Scott Webb (Host): Today, we're discussing what happens after a heart attack from acute care to hospital treatment and, finally, post-discharge lifestyle changes with Dr. Yoni Litwok, Director of the Cardiac Intensive Care Unit, the CICU at the Valley Hospital and cardiologist, Dr. Kate Raiti-Palazzolo.

 Welcome to Conversations Like No Other: Heart Care, presented by the Heart and Vascular Institute of Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad everyday cardiac topics to discuss very real and very specific subjects that impact your heart health. We think you'll enjoy our fresh take. I'm Scott Webb. Thanks for listening.

It's great to have you both here today. Dr. Litwok, I'm going to start with you. What happens in the first few hours after a heart attack? Like, walk us through what patients experience when they arrive at the hospital and why those first few hours are so critical.

Dr. Yonathan Litwok: Thank you, Scott. And so, taking a step back, what a heart attack is, is when your heart muscle is not obtaining enough blood flow and oxygen. So, just like any other muscle in your body, the heart is a muscle and its function is to fill with blood, and then squeeze that blood and deliver that blood, which is full of oxygen to the rest of your organs and muscles, and keep your body nice and happy. And just like every other organ in muscle, the heart relies on the same amount of oxygen in order to function normally. Blood is supplied to the heart through tiny arteries and we call those coronary arteries. And the most common cause of a heart attack is when the heart's not getting enough blood and oxygen because there's a blockage in one of those coronary arteries.

Now, when that happens, when the heart's not getting enough oxygen, most commonly, it starts to hurt. And that's why chest pain is the most common presentation of a heart attack. Though pain can also be located in the arms, more commonly on the left side, it could even be in the jaw or in the back. And sometimes the symptoms of a heart attack are not necessarily pain, but other symptoms like sweating, palpitations, dizziness, even indigestion. And some stomach symptoms can be indicative of a heart attack.

If you are experiencing those symptoms, you know, any sort of chest pain, anything that is really out of the ordinary for you and new, that might be along the lines of what I described as being a heart attack, it's really important that you come to the emergency room as soon as possible. And I would suggest that you call 911. The reason I suggest calling 911 is that paramedics and EMTs, they can now perform EKGs—those stickers they put along the chest—and determine if you're having a heart attack before you even arrive to the hospital. They can start some medications if needed, and they can even alert us in the hospital that they're on their way with someone who may be having a heart attack.

So then, when you do arrive in the emergency room, you'll be met by a team of doctors, nurses, and they're going to be performing a number of tests on you, probably simultaneously. They'll be repeating that EKG, which is again those stickers that they put along your chest, and that prints out a piece of paper, which shows the electrical activity of the heart, that allows us to determine if you may be having a heart attack. Additionally, they'll do some blood tests and some of the blood testing that we do gives us an idea if your heart is under stress. There's a very specific blood test that we call troponin. And if that's abnormal, that's a sign that your heart is under stress. And it's really so critical that you come quick because cardiologists have gotten really, really good at opening up those blockages, and they can do that within a number of minutes. The sooner we restore blood flow to your heart, the happier your heart is, and the less of a risk of permanent injury to your heart muscle.

As cardiologists, we try to open up any sort of blockage within 90 minutes and we found that, if we can open the blockage within that amount of time, there's a very good chance that your heart will have a very good recovery. So, the sooner you come to the hospital, the sooner we're able to treat you, the better.

Host: Yeah. I know they say with a stroke, Doctor, time is brain with heart. Time is heart, of course. So, time is of the essence, and we do want what you want, which is those happy hearts. So then, how do you assess the severity of a heart attack, and what treatments or procedures might patients receive during their stay?

Dr. Yonathan Litwok: Great question. So if the team in the emergency room, the paramedics, if they are feeling that you might be having a heart attack, the next test they're going to perform is a test where they actually take a look at those coronary arteries, those blood vessels that are bringing blood and oxygen to your heart. And that procedure is called a coronary angiogram.

Now, that happens in a special room in the hospital. It almost looks like an operating room, but you're not going to be having surgery. You're awake during the procedure, although they'll give you a little sedation so that you're not anxious. And a special cardiologist called an interventional cardiologist will place a teeny tiny catheter either in the artery in your wrist, your radial artery, or the artery in your groin, your femoral artery. And with that tiny catheter, he can put it in your heart and take pictures of those coronary arteries, those blood vessels bringing blood and oxygen to your heart. Of course, we hope that that test shows that there's no blockages and everything's okay. However, you know, if the team suspects you might be having a heart attack, there's probably a good chance that they're going to find some blockages.

Host: Of course.

Dr. Yonathan Litwok: The most common situation, the more common situation is if you do have a blockage, even if you have two blockages or three blockages, they can fix it right then and there. An interventional cardiologist can place a stent across the blockage. A stent is kind of like a mesh tube that goes through the blockage and then expands, pushing whatever's causing the blockage off to the sides and allowing for blood flow to return to the heart. So, that's the most common situation where they find a blockage. And right then and there, they could fix it with stents.

Rarely, but on occasion, if there's multiple blockages and numerous different arteries that would require many, many stents, that can become pretty high risk. And in those situations, they might suggest that you have coronary bypass surgery, which is not common, but it is one of the possible outcomes of the procedure. After the procedure is completed, you'll be moved to a specialized unit in the hospital called the Cardiac Intensive Care Unit. That's the unit where I work as a critical care cardiologist. You'll be taken care of by a team, that's composed of intensivists. These are doctors that are specialized in treating critically ill patients as well as nurses, nurse practitioners, medical residents. And in the cardiac ICU, we monitor you very, very closely. We monitor your vital signs closely. We ask you frequently if you're having any chest pain or any symptoms of a heart attack. And we really want to assure in those first 24 to 48 hours that you're on the right path to recovery.

We'll also start you on new medications for your heart, which I'll speak about in a few moments. And we'll also perform an ultrasound of your heart, something called an echo. And that ultrasound, similar to how they look at babies with an ultrasound, we look at the heart with the ultrasound. And that gives us an idea of how the heart is functioning. Something called an ejection fraction, how well it's squeezing, as well as how the valves within your heart are working.

Host: So, let's talk about recovery, Doctor, before discharge, right? We often think about after discharge. But while the patients are still there, like what milestones do patients typically reach before going home, and what should they understand about the medications that you reference there and followup care.

Dr. Yonathan Litwok: So after having a heart attack, you'll probably be in the cardiac ICU for at least 24, maybe 48 hours. Once you're stable and on the path to recovery, you'll probably be transferred to another area of the hospital that is less intense when it comes to monitoring you closely, a unit where you have more time to rest, recover, but also where we'll start walking you around doing physical therapy. We have a special team in the hospital called cardiac rehab that will work with you to ensure that you have no symptoms with exertion, that you can walk up and down stairs if you have stairs in your home, and that you're ready physically to leave the hospital.

You'll also, when you are ready for discharge, be on a number of new medications, and you really have to be committed to taking your medicine every single day. As I said, most commonly are treated with a stent, and a stent is a foreign object in your heart. You'll be on some medications to assure that your blood stays a little bit thin so that those stents don't clog up again. So, you'll typically be on two medications for that. You'll be on aspirin, and then you'll be on a second medication to keep your blood thin, most commonly, Plavix or Brilinta. And again, these medications are designed to assure that those stents do not clog up or reocclude because if they clog up again, it can lead to you having another heart attack.

So, you really have to be religious about taking the aspirin and the other medication every single day. You'll also be on probably at least one or two other medications, which are there to allow your heart to rest and recover and to the state it was prior to your heart attack.

So, you will be on some new medications. And it's very important that you take your medications as prescribed. And then, when you leave the hospital, you'll need to followup with a cardiologist within one or two weeks. If you have a cardiologist, we'll ensure that you have an appointment with them. And if you don't, we'll make sure that you are set up to see your cardiologist very soon after you're discharged from the hospital.

I will say that cardiologists have gotten excellent at fixing these blockages, and patients oftentimes have a complete recovery and return to living a completely normal life just as they did before their heart attack.

Host: Yeah, it's amazing. Dr. Raiti, let's talk about after discharge. Like, what lifestyle changes matter most after a heart attack?

Dr. Kate Raiti-Palazzolo: Thanks, Scott. Very happy to be here and discuss what we talk about patients come see me after they leave the hospital. So, just as Dr. Litwok was saying, you know, you're on a whole new set of medications. So typically, once I see you in the office, we go through these medications again. Talk about potential side effects that you may have and how you're dealing with this new set of medications that you're taking.

The next steps that we do is really focus on your risk factors, making sure that you don't have another heart attack, and make sure that we're keeping that stent open. So really, we're focusing on physical activity and we are talking about getting into that physical activity after having the heart attack, particularly with cardiac rehab. We're focusing on your cholesterol levels. We're making sure that you're at the right goal that we need you to be. We're talking about different dietary modifications, meaning that you're on a Mediterranean diet. Having lean protein, lots of vegetables, legumes, whole grains.

And also, we want to make sure that you're able to deal, I think, psychologically with the event that just occurred in your life as well. And then lastly, if this pertains to a patient, we want to make sure that you have complete smoking cessation. If you were a prior smoker, we work with you to ensure that you don't go back to that habit.

Host: Yeah. It's interesting you mentioned there the psychological impact or effects of a heart attack. We were talking today mainly about the physical part of it, but there's a big psychological component as well, right?

Dr. Kate Raiti-Palazzolo: Yeah, definitely. I think a lot of patients have a lot of anxiety, a lot of depression, and fear of having another heart attack, and we work with you to get through those feelings that you're having and it's definitely warranted. And, you know, we go through that with you as well as, when you attend cardiac rehab, there's also a lot of emotional support that's provided there that allows you to get through this.

Host: Yeah. I'm glad you mentioned cardiac rehab, because I wanted to focus on that a little bit. Just sort of an open-ended question, but is it worth it, right? Are all patients, you know, candidates for cardiac rehab?

Dr. Kate Raiti-Palazzolo: Yeah. So, cardiac rehab is a critical component of your post-heart attack care. In general, cardiac rehab allows us to get back to activities and do it in a safe manner. I think you have some group of patients who feel they were really active beforehand, and they can just get back to what they were doing after their heart attack.

And then, you have the patients who are fearful of exercising after the heart attack. So, this is a way of getting into exercise training, but having supervision and having our heart rate monitored and having the appropriate staff there, to make sure that we're doing this in a safe manner. And cardiac rehab, it's not just about the physical aspect, but again, the psychological and emotional support as I was discussing before, it gives a lot of patient education as well in terms of their risk factor modifications. And also, just making sure that they're addressing any questions that they may have and helping them with their nutrition and dietary changes. So, it really is a comprehensive center to help patients recover, and it's shown that it actually reduces your risk of death. And it also reduces the risk of you having another cardiovascular event.

Host: Right. Yeah. As you say, education, confidence, you know, all good stuff. So, the answer to that question, cardiac rehab, is it worth it? The answer is yes, right?

Dr. Kate Raiti-Palazzolo: Yup.

Host: Absolutely. What's the biggest misconception people have about heart attack recovery, Doctor?

Dr. Kate Raiti-Palazzolo: So, one misconception on sort of the other end of things and alluding to what Dr. Litwok said earlier is, you know, our patients are coming to the hospital earlier. They're identifying the discomfort that they're having. They're able to have their vessel opened up on a sooner basis and they're going back to life just as they knew it before.

And I think that some patients may feel that this was just a one-time event that was cured. And now, we're able to go back to life as we know it. But actually, this is a chronic disease. And it's not just opening up the vessel, but understanding that because you have had this event, you're more likely to have another event. And so, really focusing on all of your risk factors, like I discussed earlier, terms of your blood pressure, in terms of your cholesterol, in terms of your diet, and physical activity. All of that is so important to make sure that we are monitoring you on a chronic basis.

So once you have had that event, you are now sort of wed to coming to see me as an outpatient cardiologist on a regular basis for the rest of your life. And this truly is a chronic disease and not just a one-time event.

Host: Right. Yeah. It would be great if we just popped a stent in there and little cardiac rehab and you're on your way. But as you say, the relationship with you or, you know, other providers who do what you do is probably for a lifetime.

Dr. Kate Raiti-Palazzolo: Right, exactly.

Host: It's been great to have you both here. I want to finish up here. Dr. Litwok, if you could tell every heart attack survivor one thing, what would it be?

Dr. Yonathan Litwok: To add on to what Dr. Palazzolo was saying, if you have good outpatient followup, if you see your cardiologist regularly, if you take your medications and you take care of yourself, you eat healthy exercise, you stop smoking if you are a smoker, with the medications we have now and the technology we have now, we can hopefully assure that you'll have many, many more healthy and happy years.

Host: Yeah, that's perfect. And Dr. Raiti, same question to you. If there was just that one thing—I know you probably want to tell them a hundred things—but if there was just that one thing for a heart attack survivor, what would it be?

Dr. Kate Raiti-Palazzolo: Yeah, I agree with that. I think it's all about protecting the rest of your life. And it's about making sure that, you know, we are staying on top of all of these activities together. And I think, you know, that's the point of establishing care with us, is that we work together with the partnership to help make sure that everything is aligned and making sure that, you are living the long, healthy life that you want.

Host: Right. Well, many great takeaways today for me, for listeners, I appreciate you both being here, your time, your expertise. Thanks so much.

Dr. Kate Raiti-Palazzolo: Thank you.

Dr. Yonathan Litwok: Thank you, Scott.

Host: And we hope today's conversation has given you a clear look at what happens after a heart attack, from hospital care and recovery to lifestyle changes and emotional healing. Understanding these steps can help patients and families feel more confident and supported on the road to recovery. If you or a loved one have questions about heart health, don't wait. Talk to your doctor.

 Thank you for joining us on this episode of Conversations Like No Other: Heart Care. Be sure to subscribe, share this episode. And for more heart health resources, visit valleyhealth.com/heart.