AfterTheHeartAttackRiskIsHighForSecondHeartAttack.pdf

Heart attacks are dangerous.

What they tell you when you leave the hospital:

You’ll be OK if you take these medications.

what they don't tell you when you leave the hospital:

Heart attack survivors have a high risk of having another heart attack. And the next one can be fatal.

Of heart attack survivors 45 and older, 1 of 5 men (18%) and 1 of 4 women (23%) will die within 1 year (1). In the first year after being discharged from the hospital, 25% of heart attack survivors over 65 die (2).

We in the health field too often fail to inform heart attack survivors of the risks associated with these statistical realities (3,4).

5-year risk for heart attack survivors:

Within 5 years after surviving a heart attack at 45 or older, 1 of 3 men (36%) and 1 out of 2 women (47%) will die (1). 

Women, who tend to have heart attacks older, are more likely than men to die within the first few weeks after a heart attack (1). Additionally, women have smaller arteries, and may experience unusual symptoms of heart disease compared to men. Odd symptoms can be associated with a delay in diagnosis.

We have a 100% survival rate during the first year and within the first 5 years after the heart attack.

— Dr. Thomas Hight (5)
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lifetime risk:

The risk of sudden death among heart attack survivors is 17x higher compared to those who've never had a heart attack (1).

The most important question a heart attack survivor can ask:

Are my arteries getting better? Are worse?

Our Ask the Arteries trending program uses cutting edge technology to take two snapshots of your plaque disease, 3 months apart. We test more arteries than anyone.

Ask your arteries. They’ll tell you.

Why are heart attacks so unpredictable?

After you’ve survived your heart attack, your cardiologist will most likely order a nuclear stress test every year, to determine when you might need a stent, or another stent. But, when you had your heart attack, the stent they put in only keeps open the obstructive lesion right there. That stent cannot prevent another heart attack in a vulnerable plaque somewhere else. Why not?

As time goes on, artery disease slowly and steadily gets worse, as illustrated below, Chest pain occurs when the blood flow is cut off. Notice the two red arrows below, showing the blood flow. The small one on the right is in "obstructive" artery disease where the blockage obstructs the flow of blood, so the blood can't get through the artery to the heart muscle. This is the type blockage that causes chest pain when someone is exercising. Obstructive blockage is why we do stress tests, to find someone who needs a stent or bypass surgery.   

But that's not where most heart attacks strike.

Now look a the big red arrow where there is plenty of blood flowing through the artery. Most heart attacks happen in "vulnerable plaque," not in obstructive plaque. When "vulnerable" or soft plaque ruptures, a clot or "thrombus" forms, and often blocks off the entire artery within moments (see "Rupture, Thrombus, Myocardial Infarction" above). You would think that most heart attacks occur where plaque causes severe obstruction. That's just not true. Less than 20% of heart attacks do. Over 80% of heart attacks occur in "vulnerable" plaque where the blood flow was fine just moments before the heart attack (4). So in most heart attacks, the thrombus (or blood clot) is what shuts off the blood flow, not the obstructive plaque.

Stress tests are designed to identify obstructive plaque. But most heart attack patients would have passed the stress test the day before. Vulnerable plaque doesn't show up on a stress test. Only obstructive plaque (which needs a stent) does.

This is why heart attacks are so unpredictable. Most heart attacks shut off the blood flow suddenly and without warning.

Cardiovascular disease can be confusing, with so many voices saying so many things about prevention. At CardioSound, we specialize in high-risk patients. We know this arena. We have a track record (5).

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reFERENCEs

  1. Benjamin, EJ, et al, Heart Attack and Stroke Statistics-2017 update. Circulation 2017 Mar 7; 135(10): e146-e603.

  2. Dharmarahan K, et al. Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia; Retrospective cohort study. BMJ 2015 Feb 6; 350:h411

  3. Leifheit-Limson EC, et al. Sex differences in cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction: the VIRGO study. J Am Coll Cardiol. 2015;66:1949-1957.

  4. Dracup K, et al. Acute coronary syndrome: what do patients know? Arch Intern Med. 2008; 168: 1049-1054.

  5. Hight, T, "We physicians love to say we have no events in patients who follow our advice. But what about our track record with non-compliant patients?" Over a 12 yr. period, all heart attack and sudden cardiac death diagnoses were documented and tracked and then retrospectively analyzed. In total, 37 patients had heart attacks or sudden cardiac death. Of those, 18 were excluded for these reasons: 5 had lethal 1st events (2 of those died while hospitalized for MI), 5 were lost to followup, 3 had a past silent MI diagnosed later on EKG or at nuclear or echo stress testing with no event date known, and 8 patients chose soon after the event to have their lipid and risk factor management provided by a cardiologist (3 of those 8 were also lost to followup). Of 19 MI survivors who chose treatment by primary care, none died within the first year. One died of multiple myeloma 14 months after the MI. None died within 5 years after the MI. After the MI, 110 patient-years of care were provided. Of two patients who had a second heart attack and survived it, one (age 89) had stopped statins and blood pressure medications several months prior. At the time of the MI, ages ranged from 47 to 89, with the average being 65. All MI patients were non-compliant with at least one and usually multiple risk factors. No patients were excluded for non-compliance, except those who failed to return for followup. (unpublished data, updated 12/2/2017)

  6. Symptoms are treated with procedures like stents and bypass surgery when the degree of stenosis or obstruction is 70% or more. Yet 86% of heart attacks are caused by plaque lesions which are < 70% obstructed, and 68% of heart attacks are caused by lesions which cause a stenosis < 50%. This may seem counter-intuitive. But there are a lot more people walking around with vulnerable plaque than with obstructive plaque. E. Falk, PK Shah, V Fuster, Coronary Plaque Disruption, Circulation 1995;92:657