The Heart Manual Revascularisation Edition
A six-week programme for healthy living for people recovering from coronary angioplasty (stent) or bypass surgery.
How to use the Manual Part 1:
Your Heart Condition: the Facts (pages 9–22) This part is for you to read in the first days after your angioplasty (stent), or bypass operation. It is called:
Starting your recovery
It tells you the plain facts about your heart condition. You should read this section first, and you might want to come back to it a few times over the coming weeks. If you live with someone, get them to read this section, too. It can help them just as much as it helps you.
The Weekly Programme (pages 23–138) 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 ■ 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 139–175) This part provides extra information about your recovery, medicines, wound healing, and other things you might want to know. You can read it right through or dip into it to answer your questions.
The Heart Manual: Revascularisation 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 people in the first weeks after their angioplasty (stent) or bypass operation. 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. In 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 Name Contact phone number Community (home) Facilitator Name Contact phone number
Important message If you know someone else who has a heart condition, please do not show them this Manual or the CD. 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 Condition: the Facts
Starting your recovery What this Manual is for?
Starting your recovery
This Manual is designed to help you to make important changes to your lifestyle which can improve your coronary artery disease. By changing the way you live, you can: ■ feel much better ■ reduce the chance of having further heart problems ■ improve the condition of your arteries ■ help to prevent other health problems The Heart Manual was originally designed for people who have had heart attacks. For many of them it has helped to transform their lives. Many of them are now fitter, happier and healthier than they were before their heart attack, and this makes them better able to fight off a lot of other diseases as well.
Who is this Manual for? The people who use this Manual all have the same heart condition – coronary artery disease. You will learn much more about this disease in the following pages and in the weekly programme in Part 2. Although everyone who is given this Manual has the same disease, they haven’t all had the same treatment. This Manual has been designed to help those who have had two different procedures: ■ Those who have had percutaneous transluminal coronary angioplasty or PTCA. This procedure might also be referred to as percutaneous coronary intervention or PCI. In many cases this procedure also includes the insertion of a stent OR ■ Those who have recently had a coronary artery bypass graft operation. This operation is sometimes shortened to CABG – you may hear it pronounced ‘cabbage’ for short. To make things simple we shall either refer to angioplasty (stent) or coronary artery bypass graft (bypass) individually or refer to them both as ‘your procedure’.
You and your heart condition The first section of this Manual gives you the plain straightforward facts about your heart condition and the treatment you have had for it. It answers some of the questions that people usually ask. We suggest that you read through this section in the early days after your procedure. If you live with someone, they should read it, too. 11
As soon as you can – we suggest straight away after angioplasty (stent), or as soon as you get home after a bypass – move on to Part 2 (page 23) and start the weekly programme.
Starting your recovery
But please remember not to show this Manual to anyone else who has a heart condition. This is because: ■ their heart condition may have a different cause ■ 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 was the procedure that I had? Your procedure Before you had your procedure, your cardiologist or surgeon will have explained in some detail what was going to happen. People are often rather anxious at this stage, and sometimes find all the information too much to take in. Doctors also sometimes use complicated and difficult language which some people find hard to understand. Don’t be afraid to ask them to explain again if you are unsure what they mean.
Why did I have one procedure and not the other? The main reason why people have either procedure is to improve the circulation of blood through the arteries in their heart. Both procedures have been proven over many years to work well. Angioplasty (stent) is done by the cardiologist, most often as a follow-on at the same time as an angiogram (X-ray) investigation. If angioplasty (stent) was not suitable for you, you may have been referred to a surgeon for a bypass operation. The reason you have had one procedure and not the other depends on many factors, such as: ■ how many narrowings there were in your arteries ■ where the narrowings were and how severe they were ■ your previous medical history ■ which procedure was best for you. If the person in the next bed or your neighbour or a relative has not had the same procedure as you, this doesn’t necessarily mean that your condition is better or worse than theirs. It’s just a different treatment. Some people have both. Try not to compare yourself with other people. 12
Why … ? How … ? When … ? You probably have many more questions to ask. It may help to write them down here and ask them the next time you speak to your doctor or facilitator. Write down the answers, too. Don’t be afraid to ask what you think is a ‘silly question.’ It is important to get questions cleared up so that you don’t dwell on them. Your doctor or facilitator will have heard it before!
Part 2 The Weekly Programme
Week 1: The Programme Begins Welcome to the first week of your 6-week recovery programme
In this first week we shall: ■ answer some more questions about your condition and why you feel the way you do ■ introduce you to the Exercise and Relaxation Plans which will play an important part in your recovery and afterwards ■ look at some of the things which might be worrying you, and show you how you can fight back. ■ if you live with someone, get them to read this section - it can help them as much as it helps you.
I still don’t feel well After an angioplasty (stent)
You should notice quite quickly that your symptoms have improved. Any bruising in the place where the catheter was put in will gradually settle, but if you notice any increase in pain, redness or swelling, tell your doctor.
After a bypass operation
Even though your heart has a new blood supply, it will take a few weeks for you to feel more energetic. An operation can often make you feel very tired afterwards because your body is using so much of its energy to heal your wounds. In these early stages be sure to pace your activity to avoid getting over-tired. Try to take a nap after activities like eating or going for a walk. It’s important not to be too worried if you feel tired or breathless – this will gradually improve with time. However, if it becomes worse rather than improving, you will need to contact your doctor. After a major operation it is quite natural to notice a lot more sensations coming from the chest or stomach. This may be because you are paying more attention to that area. Some of these feelings would have passed unnoticed before your operation. It’s normal to feel pain or discomfort from the wound in your chest. If a blood vessel was taken from your arm or leg it may feel sore and puffy for a while. Gentle exercise and elevating the area while sitting will help to reduce the swelling. If you have been given a support stocking remember to wear it as recommended.
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 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 exercises continue on the CD. It contains 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
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.
To help your recovery by lowering your adrenaline levels. If you keep listening to the CD twice a day this will happen automatically.
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
As the first step in learning to control stress, you need to learn ways of using relaxation in real life.
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 CD, you should find plenty of tension to get rid of.
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.
Try it now
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. 50
Relaxation is good for everyone. It is good for both the body and the mind.
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 further heart related problems. Now read John McKay’s story.
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
Notice when you are getting tense.
■ Then do any of the rapid relaxation techniques on
Remember the feelings of relaxation.
■ Now bring back that mood whenever you want to during
watch that can beep every hour, set it and check your tension when it beeps. relaxation CD. the day.
Do more of the things that ■ When you are enjoying yourself like this you you enjoy and do just for fun. 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 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. 77
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 if you have recovered fully. Please refer to page 135 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 39) 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
Week 5: Feeling More Like Yourself? Week 5 - as you work towards the end of this programme you may be feeling more like your old self
Here’s what the Manual programme covers in Week 5
This week you should keep up your regular exercise and relaxation. Hopefully you are beginning to feel the benefits of your procedure. This is Week 5 of the 6-week programme, but it doesn’t mean that it is the beginning of the end. Think of it as getting near the end of the beginning – of a new and healthier lifestyle than you led before. In Week 5 of the programme: ■ You’ll keep building up your Exercise/Activity Plan. ■ Remember to fill in your walking, exercise and activity record sheets. ■ Keep listening to the relaxation CD. ■ You’ll hear more about stress. If you are thinking more and more about diving back into a busy lifestyle, you’ll find some very useful advice about speeding, overworking and driven behaviour. ■ This week’s risk factor is lack of exercise. If you have been following the Exercise/Activity Plan you should already be seeing benefits from regular exercise, but this section goes into a little more detail about why it’s so important. ■ There’s a section about sex (if you’re interested).
The Exercise/Activity Plan By now you should be thinking about lifelong exercise
By now you should be really making progress with your Exercise/Activity Plan. Now’s the time to start looking ahead and thinking about lifelong exercise. Turn to page 122 for some suggestions about how to build exercise into your daily life.
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 procedure. Information:
■ what coronary artery disease is and what causes it ■ wrong ideas about coronary artery disease ■ how to fight back and reduce the chances of having further heart problems.
You have been helping your recovery and improving the strength of your body by using the Exercise/Activity Plan.
By now you should know from the Manual and the relaxation CD about all the different ways in which relaxation can help you. 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.
You have looked at some of the ways in which stress can affect you, and what you can do about it.
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.
You know that coronary artery disease 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 the after-effects of your procedure anxiety after a heart procedure – 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 much better. 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 in the future. Or you may still be feeling less than 100%. That’s only to be expected, so long as you don’t let it get you down. There is no ‘normal’ time for recovering. 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. 136
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.
What has happened over the last 6 weeks
Coping with setbacks (continued)
You may have had to deal with some breathlessness, infections, swelling and aches and pains. You may even have had to go back into hospital. If so, there is no reason for despair. Everything in the Manual remains just as true. Read through the true facts about coronary artery disease again to remind yourself. If your recovery has not been as quick as you had hoped, this doesn’t mean that the outlook is bleak. Far from it. There are many things that can be done to cope with the complications that sometimes arise.
Finally, you may like to try this checklist How many of these things are you doing to protect yourself? I am reducing my risk factors by: ❑ stopping smoking ❑ reducing smoking ❑ reducing fat consumption ❑ losing weight ❑ eating less ❑ exercising more I am lowering my blood pressure by: ❑ relaxing ❑ losing weight ❑ reducing salt intake ❑ exercising more
I am eating more: ❑ fruit and vegetables ❑ fish ❑ wholemeal bread ❑ high-fibre cereal ❑ beans and lentils ❑ wholemeal rice and pasta I am eating less: ❑ red meat ❑ bacon ❑ crisps, cakes and biscuits ❑ fried take-aways ❑ butter ❑ whole-fat cheese ❑ sugar ❑ and I’m drinking less alcohol
I am doing regular exercise: ❑ walking more ❑ cycling ❑ exercise classes ❑ other interesting and enjoyable exercise ❑ and I’m planning regular exercise or sport sessions in future I relax regularly by: ❑ using the methods on the relaxation CD ❑ using my own method ❑ using imagery ❑ using breathing exercises ❑ making regular times to relax ❑ finding new hobbies or interests (continued overleaf)
Part 3 Facts and Advice to Help Your Recovery
Wound healing Medicines Hospital tests Angina Other chest pain Breathlessness Hyperventilation Palpitation Anxiety about your coronary artery disease Low spirits (depression) Stress in relationships Sleep Patient Questionnaire The Exercise Plan
141 142 150 151 153 154 155 155 156 167 170 170 171 173-175 139
If you have had a bypass operation your wounds will take several weeks to heal fully. The wounds can feel tender and you may experience swelling and bruising. Sensations such as tingling, numbness and itching are also common at the wound sites. You may also notice a slightly hard lumpy feeling as the new tissue forms, along with a pulling sensation around the stitches as the wound heals. Most stitches do not need to be removed as they are dissolvable. Check your wounds daily, and call your family doctor or nurse if you notice any of the following: ■ increased redness around any of the wounds ■ oozing from the wounds ■ increased pain ■ excessive swelling or warmth of the wounds. What you can do to help your wounds heal Keep your wounds clean. Prevent the build-up of bacteria by showering daily. ■ ■ Avoid bringing your wounds into direct contact with perfumed soaps, shower gels, talcum powder, deodorant sprays, perfume or creams. ■ Get plenty of rest and sleep, as the healing process takes place during this time. ■ Protect your wounds from injury. ■ Wear loose, comfortable clothing next to your wounds, preferably made of cotton. Avoid wearing clothes made of wool or ‘fluffy’ materials that have loose fibres, as these can stick to your wounds and cause discomfort, as well as slowing down the healing process. ■ Ensure that you have a well-balanced diet that contains protein (e.g. lean meat and fish), calcium (e.g. low fat dairy products), vitamins and minerals (e.g. fruit and vegetables). ■ Do not poke, pick or scratch your wounds. ■ Do not use any dressings other than those advised by the doctor or nurse. ■ Do not expose your wounds to sunlight for at least 6 to 8 weeks. Then use a protective sunscreen lotion. Breastbone healing It takes at least 3 months for the bone to fully heal so avoid pushing down on your arms to help you get out of bed or a chair. It is also important that you avoid heavy lifting, pushing or pulling during this time. It is common to feel as if your breastbone is moving slightly or to hear a slight cracking sound. This will disappear as the bone settles and begins to heal. If you notice that your chest is becoming more painful or these symptoms are getting worse speak to your doctor. It is normal to feel a little uncomfortable around your shoulders and neck. Try to sit up straight using cushions for support and remember to regularly move your arms and shoulders to help reduce stiffness. Remember to follow the advice given to you by your physiotherapist. You may have been given advice on ways to reduce pain especially when coughing or sneezing as well as breathing exercises. Swelling You may experience some swelling of your arms or legs particularly if you have had a blood vessel taken from this area. This is quite normal. To reduce this, it is helpful to raise the affected parts, particularly when sitting, and avoid crossing your legs.