Three weeks later

Diet:

Hamish needs to maintain a healthy diet, get healthy and stay healthy. It is important that Hamish aims to:

• Eat less saturated fat and include more poly and monounsaturated fats, this will help to lower cholesterol.
• Eat more fruit and vegetables, at least 5 portions per day to increase intake of vitamins, mineral and dietary fibre.
• Reduce salt intake to lower risk of high blood pressure by not adding to his food or cooking. Try using more pepper, herbs, garlic and spices.
• Eat more Omega-3 fatty acids, including fish such as salmon, trout, herring, mackerel- at least 2 portions per week. If Hamish is not keen on fish he can supplement by eating unsalted nuts and seeds, to help lower cholesterol.

Physical activity:

Hamish will be advised and supported in gaining physical activity through Cardiac Rehabilitation programme pre and post discharge. Physical activity benefits include reducing BP, stress, cholesterol level, aches and pains, risk of a further heart attack. It will aid weight loss and improve strength and flexibility, and self-confidence. Hamish should aim to build up his exercise, to do 30 minutes of moderate-intensity physical activity on a daily basis. This can be done in two 15-minute sessions or three 10-minute sessions.

Smoking:

Smoking is a major cause of Coronary Heart Disease and increases the risk of a Heart Attack. Hamish will be counselled and advised to stop smoking, whilst in hospital he will be able to avoid smoking. On discharge Hamish may require support from Smoking Cessation or nicotine replacement therapy.

Alcohol:

A high intake of alcohol can directly poison the heart muscle, however a moderate amount may protect the heart. Hamish is advised that his recommended limit is 21 units per week, and he should have at least two alcohol free days per week.

Mental health:

Hamish may experience feelings of anger, loss of confidence, low mood, denial and fear of having another heart attack. These are normal reactions for Hamish to experience and his level of anxiety may be assessed using a ‘Hospital Anxiety and Depression’ score. This may be reassessed after discharge, if there is any serious concern regarding Hamish’s psychological state he can be referred to a psychologist for assessment and support.

Flora:

As Hamish’s wife, Flora will be included in all his care, treatment and recovery process. Flora will be encouraged to be involved with Hamish’s exercise programme and addressing his lifestyle changes such as dietary intake and stopping smoking. It is important to recognise that Flora will be worried about Hamish and what he can and cannot do when he is discharged. It is important to emphasise that Hamish will be able to get back to country dancing once he has had a chance to recover and build up his strength and confidence.

Medications:

Hamish should be considered for the standard secondary prevention medication regimen, although the surgical procedure may require some modification to it.

• Aspirin: Start on initial presentation, continue pre-operatively and on discharge. Usual dose is 75mg once daily for life.
• Clopidogrel (or alternative): Start on initial presentation, stop up to 7 days before surgery. Normally clopidogrel would not be restarted due to the risk of post-surgery bleeding. If CABG had been performed following coronary intervention involving stent insertion, the clopidogrel may be restarted according to local protocols.
• Statin: Usually commenced Simvastatin 40mg at night or Atorvastatin up to 80mg once daily. Start on presentation and continue throughout the admission and on discharge. Usually continued for life.
• Beta-blocker, e.g. Bisoprolol: Used to control heart rate at about 50-60 beats per minute. Dose may need to be increased (or decreased) post-discharge to achieve this.
• ACE Inhibitor, e.g. Ramipril: Routinely used post-ACS, especially if evidence of left ventricular dysfunction on echocardiography or clinical heart failure. Dose should be titrated to target dose if tolerated (see local protocol).
• GTN Spray: Should be prescribed for all ACS patient even if no subsequent chest pain. Education on use and what to do if chest pain not relieved, is essential.
• Other medicines: These may be required if further problems develop such as angina, heart failure or arrhythmias as a consequence of the ACS episode or subsequent surgery.