Recovery after a heart attack: care and prevention

What does recovery after a heart attack involve?

Recovery after a heart attack is a progressive, multidisciplinary process involving clinical assessment, prescribed exercise, nutrition and weight guidance, risk-factor management, emotional support, medication review and outcome monitoring; cardiac rehabilitation is not the same as exercising on your own. It is recommended after acute coronary syndrome, including myocardial infarction, and should reflect each person’s clinical condition, functional capacity, comorbidities, preferences and goals^1,2,3. A review published in 2023 involving more than 23,000 people with coronary heart disease associated exercise-based rehabilitation with fewer cardiovascular deaths, recurrent heart attacks and all-cause hospital admissions, as well as better quality of life, but it did not find a statistically significant short-term reduction in all-cause mortality⁴. A separate meta-analysis of contemporary trials found fewer cardiovascular hospital admissions and a small improvement in quality of life through 12 months, without a difference in overall mortality⁵. Overall, rehabilitation provides functional benefits and reduces admissions, while the size of its effect on mortality and recurrent infarction varies with the population, study period and program design^2,4,5. September’s Heart Month is a useful reminder that surviving a heart attack marks the beginning of long-term secondary prevention, not the end of treatment.

When should cardiac rehabilitation begin?

Outpatient cardiac rehabilitation should ideally begin within 14 days of acute coronary syndrome and no later than 30 days, provided that the patient is clinically stable². While still in hospital, stable patients without recurrent ischemia, decompensated heart failure, a significant arrhythmia or another complication may receive light, supervised mobilisation. This is not the same as an exercise stress test or the start of structured training: those interventions require specific assessment, and their timing depends on symptoms, hemodynamic stability, ventricular function and the risks of arrhythmia or ischemia; “approximately two days” should therefore not be presented as a general prohibition applying to all physical activity². After assessment and supervised progression, the European Society of Cardiology uses aerobic exercise three to five days per week for 30 to 60 minutes, plus strength exercise on at least two days, as training goals rather than an automatic prescription for the first week after discharge². Intensity should be determined individually, preferably with a functional assessment or exercise stress test when this is safe and indicated. Older adults and people with low physical capacity, heart failure, residual ischemia, arrhythmias or complications may need shorter, gentler and more closely supervised sessions^1,2. Prescribed strength training can provide greater functional gains than aerobic exercise alone, while high-intensity interval training should be limited to selected, medically cleared and preferably supervised patients².

Which medicines help prevent another heart attack?

Post-heart attack medicines address different risks and must be selected for each patient’s clinical profile. Secondary prevention commonly includes antiplatelet treatment and a high-intensity statin, with an ACE inhibitor or angiotensin receptor blocker, beta-blocker, aldosterone antagonist, and medicines for diabetes, hypertension or angina added when indicated^6,7,8. For most patients after acute coronary syndrome, the traditional approach is dual antiplatelet therapy for about 12 months, usually aspirin plus a P2Y12 inhibitor such as clopidogrel or ticagrelor; treatment may be shortened or extended according to bleeding and thrombotic risks^6,7,8. Aspirin, clopidogrel, ticagrelor or another antiplatelet drug should never be stopped without medical advice, especially after stent placement; bleeding, planned surgery and adverse effects must be discussed before any change^6,8. Brazil’s Ministry of Health recommends a high-potency statin after myocardial infarction regardless of the initial LDL level when there is no contraindication; the European Society of Cardiology’s secondary-prevention reference is an LDL below 55 mg/dL and at least a 50% reduction from baseline, with reassessment after four to six weeks^7,8. Beta-blockers remain indicated for conditions such as reduced ejection fraction, heart failure, certain arrhythmias or angina, but not every survivor with preserved heart function requires lifelong therapy^8,9. In the randomised REDUCE-AMI trial, long-term beta-blocker treatment did not significantly reduce the composite outcome of death or recurrent myocardial infarction among patients with an ejection fraction of at least 50% who underwent angiography and received contemporary care⁹. Patients should still never stop a beta-blocker on their own; the decision depends on ventricular function, symptoms, blood pressure, heart rhythm and other medical needs.

What follow-up is needed after discharge?

Hospital discharge does not end treatment, and the first 12 months require close monitoring for adherence, recovery and therapeutic adjustments. Brazil’s Ministry of Health recommends at least two follow-up appointments during the first year⁷. As a general reference, low-risk patients with complete revascularization and no ventricular dysfunction may be reassessed in primary care within two to six weeks; people with ventricular dysfunction, multivessel disease or incomplete revascularization should receive specialist assessment in approximately 14 to 30 days⁷. The final schedule depends on the severity of the infarction, treatment received and local access to care. Follow-up should review symptoms, blood pressure, heart rate, medication adherence and adverse effects, cholesterol, blood glucose, kidney function, smoking, nutrition, physical activity, emotional health and the need for tests^7,2,8. Stopping smoking, controlling blood pressure, cholesterol and diabetes, reducing sedentary time, managing weight and following a heart-protective eating pattern are essential; angioplasty and coronary artery bypass surgery treat narrowed arteries but do not eliminate atherosclerosis^6,7,2,8. For smokers, structured counselling combined with medication when appropriate improves the chance of quitting, and smoking-cessation treatment is a required component of rehabilitation². Expatriates, international visitors and crew members passing through the Port of Santos should arrange continuity of care and carry an updated medication list and records of the heart attack, angioplasty or surgery.

How can emotional recovery and daily activities be managed?

Emotional recovery is part of cardiac treatment because depression, anxiety and fear of another heart attack can interfere with quality of life and adherence. Prevalence estimates cited by European guidance include people with several types of heart disease and should not be interpreted as applying exclusively to heart attack survivors². Screening for depression and anxiety belongs in a comprehensive assessment, and psychological interventions, including cognitive behavioural therapy when indicated, can improve emotional symptoms and quality of life^2,3. Persistent sadness, disabling anxiety attacks or insomnia, loss of interest or social withdrawal require professional assessment and should never be dismissed as weakness or an inevitable consequence of myocardial infarction. Thoughts of death or self-harm are a separate concern and require urgent assessment; if there is a current or imminent risk, an emergency service should be contacted immediately². There is no universal waiting period for returning to work, driving, travelling or resuming sexual activity; decisions should consider clinical stability, functional capacity, symptoms, cardiac function, treatment and the demands of the activity². In a meta-analysis cited by the European Society of Cardiology, 66% of rehabilitation participants returned to work compared with 58% of controls, although the effect was modest and the evidence had limitations². Sexual counselling can reduce fear and correct misconceptions. Erectile-dysfunction medicines such as sildenafil can interact dangerously with nitrates and must be discussed with a physician^7,2.

Which warning signs require urgent care?

New or recurrent chest pain, pressure or discomfort—particularly with shortness of breath, cold sweats, nausea, profound weakness or fainting—requires emergency assessment. In Brazil, anyone with a suspected heart attack should immediately call the SAMU emergency medical service on 192¹⁰. Do not drive yourself to the hospital when emergency transport is available. A progressive decline in exercise tolerance, breathlessness at rest, palpitations with marked discomfort or fainting, or signs of heart failure such as increasing swelling or difficulty breathing while lying down require prompt contact with the healthcare team; exercise should be stopped until reassessment².

How can a personalised plan help prevent another event?

Preventing another heart attack requires an individual plan combining cardiac rehabilitation, correct medication use, regular follow-up, risk-factor control and emotional care. Every patient should leave an appointment knowing what each medicine is for, which targets need to be reached, what level of physical activity is safe and which symptoms require help. The plan should be reviewed whenever symptoms, adverse effects, travel, lifestyle changes, new diagnoses or procedures arise. References:¹ Carvalho T, Milani M, Ferraz AS, et al. Brazilian Cardiovascular Rehabilitation Guideline — 2020. Arquivos Brasileiros de Cardiologia. 2020;114(5):943–987. DOI: https://doi.org/10.36660/abc.20200407⁶ Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 2023;148:e9–e119. DOI: https://doi.org/10.1161/CIR.0000000000001168⁷ Brazil, Ministry of Health. Clinical Protocol and Therapeutic Guidelines for Acute Coronary Syndrome. Joint Ordinance SAES/SCTIE/MS No. 14, 2022. URL: https://www.gov.br/saude/pt-br/assuntos/pcdt/s/sindrome-coronariana-aguda² Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal. 2021;42(34):3227–3337. DOI: https://doi.org/10.1093/eurheartj/ehab484³ National Institute for Health and Care Excellence. Acute coronary syndromes: NICE guideline NG185. 2020, updated 2025. URL: https://www.nice.org.uk/guidance/ng185⁸ Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal. 2023;44(38):3720–3826. DOI: https://doi.org/10.1093/eurheartj/ehad191⁴ Dibben GO, Faulkner J, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis. European Heart Journal. 2023;44(6):452–469. DOI: https://doi.org/10.1093/eurheartj/ehac747⁵ Powell R, McGregor G, Ennis S, Kimani PK, Underwood M. Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence. BMJ Open. 2018;8:e019656. DOI: https://doi.org/10.1136/bmjopen-2017-019656⁹ Yndigegn T, Lindahl B, Mars K, et al. Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction. New England Journal of Medicine. 2024;390:1372–1381. DOI: https://doi.org/10.1056/NEJMoa2401479¹⁰ Brazil, Ministry of Health. Mobile Emergency Care Service — SAMU 192. Official portal, 2022. URL: https://www.gov.br/saude/pt-br/composicao/saes/samu-192 This content is for information and education only and does not replace an individual medical consultation.