The days in hospital are the treatment of the heart attack. The years after are the treatment of the disease that caused it, and that is where most of the difference between a good outcome and a bad one is made: whether the drugs are taken and reviewed, whether the rehabilitation is attended, whether the cause was found, and whether daily life changed. This chapter is the plan, with the numbers, the rules for driving, flying, work and sex that nobody tells people, and the review schedule.
1. The drugs, and how long
| Drug | How long | What to know |
|---|---|---|
| Aspirin 75 mg | Lifelong after a plaque-rupture heart attack | With food; a stomach protector if there is reflux, previous ulcer or age over 65 with a second antiplatelet. Never stop it on your own (the aspirin chapter) |
| The second antiplatelet (ticagrelor, prasugrel or clopidogrel) | 12 months as standard; shortened to 1–3 months if bleeding risk is high (then one drug continues); sometimes longer after complex stenting | Missing doses in the first months risks the stent clotting, which is a heart attack worse than the first. Do not let a dentist or a surgeon stop it without the cardiologist; most dental work is done on it. Ticagrelor causes breathlessness in some people, which is harmless but is a reason to switch, not stop |
| High-intensity statin (atorvastatin 80 mg) | Lifelong | Recheck lipids at 2–3 months against the target below; muscle aches are common and usually not the statin (the nocebo evidence is in the heart topic); a switch of statin is tried before giving up |
| ACE inhibitor (ramipril) or ARB | Lifelong, titrated up over weeks | A dry cough in about one in ten is the reason to change to an ARB; kidney function and potassium checked after each increase |
| Beta-blocker (bisoprolol) | Lifelong if the pump is weakened (ejection fraction under 50%); the UK guideline says 12 months if it is normal, and the 2025 evidence says that year may not be needed | Tiredness, cold hands, vivid dreams, erectile difficulty; a conversation at the review, not a self-stop, because stopping abruptly can provoke angina |
| Heart failure drugs (an SGLT2 inhibitor, a mineralocorticoid antagonist, an ARNI) | If the pump is weakened | Each has its own trial evidence for a weak pump; none is routine after a heart attack with a normal one |
| GTN spray | Carried always | The two-dose rule, then 999 |
| An anticoagulant | If atrial fibrillation is present | With an anticoagulant on board the antiplatelets are reduced to one, usually clopidogrel, and dropped sooner; a specialist decision |
| Colchicine 0.5 mg | Not routine | Two trials found fewer events; the largest (2024) found none; both guidelines call it "may be considered" |
The cholesterol target. UK (NICE 2023): LDL cholesterol 2.0 mmol/L or lower, or non-HDL 2.6 or lower, on the maximum statin, adding ezetimibe if not met, and an injectable (a PCSK9 inhibitor or inclisiran) for those who remain above the NHS thresholds. Europe: below 1.4. US: a non-statin added at 1.8 or above, and reasonably at 1.4–1.8. The test at two to three months is the one most often not done; if nobody has measured your cholesterol on treatment, ask. The full lipid mechanics are the heart topic.
Blood pressure below 140/90 in clinic (130/80 in the US and in Europe for those who tolerate it), and lower where the pump is weak. Diabetes: HbA1c checked; the SGLT2 inhibitors and GLP-1 drugs reduce cardiovascular events in people with diabetes or obesity and established heart disease and are increasingly used for that reason rather than the glucose.
2. Cardiac rehabilitation: the treatment most often declined
A programme, usually eight to twelve weeks, of supervised exercise, education about the drugs and the risk factors, dietary advice, psychological support and help with stopping smoking, delivered by nurses, physiotherapists and dietitians, in a hospital gym, a community centre or at home. The Cochrane review found it reduces cardiovascular death and hospital readmission, by around a quarter in the site's rounding of the range, and improves quality of life; the effect is comparable to any of the drugs. In the UK it is offered to everyone after a heart attack, a stent or bypass surgery and should start within days; the national audit finds only about half of eligible people attend, fewer among women, the old, ethnic minorities and the poor. It is where the questions in this chapter get answered, and where the fear that stops people exercising after a heart attack is dealt with. If you have not been referred, ask; if you were referred and did not go, it is not too late.
3. Driving, flying, work, sex and exercise
| Activity | The rule |
|---|---|
| Driving a car (Group 1) | After a heart attack treated successfully with a stent, ejection fraction over 40% and no other procedure planned: stop for one week. After a heart attack without a successful stent, or with a weakened pump, or after bypass surgery: stop for four weeks. Angina: no driving while it occurs at rest or at the wheel. A pacemaker: one week. An ICD for primary prevention: one month; after an arrest or a shock: six months. AF: no restriction unless it causes faintness. In none of these must the DVLA be told unless there is a continuing disability |
| Bus and lorry (Group 2) | Licence suspended at least six weeks after a heart attack, and restored only after an exercise test and cardiology assessment; an ICD disqualifies permanently |
| Flying | The Civil Aviation Authority's guidance: after an uncomplicated heart attack treated with a stent, fit to fly from about three days; after a complicated one, ten days or when stable; after bypass surgery, about ten days; a pacemaker, a few days; an ICD, once settled. Airlines may ask for a fit-to-fly letter. Airport security does not affect devices |
| Work | Most people return in four to six weeks; sooner for sedentary work, later for heavy manual work or after surgery. A phased return is normal. Some occupations (pilots, HGV, some safety-critical roles) have their own medical standards |
| Sex | Safe once you can climb two flights of stairs without symptoms, typically two to four weeks after an uncomplicated heart attack. The exertion is that of a brisk walk. Erectile drugs are safe with most heart drugs but never within 24–48 hours of GTN, and not with some anti-anginals; say which you take |
| Exercise | Start with rehabilitation; aim for 150 minutes a week of moderate activity plus strength work; walking from the first week. After myocarditis or pericarditis, a strict rest period first (the unusual-ones chapter). Heavy straining is avoided after SCAD |
| Alcohol | Within 14 units; none for the first days on new drugs; heavy drinking raises blood pressure and AF risk |
4. What should be rechecked, and when
| When | What |
|---|---|
| Before discharge | The echocardiogram (ejection fraction written on the letter); the named diagnosis; every drug with its duration; the GTN rule; the rehab referral; a follow-up appointment; the driving and work advice in writing; smoking cessation started |
| Weeks 1–4 | Rehab started; blood pressure and pulse; kidney function and potassium after each ACE-inhibitor step; symptoms of angina or breathlessness reported; wound check if a bypass |
| 2–3 months | Lipids on treatment against the target and the next drug if not met; HbA1c; kidney function; a repeat echocardiogram if the pump was weakened, to decide the defibrillator question at 90 days and the heart failure drugs; the beta-blocker conversation if the pump is normal; mood screened |
| 6 months | Cardiology or GP review: symptoms, exercise capacity, drugs and side effects, blood pressure, weight, the return-to-work and driving position, the anticoagulant if AF |
| 12 months | The second antiplatelet stopped (or continued, deliberately, for a stated reason); lipids, HbA1c, kidney function; flu vaccination each autumn (it reduced death after a heart attack in a 2021 trial) |
| Annually | Blood pressure, lipids, HbA1c, kidney function, weight, smoking, a medicine review asking whether each drug is still earning its place; an ECG if any symptom; for a device, the clinic check or remote monitoring |
| Any time | Chest pain at rest, or angina that has changed its pattern, is 999 and the two-dose rule, not a follow-up question. New breathlessness, swelling of the ankles, palpitations or a faint are same-week problems |
5. Daily life: what moves the risk
| Change | Effect |
|---|---|
| Stopping smoking | The single largest: it roughly halves the risk of a second heart attack and of death within a few years. Every rehab programme offers help; vaping is a lesser harm than smoking, not a safe one |
| Mediterranean-pattern eating | Reduced cardiovascular events in people with established heart disease in the CORDIOPREV trial, more than a low-fat diet. The eating topic |
| Activity | Fitness after a heart attack predicts survival better than most tests; rehab is where it starts |
| Weight | Central adiposity drives blood pressure, glucose and lipids; the GLP-1 drugs reduce events in people with obesity and heart disease (SELECT) |
| Blood pressure at home | A monitor from discharge; the target above |
| Sleep apnoea | Common after a heart attack and in AF; treating it helps symptoms and blood pressure |
| Mood | Around one in five is depressed after a heart attack and it doubles the risk of a further event; it is under-recognised and treatable, and rehab screens for it |
| Anti-inflammatory painkillers | Ibuprofen, naproxen, diclofenac and the like raise the risk of a further heart attack and are avoided; paracetamol is the choice. Say so at every pharmacy |
| Air pollution and cold | Both trigger heart attacks; the practical measures are avoiding exertion outdoors on high-pollution days and in extreme cold |
| Stress | A trigger for takotsubo and for plaque-rupture events; the evidence for stress-management programmes is modest but real, and rehab includes it |
6. The heart attack that was not a plaque
Everything above assumes a plaque-rupture heart attack, which is most of them. After takotsubo, SCAD, MINOCA, myocarditis or pericarditis the drug list is different, the rest periods are different and the follow-up imaging is different; the unusual-ones chapter has each. After an arrest or a dangerous rhythm, the defibrillator decision and the search for an inherited cause are in the rhythm chapter and the every-test chapter.
7. Where UK and US guidance differ
- Lipid targets: UK 2.0 / non-HDL 2.6; Europe 1.4; US triggers at 1.8 and 1.4, with ezetimibe from day one as an option. The UK is the least aggressive on paper, and the NHS thresholds for the injectables are stricter than the guidelines' own targets.
- Beta-blocker duration with a preserved pump: UK 12 months; US and Europe "may be considered"; the 2025 pooled analysis supports the latter.
- Antiplatelet duration: both 12 months; the US guideline gives the shortened options in more detail.
- Cardiac rehabilitation: both recommend it for everyone; the UK's national audit publishes uptake, and it is not good enough in either country.
- Driving: the DVLA rules are UK law; US rules vary by state and are generally less prescriptive.