Angiotensin converting enzyme (ACE) inhibitors, another class of blood vessel dilators, often are given orally after a large heart attack to improve the healing of heart muscle. Examples of ACE inhibitors include captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril and Prinivil), and ramipril (Altace).

These medications lower the blood pressure and reduce the workload of the heart, thereby helping the damaged heart muscle to recover. They are especially helpful in patients who have recovered from heart attacks but have high blood pressure, heart failure, major damage to the left ventricle, and diabetes mellitus. For additional information, please see the Beta Blockers article.

Beta-blockers

Beta-blockers such as propranolol (Inderal), metoprolol (Lopressor, Toprol XL), and atenolol (Tenormin) usually are given early during a heart attack and are continued long-term. Beta blockers antagonize the action of adrenaline and relieve stress on the muscles of the heart. Beta-blockers decrease the workload of the heart by slowing the heart rate and decreasing the force of contraction of heart muscle. Decreasing the workload decreases the demand for oxygen by the heart and limits the amount of damage to the heart muscle. Long-term administration of beta-blockers following a heart attack has been shown to improve survival and reduce the risk of future heart attacks. Beta-blockers also improve survival among patients with heart attacks by decreasing the incidence of life-threatening abnormal heart rhythms, for example, ventricular fibrillation. Beta-blockers can be given intravenously in the hospital and then can be taken orally for long-term treatment.

The side effects of beta-blockers are wheezing (worsening of breathing in patients with asthma), abnormally slow heart rate, and exacerbation of heart failure (especially in patients with significant damage to their heart muscle); however, in patients with chronic heart failure, beta blockers have recently been demonstrated to be helpful in decreasing symptoms and prolonging life.

Oxygen

Oxygen also is commonly administered during the acute phase of a heart attack as are narcotics such as morphine; these agents aid in the reduction of discomfort and actually help minimize the amount of heart damage.

Coronary artery bypass

In some patients, PTCA can be technically difficult or dangerous to perform. In others, PTCA and clot-dissolving medications may fail to achieve reperfusion or maintain open arteries. These patients may be considered for coronary artery bypass grafting surgery. For more information, please see the Coronary Artery Bypass Graft article.

What can a patient expect during recovery from a heart attack?

Heart attack patients are monitored in the hospital for three or more days prior to discharge home. Rhythm disturbances, shortness of breath due to heart failure, or recurrent chest pain are reasons for further therapy such as balloon angioplasty or coronary stenting, additional medications, or bypass surgery.

Patients gradually increase their activity under observation. Before discharge, a low-level Exercise stress test may be performed to detect important residual narrowing in the coronary arteries, exercise-induced cardiac rhythm abnormalities, and heart muscle failure, and to help guide the doctor in prescribing an activity regimen after hospitalization. An abnormal stress test prior to hospital discharge following a heart attack predicts a high risk for subsequent cardiac events; if the patient has not yet had a coronary angiogram, an abnormal pre-discharge stress test is a strong reason for doing angiography. Since most patients usually receive angiography early, the use of pre-discharge stress testing has declined.

Before resuming full activity or work, several weeks may be needed for the heart muscle to heal. After a small heart attack (little damage to heart muscle), patients usually can resume normal activities after two weeks. These activities include returning to work as well as normal sexual activity. A moderate heart attack (moderate damage to heart muscle) requires limited, gradually increasing activity for up to four weeks, while a large heart attack(much damage to heart muscle) may result in a recovery period of six weeks or longer. These time frames are necessary in order for the dead heart muscle to substantially complete the scarring process. During this healing period, patients should avoid vigorous exertion and heavy lifting (over 20 pounds) or any strenuous activity that causes shortness of breath or undue fatigue.

Cardiac rehabilitation typically begins during hospitalization and continues during the months following a heart attack. Cardiac rehabilitation programs provide a helpful transition to a safe and full return to a normal lifestyle. In addition, cardiac rehabilitation allows the prescription of a long-term exercise program tailored to each patient and helps patients and their families adjust to lifestyle changes and the difficult and conflicting emotions that often follow a heart attack.