Heart Attack What's Ahead

A GUIDE FOR HEART ATTACK SURVIVORS AND THOSE WHO LOVE THEM

Product # 28C

Order this book from : PRITCHETT & HULL ASSOCIATES, INC. 3440 OAKCLIFF RD NE STE 126 ATLANTA GA 30340-3006

or call toll-free: 800-241- 4925 Copyright© 2025

by American Heart Association, Inc., a 501(c)(3) not-for-profit and Pritchett & Hull Associates, Inc. All rights reserved.

No part of this book may be photocopied, reprinted or otherwise reproduced without written permission from Pritchett & Hull Associates, Inc. Published and distributed by: Pritchett & Hull Associates, Inc. Printed in the U.S.A.

A GUIDE FOR HEART ATTACK SURVIVORS AND THOSE WHO LOVE THEM

This book is to help you learn about your heart.

It should not be used to replace any of your doctor’s advice or treatment.

Appreciation is expressed to the original authors of this book, formerly published as Heart Attack, What Now, and to the many reviewers, patients and families that have helped us develop this book since its first printing.

We believe that you have a right to know as much as you can about your health. Our goal is to give you enough facts to get the main points clearly in mind. We do this with medical accuracy and warmth. The result for you: less tension, more healing and a good idea of what to ask your doctor, nurse or others on your health care team.

2

Introduction A heart attack occurs when blood flow to the heart muscle slows down or stops for a period of time. Why this happens and what you can expect are explained in this book.

It will tell you: ● what causes a heart attack ● options to stop some heart attacks ● how the heart heals ● how a heart attack affects your moods and activities (including sex) ● the risk factors for heart disease

Few of us expect to have a heart attack, but it can happen. If it has just happened to you or a loved one, you may be glad to know this: Most people (over 90%) recover, but outcomes depend on the severity of the attack, promptness of treatment and the person's overall health. They get another chance to look at their lives, change some things and, perhaps, have a better life ahead.

As you recover, find out all that you can about your heart and * health.

We do not intend be sexist, but to keep the text simIf you still to have questions after reading this book, talk ple, we often say to your doctorwhen or nurse.

The more know about “he” or “him” talking about theyou person who has your had heart, the smoother your recovery will be.

3

Table of contents About the heart ......................................................................................................5-7 What is a heart attack? ................................................................................... 8-10 Early treatment for a heart attack ..................................................................11 How the damaged heart heals ......................................................................... 12 First days in the hospital ....................................................................................13 How serious is your heart attack? .................................................................14 Watching your progress ................................................................................15-18 Your moods ......................................................................................................... 19-20 What your family can do .............................................................................. 21-22 Getting stronger .............................................................................................. 23-24 Going home ........................................................................................................ 25-26 First steps ............................................................................................................ 27-31 What to do about angina ................................................................................... 32 Lowering the risk of another heart attack ......................................... 33-52 Establish heart-healthy eating habits ................................................... 34-39 Be physically active ....................................................................................... 40-41 Reach and keep a healthy weight .......................................................... 42-43 Get healthy sleep .......................................................................................... 44-45 Stop smoking ...................................................................................................46-47 Manage stress ....................................................................................................... 48 Lower your blood pressure ....................................................................... 49-50 Control your blood cholesterol ........................................................................51 Control your blood sugar .................................................................................. 52 Appendix ............................................................................................................. 53-64 Heart card ............................................................................................................... 53 Identifying any future heart attack ................................................................ 54 How to call for help for a heart attack ......................................................... 55 Simple exercises for your heart ................................................................56-57 Home walk program ............................................................................................ 58 Ways to relax ................................................................................................... 59-61 Home activity guide ..................................................................................... 62-64 4

About the heart The heart is a strong muscle about the size of a fist. It lies in the center of the chest and is tilted slightly to the left. The heart must pump blood, oxygen and nutrients to all parts of the body.

left side of the heart (pumps blood to body) right side of the heart (pumps blood to lungs) septum

A thick band of muscle tissue (the septum) divides the heart into 2 sides — the right side and the left side. Each has a different job in the heart’s pumping action. The right side of the heart only pumps blood to the lungs while the left side must pump blood to all other parts of the body. For this reason, the left heart muscle is thicker than the right.

5

Blood returns from the organs of the body and enters the right atrium. The atrium pumps the blood into the right ventricle, which pumps it to the lungs. Oxygen is picked up there, and carbon dioxide (a waste product) is breathed out. The oxygen-rich blood flows back into the left atrium. The atrium pumps the blood into the left ventricle, which pumps it through the aorta to the body.

blood flow going to the body

aorta

right atrium left atrium

right ventricle

6

left ventricle

left coronary artery

right coronary artery

circumflex branch

left anterior descending branch

The heart muscle gets its oxygen and nutrients from the blood that flows through the coronary arteries. The major branches of these arteries circle the heart and take blood into the heart muscle (myocardium).

The right coronary artery supplies the right atrium, right ventricle, the bottom of the left and right ventricles, and the back part of the septum. The left coronary artery has two branches, the circumflex and the left anterior descending, which supply the bottom and front of the left ventricle and the front part of the septum.

7

What is a heart attack?

When blood flow to the heart muscle is slowed or stopped and not quickly restored, there is damage to the heart muscle.

That’s a heart attack. This can happen if any of the coronary artery branches develop: ● fatty buildup or plaque (atherosclerosis*) ● or a blood clot (thrombus) ● or spasm Whichever happens, the result is the same: not enough blood and oxygen reaching the heart muscle. Without enough blood and oxygen, the heart muscle begins to die.

artery wall

blood clot cracks in fatty buildup

fatty buildup

* Atherosclerosis refers to a buildup of fatty deposits in the arteries. It is one type of arteriosclerosis, the medical term for “hardening of the arteries.”

8

Fatty buildup All body arteries suffer wear and tear after years of use. They become less elastic, and fatty layers build up along the artery walls. Over time, these fatty layers harden and restrict blood flow. If an artery is mostly blocked, the heart muscle may not get enough oxygen. When this happens, you may feel the symptoms known as angina pectoris. You may also have a heart attack. The symptoms of a heart attack are like those of angina, but they’re often more intense. The pain may be more widespread and may radiate down either arm. Most often, rest and nitroglycerin will not bring quick relief for a heart attack.

Angina often*, but not always, occurs days, weeks, months or years before a heart attack. Angina is most often felt when the heart is pumping harder than usual. This may be after a meal or during physical or emotional stress. You may feel tightness, squeezing or aching in the chest; pain or discomfort in the neck, jaw, upper back or arms; indigestion; shortness of breath, sweaty or dizzy.

Nitroglycerin and rest are the quickest ways to relieve angina. * Angina symptoms do not always mean a heart attack will occur. Some people only have angina once in a while. They may never have enough artery blockage to have a heart attack.

9

Blood clot Blood is naturally thick, and it flows easily through arteries that are smooth and not clogged by fatty layers. When a lot of fat builds up in an artery, blood flow slows down. Materials in the blood can stick to these fatty layers and start to form a clot. Once the clot closes off the artery, blood flow stops, and a heart attack begins. Coronary thrombosis is the name for a heart attack caused by a clot.

spasm

artery

blood flow stops

Spasm A sudden spasm in a coronary artery can cause angina or a heart attack. If the spasm only lasts a few minutes, brief symptoms of angina are likely. A longer spasm stops blood flow enough to damage the heart muscle.

The causes of artery spasm are unknown. Any artery can spasm at any time, whether a person is healthy or unhealthy. Chemicals such as nicotine or drugs such as cocaine may lead to coronary artery spasm.

10

Early treatment for a heart attack At the doctor’s office or hospital, one or more tests may be done to see if symptoms are due to a heart attack. An EKG* (ECG) records the electrical currents moving through the heart muscle.

If the EKG shows that a heart attack has just begun, your doctor may try to open the blocked artery before major damage happens.

Thrombolytic drugs (“clot-busters”) Since a blood clot is the common cause of a blocked artery, a drug may be given to see if the artery can be opened. These include t-PA, streptokinase, APSAC and urokinase. To be useful, the clot must be dissolved within the first few hours of heart attack symptoms (before a lot of heart damage occurs). Most of the time, the drug is given through an intravenous catheter (IV).

Sometimes it is given directly into the blocked coronary artery during an emergency heart cath.

Heart catheterization or percutaneous coronary intervention (PCI) Sometimes a heart catheterization is needed during the early part of a heart attack. It may help to see which artery is blocked. And giving the thrombolytic drug right on top of the clot may cause it to dissolve much quicker. Other times a balloon catheter is used to stretch the artery open, and a stent may be placed to keep the artery propped open. (See page 17.) Some patients can avoid major heart damage with one of these options. If damage has already occurred, though, the heart has its own way of healing. * electrocardiogram

11

How the damaged heart heals The heart begins to heal during the first few weeks after a heart attack. It heals in two main ways: ● by forming scar tissue ● by expanding the smaller blood vessels

expanding vessels (collaterals)

scar tissue damaged area that may recover

In time, scar tissue replaces the damaged heart cells, making the injured part of the heart muscle stronger. In 2 to 3 weeks, these arteries will be large enough to bring more blood to the surrounding tissues. These arteries are called “collateral blood vessels.” It may take these vessels several months to bring enough blood to the tissues around the heart damage.

12

First days in the hospital The hospital stay for a heart attack can vary. It may be as short as a few days (if the blocked artery is opened in time to prevent major damage). Most often, healing takes place over the next few weeks. The time it takes to return to normal activity depends on the size of the heart attack.

CCU

Medications

In the coronary care unit (CCU), continuous EKG monitoring is routine.

Your vital signs are checked often, and an IV is inserted. Also, you may be given oxygen.

After a heart attack, medications are often needed to: ● improve blood flow to the heart ● lower the body’s demand for oxygen ● treat or prevent irregular heart rhythms

Sometimes, drugs are needed to improve pumping action and to regulate blood pressure.

13

How serious is your heart attack?

The severity of a heart attack is measured by the amount of damage to the heart muscle. Certain blood tests can show a rise in blood enzymes (chemicals) after a heart attack. Damaged heart cells release these enzymes into the blood. In some cases, blood enzymes may be helpful to diagnose a heart attack and determine its size. Other times, the size of the heart attack can be decided by watching the heart’s pumping action. This action may be seen on a nuclear scan, echocardiogram, heart cath or from your vital signs/chest X-rays. The more damage there is, the harder it will be for the heart to pump the normal amount of blood. Even with moderate heart damage, there may be some temporary heart failure or weakness.

Also, there may be complications or other problems after a heart attack. These might include: ● irregular heartbeats (arrhythmia), which can be mild or serious, even life-threatening ● more heart damage caused by reduced oxygen in the heart muscle ● inflamed heart sac (pericarditis) ● blood clots moving from the legs to the lungs (pulmonary emboli) or to the brain (stroke)

14

Watching your progress A doctor or nurse will use a stethoscope to listen to the heart’s pumping sounds. Also, a lot can be learned about the heart by watching the veins in your neck or feeling your heart beat against your chest.

Chest X-rays Your doctor may order a chest X-ray to check the size of your heart and assess the condition of your lungs. Although chest X-rays do not directly show heart function, they can reveal signs that may suggest heart failure. When a large area of the heart is damaged, the remaining muscle often tries to work harder to maintain blood flow, which can lead to fluid accumulation in the lungs if the heart is struggling to pump effectively.

15

Checking pressures

Intra-aortic balloon pumping

Small tubes (catheters) can be put into the arteries or veins to check pressures in the heart and blood vessels.

This also helps a doctor decide which medicine will best improve blood flow.

When the heart is not pumping well, a small balloon may be used to help it pump. A catheter with a balloon on one end is inserted through a leg artery into the aorta. A pump on the other end of the catheter inflates and deflates the balloon with each heartbeat. The action of this balloon forces blood out through the aorta.

The intra-aortic balloon may be left in place for a few days.

balloon

catheter

16

Cardiac catheterization

Percutaneous coronary intervention (PCI)

A heart cath is often needed to find out how much damage has occurred or if future heart damage is likely. During this procedure, a catheter is used to inject dye into the heart.

Pictures can then be made of the coronary arteries and the heart’s pumping chambers. If a narrowed coronary artery seems likely to cause a large heart attack in the near future, bypass surgery or percutaneous coronary intervention (PCI) may be needed.

A catheter with a tiny balloon on the end is placed in the narrowed coronary artery. The balloon is inflated one or more times to try to flatten the fatty layers against the artery wall.

When successful, this creates a bigger opening inside the artery and blood flow improves. A stent may be placed at this time to prop open the artery.

stent

vessel

17

Bypass surgery A piece of vein from the leg or an artery from the chest is used to make a bypass. The bypass lets blood flow around the blockage to reach the heart muscle.

i 18

Neither PCI nor bypass surgery may be needed after a heart attack. (Either one may be useful later to open or bypass other narrowed arteries after the damage has had time to heal.)

Your moods There is no way to have a heart attack and not be upset by it. It interrupts your life and that of your family and friends. Not everyone will have the feelings mentioned on these pages, but it is normal to have some moody days.

19

Anxiety, anger The experience of a heart attack can make aassesses person anxious, angry, and provides treatment forunable problems in A communication, frustrated or to sleep. thinking skills and how the person can even deny that a heart patient attack occurred.

Thesewith feelings interacts others. are common He to anyone who hasassesses or she also had a major illness.

If your moods and treats swallowing problems that may occur during andisdrinking. are like this, theeating best cure to take recovery one day at a time.

Don’t think about next week or next month. Think about now.

While you are in the hospital, you will learn what your body can do.

Slowly, you will begin doing more.

In time, you will gain confidence in your body’s abilities.

Depression Depression, withdrawal and sadness are also common among people who have had heart attacks. Temporary moods such as these are even thought to be one step toward a full recovery. But if you are depressed for several days with no relief, your doctor may suggest medications and/or counseling. Everyone’s situation is different.

20

What your family can do A heart attack is almost as hard on the family as on the person who had it. The first shock is quickly followed by frustration and a desire to help in some way. So, here are some ways family members can help:

1. Be reasonably cheerful and hopeful. Share with the patient any encouraging news given to you by the doctors or nurses.

2. Be honest with your cares and feelings.

3. Be a listener. Encourage the patient to share feelings.

4. Handle with tact as many business and family concerns as

you can. This will let your loved one rest more easily while in the hospital. As you visit, try to share matters of interest so that the patient does not feel left out. If unusual stress occurs in your family, such as an accident, severe illness or death, ask the doctor or nurse if and when the patient should be told.

5. Observe visiting hours. Keep visits to a minimum.

It is important that the patient rest.

Find some way to keep friends and relatives informed. Consider using text, email and social media to help avoid the stress of too many calls to you or the hospital.

21

As a family member, you have a very important role in helping the patient recover at home.

This will be especially true during the first few days. To be ready for this, plan your time and hospital visits so that you will feel rested when the patient is discharged.

22

Getting stronger

Once the heart begins to heal, you can begin a few activities. It may seem simple and slow at first, but you will soon be able to do more.

Your heart needs time to form scar tissue and restore blood flow.

How much you do and how soon depends on: ● the size and complications of your heart attack ● your activities before the heart attack ● how your heart responds to increases in activity You may be asked to exercise on a treadmill or stationary bicycle while a doctor watches the action of your heart. This helps them test your heart’s response to low-level activity and plan your recovery activities better.

23

This chart gives you an idea of how your activities will be increased in the hospital.

Stage 1 (likely in CCU)

Stage 2 (after CCU)

Stage 3 (toward the end of hospitalization)

hygiene

help bathing and shaving; use of bedside commode

bathe yourself (with help, if needed) at bedside or tub; bathroom privileges

bathe yourself (at bedside or tub); may shower when doctor permits

chair/ walking activity

limited time in a chair

longer time in a chair; walking in room

walking outside your room on level surfaces

visitors

limited

moderate precaution with visitors to avoid fatigue

moderate precaution with visitors to avoid fatigue

exercise (for some patients)

bedrest with arm/leg exercise or low-level self exercise

supervised arm and leg exercises

supervised and unsupervised arm and leg exercises

Your doctor will give you guidelines for home activity. You can also ask your doctor to complete the Home Activity Guide on pages 62-64. It can help you decide how much and how fast to increase your activities.

24

Going home You may have mixed feelings about leaving the hospital. You may wonder if you can really take care of yourself. Talking about this can build confidence for you and your family. Before leaving, you may want to ask your doctor or nurse to join the conversation.

On your own You may go through one or more stages when you first go home.

It may seem that your family is being too protective. As they try to help with medications, diet and activities, you may feel smothered. If so, talk about it. Each of you is trying to rebuild roles and independence.

Some people who have had heart attacks are afraid of what the future holds for them. They are afraid anything they do might bring on angina or another heart attack. As a result, they do very little. This kind of lifestyle can cause other health problems and does not prevent future heart problems. If you find it hard to get back to normal activities, tell your doctor. You may benefit from a group exercise program. A sense of humor at this time can also bring relief from stress and fear.

25

Other people do not accept their heart attacks. When they get home, they take up old habits like smoking, not getting enough exercise and eating foods high in saturated fat and sodium. They may also skip their medications or doctor’s appointments just to prove that they are all right. This kind of behavior could lead to setbacks in recovery.

Both rest and gradually increasing physical activity are important to your recovery. Some people will work up to high-level exercise like tennis, swimming or running. Others will work up to daily walks or pedaling a stationary bicycle.

Everyone’s recovery is different.

26

First steps As you begin to build your strength, you may feel more tired on some days. This could be a sign that you need to slow down a bit.

Here are some hints to help you pace yourself: ● Alternate hard tasks with easy ones. Rest for 15 to 30 minutes in between. ● Don’t rush. Plan plenty of time for everything. ● Be sure to get plenty of sleep at night.

27

Tell your doctor if any activity brings on: ● shortness of breath ● extreme fatigue ● dizziness ● chest pain or discomfort If the symptoms are severe or do not go away quickly, call your doctor or 911.

Smoking If you smoke, you need to quit now. Smoking is the worst thing you can do to your heart. (For information on how smoking affects your heart and for suggestions on how to stop, see pages 46-47.)

Alcohol If you don’t drink, don’t start. If you do drink, it’s important to limit your intake of alcohol to lead a heart-healthy lifestyle. (See page 37 for the American Heart Association recommendation.) Drinking too much alcohol can raise the levels of triglycerides in your blood. It can also lead to high blood pressure, heart failure and an increased risk of stroke. If you used to drink alcohol before your heart attack, you may be able to continue, but in moderation. Be sure to ask your doctor about your individual risks if you continue to consume alcohol.

28

Heat and cold Avoid very hot or very cold temperatures.

If you must be outdoors in the winter, go out in midday. In the summer, go outdoors in the early morning or early evening. Be less active outside in very hot or very cold weather.

Check with your doctor before using saunas, steam rooms or whirlpools.

Meals Large meals make the heart pump harder.

Eat 3 or 4 small meals a day instead of one large, heavy meal. Eat slowly, and rest for an hour after the meal.

Cut down on caffeine to 1 or 2 cups of coffee a day. Caffeine makes the heart work harder and can cause skipped heartbeats. It is also in tea, many soft drinks, chocolate and some over-thecounter drugs. Read all labels for caffeine to know how much you are getting.

29

Sex Most people can begin to have sex again about 3 to 6 weeks after a heart attack. The energy used during sex is less than it takes to climb 2 flights of stairs. If you have no pain or discomfort when climbing stairs, you can assume that it’s OK to have sex. Just be rested, and don’t rush.

If sex brings on angina, stop and rest. Be patient with yourself. You might want to wait until another time or vary your position so you will be more comfortable. If you have any concerns, don’t be embarrassed to ask your doctor for advice. You may need to make a small change in your daily routine or medications.

In particular, check with your doctor before taking any type of drug for sexual enhancement. For example, if you take nitrates (including nitroglycerin), you should not use drugs used to treat erectile dysfunction (ED). Combining these two types of drugs can cause a dangerous blood pressure drop. To be safe, talk about this with your doctor.

Stress Stress in life cannot be avoided, but you can learn how to deal with it.

Turn to page 48 for some suggestions on how to manage stress.

30

Travel Your doctor will tell you when it is OK to travel. Before you go, consider these suggestions:

1. Keep your medications in your

carry-on luggage or your purse.

Then they will always be handy when you need them.

2. Pack your clothing and/or carry-on bags so that you can lift them easily.

Avoid carrying heavy suitcases. Use a wheeled suitcase or a pull-cart to cut down on lifting. Get help from a porter if one is available.

3. Allow plenty of time to get to the

airport, bus or train station so that you can walk, not run, to the carrier.

4. Walk around at least every two hours during car or

airplane trips. While sitting, do simple exercises to increase blood flow in the legs and prevent blood clots.

5. Check with your doctor before going to places at high

altitude (greater than 6,000 feet) or places where the temperature will be very hot or cold. Rest when you first get there. Don’t jump right into an activity.

31

What to do about angina If you have angina, stop what you are doing. ● Take a nitroglycerin (NTG)* tablet as prescribed by your health care team. ● Call your doctor if angina still does not go away. If your doctor is not available, go to the nearest hospital emergency room.

If NTG brings relief, wait until another time to finish what you were doing. If the same activity causes angina again, take a nitroglycerin ahead of time to prevent discomfort.

Let your doctor know how often you have angina and which activities bring it on. Even if NTG gives complete relief, you should let your doctor know if your angina: ● occurs with little or no exertion ● requires more NTG for relief ● lasts longer each time Something about your treatment may need to be changed.

Also let your doctor know if you have shortness of breath, unusual fatigue, swelling of the feet or ankles, fainting or very slow or rapid heart rate. * To work effectively, NTG tablets must be fresh. Replace any bottle that has been open for 6 months. Replace unopened bottles yearly. Old tablets can lose their strength.

32

Lowering the risk of another heart attack Choosing healthy lifestyle behaviors can reduce your risk of heart attack and improve your well-being. On the other hand, certain factors can increase your risk of heart attack and other cardiovascular problems. The lifestyle choices you make now and in the future can make the difference between having another heart attack or not.

For a heart-healthy lifestyle, aim to: ● Establish heart-healthy eating habits. ● Be physically active. ● Reach and keep a healthy weight. ● Get healthy sleep. ● Stop smoking. ● Manage stress. ● Lower your blood pressure. ● Control your cholesterol. ● Control your blood sugar.

As you get older or if you have a history of heart disease in your family, it is very important to follow a healthy lifestyle. Doing as much as you can to reduce or manage the conditions that increase your risk is just as important.

33

Establish heart-healthy eating habits A healthy diet and lifestyle are your best weapons to fight cardiovascular disease. You get the most benefits and protection for your heart by making healthy foods part of your overall diet.

Choose foods that are: ● high in nutrition ● low in sodium, saturated fat, trans fat and added sugars If you’ve heard mixed messages about what healthy eating means, you may be confused about what’s right for you. It’s best to get information from credible sources so you can make smart choices about your diet for long-term health benefits. Follow the advice of your doctor and dietitian.

Focus on eating different kinds of nutritious foods. Eat the right amounts for your individual energy needs. You may be eating plenty of food, but your body may not be getting the nutrients it needs to be healthy. Nutrient-rich foods have vitamins, minerals, fiber and other nutrients but are lower in calories.

Just remember: It’s the overall pattern of your choices that counts most.

34

How to eat healthy at home ● Avoid deep frying and other ways of cooking that let food sit in fat while it cooks. Instead, try stir-frying, air-frying, baking, broiling, grilling, microwaving, poaching and steaming. ● Before you cook meat, trim and throw away any fat you see. It’s OK to cook poultry with the skin on, but throw away the fatty skin before you eat the food. ● Add more vegetables and legumes (see suggestions on pages 38 and 39) to soups, stews, stir-fries and casseroles. Try to find new ways to add vegetables where you might not expect them. One way is to add a layer of chopped broccoli or spinach to lasagna. ● Replace salt and add flavor to your favorite dishes by using herbs, spices, citrus juice, chiles and fruits and vegetables. ● Use healthy and flavorful recipes from American Heart Association cookbooks and online at www.heart.org/recipes.

How to eat healthy when eating out ● Limit or avoid fast foods. ● Stay away from battered and fried dishes. ● Choose healthier options, such as green salads and grilled or broiled chicken and fish. ● Ask for salad dressings and condiments, such as ketchup, on the side. ● Plan to split a main dish or take half home.

35

Choosing foods that are nutrient rich ● Vegetables and fruits are high in vitamins, minerals and fiber and they’re low in calories. Eating lots of fruits and vegetables may help you control your weight and lower your blood pressure. ● Fiber-rich whole grains contain both soluble and insoluble fiber as well as other important nutrients. Eating enough whole grains with fiber can help lower your blood cholesterol. It can also help you feel full, which may help you manage your weight. ● Fat-free and low-fat dairy foods provide calcium, protein and other vital nutrients. Choose fat-free or 1%-fat products whenever you can. That way you can avoid the saturated fat found in full-fat or 2%-fat dairy products. ● Fish, especially those that contain omega-3 fatty acids, are an important part of a heart-healthy diet. Eat at least two weekly servings of non-fried fish (3 to 3.5 ounces cooked weight per serving) to reduce your risk of death from coronary artery disease. ● Lean and extra-lean meats and skinless poultry are great sources of protein. To keep from eating too much saturated fat, be sure to trim away all visible fat and discard. Also, remove and discard any skin from poultry before consuming. ● Legumes, nuts and seeds offer great nutritional payback. Legumes (beans and dried peas, for example) provide protein and are rich in fiber and other nutrients. Nuts and seeds contain heart-healthy monounsaturated fats. Watch your portion size because nuts and seeds are high in calories. ● Unsaturated fats are essential to good health, and nontropical vegetable oils are the best ones for you. Remember that all fats are high in calories, so be aware of how much you include each day.

36

Limiting foods that are nutrient poor ● Sodium can increase blood pressure, and high blood pressure increases your risk of heart disease. Many of the foods that you buy or eat in restaurants are loaded with sodium. Aim to eat no more than 1,500 milligrams of sodium each day. ● Saturated fat and trans fat raise the amount of harmful LDL cholesterol in your blood, which increases your chance of having a heart attack or stroke. Most of the saturated fat you eat comes from animal-based foods. Some examples are whole milk and other whole-fat dairy products, marbled meat and tropical oils (coconut, palm and palm kernel). Most trans fat comes from the partially hydrogenated oils used in commercial baking and frying.

Less than 7 percent of your total daily calories should come from saturated fat, and less than 1 percent should come from trans fat. ● Added sugars are found in regular soft drinks, fruit drinks, sweetened milk products, sweetened snacks and desserts and candy. Save sugary foods for occasional treats, not something you have every day. Limit the amount of added sugars to no more than 100 calories or 6 teaspoons per day, for most women and no more than 150 calories or 9 teaspoons per day, for most men.

● Alcohol adds empty calories but no nutrients. If you drink, limit your alcohol consumption to one to two drinks per day for men and one drink per day for women.

A drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.

37

Shopping with your heart in mind To be sure you get the most nutritional value from your grocery store choices: ● Read Nutrition Facts panels and compare products. ● Follow these guidelines as you shop.

Vegetables and fruits

Whole grains

38

Try a wide variety of different kinds of produce of different colors.

Choose breads, cereals, pastas and flours that list whole grains first in the ingredient list. Look for high-fiber whole grains, such as oats, barley, bulgur and quinoa.

Dairy products

Shop for fat-free, 1% and low-fat versions of milk, yogurt, cheeses, cream cheese, sour cream and ice cream. Compare these with whole-milk products to see the huge nutritional differences.

Fish and shellfish

Include fatty fish, such as salmon, trout, tuna and herring, on your weekly shopping list. They give you the heart-health benefits of omega-3 fatty acids.

Meats and poultry

Focus on lean and extra-lean cuts. When choosing poultry, keep in mind that the white meat is leaner than the dark.

Legumes, nuts and seeds

Use beans (dried or canned), lentils, edamame (green soybeans), peas and peanuts to provide meatless protein in your weekly diet.

Round meals out with nuts and seeds, which are nutrient dense and contain protein as well.

Unsaturated fats

Select heart-healthy nontropical oils, such as canola, olive, sunflower and safflower. Replace butter or stick margarine with light tub or fat-free spray margarine.

Watch out for foods that are high in:

● saturated fat, such as animal fats found in meats and poultry, whole-milk and other full-fat dairy products and egg yolks

● saturated fat, such as palm kernel oil, palm oil, coconut, coconut oil, vegetable oil made from coconut, palm or palm kernel oil and cocoa butter

● trans fat, such as partially hydrogenated vegetable oil and vegetable shortening

● sodium, such as processed or cured meats, brined products, seasonings, condiments, canned soups and broths, breads and bread products, cereals, cheeses, crackers and chips, frozen entrées, canned vegetables and salted nuts

Limit convenience and processed foods. Many commercially prepared foods and drinks are high in added sugars, sodium, saturated fat and trans fat. Read the Nutrition Facts panels carefully and watch out for marketing labels or claims on the packaging that may be misleading.

39

Be physically active After a heart attack, you may feel uneasy about being active and getting regular exercise. However, your heart, like your car engine, can’t work right if it isn’t kept tuned up. In fact, without regular physical activity, the body slowly loses its strength and ability to function well.

A physical activity is anything that makes you move your body and burns calories. Aerobic exercises, such as walking, jogging, swimming or biking, directly benefit your heart. (Also include strength and stretching exercises to help maintain muscle mass, overall stamina and flexibility.) Aerobic exercise can: ● reduce your risk of another heart attack

● help control blood sugar levels

● lower your blood pressure

● tone your muscles and maintain your strength

● lower levels of LDL cholesterol and increase HDL cholesterol

● give you a feeling of well-being and reduce stress

● help you lose weight when combined with eating the right foods 40

How to be physically active Move more and sit less. Get up and move throughout the day. Some physical activity is better than none.

Aim for: at least 150 minutes per week of moderate-intensity aerobic activity, preferably spread throughout the week OR at least 75 minutes of vigorous aerobic activity, preferably spread throughout the week OR a combination of moderate- and vigorous-intensity aerobic activity as described above AND moderate- to high-intensity muscle-strengthening activity at least 2 days per week for additional health benefits Follow your doctor’s instructions and work up to the amount and kind of exercise recommended for you.

Listen to your body. Don’t feel you need to compete or push yourself, and don’t exercise when you are upset or after eating a heavy meal or drinking alcohol.

Stop at the first sign of: angina

severe fatigue

shortness of breath

Rest and take nitroglycerin if angina occurs, as recommended by your doctor. Keep your health care team informed about how exercise affects you.

41

Reach and keep a healthy weight The more body fat you are carrying, the harder your heart needs to pump to deliver oxygen-rich blood throughout your body. The harder your heart pumps, the more stress there is on your entire circulatory system, which increases your risk of heart disease and heart attack.

If you’re overweight or obese, reduce your risk by losing weight and keeping it off. Controlling your weight will also help you control your blood pressure, blood sugar and blood cholesterol levels.

BMI, or body mass index, assesses your body weight relative to height. (It’s a good way to measure body fat and obesity in most people.)

To calculate your BMI: ● Multiply your weight in pounds by 703. ● Divide by your height in inches. ● Divide again by your height in inches.

What does your BMI score mean? ● less than 25 is considered a healthy weight for your height (less than 18.5 is considered underweight, however) ● between 25 and 29.9 is considered overweight ● 30 or more indicates obesity

42

How to manage your weight If you need to lose weight, start by finding out how many calories you should eat and how many calories you’re burning daily through physical activity. Then decide whether it’s best for you to cut back on calories by eating less, exercising more or doing a combination of both. Talk with your doctor or visit www.heart.org for more information on how to decide what approach is right for you.

Remember: Be realistic about your weight-loss goal. Expect your loss to be slow while you are less active. Setting both weekly and long-range goals will help. Losing several pounds a week is not realistic, or healthy, especially after a heart attack, but you could aim to lose 1 pound a week while your heart is healing.

Do not try a fad diet or an extremely low-calorie diet. Work with a dietitian or join an organized weight-loss group for support and to share your experiences with others.

Reward yourself for your successes — but not with food.

Buy some new clothes or take a trip.

Long-term weight control is a matter of balancing healthy eating with a healthy level of physical activity.

43

Get healthy sleep Getting a good night’s sleep every night is vital to cardiovascular health.

Adults should aim for an average of 7-9 hours.

Poor sleep may put you at higher risk for:

The benefits of sleep include:

● Cardiovascular disease

● Healing and repair of cells, tissues and blood vessels

● Cognitive decline and dementia

● Stronger immune system

● Depression

● Improved mood and energy

● High blood pressure, high blood sugar and high blood cholesterol

● Better brain function including alertness decision-making, focus, learning, memory, reasoning and problem-solving

● Obesity

● Less risk of chronic disease

44

How to get better sleep Move it.

Charge your device as far away from your bed as possible. Added bonus?

The distance may help you feel less overwhelmed in general.

Dim it.

Dim your screen or use a red filter app at night. The bright blue light of most devices can mess with your circadian rhythm and melatonin production.

Set it.

Alarms aren’t just for waking up. Set a bedtime alarm to remind you that it’s time to wrap it up for the night.

Lock it. if you’ve got a scrolling habit you need to kick, try an app-blocking app that makes it impossible to get lost in after-hours emails, social media or gaming.

Block it.

Tell notifications to buzz off if they’re waking you up at night. Put your phone on “do not disturb” mode to block it all out when you’re trying to sleep.

45

Stop Smoking We know these facts about smoking: ● It causes blood vessels to narrow. ● It causes the lungs to make more mucus. ● It causes an increase in carbon monoxide in the lungs and blood. ● It increases the tendency for blood to clot. ● It increases the risk of coronary heart disease, peripheral artery disease and aortic aneurysm.

Smoking increases the heart’s workload because the heart must beat harder and faster to pump blood through narrowed vessels and to get more blood to the lungs to provide enough oxygen.

Smokers have a higher risk of developing many chronic disorders, including atherosclerosis, the buildup of fatty substances in the arteries. Atherosclerosis can lead to coronary heart disease, heart attack and stroke.

46

How to quit smoking ● Make a commitment to quit. ● Ask your family and friends to not smoke around you. ● Join a stop-smoking group to learn how others have successfully quit. ● Set interim goals to cut back. For example, start with less than a pack and a half a day, then go to less than a pack, then less than half a pack, and so on, until you can give up cigarettes altogether. ● Ask your doctor for advice on which methods would be best to help you quit smoking.

Stay motivated and get support. When people try to quit, they often slip and have a cigarette. If this happens to you, don't feel as if you failed. Keep trying! If you need more help, look for quit-smoking programs through hospitals. Also, there is a national hotline with trained staff to help you with quitting 1-800-QUIT-NOW (1-800-784-8669).

Watch your weight. When you don’t smoke, food begins to taste better. You also may eat more to fill the need that smoking once met. Keep low-calorie snacks on hand so you can reach for fruit, a small handful of unsalted nuts or a low-fat cheese stick instead of a candy bar.

47

Manage stress Stress, or tension, causes the body to produce hormones such as adrenaline that cause your heart rate to increase and your muscles to tense. These hormones cause a narrowing or clamping down of blood vessels. That, in turn, causes a temporary rise in blood pressure. These changes force your heart and arteries to work harder to carry oxygenrich blood throughout your body.

It’s important to learn how to manage stress since a stressful lifestyle and unhealthy habits often go together.

Learn to relax. What makes you tense? Whatever the cause, find ways to avoid or lessen the pressure you feel from the stresses of life.

Choose a relaxation technique that works for you. Regular physical activity helps if you want to relax, as do the methods suggested on pages 59-61. Whatever technique you choose, practice it daily. Talking things out with family, friends or a professional counselor may also help you.

If you are a workaholic, do something about it. Find ways to relieve the pressures from your job that make your heart work harder. Be sure to eat a nutritious diet, be physically active and find ways to relax.

i 48

Use nitroglycerin if stress causes angina, as recommended by your doctor.

Lower your blood pressure Blood pressure is the force that circulating blood exerts on your artery walls. When blood pressure is high, the blood flows with too much force. That force can stretch your arteries past a healthy limit, causing microscopic tears. The body then repairs the tears with scar tissue. The damage that’s been done to the artery lining makes it easier for plaque and white blood cells to form into blockages and blood clots and to harden and weaken your arteries.

High blood pressure is the single most significant risk factor for heart disease. If left untreated, high blood pressure can also damage the heart, brain and kidneys. It’s sometimes called “the silent killer” because it has no symptoms, and you may not even realize you have it.

The good news is that high blood pressure does not have to be a killer: Although there is no cure for high blood pressure, it is manageable.

49

How to manage your blood pressure By keeping your blood pressure in the healthy range (less than 120 systolic and less than 80 diastolic), you can reduce damage to your arteries and vascular system and lessen your heart’s workload.

This will help protect your entire circulatory system so that your body gets a regular supply of blood that is rich in the oxygen it needs.

To keep your blood pressure under control: ● Get your blood pressure checked often and regularly. ● Eat a heart-healthy diet and limit your daily intake of sodium to 1,500 mg or less. ● Take part in regular physical activity. ● Reach and maintain a healthy weight. ● Do not smoke, and avoid secondhand smoke. ● Manage stress. ● Limit alcohol.

If your doctor recommends treatment in addition to lifestyle changes, be sure to take medications as directed, and follow all instructions as prescribed.

50

Control your blood cholesterol Cholesterol is a soft, fatlike, waxy substance found in the bloodstream and in your body’s cells. ● Total cholesterol includes the two major types of cholesterol: LDL (low-density lipoprotein) and HDL (high-density lipoprotein). ● LDL cholesterol is the “bad” cholesterol. It can clog arteries, increasing your risk of heart attack and stroke.

Your body produces the LDL cholesterol in your blood.

Eating a diet that is high in fat and trans fat increases how much LDL your body produces. Some people inherit genes that cause them to make too much LDL. ● HDL cholesterol is the “good” cholesterol. It can help carry LDL cholesterol away from artery walls and help protect against heart disease.

Be sure to ask your doctor what levels of LDL and HDL cholesterol are right for you.

How to manage your cholesterol ● Schedule regular blood screenings. ● Eat foods low in saturated fat and trans fat. ● Reach and maintain a healthy weight. ● Stay physically active.

Your doctor may have prescribed medication or advised you to make diet and lifestyle changes to help manage your cholesterol.

51

Control your blood sugar If left uncontrolled, diabetes (elevated levels of glucose, or sugar, in your blood) can lead to devastating health problems. Have your glucose levels checked regularly, especially if you have a family history of diabetes.

Diabetes is diagnosed using a simple blood test, such as the fasting plasma glucose test. A fasting glucose test reading of 126 mg/dL or more indicates that you may have diabetes. A fasting test reading of 100 to 125 mg/dL indicates a condition called prediabetes. If your glucose level falls in either category, you and your doctor should discuss how you can monitor and prevent or manage diabetes.

Often, people with diabetes also have high blood pressure, high blood cholesterol and are overweight. Those conditions further increase the risk for heart disease and stroke. Being overweight or obese is a major cause of diabetes. Losing weight can help stop or reverse the development of diabetes.

If healthy eating and regular physical activity aren’t enough to reduce your risk of stroke, your doctor may suggest medication. If you do need medication to control blood pressure, cholesterol or diabetes, be sure to take it as prescribed.

52

Appendix ● identifying a heart attack ● calling for help ● simple exercises ● home walk program ● ways to relax ● home activity guide

Fill out this HEART CARD and keep it in your wallet:

Name:

EME R G E N C Y I NFOR MA T I ON Call 911 (or your local rescue service) if you or someone else is experiencing signs of a heart attack (listed on the back of this card).

Nearest hospital with 24-hour emergency cardiac care unit: From home:

From work:

Doctor (name):

Phone:

Emergency contact (name):

Phone:

Medications and allergies:

53

As with men, women's most common heart attack symptom is chest pain or discomfort.

But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/ vomiting, and back or jaw pain.

Identifying any future heart attack You may never have another heart problem, but you and your family should review all the symptoms of a heart attack. They are: ● Chest discomfort. Most heart attacks involve discomfort in the center that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. ● Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. ● Shortness of breath (with or without chest discomfort).

Other symptoms might be: ● breaking out in a cold sweat ● nausea/vomiting ● lightheadness 54

How to call for help for a heart attack Learn the signs, but remember: Even if you're not sure it's a heart attack, have it checked out.

Minutes matter! Fast action can save lives ― maybe your own.

Don't wait; call 911 or your emergency response number.

Call 911 Calling 911 or your local rescue service is almost always the fastest way to get lifesaving treatment. Emergency medical services (EMS) staff can begin treatment when the person arrives ― up to an hour sooner than if someone gets to the hospital by car. EMS staff are also trained to revive someone whose heart has stopped.

Patients with chest pain who arrive by ambulance usually receive faster treatment at the hospital, too. It's best to call EMS for rapid transport to the emergency room.

Remember a heart attack is a life-and-death emergency. Some suffering from a heart attack can benefit from new medications and treatments that weren't available to patients in years past.

But to be effective, these drugs must be given relatively quickly after a heart attack or symptoms first appear. So, don't delay ― get help right away!

55

Simple exercises for your heart These exercises are often given to patients after a heart attack.

They begin in the hospital and continue at home until full recovery.

Do not hold your breath during any exercise. Do all exercises slowly and smoothly. Rest your arms and legs after each repetition.

Take your pulse before and after these exercises. Your pulse rate should be less than ___________ beats per minute. Get this figure from your doctor.

Once you are at home, add repetitions at a rate of one per week up to a maximum of 15. Do not do more repetitions if you have shortness of breath, unusual fatigue or chest pain during or after the exercises. And do not add more if your pulse goes over the set limit.

Continue these exercises on a daily basis until you are back to your normal routine of daily living.

Check with your doctor before doing these exercises.

Keep good posture throughout.

56

I.

SITTING: __________ times each

1. Raise your knee toward your chest and then lower it to the floor. Do not hold it up. Alternate each leg.

2. Straighten your knee and then return the foot to the floor.

Alternate each leg.

II. STANDING: __________ times each 1. Make large circles with your arms. Change directions each day.

2. Twist trunk to the left and then to the right. (Do not perform if you have had recent open-heart surgery.)

3. Bend trunk at the waist to the left and then to the right.

4. Half knee bends. Return to the starting position.

57

Home walk program Your doctor may tell you to begin a walking program. They may ask you to go at an easy pace or follow a specific guide as shown here. Work up to the level that is comfortable, and continue at that level.

Home Walk Program Week After Heart Attack

Distance

Time (each walk)

weeks 3-4

walk ¼ mile twice a day

5 minutes

weeks 5-6

walk ½ mile twice a day

10 minutes

week 7

walk ¾ mile once a day

15 minutes

weeks 8-9

walk 1 mile once a day

20 minutes

week 10

walk 1½ to 2 miles 3-4 times per week

30 minutes

Check your pulse rate right at the end of every walk. Do not go to the next stage (as from week 4 to week 5) unless your pulse rate right after exercise is less than __________ beats per minute. Get this figure from your doctor.

If you are very tired or become short of breath, stop the exercise.

If this continues, call your doctor. If you have chest pain that is unusual or more severe, stop the exercises, and call your doctor.

58

Ways to relax This relaxation method uses many body muscles. It will take 15-20 minutes to practice it once or twice every day. Find a quiet, comfortable room where you will not be disturbed. You may either sit or lie down. If sitting, be in a comfortable armchair where your head and arms can be supported. Many people prefer to sit because they tend to fall asleep when lying down. Once you are comfortable, close your eyes and think about a pleasant, quiet place.

(Some people like to think about being on a beach and hearing the waves or being on a mountain.) Stay in this place for 15-20 minutes. If you find yourself thinking about problems at work or things you have to do, gently ease them away by returning to your pleasant thoughts.

Another method of relaxation is to tense and relax certain muscles of your body. As you practice this method, you will become aware of the difference between being tense and feeling relaxed. First sit for 30 seconds to 1 minute.

Keep your eyes closed, and give your body a chance to feel relaxed. Then go through the steps on the next page.

The steps on pages 60-61 come from a relaxation exercise by Dr. Arnold Lazarus.

We express thanks for use of this information.

59

Tense each muscle group for about 5-10 seconds, and then release it.

Enjoy the relaxation you feel for 30 seconds to 1 minute before going on to the next muscle group. Keep your breathing normal.

1. Hands: Clench each fist one at a time and feel the tension; then do both together.

2. Lower arms: Make a fist with your right hand and bend the arm up at the elbow. Repeat with left arm.

3. Upper arms: Stretch out your right arm in front of you like you are reaching for something, then relax it. Repeat with left arm.

4. Facial muscles: squinch up your face clench your teeth purse your lips push tongue to the roof of your mouth lift your eyebrows with your eyes still closed 5. Neck: Bend your head back, then forward so chin touches chest.

6. Shoulders: Hunch up your shoulders as if you are trying to touch your ear lobes.

7. Chest: Tense your chest muscles by taking a deep breath and holding it for 4-5 seconds.

8. Back: Arch your back.

60

9. Abdomen: Tense your stomach muscles by bearing down.

10. Thighs and buttocks: If sitting, tense your thighs and buttocks by pressing your heels into the floor. If lying down, do this by pinching your hip muscles together.

11. Lower legs: Point your toes toward your head, then away from your head.

12. Toes: Curl your toes up.

After you have gone through steps 1-12, sit again with your eyes closed.

Notice how you feel. Your breathing and pulse rate may now be slower than before you started.

Stay relaxed and keep your eyes closed for at least 2 more minutes. Start to let your mind wander to things you will be doing during the day. When you feel ready to open your eyes, count backward from 4, stretch, and stand up slowly. You should now feel relaxed and refreshed.

61

Home activity guide

(to be completed by your doctor) Your recovery will last about _____________________ Activity

At home Beginning level _________ to _________

At the end of hospitalization

(2 weeks is average) walking

short walks on hospital

Stay on level ground or floor; can go outside

floor (200 to 400 feet twice daily)

if weather is mild. Relax; do not hurry. Slowly increase the distance until you are walking ¼ to ½ of a mile twice a day.

bathing

self-bathing at bedside; in tub or shower

When bathing, avoid very hot or very cold water, hurrying, excessive scrubbing or drying off (arm activity).

visitors

limited to your condition

Limit visitors to 3 or 4 a day and 15 or 20 minutes at a time or less if you get tired. Limit texting and phone conversations as well.

riding in a car or driving

may ride in car from hospital to home, if nearby

A family member may drive you to a level place for walking if steps or hill at home prevent you from taking short walks. No driving at this time, but you may enjoy a short ride.

lifting

personal articles, such as books, clothes, etc.

Less than 15 lbs. You may help with meals, wash dishes, etc.

misc.

read, watch TV, do handicrafts, paint

Continue with lap activities (sewing, painting, reading, limited paperwork) 15 to 20 minutes several times a day. Make small meals for yourself; pull covers on bed; watch TV. Ask about other hobbies.

Increase your activities gradually.

62

Activity

Middle level _________ to _________ (2 weeks is average)

walking

Continue walks; include some steps and inclines. Increase steps and distance slowly (½ to ¾ of a mile twice a day).

bathing

Continue.

visitors

You may go to a nearby friend's home for dinner or to enjoy other social activities.

Continue low-level activities.

riding in a car or driving

You can take short neighborhood trips (grocery, movie, theater, post office, see friends). In cities, get a friend to drive. Attend parties or church activities at the end of this period or in the next.

lifting

You should avoid lifting more than 20 lbs. Don't strain to open jars or stuck windows.

misc.

Continue with hobbies and household activities. Avoid strenuous arm activity such as sanding, hammering, using a wrench, vacuuming, heavy scrubbing or overhead painting. You may use your computer for short periods.

sex

Sex with your usual partner requires about the energy it takes to climb 2 flights of stairs. Many people return to sex about a month after a heart attack. Your doctor will let you know when it's all right for you.

Give yourself plenty of time for sex, and reduce the chance of interruptions by turning off/muting your cell phone or taking your house phone off the hook.

If you are tired or have eaten a large meal within the last 1-2 hours, have sex after you have rested several hours.

Be in a good mood.

Return to your usual sexual positions unless you would just like to change or these positions seem strenuous for you.

If you are prone to having angina, take nitroglycerin before sex. If angina develops during sex, stop and rest. You may need more nitroglycerin. If you have angina during sex, you should tell your doctor.

63

Activity

Upper level _________ to _________ (2 weeks is average)

64

walking

Continue walks of 1½ miles a day. After a heart attack, jogging should be done with supervision. It may be considered undesirable for you. Ask your doctor.

bathing

Continue.

visitors

Gradually increase to what is normal for you. You may be able to go back to work.

Ask your doctor when and how much.

riding in a car or driving

Drive in the neighborhood. Ask your doctor about longer trips of 45 to 50 miles or more.

lifting

You can gradually lift things up to 30 lbs. If your job requires heavier lifting, ask your doctor when to begin this.

misc.

Gradually resume your usual level of physical activity. Many people can play a few holes of golf with a cart. Ask your doctor about more strenuous sports and yard work.

sex

Continue.

The heart Your doctor or nurse may use these drawings when talking with you about your heart.

left main coronary artery circumflex branch left anterior descending branch marginal branch

right coronary artery

posterior descending branch

Please let us know how this book is helping you (or your patients).

Share your comments at http://p-h.com/28

3440 Oakcliff Road, NE, Suite 126 Atlanta, GA 30340-3006 1-800-241-4925 • www.p-h.com