least 12 weeks. The relaxation course continues on the relaxation CD. It includes several other ways of relaxing that you may find useful. You may choose to listen to them all now, but they will probably be more effective if you work through them in the order suggested on the CD.

Two reasons for learning relaxation

1 2

To help your recovery from the heart attack by lowering your adrenaline levels. If you keep listening to the relaxation CD twice a day this will happen automatically. As the first step in learning to control stress, you need to learn ways of using relaxation in real life.

The rapid relaxation exercises are some of the ways that you can do this. It is important to learn to do them without the CD. Then you will be able to use them whenever you want – at home, at work, on a bus or on a plane. Wherever you are and whenever you feel tense, angry or frustrated you will be able to control your adrenaline level.

The other thing that is important is to avoid carrying any spare muscle tension around. We usually don’t notice this. It’s only when you

check your body that you notice the tension. If you check as often as possible during the day, you will find that you become a more relaxed person.

Try it now Can you relax your shoulders a little more? Let them slump down. Can you relax your face a little more? Let the lines smooth out in your forehead, and relax your jaw. Can you relax your arms and your hands a little more? Let your hands spread open and relaxed. If you go through all your muscles as it describes on the relaxation CD, you should find plenty of tension to get rid of. Try to do this each time you look at your watch, or look out of the window, or look in your driving mirror. You could stick a small Post-it note to these things to remind you. If you notice feelings of anger or frustration, do it then.

After you’ve relaxed yourself, think: Is it really worth getting anxious, cross or upset about it? If it is, then go ahead, but you will probably find that a lot of the time it isn’t, and that it was just tension inside you that made it seem so bad, or so annoying, or so important.

Sometimes people who are learning relaxation find it difficult to get started. It can be hard to find the time or to concentrate. It is important not to give up. Discuss your feelings with your facilitator, who may be able to help. 44

Relaxation is good for everyone. It is good for both the body and the mind.

Worrying after a heart attack



Try this quiz to see how much you are affected by worry Tick the answer on the right that best describes you

I get sudden feelings of panic:

❑ ❑ ❑ ❑

a lot occasionally hardly ever not at all

I get a feeling that something awful is going to happen:

❑ ❑ ❑ ❑

a lot occasionally hardly ever not at all

I put off doing things that I could probably do straight away:

❑ ❑ ❑ ❑

a lot occasionally hardly ever not at all

I am having unpleasant thoughts about my heart attack:

❑ ❑ ❑ ❑

a lot occasionally hardly ever not at all

If you ticked ‘a lot’ for any of these things

Have another look at pages 33 and 34 in Week 1. There is more about this subject on pages 152–162 in Part 3 of the Manual.

If you ticked ‘occasionally’ for one or more of these things

If you would like to know more about why it happens, read pages 152–162 in Part 3 of the Manual.

If you ticked ‘hardly ever’ or ‘not at all’ for most of these things



You can fight back



by reducing your risk factors You need to know It’s a lot to take in. So we’re cutting it up into handy-sized chunks much more about over this week and the future weeks of this Manual programme. risk factors. Each week we shall take a detailed look at one of the main risk factors. These are: This week: Smoking Week 3: Diet Week 4: Being overweight Week 5: Lack of exercise Week 6: High blood pressure This doesn’t mean that you should be reducing your risk factors in chunks. If you can, start to make the changes now. Right now you should: ■ stop smoking (or don’t restart) ■ eat a healthy diet ■ follow the Exercise/Activity Plan in the Manual. These things will help your recovery and dramatically reduce your chances of having another heart attack. Now read Jim McGuire’s story.


Exercise/Activity Plan



Gradually building up your plan How much activity should I be aiming for? It is important to take your time and build up your activity gradually. This may mean taking regular smaller walks throughout the day rather than one longer one. The general recommendations are to increase your physical activity until you are doing at least 30 minutes of exercise on at least 5 days of the week. The activity should make you breathe faster and feel warmer. For some people this may take several weeks or longer to achieve.

Are you ready to increase your walking target? Look at your walking records for the last two weeks. Have you been achieving your target?

■ Remember it is important to keep building up your walking ■ Think about the walk you are doing, can you increase this by either walking a bit further or by increasing the pace during part of it? ■ Remember you are aiming to breathe faster and feel a little warmer. ■ Remember this needs to be a walk you can do every day. ■ Some people prefer to walk indoors if the weather is bad. Perhaps you may wish to try walking around a shopping centre or museum, but remember you are there to do your walk. ■ Keep filling in your walking record. ■ There is a chart for recording your walks similar to the exercise record. After you have done your walk, note down your level of effort by placing a cross on the chart. If you have scored ‘easy’ or ‘hard’ for 2 days in a row you should choose a new distance that is halfway between ‘fairly easy’ and ‘fairly hard’.

If you are unsure about setting an achievable target or need some more specific advice speak to your doctor or facilitator.


How to become a relaxed person in three easy stages



1 Learn to spot when the stress level is building up. One of the problems about being under stress is that we may be the last person to notice it. To other people we may seem like this: ■ ■ ■ ■

always rushing impatient a nag always critical of others and self

■ ■ ■ ■

no sense of humour forgetful sudden changes of mood hate sitting doing nothing

■ unable to make decisions or stick to them ■ tense ■ quick to flare up ■ don’t really listen to other people.

We may think: ‘If they had all the things that I have to do and all the problems I’ve got they wouldn’t have time to sit around chatting. As for being bad-tempered, it’s no wonder I get like that with the kind of support and help they give me.’ Or we may think: ‘They’re right, but what can I do about it?’ … Read on!

2 Use relaxation and increase relaxing activities. Set aside a regular time for relaxing, one or more times a day.

■ This will automatically lower your stress levels.

Check your tension level regularly.

■ Think of something to remind you. For example, if you have a watch that can beep every hour, set it and check your tension when it beeps.

Notice when you are getting tense.

■ Then do any of the rapid relaxation techniques on the relaxation CD.

Remember the feelings of relaxation.

■ Now bring back that mood whenever you want to during the day.

Do more of the things that you enjoy and do just for fun.

■ When you are enjoying yourself like this you can’t be under stress.

3 Learn new ‘low stress’ ways of living and working. We often add to the stress we already have to cope with by: ■ ■ ■ ■

taking on more than we can possibly do never saying no to people always rushing thinking the worst about things.

■ never being satisfied with what we’ve achieved ■ not having enough relaxing things to do ■ trying to beat the clock.

In the next couple of weeks of the Manual programme we shall describe these ways of behaving and thinking. You may find that some of them ring bells with you. We’ll also suggest some different ways of working that can help to reduce the pressure we cause ourselves. 71

Week 4: Getting Better All The Time



You are into the second half of your 6-week programme. Most people are feeling much better by now.

This week you’ll carry on building up your regular exercise and doing regular relaxation. Most people at this stage are feeling considerably better and making good progress towards a full recovery. If you still don’t feel quite as well as you think you should, discuss your feelings with your doctor or facilitator.

Here’s what the Manual programme covers in Week 4

In Week 4 of the programme: ■ You will keep on building up your Exercise/Activity Plan. You should also be walking daily and increasing the frequency, speed and distance as advised. ■ Remember to fill in your walking, exercise and activity record sheets. ■ Keep listening to the relaxation CD. ■ There’s more this week about stress. Remember that although there’s no proof that stress itself can cause heart attacks, a stressful lifestyle can play a big part in building up risk factors. ■ This week’s risk factor is being overweight – a major problem for some people. But getting control of your weight can have a big benefit in reducing the risk of having another heart attack.

The Exercise/Activity Plan It’s time to review your Exercise/Activity Plan again. Ask yourself these questions: ■ How has your exercise gone over the past week? ■ How much progress have you made? Compare what you can do today with the same day last week. If your exercise is going OK and building up – well done! If not, try to think why and discuss it with your facilitator. Remember that if you have a medical or physical problem that makes it difficult to do some of the exercises, there are some suggestions in the section on ‘Exercise modification’ in Part 3 of the Manual (see page 170). 83

Getting control over your workload Can I skip this section of the Manual if I don’t have a job?

There’s a lot in the next few pages about WORK. When we talk about work we don’t just mean a job, because people in regular jobs aren’t the only ones who can lead busy, stressful lives. If you are at home looking after a family or caring for a disabled relative … or retired and doing voluntary work … or unemployed and looking for work … or in full- or part-time education … your life might be affected by stress. If it is, then the following pages should be of just as much use to you as to people in a conventional ‘job.’

✘ Constantly tense



The first thing to say is that once your doctor gives the OK, a normal day’s work will not harm you in any way. Please refer to page 129 in the ‘Back to work’ section for further guidance on this. Hard work will not cause any problems (unless your doctor has advised you that your work is too physically demanding). It is only when your Stress Thermometer (see page 33) is constantly around the tense level, or when you are feeling under constant pressure, that it becomes a problem. If you have a lot to do but you are enjoying it, feel confident and successful and have regular times when you can relax, you are protecting yourself from stress.

One of the reasons for feeling under pressure is knowing that we have got a lot to do but having no clear idea of how we are going to get it all done in the time available. The result is that we end up with a whole list of things rushing round in our minds, and life can become a nightmare. Even after work or when we should be relaxing, we suddenly remember other things that we have to do. This keeps the stress level high all the time. One solution is to put it all down on paper. This has several advantages. ■ Most people start to feel calmer as soon as they have written it down. Very often there isn’t as much to do as they thought. ■ You can decide which are the most important things. Most people find that several of the things on the list can be ignored. ■ You can relax, knowing that there is nothing that you’ve forgotten about. ■ You can use your time in the most efficient way.

✔ Busy, excited, coping well


What has happened over the last 6 weeks



Over the last 6 weeks we have covered all of the most important things that you need to know about and to do after a heart attack. Information:

■ ■ ■ ■


You have been helping your recovery and improving the strength of your body by using the Exercise Plan.


By now you should know from the Manual and the relaxation CD about all the different ways in which relaxation can help you.

what a heart attack is and what causes it what coronary artery disease is and what causes it wrong ideas about heart attacks and coronary artery disease how to fight back and reduce the risk of having another heart attack ■ what to do if you think that you may be having another heart attack.

You should be able to notice tension developing and have ways to reduce it. Make these a part of your life without the relaxation CD.

Stress reduction

You have looked at some of the ways in which stress can affect you, and what you can do about it.

Risk factors

You have looked at the main controllable risk factors and how to control them. These risk factors are smoking, poor diet, being overweight, lack of exercise and high blood pressure.

Other worries

You know that having a heart attack doesn’t mean that you have to give up the more enjoyable things in life, like alcohol, eating out and sex.

You may also have used Part 3 of this Manual to find out more about:

■ ■ ■ ■ ■ ■

medicines – what they do for you and their side-effects treatments you may have had or may be waiting for anxiety after a heart attack – why it happens and how to cope stress in relationships angina, other chest pains and palpitations low spirits and how to reduce them.

Coping with setbacks By now you may be feeling fully fit. You may be wondering what all the fuss was about. That’s fine, so long as you don’t forget about the things you need to do to protect yourself from having another heart attack. Or you may still be feeling less than100%. That’s only to be expected, so long as you don’t let it get you down. There is no ‘normal’ time for recovering from a heart attack. Indeed we wouldn’t expect some people to be fully fit for some months yet. Week by week you will be getting stronger. Sometimes you may feel as if you have stopped making progress. It’s only when you look back a few months later that you can see that this isn’t the case. 130

If it begins to worry you, look back over your activity or exercise sheets or discuss your feelings with your facilitator. See how much more you can do now compared with what you could do before.

Part 3 Facts and Advice to Help Your Recovery



Medicines Chest pain Angina Breathlessness Hyperventilation Palpitation Hospital tests Treatments Anxiety Low spirits (depression) Stress in relationships Patient Questionnaire The Exercise Plan

135 143 144 147 148 148 149 150 152 163 166 167 169



Medicines (continued)

Here is a summary of the main medicines and what they can be used for.

Reduce risk Antiplatelet agents Beta-blockers Statins ACE inhibitors or ARB's

✔ ✔ ✔ ✔

Treat risk factors

Potassium-channel activators

Blood pressure

✔ ✔ ✔

✔ ✔ ✔

Anti-arrhythmics Anticoagulants

✔ ✔

Blood pressure

Blood pressure


Improve heart Treat the as a pump heart rhythm


Nitrates Calcium-channel blockers

Treat angina

If you think it would be helpful, fill in the following table with the names of your medicines, the type of medicine, why you are on it, how long for, and any questions. Then ask your doctor or facilitator to help you fill in the blanks! Name of medicine Type of medicine Why am I on it? How long for? Questions

Name of medicine Type of medicine Why am I on it? How long for? Questions


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