Heart Attack

Okay, you've had a heart attack. But that doesn't mean that you have to live the rest of your life in slow gear. After all, Lyndon Johnson served as vice president and president of the United States after surviving a heart attack. Other survivors have competed in marathon races.

"You can go on to a whole new, enjoyable life after a heart attack," says Andreas T. J. Wielgosz, M.D., Ph.D., head of the Division of Cardiology at Ottawa General Hospital in Canada.

Researchers are finding that lifestyle changes will speed your recovery and even shield you from another attack. And if you don't make these changes after a heart attack? Your risk of another attack skyrockets.

"If you've had a heart attack, your risk of a second one is three or four times greater than it is for someone who has never had an attack," says Daniel Levy, M.D., director of the Framingham Heart Study in Massachusetts, the nation's most important long-term study of heart disease. "You have to take aggressive steps to minimize your risk."

The idea that lifestyle changes can lower your risk of a second attack isn't all that new. Heart attack survivors were once urged to recuperate at health spas, with a regimen of relaxation, exercise, and special diets—not too different from what contemporary cardiologists prescribe. But patients also underwent some treatments that by today's standards seem just plain peculiar—long, hot baths in saltwater, for instance.

Even today, researchers note that spa time seems to speed recovery. That's not surprising when you consider that life at the spa includes many elements that cardiologists believe are crucial if you want to avoid another heart attack.

* The calm, ordered life that frees spa residents from daily stresses

* A ready-made social support system, critical to prevention in today's world

* Regular exercise, also an essential part of today's regimen for recovery

If you've had a heart attack, here is how to lower your risk of a recurrence.

Take Charge of Cholesterol

When you lower your low-density lipoprotein (LDL) cholesterol count to 100 milligrams per deciliter (mg/dl) or less, keep your protective high-density lipoprotein (HDL) cholesterol above 35 milligrams per deciliter, and add exercise to the mix, something magical happens—you could help to reduce your risk for a second heart attack by 89 percent, says Tom LaFontaine, Ph.D., manager of disease prevention and community wellness at Boone Hospital Center in Columbia, Missouri.

"Cholesterol is a major risk factor for heart attacks. We've become much more aware in recent years of how important it is to lower cholesterol," says Dr. Levy. A diet and exercise program can lower your cholesterol by 10 to 15 percent. If that's not enough, a combination of diet, exercise, and cholesterol-lowering drugs can do the trick.

"When you lower your cholesterol levels, you can stabilize or even reverse the atherosclerotic process," says Dr. LaFontaine.

That process is a big part of what got your heart into trouble in the first place. Here is how your system got started down the road to a heart attack: Over the years cholesterol, or fats, in the blood found a home in your artery walls. These squatters really gummed up the works. Their population swelled as they built up thick deposits on your artery walls. Along the way, they turned into the hardened plaque that made your arteries stiffer and less flexible. They started to take up space that your blood needs to flow to your organs and tissue. That raised your blood pressure, leading to extra wear and tear on the artery walls.

And here's the worst part of the scenario—if the built-up plaque ruptures and breaks free, it can make a clot all by itself. Chances are, that's what caused your first heart attack. When the blood flow gets blocked, the heart muscle is denied the oxygen its cells need to stay alive and healthy. Beyond 20 to 30 minutes, the longer the heart muscle goes without oxygen, the more cells die, the more damage to the muscle—and the slower your recovery.

Since you've had a heart attack, it's a safe bet that other arteries have filled with plaque and become vulnerable to blockages. You need to get rid of the squatters—or at least stop the population explosion.

"You have to do everything you can to slow down the process that allows fats to oxidize and attach to your artery walls," says Dr. LaFontaine. "And it can be done. We're seeing that not only can you stabilize the plaque, but also you can make changes in the way you live to make it less likely to rupture and cause clots." You should start to see lower levels of cholesterol in your blood just a few weeks after you begin a cholesterol-lowering diet.

Regardless of your age or how much cholesterol has been setting up shop in your artery walls, getting the cholesterol down still lowers your risk. "In one study the oldest adult in the project got the most benefit from lowering cholesterol," says Dr. LaFontaine.

Here's how to get your cholesterol down.

Make a list. After your heart attack, your dietitian probably prepared a list of menus and foods that you should eat to protect your heart. Make a list of what you are eating now and compare it with those recommendations. If you threw the list away when you started to feel better, ask your dietitian to review your current diet. As time passes, it is easy to fall into old habits, says Dr. Wielgosz.

Take your spouse. If you recently had a heart attack, you will meet with a dietitian or nutritionist to help plan a protective diet. Don't go alone—ask your spouse to go with you, suggests Dr. Levy. After all, both of you will probably end up eating the heart-protecting diet that you'll be given. It will be easier for both of you to stick to the diet if your spouse understands how important the new diet is to your future health.

Play the percentages. Read package labels and compare nutritional content. Choose low-fat, low-cholesterol, and low-calorie products over those that contain higher amounts, suggests Fredric J. Pashkow, M.D., medical director of the Cardiac Health Improvement and Rehabilitation Program at the Cleveland Clinic Foundation.

Buy low-fat dairy products made from either skim or 1% low-fat milk. Try nonfat or low-fat yogurts. Choose cheeses that feature 3 grams of fat or less per ounce—and plan on a 1-ounce serving, suggests Dr. LaFontaine.

Pay particular attention to artery-clogging saturated fat. Make that less than 7 percent of your day's total calories.

You can automatically lower the amount of fat in your diet just by substituting foods high in starch and fiber. Increase your consumption of breads, cereals, pasta, grains, fruits, and vegetables.

Divide and conquer. Shave off a third of your fat intake, and you may help beat high cholesterol, experts say. Here's how to do it.

Figure out the calorie and fat content of a day's worth of food. If you're eating 2,000 calories a day, your fat content should total no more than 400 calories, or 20 percent of your total food intake. Make that figure—or a lower one—your daily target, says Dr. LaFontaine. Look at product labels that show "calories from fat."

You'll get even greater results by switching to a diet with fat levels at a super-low 10 percent, the level recommended by Dean Ornish, M.D., who devised a widely known program for reversing heart disease. Dr. Ornish's programs are so successful that they're finding favor with insurance companies. Some reimburse subscribers for the cost of participating in the programs, which focus on making changes in lifestyle through diet, exercise, and meditation.

Count calories. Just reaching for the low-fat products on grocery store shelves isn't enough by itself. You can choose low-fat foods and still end up with too many calories. Researchers from the National Center for Health Statistics note that in the 1970s, Americans took in about 36 percent of calories from fat. In 1990 they took in only 34 percent of calories from fat. Sounds like an improvement, until you realize that calorie consumption jumped and fat intake actually increased. What's more, unburned calories get stored in the body as fat, perpetuating the problem.

Drop dietary cholesterol. When you read the label, you'll see that many foods contain cholesterol, in addition to fat. That's not as bad for your system as fat, but it still adds to the assortment of harmful fats in the bloodstream. Look for products with low cholesterol. Try to consume less than 200 milligrams a day, says Dr. Pashkow.

Eat more often. Eat smaller meals more often, suggests Dr. Wielgosz. Emphasize fruits and vegetables. Your overall food consumption will probably drop, and your body will have an easier time burning the calories you take in.

Stay low on oil. Choose products that are low in oils. Read the labels to make sure that oils appear far down on the ingredient list, a sign that they played a small part in the food's production. All fats aren't created equal either. "Substitute monounsaturated fats for unsaturated or polyunsaturated fats," says Dr. LaFontaine. "Monounsaturated fats, such as olive oil or canola oil, don't seem to contribute to fats in the bloodstream the way other fats do."

He cautions that most of the studies showing the benefits of monounsaturated fat have centered on the Mediterranean diet. While this eating approach is high in monounsaturated fats and low in other kinds, it is also loaded with protective fruits and vegetables, which lend protection against high cholesterol. So far, researchers haven't determined whether the heart-saving benefits come from the oil or the other foods it flavors.

Avoid products that don't specify the kind of oil they contain. They're probably high in the artery-clogging kind, says Dr. LaFontaine.

Stay liquid. Keep away from oils such as shortening that come in cans and are solid at room temperature. They're particularly high in the harmful kinds of fat.

Cut the fat. Buy "select" and "choice" cuts of meat because they are lower in fat than prime cuts, which are marbled with fat. Better yet, just generally cut down on the amount of meat you eat. Make portions smaller or, several days a week, prepare meatless entrées, suggests Dr. LaFontaine. Instead of relying on meat for your protein needs, look to beans and other vegetables. Not only will you take in less fat but also you'll consume more fiber, which also protects your heart.

Make substitutions. Small changes can make big differences in helping to get the cholesterol levels down. For instance, instead of eating whole eggs, use egg whites or egg substitutes. Switch to filtered coffee. The paper filters trap substances that are high in cholesterol. And buy fat-free salad dressing and fat-free margarine, says Dr. Pashkow.

Fortify with fiber. When you eat a high-fiber diet, you're also picking foods that are generally low in cholesterol. Try to take in 25 to 35 grams of fiber a day. "You can get that by eating a lot of vegetable protein, consuming soy and other bean products, for example," says Dr. LaFontaine. "You can also get fiber in fruits, vegetables, and cereals. Evidence suggests that the fiber you get from cereal may be particularly important for protecting your heart."

Step on the scales. Every time you stand on the bathroom scale, you get an instant readout of your cholesterol risks. "The best way to lower cholesterol is to burn off as many or more calories than you take in," says Dr. Wielgosz. What stays in the system can turn into fat and clog up your arteries.

Get reminders. Tell friends and family about the changes that you are making in your diet—and that they can help keep you alive and healthy with their support and encouragement. Ask them to remind you if you start to slip into your old eating patterns. Experts think that social support is one of the biggest motivators in keeping people on track.

Call for help. Your doctor or dietitian should be an important part of the support system that keeps you on the path to heart recovery. Choose a doctor who invites your calls, checks on your progress, and is interested in whether you are sticking to the lifestyle changes that you have made to protect your heart. You'll get encouragement and psychological support just from the fact that you know your doctor cares about how you are doing.

Take the Pressure Off

Not that long ago, doctors thought that high blood pressure was okay as you got older. The theory was that you needed the extra pressure to keep the blood flowing. But study after study shows just how important it is that you get your blood pressure down into the normal range to lower your risk of a second heart attack. "Even if you're 80, your blood pressure can be similar to what it would be for someone 40 years old," says Dr. Pashkow.

Here's how to bring high blood pressure down.

Tip the scales. If you're overweight, lose it. Not only will excess baggage make you more prone to high blood pressure, it will increase your risk of diabetes, which will raise your risk of a second heart attack even more, says Dr. LaFontaine.

Add the fiber. Fiber is one of those all-purpose substances. Not only does it lower your cholesterol but also it helps reduce your blood pressure.

Focus on fat. Make sure that you're getting no more than 20 percent of your calories from fat—an eating approach that will lower both your cholesterol levels and your blood pressure, says Dr. LaFontaine.

Cut the salt. For heart protection stay away from high-salt, high-fat foods, such as potato chips, anchovies, sauerkraut, pickles, and salami as well as other highly processed foods, says Dr. Wielgosz. Your total daily sodium intake should be under 2,400 milligrams, according to the National Academy of Sciences.Your system may also be salt-sensitive, something that often contributes to high blood pressure. Talk with your doctor or dietitian about cutting back on your salt consumption.

Check your supplement. High blood pressure is linked to low levels of potassium, calcium, magnesium, and vitamin C. Eat foods rich in these nutrients. Make sure that they are in your daily multivitamin, but discuss changes that you plan to make with your doctor. And don't consume more than these daily levels recommended by Jeffrey Blumberg, M.D., associate director and chief of the Antioxidants Research Laboratory at the U.S. Department of Agriculture Human Nutrition Research Center on Aging in Boston: 1,200 to 1,500 milligrams calcium, 400 milligrams magnesium, 3,500 milligrams potassium, and 250 to 1,000 milligrams vitamin C.

Stop the Stresses

Researchers have identified stress as an important risk factor for heart attacks. Researchers found that how someone responds to mental stress gives as clear a picture of heart attack risk as does the traditional exercise stress test, says Dr. Wielgosz. This finding underscores just how important a stressful environment may be in heart attack risk.

"While you can't eliminate stress a lot of the time, you can change how you cope with it and manage it. That may be an important factor in reducing your risk for a second heart attack," he says.

Here's how you can cut your risk.

Take time out. During the day spend a few minutes for quiet reflection, contemplation, or isolation from daily life. In your office, bedroom, or outdoors, tune out stress-provoking pressures and thoughts. Focus on pleasant thoughts. Many people relax by repeating a single thought or a prayer over and over again, says Dr. Wielgosz.

Walk the dog. Fido may not be up for a brisk, nonstop, 10- to 20-minute walk, the kind of workout that is intensive enough to benefit your heart. But even leisurely dog-walking has beneficial aspects: It will help you reduce stress. You'll benefit from the repetitive action of your muscles as you walk. You'll enjoy the scenery. But most important, you'll have social interaction with another being, says Dr. Wielgosz.

Find a hobby. A hobby can refresh you and help clear out stress. Write down a list of things that you enjoy, suggests Dr. Wielgosz. Knitting? Reading? Volleyball? Dancing lessons? Pottery? Continuing education courses?

"An amazing number of cardiac patients can't name anything that they do to relax and unwind," he says. "They don't have a hobby or other activity that's unrelated to the demands of their daily life. Think about what you might get pleasure and satisfaction from."

Enjoy the moment. Practice getting enjoyment out of routine activities, such as preparing dinner. "It's easy to see everything you do as one more thing to be checked off on the agenda," says Dr. Wielgosz. "But you end up not enjoying anything, whether it's watching your grandchild in a school recital or eating dinner."

Dr. Wielgosz speculates that enjoyment of eating may explain the French paradox—the fact that people in France and Italy eat a lot of fat but have fewer heart problems. "These people have more joie de vivre at the table," he says. "Their meals take longer. There is more socializing around the dinner table. People enjoy the moment and live in the moment."

Get Moving

You'll need a two-part program of strength training and aerobic exercise to help optimize your recovery from a heart attack, says Dr. LaFontaine. Strength training builds a larger musculature, which burns more calories and helps to keep weight down—which is important to reduce risk. Aerobic exercise strengthens your cardiovascular system and actually reduces the levels of atherosclerosis that contributed to your first attack.

"If you have had a heart attack or have coronary artery disease, you have to do more exercise, not less," says Dr. LaFontaine. "Of course, you have to work up to it gradually."

"If your cardiologist didn't automatically refer you to a cardiac rehabilitation exercise program after you left the hospital and didn't recommend exercise, call him or her for a referral," adds Dr. Pashkow. "Even if your heart is severely damaged and you don't think that you can tolerate exercise, you should get into a program."

Cardiologists sometimes assume that older patients are too frail or won't participate in an exercise program. But it can mean the difference between life and death for you. "Researchers in Finland did a 15-year follow-up study and found that people who participated in a cardiac rehabilitation exercise program and risk factor¹reduction program had a significantly lower risk of death," says Dr. LaFontaine.

While exercise will help your heart get healthy, there is a catch. To get the job done, you'll have to put the pump to work for 2 to 5 hours a week. "Studies show that people with coronary artery disease show the most benefit from this amount of exercise," says Dr. LaFontaine. "That's the threshold at which their atherosclerosis stabilizes or even regresses. If you do less exercise, the atherosclerosis continues and more plaque builds up in the arteries."

As you are burning off calories, your levels of the beneficial HDL cholesterol go up. That's the stuff that helps keep your arteries clean and helps stop plaque buildup. The effort that you expend through exercise also helps lower triglycerides, harmful fats in the blood.

While several short daily bursts of activity (10 to 15 minutes in length) seem to help prevent cardiac problems in the first place, it is not sufficient to reverse risk if you have already had a heart attack, says Dr. LaFontaine.

If you have been inactive for a long period of time, you won't have the capacity to exercise as strenuously as you need to. You won't burn calories at as high a rate as someone with more exercise tolerance. This means that you will have to exercise for longer periods at a moderate level to get similar results. So talk with your doctor about the exercise level appropriate for you. It's important to make sure that you are not overdoing it, advises Dr. LaFontaine.

Exercise also benefits your system in another way, by speeding up your metabolism, says Dr. Pashkow. As you get older, your metabolism shifts into lower gear. "That seems to accompany a drop in the beneficial HDL cholesterol," he says. Higher metabolic rates are tied to higher levels of the protective HDL cholesterol.

The changes in your metabolism also help fight off diabetes. As you get older, some of your systems don't work as well as they used to. You don't metabolize carbohydrates as efficiently, which can lead to insulin insufficiencies and diabetes, a major risk factor for heart problems, says Dr. Pashkow. "When you change your metabolism, you also make it easier for your body to use carbohydrates over the next 24 hours," he says.

Here's how to get the most out of your workout.

Get attention. When you start an exercise program, you may be going against a lifetime of habits. You'll have the most success in sticking with your efforts if your cardiologist provides extensive follow-up and support. If this kind of follow-up isn't a routine part of your cardiologist's program, ask for it.

"We get patients in four times a year just to monitor their progress because it helps them stay on track," says Dr. LaFontaine. "We ask them about their exercise and diets, check their symptoms, and look for improvement." This follow-up procedure is particularly important once you recover from the heart attack and start to feel fine. It will be tempting to go back to your old habits. "In the early months people have a lot of incentive to stay with the program. They see the heart attack as a wake-up call to make lifestyle changes. But it is easy to revert to former habits when everything seems back to normal," he says.

Get rhythm. You can get your aerobic workout through walking, bicycling, working out on ski machines, or using other exercise equipment. "What makes exercise aerobic is that it's rhythmical, can be sustained for 30 minutes, and burns about 300 calories in a session," says Dr. LaFontaine.

Build slowly. "At first, do what you can handle," says Dr. Pashkow. "You may not be able to work up to 45 minutes of aerobic activity five times a week—what I recommend for people who have had a heart attack. If you can just do 10 minutes, start there."

Regardless of how long your exercise, make it fairly intense, says Dr. Pashkow. "The exercise stress test that you had in the hospital and in follow-up visits will let you know what you can safely handle. The kind of exercise that helps prevent another heart attack is different from just strolling in the mall and window shopping."

Choose with care. Sticking with an exercise routine will be a lot easier if you get support from your rehabilitation group or exercise program as well as friends and family. "It's probably as hard to stay with exercise as it is to stop smoking," says Dr. Pashkow. After a year, you have a 1-in-3 chance of returning to inactivity. After four years, your chances of going sedentary are about 1 in 13.

So if you have a choice of rehabilitation centers, pick one that will help you stay with the program. "We know that can make a big difference. We put a lot of effort into getting to know the patients, having special events and dinners with them, and recognizing their birthdays," says Dr. LaFontaine.

Take the time. If your local hospitals don't offer a rehabilitation exercise program beyond the standard 8- to 12-week regimen, discuss other programs with your doctor. The ideal program is a Phase 3 or Phase 4 cardiac rehabilitation program, also called a maintenance program. (Your in-hospital program is classified as a Phase 1 program, and the 8- to 12-week program conducted at the hospital or in another institution is the Phase 2 program.)

Phase 3 programs are usually supervised and may be geared specifically for people who have had heart attacks or coronary procedures. They are often offered through community centers and generally aren't covered by insurance, but the costs are usually very low, says Dr. Pashkow.

In a Phase 4 program you exercise on your own, perhaps at home or in an unsupervised group.

Your only options may be the YMCA or community center programs designed for the general public, not heart patients. Ask your cardiologist to discuss your exercise treatment with the class leaders. They can work together to set up target goals and monitor your progress through periodic telephone calls, says Dr. Pashkow. It becomes a low-cost program tailored just for you. Follow-up involvement from your cardiologist and class leader provide an important psychological incentive for you to keep at it.

Find safety in numbers. Regardless of where you are in the recovery process, you're better off exercising with a group. "Group exercise sessions give you social interaction, as important for recovery from a heart attack as the exercise itself," says Dr. Pashkow. This can help you ward off the feelings of social isolation and depression that often come with a heart attack and dramatically increase your risk of another one, he says.

Go high-tech. If you live in a rural area or if it is hard for you to get to group exercise sessions, look for a cardiac center that has developed "transtelephonic" programs. In these programs patients exercise at home, in their physician's office, or in a medical clinic. Regardless of where they are, a telephone link allows their cardiologist to monitor their activities with an electrocardiogram readout. Four to six people can exercise together, even though they are in different settings. Participants can also communicate with each other during exercise, which is important to provide the social support that helps them stay with the exercise program and keeps them healthier in general, says Dr. LaFontaine.

Spread the word. Tell your loved ones and friends that you are starting an exercise program to help your heart. Ask them to remind you to exercise if you lapse, says Dr. LaFontaine. Ask them to ask you about your progress. Let them know that their support is important to your success. Not only will their support help you stay with exercise but also it will reinforce your sense of having friends and family, which will help you fight off the depression that often follows a heart attack.

Tell Tobacco Good-Bye

If you smoke, the habit played a big part in your first heart attack. If you have since continued to smoke, you just have to snuff out the habit. "Studies show that even in people age 75 and over, quitting smoking reduces the chance of recurrent cardiac problems. That's the most important thing that you can do to prevent future attacks," explains Dr. LaFontaine.

"If you continue to smoke, you will have a sevenfold increase in risk for a second heart attack and a threefold increase in the risk of dying within the first year after the attack," explains Dr. Wielgosz.

Keep trying. "We know that smokers go through phases to quit. And often it takes many attempts. So, if you have tried and tried but haven't been able to quit, don't be discouraged—it's part of the normal process," says Dr. Wielgosz.

Take the three-pronged attack. You are most likely to stop smoking if you take the three-pronged approach, consisting of counseling, group therapy, and wearing the nicotine patch, recommends Dr. Wielgosz.

Look for a cardiac rehabilitation program that puts all the pieces in place to help you quit. Your health insurance may cover the costs, says Dr. LaFontaine.

Think long-term. Cardiologists agree that you can claim to have kicked the habit only if it has been a year or more since your last puff. Even then, there is a 50-50 chance that you will fall back into your old ways. Minimize the risk by joining a heart attack survivors' discussion group, says Dr. Wielgosz. You'll get important psychological support from other heart attack survivors.

If you start smoking again or feel the urge, call your cardiologist immediately. Ask for a referral to a smoking-cessation group (possibly covered by insurance) and jump-start the stopping process.

Take Mental Control

Researchers believe that your mental outlook can make a big difference in whether you experience a second heart attack. "Depression and social isolation put you at greater risk for a second heart attack than even smoking," says Dr. Wielgosz. "If you fall into that category, you have the highest mortality rate after a heart attack."

People with heart disease who become depressed are four to six times more likely to die than those who don't, regardless of other risk factors, says Robert Carney, Ph.D., professor of medical psychology at Washington University School of Medicine in St. Louis. He adds that when you're depressed, you'll be more likely to smoke and have a more difficult time following your doctor's instructions and staying on medication that you need. More important, researchers believe that depression affects the autonomic nervous system that regulates heartbeat and heart rhythm.

Most people who have a heart attack go through bouts of depression. But if your depression lasts one week or longer, contact your cardiologist—you may need help to break free. Let your cardiologist know if you experience some of these symptoms, says Dr. Carney.

* Depressed mood

* Loss of interest in things that you normally enjoy

* Problems concentrating

* Feelings of hopelessness or helplessness

* Appetite and weight loss

* Sleep problems

* Crying for no apparent reason

The good news is that there is a lot you can do to end isolation and depression.

Get a confidante. Having just one close friend makes a difference. You need someone that you feel comfortable sharing your worries and feelings with. "Heart patients who have someone that they can confide in generally do better than those who don't," says Martin Sullivan, M.D., a cardiologist at the Duke University Center for Living in Durham, North Carolina.

A lot of people are more isolated than they realize. Ask yourself: If your car was broken down, would someone drive you to the doctor? If the answer is no, you need to work on getting friends and a possible confidante. And that takes practice. Start by getting out—get involved in a church, club, and neighborhood activities.

Make an appointment. Talk to someone in your church, a social worker, or a counselor. Talk about your feelings and worries. Even if this activity seems foreign to you, remember that you are helping your heart.

Give advice. Be part of the community, helping others as you help yourself. Do volunteer work, perhaps as a senior business consultant or in a partner program in which you work with disadvantaged young people, such as Big Brothers and Big Sisters. You will benefit your community and lower your risk of a second heart attack because you will feel part of a social network.

Join the survivors. Join a focused support group for heart attack survivors. These groups often engage in community activities. They may do fund-raising for nonprofit heart associations. Groups often sponsor educational sessions, meet with nutritionists and exercise specialists, and just discuss their problems with people who have had similar experiences, says Dr. Wielgosz.

Usually, group members also get together to discuss their heart attack experiences and their concerns for the future. Some cardiac rehabilitation programs include programs of this type. "Group sessions are very important in our program," says Dr. LaFontaine. "After an attack, patients are scared, nervous, depressed, and anxious. It helps them to interact with other people, to know that other people have the same worries and concerns. Once they get better and find that they can exercise and carry on life normally, they can bring that information back to the support group to help other people who have recently had a heart attack. It benefits everyone."

These groups also provide an important sense of community. "Studies show that people who belong to groups and have social interaction are less likely to have a second heart attack," says Dr. Pashkow.

List your questions. Next time you visit your doctor, ask questions. You will feel more in control of your fate, which helps reduce depression and isolation. You will also get used to interacting with people that you don't know very well. "Many elderly patients, especially women, don't ask questions," says Dr. Wielgosz. The more you ask, the easier it will be to talk in other settings and become involved.

Before your next appointment, write down the issues that you want to discuss with your doctor. Ask a spouse or other family member to go over it with you to help clarify the issues that are important to you. Take the list to your appointment—and talk it over with your doctor, suggests Dr. Pashkow.

Stay informed. Subscribe to one of the quality newsletters, such as Heartline or the Harvard Heart Letter, that keep heart patients up to date on research and relevant issues, says Dr. Pashkow.

Get a follow-up. Your cardiologist or cardiac rehabilitation program can help you avoid depression, says Dr. Wielgosz. A Canadian study showed that simple things make a significant difference. For instance, patients showed more improvement if a nurse made a follow-up call to check on their progress and, if necessary, referred them to a doctor.

If your program or doctor doesn't do such follow-ups, ask for it or look for an alternative program, suggests Dr. Pashkow.

Get family support. Emotional support from friends and family is critical. "People who are depressed feel isolated," says Dr. Carney. "They worry that they don't have anyone who cares for them. They often ask after a heart attack, 'Is there a future for me?' " Discuss your feelings with family members and friends. You will all benefit—you won't feel as isolated, and they will understand your needs better.

Consider purchasing a pet. A pet will provide you with crucial support and interaction. "Pets depend on you, and that gives your life some purpose and gratification that sustains you," says Dr. Wielgosz.

Researchers at the University of Montreal in Canada found that people who are depressed and angry are much more likely to die within one year of a heart attack than people who aren't. And at Brooklyn College of the City University of New York, researchers found that cardiac patients who owned pets had better survival rates than those who didn't. Pet owners were less anxious, less depressed, and less angry. Dog owners fared the best in the study, but Dr. Pashkow says that you should benefit from any pet to whom you are strongly attached.

Get a grip. Emotions play an important role in heart attack risk. Teach yourself to spot and defuse anger and hostility, emotions that could pave the way for a second heart attack. When you are feeling upset, just stop, step back, and try to analyze the emotion. Distance yourself from your feelings. Ask yourself if what is bothering you is really important, says Dr. Sullivan.

If, for instance, you get cut off in traffic, is it worth getting mad? Did the incident really slow you down? Is your anger at another driver worth an increased risk of a heart attack? With time, putting your emotions into perspective will become second nature, and you will learn to control heart-threatening feelings.

Redefine yourself. A lot of people define themselves by what they can do: their jobs, their physical activity, or their health. A heart attack can lower your self-esteem, says Dr. Sullivan. "It can take away a layer of who you are, especially if you define yourself by things you can't do right after a heart attack." Determine other ways of defining yourself. Even though you've had a heart attack, you are still just as important to family and friends, for example.

Use existing resources. If you're just recovering from a heart attack and have physical limitations, use the resources already in place in your community. Take advantage of programs that offer senior transportation or home delivery of meals—at least until you feel better.

A lot of cardiac patients don't like to feel dependent, but these organizations also help you feel like a part of the community, which speeds recovery and lowers your risk. Remember that the whole community benefits, because staying healthy is a lot less costly. "You're doing everyone a favor by taking advantage of resources and staying involved in the community," says Dr. Pashkow.

Prescription for Prevention

Get back on track for a healthy, active life by making the lifestyle changes that both help your heart recover and protect it from a second attack. If you don't, your risk of another attack soars.

Do:

* Become a label reader in the grocery store. Choose low-fat, low-cholesterol, and low-calorie products.

* Increase your consumption of breads, cereals, pasta, grains, fruits, and vegetables.

* Choose a doctor and a cardiac rehabilitation program that provide you with encouragement and follow-up.

* Reduce stress. Make time for quiet reflection, contemplation, and hobbies.

* Get 2 to 5 hours of aerobic exercise a week.

Don't:

* Smoke.

* Let small things get you stressed out.

* Live in isolation. Get involved in a church, club, and neighborhood activities. Do volunteer work. Join a focused support group for heart attack survivors.

DISCLAIMER:
This book is intended as a reference volume only, not as a medical manual. The information given here is designed to help you make informed decisions about your health. It is not intended as a substitute for any treatment that may have been prescribed by your doctor. If you suspect that you have a medical problem, we urge you to seek competent medical help.