Document 6424796

Editorial board no. 1033/12
Copyright University Hospital of South Manchester NHS Foundation Trust
All rights reserved
Issue Date : October 2012
Review Date : October 2014
Foreword
As a group of former heart patients, The Ticker Club, has been providing support for patients
and their relatives since 1987, in the outpatient department and on the cardiac wards at
Wythenshawe Hospital (UHSM). As part of this work, the Club has for some years now, been
privileged to provide the funding that makes this booklet available to all the hospital’s cardiac
patients.
In our direct personal contact with patients, their relatives and friends - from diagnosis at the
beginning of the “patient journey”, through the hospital stay and beyond - it is the feedback we
receive from all concerned that has established beyond doubt the high value placed on this
booklet and its contents.
We have all found here, in this booklet, information and advice we can rely on to help us
understand and benefit from the procedure we have undergone. At the same time it is clear this
booklet has proved to be a valuable reference facility, not just for patients, but also for relatives,
carers and supporters alike.
As patient support providers we, in the Ticker Club, are pleased to help underpin the care and
professionalism of all the Wythenshawe Hospital staff who will feature in your patient
experience. We see this booklet as a key part of the support on offer. We hope you too will find it
helpful.
The Ticker Club
Charity No. 519754
The Ticker Club
Founded 1987
This booklet was produced by the Clinical Lead Physiotherapist for cardiac rehabilitation at
Wythenshawe Hospital in 1992. The Cardiac Rehabilitation Team, along with colleagues from
various wards and departments, has continued to write and develop this information, for
patients undergoing heart surgery.
For further information about cardiac rehabilitation, please contact the Wythenshawe Hospital
Cardiac Rehabilitation Service on 0161 291 2177 or email us at [email protected]
We thank The Ticker Club for their continuing support in funding this booklet.
Cardiac Rehabilitation Clinical Lead Physiotherapist/Team Manager
Weeks 8 – 10
May be able to return to light or management types of work
Wash and polish car, clean windows with regular rest breaks
Gardening may include digging, hoeing, raking leaves, mowing the lawn (powered mower)
If possible, use a hose, rather than a watering can
Continue cardiac rehabilitation programme
Daily brisk walk
Contents
Introduction
5
Week 12
May be able to return to manual types of work
D.I.Y. – decorating, painting with regular rest breaks
Carpentry, moving furniture, trimming a hedge
May start golf, badminton, tennis, jogging, and football
Swimming (as long as wounds are completely healed)
Daily brisk walk
Patient Information Day
5
Information about your admission
5
How long will I be in hospital?
6
On completion of your cardiac rehabilitation programme, you may choose to be referred
to a local exercise referral scheme or a local community-based exercise group.
Alternatively, you will be advised to continue daily physical activity in the long-term and/or
take up an exercise or hobby that you enjoy.
What is Coronary Heart Disease?
6
Coronary Artery Bypass Grafting
6
What is heart valve disease?
8
Heart valve surgery
9
What will happen on the day of my operation?
10
Cardiothoracic Critical Care Unit (CTCCU)
11
Page No.
Section A - Your heart operation
•
Pain
11
•
Intravenous infusions (drips)
11
•
Eating and drinking
12
•
Telephone enquiries and visiting arrangements
12
Cardiothoracic Ward
12
Section B - Your recovery
52
Post-operative physiotherapy
13
•
Breathing exercises
13
•
Foot and leg exercises
13
1
•
Arm and shoulder exercises
14
Summary: recovery and rehabilitation guide
•
Moving about the bed
15
•
Positioning and posture
15
Below is a weekly guide intended to give you an overall picture of how you might hope to
progress.
Remember - it is only a guide. Everyone progresses at a different rate and a return to your
normal daily activities should be determined by how you feel during each activity.
Clothing advice
15
Physical effects of surgery
15
Psychological effects for you and your family
17
Wound care, healing and bathing
17
Going home
18
Medication
18
Your follow-up
22
Advice about financial matters
22
Section C - Your rehabilitation
Cardiac rehabilitation
23
First few days at home
24
Sleep and rest
24
Relaxation
25
Physical activity
26
Perceived exertion scale
28
Walking
28
Home exercises
30
Household tasks and gardening
31
2
Week 1
Cardiothoracic Critical Care Unit (CTCCU) on day of operation
CTCCU or ward (day one)
Breathing exercises, begin foot, leg and arm exercises
Return to ward, begin walking (day two)
Progress walking gradually (days three to five), climb stairs if appropriate
Week 2
Return home
Inform GP of your return home
Home visit by district nurse (where appropriate)
Rest and walk around your home and garden, climb stairs as necessary
Continue arm and shoulder exercises
Take things gently - read, listen to music, watch television
Make yourself a light snack
Week 3
Continue arm and shoulder exercises
Begin light activities, i.e. dusting, set the table, prepare light meals
Short daily walk
Week 4
Continue arm and shoulder exercises
Increase activities in the house
Begin light activities (seated) outside
Begin light social activities
Sexual activity may be resumed
May take a restful holiday in own country
Daily walk
Week 5
Continue arm and shoulder exercises
Increase activities to include machine washing, cooking and ironing
Daily walk
Weeks 6 - 7
Continue arm and shoulder exercises. Add arm stretches (see page 14)
May lie on stomach when sleeping
May start walking a dog on a lead
May start to lift weights exceeding 5 lbs (2.3 kg), carry shopping bags, push supermarket
trolleys
Increase activities to include sweeping, vacuuming, mopping floors
May start driving a car
Start the exercise component of your local cardiac rehabilitation programme
May start cycling, bowling, dancing, putting for golf
You should have had or received your appointment for your surgical outpatient
follow-up
Daily brisk walk
51
Wythenshawe Hospital (UHSM) contact numbers
Active hobbies and sports
32
Contact
Contact no.
Driving
33
Cardiac Rehabilitation Secretary
0161 291 2177
Returning to work
33
Cardiac Rehabilitation Physiotherapists
0161 291 2128
Cardiac Rehabilitation Occupational Therapist
0161 291 2110
Holidays and air travel
34
Cardiothoracic Surgical Specialist Nurses
0161 291 5067
Sexual intercourse
34
Cardiology Liaison Nurses
May be contacted by telephoning the hospital
switch board on 0161 998 7070 and asking switch
to air-call the cardiac rehabilitation specialist nurses
0161 291 2679
Dietitian
0161 291 2701
Pharmacist
0161 291 3331
Smoking Cessation Service
0161 291 5030
Waiting List Co-ordinator
0161 291 2463
Cardiothoracic Critical Care Unit (CTCCU)
Main reception
Section D - Maintaining a healthy heart
Risk factors associated with the development of
coronary heart disease
35
Modifiable risk factors
35
•
Smoking
35
0161 291 4522
•
Lack of physical activity
36
Zone 1 Beds 1 - 6
0161 291 4833
•
Poor diet
36
Zone 2 Beds 7 - 10, 17 - 20
0161 291 4836
•
Being overweight
36
Zone 3 Beds 11 - 16
0161 291 4837
Cubicles 1 - 2
0161 291 4536
•
Alcohol
37
Cubicles 3 - 4
0161 291 4537
•
Stress
38
Cubicles 5 - 6
0161 291 4538
•
High blood pressure
38
Ward F6
0161 291 2566
•
High levels of fats in the blood (cholesterol)
40
Jim Quick Ward
0161 291 2204
•
Diabetes
41
50
Non-modifiable risk factors
42
•
Family history
42
•
Age
42
•
Gender
42
3
•
Ethnic background
Healthy eating
42
Useful addresses
43
British Heart Foundation (BHF)
• Fats
43
• Omega-3 (polyunsaturated fats)
44
• Fruit and vegetables
45
Greater London House
180 Hampstead Road
London
NW1 7AW
Tel: 020 7554 0000
Fax: 020 7554 0100
Email: [email protected]
www.bhf.org.uk
Heart helpline 0300 330 3311 Monday – Friday 9am – 6pm
• Plant sterols and stanols
46
The BHF produces a range of booklets and videos. The booklets are free of charge and can be
ordered on line or by telephoning 0870 600 6566.
• Salt
46
Driver and Vehicle Licencing Agency (DVLA)
• Watch your weight
47
• Additional dietary information
47
Support groups
48
• Ticker Club
48
• Other support groups
48
Useful addresses
49
Wythenshawe Hospital (UHSM) contact numbers
50
Summary: recovery and rehabilitation guide
51
4
Drivers Medical Group
DVLA
Swansea
SA99 1TU
Tel: 0300 790 6806 Monday – Friday 8am – 5.30pm, Saturday 8am – 1pm
Fax: 0845 850 0095
Email: [email protected]
www.dvla.gov.uk
49
Support groups
Section A - Your heart operation
Ticker Club
Introduction
Tel: 0161 291 2873
This booklet has been written to provide you and your family with information about your
forthcoming operation. It will inform you how you are likely to progress afterwards and also
inform you how to lead a healthier lifestyle in the future.
[email protected]
https://www.uhsm.nhs.uk/patients/tickerclub/pages/default.aspx
The Ticker Club, a registered charity for Wythenshawe Hospital (UHSM) patients, was founded
in 1987, by a group of patients who had recovered from open-heart surgery. It is a totally
voluntary organisation open to all those who have undergone, or are about to undergo some
form of cardiac or vascular procedure. It is also open to their families and to all who wish to
support the aims and objectives of the Ticker Club.
The Ticker Club raises money through subscriptions, donations, prize draws and other events.
All funds raised are spent on facilities and equipment for the hospital's heart, vascular and
cardiac rehabilitation units.
Patient support volunteers visit the cardiac wards and clinics daily to offer practical advice and
moral support to new patients, both before and after surgery. The Club also produces a
quarterly Newsletter with information on the Club’s activities.
If you would like to join the Ticker Club, or require any further information about the work they
do, please contact them on the above telephone number or email address.
Other support groups
If you wish to find out about the support or community based exercise groups available in your
area, please contact your local cardiac rehabilitation co-ordinator. Alternatively, you may contact
our cardiac rehabilitation secretary on 0161 291 2177.
You should bring this booklet into hospital when you come in for your operation so you may refer
to it when the staff talk to you during your stay.
An electronic version of this booklet and further information can be found at
www.uhsm.uk/patients/cardiacs/pages/default.aspx
You will have been given a free (returnable) copy of the DVD called ‘Hearts and Minds’ when
you were listed for surgery. If you have not got a copy, you should contact your Cardiac Surgery
Liaison Nurse or you can access the DVD on the internet by going to UHSM hearts and minds
DVD.
You can also access a presentation of the above DVD by logging onto the Hospedia television
system by your bedside. Press the operator button. You will be asked for your name and
postcode. You will have access to the DVD, all radio channels and 45 minutes of television
from 9am - 9.45am. This service is available for free.
Patient Information Day
Approximately 1 or 2 weeks prior to your surgery you will be invited to attend a Patient
Information Day on the Cardiothoracic Critical Care Unit (CTCCU ).This takes place on a Friday
afternoon between 2.00 and 4.00pm.
The purpose of the afternoon is to meet members of the team who will care for you during your
stay in hospital and give you an insight into your journey from admission until discharge. The
session allows for questions to be asked by patients and relatives.
Information about your admission
If you have a cough or flu, or if you are taking antibiotics, it is very important that you contact
your Cardiac Surgery Liaison Nurse. Even if you think it is only something minor, please contact
us for advice.
Items to bring in on admission to the ward
As we have limited amount of storage space we would appreciate it if you would only bring into
hospital the suggested items below:
Toiletries (denture pot if needed), towel
Clean nightwear, slippers that are comfortable for walking and dressing gown
Small amount of money if required for newspapers etc
Book or magazine, glasses (if required)
Comfortable clothes such as a T-shirt and tracksuit bottoms to wear after a few days.
48
On the day of admission you will need to telephone the ward before setting off to check there is
a bed available. On arrival you will be asked to report to the admissions desk near the
outpatients entrance before going to the ward.
5
Once all your details have been checked you will be directed to a ward. You will be
admitted to a cardiothoracic ward, normally F6. When you arrive on the ward you may
have to wait in the dayroom until your bed is ready.
When you are settled, the nursing staff will ask you some questions about your history and
will take your temperature, pulse and blood pressure. As part of your introduction to the
ward, the nursing staff will discuss any support that you may require at home after your
operation.
The anaesthetist and the surgeon will visit you and talk to you about your operation. This
will give you an opportunity to ask any remaining questions you may have before your
operation.
It may be necessary to remove any body hair from your chest, legs and forearms before
you have your bath or shower. As shaving can increase the risk of infection, the hospital
policy is to use clippers.
How long will I be in hospital?
You can usually expect to stay in hospital for 5 -10 days.
Prior to your admission, every effort is made to ensure that a bed on the ward and the
Cardiothoracic Critical Care Unit (CTCCU) is available for you. Sometimes, due to the
pressure of emergencies, a bed may not be available on CTCCU. In this case, we will
make every effort to ensure you can remain in hospital and reschedule your operation
within the next day or two.
What is Coronary Heart Disease?
The coronary arteries supply blood and oxygen to the heart muscle. In people with
Coronary (artery) Heart Disease (CHD), a fatty substance builds up in the walls of the
arteries, causing narrowing or blockages inside the coronary arteries. When the arteries
become narrowed the blood flow and amount of oxygen delivered to the heart muscle is
reduced. This can cause chest pain (angina) or may lead to a heart attack (myocardial
infarction).
Coronary Artery Bypass Grafting
The purpose of Coronary Artery Bypass Grafting (CABG) is to improve the flow of blood to
the heart muscle. The surgeon may use sections of healthy vein or artery from the arm, leg
or chest wall to ‘bypass’ these narrowed segment/s of coronary artery and provide new
routes to restore normal blood flow to the heart.
The internal mammary artery, an artery from the chest wall, is used as a bypass graft for
the main branch of the left coronary artery whenever possible, as its life span has proved
to be longer than that of a vein graft.
In some instances, however, it is preferable to only use vein grafts, for example, in
emergency surgery when time is important (removal of the internal mammary artery is a
longer procedure). Your doctor, physiotherapist or nurse will tell you if the internal
mammary artery was used for your operation.
Watch your weight
If you are overweight, losing 5 -10% of your body weight can lower your risk factors of coronary
heart disease and result in an improvement in your health. It is much better to lose weight slowly
and consistently than to go on a crash diet. Studies have shown that it is also easier to maintain
the loss if you lose it slowly (1 - 2lb per week).
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. You can’t choose your shape but if you
are carrying extra weight around your waist, it is a greater strain on your
heart. If you are “apple shaped” rather than “pear shaped”, make an effort
to lose some of those extra inches.
Men
Below 94cm (37”)
94 – 100cm (37” – 40”)
Above 100cm (40”)
Normal
Increased risk
High risk
Women
Below 80cm (31.5”)
80 – 87.9cm (31.5” – 34.5”)
Above 88cm (34.5”)
Normal
Increased risk
High risk
Recent evidence suggests that if you are from an Asian background you should aim for a weight
in the lower half of the recommended range and a slightly lower waist measurement.
If you have a poor appetite or have been losing weight unintentionally, ask one of the cardiac
rehabilitation team or your doctor to refer you to a dietitian.
Summary
•
•
•
•
•
Limit foods containing a lot of saturated salt, hydrogenated or trans-fats
Include one portion of oily fish per week
Aim for 5 portions of fruit and vegetable daily
Limit intake of salt
Check your weight and waist measurement
Additional dietary information
The British Heart Foundation produces various dietary information booklets and videos. Many are
available in the hospital or you can contact them directly.
If you have access to the internet, the following web addresses have useful dietary information:
www.bhf.org.uk
www.heartuk.org.uk
www.bda.uk.com
www.foodstandards.gov.uk
www.nutrion.org.uk
Part of a vein (the long saphenous vein) taken from the leg is used for your bypass graft
which means you will have a leg wound. The position and length of the wound depends
upon where your surgeon/surgical care practitioner can find the most suitable vein to use
for the graft. Please refer to the ‘Vein Harvesting’ patient information leaflet that you will
have been given at your out-patient clinic appointment.
6
47
A guide to portion size:
−
pineapple or melon
−
grapefruit
−
apple, pear, orange, banana, peach
−
plums, kiwi, satsuma
−
berries, cherries or grapes
−
vegetables e.g. carrots, peas
−
salad
bowl.
1 large slice
1/2 fruit
1 fruit
2 fruits
1 cupful
3 large tablespoons
1 small dessert
Occasionally your surgeon will choose to use the radial artery in the arm as a graft. In this
case, the incision is in the forearm, from elbow to wrist.
Heart showing Coronary Artery Bypass Grafting
Plant sterols and stanols
Plant sterols and stanols which are added to some foods including spreads, soft cheeses, yogurts
and yogurt style drinks may reduce cholesterol levels. However these products can be expensive
and must be taken regularly. They may be helpful for people who cannot take
cholesterol-lowering drugs or for those who have high cholesterol levels even after making
changes to their diet. For further advice ask your doctor or dietitian.
Salt
Salt can raise your blood pressure. High blood pressure can increase your risk of developing
heart disease and stroke.
Limit salt to about 6g per day which is about one teaspoonful. This is not a large amount when
you consider that around 75% of the salt we eat is in the food we buy.
Foods which contain a lot of salt
•
•
•
•
•
•
Tinned/packet soup and gravy/stock cubes
Bacon and processed meats e.g. ham, sausages, pate
Crisps and salted nuts or crackers
Soya sauce, bottled sauces
Ready meals e.g. lasagne
Processed foods.
Coronary artery bypass graft surgery may be performed using either of the following
techniques:
1. When using a heart-lung bypass machine, blood is diverted away from the heart and into
the machine, allowing the surgeon to work on an ‘empty and dry’ heart. The heart-lung
machine takes over the role of the heart and lungs during surgery.
2. The ‘beating heart’ technique is where the heart is not stopped and the surgeon bypasses
the blockages while the heart is still beating and working. This is called ‘off pump’ surgery.
The decision regarding whether your operation requires the heart-lung bypass machine or
not, will be made by your surgeon.
A guide to reducing salt in your diet
•
•
•
•
Avoid adding salt at the table
Limit salt in cooking and gradually reduce. Use alternative flavourings e.g. pepper, herbs
and spices
Avoid salty foods, choose fresh food where possible
Compare labels when you are shopping and choose the ones lower in salt. Be careful of
other terms used for salt such as sodium, monosodium glutamate and sodium bicarbonate.
To find out if a product has ‘a lot’ or ‘a little’ salt and sodium, look at the nutrition information label.
Compare the ‘per 100g’ figures with the information below.
This is a lot (per 100g of food)
1.25g of salt or more
0.5g of sodium or more
This is a little (per 100g of food)
0.25g of salt or less
0.1g of sodium or less
Chest incision - In order to operate on the heart, an incision through the chest is necessary.
This involves cutting through the breastbone lengthways. This is called a median sternotomy.
Afterwards the bone is held together with about six stainless steel wires, which stay in place.
They rarely need to be removed. The wound is approximately 30 cm (12 inches) long.
What are the benefits of Coronary Artery Bypass Grafting?
CABG can:
•
•
•
•
reduce angina and/or breathlessness
reduce the amount of medication you need to take
improve your quality of life
increase your chance of living longer.
The benefits of CABG surgery vary for each person. Your surgeon will discuss the expected
benefits for you, as an individual, at your out-patient clinic appointment.
The benefits of CABG surgery vary for each person. Your surgeon will discuss the expected
benefits for you, as an individual, at your out-patient clinic appointment.
46
7
What are the risks and complications of Coronary Artery Bypass Grafting?
How much omega-3 fats do I need to eat each week?
You will have a chance to discuss your individual risk and possible complications with your
surgeon. CABG surgery, like any other surgery, carries a risk of complications. The risk of
complications varies for each person and will depend on several factors including:
•
•
•
your age and sex
•
•
•
the urgency of the operation
•
•
•
•
whether you are having additional surgery at the same as your CABG
whether you have diabetes, lung problems, kidney damage or any significant problems
with the circulation to your brain or legs
I do not eat fish, how do I get omega-3 fats?
•
your weight
•
whether you are a smoker and/or a heavy drinker.
Possible complications
Bleeding – you may need to be taken back to theatre to treat excessive bleeding.
•
•
Heart attack – on rare occasions during surgery the heart can suffer a heart attack.
•
Stroke – which may be temporary or permanent.
Infection – this may involve one of the wounds (chest, leg or arm), or the lungs, and will
be treated with appropriate antibiotics depending on the severity of the infection.
Kidney problems. Bypass surgery can affect your kidney function. If you have any
problems, you will be referred to a specialist.
A member of the surgical team will ask you to sign a written consent form for the operation to
be carried out. Your surgeon will discuss the risks, benefits and alternatives for you as an
individual. If you have any questions, please talk to the doctor before you sign the consent
form.
What is heart valve disease?
Your heart has four valves. They ensure that blood is pumped in one direction only within the
heart and towards the lungs and body. These valves can be damaged in many ways; for
example be abnormal from birth, after rheumatic fever, from wear and tear or following a heart
attack.
There are two main types of valve problem:
•
the valve may become narrowed (called stenosis), which causes a block to normal
blood flow
•
the valve may become leaky and allow blood to flow in the wrong direction called
regurgitation.
In both cases the heart has to work harder and eventually surgery may be necessary.
The drainage of blood from the lungs to the heart may be affected. This will result in a build up
of fluid on the lungs and cause breathlessness. The drainage of blood from the rest of the body
to the heart may also be affected causing swollen ankles. Chest pain, palpitations and
dizziness may also be experienced.
8
Your body can convert a type of fat called alpha-linolenic acid (ALA), into small amounts of
the more useful omega-3 found in oily fish.
To help your body convert as much omega-3 fats as possible from plants, it is important to
eat a varied mixed diet with plant rich sources daily.
−
−
−
−
−
Your surgeon will take the above factors into account when assessing your individual risk.
•
•
If you’ve had a heart attack aim for 2 - 3 large servings of oily fish per week
Everyone else should aim for one serving of oily fish and one serving of white fish per
week
A serving is roughly 100 -150g (4 - 6oz) of fresh, frozen, or smoked fish
To help lower salt intake, keep smoked fish to no more than once a week.
•
rapeseed, walnut, soya, flax or linseed oil
ground or crushed linseeds, flax or pumpkin seeds
unsalted nuts e.g. walnuts, pecans, peanuts, almonds
soya beans and tofu
dark green leafy vegetables, sweet potato and whole grains
Some foods have omega-3 added to them e.g. eggs, milk, yogurt and yogurt drinks.
Omega-3 contents vary greatly, so check labels.
Should I take omega-3 supplements?
•
•
If you eat oily fish you do not need to take a supplement.
If you have had a heart attack and do not eat oily fish either:
−
Take a prescribed or bought over the counter capsule containing 1.0g omega-3 (EPA
and DHA) daily.
Or
−
If you are unable to take fish oil capsules, try a supplement derived from algae (a good
source of DHA).
If using fish oil capsules, look at the label and check the content of omega-3 fats.
These may be listed as EPA and DHA. Just add the total of both EPA and DHA together to find
the total omega-3 fat content.
Cholesterol
Cholesterol (as discussed on page 40), is an important fatty substance found in every cell of the
body. Too much cholesterol in your blood can increase your risk of heart disease. The most
common cause of high cholesterol levels is eating total fat especially saturated fat.
Fruit and vegetables
Government agencies recommend that you aim to include five portions of fruit and vegetables a
day because of the health benefits this brings. Fruit and vegetables contain vitamins and minerals
and are low in fat. Aim to eat a variety to get the most benefit. These can be fresh, frozen,
canned, dried or as a juice.
45
How to reduce saturated, hydrogenated and trans-fats
•
•
•
•
•
•
•
•
•
Choose lean cuts of meat, lean mince, low fat pate. Trim all visible fat and remove
poultry skin.
Skim fat from gravy. Choose tomato-based sauces rather than
cheesy or cream sauces.
Choose potato topped pies instead of pastry e.g. shepherd’s pie,
fisherman’s pie.
Vegetarian options. Base meals on pulses, tofu, quorn, soya meats,
nuts and seeds.
Use rapeseed oil, olive oil, sunflower oil instead of lard, ghee, suet, vegetable suet.
Avoid deep-frying or re-using oil. Use olive spread, sunflower spread, low fat spread
instead of butter or ordinary margarines.
Choose fat-reduced cheese and limit quantity to 110g (4oz) per week. Spread this out
over three meals. Avoid eating cheese as a snack unless it is very low-fat such as
cottage cheese.
Choose semi-skimmed (in moderation), skimmed milk, low fat yogurt, low fat fromage
frais. (If you have diabetes or wish to lose weight, choose healthy eating or diet yogurts
as these are low in fat and low in sugar).
Desserts. Fresh or frozen fruit, tinned fruit, low fat custard or milk pudding, jelly,
meringue, low fat ice cream or frozen yogurt, trifle sponge cakes, sponge flan are lower
fat options.
Cakes and biscuits. Malt loaf, garibaldi, ginger nuts, fig rolls, marie biscuits, rice cakes,
oatcakes are better choices but remember to limit the quantity eaten. Once you have
reached your target weight, you could try making your own biscuits or cake using
suitable fats and oils.
The most common valves, which require surgery, are the mitral and aortic valves (see
picture). They are found in the left side of the heart.
Surgical treatment has a very good success rate for severe valve disease and is the
treatment of choice. However, alternatives to valve surgery, including other medical
treatments, may have already been discussed with you by your cardiologist and surgeon.
Check food labels
To find out if a product has ‘a lot’ or ‘a little’ fat and saturated fat, look at the nutrition information
label. Compare the ‘per 100g’ figures with the information below.
This is a lot (per 100g of food)
20g of fat or more
5g of saturated fat or more
This is a little (per 100g of food)
3g of fat or less
1g of saturated fat or less
Heart showing valves and chambers
Heart valve surgery
There are two types of valve surgery. The damaged valve can either be repaired or
replaced. A replacement valve can either be mechanical (metal or plastic) or tissue
(obtained from an animal, usually a pig or cow).
Omega-3 (polyunsaturated fats)
Omega-3 fats are healthy fats which help to protect your heart by:
•
helping the heart to beat more regularly
•
reducing the stickiness of blood, making it less likely to clot
•
helping to keep arteries smooth and supple.
•
Mechanical valves are longer lasting, but you will need to take anti-coagulant drugs
(those which thin the blood) for the rest of your life (see page 20).
•
Tissue valves do not last indefinitely, but you are less likely to require
anti-coagulant drugs.
Omega-3 fats are also known as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).
Your surgeon will discuss with you the most suitable valve in your case.
Sources of omega-3 fats
•
Oily fish
•
Other sources are rapeseed (or canola) oil, nuts and dark green leafy vegetables.
Examples of oily fish:
mackerel
fresh tuna
sardines
All valve operations are performed using the heart-lung bypass machine.
What are the benefits of valve surgery?
kippers
trout
herring
pilchards
salmon
sild.
44
The benefits of valve surgery vary for each person. The benefits for you will depend on
your particular symptoms before the operation. You can expect to see an improvement in
your symptoms. The surgery will also help to prevent your heart valves from deteriorating
further.
9
What are the risks of valve surgery?
Healthy eating
Valve surgery, like any other surgery, carries a risk of complications. The risk of complications
varies for each person and will depend on several factors including:
Research has shown that by making changes to your diet you can reduce your risk of recurrent
heart problems.
•
•
•
You should aim to achieve this by:
your age and sex
which valve is being operated on, and the extent of valve and heart muscle disease
whether you are having a coronary artery bypass graft at the same time as your
valve surgery
•
whether you have diabetes, lung problems, kidney damage or any significant problems
with the circulation to your brain or legs
•
the urgency of the operation.
Possible complications are:
•
•
•
•
reducing your saturated fat intake
including omega-3 fats weekly
having at least five portions of fruit and vegetables per day
reducing your salt intake
maintaining a healthy weight
Fats
Your surgeon will take the above factors into account when assessing your individual risk.
•
•
•
•
•
•
•
All fats and oils contain a mixture of saturated fats and unsaturated fats in different proportions.
Unsaturated fats are either mono-unsaturated or poly-unsaturated.
Saturated fats
wound or chest infection
ongoing risk of infection (endocarditis). To reduce this risk all patients should have
regular dental checks
irregular heart beat
blood clots can form, mostly on mechanical valves
wear or damage to valves - this is more common with tissue valves
stroke - there is always a very small risk of stroke with valve surgery.
Consent for your operation
A member of the surgical team will ask you to sign a written consent form for the operation to
be carried out. Your surgeon will discuss the risks, benefits and alternatives for you as an
individual. If you have any questions, please talk to the doctor before you sign the consent form.
What will happen on the day of my operation?
On the day of your operation the anaesthetist will have prescribed for you a ‘premedication’ to
be given a few hours before your operation. This will involve you being given some tablets or an
injection and possibly some of your normal medication. The premedication will help you relax
and may make you drowsy. You will be taken to theatre on your bed.
In the anaesthetic room the anaesthetist will put a drip into the back of your hand and give you
the anaesthetic injection. Whilst you are asleep the anaesthetist will put a tube down your throat,
into your windpipe and connect you to a ventilator (breathing machine). This tube stays in place
throughout your operation. It is needed because during the operation it is necessary for your
body temperature to be lowered to rest your heart and lungs and allow their function to be taken
over by the “bypass and breathing machine”. Whilst the thought of having this tube in your
windpipe is not pleasant, please remember that you will be asleep and therefore not aware
of its presence.
Too much saturated fat causes the level of cholesterol in your blood to increase.
Therefore you should reduce your intake of saturated fat.
Saturated fats are mainly found in:
•
butter, lard, suet, ghee, coconut oil, palm oil, and any products made using these, for
example pastry, pies, cakes, biscuits
•
fat on meat, processed meats such as sausages, beef burgers, salami, corned beef
•
full-fat dairy products such as full-cream milk, cream, cheese, full-fat yogurt
•
manufactured foods such as chocolate, mayonnaise, cream substitutes.
Unsaturated fats
As part of a healthy diet you could replace foods that contain saturated fats with foods that
contain unsaturated fats. Unsaturated fats can be good for our hearts.
Some foods that could replace products high in saturated fats include:
•
oily fish
•
nuts and seeds
•
olives and olive oil
•
sunflower and rapeseed oil
•
avocado.
Trans-fats and hydrogenated fats
These fats are formed during food processing when they are subjected to high temperatures.
They are mainly found in deep fried foods, shop bought cakes, biscuits, confectionery and crisps.
It is important to eat as little trans-fats and hydrogenated fat as possible, because they cause
your blood cholesterol to increase.
After your operation you will be transferred into the CTCCU whilst still under the anaesthetic. It is
important for us to monitor your heart rate, breathing and blood pressure. Your sedation will be
reduced once you are stable. The tube in your windpipe will be removed when your lungs are
strong enough for you to breathe properly.
10
43
Non-modifiable risk factors
Cardiothoracic Critical Care Unit (CTCCU)
Family history
The amount of time spent recovering on CTCCU can vary from one individual to another.
Patients will stay on CTCCU until they are fit to be cared for on the ward.
Coronary heart disease runs in families. Your own risk of developing
coronary heart disease is increased if your father or brother was
diagnosed with the disease under the age of 55, or your mother or
sister was diagnosed under the age of 65. Other conditions which
can run in families include high cholesterol levels, diabetes and
hypertension. It is important that family members are aware of their
own risk factors and take steps to prevent heart disease.
Age
The older you are the more likely you are to develop coronary heart disease.
Gender
Men are much more likely to develop coronary heart disease at a younger age than women.
Women appear to be protected by their hormones until the menopause, after which their risk of
heart disease increases.
Ethnic background
People from Afro-Caribbean backgrounds and South Asians are at a higher risk of developing
coronary heart disease.
The morning following your operation the consultant and anaesthetist will visit you. They will
review your condition and decide whether you are to stay on CTCCU or be transferred to the
ward.
In general most patients are transferred between 12 to 36 hours after their operation. The nurse
who is looking after you will keep you fully informed about your transfer.
Your nurse will monitor your condition and assess when you are ready to begin breathing
unassisted again. As you start to wake up your nurse will tell you that you are back on the
CTCCU and that your operation is over. To check that you have woken up properly your nurse
will ask you to move your toes and squeeze their hand. This helps them to assess how awake
you are. You will still be very sleepy at this stage and you may become aware of the tube in
your throat and windpipe. If, at this stage, your condition is considered stable the nurse will
remove the tube in your throat. If not, the sedation will be topped up until you are ready for
the tube to be removed. It is important to remember that whilst the tube remains in your throat
you will be unable to talk. Do not be alarmed – your voice will return once the tube is removed.
As your nurse will be monitoring your breathing very closely they will be with you all the time.
They will ask you to communicate with them by nodding or shaking your head or by squeezing
their hand.
Some patients who have existing lung disease, for example asthma or chronic bronchitis, may
need more assistance with their breathing. The consultant anaesthetist who speaks to you
before the operation will tell you if they consider that this will be the case.
Once you are off the ventilator and the tube is removed you will need extra oxygen via a
facemask for approximately the next two days. The mask should remain in place for most of the
time, but you can take it off in order to eat or drink.
Pain
Your comfort is very important to us. When you are pain-free it will improve your breathing and
help your physiotherapy (see page 13). We will give you painkillers through one of your drips
and gradually replace this with tablets as you recover sufficiently to be able to eat and drink
again. It is important that you let us know if you are experiencing any discomfort so that we can
adjust your painkillers to suit your need.
Intravenous infusions (drips)
Whilst you are sedated you will have several drips inserted. Some of these will be in your hand,
others in your neck or shoulder. Most of these will be removed on the CTCCU before your
transfer to the ward. You will be left with one drip in your hand and possibly one in a neck vein.
Whilst you are under the anaesthetic, a tube (catheter) will have been put into your bladder.
This will drain your urine whilst you are asleep and for a short time afterwards. The catheter
may be removed during your stay on CTCCU or on the ward.
42
11
Eating and drinking
Diabetes
Soon after the tube in your throat has been removed you will be able to drink again. Most people
are ready to eat again on the evening of the first day after the operation. You will be offered light
meals to start with.
Diabetes occurs when the glucose level in the blood is too high. Glucose is a sugar that the body
makes mainly from the starches and sugars (carbohydrates) in food. The blood carries glucose
to all the cells in the body, where it is used to produce energy. However, the cells cannot just
take the glucose out of the blood; to do this, they need a hormone called insulin. Insulin is made
in the pancreas – (a large gland that lies behind the stomach), and is carried in the blood. Insulin
allows the glucose to move from the blood and into the cells, therefore enabling the glucose level
in the blood to fall.
Telephone enquiries and visiting arrangements
A member of staff will telephone your next of kin (within the hour) when you have been
transferred from the theatre and arrived on CTCCU.
There are two types of diabetes:
Telephone enquiries are welcome at any time of the day or night. In order to help the nursing
staff who are caring for you, we ask that only one or two family members ring the unit. They
can then pass on the information to other family members. We understand that relatives are
anxious to enquire but each time the nurse has to answer the phone they are taken away from
caring for you.
Visiting on the CTCCU is restricted to immediate family only. On the day of your operation we do
not encourage relatives to visit. Nevertheless we realise that this day will be an anxious time for
your family and in some instances visiting may be possible. Please ask members of your family
to contact the CTCCU and speak to the nurse who is looking after you. He/she will make
arrangements for them. Normal visiting arrangements can be resumed on the first day after your
surgery. Before visiting, your family should contact the CTCCU by telephone to check whether
you have been transferred to another ward. Visiting times on CTCCU are 2 - 4.30pm and
6 - 8pm. This is to allow protected meal times for patients and also to provide rest time for
patients. Unfortunately due to health and safety reasons and also infection control, flowers are
not allowed on the unit or wards.
Type 1 – when the body does not produce any insulin
Type 2 – when the body does not produce enough insulin, or the cells of the body are
unable to use insulin effectively.
In diabetes, glucose levels in the blood rise because glucose cannot move from the blood into
the cells due to a lack of insulin. The cells become starved of glucose (fuel) which leads to
symptoms of diabetes. Diabetes increases the risk of coronary heart disease and can cause
other serious health problems. Diabetes damages the heart in several ways.
•
High glucose levels in the blood affect the walls of the arteries, making them more
likely to develop atheroma (plaque).
•
Platelets stick together more easily.
•
Diabetes increases the damage done by the major coronary heart disease risk factors
of smoking, high blood pressure and high blood cholesterol.
Cardiothoracic Ward
•
Diabetes can affect the heart muscle itself, making it a less efficient pump.
When you are transferred off the CTCCU, it is likely you will move to Ward F6 (or to Jim Quick
Ward). It is recommended that the number of visitors to the ward is restricted to a maximum of
three visitors per patient. Children under the age of 12 are discouraged from visiting the ward.
Permission for children to visit should be obtained beforehand from the nurse in charge. Visiting
times on Ward F6 are 2 - 4pm and 6 - 8pm. Out of hours visiting will need prior arrangements
with the ward sister.
•
People with Type 2 diabetes often have lower levels of HDL cholesterol.
•
Diabetes can affect the nerves to the heart so that the symptoms of heart disease
are not felt in the usual way.
Mobile phones and camera attachments are not to be used on the CTCCU.
If you have this condition we will give you more information and, if necessary, you may be
referred to a Diabetic Nurse whilst you are in hospital.
A normal blood sugar is between 4 - 9 mmols. If your blood sugar is consistently higher than this
your medication (either insulin or tablets) may need adjusting. You should 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).
12
41
High levels of fats in the blood (cholesterol)
Section B – Your recovery
Cholesterol is a word you may well have heard, but never understood. Cholesterol is the best
known of a group of fat-like substances in the body called lipids. The liver makes cholesterol from
the saturated fats we eat. A certain amount of cholesterol is essential for life and it is present in
every cell in the body and also in the blood. When people have an excess of fats in their blood,
the body is unable to break these down and may therefore be deposited in the artery wall. These
affected areas are known as atheroma or atherosclerotic plaques. Over time these get bigger
and can spread into the centre of the artery, making the artery smaller. This may cause the
symptoms of angina or more seriously lead to a heart attack.
Atherosclerotic
plaques
This is a normal
artery wall
•
•
•
•
Here atherosclerotic
plaques are beginning
to develop
Cholesterol is carried around the blood in different forms
The two main forms are high density lipid (HDL) cholesterol and low density lipid (LDL)
cholesterol
HDL is sometimes known as ‘good cholesterol’ because it carries the cholesterol away from
your arteries back to your liver
LDL is sometimes referred to as ‘bad cholesterol’ because it carries the cholesterol to your
arteries where it can contribute to the build up of fatty deposits (atheroma), in your artery
walls.
If you have high total cholesterol or a high LDL cholesterol and low HDL cholesterol you are more
at risk of a heart attack.
A high level of cholesterol may be inherited (a condition called familial hyperlipidaemia or
hypercholesterolaemia) or it may be affected by diet and lifestyle.
If you are known to have a heart problem, you should try to lower your cholesterol. The best way
is to cut down on saturated fats in your diet, have moderate alcohol intake and take regular
exercise.
For many people these natural ways are not enough on their own. In this case, research has
shown that the need for tablets is essential (see page 19). The test for cholesterol is often done
as a fasting test which means you will be asked not to eat or drink anything other than water for
12 hours before the test.
My cholesterol result was:
Total cholesterol (T.C.)………….. mmol/l (recommended less than 4mmol/l)
HDL ……………………………….. mmol/l (recommended greater than 1mmol/l)
LDL ……………………………….. mmol/l (recommended less than 2mmol/l)
Triglycerides ………………………
Ratio ……………………………….
Post-operative physiotherapy
Physiotherapy is a very important part of the recovery process after your operation. You will be
assessed by a physiotherapist the day after your operation and treated either once or twice a
day whilst you are in hospital. They will encourage you to do breathing exercises and will help
you to get back on your feet.
Breathing exercises
After your operation, breathing exercises help to prevent the development of chest infections.
Breathing exercises are important because the anaesthetic (used during the operation) can
cause sputum (phlegm) to collect on your chest. You do not breathe as deeply when in bed as
you do when you are up and about which can mean that the bottom parts of your lungs don’t
fully expand in the early post-operative period. Many patients are also reluctant to take deep
breaths and cough because of their wound, pain and drains.
After your operation until you are discharged or advised by your physiotherapist you should carry
out the following deep breathing exercises:
•
•
•
•
take a slow deep breath in, trying to fill your lungs as much as you can, hold it for three
seconds and then breathe out
repeat this three times
perform a ‘huff’. This is a short sharp breath out with your mouth open
cough.
Repeat the cycle again.
To reduce any discomfort when huffing or coughing you can support your chest with your hands
or you may be given a rolled up towel. You should expect some discomfort when carrying out
the breathing exercises but if the pain is stopping you from doing them effectively you must
inform your physiotherapist or nurse. Your painkillers will then be reviewed. You may be given
an incentive spirometer to encourage you to breathe deeply. This device helps to exercise your
lungs to improve their function and measure how well your lungs fill up with each breath.
Foot and leg exercises
Your physiotherapist will also teach you how to do the foot and leg exercises (pictured below)
regularly. These will help reduce the risk of blood clots forming and reduce swelling in your leg
and ankle. Early movement of your leg will also help to reduce tightness and pain of the leg
wound. You can help to reduce swelling in the leg by sitting with your leg up, knee fully
supported by a pillow or chair, so that your foot is higher than your hip. This helps the fluid to
drain away more easily. Also, do not sit with your legs crossed as this reduces the normal
flow of blood in the veins.
1. Lying on your back or sitting,
bend and straighten your ankles quickly.
Repeat 10 times.
Date taken…………………………
I need to get my cholesterol re-checked in three months time on ……………………………at the
GP surgery.
40
13
2.
You have probably heard the doctor or nurse say something like, ‘the BP is 140 over 80’. Blood
pressure is measured in millimeters of mercury. This is usually written down as mmHg. The top
number (140) is the pressure that your heart is pumping at (systolic). The lower number (80) is
the pressure between heart beats when the heart relaxes (diastolic).
Sitting up in bed, bend
your hip and knee upwards.
Repeat 10 times.
High blood pressure is often unrecognised as there are no obvious symptoms. This is why
hypertension is particularly dangerous. If left untreated, it can cause damage to many parts of
the body including blood vessels, the heart, the kidneys and the eyes. It is a major risk factor for
hardening of the arteries, heart attack, stroke, heart failure, kidney failure and sight loss.
On the second day after your operation, you are likely to start walking with help from your
physiotherapist. If necessary, you can be given a walking aid to assist with your walking. Between
the third and fourth day after your operation you will be encouraged to walk without supervision
around the ward. Before you go home, if appropriate, your physiotherapist will make sure you can
climb the stairs safely.
Arm and shoulder exercises
In order to prevent stiffness in your shoulder joints and to stretch the scar tissue over your
breastbone, your physiotherapist will teach you to do arm exercises. They should be carried out
five times each, three times a day, until full pain-free movement is gained.
From day 1 after your operation:
1. Lying on your bed or sitting
raise one arm out in front and then up
above the head. Progress to raising both
arms together.
You should have regular blood pressure checks at your GP surgery. A small reduction in blood
pressure can help protect your heart. You can help by:
•
not smoking
•
reducing your weight by eating healthily
•
using less salt when cooking or on your food
•
reducing your alcohol intake
•
becoming more active and taking regular exercise
•
taking your prescribed medications
•
avoiding stressful situations
•
practicing relaxation and using other stress management techniques.
My blood pressure is:……………………………………………….mmHg
Once at home include:
2. Standing - raise both arms out to the side,
then up above the head.
At six weeks after the operation include:
3. Standing or sitting - stretch both arms
back. Hold each stretch for 10 seconds.
14
39
Stress
Moving about the bed
Research evidence has shown that, for some people at least, stress may contribute towards
coronary heart disease. Stress is hard to measure but it is known that stress increases the
production of cortisol and adrenaline which prepares the body to react to a new challenge or to
cope with danger or emergencies. These hormones can increase blood pressure and encourage
clotting in the arteries.
We encourage patients to be independent in moving about and getting on and off the bed and
chair as early as possible. You will find it less painful to move up and down the bed by shuffling
your bottom from side to side. When getting off the bed it is easier to roll onto your side first,
swing your legs over the edge of the bed and then push up with your arms. Do the same in
reverse for getting into the bed. It is important in the early stages not to put too much pressure
through your arms. You will be advised how to do this correctly by your physiotherapist.
Stress can also affect how you feel psychologically and change the way you respond in situations
that you perceive as challenging. We all experience stress in different ways and have good stress
and bad stress. Too much bad stress over a long period of time can have a negative effect on
your health and wellbeing. It is important to be able to recognize when stress is affecting you and
identify the things that are causing you stress.
Stress can make you rely on short term fixes rather than taking long term action to deal with
stress. It can encourage less healthy behaviours such as overeating, drinking too much alcohol or
smoking rather than spending time on healthy behaviours such as relaxation or physical activity.
Take time to look at the kind of things that are stressful to you. By identifying the sources of
stress, you can start to think about how you can deal with them. Try to reduce the source of
stress if you can. Even if you cannot change a situation, it may help to talk to someone about it.
Using relaxation techniques as described earlier in the booklet can help to reduce your stress
levels. Also your cardiac rehabilitation may have a stress management programme you can
attend during your rehab period or after.
There are many things you can do to manage stress or anxiety.
•
•
•
•
•
Avoid stressful situations at home or work if you can.
Learn to say no to people when you feel overburdened.
Learn different techniques for managing stress.
Talk to family or friends or find out about support groups.
Learn to relax. There are many different ways of relaxing
such as physical activity, yoga or relaxation techniques.
Making changes to your lifestyle such as taking more
exercise, healthy eating, cutting down on alcohol and
giving up smoking.
Making more time for yourself and enjoying activities
that make you feel good.
Positioning and Posture
When you are in bed or sitting in a chair it is important to be as upright as possible, with your
head supported and your shoulders relaxed. This will help you with your breathing and also help
to relieve tension in your muscles. Also remember not to allow yourself to become round
shouldered or 'stooped'. This could lead to poor long-term posture and discomfort.
Clothing Advice
Please wear underpants as soon as possible if you have any groin surgical wounds. If you are
female, please wear a bra as soon as you can (unless you have pacemaker wires or ECG wires
etc). Wearing a bra whenever possible will help reduce pressure on the chest wound. A surgical
pad or some gauze can be fitted under the bra to minimize discomfort across the wound.
Physical effects of surgery
Below are some common immediate post-operative problems. They can be attributed to
the surgery, the effects of the heart/lung bypass machine or the anaesthetic used during
the operation. Most of these problems should settle during the first few weeks after your
operation.
•
Tiredness. This is very common and may last for up to six weeks. Ensure you pace
yourself with any activities you may do.
•
Sore throat and hoarse voice. Due to bruising of tissues by the tube in your mouth.
•
Sweatiness. Suddenly feeling hot and cold and having night sweats is normal. It is
due to the temperature regulation of your body settling down again.
•
Change in sense of smell. This should soon return to normal.
•
Reduced sense of taste for a short time only. Many people have a metallic taste in
their mouths or find that all food tastes the same or is tasteless.
Ideally your blood pressure at rest should be no more than 140/85 (or 130/80 if you are diabetic).
It is normal for your blood pressure to rise and fall depending on your activity.
•
Poor appetite. Try to eat something at each meal time and eat a small snack between
meals. This is important for both nutrition and wound healing.
High blood pressure happens if the walls of the larger arteries lose their natural elasticity and
become rigid, and the smaller arteries or vessels constrict (become narrower).
•
Indigestion and constipation. This is also common, as normal function of the gut
slows down during surgery. Inform your nurse if you have a problem so they may give
you something to help.
•
Visual disturbances. You may have blurred vision, spots before your eyes and visual
hallucinations. It is advisable to wait about three months before having your eyes
tested.
•
•
High blood pressure (hypertension)
Blood pressure (BP) is the pressure in the arteries as the heart pumps blood around the body.
As we get older, we often need a ‘higher pressure’ to force the blood through vessels that have
‘stiffened’ with age.
So, what might be a high reading for a young person can be perfectly normal for someone older.
Your doctor or nurse will tell you the correct reading for you.
38
15
•
Vivid dreams. These are commonly experienced during the early days.
•
Thumping sensations. Many patients experience a thumping noise in their ears or at
the back of the head when lying flat or on their left side. If this occurs, change your
position. It will settle after a few weeks.
•
•
•
•
Fast Heart Rate. You may feel your heart beating fast, irregularly or missing a beat,
especially at night. This is very common after heart surgery and is a reaction to the
heart being handled during surgery. You should inform a member of staff. You may
be attached to a monitor for a short time and will need to carry a portable transmitter
with you. A fast heart rate is easily treated with medication (see page 19).
Discomfort. It is quite common after major chest surgery to have aches and pains in
your back, neck, shoulders and in the front of your chest. This discomfort is due to
stiffness in the muscles and ligaments that have been stretched during the operation.
Do not confuse this with angina, which you may have had before the operation. The
degree of pain is extremely variable and is often worse in the morning after waking,
late at night and when moving arms and shoulders. It will improve with time, but may
take up to three months or even longer. It is important that you take adequate pain
relief.
'Clicking' of breastbone. It is not unusual to feel the edges of the breastbone 'grate'
together for the first few weeks. However, frequent 'grating' or 'clicking' when moving,
coughing or sneezing should be reported to a member of staff on the ward or your GP.
Lump or swelling at the top of the chest wound. This should gradually disappear
over several weeks.
You can do this in three ways:
•
by eating and drinking fewer calories
•
using more calories by becoming more active
•
a combination of both the above.
Most people find that doing both achieves the best results.
In order to determine if someone is a healthy weight it is important to consider both the Body
Mass Index (BMI) i.e. height in relation to weight and waist circumference. Ask the nurses on the
ward or the cardiac rehabilitation team in hospital to measure these to see how much weight you
need to lose. Please see page 47 for further information.
Alcohol
Many people enjoy a drink and alcohol in moderation is fine. It is thought that a small amount of
alcohol may actually protect the heart from coronary heart disease. However an increased intake
of alcohol may result in high blood pressure. All alcoholic drinks contain calories but little else of
nutritional value. If you are trying to lose weight you should reduce your intake of alcohol to below
recommended levels or less. It is also recommended you have two alcohol free days in the week.
Current advice:
Men:
3 - 4 units per day, 21 units in total for the week
Women: 2 - 3 units per day, 14 units in total for the week
These guidelines apply whether you drink everyday, once or twice a week or occasionally.
•
Ache or stabbing pain inside the chest. This is common when the internal mammary
artery is used especially when moving (see page 6). It tends to occur in the same place
each time. You may be aware of an area of numbness, tingling or discomfort on the
outside of your chest, which can be temporary or remain permanent for some people.
Leg incision - there are three main after effects:
•
Pain. It is common to experience pain along the wound site, particularly if the wound
crosses the knee joint or extends to the groin area. Gentle movement of the leg will
help to ease this pain.
•
Numbness. It is common to experience unusual sensations (pins and needles and
numbness) along the leg wound. At the lower end of the wound there may be a small
area which feels numb. This is because a small nerve, which runs to this area of the
foot and ankle, lies very near the veins and it often stops working after being disturbed.
These sensations are likely to improve after a few months.
•
Swelling. It is normal for swelling to occur in the ankle and leg from which the vein
was removed. It is often present for about three months, until the other veins have
taken over the job of the missing vein. Wearing compression (also called anti-embolitic
or thrombo-embolus deterrent -TED) stockings can help to prevent fluid from
accumulating in the tissues and reduce the risk of you developing a blood clot
immediately after your surgery.
16
It is not accurate to say one glass of wine is one unit. How many units a drink contains depends
on the strength of the drink (%ABV) and the volume of liquid. In order to work it out you multiply
the volume of drink by %ABV, and then divide by 1000.
e.g. 175ml glass of 14% wine = 175 x 14 ÷ 1000 = 2.45 (2.5 units)
A small glass of wine
1.5 units
A large glass of wine
3.5 units
1bottle of alcopop
1.7 units
Double measure of spirits
3 units
A pint of strong lager
5 units
A pint of strong cider
4.5 units
My alcohol consumption in one week is:…………………………………………..
37
Studies show that benefits of using NRT to quit smoking outweigh any risks there may be with
NRT. There are six different products available including: patches, inhalator, gum, lozenge, micro
tab and nasal spray and also two medication products which can be prescribed by your doctor or
smoking cessation clinic.
The nicotine replacement therapy I have chosen is……………………………………………….
…………………………………………………………………………………………………….........
If you require further help or advice on NRT whilst you are in hospital we can refer you to the
smoking cessation nurses (0161 291 5030) who can offer you support in stopping smoking.
You can also obtain help from:
•
National NHS Quit line 0800 169 0169
•
Manchester Stop Smoking Service 0161 205 5998
www.stopsmokingmanchester.co.uk - www.gosmokefree.co.uk
•
Practice nurse at your GP practice.
The nursing staff on the ward will advise, as appropriate, on:
•
•
the need to wear compression stockings (for you as an individual)
•
•
the need to change and wash them regularly
•
how to ensure they are pulled up correctly as areas where the stockings ‘bunch
up’ will put pressure on your legs and may cause an indentation (sunken ridge)
where they put pressure on the soft tissues.
Your local cardiac rehabilitation team will advise you regarding
appropriate exercise. Physical activity and the heart are
discussed on page 26.
•
Lack of concentration and memory lapses. Many people find it difficult to
concentrate when reading and often find they cannot remember simple things,
for example their own telephone number. This should improve over the first few
weeks, but you may continue to be affected for 6 -12 months, when you are tired
or under stress.
•
Change in mood or emotion. Immediately following a major operation it is
perfectly normal to have days when you feel down, depressed, more emotional
than usual and even tearful. On other days you may feel on top of the world. It is
possible for these feelings to recur now and again over the next 12 months. They
will go with time, as you become stronger and more confident.
•
Anxiety. This is quite common following major surgery. This may result in
feelings of irritability, tension, poor sleep, lack of energy and anxieties about
minor aches and pains. There is also fear and frustration that you might not be
making sufficient progress and a tendency to compare yourself with someone
else. Try to avoid making comparisons as everyone is different and recovers at a
different pace. It is important to think positively and remember that the aim of the
operation is to improve your quality of life.
•
Your family may also have worries about your discharge from hospital. We would
encourage you to talk about the written and verbal information you have been
given. Try and explain how you feel to help your family understand. It is also
important for the person looking after you to have a break during the day.
Poor diet
Eating should be a pleasure. A healthy diet does not mean eating things you do not like. There is
no such thing as bad or good foods. The key to a healthy diet is to have a balanced diet so you
get all the nutrients you need.
Dietary advice is discussed in detail on pages 43 - 47
Being overweight
Being overweight can make you more at risk of developing
conditions such as high blood pressure, diabetes, osteoarthritis
and coronary heart disease. Losing weight has many health
benefits as well as making you feel more energetic and
increasing your confidence. To lose weight you need to use
up more energy (calories or joules) than your body takes in
from food and drink.
36
the length of time your consultant has asked for you to continue wearing them
post surgery
Psychological effects for you and your family
Lack of physical activity
Before coming into hospital for surgery you may have been
limited as to the amount of activity you could do. Following
your operation you should now find that you are able to do a
great deal more. It is important to take some form of exercise
as a non-active lifestyle can be considered another risk factor.
It has been shown that inactive people have twice the risk of
developing coronary heart disease compared with active
people.
the need to take them off every day to wash your legs and check the condition of
your skin
Wound care, healing and bathing
Your wound dressings will normally be removed 48 hours after your operation; if your
wounds are clean and dry they will be left uncovered. If they are oozing, another dressing
will be applied.
Most of the wounds are sewn together using dissolvable stitches which cannot be seen
when the dressing is removed. Occasionally stronger stitches are used in addition to the
dissolving sutures. These are usually removed 10 days after surgery, either in hospital or at
home by the district nurse. Very occasionally, a piece of ‘stitch’ remains beneath the skin
and looks as though it has come out of the wound. If it becomes troublesome, arrange to
see your GP.
17
The skin layers will begin to heal very quickly and top layers are usually healed sufficiently within
48 hours. They will continue to heal across the full depth of the wound for at least a further six
weeks or more. As the wound heals, the scar shrinks to a thin white line. Occasionally it can
remain red for a long time.
It is vitally important that you look after your surgical wounds once you get home. You should
report immediately, to your nurse or GP, if you notice any of the following symptoms:
•
•
•
•
•
increased pain – as the wounds heal the pain should decrease steadily
discharge (leakage)
increased redness/tenderness – the skin around the wound edges should be healthy
in appearance
swelling
itching.
At first we will help you to wash yourself but you will be encouraged to become independent as
soon as possible. It is important to keep your wounds clean. A warm daily bath or shower will
keep your wounds clean and encourage healing. Avoid strong perfumed soaps as they can
cause irritation. Do not use flannels on wounds as they can harbour bacteria and can actually
infect wounds. Use either your hand or a disposable cloth to wash the wound. If you need to
touch your wounds make sure you wash your hands first and then afterwards to avoid
contamination with unseen germs.
Going home
You will be able to go home when the doctor thinks you are medically fit.
When you go home, a relative or friend should collect you from the ward. The nursing staff can
give you a sickness certificate covering your stay in hospital.
In most modern day cars, front airbags are standard. In the event of an accident, activation of an
airbag could cause considerable harm to your chest. It is therefore not advisable to sit in the
front passenger seat for the first six weeks.
Medication
A pharmacist or pharmacy technician will sort through any medication you bring into hospital.
When you leave hospital you will be given at least one week’s supply of medication to take
home. Your nurse or pharmacist will explain how and why to take your tablets before you are
discharged. You will be given a copy of the discharge prescription for your own records. Your
GP will prescribe your medication from there on. Continue to take your prescribed medication
until you are told not to, either at the out-patient clinic, or by your GP. If you have supplies of
your medication at home and are unsure whether you are still to take them, ask your GP or local
pharmacist (chemist).
Following surgery, you will find that your medication will be altered. Angina medication such as
Isosorbide Mononitrate, and Nicorandil (Ikorel) will be stopped. However, medicines for other
medical conditions you have will normally be restarted following your operation. The doses of
these medicines might have changed so please check carefully.
18
Section D – Maintaining a healthy heart
Risk factors associated with the development of coronary
heart disease
In Britain today we continue to have one of the highest rates of heart disease known in the
western world. Although no single reason has been shown to cause coronary heart disease,
research has shown that certain factors in a person’s lifestyle can increase the risk of getting
coronary heart disease. These factors contribute to narrowing of the arteries surrounding the
heart, which leads to coronary heart disease.
These factors are called risk factors and generally fall into two categories; modifiable and
non-modifiable. Modifiable means you can do something about them. Non-modifiable means you
cannot change them. Many non-modifiable risk factors can be controlled and their effect reduced
by making changes to your lifestyle.
It is important to remember that some people may have many risk factors and others may have
none.
Modifiable risk factors
Smoking
Major studies show that smoking is the most significant preventable risk
factor. People who smoke tobacco have twice the risk of developing
coronary heart disease as those who do not. People who do not smoke
but have to inhale the smoke from others (passive smoking) are also at
risk of heart disease.
Smoking affects the heart in many ways: There are more than 4000
chemicals contained in tobacco smoke, many of which are harmful
when inhaled by smokers and those around them. Smoking just three
cigarettes a day doubles the risk of having a heart attack. Other main
components include;
Carbon monoxide. This is a poisonous, invisible gas with no smell. It is found in car exhausts,
leaking gas heaters and burning cigarettes. It is carried around the body in the blood. To try and
get more oxygen in, the heart beats faster and more red blood cells are produced. The heart has
to work harder which increases the risk of heart attack or heart failure.
Nicotine. This is the drug that causes addiction. It is very powerful and fast acting, hitting the brain
in seven seconds after each drag. Nicotine appears to have minimal long term effects on health. In
the short term it causes stimulation of the nervous system and an increase in blood pressure and
heart rate. These return to normal after about 20 minutes (Manchester Stop Smoking Service 2007).
Even if you have tried to give up before, it is worth another try. Stopping smoking dramatically
reduces your risk of a heart attack and stroke. Did you know that former smokers live longer than
continuing smokers, no matter what age they stop smoking, so whatever age you are, it is never
too late to stop. Your chances of a heart attack or stroke reduce with every day you continue not to
smoke.
Nicotine Replacement Therapy (NRT) helps by providing the body with nicotine. The purpose of
NRT is to take the edge off withdrawal symptoms. The nicotine provided from NRT is clean i.e. it
does not contain the other 3999 chemicals found in cigarette smoke. Consequently it can now be
used by smokers with cardiovascular disease. Stopping smoking is critical for those with heart
disease as it can slow the progression of the disease down.
35
Generally you may return to:
Pain killers
Light occupations
from 8 weeks after your operation
e.g. Paracetamol, Dihydrocodeine, Codeine, Tramadol
Management type work
(if stressful, you should
look into ways to modify it)
10 weeks after your operation
Manual work
(including lifting weights
- you should build up to this
kind of work gradually)
3 - 4 months after your operation
Take your painkillers regularly as prescribed by your doctor, for as long as you have pain.
This will help you to breathe deeply, cough, sleep, move around more comfortably and
exercise. Dihydrocodeine (and Codeine) commonly cause constipation. You can take
regular laxatives to prevent and treat this.
Aspirin
Aspirin will normally be restarted following surgery, although your dose may have changed.
If you cannot take aspirin you will be prescribed Clopidogrel (Plavix). These medicines
reduce the ‘stickiness’ of your blood and reduce the risk of clots forming in the new grafts.
Holidays and air travel
A restful holiday in this country may be taken after the first couple of weeks at home, as long as
you are well and able to cope with the travelling. During a long journey, you should have frequent
breaks and get out of the car to stretch your legs.
After heart surgery there are usually no restrictions placed on air travel. If it is vital that you fly
before your clinic appointment (usually about 6 - 8 weeks after your operation), discuss this with
your doctor prior to discharge. Otherwise delay a holiday abroad until you are feeling stronger and
more able to cope with a change in climate. During a long flight you should walk up and down the
aisle of the aircraft every half hour or so. Avoid lifting and carrying very heavy luggage for long
distances. Make use of the baggage trolleys wherever possible.
Make sure that you have adequate health insurance. Check your policy carefully. If you go
somewhere very hot protect your scar with a sun block. In hot weather you will tire more easily so
reduce the intensity of your daily exercise.
For more information please contact the British Heart Foundation or visit www.bhf.org.uk
Sexual intercourse
Sexual activity may be resumed after about four weeks, but be guided by how you are coping
with other physical activities. It is normal to feel anxious about resuming your sex life so start
when you feel ready and ensure you and your partner talk about your feelings. Cuddling,
touching and caressing are good ways to build up self-confidence and may help you both to
resume your normal relationship.
It may be helpful to keep the room and bed at a relaxing temperature. Choose a position which
is comfortable and does not place a strain on your chest. It is sensible to wait a few hours
following a meal or after drinking alcohol. Ask your partner to play a more active role.
Emotional stress and some of the tablets that people take for their heart condition can cause
problems for a very small number of people. Men may experience problems with their erections;
women may lose their desire to make love. Talk to your doctor or nurse about it; don’t be shy.
A simple change of medication may be all you need.
34
Lipid lowering medication
e.g. Simvastatin (Zocor), Pravastatin (Lipostat), Atorvastatin (Lipitor)
These medicines will normally be restarted following surgery. They help reduce the
likelihood of your grafts becoming narrowed or blocked, due to fatty deposits. Occasionally,
the dose may be increased in order to achieve a lower cholesterol level. We recommend
that you take them in the evening as this is when your body produces the most cholesterol
and the level in your body is the highest.
Blood pressure lowering medication
e.g. Bendrofluazide, Bisoprolol, Ramipril, Doxazosin, Amlodipine
These medicines may or may not be restarted in hospital after your operation. This will
depend on your blood pressure. If they are restarted then this is frequently at a lower dose
than before your heart surgery. Once you return home, your GP or practice nurse should
check your blood pressure regularly. It may then be necessary for the GP to gradually
increase the dose again.
Angiotensin-converting enzyme (ACE) inhibitors
e.g. Ramipril, Lisinopril, Perindopril
ACE inhibitors work in a complex way by stopping certain enzymes working within the body.
They are used to help the heart pump blood around the body, if you suffer from heart failure
and are also used to treat high blood pressure.
After surgery, using an ACE inhibitor can prevent your heart from weakening further and
has been shown to reduce the risk of you suffering a heart attack, whether or not you suffer
from high blood pressure.
After starting on an ACE inhibitor some patients complain of a dry tickling cough. This is a
possible side effect of the drug. We advise patients that they should continue taking the
tablets. However if the cough becomes troublesome your doctor may reduce the dose or
stop the tablets and prescribe a suitable alternative.
19
Medication to control heart rhythm
•
•
e.g. Bisoprolol, Amiodarone, Digoxin
It is possible that you may be started on a medicine to correct an irregular/fast heart beat, which
sometimes occurs after this type of surgery (see page 16).
if you are feeling tired
if you are unwell with a virus, cold or stomach bug. Wait until at least two days after the
symptoms have disappeared.
If you or your relatives have worries about you starting or progressing physical exercise, please
contact the cardiac rehabilitation physiotherapists on 0161 291 2177 or
[email protected]
Medication to reduce amount of acid in the stomach
Driving
e.g. Lansoprazole, Omeprazole, Ranitidine
These are commonly started after surgery to protect your stomach. If you were not on this type of
medication before your operation, it is normally stopped shortly after discharge.
Medication to remove extra fluid from your body (water tablets)
e.g. Furosemide, Bumetanide, Co-Amilofruse (Frumil)
After surgery you may be started on a water tablet if you have any extra fluid in your body. This
may only be for a short while and the tablets will be stopped before you go home. Sometimes the
doctors will send you home on these drugs if they think that the fluid will return if you stop taking
them or if you are still retaining excess fluid. Water tablets should be taken in the morning. If you
have to take them more than once a day, you should take the second dose before tea-time or you
may find that you are waking up in the middle of the night to go to the toilet.
Anticoagulants
This information applies to all patients who have a mechanical valve and in a few circumstances
to some patients with a tissue valve or who have had coronary artery bypass grafts.
The most common anti-coagulant treatment is called warfarin. Warfarin slows the clotting of the
blood and so prevents clots forming on the new valve. The clotting or ‘thinness’ of your blood is
measured by a blood test. This is called the International Normalised Ratio (INR). The higher the
INR the ‘thinner’ the blood. The doctors will decide what the Target INR should be, for each
patient, receiving warfarin. The dose of warfarin may change from day to day, but this is quite
normal. You will only be allowed to go home when your blood is ‘thin enough’ and the desired INR
has been achieved.
The hospital normally supplies 1mg (brown) warfarin tablets. The doctors will prescribe your daily
dose of warfarin in milligrams (mg). For example, 4mg of warfarin is four brown warfarin tablets.
This should be written in your yellow anticoagulant book. There is some important information in
the front of the anticoagulant book that you must read. We recommend you carry your
anticoagulant book with you. You must inform doctors, dentists, and pharmacists about your
anticoagulant treatment.
It is best to take your warfarin at the same time each day, at tea-time. If you forget to take your
warfarin at the usual time, but remember later the same day, you can take your dose.
However, if you remember the following day, do not take the dose you have missed, but do take
the dose for that day as prescribed. Please make a note of any missed doses in your
anticoagulant book.
20
Although the Driver and Vehicle Licencing Agency (DVLA) say you may start driving at one month
after your operation, we prefer you to wait at least six weeks. It is essential that you do not drive
until the healing process is sufficiently advanced to allow you to cope with sudden movements. As
the recovery process varies from person to person, it is advisable to check with your doctor first.
It is advisable to inform your car insurance company of the operation you have had or you may
invalidate your insurance. If you decide you would like to change your insurance company, the
British Heart Foundation provide a list of current companies who do not raise their premiums for
people after heart surgery. If your insurance company insists on a fitness to drive certificate your
GP should issue this. You do not need to inform the DVLA of your operation unless you have
recurrent angina, attacks of dizziness, palpitations or are diagnosed with diabetes.
You are not exempt from wearing a seat belt. Try placing a small flat cushion between the belt
and your chest for protection. If necessary, you can purchase a plastic product from shops which
relieves the tension from the seat belt. It eases any discomfort caused by the seat belt rubbing
across your chest and shoulders but it allows the seat belt to work normally in an emergency. You
should avoid driving in heavy traffic at first, as this can be very stressful. Increase driving
gradually in the same way as physical exercise starting with a short, quiet drive with a friend or
partner to help you regain your confidence.
Large goods and public carrying vehicle licences
If your job requires that you hold a large goods vehicle (LGV) or passenger carrying vehicle
(PCV) licence, you must inform the DVLA of your medical condition. You can also visit
www.direct.gov.uk or contact the DVLA on their direct line for HGV/PCV enquiries on
0870 241 1879 to speak to staff with additional training regarding Group 2 guidelines. Under the
medical conditions and disabilities section you should download, fill in and return questionnaire
VOCH1 to tell the DVLA about your medical condition. Re-licensing will be considered after a
successful exercise test result and a satisfactory report from your cardiologist.
Returning to work
Most patients who want to return to work will be able to return to their previous occupations.
Where possible, you should leave the decision of when and whether to return to work until you
feel able to cope with considering all the options open to you. When you return, will depend on
the type of work you do and the amount of physical or emotional stress involved. Discuss your
individual circumstances with your consultant or GP and your employers.
Attending your local cardiac rehabilitation programme can help you in your return to work by
discussing your progress week by week and reviewing your exercise programme. Ideally you
should begin working on a part-time basis and gradually increase the hours worked. Your
employer may be willing to give you lighter duties when you first go back. If a change of
employment is suggested, the Disability Employment Adviser (DEA) at the Job Centre is available
to help you find a suitable new occupation.
33
Active hobbies and sports
In most cases you may return to activities you previously enjoyed. If you were not physically
active before your illness you may now decide to take up a new enjoyable activity. When
undertaking any activity always start gently and gradually build up. If one particular activity
causes discomfort, it should be discontinued and replaced with another.
It is important to remember that each person’s progress with an activity will be different. It may
depend upon whether it is a new activity or sport for you, your rate of recovery after your
operation and your previous level of fitness.
At six weeks after your operation it is recommended that you attend a cardiac rehabilitation
programme in your local area (see page 23) to improve your fitness. You will obtain guidance
regarding the sports and activities you may do and at what stage they may be undertaken.
•
Cycling - start with short periods on the flat, preferably not in heavy traffic. Increase the
distance, speed and include hills when you feel able, in the same way as with your
walking programme.
•
Static cycling - may be started slightly earlier but do not put too much weight through
your arms as your breastbone will still be healing.
•
Bowling - you can start playing using light wood bowls. Practice gently swinging your
arm before you play. Gradually increase to playing with your usual weight of wood and
to a full game.
•
Dancing - this is an excellent exercise and also a very sociable one. You may return to
ballroom dancing once you can hold your arms up for a period of time.
•
Golf - start by walking the course and putting the ball but wait 8 -12 weeks before
starting the full swing. It may be useful practicing on the driving range before attempting
a full game of golf. Ensure you do not carry your golf clubs. You should make use of a
trolley, preferably a powered one.
You will need to attend the anticoagulant clinic at your local hospital for regular blood tests. The
staff on the ward will give you details of your first appointment. Your anticoagulant clinic
appointments will be quite often to begin with. Once your dose is stabilised, your appointments
will become less frequent. It is useful if you take a list of your medicines (such as a copy of the
take home prescription) with you to the clinic, especially on your first visit.
Many medicines will interact with warfarin. They can increase its effect, making the blood even
thinner or work against it and lead to a thickening of the blood (both of these things can have
serious implications). For this reason, ALWAYS check first with a doctor or pharmacist before
deciding to take any medicines that are not part of your usual regimen, such as those you may
have purchased over the counter. Despite the cautions highlighted, warfarin is an extremely
valuable medicine for certain heart patients.
Medication list
You can list all your heart tablets below
Name of tablet
What is the dose?
How often
you take it?
At 12 weeks after your operation you may consider one of the activities below.
•
Swimming - if you are a keen swimmer and wish to return, make sure your wounds are
fully healed before you go for a swim. Start by swimming widths in the shallow end
before you progress to swimming lengths. If you have not previously been a regular
swimmer, the cardiac rehabilitation team may advise that at first it may be more
preferable to take up a different activity.
•
Tennis and badminton - avoid a high level of competition for up to six months.
•
Fishing, jogging, football - be guided by your cardiac rehabilitation team member.
Avoid sports which are highly competitive or of high intensity, which impose sudden severe loads
on the heart, such as squash, scuba driving, water skiing or weight lifting. If you want to start
contact sports, such as rugby, discuss this with your GP or cardiac rehabilitation team member
before beginning.
Avoid sports and activities in the following circumstances:
•
•
extremes of temperature
for two hours after eating a large meal
32
21
What are they for?
Your follow up
•
Household tasks and gardening
By General Practitioner
You will be given a discharge summary with details of your operation and discharge medication.
You should inform your GP practice when you arrive home and give them a copy of the discharge
summary. The information of your operation, recovery and the medication you are on will also be
faxed to your GP after discharge.
You should contact your GP if you feel unwell or if you have any worries about your recovery.
•
Surgical out-patient appointment
Everyone will progress at a different rate. It can depend upon your level of fitness and severity
of your illness before your surgery, the nature of your surgery and your age. During activities it
is important to take regular rest breaks, even when you do not feel tired.
Activities should be restricted for approximately six weeks after your operation to allow time for
the breastbone (sternum) to knit together and become stronger.
Up to six weeks after your operation avoid activities which require pulling, pushing or a sudden
burst of energy. Avoid carrying heavy shopping bags, pushing supermarket trolleys or lifting
babies/toddlers. Do not lift anything heavier than about 5lbs (2.3 kg) in weight.
About 6 - 8 weeks after you go home from hospital you will see your surgeon for a check up at
either the centre where you had your operation or at your local hospital. If you have not
received your appointment by six weeks, please contact your surgeon’s secretary.
Some people will see caring for the household and the family as mainly their responsibility. This
can lead to them starting heavier household tasks sooner than they should. It is important not to
feel guilty about leaving the housework for a while and letting others help.
Advice about financial matters
Remember the following information should only be used as a guide for returning to normal daily
activities.
Having heart surgery can lead to concerns about managing financial matters. There are agencies
who offer free, confidential and independent advice on benefits, rent or mortgage arrears and
possible rebates. Please inform the nursing staff as soon as possible if you would like to see the
Welfare Rights Adviser whilst you are on the ward.
Up to 2 weeks
Take things gently. Read, listen to music or watch television.
Make yourself a light snack.
Week 3
Begin light activities, i.e. dusting, set the table, prepare
simple meals, washing and drying dishes and tending indoor plants.
Week 4
Increase activities to include light hand washing, ironing small items,
changing the bed linen (do not pull the bed out).
Begin activities outside (seated), such as light cutting and weeding.
Begin light social activities i.e. visiting friends or going out for a meal
when you feel ready.
Week 5
Increase activities to include machine washing, cooking and ironing.
Week 6 - 7
Increase activities to include sweeping, vacuuming, mopping floors, food
shopping with trolley.
Weeks 8 - 10
Wash and polish car, cleaning windows with regular rest breaks.
Gardening may include digging, hoeing, raking leaves, mowing the lawn
(powered mower). If possible, use a hose, rather than a watering can.
Week 12
D.I.Y. – decorating, painting with regular rest breaks. Carpentry, moving
furniture, trimming a hedge.
Additionally there are people known as money advisers who offer advice on problems paying
debts and negotiating repayments. Your local Citizens Advice Bureau will have the number of
your local Welfare Rights Adviser and money advisers.
Limit the amount of sustained work that you do with your arms above shoulder height as this can
increase the workload of the heart.
In the long term, certain activities including lifting or pushing heavy weights require a degree of
caution. If you are keen to undertake these activities you can discuss this when you attend your
cardiac rehabilitation programme.
22
31
Home exercises
Section C – Your rehabilitation
The following exercises should be carried out if you are unable to go for your daily walk due to
bad weather:
What is cardiac rehabilitation
1. Standing
Hold on to a stable object.
Push up on your toes.
Hold for 10 seconds. Rest.
Repeat 10 times.
2. Step-ups
Stand 10 inches away from the
step. Step up with right leg for 15
seconds and then change to lead
with left leg for 15 seconds.
Cardiac rehabilitation is a specialist service, usually delivered by a team of healthcare
professionals in a hospital, community or home-based setting.
We will support you and your family in helping you return to the best possible health and
well-being following your operation.
When do I start cardiac rehabilitation?
Cardiac rehabilitation normally starts when you are in hospital. A cardiology liaison nurse will
visit you on the ward to provide you with cardiac rehabilitation and give you advice to prepare
you for home. As well as discussing the information in this booklet, you will have the opportunity
to discuss any individual concerns about getting back to your usual activities. You will be
informed of your nearest available programme and given their contact details. The UHSM
cardiology liaison nurse team may be contacted on 0161 291 2679.
3. Walk on the spot
Walk or march on the spot
at a comfortable pace for
30 seconds.
4. Sitting to standing
Sit on a dining room chair and
push up with one hand. Progress
to standing up with arms crossed.
Stand up and sit down 5 - 10 times.
Once you are discharged, your details will be sent to your local cardiac rehabilitation
programme. You should be contacted at home within one week of discharge. If you are not
contacted, please call your local programme to confirm that they have received your referral. In
some areas you may be contacted and/or visited by a member of staff soon after you arrive
home.
Depending on your individual case, you may start the exercise sessions, as part of the cardiac
rehabilitation programme from 6 weeks after your heart operation.
What are the aims of cardiac rehabilitation?
•
•
•
•
•
•
To give information on heart disease and its causes.
To improve your awareness and understanding of coronary heart disease.
To develop an individual plan to help you to make positive lifestyle changes.
To restore your confidence to be physically active and to exercise regularly and
independently to improve your physical fitness.
To discuss physical activity and exercise opportunities for you in the future.
To reduce the risks of further cardiac problems and improve your quality of life.
What do cardiac rehabilitation programmes provide?
Try to begin with the time or number of repetitions suggested above.
When you are able to cope comfortably with the above exercises, you may slowly progress by
increasing the time or number of repetitions, for instance 30 seconds to 40 seconds, 10
repetitions to 12 repetitions and so on. Refer to the scale on page 28 and do not allow yourself
to become uncomfortably breathless.
These programmes are available all over the country. If you have access to the Internet, you can
locate your nearest programme on the website www.cardiac-rehabilitation.net The actual
content varies depending upon local resources and the staffing levels available . Your spouse or
partner is usually encouraged to attend with you.
The main areas of provision included in any cardiac rehabilitation programme are:
•
30
Initial assessment of your individual patient needs
- to discuss any concerns
- to tell you about the various options within the local programme
- to refer you for appropriate interventions
23
•
Exercise classes
- usually in a group setting, usually lasting between 6 to12 weeks.
- exercises are adapted to you and you are encouraged to increase activity
gradually under supervision.
•
Risk factor management (see page 35) and lifestyle behaviour change.
•
Education topics often included:
- benefits and effects of physical activity and exercise
- healthy eating
- medication
- risk factors of Coronary Heart Disease (CHD)
- relaxation
- emotions and feelings about CHD
- recommendations for long-term physical activity and healthy lifestyle
- cardiopulmonary resuscitation (basic life support).
You should always be able to walk and talk at the same time. Feeling slightly short of breath
whilst exercising is normal, but you should not feel exhausted.
If you do too much one day, rest the following day and then continue at a reduced level the
next day until you feel happy to increase it. Listen to your body and on days when you feel
less energetic, reduce the amount you do or walk at a slower speed. Be careful if walking a
dog on a lead as the dog may pull too much or want to walk at a faster pace.
Below is intended as a guide to the amount of walking you may undertake:
Stage of recovery
(approximate)
Length of walk (in minutes)
Gradually increase the time you spend walking as
you feel ready
Week 1
5 minutes, several times a day as a stroll
Week 2
10 minutes, twice a day, leisurely pace
Other possible services are:
- stress awareness, stress management, and other psychological support
- smoking cessation
- diet and weight management.
Week 3
15 minutes daily, leisurely pace
Week 4
20 minutes daily, moderate pace
Weeks 5 - 6
25 - 30 minutes daily, moderate/brisk pace
For further information about cardiac rehabilitation, please contact the Wythenshawe Hospital
Cardiac Rehabilitation Service on 0161 291 2177 or email us at [email protected]
Alternatively you can visit the web page
http//www.uhsm.nhs.uk/patients/cardiacrehab/pages/defalt.aspx
Target
At least 30 - 40 minutes daily, brisk pace
•
First few days at home
For the first few days at home, you should rest, following the same routine as in hospital. You
may walk around the house and up and down stairs as necessary.
During this time it is quite common for you to only want to see close friends and family. As
receiving visitors can be very tiring, ask them to stay for a short period only so you can enjoy
their company without getting over-tired. It is advisable to have no more than two visitors a day
for the first two weeks.
For the first few days it is advisable to have someone with you at all times if possible. You may
get out and about and be driven to places as soon as you feel able.
Sleep and rest
It is normal to feel tired in the first few weeks after leaving hospital. During this time it is
important that you get adequate sleep and rest, as there is still a lot of healing taking place.
Take a rest as necessary. It is sensible to rest for at least ten minutes after a meal or after
having a shower.
It can take a few weeks to settle back into your normal sleep pattern. You can help yourself by
going to bed at your usual time and making yourself as comfortable as possible. Use as many
pillows as you need and sleep in your normal position. Avoid lying on your stomach for the first
six weeks due to the healing of the breastbone. If you wake in the night, try getting up and
moving around before settling back down again.
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It is better to go for your walk in the day time, preferably the morning. Do not leave it until the
evening when you are likely to be tired. Do not go for a walk sooner than one hour following
a meal. In cold or windy weather, wear a hat, scarf and gloves, as the heart has to work
much harder in these conditions.
Gradually progress by:
•
increasing the distance or time of your walk (as above). If you find a week difficult,
repeat the week (rather than increasing) until you are able to progress comfortably.
•
increasing the speed of your walk – start by strolling at a leisurely pace, then walk
at a moderate pace and aim to walk at a brisker pace by six weeks.
•
going up and down slopes or hills in your walk. If possible walk uphill on the way
out and downhill on the way home. If you live in a hilly area, it is best if you are
taken by car to a flat park with level ground, for the first few weeks.
It is very important to gradually build up the pace during the first few minutes of the walk,
(warming up), to ensure your body and particularly your heart has a chance to adapt to the
increase in physical activity. Likewise, it is important to gradually slow down your pace during
the last part of your walk rather than suddenly stopping when you reach home.
You should aim to go walking at least five times a week, gradually building up to a brisk pace
for at least 30 minutes. If you find it difficult to fit in a 30 minute continuous walk, then try
doing three walks of 10 minutes during the day.
If you have not been used to walking regularly before your operation or suffer from other
restricting conditions, the above programme may be too strenuous for you. Your cardiac
rehabilitation physiotherapist will discuss your specific needs. If you are used to regular
waling or other types of exercise you may find you progress more quickly than suggested.
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Perceived exertion scale
Relaxation
When carrying out physical activity, the scale below can be used to help ensure you are working
at the correct level of intensity of effort. The perception depends mainly on the strain and fatigue in
your muscles and on your feeling of breathlessness or aches in the chest. This scale will be
explained in more detail when you attend your cardiac rehabilitation programme.
It is important that you spend time relaxing after your operation. Relaxation benefits the heart as
it can help to lower your blood pressure, heart rate and possibly your cholesterol. Relaxation can
be learnt by anyone and with practice you should be able to relax almost anywhere.
Five minute relaxation
The correct guidelines are given below:
•
Find a quiet room and make sure you are warm.
•
Wear loose clothing and remove any spectacles.
•
You may relax either lying down or sitting in a chair.
•
If you are sitting make sure your head, thighs and back are well supported (use a
cushion in the small of the back if it helps).
No.
Intensity of effort experienced
Perception of how strenuous the activity feels to you
0
Nothing at all
No exertion at all
0.5
Extremely weak
Just noticeable
1
Very weak
No problem
2
Weak
Light/very easy to continue
3
Moderate
Comfortable to continue
•
Place your hands on your lap.
Beginning to feel puffed
•
Close your eyes. If you are uncomfortable with your eyes closed, keep your eyes
focused on one point ahead of you throughout the session.
4
5
Strong
6
Heavy/feeling a bit puffed
Feeling puffed
7
Very strong
Tiring/You have to push yourself to continue
Spend a short time each day practising the following technique. If possible ask someone
to read out the below instructions.
Begin by breathing out:
8
Very tiring
9
Out of breath/shattered
Then breathe in steadily, just as much as you need.
Maximum - think of the hardest thing you have ever done
and you could only sustain for 1 - 2 minutes
Now breathe out slowly, with a slight sigh, like a balloon slowly deflating.
10
Extremely strong
When you first leave hospital, only carry out activities which are very easy (i.e. up to 2 on the
above scale) for you to continue. Once you start the exercises in the cardiac rehabilitation
programme the intensity will be increased gradually to a more moderate level (i.e. 3 - 4) as appropriate for you as an individual. It is not advisable ever to push yourself to continue activity
where you feel very tired and out of breath (i.e. 7 -10 ).
Never continue to carry on with physical activity if you have any of the following symptoms:
•
•
•
•
•
•
•
chest discomfort or pain
dizziness
nausea
excessive shortness of breath
palpitations
muscle cramps
extreme or unusual fatigue.
Do this once more, slowly breathing in….breathe out sigh….as you breathe out feel the tension
begin to drain away. Then go back to your ordinary breathing, even, quiet, and steady.
Now direct your thoughts to each part of your body in turn, to the muscles and joints. Think first
about your left foot. Your toes are still. Your foot feels heavy on the floor. Let your foot and toes
start to feel completely relaxed.
Now think about your right foot….toes….ankle….they are resting heavily on the floor. Let both
your feet, your toes and ankle start to relax.
Now think about your legs. Let your legs feel completely relaxed and heavy on the chair or floor.
Your thighs and your knees roll outwards when they relax, so let them go.
Think now about your back. Let your back relax into the chair and let the tension drain away from
your back. Follow your breathing, and each time you breathe out, relax your back and spine a
little more.
Now to your abdominal muscles. Let them become soft and loose. There is no need to hold your
stomach in tight, it rises and falls as you breathe quietly. Feel that your stomach is completely
relaxed.
Walking
Regular walking is recommended as the main physical activity to regain or improve fitness during
the initial weeks before you start the exercise sessions in the cardiac rehabilitation programme. It
is also a good choice of exercise to help maintain your fitness in the future.
At first, try to walk with a relative or friend at a steady pace on the flat. This will help with your
confidence and is also more fun. You should feel warm and be breathing slightly heavier than
normal.
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Without tension in your chest, let your breathing be slow and easy, and each time you breathe
out, let go a little more.
Think now about the fingers of your left hand – are they curved, limp and quite still?
Now think about the fingers of your right hand – are they relaxed, soft and still?
Let this feeling of relaxation spread up your arms….feel the heaviness in your arms – up to your
shoulders. Let your shoulders relax, let them drop easily….and then let them drop even further
than you thought they could.
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Think about your neck. Feel the tension melt away from your neck and shoulders. Each time you
breathe out, relax your neck a little more.
Now before you move on, just check to see if all these parts of your body are still relaxed - your
feet, legs, back, tummy, hands, arms, neck and shoulders. Keep your breathing gentle and easy.
Every time you breathe out relax a little more and let all the tensions ease away from your body.
No tensions - just enjoy this feeling of relaxation.
Now think about your face. Let your whole face relax. Smooth out your brow and let your
forehead feel wide and relaxed. Let your eyebrows drop gently. There’s no tension round your
eyes - your eyes are still. Let your jaw relax with your teeth slightly apart.
The heart is a muscle, and like any other muscle, it needs physical activity to stay healthy.
Regular physical activity will improve the blood flow to the heart muscle and will help your heart
to become stronger and more efficient. The type of exercise that is most beneficial for your heart
is called aerobic or cardiovascular activity. This is any repetitive, rhythmic activity, involving the
large muscle groups in your body such as the legs, shoulders and arms. Examples of aerobic
activity include walking, cycling and dancing. This type of activity increases the body’s demand
for oxygen and adds to the workload of the heart and lungs. This makes the heart and circulation
more efficient, and helps to develop your stamina.
You should aim for 30 minutes a day of moderate activity, such as brisk walking. It is better to
take regular exercise, rather than isolated sessions. With any activity it is important to begin
slowly and to build up gradually.
Feel the relief of letting go of any tension.
Now think about your tongue and throat. Let your tongue drop down to the bottom of your mouth
and relax completely. Relax your tongue and throat and your lips…. lips lightly together, no
pressure between them.
Let all the muscles in your face relax so there is no tension in your face, just let it relax more and
more.
Now, instead of thinking about yourself in parts, feel the all over sensation of letting go, think of
quiet and of rest. Check to see if you are still relaxed. Clear your mind of thoughts by
concentrating on this relaxed sensation, as this time is for relaxing not thinking. Stay like this for
a few moments, and listen to your breathing….in….and out…. Let your body become looser
and heavier each time you breathe out.
Other activities are good for improving flexibility and mobility. Keeping your body supple and
flexible will help you keep a full range of movement and stay independent as you get older.
Examples are gardening and yoga.
Strengthen your muscles and bones with strength-type activities. These will help give you good
balance, good posture and bone strength. Examples are climbing the stairs and digging the
garden.
Normal response to exercise:
•
faster and stronger heart beat (pulse rate)
•
slight breathlessness
•
slight sweating
Now continue for a little longer, and enjoy this time for relaxation.
•
slight muscle ache approximately 36 hours after exercising
Coming back - slowly, wiggle your hands a little, and your feet. When you are ready, open your
eyes and sit quietly for a while, stretch, if you want to, or yawn, and slowly start to move again.
•
start to get warm and flushed.
If you have any questions about the above, or would like details of where to obtain relaxation
CDs, please contact the cardiac rehabilitation team on 0161 291 2177.
Physical activity
The convenience of modern life is making us increasingly inactive and this is proving hazardous
to our health. Inactive people have twice the risk of developing coronary heart disease compared
with active people. Inactivity increases the risk of coronary heart disease as much as smoking
does.
Physical activity:
•
halves the risk of developing coronary heart disease
•
reduces the risk of having a stroke
•
lowers blood pressure
•
reduces the chance of developing diabetes and helps control diabetes
•
helps you to lose weight
•
relieves stress
•
makes you feel more energetic
•
improves your blood cholesterol levels.
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