Cardiac Rehabilitation

Oxford Heart Centre Cardiac Rehabilitation Information Booklet and Personal Plan Heart Disease Diabetes Physical Activity Stress? Medications Blood Pressure Diet Smoking Information booklet and personal plan. Page 1

Name... Your Cardiac Rehabilitation Nurse is... Contact Number... Horton Hospital: (01295) 229753 or (01295) 229426 John Radcliffe Hospital: (01865) 220251 or (01865) 222695 Contents Page The Cardiac Rehabilitation Department 4 How we will help you 4 Heart disease 7 Treatments for your heart condition 13 What will happen during your stay in hospital? 15 Medications 17 Physical activity 25 Healthy eating 35 Smoking 45 High blood pressure 49 Diabetes 53 Anxiety / Stress 57 Driving 65 Moving on 69 Tests and appointment log 73 Useful contacts 76 Information booklet and personal plan. Page 2

Winner of the Patient Information Award (NHS Trust) in the BMA Medical Book Awards 2009 This is an extremely comprehensive resource with clear headings and information divided up into appropriate sections. It contains a wealth and range of information, is original, and links to other sources or services. Additionally, it has excellent potential for record-keeping with clear instructions, particularly with regard to healthy eating and exercise. It seems to cover all bases very well. 2009 BMA Medical Book Competition. Cardiac Rehabilitation Department Philosophy Our aim is to help patients on the road to recovery after a cardiac event such as a heart attack, heart surgery or stent insertion. We encourage a holistic and individual approach to care, acknowledging our patients physical, psychological, social, vocational and cultural needs. We support patients in making lifestyle changes to reduce the risk of further cardiac events. We maintain a high standard of service, which is based on current research. We work as part of a multi-disciplinary team to provide support and education which encourages patients and their families to make informed choices about their care. Our ultimate goal is to empower and assist patients to attain optimal health and wellbeing, enabling them to fulfi l their roles within the family and wider community. Information booklet and personal plan. Page 3

The Cardiac Rehabilitation Department The information in this booklet will help you and your family to understand what has happened to you, and help you recover and plan for the future. It contains quite a lot of information, but you can read it at your leisure. Your Cardiac Rehabilitation Nurse will go through the booklet with you. If there is anything that you do not understand or would like more information about, please do not hesitate to ask any member of the team we are here to help you. The Cardiac Rehabilitation team consists of: Clinical nurse specialists Cardiac rehabilitation nurses Exercise physiologists Administration assistants A clinical psychologist Volunteers How we will help you One of the nurses will visit you on the ward to: Provide written information Explain what has happened to you Identify your risk factors Help you plan to set your own goals using My self-care Plan. This will assist you to identify lifestyle changes with regard to your health and daily living Provide advice on dealing with chest pain Explain driving regulations After you are discharged home the nurse will: Telephone you within a week (fortnight if you have had heart surgery) Arrange a cardiac rehabilitation clinic appointment Send you a copy of the letter sent to your GP Arrange for you to attend the cardiac rehabilitation programme which consists of information sessions and a supervised exercise programme in a locality closer to where you live. Information sessions These are held at both the Horton Hospital and the John Radcliffe Hospital. There is a rolling programme of different topics which include: Medications Healthy eating Risk factors for heart disease Benefi ts of exercise Stress and relaxation methods Effects of heart disease and treatments Emergency fi rst aid Please ask your cardiac rehabilitation nurse for more details. Information booklet and personal plan. Page 4

Exercise programme The programme takes place at either the Cardiac Rehabilitation gym at the Horton Hospital or local leisure centres in and around Oxford. Before you start exercising in the gym you will be given an appointment for an assessment. An individual exercise programme will be written for you. You will be taught how to use the equipment safely and to monitor how hard you are exercising. Once you are ready to leave the supervised programme you move on to the long term Graduate or Phase lv programme. This can be in the Cardiac Rehabilitation Gym at the Horton Hospital or at a facility nearer your home. At fi rst you may feel nervous about exercising, but quite soon you will feel more confi dent. You may even enjoy meeting new people and learning new skills! We are developing a Home Exercise programme for people who are unable to travel to the gyms please speak to your Cardiac Rehabilitation Nurse for more information. Information booklet and personal plan. Page 5

Information booklet and personal plan. Page 6

Heart Disease How does my heart work? What is the difference between angina and a heart attack? What are the rules of chest pain?? What has caused my heart attack? What investigations will I need? Information booklet and personal plan. Page 7

The heart in brief How your heart works The heart circulates blood around the body. The blood carries oxygen and nutrients to the rest of the body through the blood vessels called arteries and veins. The heart is a muscular pump, which like all organs, needs its own blood supply. The main blood vessels supplying the heart muscle are called coronary arteries; these supply the heart muscle with oxygen. Blood Pressure This is the pressure measured in the arteries. It rises and falls as the heart pumps out blood. Systolic When the heart contracts to pump blood 140 or below is a normal systolic out, the pressure in the artery goes up Reading 140 (systolic reading). Diastolic When the heart relaxes, the pressure in 85 or below is a normal the artery goes down (diastolic reading). diastolic reading 85 (If you are diabetic you should aim for a your blood pressure of 130/80.) (Department of Health 2000) These two sounds are measured when blood pressure is taken The Heart Heart rate The heart pumps at different speeds according to the needs of your body. There is a wide range of normal heart rates. Everyone s heart rate goes up and down according to whether they are resting or exerting themselves. Heart rate and blood pressure are also affected by things such as our emotions (e.g. fear, anger), medications, smoking, and a variety of illnesses. Information booklet and personal plan. Page 8

The heart and coronary arteries Causes of heart disease The reasons why the coronary arteries narrow is not yet fully known. Research has shown that there are several risk factors which can cause heart disease, which may lead to the development of angina and heart attacks. Risk factors are habits and bodily characteristics which tend to increase your risk of developing angina or a heart attack. Risk factors include: Smoking High blood pressure High cholesterol levels Being over weight Diabetes Family history of heart disease Ethnicity Being inactive Age Gender Stress and psychological issues However, some people still have heart disease even though they have none of the above risk factors. Research is ongoing to try and fi nd out the causes and to improve the treatment of heart disease in general. Risk factors such as your age, gender, ethnicity and family history of heart disease are unavoidable. Do not worry about these risk factors but it may be useful to be aware of them. For example, if you have a strong family history of heart disease, you may be able to encourage family members to read this information and have a check-up with their GP. However, this is their responsibility and not something for you to worry about. Try and concentrate on the risk factors you can do something about. Your Cardiac Rehabilitation Nurse will help you to identify your risk factors for heart disease and work with you to set goals that will help and support you to make lifestyle changes. You might fi nd this thought challenging at the moment but your Cardiac Rehabilitation Nurse will talk to you about the cycle of change and at what point you may be ready to make positive changes with support. Information booklet and personal plan. Page 9

This diagram is produced by kind permission of Rick Maurer. Cardiac Rehabilitation The Cardiac Rehabilitation Nurse who supports you on this will work with you to complete a Self Care Plan which is right for you and will be led by what you want to achieve. They may make some extra suggestions but it is YOUR plan. My Selected Goals Example: I want to understand more about the causes and treatment of my condition 1. 2. 3. Information booklet and personal plan. Page 10

Heart Conditions Acute Coronary Syndrome This is a term which you may hear the doctors using when they discuss your diagnosis. Acute Coronary Syndrome is a broad term that was introduced by the World Health Organisation in 2001 which includes a diagnosis of either unstable angina or a heart attack (acute myocardial infarction). The doctor makes the diagnosis based on your recent history, clinical examination, the Electrocardiogram (ECG) and blood test over 12-24 hours. The blood tests, measure an enzyme called Troponin a chemical released by the heart when the heart muscle has been damaged. This measurement will be slightly raised even if only a very small amount of damage has occurred. The doctor may then talk to you about having had a heart attack. Heart Attack (Acute Myocardial Infarction) A heart attack may also be called a myocardial infarction, a coronary thrombus, a coronary occlusion of an artery or acute coronary syndrome. A heart attack occurs when an area of heart muscle has been deprived of oxygen for a short period of time by a blood clot or blockage in a coronary artery. This usually causes severe pain or discomfort which may last for several hours. However, it can be mistaken for indigestion like pain and may not always be present in the chest (especially in women or people with diabetes - see below under angina ). The area of the heart muscle that is deprived of oxygen forms an area of scar tissue over the next few weeks. The aim of all the treatment you receive in hospital is to help your heart recover and to reduce the chances of further coronary heart disease. Angina Angina is a warning sign that the heart muscle is temporarily not receiving enough oxygen. Stable angina Angina can occur when the heart is working a little harder than usual. For example, exercise, excitement, brisk walking, cold or very hot weather or eating a large meal might cause this. Angina can be described as a pain, discomfort, tightness, or indigestion-like ache, but everybody s experience of Angina can be different. This type of Angina is normally well controlled with medication. Unstable angina Unstable angina can occur over a few days with increasing frequency. Symptoms can be similar to stable angina or may be new. This might occur with progressively less exercise, at rest or can even wake you at night. Angina is your heart s way of saying it is not getting enough oxygen and should not be ignored. If you experience symptoms of either stable or unstable angina you should use your GTN. It is very important that you call 999 if you have a pain that is not relived by either rest or GTN and lasts for more than 15 minutes. (See What to do if you get chest pain on page 17.) It is important to let your GP know if you are experiencing Angina symptoms, particularly at rest, or if this has started to wake you from your sleep. Information booklet and personal plan. Page 11

Tests for your heart condition Electrocardiogram (ECG) The ECG records the rhythm and electrical activity in the heart. The doctors and nurses will look for specifi c changes on your ECG of which there are two types: - Changes which show a blood clot in one or more of the coronary arteries in your heart. - Changes which show a blood clot is partly blocking one or more of the coronary arteries in your heart. Blood tests Troponin: If a heart attack is suspected a blood test will be taken to measure for an enzyme called Troponin a chemical released by the heart when the heart muscle has been damaged. This measurement will be slightly raised even if only a very small amount of damage has occurred. This test tells us whether you heart muscle has been damaged. Cholesterol: You will also have a blood test to measure for the cholesterol levels in your blood. Glucose: You will also have a blood test to check your blood glucose levels even if you are not diabetic. Echocardiogram (Echo) This is an ultrasound scan of your heart. It is safe, easy to do and does not hurt. This tells us how the heart muscle has been affected. Myoview (Myocardial Perfusion Imaging) This is to look at the blood fl ow to the heart muscle and how well your heart is pumping, both at exercise or stress and rest. This will help to diagnose if you have Coronary Heart Disease. The two images are then compared to allow an assessment of damage to the heart muscle (heart attack) or decreased heart blood fl ow during exercise or stress. Exercise Tolerance Test (ETT) or Treadmill Test This is an ECG carried out while you are walking on a treadmill. Your heart rate, heart rhythm and blood pressure are recorded while you exercise. The treadmill will speed up and become steeper every three minutes so that you work harder and your heart rate and blood pressure will increase. This test helps to determine if your symptoms are caused by Angina. Coronary Angiogram This is used to look inside the coronary arteries to see if they are blocked or narrowed. A local anaesthetic is used to numb your groin or wrist. A fi ne tube is passed up the artery at the top of your leg or arm and into your heart. A special dye which shows up on x-ray is then injected into the tube and to the coronary artery. This is fi lmed using X-ray screening equipment. You may be able to watch the procedure on the screen if you want to. This allows the doctor to see any blockages or narrowing that may be responsible for your symptoms, which will help him/her to decide what, if anything, needs to be done to improve the blood supply to your heart muscle. The investigation generally takes between 20 minutes and an hour. After your angiogram your blood pressure and heart rate are checked regularly. You will need to lie fl at on the bed for a few hours to prevent any bleeding. Information booklet and personal plan. Page 12

Treatments for your heart condition Your Doctor will discuss the possibility of further treatments. This may involve a percutaneous coronary intervention or coronary artery bypass surgery. Percutaneous Coronary Intervention (PCI): An angioplasty or percutaneous coronary intervention (PCI) may be performed immediately following the angiogram. The artery is opened up by infl ating a small balloon inside the artery which is narrowed, squashing the atheroma (fatty tissue) and allowing the blood to fl ow more easily. A small piece of stainless-steel mesh (coronary stent) is placed inside the artery to make sure it stays open. After the procedure, your blood pressure and heart rate are checked regularly. You will need to lie fl at on the bed for a few hours to prevent any bleeding from the groin or wrist. If the doctors put the catheter in your wrist, a tight band will be placed around your wrist to prevent bleeding; this will be gradually loosened over the next few hours. Primary Percutaneous Coronary Intervention (PPCI) This is the same as a PCI (see above) but in the urgent situation this procedure is called Primary Percutaneous Coronary Intervention (PPCI) and is the most effective and safest treatment for an acute heart attack. Patients with an ECG that shows a particular pattern called ST elevation will be considered for PPCI Coronary Artery Bypass Surgery The purpose of this surgery is to bypass the narrowed/damaged sections of the coronary arteries. The heart surgeons do this by attaching a section of blood vessel between the aorta (the main artery leaving the heart) and a point in the coronary artery beyond the narrowing. A bypass graft can be carried out for each of the main coronary arteries affected. The surgeon uses the mammary artery from your chest wall but blood vessels from other parts of the body, such as the leg, are also used. Implantable Cardioverter Defibrillator (ICD) You may have had a dangerous heart rhythm before, or you may be at risk of one in the future due to an underlying heart condition. Your Cardiologist may recommend that you are fi tted with an ICD. An ICD can recognise and monitor your heart rhythm, and will administer an electric shock if your heart rhythm becomes dangerously fast. This is not a replacement for your normal heart medications. Information booklet and personal plan. Page 13

artery Coronary angioplasty with a stent Atheroma (fatty deposits) in the artery wall restrict the flow of blood. stent The guide wire of the catheter goes beyond the narrowed part of the artery. The balloon and stent are positioned in the narrowed area. The balloon is gently inflated and the stent expands, flattening the atheroma in the artery wall. The balloon is then let down and removed, leaving the stent to keep the artery open. This diagram is reproduced with the kind permission of the British Heart Foundation, the copyright owner. Information booklet and personal plan. Page 14

What will happen during your stay in hospital? During your stay you will probably have undergone various investigations and treatments as explained above. You may also experience the following: Heart monitoring You will be attached to a heart monitor so that we can observe your heart rate and rhythm. Simple things such as moving, scratching and even cleaning your teeth can cause the heart monitor to alarm. Try not to worry about this - we will be watching the monitor to make sure everything is going well. The nursing staff will also monitor your blood pressure and heart rate. If you are experiencing any unpleasant sensations, pain, or shortness of breath, it is very important that you tell the nurses on the ward so that you can be treated. At fi rst your mobility may be restricted by the leads attached to the monitor. As you improve the monitoring will be reduced and you will be able to move around more. As you recover you will be able to walk short distances and become more independent. Emotional well-being It is normal to feel emotional during this time. It can be helpful to talk to someone about this such as your Cardiac Rehabilitation Nurse. Your psychological well-being is equally as important as your physical care. The cardiac rehabilitation team is experienced in this aspect of care, so do not be afraid to talk to us about your feelings. Visitors Time and rest are amongst the best healers and it can be surprisingly tiring to have a lot of visitors. It is best that you keep visiting to close family at fi rst. The nurses will explain the special visiting arrangements and times to you (especially on the Coronary Care Unit). Cardiac rehabilitation A nurse from the cardiac rehabilitation team will come and see you during your hospital stay and before you are discharged home. Going home You will be discharged from hospital within 2-5 days of admission, but everyone is different so don t worry if your stay is longer. It is normal to have an increased awareness of all the sensations in your body; this is normal and will settle down over time. Your GP will be sent an electronic summary of your hospital stay. You may also be given a letter on discharge and in this case you must take it to your GP. You will be given 28 days supply of medications. You will need to make an appointment to see your GP before your supply of tablets runs out. After your discharge you will generally have a hospital follow up appointment. This can be with one of a variety of health professionals. This may include a Cardiologist, Cardiac Surgeon, Consultant Nurse for Cardiac Medicine or Cardiac Rehabilitation Nurse. You will of course have regular contact with your cardiac rehabilitation team. Information booklet and personal plan. Page 15

Information booklet and personal plan. Page 16

Medications What tablets will I have to take home? Who should I contact if I have side effects? Are there any side effects?? How do the tablets help my heart? How long will I be on this medication? Information booklet and personal plan. Page 17

Medications This section gives you information about groups of drugs that are commonly used in the treatment of coronary heart disease. Here is a list of the commonly used drugs: GTN Aspirin Other antiplatelet drugs such as Clopidogrel, Prasugrel, Ticagrelor Beta Blockers ACE inhibitors Statins GTN (Glyceryl Trinitrate) - tablets or spray GTN treats chest pain quickly. It may also be used before an activity that would usually start your chest pain. How does it work? Angina is caused when an area of the heart muscle doesn t get enough oxygen. GTN dilates (widens) the blood vessels and allows the affected heart muscle to obtain more blood and oxygen. How to take your GTN medication If you get angina, stop what you are doing and rest. Sit down if possible. If your pain does not ease within a minute, use your GTN under the tongue. Many people who know that a certain activity will bring on angina fi nd it helpful to use their GTN medication before they start the activity to prevent the chest pain. If, after 5 minutes of using your GTN, the pain is still present, take another dose. Wait a further 5 minutes before using a third dose. If the pain does not improve with three doses, you should call an ambulance. With GTN tablets, once the pain has stopped you may spit out the tablet or swallow it. If your pain becomes severe at any stage, or if you feel unwell, use your GTN and call an ambulance. N.B. Please see flow diagram overleaf. Storage of your GTN The GTN spray should have its expiry date printed on the bottle. Once GTN tablets are opened, they lose their effectiveness after 8 weeks. Write the date they will expire on the bottle and make sure you have a new supply before this date. When using the tablets you should get a slight tingling sensation under your tongue. If you do not, they may be out of date, so you need to replace them. Do not transfer the tablets to any other container and do not mix them with any other drugs. The tablets or spray can be obtained on prescription. However if you run out of GTN it can be bought over the counter at a pharmacy. Information booklet and personal plan. Page 18

It is very important to carry your GTN spray or tablets with you at all times. Do not give your GTN to a friend or partner to put into his/her bag or pocket. If you do, it may not be available when you need it. You may wish to get an additional GTN spray, one to carry with you and one to have at home. Side-effects GTN may cause facial fl ushing, dizziness and headaches. To reduce the risk of dizziness use the GTN as recommended. To relieve a headache, simple painkillers such as Paracetamol may be used. What to do if you get chest pain: This is a guide BUT If at any point your pain becomes worse, or if you feel unwell (e.g. dizzy, sweaty, short of breath) please call 999 for an ambulance immediately. Information booklet and personal plan. Page 19

Symptom record It is important that you keep a record of any symptoms that you think are related to your heart condition. It is often difficult to recall details when asked about such things after the event. If you write it down it helps to order things in your mind and is very useful when you come to tell the doctor or nurse about it. Below is a chart on which you can record your symptoms. Date and What were you doing? What kind of symptom Action taken. Did the Time was it? Describe.... symptom disappear? Aspirin Aspirin tablets may be: soluble (these can be dissolved in water or swallowed whole), or coated (these tablets cannot be dissolved and should be swallowed whole and not chewed) Information booklet and personal plan. Page 20

What does aspirin do? Aspirin lowers the risk of blood clots forming by making blood cells called platelets less sticky. This makes the blood less likely to form clots in narrowed blood vessels. Blood clots can be responsible for causing a heart attack or symptoms of angina. Side-effects As aspirin affects the time it takes for a clot to form, you may fi nd that you bleed for longer if you cut yourself. You may also bruise more easily. Aspirin may irritate the gut, causing indigestion or stomach pain. It is important that you take aspirin with or after a meal. Some people can be allergic to aspirin; this is more common in people who have a history of asthma. If you become short of breath, or notice a wheeze after taking the tablet, please tell your GP. If you have problems with these symptoms, we advise you to see your GP. When taking aspirin for your heart, do not take further doses to use as a painkiller. Try using Paracetamol instead. Non-steroidal anti-infl ammatory drugs such as Ibuprofen are not recommended long term due to a small risk of clot formation. Please contact your pharmacist if you are considering taking Ibuprofen for pain. These drugs may interact with each other so you should seek advice before taking them together. Antiplatelet drugs: Clopidogrel At the moment Clopidogrel is the most commonly used antiplatelet drug. However other antiplatelet drugs are being introduced. These include Prasugrel and Ticagrelor. Clopidogrel lowers the risk of blood clots forming by making blood cells called platelets less sticky and less likely to form clots. Blood clots can lead to a heart attack, stroke, or thrombosis (a blood clot) in the veins of the legs. Clopidogrel is used in most patients after a heart attack in addition to Aspirin. Clopidogrel is often used for a limited time (usually 12 months) following a heart attack and after a coronary stent insertion to prevent blood clots forming on the stent. Check with your doctor or cardiac rehabilitation nurse if you are unsure how long you should be on it for. For people who are allergic to aspirin, Clopidogrel can be used as an alternative. Side-effects To help reduce potential stomach irritation, please take Clopidogrel with or after food. Clopidogrel is a very effective medicine in the prevention of clot formation. However, it can lead to bleeding problems in some people. Please contact your doctor if you experience any problems, such as: Bruising Rash Nausea (feeling sick) Stomach discomfort Diarrhoea Fever, sore throat, mouth ulcers. Information booklet and personal plan. Page 21

ACE Inhibitors ACE inhibitors widen (dilate) and relax blood vessels; this reduces blood pressure, and helps to protect the lining of blood vessels. After a heart attack and in heart failure it is easier for the heart to pump into widened and relaxed blood vessels. ACE inhibitors can be used after a heart attack to reduce the risk of further heart attacks, to treat high blood pressure, or to treat heart failure. These are normally started at a low dose and gradually increased over the weeks following discharge. Common tablets / capsules: Ramipril, Lisinopril, Captopril, Enalapril, Perindopril, Quinapril Side-effects As the aim is to lower your blood pressure, you may feel dizzy for a short time after taking the tablet. This usually goes away after taking the medication for a few days. If the dizziness continues, try taking it at bedtime. Other side effects include a dry cough, which normally goes away after 2-3 months, and a runny nose/cold like symptoms. A simple linctus can help with this. If you are experiencing these side effects and they are a problem for you, please see your GP for advice. Beta-blockers Beta-blockers slow your heartbeat down; this reduces the workload of the heart. They are used for a number of reasons such as reducing high blood pressure, reducing the symptoms of angina, and to control fast heartbeats. They can also reduce the risk of further heart attacks, and are sometimes given in heart failure to improve the function of the heart. Common tablets/capsules: Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol, Propranolol, Sotalol Side-effects When fi rst taking your beta-blocker you may feel more tired than usual and get cold hands and feet. These problems usually go away with time. Some people experience vivid dreams, which should ease within a couple of weeks. It is recommended to take your beta-blocker at night to reduce the chance of this happening. If you have diabetes, they may affect the amount of insulin you require. Please note that they may also hide the signs of a hypo (low blood sugar) so it is important that you keep strict control of your blood sugar level. In a very small number of people beta-blockers can cause a wheeze or diffi culty in breathing. This is more common in people who have a history of asthma or lung problems. If this occurs, you must contact your doctor immediately. Do not stop taking the tablets unless instructed by your doctor. For men, beta-blockers may lead to impotence (inability to have an erection). If you are experiencing these side effects and they are a problem to you please contact your GP for advice. Information booklet and personal plan. Page 22

Statins and fi brates Statins and fi brates lower the cholesterol and triglyceride levels in the blood. These are types of fats. High levels of cholesterol and triglycerides can clog up the coronary arteries that supply blood and oxygen to the heart muscle, which can lead to a heart attack. For information about Omega 3 supplements please refer to page 35. Common tablets / capsules: Statins: Atorvastatin, Fluvastatin, Simvastatin, Pravastatin, Rosuvastatin. Fibrates: Bezafi brate, Fenofi brate. Ezetimibe is also used to control familial hypercholesterolaemia in conjunction with a statin and dietary measures. Taking your cholesterol lowering medication Any drug therapy to lower cholesterol should be combined with a low fat diet. It is best to avoid taking grapefruit juice with these medications because it can affect the way the medication works. (Lilja et al 2004.) Statins are most effective if taken in the evening or before you go to bed, because it is during the night that most cholesterol is produced. Fibrates should be taken with or after food as instructed on the packaging. Your GP will monitor your liver function closely by doing a blood test and also check your blood cholesterol to make sure the tablets are working. Even when your blood cholesterol level is reduced you will still benefi t from following a low fat diet and continuing to take your medication. Side-effects Some people experience a mild stomach upset, and a rash. Also muscular weakness, aches and pains have been reported. If you have problems with these symptoms, we advise you to see your GP. Medications allergies and side effects Are you allergic to any medications? If so, please list them and describe the allergic reaction.......... Information booklet and personal plan. Page 23

Use this section to make a record of your medications Drug name What is the dose? How often do you Write any changes take it? and dates in here Information booklet and personal plan. Page 24

Physical Activity What can I do when I go home? How can I help my recovery? When can I go swimming?? What level of activity is good for my heart? When can I play golf? Information booklet and personal plan. Page 25

Some good news Regular physical activity has been shown to have numerous benefi ts for people with heart disease. For example, it can: help lower your blood pressure improve your blood cholesterol levels reduce your risk of diabetes help you to lose weight reduce your angina reduce your risk of having a stroke help you to return to work earlier after a heart attack reduce the number of hospital visits that you make or tablets that you have to take. Physical activity is a broad term that includes everything from walking the dog or gardening, to structured forms of exercise such as swimming or playing a sport. Many people who do regular physical activity report that it makes them feel better and more energetic, provides relief from stress and anxiety, improves their sleep, helps them to stay independent, as well as enhancing their mood and level of self-confi dence. It can also be sociable and a lot of fun! So what are you waiting for? Most people in your position are understandably concerned about how much exercise and physical activity is right for them. However, the heart is a muscle, and like any other muscle, it needs physical activity to stay healthy. Regular physical activity will improve the blood fl ow to the heart muscle and will help your heart to become stronger and more effi cient. Physical activity is a very important part of your recovery, but the amount and type of activity that we advise will differ tremendously from person to person, and it is important that you work within your own limits. It is important that during any form of physical activity, you: STOP if you experience any undue shortness of breath Chest pain / discomfort (or pain in your neck/arm/jaw) Nausea/headaches/dizziness Inappropriate tiredness Persistent palpitations Feeling unwell If in doubt STOP and check with your GP before continuing Information booklet and personal plan. Page 26

Everyday tasks During your fi rst week at home, rest and enjoy being there. You may fi nd that you tire easily when you fi rst return home. If you feel tired, have a sleep during the day. As far as possible stick to your normal routine, i.e. get up and get dressed it is not necessary to take to your bed. Don t let visitors stay too long in the early days. From the second week at home, try to increase the number of activities that you do, ensuring that you don t get too tired. Walk up and downstairs as necessary. As a very general rule, light household chores may be resumed as soon as you feel fi t, but heavy manual work such as bed changing and vacuuming should be avoided for at least 6-8 weeks. Similarly, light gardening may be undertaken but heavy lifting and straining, digging, sawing, or mowing should be avoided for 8-12 weeks. Initially, you should also try to avoid long periods of work with your arms above your head, such as trimming a high hedge or painting the ceiling, because this will raise your blood pressure and put extra strain on your heart. When you feel able to do larger tasks such as mowing the lawn, or vacuuming for the fi rst time, split the job into manageable chunks have a rest and sit down if you are feeling tired, and fi nish the task later or the next day if necessary. Also try to space out activities during the day. Try not to compare what you are able to do now with what you used to do. Do not be afraid to ask for help. Friends and family members will be more than willing to lend a hand. In time, you should be able to get back to normal if not better! ICD s: Exercise is possible even if you have had an ICD fi tted. If you have had an ICD fi tted you will be asked to undertake an exercise tolerance test with the ICD deactivated prior to commencing cardiac rehabilitation. For further advice on exercise and ICD s please refer to the Arrhythmia Alliance booklet on Physical activity and exercise advice for patients with an ICD. You can ask you cardiac rehabilitation or specialist nurse for a copy or alternatively this can be downloaded from: http://www.heartrhythmcharity.org.uk/patient-area/patient-information. What sort of exercise is best? The type of activities that are most benefi cial for the heart are called aerobic activities. Aerobic activities are repetitive, rhythmic forms of exercise such as walking, cycling, swimming and dancing, which involve large muscle groups (e.g. leg muscles). The other main type of exercise is called resistance or strength training, e.g. press-ups and heavy lifting. However, these activities are not recommended for everyone, especially if you have high blood pressure, because they increase your blood pressure and put your heart under more stress. With this in mind, it is strongly recommended that you incorporate regular, continuous aerobic activity into your day. This should be of a moderate intensity, i.e. exercise that makes you feel slightly warm and slightly out of breath. Walking is an ideal activity that can easily become part of your daily routine. The following programme is designed to provide you with a framework so you can build up your walking levels gradually. Walking programme The walking programme shown below is a rough guide only. Everybody recovers at a different rate. Be sensible if you are fi nding the distances hard, take things nice and slowly. If you are fi nding them very easy you may progress through the stages quite quickly. Progress through each stage in order; do not miss any stages out regardless of how well you think Information booklet and personal plan. Page 27

you are progressing. (If you are not starting this walking plan straight away after being discharged from hospital, try to judge what activity level you are comfortable with, and start from there.) If you feel comfortable, try to increase your walk by 1 or 2 minutes, and move on to the next stage when you are ready. It is important that you increase the time and speed very gradually. By the end of the programme your aim should be to go walking at least fi ve times a week, at a brisk pace for at least 30 minutes. This is the amount of activity that is recommended to keep your heart healthy. Stage of Recovery (approximate) Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Target Length of walk (in minutes) Gradually increase the length of the walk and move on to the next stage when you are ready 5 minutes: several times per day. Strolling / leisurely pace 10 minutes: twice a day. Leisurely pace 15 minutes: daily. Leisurely / moderate pace 20 minutes: daily. Moderate pace 25 minutes: daily. Brisk pace 30 minutes: daily. Brisk pace 30-40 minutes: daily. Brisk pace Important points to remember Once you have established the walking programme it is important to: Warm-up: It is extremely important that when you go for a walk, you don t start walking at your full pace immediately, but build up gradually during the fi rst few minutes of the walk. Ideally this warm up period should be between 5 and 15 minutes long. The warm up should be less effort than the walk and should be adapted to your stage of recovery. e.g. walking on the spot, walking slowly. This will give your body and heart time to adapt to the work that you are asking it to do. This warm up period has very important safety implications, including reducing the risk of angina and disturbances in your heart rhythm. Cool down: Similarly, you should never speed up towards the end of your walk and then stop suddenly. It is important that you gradually slow your pace during the last portion (ideally 10 minutes) of your walk. This cool down helps to reduce the risk of sudden heart problems or a sudden drop in blood pressure, and should be taken very seriously. It may be diffi cult for you to follow this advice on warm-up and cool down if you have to walk uphill straight away e.g. if you live at the bottom of a hill. If this is the case you should fi nd a fl at spot (e.g. your garden/house) to do your warm-up before you attempt the hill (at a slow pace). Alternatively, it may be more suitable to travel by car to a fl at place to do your walk. If you live at the top of a hill you may be able to do a warm-up period by starting off slowly and easily downhill, but on your return you will be fi nishing your walk climbing the hill and therefore Information booklet and personal plan. Page 28

working hard. In this case, rather than just stopping your walk abruptly when you reach the top, we recommend walking slowly around on the fl at for a reasonable amount of time to get your breath back and cool down safely. Plan your route on fi rm, level ground if possible, especially for the fi rst few weeks of your programme. As you gain in confi dence and fi tness, increase the pace and try to introduce some gradual hills into your route. If necessary at fi rst, slow down your pace when you are walking up hill, and if going uphill usually brings on angina, use your GTN before you start to climb. Occasionally you may have a day when you are not feeling as energetic as usual. Please don t feel disheartened this is not a step backwards in terms of your recovery. Reduce the amount that you do that day, or walk at a slower speed. Everyone has good days and bad days so remember to listen to your body. You may fi nd it useful to map out a specifi c walking route before you start. If possible, fi nd out how far it is and time how long it takes you to walk it, and then you have a means of monitoring your progress. It is a good idea to choose a circular route, so that you are never too far away from home or the house of a relative or friend. Alternatively, you could fi nd out about catching the bus back home if you are on a bus route. To start with it may be a good idea to take a friend or relative with you when you walk this will help your confi dence and enjoyment, as well as their health! Do not walk straight after a meal as this may bring on angina. Try to leave at least an hour after you have eaten before you start exercising. How fast should I walk? For the fi rst few weeks of the programme, you should walk at a leisurely to moderate speed. As you get fi tter you should try to increase your pace gradually, building up to a brisk pace. One way of checking your pace is by doing the talk test while you are walking. Talk test If you can talk very easily, you are not walking briskly enough. If you can talk but feel warm and are breathing heavier than normal, you are walking at about the right pace. If you can t talk, you are walking too briskly, so you should slow down. By the time you have completed this programme physical activity should have become a regular part of your life. For example, when you go back to work why not try going for a brisk walk during your lunch break. Ideally, you should be doing at least 30 minutes of physical activity on 5 or more days of the week. Don t forget that you can split up the 30 minutes doing two lots of 15 minutes may be more convenient for you. Remember that it is current physical activity that protects your heart i.e. what you are doing at the moment, not what you did last month, so you must keep up the good work! Specifi c activities and tasks It is very important to remember that people differ in how seriously their heart has been damaged, and that people progress at different speeds. The following pages give general guidelines. Any specific questions should be discussed with your Cardiac Rehabilitation Nurse or exercise physiologist. Information booklet and personal plan. Page 29

0 2 weeks Activity Advice - Light housework - Dusting - Making the bed - Washing up - Food shopping (using a trolley) Lift one bag at a time, and avoid lifting heavy bags - Carrying light rubbish - Walking, strolling, walking See the previous walking programme for advice on around the house page 25 - Sexual activity See page 30 - Bathing and showering Avoid very hot or very cold water as this can cause dizziness or angina - Dressing and undressing 4 6 weeks Heavier cleaning - washing windows - mopping - sweeping - washing car Bicycling Initially, choose a fl at route and pedal gently. Gradually - gentle pace, to work or for leisure build up time (i.e. add 1 minute). Using a push bike is harder than a static bike. Don t forget that there is wind resistance and the roads are not totally fl at, but go uphill and downhill. Don t be afraid to get off your bike, rest, and push it up a hill if you feel tired. 10 12 weeks Gardening Avoid excessive bending. Kneel whilst weeding. - planting and trimming shrubs Avoid lifting heavy watering cans use a hose if possible. - digging, mowing lawn Only mow/rake for short periods at fi rst and take regular (powered mower) rests. Finish the job the next day if necessary. - raking leaves Limit the amount of sustained work that you do with your arms above shoulder height which increases the workload of the heart. Take regular breaks even if you don t feel tired. DIY decorating, painting Scrubbing fl oors (hand & knees) Carpentry sawing hardwood This is a high-energy activity. Moving furniture Carrying groceries upstairs This is a high-energy activity. Do not try to carry too much at once. Swimming breast stroke Swimming is not appropriate for everyone please check with your Cardiac Rehabilitation Nurse or Exercise Physiologist before you do this activity. Walking hiking, cross country Start gradually, remembering that walking on uneven ground is much more tiring than walking on the fl at. Information booklet and personal plan. Page 30

When trying to decide if you are ready to start doing a certain activity, think about how you are progressing with less demanding activities: If you are comfortable doing light activities on a regular basis, and have been doing so for a couple of weeks, then why not gradually try some moderate tasks (e.g. progressing from 30 minutes of a light activity, to 15 minutes of a moderate activity). Similarly, if you have been comfortably performing tasks classed as moderate on a regular basis for a few weeks, then you may well be ready to incorporate some more demanding activities into your day. Be sensible start slowly and build up gradually. Take things one step at a time. Sensible precautions In order to maximise your safety, it is important to read and follow these guidelines: Exercise only when you feel well. If you are unwell with a virus, cold or tummy bug please do not attempt to undertake any exercise as this will slow your rate of recovery. Wait at least 2 days after the symptoms have disappeared. Do not exercise in extremes of temperature. If it is warm, slow your pace. When exercising in the cold, dress warmly. Cold and/or windy weather may provoke angina. You can help to prevent this by covering your mouth with a scarf when you are walking so that you warm the air that you are breathing in. You must also compare how you feel on any given day with your usual symptoms and capabilities. If you have developed any new symptoms or you have found that your usual symptoms have got worse (i.e. more breathlessness, more frequent angina, swollen ankles) you must inform your GP as soon as possible. Home Exercise Programme If you are not able to attend the supervised sessions then you may prefer our home exercise programme. The home exercise programme is a walking programme using a pedometer for you to count and record your daily steps. The home exercise programme is not appropriate for every patient. If you are interested please discuss your options with your Cardiac Rehabilitation Nurse. Your walking programme will be designed around you, your needs and your capabilities. Motivation is an important part of the home exercise programme. Your progress will be monitored by weekly phone calls from an Exercise Physiologist. Supervised exercise classes Many people fi nd that they benefi t greatly from attending a series of supervised exercise classes during their recovery after a heart attack. These sessions are provided by the Cardiac Rehabilitation Team at a variety of local venues, and will help you to fi nd out about how much activity you can safely do, and provide you with the confi dence to become more active. If you would like to fi nd out more about these classes, please speak to your Cardiac Rehabilitation Nurse. Exercise programmes are held as follows: Abingdon White Horse Leisure Centre Banbury Horton Hospital, Cardiac Rehabilitation Gym Oxford Blackbird Leys leisure Centre Witney Windrush Leisure Centre Information booklet and personal plan. Page 31

Keeping fi t in the community There are a number of groups across the county which organise activities outdoors, for example the walking for health initiative (www.whi.org.uk) and the BTCV s green gym project which organises community conservation and gardening projects (www.btcv.org.uk). Resuming sexual activity after a diagnosis of coronary heart disease People may fear that a heart attack, angina or acute coronary syndrome could put a stop to their sex lives. However, this need not be the case. The vast majority of people can resume their normal level of sexual activity with no ill effects. Sexual intercourse is no more strenuous than walking upstairs. You actually use more energy arguing, driving to work or watching exciting TV! You will not live longer by avoiding sex. It is very rare for anyone to be advised by their doctors to stop sexual relationships. If you have any queries or are having problems, please do not hesitate to discuss this with your Cardiac Rehabilitation Nurse or your doctor. They can give you advice, support and information, or put you in touch with others who will be able to help. Your GP should be able to prescribe medication if this is what is ultimately required. Those with younger partners may sometimes experience diffi culties as the demands of younger people may be greater. If each understands the needs and abilities of the other it is possible to overcome this. However, where problems do exist, seek help early. When can I resume sexual intercourse? There are no rules it is whenever you and your partner feel ready. This can be from as soon as 2-3 weeks after a heart attack. If you are able to walk briskly up and down two fl ights of stairs without angina (chest pain), then sex should not be a problem. Touching, holding and caressing are good ways to build up self-confi dence and may help ease you both into resuming your normal relationship. What can I do to stop angina occurring during intercourse? If climbing the stairs provokes an angina attack, you may also experience angina during sexual intercourse. Take a GTN spray or tablet before attempting the stairs. If this prevents angina, use it in the same way before sexual intercourse. Also, keep your GTN handy on the bedside table as a back-up. Which is the safest position? It is safe to resume your normal routine and positions no one position is safer than another. It can also be stressful to try new positions. Oral sex causes no added strain to the heart. However, anal sex should be avoided initially as it may cause the heart to beat irregularly and more slowly. It is advisable to wait 8 weeks after your heart attack in this case. What about sex after surgery? After a heart operation people sometimes feel that sex will undo the work the surgery has done, or that the wound may come apart. This will not happen. Small but signifi cant problems can include chest wall tenderness and scratchy feelings from the re-growth of male hairs. The tenderness can be dealt with by taking Paracetamol. Stronger medication may be required if Paracetamol does not help. Do not suffer in silence! Information booklet and personal plan. Page 32

Try to fi nd a comfortable position that does not put too much strain on the sternal wound. It may help to resolve these problems by placing a small slim cushion (headrest size) between partners. Practical tips! Avoid sex within two hours of a heavy meal or bath as both increase the workload of the heart and can bring on angina if exertion occurs too soon afterwards. Try eating a light meal and taking a shower to avoid this. Keep the bedroom at a comfortable temperature. Avoid cold sheets. It may be an idea to invest in an electric blanket, particularly if there is no upstairs heating. Avoid too much alcohol this reduces the circulation to the heart and other organs. It can be a cause of impotence in men. Impotence This may be a side effect of the medication you are taking, particularly Beta Blockers. Do not accept it as part of ageing or the fact that you have coronary heart disease. Either discuss this with your Cardiac Rehabilitation Nurse or your GP. It may be possible to change or reduce the dose of your medication. Please note: if you are using the GTN tablets / spray or an Isosorbide Mononitrate or Isosorbide Dinitrate you cannot use drugs such as Viagra. Again, please discuss this with your GP, Cardiac Rehabilitation Nurse or specialist advisor. Impotence may not be just a male problem. Women are also known to suffer a loss of sexual desire as a result of drug therapy. You may wish to complete our questionnaire about impotence please ask your Cardiac Rehabilitation Nurse for a copy. If you wish to discuss this further, please talk to your Cardiac Rehabilitation Nurse, GP or specialist advisor. Information booklet and personal plan. Page 33

Use this Change Planner to help you set and meet your goals! Week Weekly Plan Tick if met What can I do to help next week? 1 2 3 4 5 6 7 Information booklet and personal plan. Page 34

Healthy Eating How can I help reduce my cholesterol level? What counts as a portion of fruit and veg? Can I drink alcohol? How much oily fish should I eat?? Should I try to loose lose weight? Information booklet and personal plan. Page 35

Healthy eating general guidelines Have a good intake of Omega 3 fats each week (such as those found in oily fi sh) Have at least 5 portions of fruit and vegetables a day Reduce your intake of saturated fat Have less salt 1. Have a good intake of Omega 3 fats each week Omega 3 (polyunsaturated) fats help protect your body against heart disease by: protecting your blood vessels from damage helping to keep your blood from getting too sticky and so preventing blood clots helping to maintain a steady rhythm to the heart Which foods are rich in Omega 3 fats? Our bodies can make omega 3 fats from other fats in the diet, but this can be a slow process. It is best to get them from a concentrated source, particularly oily fi sh. Which fish are oily? Anchovies Mackerel Swordfi sh Carp Pilchards Trout Eel Salmon Tuna (fresh only) Herring Sardines Whitebait Kippers Sprats What is the portion size for oily fish? A portion is approximately 140g or 6oz of fresh, frozen or smoked fi sh, or 1 small tin of canned fi sh. How much fish do I need to eat each week? Risk Factor If you have risk factors for heart disease e.g. high cholesterol, high blood pressure, over weight, diabetes but have not had a heart attack Portions per week 2 portions of fi sh (1 of which is oily) If you have already had a heart attack or 2-3 portions of oily fi sh * heart surgery (*But if you have diabetes or are a woman of childbearing age we suggest that you talk to your Cardiac Rehabilitation Nurse.) Information booklet and personal plan. Page 36

What about taking omega-3 supplements? Some people may benefi t from taking Omega-3 supplements, particularly if they do not eat oily varieties of fi sh. However, fresh fi sh remain superior. Commercial supplements must contain EPA and DHA, which indicates that the oils are extracted from the fl esh of the fi sh (where the benefi ts lie). Please note that cod liver oil is not a rich source of omega-3 fatty acids. Flaxseed oil supplements can be taken by vegetarians as an alternative to oily fi sh, or alternatively they should seek to include vegetarian omega-3 sources from the diet (see table). It is important to advice your GP or dietician if you are intending to take fi sh oil supplements independently. What other food sources contain Omega 3? The following plants are rich in Omega 3. However, it is not clear whether these foods are as benefi cial as oily fi sh: Rapeseed or canola oil Walnut and soya oil Unsalted nuts, particularly walnuts, pecans, peanuts, brazils, macadamia and almonds Dark green leafy vegetables Soya, soya beans and tofu Flax seeds (linseeds) and fl ax oil Food products enriched with Omega 3 such as Columbus eggs, margarine, bread, yogurt and milk labelled with Omega 3. 2. Have at least 5 portions of fruit and vegetables a day People who eat more fruit and vegetables are less likely to develop heart disease. Why are they good for me? Fruit and vegetables are good because they: contain vitamins and minerals (including antioxidant vitamins and minerals) which can help protect our blood vessels contain soluble fi bre which helps lower cholesterol contain insoluble fi bre which helps to keep our stools regular are rich in potassium which is required for good heart rhythm and helps control blood pressure tend to be low in calories and fat which can help with your cholesterol and weight management. How much should I eat? It is recommended we eat at least 5 portions of fruit and vegetables daily. These can be fresh, tinned, frozen, dried or as juice. Juice and dried fruit should only count as one portion though, however much you have. Try to aim for a rainbow of fruit and vegetables. The different colours represent different vitamins and minerals; it is good to eat a variety. Information booklet and personal plan. Page 37

Rough guide to portion size Vegetables raw, cooked, frozen or canned 3 full tablespoons Salad 1 cereal bowl Dried fruit 1 tablespoon Avocado ½ fruit Apples, pears, bananas, oranges and other citrus fruit 1 fruit Plums and similar small fruit 2 fruits Grapes, cherries and berries 1 handful (cupful) Fresh fruit salad, stewed or canned 2-3 tablespoons (including a little juice) Fruit juice 1 medium glass (150ml) 3. Reduce your intake of saturated fat Why? There are 2 main types of fat saturated and unsaturated. Eating food that is high in saturated fat can raise cholesterol levels in the blood. Most people in the UK eat too much saturated fat. Eating less saturated fat can reduce the cholesterol in your blood and therefore be better for your heart. What foods contain saturated fat? sausages and fatty cuts of meat dairy products (full fat milk, butter, cream and cheese) processed foods (crisps, pastries, pies and pasties) cakes, biscuits and chocolate ice cream and full fat dairy desserts lard, dripping and ghee foods containing coconut and palm oil As part of a healthy diet you could replace the foods that contain saturated fat with foods that contain unsaturated fat. Unsaturated fat can be good for our hearts. Some foods that could replace products high in saturated fat include: oily fi sh: mackerel, salmon, trout, sardines and fresh tuna nuts and seeds olives and olive oil sunfl ower and rapeseed oils avocado. 4. Have less salt Eating too much salt could contribute to high blood pressure. 6g of salt is about a teaspoonful do not have more than this in a day. This is not a large amount, especially when you consider that 75% of the salt we eat is already in everyday foods. Which foods contain a lot of salt? Tinned/packet soup and gravy/stock cubes Bacon and processed meat e.g. ham, sausages, paté Crisps and salted nuts or crackers Soya sauce, cook-in sauces (jars/tins/packets) Ready meals e.g. lasagne/chicken Kiev Information booklet and personal plan. Page 38

How can I cut down on salt? Cook without adding salt (this also includes rock salt, garlic salt, and sea salt) Watch out for hidden salt in the food Read labels and be careful of other terms used for salt such as sodium, monosodium glutamate and sodium bicarbonate. Also consider food items that contain moderate levels of salt e.g. bread, tomato purees, malted milk drinks This is a lot of salt This is a little salt 1.25g salt or more per 100g 0.25g salt or less per 100g (or 0.5g sodium or more per 100g) (0.1g sodium or less per 100g) REDUCING YOUR RISK OF HEART DISEASE? Reduce your blood cholesterol Cholesterol is a fatty substance found in the blood and cells of the body. Most of the cholesterol is produced by our own liver from the saturated fat we eat. A high level LDL cholesterol, this is the undesired or bad cholesterol, can increase our chances of heart disease. In contrast we would encourage a high level of HDL cholesterol as this is protective. What matters most? Reduce saturated fat (see page 36) and trans fats Eat plenty of soluble fi bre Increase your intake of plant sterols and stanols Keep to a healthy weight Remember to take cholesterol lowering medication if prescribed Trans fats (hydrogenated vegetable oils) These fats occur naturally in small amounts in beef, lamb, mutton and dairy products. They are also made when vegetable oils are processed to make them hard (hydrogenated) and are mainly used in processed foods like biscuits, pastry and cakes. They may appear on food labels as partially hydrogenated vegetable oil. Trans fats raise bad low density lipoprotein (LDL) blood cholesterol and reduce the good high density lipoprotein (HDL) cholesterol, and should be limited in the diet. Information booklet and personal plan. Page 39

Soluble fibre Eating a diet that contains plenty of soluble fi bre can also help to reduce the amount of cholesterol in your blood. The following foods contain soluble fi bre: oats lentils, chickpeas broad beans, baked beans, kidney beans, butter beans etc. fruit (e.g. berries, applies) vegetables granary and seeded bread Plant sterols and stanols Plant sterols and stanols are natural substances found in plant cells that can help to lower cholesterol levels. They are found naturally in a range of plant sources such as vegetable oils and nuts, but to get enough of them to lower your cholesterol levels you may need to have specially manufactured products. Examples of these are Benecol and Flora Pro-Activ. This is an option you can explore, but for the most effective results, they must be taken as part of a healthy balanced diet and moderate exercise regime. How much do I need? Sterols and stanols work best to lower cholesterol if a certain amount is taken each day. To ensure a high enough intake, it is recommended that you take 2-3 portions a day of Benecol or Flora Pro-Activ. 1 portion is: 12g (½ oz) margarine (either full or low fat) 1 pot (125g) yoghurt 250ml (½ pint) milk There is no benefi t in taking more than the recommended 2-3 portions a day and there is some evidence that having excess may be harmful. Alternatively you could take 1 Benecol or Flora Pro-Activ yoghurt drink daily. Benecol and Flora Pro-Activ drinks contain a high quantity of plant sterols and stanols and a bottle taken every day could help to lower your cholesterol level. Take care, however, if you are also trying to lose weight, as these products can encourage weight gain (look out for low fat versions). Please note: If you have been told by your doctor that you have Familial Hypercholesterolemia (FH) then you should avoid using these specially manufactured products. Reduce your triglyceride levels Triglycerides, like cholesterol, are a type of fat in the body. They come from fats in food, or fats made by the body from other energy sources such as carbohydrates. At normal levels they are not harmful, but if your triglyceride levels are raised, this may be putting you at more risk of heart disease. Information booklet and personal plan. Page 40

What matters the most? i) Reduce your sugar intake Have less sugar in your food. Eating a lot of sugary foods and drinks can contribute to a high level of triglycerides in your blood. Try the following ideas: Fill up on fresh or frozen fruit, or fruit tinned in natural juice, rather than sugary cakes and biscuits Drink diet, low calorie or sugar free fi zzy drinks and squashes Choose fruit juices which are labelled unsweetened rather than juice-type drinks Other ideas could be ii) Have less highly-processed starchy food All starchy foods are broken down in the body to produce blood sugars the amount of these foods you eat can affect the level of triglycerides. Try to choose more wholegrain, unprocessed foods as these are broken down more slowly. Some people fi nd that choosing wholegrain breads and cereals instead of their usual cereal helps to lower their highly processed starchy food intake. iii) Cut down on your alcohol intake Moderate amounts of alcohol (1-2 glasses per day, 2-4 times a week) will not affect triglyceride levels. However, if you tend to drink large amounts of alcohol (especially at one time), this can raise triglyceride levels and increase your risk of heart disease. How much alcohol can I drink? Men: 3-4 units per day but not every day and no more than 21 units in total for the week. Women: 2-3 units per day but not every day and not more than 14 units in total in a week. A unit is It is no longer accurate to say one glass of wine = 1 unit. This is only true of a glass of wine at 8% alcohol by volume (ABV) in a 125ml glass. A glass of wine at 13% in a 175ml glass = 2.3 units. It is important to know the strength of drink (%ABV) and volume of liquid to know how many units a drink contains. Here s how to work it out: Multiply the volume of drink by %ABV, and then divide by 1000. For example 175ml x 13% = 2,275 1000 = 2.275 (2.3 units). How can I cut down? Why not start your evening with a large sugar-free non-alcoholic drink? This is the time when we tend to be most thirsty, and drink the largest quantity most quickly. Other ideas could be iv) Increase your intake of Omega-3 fats Oily fi sh such as mackerel, fresh tuna, sardines, trout, salmon and herring contain high levels of omega-3 fatty acids. Eating 1-2 portions of these per week will help lower your triglyceride levels and therefore lower your risk of heart disease. Also, replacing butter or lard with either olive or rapeseed spread, and including dark green leafy vegetables, cereal products and some nuts (such as walnuts, pecans, peanuts and almonds) in your diet can also help to reduce your triglycerides levels. Information booklet and personal plan. Page 41

v) Watch your weight If you are overweight, losing weight will automatically help lower your triglycerides and reduce your risk of heart disease, and may also decrease your cholesterol and blood pressure. It can be very effective! To lose weight we need to eat less energy than our bodies use. However, the way this is best achieved is different for everyone. Waist circumference Evidence suggests that carrying too much weight around your middle increases your risk of heart disease more than a similar weight of fat deposited elsewhere in the body. Find out how your waist measures up Men Women Health risk Below 94cm (37 ) Below 80cm (31.5 ) Normal 94 100cm (37-40 ) 80-87.9cm (31.5-34.5 ) Increased risk 100cm and above (40 ) 88cm and above (34.5 ) High risk If you are overweight or have a larger waist circumference then changing your eating habits and increasing your physical activity to aid weight reduction would improve your health. You should aim to lose 1-2 lbs (0.5-1.0 kg) per week. Use this chart to check if you are the right weight for your height Reproduced with permission of the Food Standards Agency Information booklet and personal plan. Page 42

To lose weight effectively we need to look closely at what we eat. Some people fi nd that keeping a food diary helps, whilst others can immediately identify areas of their diet they could improve. There may be a trigger time, e.g. boredom in the evening, or a trigger food e.g. a favourite food that you fi nd diffi cult to stop eating. Think what your trigger foods and situations are. If you are interested in losing weight and would like more support, speak to your practice nurse or dietician. Please use the following pages to monitor your progress action plan and change planner. HEALTHY EATING Action Plan:- Consider your diet, refer to healthy eating information Attend information session on Healthy Eating (Part I & II) Assess drinking habits: Men = 21 units or less per week Women = 14 units or less per week Find alternatives to alcoholic drinks. Add your own goals:- CHOLESTEROL Date:.. Total Cholesterol (recommended = under 4mmol/l) HDL. (greater than 1mmol/l) LDL. (less than 2mmol/l) Triglycerides.. Ratio.. Action Plan: Regular checks with your GP Medication / Dietary changes Attend information session on cholesterol We advise 6-12 weeks fasting cholesterol test when starting new cholesterol lowering medication. Add your own goals:- OVERWEIGHT Weight Height... BMI (Body Mass Index) Action Plan:- Dietary changes Increase exercise Attend information session on Physical Activity Add your own goals:- Aim to lose 5-10% of body weight if you are presently obese or extremely over-weight. This level of weight loss is evidenced to help reduce blood pressure, cholesterol levels, improve control of blood glucose levels and reduce your overall risk of further cardiovascular events. Information booklet and personal plan. Page 43

Use this Change Planner to help you set and meet your goals! Week Weekly Plan Tick if met What can I do to help next week? 1 2 3 4 5 6 7 Information booklet and personal plan. Page 44

Smoking How does smoking affect my heart? Should I cut down if I can not stop? What could happen if I continue to smoke?? How do I access help to quit? What NRT product can help me? Information booklet and personal plan. Page 45

Smoking If you have coronary heart disease (if you have angina or have had a heart attack), you probably already know that smoking is harmful to your heart. Quitting smoking is something positive you can do to improve your health. Stopping smoking is the single most important thing a smoker can do to live longer. Although it may be a stressful time, the period when you are in hospital is a good time to try and stop smoking. You will have access to staff at the hospital, your doctor s surgery and some retail pharmacies. Nicotine Replacement Therapy (NRT) is available to help your quit attempt. You are 4 times more likely to quit if you get support and use NRT. If you have used NRT before it is still worth discussing as many new products are now available. Staying in a non-smoking hospital for a few days will help you make a good start nicotine is out of the body in two days. Get support and try NRT products. If members of your family smoke, they could help by quitting too. Believe in yourself, prove to yourself and others that you don t have to smoke. Take one day at a time every day without a cigarette is a real achievement. Treat yourself with the money you have saved when you have had a few days without cigarettes. Staying stopped Don t give in to temptation to have just one it s too easy to start smoking again. Keep thinking of the benefi ts to you and your family of not smoking. Remind yourself of your own reasons for wanting to be a non-smoker and stay determined. If you do smoke a cigarette, don t feel that you have failed and give up on your attempt to stop. Use it as a learning tool and think of ways to avoid that situation again. Think of all the reasons and benefi ts of stopping smoking and plan to have another go at stopping. Ask your nurse or Cardiac Rehabilitation Nurse for more information, support and access to NRT. Help is also available from: Your smoking cessation practice nurse or your GP surgery Oxfordshire Smoking Advice Service: Telephone 0845 4080300 www.oxfordshirepct.nhs.uk/local-services/smoking-advice-service.aspx Quitline: Telephone 0800 002200 / www.quit.org.uk NHS Smoking Helpline: Telephone 0800 1690169 ASH (Action on Smoking Health) www.ash.org.uk Information booklet and personal plan. Page 46

Smoking Daily Consumption: a day Cigarettes Pipe Tobacco Action Plan: STOP! Cut down if you can t stop (but seek further help) Try support groups (your nurse can put you in touch) Ask your nurse to refer you to the smoking cessation service Read the information in your folder Attend information sessions in the Cardiac Rehabilitation Department. Add your own goals: Use this Change Planner to help you set and meet your goals! Use this Change Planner to help you set and meet your goals! Week Weekly Plan Tick if met What can I do to help next week? 1 2 3 4 5 6 7 Information booklet and personal plan. Page 47

Information booklet and personal plan. Page 48

High Blood Pressure What is high blood pressure? How do my tablets help? Who will monitor my blood pressure? Blood pressure? How can I help reduce my blood pressure? Does salt affect my blood pressure? This is the pressure measured in the arteries, which rises and falls as the heart pumps. When the heart contracts, blood is pumped out and the pressure in the artery goes up (this is the top number systolic). When the heart relaxes, the pressure in the artery goes down (the bottom number diastolic). Information booklet and personal plan. Page 49

Blood Pressure This is the pressure measured in the arteries, which rises and falls as the heart pumps. When the heart contracts, blood is pumped out and the pressure in the artery goes up (this is the top number - systolic). When the heart relaxes, the pressure in the artery goes down (the bottom number - diastolic) This diagram is reproduced with the kind permission of the Centres for Disease Control and Prevention. Ideally your blood pressure should be no greater than 140/85 or 130/80 if you are diabetic. These fi gures are for a resting blood pressure. It can be normal for your blood pressure to rise and fall depending on your activity. Controlling blood pressure is important because having too high a blood pressure is one of the known major causes of heart disease. If your blood pressure is at the top end of the range you have an above average risk of developing coronary artery disease or other circulatory problems. There are some factors which tend to put your blood pressure up into the high range, including: Being overweight Drinking too much alcohol Kidney disease Lack of exercise Too much salt in your diet Stress There are many drugs available which can lower blood pressure and reduce your risk of coronary heart disease. How you can help: Reduce alcohol intake Reduce your weight by eating healthily Use less salt when cooking or on your food Take regular exercise Practice relaxation Take prescribed medication Information booklet and personal plan. Page 50

Blood Pressure.../... mmhg (in hospital) Action Plan: Aim for a blood pressure no greater than 140/85mmHG, 130/80 if you are diabetic Regular checks at the GP surgery (discuss with your nurse) Medication (understand tablets and when to take them) Reduce salt intake (less than 6g per day) Attend information session in the Cardiac Rehabilitation Department on dietary advice Increase your activity levels after discussion with your Cardiac Rehabilitation Nurse. Add your own goals:- Blood Pressure Record Date and time Blood pressure / / / / / / / / / / / / / / / Information booklet and personal plan. Page 51

Information booklet and personal plan. Page 52

Diabetes What is diabetes? Why is it important to control my blood sugar level? What should I avoid eating?? What is a normal blood sugar level? How will I monitor my blood sugar level? Information booklet and personal plan. Page 53

Diabetes As a diabetic you have a higher risk of developing Coronary Heart Disease. Diabetics can often have high blood cholesterol. Maintaining good control of your blood sugars, with diet and medications, can help to reduce the risk. Platelets, which are substances in the blood, help clotting and healing of damaged tissues. In diabetics the platelets stick together more easily. Research has shown that good control of your blood sugars combined with a reduction in cholesterol levels, maintenance of a normal blood pressure (<130/80mmHg), stopping smoking and increasing physical activity considerably reduces this risk. Regular blood sugar testing is probably something which you are already used to. It is important though to understand why you are doing this and what to do if it is abnormal. A normal blood sugar is between 4 7mmols. If your blood sugar is consistently higher than this your diabetic medication, either insulin or tablets, may need adjusting. If you are unused to adjusting your own insulin please contact your practice nurse, district nurse, GP or Diabetes Nurse Specialist. You should attend your GP surgery for regular diabetic check-ups, which include a blood test which tests your long-term blood sugars (HbA1c). You need to pay extra special care to your eyes and feet. Both eye (optical) and feet (podiatry) checks are available free of charge to diabetics. It is very important to make use of these services. What to do if you are unwell Your blood sugar will usually rise if you are unwell. Even though you may be sick and unable to eat normally it is important to continue to take your insulin if necessary. During your illness you should test your blood sugar at least before each meal and at bedtime. You should also drink plenty of water and sugar-free drinks and test your urine for ketones. If vomiting persists for more than eight hours you will need to see your GP immediately. If you have any further queries, please discuss these with your Cardiac Rehabilitation Nurse. There are information booklets about Diabetes available in the department. Exercise When you are invited to join the exercise programme we will ask you to monitor your blood sugars both before and after exercise. You should bring your own blood sugar monitoring kit with you each time you come to exercise. Sometimes your blood sugars will go down after exercise and occasionally they will rise. It is important to ensure that if they do rise, you continue to eat normally for the rest of the day and check your blood sugars regularly. Sometimes after exercise your blood sugars can drop in the afternoon or evening, causing a hypo if you do not monitor them closely. When you come to exercise always remember to bring along your glucose tablets, a carton of drink such as Ribena, and a couple of biscuits or small chocolate bar. This is in case your blood sugars are low after you have exercised. Although this may seem a lot to remember, the Cardiac Rehabilitation staff are here to support you. As well as being benefi cial to your health, physical activity is part of everyday life and should be enjoyable. Information booklet and personal plan. Page 54

Diabetes Action Plan: Is your diabetes well controlled? Medication (understand tablets and when to take them) Dietary changes (information in your folder) Regular check-ups at the GP Surgery Add your own goals:- Use this Change Planner to help you set and meet your goals! Week Weekly Plan Tick if met What can I do to help next week? 1 2 3 4 5 6 7 Information booklet and personal plan. Page 55

Information booklet and personal plan. Page 56

Anxiety / Stress How do I recognise signs of stress? How will I cope when I go home from hospital? Is it normal to feel so anxious? How can I help? manage stress? Is there any professional help available? Information booklet and personal plan. Page 57

Anxiety It is quite normal to feel anxious and worried after a heart attack or any other frightening experience. Most people start to feel less anxious as they get better and the memories of the heart attack begin to fade. Finding out more information about worry and anxiety can help you to deal with it better. Anxiety can cause some of these symptoms: Rapid pulse and palpitations Dry mouth Butterfl ies, or a sinking feeling in the tummy Tingling and cold clammy hands and feet Rapid breathing Feeling faint Strange pains. Anxiety can have these mental effects: Diffi culty concentrating and remembering Lack of self confi dence Problems sleeping at night Racing thoughts Finding it diffi cult to make decisions Feeling that your personality has changed or that you are going mad. Anxiety can cause these kinds of behaviour: Not listening to what people are saying Restlessness, fi dgeting, bad temper Losing your sense of humour Feeling unsatisfi ed. When we are in danger or under stress our bodies produce a chemical called adrenaline which helps us to cope. Problems start when we have a worrying thought which produces adrenaline in our bodies. This extra adrenaline does not get used up and causes unpleasant physical and mental symptoms. When you notice these physical symptoms it can make you worry and feel scared. It makes you feel there must be something wrong, and you may be worried that you may have another heart attack. (The Heart Manual 2004) Panic attacks Occasionally these worrying thoughts and the increase in adrenaline can build up to a high level and you may have a panic attack. A panic attack is not dangerous and is usually over within 10 to 30 minutes. This is because after a while the body runs out of adrenaline. The worrying thoughts disappear, the heart rate and breathing slows down, the stomach stops churning and you start to feel better. Six things to remember to help you cope with anxiety It is not your heart or mind which is going wrong. What you feel is the effects of adrenaline. These feelings are not dangerous, just unpleasant. Notice what is happening to your body at the moment - not what you fear may happen. Remember that when you stop adding to your anxiety with negative thoughts, it starts to fade by itself. Wait and give the fear time to pass. Do not fi ght or run away from it. Just accept it. Information booklet and personal plan. Page 58

Feeling low after a heart attack It is normal to feel low in spirits following a heart attack; these feelings will usually go away as time passes. Here are some of the common symptoms: Sadness Tearfulness Poor appetite Early waking Loss of interest in thing that were once enjoyable No energy for doing things Loss of interest in your appearance These feelings are not dangerous but they are unpleasant. However, if they become worse they are called depression. A depressed person can usually only see the bad side of things. While you are in hospital your Cardiac Rehabilitation Nurse may ask you to complete two simple questionnaires which will give us an idea about how you are feeling at the moment. There is also a clinical psychologist who works within our team to provide support for patients who are feeling anxious or low in mood following a heart attack. If you would like to be referred to this doctor then please ask your Cardiac Rehabilitation Nurse. Stress Stress has many meanings but most people think of stress as the demands of life. Stress, and the effect it has on your body, has been linked to heart disease. If you can avoid smoking, excessive alcohol, and tension that causes high blood pressure, you can help to protect your health and heart. Learning how to relax is very important. Ask your Cardiac Rehabilitation Nurse about our relaxation sessions. Everyone gets stressed sometimes. A moderate amount of stress can be helpful, but too much is not only unpleasant it is bad for us. We are affected both by external pressures (e.g. work, money, other people) and by internal pressures (i.e. our reactions to these pressures). If the pressures are too much, and our resources don t seem to be enough, we will feel stressed. The viewpoint you take in any situation is important. How you view an event can infl uence how you deal with it and the effect it has on you. For example, being stuck in a traffi c jam. You may say to yourself This is terrible, I m going to be late, this always happens to me.. The result would be getting very wound up, physically tense, exhausted and angry. An alternative would be to say, This is a real pain, but there is nothing I can do about it right now, I may as well listen to the radio. Hopefully this will make you feel calmer. The fi rst step in a potentially stressful situation is to be aware of what is happening and how you are feeling both physically and emotionally. Then you can choose how to respond, rather than just reacting in a certain way. Recognising the signs of stress Physical: Aches and pains (e.g. headache) Tension (e.g. in your neck and shoulders) Disturbed sleep pattern (e.g. waking early) Flare-up of stress related illness (e.g. asthma or psoriasis) Information booklet and personal plan. Page 59

Behaviour: Getting worse at organising yourself or managing your time Finding it hard to delegate Working longer hours and bringing work home Avoiding tackling problems Cutting down on the things you do for pleasure Losing touch with your friends Taking it out on others (i.e. blaming others when things go wrong) Mood: Irritable or short-tempered Anxiety or feelings of panic Fear (e.g. of being out of control) Low self-esteem Feeling miserable Apathy (e.g. lack of motivation or interest), or agitation A simple relaxation exercise Relaxation is the natural answer to stress but it can be diffi cult to fi t into your day. To get the most out of relaxation it needs to be practised regularly you won t feel the benefi ts immediately. Maybe you could plan to do the following exercise at a set point once or twice in the day; it should take you no more than 5 10 minutes. Every now and again, have a stretch. Then let your shoulders and arms relax into a comfortable position. Shrugging, wriggling and shaking all help your muscles to relax. Ease off the tension in your feet, ankles, calves, knees, thighs, chest, arms and neck. If you are sitting in a chair, or on the fl oor, allow yourself to feel as if the chair or fl oor is supporting your whole weight; feel yourself letting go. Try to be peaceful, loosen your jaw and face. A bland expression will help your face muscles to relax. Close your eyes and imagine a peaceful scene. Choose your own special place, wherever seems most restful to you. For a few moments imagine that you are really there. Some tips for managing stress Learn to relax this might involve using the technique mentioned above or using a relaxation tape or listening to soothing music. Exercise this will improve your sense of well-being, make you feel good about yourself and may take your mind off your problems (this will depend on the stage of physical recovery you have reached). Time management prioritise and plan your time. Be realistic about what you can do, break-up tasks, delegate, and pace yourself. Talk share your problems and learn to say no sometimes. It can be done without letting others down. Challenge unhelpful thoughts be positive, you can cope with this, so be kind to yourself. Rest when you feel tired; try to relax before going to bed (e.g. a hot milky drink, a relaxing bath, and essential oils) Information booklet and personal plan. Page 60

Treat yourself make time for your hobbies, to have fun, and socialise. Good nutrition avoid excessive alcohol, nicotine and sugars these can make you feel worse. Instead treat yourself to healthy food and drink plenty of water. Worry buster write down your worries, it really helps you to think clearly. Get professional help if you feel very low or anxious there are services in Oxfordshire to help you manage stress. Cognitive Behavioural Therapy (CBT) Many people feel anxious, panicky or low after a heart attack, surgery or diagnosis of heart disease. The early days and weeks can be a diffi cult time for you and your family. Very often, these feelings get better by themselves once you have adjusted to your health diffi culties. However, some people carry on feeling bad. You may experience panic attacks that do not go away, or feel so low it is hard to know how to cope. Sometimes, problems from the past come up again, such as depression, which is diffi cult to resolve on your own. If you feel that you would like further help, we can refer you for Cognitive Behavioural Therapy with our psychologist. Cognitive Behavioural Therapy (CBT) is a short-term, focused form of counselling which is very helpful in treating a number of problems. The most common in cardiac patients include: Depression, low mood Panic attacks Stress Worry and general anxiety Diffi culties in coming to terms with what you have been through Post-traumatic reactions after surgery or intensive care Non-cardiac chest pain. Our psychologist can see you giving you the opportunity to talk through your diffi culties in detail. You will then discuss a plan for getting better, including specifi c skills and strategies, tailored to you as an individual. You can also discuss other sources of help which may be available to you. Please speak to your cardiac rehabilitation nurse if you feel you could benefi t from CBT. Psychological troubles - how to help yourself and where to get help Reading Manage your Mind by Gillian Butler and Tony Hope. Oxford University Press Booklets on Anxiety, Depression, Phobias and other problems are available from the cardiac nurses, and from Oxford Cognitive Therapy Centre (www.octc.co.uk) Tel: Oxford 738816, email octc@oxfordhealth.nhs.uk Overcoming Anxiety: Self-Help Course Helen Kennerley, Robinson, 2006 A three-part CBT self-help programme to help you overcome your anxiety. Overcoming Anxiety Helen Kennerley, Constable Robinson, 1997 Information booklet and personal plan. Page 61

A guide to overcoming a range of problem fears and anxieties - from panic attacks and phobias to executive burnout - with the aim of regaining confi dence and self-control. The Worry Cure Robert L Leahy, Piatkus Books, 2006 A CBT self-help book offering practical tools to help you to deal with your worry. Overcoming Worry Kevin Meares & Mark Freeston, Robinson, 2008 A CBT self-help book that will help you to understand and deal with your tendency to worry. Overcoming Panic and Agoraphobia Derrick Silove and Vijaya Manicavasagar, Robinson, 2006 A CBT self-help book to help you deal with your panic attacks and associated fears and avoidance. Overcoming Obsessive Compulsive Disorder David Veale & Rob Willson, Robinson, 2005 A CBT self-help book describing techniques that you can use to deal with your obsessive thoughts and compulsive behaviours. An Introduction to Coping with Depression Lee Brosan and Brenda Hogan, Robinson, 2007 A CBT self-help booklet introducing you to some strategies that you can use to cope with depression. Overcoming Depression Paul Gilbert, Robinson, 2009 A CBT self-help book describing ways in which you can overcome your depression. Mindfulness Meditation to help with anxiety, worry and depression Groups are available on the NHS and privately. For an introduction, the following books are useful: Full Catastrophe Living: How to cope with stress, pain & illness using mindfulness meditation Jon Kabat-Zinn, Piatkus Books, 2001 How to handle potentially stressful situations. How to use mindfulness meditation to help you: relieve physical and emotional pain, reduce anxiety and panic, help improve your health and your relationships, and much more. The Mindful Way through Depression Mark Williams, John Teasdale, Zindel V Segal, Jon Kabat-Zinn, Guilford Publications, 2007 A self-help guide offering helpful relief from your depression. This book explores depression and it s anatomy and the place and practice of mindfulness and cognitive therapy in breaking through the depression cycle. Pain Living Well with Pain and Illness Videyamala Burch, 2008 Explain Pain David Butler, Lorimer Mosley, Noigroup Publications, 2003 Information booklet and personal plan. Page 62

How to Get Help If you are a cardiac patient, or relative, you can talk to your cardiac rehabilitation nurse for advice, borrow a copy of a relaxation CD or ask for a referral to the Psychologist. We can also refer you on to other sources of help. Alternatively, you can obtain further information or advice from: Your GP or practice nurse The Samaritans Citizens Advice Bureau Relate See page 69 for contact details. A list of books and booklets can be found at www.octc.co.uk Oxfordshire MIND http://www.oxfordshire-mind.org.uk Oxfordshire MIND is an excellent source of information, help and support for all kinds of psychological diffi culties and mental health problems. It runs groups on Depression, Anxiety, and Improving Self Esteem. Groups are run around the county, with new groups starting in May and October 2011. For information about your next local group, or to join the mailing list, email groups@oxfordshiremind.org.uk, or call 01865 263 747 (Mondays, Wednesday mornings and Thursday mornings). TalkingSpace The TalkingSpace service was set up in Oxfordshire in April 2009 and supports people who are suffering from mild to moderate symptoms of anxiety or depression. The service is provided by Oxford Health NHS Foundation Trust in partnership with Oxfordshire Mind. If you need any further details please get in touch on 01865 325777 or via email at talkingspace@nhs.net Stress and anxiety action plan Identify triggers (things which cause you stress) Learn to recognise the signs of stress Reduce avoidable stress Practice relaxation exercises Written/taped information may help (ask your Cardiac Rehabilitation Nurse) Professional counselling Attend information session in the Cardiac Rehabilitation Department Information booklet and personal plan. Page 63

Use this Change Planner to help you set and meet your goals! Week Weekly Plan Tick if met What can I do to help next week? 1 2 3 4 5 6 7 Information booklet and personal plan. Page 64

Driving Use this Change Planner to help you set and meet your goals! When can I drive my car after a heart attack? Should I inform my insurance company? When can I drive after cardiac surgery?? Do I need to inform the DVLA? What are the guidelines for LGV/PCV licenses? Information booklet and personal plan. Page 65

Car / motor cycle licence holders (Group 1 entitlement) If you have a group 1 licence, with no other disqualifying conditions, the DVLA guidelines are as follows: If you have angina: You must stop driving if you have angina symptoms whilst driving, or if your symptoms occur whilst resting or with emotion. You may start driving again when symptoms are controlled. You do not need to inform the DVLA. If you have angina whilst driving you must stop the car and take your GTN tablets/spray. Remember to take your GTN tablets/spray with you whenever you go out. If you have had a heart attack (myocardial infarction), ACS (acute coronary syndrome) or unstable angina: You must stop driving for 4 weeks if you have had a heart attack or ACS. However in some cases driving can resume after 1 week but strict guidelines must be adhered to. Your Cardiac Rehabilitation Nurse or Doctor will discuss this with you. If you have had an elective PCI (Percutaneous Coronary Intervention) (with or without a coronary stent): You must stop driving for 1 week if the procedure was successful, 4 weeks if unsuccessful. You do not need to inform the DVLA. If you have had heart surgery: You must stop driving for at least 4 weeks. However you should wait until your sternum has been checked. Your surgeon will do this at your follow up appointment. This appointment is usually around 6 weeks after your discharge. You do not need to inform the DVLA. If you have diabetes: If you are controlled by diet alone you do not need to inform the DVLA unless you develop relevant disabilities, e.g. diabetic eye problems. If you are controlled by tablets or insulin you should contact the DVLA for further advice as there are criteria that need to be met in order for driving to continue. If you are diabetic and feel unwell whilst you are driving you must stop the car and take the keys out of the ignition. It is possible your blood sugars have dropped and you are having a hypo. In this situation you should have a snack or take glucose tablets, and wait until your blood sugar is above 4mmol/l before you continue your journey. Insurance: You should inform your car insurance company of your diagnosis as it is a change in your medical condition. This should not affect your premiums in any way and will prevent problems in the future if a claim is made. When you start driving again: When you start driving again you may fi nd you are still quite tired and may have lost some of your confi dence. It is best to avoid long journeys or peak hour traffi c. You may prefer to drive with a friend or partner until you are more confi dent. If you have any questions please discuss further with your Doctor, Cardiac Rehabilitation Nurse or DVLA. Information booklet and personal plan. Page 66

LGV / PCV licence holders (Group 2 entitlement) If you have a group 2 licence the DVLA guidelines are as follows: If you have angina: You must stop driving and inform the DVLA. Re-licensing may be permitted provided you are free from angina for 6 weeks and exercise tests and other functional tests meet the requirements. If you have had a heart attack, ACS or unstable angina: You must stop driving and inform the DVLA. You will be disqualifi ed from driving for at least 6 weeks. Re-licensing may be permitted provided exercise tests and other functional tests meet the requirements. Please be aware that these tests are rarely completed within 6 weeks. If you have had an elective PCI (with or without a stent): You must stop driving and inform the DVLA. You will be disqualifi ed from driving for at least 6 weeks. Re-licensing may be permitted provided exercise tests and other functional tests meet the requirements. If you have had heart surgery: You must stop driving and inform the DVLA. You will be disqualifi ed from driving for at least 3 months. Re-licensing may be permitted provided exercise tests and other functional tests meet the requirements. If you have diabetes: If you are controlled by diet alone you do not need to inform the DVLA unless you develop relevant disabilities e.g. diabetic eye problems. If you are controlled by tablets you should inform the DVLA. A strict criteria needs to be met in order for driving to continue. If you are controlled by insulin, even on a temporary basis, you must inform the DVLA and stop driving. It is possible your license will be barred whilst taking insulin. You must inform the DVLA as soon as you are discharged or diagnosed. The DVLA will advise you on what you need to do next. This may involve filling out forms which they will either send to you or you can download them from their website. The DVLA will request medical information from your consultant and functional tests if required. DVLA guidance is regularly updated and the information given in this booklet may change. Please see the DVLA website for the most up to date information: http://www.dft.gov.uk/dvla/medical/ataglance.aspx If you have any questions please discuss further with your Doctor, Cardiac Rehabilitation Nurse or DVLA. DVLA contact details www.direct.gov.uk Drivers Medical Group, DVLA, Swansea, SA99 1TU eftd@dvla.gsi.gov.uk 0300 709 6806 Information booklet and personal plan. Page 67

Information booklet and personal plan. Page 68

Moving on When can I return to work? Will I have a further follow up at the hospital? When can I join the cardiac rehab programme?? concerns? When can I get on a aeroplane? Who can I talk to about my financial concerns? Information booklet and personal plan. Page 69

Moving on By the time you have completed your cardiac rehabilitation programme the support and information you will have received from your local team, your cardiologists and your GP will have answered your questions and helped you address the issues identifi ed above and you will have returned to your normal life. Returning to work You should be able to return to your previous job. This is individual and will depend on your heart condition, the type of job you do and the amount of physical and emotional stress involved. You may be able to return after 4-6 weeks. If you have had heart surgery you will require longer, possibly 6-12 weeks. Initially you may need to modify your work. It is a good idea to consider returning to work on a part time basis initially, building up your hours gradually in order to give yourself time to readjust. It is a good idea to discuss this with your employer, human resources department or occupational health service. If you are a HGV driver and need a driving license for your job you will require relicensing from the DVLA (see page 62 on Driving). For further advice see Returning to Work with a Heart Condition (British Heart Foundation) Financial Concerns We are unable to give specifi c advice. For information regarding fi nancial concerns and benefi ts advice please contact your Job centre, the Benefi t Enquiry Line or AGE UK. The contact details are at the end of this information booklet. Looking Forward On completion of your cardiac rehabilitation programme you will have an appointment either at the cardiac rehabilitation gym or by telephone where your long term goals and plans will be discussed. At this appointment the cardiac rehabilitation staff will discuss further options that are available to you to maintain the lifestyle changes you have already started to make. This will include continuing with your individual goals; for example; maintaining current weight loss and continuing with regular exercise or physical activity. After you have completed your cardiac rehabilitation programme your cardiac rehabilitation team will ensure that you are referred to your practice nurse or GP who will take over your care. They will then invite you to your local GP practice for an annual heart review. My self-care plan The NHS wants everybody with a long term condition such as coronary heart disease to have a personal self-care plan. This will carry on from the goals you will have already set with your cardiac rehabilitation team. Your Cardiac Rehabilitation Nurse, GP or Practice Nurse will talk to you about this. Holidays: Your holiday is a great opportunity to relax and unwind. If you have a holiday planned very shortly after your cardiac event you may wish to talk your holiday plans over with your cardiac rehabilitation team. This advice can vary from one person to another. It is important to plan your holiday carefully so that you will be able to relax, enjoy and obtain the maximum benefi t from your holiday. carefully plan how you will get there and back allow plenty of time Information booklet and personal plan. Page 70

avoid carrying heavy bags and suitcases ensure that your accommodation is not on a steep hill check local transport options and availability take enough tablets and carry your supply in your hand luggage if travelling abroad. It is advisable not to travel to countries which are very hot or very cold or places of high altitude immediately after your recent heart condition. It is very important to inform your travel insurance company about your heart condition to ensure you have suffi cient cover. Flying: The guidelines set out by the British Cardiovascular Society (2010) now advise: 1. Low risk - If you have had a heart attack but are less than 65 years, the blocked artery has been opened and no further tests or treatments planned, you can fl y after three days. 2. Medium risk - If you have had a heart attack and your heart pump is quite good and you have no symptoms or other tests or treatments planned you can fl y after ten days. 3. High risk - If you have had a heart attack and the pumping of your heart is affected and waiting further treatment you are advised to defer travel until condition is stable. For further information or advice discuss with your Cardiac Rehabilitation team, Cardiologist or GP. However, above all enjoy your holiday. We hope that this information booklet and your cardiac rehabilitation team have answered all your questions on your heart condition. If, in the future, you or your partner needs further help or advice, please do not hesitate to contact your local cardiac rehabilitation team. Information booklet and personal plan. Page 71

Information booklet and personal plan. Page 72

Test and appointment log What tests and treatments have you had? Information booklet and personal plan. Page 73

What tests and treatments have you had? Investigation Date Result Exercise Test Echocardiogram Angiogram Treatment Date Result Angioplasty +/- stent Bypass Surgery Valve surgery Other Information booklet and personal plan. Page 74

Appointment Dates Date and time Who appointment is with Reason for and outcome of appointment Information booklet and personal plan. Page 75

Your feedback If you wish make a comment (good or bad!), make a suggestion, or to make a complaint, then initially you can talk directly to the staff involved in your care. If you wish to put your comments or concerns in writing then please send them to: The Chief Executive Oxford University Hospitals NHS Trust Headley Way, Headington, Oxford OX3 9DU Complaints should normally be made within 6 months of the event, or within 6 months of realising that you had cause to complain, providing this is within 12 months of the event itself. Email: complaints@ouh.nhs.uk. For further information about the complaints procedure contact: Patient Advice & Liaison Service (PALS): 01865 221473/740868; email: PALSJR@ouh.nhs.uk or the Comments and Complaints Offi ce on ( 01865) 221838 /221728 /228966 and request a Let Us Know Your Views leafl et. Questions or concerns If you have any questions or concerns about any of the information in this booklet, please contact your Cardiac Rehabilitation Nurse on 01865 220030/32 (John Radcliffe Hospital) or 01295 229753 (Horton Hospital). Useful contacts Arrhythmia Alliance PO Box 3697 Stratford-Upon-Avon Warwickshire CV37 8YL 24hr Helpline: +44 (0)1789450787 British Dietetic Association British Heart Foundation Greater London House 180 Hampstead Road London NW1 7AW Heart helpline: 0300 330 3311 (Monday to Friday 9am-5pm.) Dial-a-ride: 01865 876176 Food Standards Agency Green Gym My Self Care Plan http://www.heartrhythmcharity.org.uk/ www.bda.uk.com www.bhf.org.uk www.oxford.gov.uk www.eatwell.gov.uk www2.btcv.org.uk www.oxfordshireselfcareplan.co.uk Or email: myselfcareplan@oxforshirepct.nhs.uk Information booklet and personal plan. Page 76

NHS Direct: 0845 4647 Oxford Radcliffe Hospitals NHS Trust website Walking for health initiative (health walks) Personal experiences of health & illness (The award winning website of the DIPEx charity) www.nhsdirect.nhs.uk www.oxfordradcliffe.nhs.uk www.whi.org.uk www.healthtalkonline.org Benefits Age UK. Tel: 0800 169 6565 Web: http://www.ageuk.org.uk/ Citizens Advice Bureau, Tel: 08444111444 Web: http://www.citizensadvice.org.uk/contact_us.htm Oxfordshire Advice Marlborough Road, Banbury. Tel: 01295 255863 Carers Oxfordshire. Tel: 0845 0507677 Web: http://www.carersoxfordshire.org.uk/wps/wcm/connect/occ/carers/ Oxford Carers Centre. Tel: 01865 205192 Email: info@carerscentre.co.uk South and Vale Carers Centre. Tel: 01235 510212 Web: http://www.svcarers.org.uk/ Carers UK Advice Line. Tel: 0808 808 7777 Wednesday and Thursday 10-12 & 2-4pm Disability Employment Advisor: Jeremy Jarman on 01865 445142 Web: http://www.direct.gov.uk/en/disabledpeople/employmentsupport/lookingforwork/dg_4000324 Jobcentre Plus (for general advice about benefi ts and allowances) Tel: Benefi t Enquiry Line: 0800 88 22 00 Web: www.jobcentreplus.gov.uk Driving DVLA medical enquiries for car drivers 0300 790 6807 DVLA medical enquiries for HGV drivers 0300 790 6807 www.dvla.gov.uk Emergency Life support skills Training for the public You and your family may be interested to learn how to perform basic life saving skills. This training takes place at the Cardiac Rehabilitation Department, Horton Hospital or you can look on the following websites: http://www.sja.org.uk/sja/training-courses/course-search.aspx or http://www.redcross.org.uk/what-we-do/first-aid/first-aid-training Patient Advice and Liaison Service (PALS): 01295 229259 (Horton) 01865 221473 (Oxford) Information booklet and personal plan. Page 77

Smoking Oxfordshire Smoking Advice Service. Tel: 0845 40 80 300 Web: http://www.smokefreeoxfordshire.nhs.uk/. Quitline: 0800 002200 / www.quit.org.uk NHS Smoking Helpline: 0800 1690169 ASH (Action on Smoking Health): www.ash.org.uk References The information in this booklet is based on evidence. The following references were used: Arrhythmia Alliance (2010) Physical activity and exercise advice for patients with an implantable cardioverter defibrillator. www.heartrhythmcharity.org.uk/patient-area/patient-information Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR). (2009) Standards for Physical Activity and Exercise in the Cardiac Population 2009 British Heart Foundation. (2009). Coronary Angioplasty, Heart Information Series Number 10. British Heart Foundation, London. British Heart Foundation. (2010). Stop smoking: How to quit for a healthy heart. G118. British Heart Foundation, London. British Heart Foundation. (2008). Tests for heart conditions, Heart Information Series Number 9. British Heart Foundation, London. British Heart Foundation (2008). Returning to work with a heart condition. Heart Information Series Number 21. British Heart Foundation. London. British Cardiovascular Society (2010) Fitness to fl y for patients with cardiovascular disease: The report of a working group of the British cardiovascular Society. http://www.bcs.com/documents/bcs_fitness_to_fly_report.pdf Busk, M. et al. (2007). The Danish Multicentre Randomised Study of Fibronolytic Therapy versus Primary Angioplasty in Acute Myocardial Infarction (The DANAMI-2 trial). Outcome after 3 year follow up. Cited in European Heart Journal (2008) 29 (10) pp. 1259-1266. Centers for Disease Control & Prevention. High Blood Pressure http://cdc.gov/bloodpressure/ Department of Health (2000) National Service Framework for Coronary Heart Disease, Chapter 2, page 4. JBS, 2005 Joint British Societies guidelines on Prevention of Cardiac Vascular Disease in Clinical Practice. Heart 2005 Dec 91 supplement 5 v1 to 52. Lilja, J. Neuvonen, M. Neuvonen, P. (2004). Effects of regular consumption of grapefruit juice on the pharmacokinetics of Simvastatin. British Journal of Clinical Pharmacology, 58 (1) pp. 56-60. National Institute of Clinical Excellence. Secondary prevention in primary and secondary care for patients following a myocardial infarction. www.nice.org.uk/cg048. 2007 PPCI Project Team (2007).Provision of a Primary Percutaneous Coronary Intervention (PPCI) Service for Oxfordshire for Patients Presenting with ST Elevation Myocardial Infarction (STEMI). ORH NHS Trust. The Heart Manual, (2004).The Heart Manual. Lothian Health Board. Edinburgh. Information booklet and personal plan. Page 78

The Cardiac Rehabilitation Department is always very grateful for donations received from patients, families and members of the public and in the past we have used these gifts to buy gym equipment for the Horton facility and to support specialist staff training. If you would like to support the Cardiac Rehabilitation team please speak to your Cardiac Rehabilitation Nurse or Exercise Physiologist who will be please to give you details. You can also contact the OUH Charitable Funds team on: 01865 222525 or 743444. Marion Elliot, Manager, Cardiac Rehabilitation Helen Nolte & Carol Schofi eld, Cardiac Rehabilitation Nurses Version 6, October 2011 Review, October 2013 Oxford University Hospitals NHS Trust Oxford OX3 9DU www.ouh.nhs.uk/patient-guide/leafl ets Printed by Prontaprint Stratford-upon-Avon, 01789 204272 Information booklet and personal plan. Page 79