Surviving a Heart Attack - After the First Day

After you’ve survived the first day of a heart attack, you’ve got a lot to learn about and a lot to think about. While in the good old days you might have had a week or two of hospitalization to go through all the testing, risk assessment, education, and initiation of therapy necessary to optimize your long-term prognosis, today whatever is going to get done must happen in the first three (or four, if you’ve got a liberal health plan) days.

Doctors and hospitals have mobilized nicely to provide adequate acute care for the patient presenting with a heart attack. But for the most part they have completely neglected approaching the necessary subacute care (the care after the first 24 hours) in an organized fashion. As a consequence, it is the rare patient who receives all the assessment, training, and treatment that has been shown to be vital to an optimal outcome. For instance, recent studies show that less than half the patients who need statin drugs receive them. Other studies show that only a minority of heart attack survivors receive beta blockers. And the proportion of patients who get an adequate assessment for the risk of sudden death – let alone who receive the implantable defibrillator – is laughable.

Until doctors and hospitals get their act together, the key to successfully navigating a heart attack is you. You need to insist that the appropriate tests are done, the appropriate referrals are made, and the appropriate medications are begun. To this end we provide a convenient check list of the things that should be done prior to discharge after a heart attack. 

If you have a heart attack, show this check list to your doctor the morning after your arrival, and announce “I’m not leaving this hospital until I can make little checks by each and every one of these items. If you want me out of here in 2 more days, better get moving.” For good measure, you may want to mention how your sister the lawyer helped you assemble this handy list, and is also anxious to view the little checkmarks.

Doctors really do want to do the right thing. It’s just that, given all the pressure and constraints they’re operating under, sometimes they need for their patients to remind them of who they’re really beholden to, and what the expectations in that regard truly are.

The Check List:

1) Lifestyle changes and other education:

• If I am a smoker, I have been counseled to stop, and referred to one or more smoking cessation programs (y/n) _____
• I have been fully instructed on the American Heart Association Step II (or similar) diet (y/n)____
• I have received detailed activity instructions for the next 4 – 6 weeks, and have been referred to an outpatient cardiac rehabilitation program (y/n) ____
• The importance of long-term exercise has been explained to me (y/n) _____
• I have been fully instructed on the warning signs and symptoms of heart attack, and the actions to take if I experience these signs or symptoms (y/n) _____

2) Assessing the risk of another heart attack in the near future:

• The status of my coronary arteries has been assessed by either stress/thallium study (y/n) ______ or cardiac catheterization (y/n) _____
• The condition of my coronary arteries has been explained to me as follows: __________________________
• The plan for following the status of my coronary arteries over time is: _____________________

3) The amount of damage done to my heart has been assessed by:

• stress/thallium study (y/n) _____
• cardiac catheterization (y/n) ____
• MUGA scan (y/n) _____
• echocardiogram (y/n) ____
• My ejection fraction is _______ (Note: if the ejection fraction is 40% or lower, see # 6 below.)
• I (do/do not) have some degree of heart failure.

4) Important numbers I need to know

• My lipid profile has been measured, and the results are: Total cholesterol ____ LDL cholesterol ____ HDL cholesterol ____ Triglycerides ___
• My blood pressure is _______
• My ejection fraction is ______

5) Names and doses of medications prescribed for me:

• Aspirin ________
• Beta blocker ________
• ACE inhibitor ________
• Statin __________
• Note: All of these medicines have been shown to help prevent further heart attacks and reduce the risk of death. If I have not received a prescription for one or more of these medications, the reason is ___________________________.

6) Preventing sudden death

• If my ejection fraction is 30% or less, I have been scheduled for an implantable defibrillator on: ______
• If my ejection fraction is between 31% and 40%, I have been referred to an electrophysiologist on: ______
• Members of my family have been trained in CPR (y/n): ______

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