Heart Attack and Unstable Angina

Cause

A heart attack or unstable angina is caused by sudden narrowing or blockage of a coronary artery. This blockage keeps blood and oxygen from getting to the heart.

This blockage happens because of a problem called atherosclerosis, or hardening of the arteries. This is a process where fatty deposits called plaque build up inside arteries. Arteries are the blood vessels that carry oxygen-rich blood throughout your body. When atherosclerosis happens in the coronary arteries, it leads to heart disease.

If the plaque breaks apart, it can cause a heart attack or unstable angina. A tear or rupture in the plaque tells the body to repair the injured artery lining, much as the body might heal a cut on the skin. A blood clot forms to seal the area. The blood clot can completely block blood flow to the heart muscle.

With a heart attack, lack of blood flow causes the heart's muscle cells to start to die. With unstable angina, the blood flow is not completely blocked by the blood clot. But the blood clot can quickly grow and block the artery.

A stent in a coronary artery can also become blocked and cause a heart attack. The stent might become narrow again if scar tissue grows after the stent is placed. And a blood clot could get stuck in the stent and block blood flow to the heart.

Heart attack triggers

In most cases, there are no clear reasons why heart attacks occur when they do. But sometimes your body releases adrenaline and other hormones into the bloodstream in response to intense emotions such as anger, fear, and the "fight or flight" impulse. Heavy physical exercise, emotional stress, lack of sleep, and overeating can also trigger this response. Adrenaline increases blood pressure and heart rate and can cause coronary arteries to constrict, which may cause an unstable plaque to rupture.

Rare causes

In rare cases, the coronary artery spasms and contracts, causing heart attack symptoms. If severe, the spasm can completely block blood flow and cause a heart attack. Most of the time in these cases, atherosclerosis is also involved, although sometimes the arteries are not narrowed. The spasms can be caused by smoking, cocaine use, cold weather, an electrolyte imbalance, and other things. But in many cases, it is not known what triggers the spasm.

Another rare cause of heart attack can be a sudden tear in the coronary artery, or spontaneous coronary artery dissection. In this case, the coronary artery tears without a known cause.

Symptoms

Heart attack

Symptoms of a heart attack include:

• Chest pain or pressure, or a strange feeling in the chest.
• Sweating.
• Shortness of breath.
• Nausea or vomiting.
• Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.
• Lightheadedness or sudden weakness.
• A fast or irregular heartbeat.

Call 911 or other emergency services immediately if you think you are having a heart attack.

Nitroglycerin. If you typically use nitroglycerin to relieve angina and if one dose of nitroglycerin has not relieved your symptoms within 5 minutes, call 911. Do not wait to call for help.

Unstable angina

Unstable angina symptoms are similar to a heart attack.

Call 911 or other emergency services immediately if you think you are having a heart attack or unstable angina.

People who have unstable angina often describe their symptoms as:

• Different from their typical pattern of stable angina. Their symptoms do not happen at a predictable time.
• Suddenly becoming more frequent, severe, or longer-lasting or being brought on by less exertion than before.
• Occurring at rest with no obvious exertion or stress. Some say these symptoms may wake you up.
• Not responding to rest or nitroglycerin.

Women's symptoms

For men and women, the most common symptom is chest pain or pressure. But women are somewhat more likely than men to have other symptoms like shortness of breath, nausea, and back or jaw pain.

Women are more likely than men to delay seeking help for a possible heart attack. Women delay for many reasons, like not being sure it is a heart attack or not wanting to bother others. But it is better to be safe than sorry. If you have symptoms of a possible heart attack, call for help. When you get to the hospital, don't be afraid to speak up for what you need. To get the tests and care that you need, be sure your doctors know that you think you might be having a heart attack.

Other ways to describe chest pain

People who are having a heart attack often describe their chest pain in various ways. The pain:

• May feel like pressure, heaviness, weight, tightness, squeezing, discomfort, burning, a sharp ache (less common), or a dull ache. People often put a fist to the chest when describing the pain.
• May radiate from the chest down the left shoulder and arm (the most common site) and also to other areas, including the left shoulder, middle of the back, upper portion of the abdomen, right arm, neck, and jaw.
• May be diffuse—the exact location of the pain is usually difficult to point out.
• Is not made worse by taking a deep breath or pressing on the chest.
• Usually begins at a low level, then gradually increases over several minutes to a peak. The discomfort may come and go. Chest pain that reaches its maximum intensity within seconds may represent another serious problem, such as an aortic dissection.

It is possible to have a "silent heart attack" without any symptoms, but this is rare.

What Increases Your Risk

Things that increase your risk of a heart attack are the things that lead to a problem called atherosclerosis, or hardening of the arteries. Atherosclerosis is the starting point for heart disease, peripheral arterial disease, heart attack, and stroke.

Your doctor can help you find out your risk of having a heart attack. Knowing your risk is just the beginning for you and your doctor. Knowing your risk can help you and your doctor talk about whether you need to lower your risk. Together, you can decide what treatment is best for you.

Things that increase your risk of a heart attack include:

• High cholesterol.
• High blood pressure.
• Diabetes.
• Smoking.
• A family history of early heart disease. Early heart disease means you have a male family member who was diagnosed before age 55 or a female family member who was diagnosed before age 65.

Your age, sex, and race can also raise your risk. For example, your risk increases as you get older.

Women and heart disease

Women have unique risk factors for heart disease, including hormone therapy and pregnancy-related problems. These things can raise a woman's risk for a heart attack or stroke.

NSAIDs

Most nonsteroidal anti-inflammatory drugs (NSAIDs), which are used to relieve pain and fever and reduce swelling and inflammation, may increase the risk of heart attack. This risk is greater if you take NSAIDs at higher doses or for long periods of time. People who are older than 65 or who have existing heart, stomach, or intestinal disease are more likely to have problems. Be safe with medicines. Read and follow all instructions on the label.

Aspirin, unlike other NSAIDs, can help certain people lower their risk of a heart attack or stroke. But taking aspirin isn't right for everyone, because it can cause serious bleeding. Talk to your doctor before you start taking aspirin every day.

Regular use of other NSAIDs, such as ibuprofen, may make aspirin less effective in preventing heart attack and stroke.

For information on how to prevent a heart attack, see the Prevention section of this topic.

When To Call

Do not wait if you think you are having a heart attack. Getting help fast can save your life. Even if you're not sure it's a heart attack, have it checked out.

Call 911 or other emergency services immediately if you have symptoms of a heart attack. These may include:

• Chest pain or pressure, or a strange feeling in the chest.
• Sweating.
• Shortness of breath.
• Nausea or vomiting.
• Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.
• Lightheadedness or sudden weakness.
• A fast or irregular heartbeat.

After you call 911, the operator may tell you to chew 1 adult-strength or 2 to 4 low-dose aspirin. Wait for an ambulance. Do not try to drive yourself.

Nitroglycerin. If you typically use nitroglycerin to relieve angina and if one dose of nitroglycerin has not relieved your symptoms within 5 minutes, call 911. Do not wait to call for help.

Symptoms can vary. The most common symptom is chest pain or pressure. But females are somewhat more likely than males to have other symptoms like shortness of breath, nausea, and back or jaw pain.

Why wait for an ambulance?

By calling 911 and taking an ambulance to the hospital, you may be able to start treatment before you get to the hospital. If any complications occur along the way, ambulance staff are trained to evaluate and treat them.

If an ambulance is not readily available, have someone else drive you to the emergency room. Do not drive yourself to the hospital.

CPR

If you see someone pass out, call 911 or other emergency services and start CPR (cardiopulmonary resuscitation). The emergency operator can coach you on how to perform CPR.

Exams and Tests

Emergency testing for a heart attack

After you call 911 for a heart attack, paramedics will quickly assess your heart rate, blood pressure, and breathing rate. They also will place electrodes on your chest for an electrocardiogram (EKG, ECG) to check your heart's electrical activity.

When you arrive at the hospital, the emergency room doctor will take your history and do a physical exam, and a more complete ECG will be done. A technician will draw blood to test for cardiac enzymes, which are released into the bloodstream when heart cells die.

If your tests show that you are at risk of having or are having a heart attack, your doctor will probably recommend that you have cardiac catheterization. The doctor can then see whether your coronary arteries are blocked and how your heart functions.

If an artery appears blocked, angioplasty—a procedure to open up clogged arteries—may be done during the catheterization. Or you will be referred to a cardiovascular surgeon for coronary artery bypass graft surgery.

If your tests do not clearly show a heart attack or unstable angina and you do not have other risk factors (such as a previous heart attack), you will probably have other tests. These may include a cardiac perfusion scan or imaging test.

Testing after a heart attack

From 2 to 3 days after a heart attack or after being admitted to the hospital for unstable angina, you may have more tests. (Even though you may have had some of these tests while you were in the emergency room, you may have some of them again.)

Doctors use these tests to see how well your heart is working and to find out whether undamaged areas of the heart are still receiving enough blood flow.

These tests may include:

Treatment Overview

Do not wait if you think you are having a heart attack. Getting help fast can save your life.

Emergency treatment gets blood flowing back to the heart. This treatment is similar for unstable angina and heart attack.

• For unstable angina, treatment prevents a heart attack.
• For a heart attack, treatment limits the damage to your heart.

Ambulance and emergency room

Treatment begins in the ambulance and emergency room. You may get oxygen if you need it. You may get morphine if you need pain relief.

The goal of your health care team will be to prevent permanent heart muscle damage by restoring blood flow to your heart as quickly as possible.

Treatment includes:

• Nitroglycerin. It opens up the arteries of the heart to help blood flow back to the heart.
• Beta-blockers . These drugs lower the heart rate, blood pressure, and the workload of the heart.

You also will receive medicines to stop blood clots. These are given to prevent blood clots from getting bigger so blood can flow to the heart. Some medicines will break up blood clots to increase blood flow. You might be given:

• Aspirin, which you chew as soon as possible after calling 911.
• Antiplatelet medicine.
• Anticoagulants.
• Glycoprotein IIb/IIIa inhibitors.
• Thrombolytics.

Angioplasty or surgery

Angioplasty . Doctors try to do angioplasty as soon as possible after a heart attack. Angioplasty might be done for unstable angina, especially if there is a high risk of a heart attack.

Angioplasty gets blood flowing to the heart. It opens a coronary artery that was narrowed or blocked during the heart attack.

But angioplasty is not available in all hospitals. Sometimes an ambulance will take a person to a hospital that provides angioplasty, even if that hospital is farther away. If a person is at a hospital that does not do angioplasty, he or she might be moved to another hospital where angioplasty is available.

If you are treated at a hospital that has proper equipment and staff, you may be taken to the cardiac catheterization lab. You will have cardiac catheterization, also called a coronary angiogram. Your doctor will check your coronary arteries to see if angioplasty is right for you.

Bypass surgery . If angioplasty is not right for you, emergency coronary artery bypass surgery may be done. For example, bypass surgery might be a better option because of the location of the blockage or because of numerous blockages.

Other treatment in the hospital

After a heart attack, you will stay in the hospital for at least a few days. Your doctors and nurses will watch you closely. They will check your heart rate and rhythm, blood pressure, and medicines to make sure you don't have serious complications.

Your doctors will start you on medicines that lower your risk of having another heart attack or having complications and that help you live longer after your heart attack. You may have already been taking some of these medicines. Examples include:

• Aldosterone receptor antagonists.
• Angiotensin-converting enzyme (ACE) inhibitors.
• Angiotensin II receptor blockers (ARBs).
• Aspirin.
• Antiplatelet medicines.
• Beta-blockers.
• Statins and other cholesterol medicines.

You will take these medicines for a long time, maybe the rest of your life.

After you go home from the hospital, take all of your medicines correctly. Do not stop taking your medicine unless your doctor tells you to. If you stop taking your medicine, you might raise your risk of having another heart attack.

Cardiac rehabilitation

Cardiac rehabilitation might be started in the hospital or soon after you go home. It's an important part of your recovery after a heart attack. Cardiac rehab teaches you how to be more active and make lifestyle changes that can lead to a stronger heart and better health. Cardiac rehab can help you feel better and reduce your risk of future heart problems.

If you don't do a cardiac rehab program, you will still need to learn about lifestyle changes that can lower your risk of another heart attack. These changes include quitting smoking, eating heart-healthy foods, and being active.

Quitting smoking is part of cardiac rehab. Medicines and counseling can help you quit for good. People who continue to smoke after a heart attack are much more likely than nonsmokers to have another heart attack. When a person quits, the risk of another heart attack decreases a lot in the first year after stopping smoking.

Go to your doctor visits

Your doctor will want to closely watch your health after a heart attack. Be sure to keep all your appointments. Tell your doctor about any changes in your condition, such as changes in chest pain, weight gain or loss, shortness of breath with or without exercise, and feelings of depression.

Prevention

You can help prevent a heart attack by taking steps that slow or prevent coronary artery disease—the main risk factor for a heart attack. A heart-healthy lifestyle is important for everyone, not just for people who have health problems. It can help you keep your body healthy and lower your risk of a heart attack.

Make lifestyle changes

• Quit smoking . It may be the best thing you can do to prevent heart disease. You can start lowering your risk right away by quitting smoking. Also, avoid secondhand smoke.
  • Interactive Tool: Are You Ready to Quit Smoking?
• Exercise. Being active is good for your heart and blood vessels, as well as the rest of your body. Being active helps lower your risk of health problems. And it helps you feel good. Try to exercise for at least 30 minutes on most, if not all, days of the week. Talk to your doctor before starting an exercise program.
  • Fitness: Getting and Staying Active
• Eat a heart-healthy diet. The way you eat can help you lower your risk. There are a few heart-healthy eating plans to choose from. Remember that some foods you may hear about are just at all.
  • Comparing Heart-Healthy Diets
• Reach and stay at a healthy weight. A healthy weight is a weight that lowers your risk for health problems including heart disease. Eating heart-healthy foods and being active can help you manage your weight and lower your risk.
  • Weight Management

Manage other health problems

Manage other health problems that raise your risk for a heart attack. These include diabetes, high blood pressure, and high cholesterol. A heart-healthy lifestyle can help you manage these problems. But you may also need to take medicine.

Manage stress and get help for depression

• Manage stress. Stress can hurt your heart. Keep stress low by talking about your problems and feelings, rather than keeping your feelings hidden. Try different ways to reduce stress, such as exercise, deep breathing, meditation, or yoga.
• Get help for depression . Getting treatment for depression can help you stay healthy.

Deciding whether to take aspirin

Talk to your doctor before you start taking aspirin every day. Aspirin can help certain people lower their risk of a heart attack or stroke. But taking aspirin isn't right for everyone, because it can cause serious bleeding.

You and your doctor can decide if aspirin is a good choice for you based on your risk of a heart attack and stroke and your risk of serious bleeding. If you have a low risk of a heart attack and stroke, the benefits of aspirin probably won't outweigh the risk of bleeding.

Learn about issues for women

Women have unique risk factors for heart disease, including hormone therapy and pregnancy-related problems. These things can raise a woman's risk for a heart attack or stroke.

Preventing Another Heart Attack

After you've had a heart attack, your biggest concern will probably be that you could have another one. You can help lower your risk of another heart attack by joining a cardiac rehabilitation (rehab) program and taking your medicines.

Do cardiac rehab

You might have started cardiac rehab in the hospital or soon after you got home. It's an important part of your recovery after a heart attack.

In cardiac rehab, you will get education and support that help you make new, healthy habits, such as eating right and getting more exercise.

Make heart-healthy habits

If you don't do a cardiac rehab program, you will still need to learn about lifestyle changes that can lower your risk of another heart attack. These changes include quitting smoking, eating heart-healthy foods, and being active.

For more information on lifestyle changes, see Life After a Heart Attack.

Take your medicines

After having a heart attack, take all of your medicines correctly. Do not stop taking your medicine unless your doctor tells you to. If you stop taking your medicine, you might raise your risk of having another heart attack.

You might take medicines to:

• Prevent blood clots. These medicines include aspirin and other blood thinners.
• Decrease the workload on your heart (beta-blocker).
• Lower cholesterol.
• Treat irregular heartbeats.
• Lower blood pressure.

For more information, see Medications.

One Man's Story: Alan, 73 "At some point in my life I was going to have a heart attack. Smoking just sped it up. It happened while I was playing basketball with some guys from work. I started getting pains in my chest. The next thing I knew, I was on the floor."— Alan Read more about Alan and how he learned to cope after a heart attack.

Life After a Heart Attack

Coming home after a heart attack may be unsettling. Your hospital stay may have seemed too short. You may be nervous about being home without doctors and nurses after being so closely watched in the hospital.

But you have had tests that tell your doctor that it is safe for you to return home. Now that you're home, you can take steps to live a healthy lifestyle to reduce the chance of having another heart attack.

Do cardiac rehab

Cardiac rehabilitation (rehab) teaches you how to be more active and make lifestyle changes that can lead to a stronger heart and better health.

If you don't do a cardiac rehab program, you will still need to learn about lifestyle changes that can lower your risk of another heart attack. These changes include quitting smoking, eating heart-healthy foods, and being active. For more information on lifestyle changes, see Prevention.

Learn healthy habits

Making healthy lifestyle changes can reduce your chance of another heart attack. Quitting smoking, eating heart-healthy foods, getting regular exercise, and staying at a healthy weight are important steps you can take.

For more information on how to make healthy lifestyle changes, see Prevention.

Manage your angina

Tell your doctor about any angina symptoms you have after a heart attack. Many people have stable angina that can be relieved with rest or nitroglycerin.

Manage stress and get help for depression

Depression and heart disease are linked. People who have heart disease are more likely to get depressed. And if you have both depression and heart disease, you may not stay as healthy as possible. This can make depression and heart disease worse.

If you think you may have depression, talk to your doctor.

Stress and anger can also hurt your heart. They might make your symptoms worse. Try different ways to reduce stress, such as exercise, deep breathing, meditation, or yoga.

Have sex when you're ready

You can resume sexual activity after a heart attack when you are healthy and feel ready for it. You could be ready if you can do mild or moderate activity, like brisk walking, without having angina symptoms. Talk with your doctor if you have any concerns. Your doctor can help you know if your heart is healthy enough for sex.

If you take a nitrate, like nitroglycerin, do not take erection-enhancing medicines. Combining a nitrate with one of these medicines can cause a life-threatening drop in blood pressure.

Get support

Whether you are recovering from a heart attack or are changing your lifestyle so you can avoid another one, emotional support from friends and family is important. Think about joining a heart disease support group. Ask your doctor about the types of support that are available where you live. Cardiac rehab programs offer support for you and your family. Meeting other people with the same problems can help you know you're not alone.

Take other steps to live healthier

After a heart attack, it's also important to:

• Take your medicines exactly as directed. Do not stop taking your medicine unless your doctor tells you to.
• Do not take any over-the-counter medicines, vitamins, or herbal products without talking to your doctor first.
• If you are a woman and have been taking hormone therapy, talk with your doctor about whether you should continue taking it.
• Keep your blood sugar in your target range if you have diabetes.
• Get a flu vaccine every year. It can help you stay healthy and may prevent another heart attack.
• Get the pneumococcal vaccine. If you have had one before, ask your doctor whether you need another dose.
• Drink alcohol in moderation, if you drink. This means having 1 alcoholic drink a day for women or 2 drinks a day for men.
• Seek help for sleep problems. Your doctor may want to check for sleep apnea, a common sleep problem in people who have heart disease. For more information, see the topic Sleep Apnea.

Medicines

Take all of your medicines correctly. Do not stop taking your medicine unless your doctor tells you to. Taking medicine can lower your risk of having another heart attack or dying from coronary artery disease.

In the ambulance and emergency room

Treatment for a heart attack or unstable angina begins with medicines in the ambulance and emergency room. This treatment is similar for both. The goal is to prevent permanent heart muscle damage or prevent a heart attack by restoring blood flow to your heart as quickly as possible.

You may receive:

• Morphine for pain relief.
• Oxygen therapy to increase oxygen in your blood.
• Nitroglycerin to open up the arteries to the heart to help blood to flow to the heart.
• Beta-blockers to lower the heart rate, blood pressure, and the workload of the heart.

You also will receive medicines to stop blood clots so blood can flow to the heart. Some medicines will break up blood clots to increase blood flow. You might be given:

• Aspirin, which you chew as soon as possible after calling 911.
• Antiplatelet medicine.
• Anticoagulants.
• Glycoprotein IIb/IIIa inhibitors.
• Thrombolytics.

In the hospital and at home

In the hospital, your doctors will start you on medicines that lower your risk of having complications or another heart attack. You may already have taken some of these medicines. They can help you live longer after a heart attack. You will take these medicines for a long time, maybe the rest of your life.

Medicine to lower blood pressure and the heart's workload

You might take other medicines if you have another heart problem, such as heart failure. For example, you might take a diuretic, called an aldosterone receptor antagonist, which helps your body get rid of extra fluid.

Medicine to prevent blood clots from forming and causing another heart attack

Medicine to lower cholesterol

Other cholesterol medicines, such as ezetimibe, may be used along with a statin.

Medicine to manage angina symptoms

• Nitroglycerin
• Beta-blockers
• Calcium channel blockers
• Ranolazine (Ranexa)

What to think about

You may have regular blood tests to monitor how the medicine is working in your body. Your doctor will likely let you know when you need to have the tests.

If your doctor recommends daily aspirin, don't substitute nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, for example) or naproxen (such as Aleve), for the aspirin. NSAIDS relieve pain and inflammation much like aspirin does, but they do not affect blood clotting in the same way that aspirin does. NSAIDs do not lower your risk of another heart attack. In fact, NSAIDs may raise your risk for a heart attack or stroke. Be safe with medicines. Read and follow all instructions on the label.

If you need to take an NSAID for a long time, such as for pain, talk with your doctor to see if it is safe for you. For more information about daily aspirin and NSAIDs, see Aspirin to Prevent Heart Attack and Stroke.

Surgery

An angioplasty procedure or bypass surgery might be done to open blocked arteries and improve blood flow to the heart.

Angioplasty

Angioplasty . This procedure gets blood flowing back to the heart. It opens a coronary artery that was narrowed or blocked during a heart attack. Doctors try to do angioplasty as soon as possible after a heart attack. Angioplasty might be done for unstable angina, especially if there is a high risk of a heart attack.

Angioplasty is not surgery. It is done using a thin, soft tube called a catheter that's inserted in your artery. It doesn't use large cuts (incisions) or require anesthesia to make you sleep.

Most of the time, stents are placed during angioplasty. They keep the artery open.

But angioplasty is not done at all hospitals. Sometimes an ambulance will take a person to a hospital that provides angioplasty, even if that hospital is farther away. If a person is at a hospital that does not do angioplasty, he or she might be moved to another hospital where it is available.

If you are at a hospital that has proper equipment and staff to do this procedure, you may have cardiac catheterization, also called coronary angiogram. Your doctor will check your coronary arteries to see if angioplasty is right for you.

Bypass surgery

Bypass surgery . If angioplasty is not right for you, emergency coronary artery bypass surgery may be done. For example, bypass surgery might be a better choice because of the location of the blockage or because you have many blockages.

Cardiac rehabilitation

After you have had angioplasty or bypass surgery, you may be encouraged to take part in a cardiac rehabilitation program to help lower your risk of death from heart disease. For more information, see the topic Cardiac Rehabilitation.

Treatment for Complications

Heart attacks that damage critical or large areas of the heart tend to cause more problems (complications) later. If only a small amount of heart muscle dies, the heart may still function normally after a heart attack.

The chance that these complications will occur depends on the amount of heart tissue affected by a heart attack and whether medicines are given during and after a heart attack to help prevent these complications. Your age, general health, and other things also affect your risk of complications and death.

About half of all people who have a heart attack will have a serious complication. The kinds of complications you may have depend upon the location and extent of the heart muscle damage. The most common complications are:

Treatment for heart rhythm problems

If the heart attack caused an arrhythmia, you may take medicines or you may need a cardiac device such as a pacemaker.

If your heart rate is too slow (bradycardia), your doctor may recommend a pacemaker.

If you have abnormal heart rhythms or if you are at risk for abnormal heart rhythms that can be deadly, your doctor may recommend an implantable cardioverter-defibrillator (ICD).

Palliative care

Palliative care is a kind of care for people who have a serious illness. It's different from care to cure your illness. Its goal is to improve your quality of life—not just in your body but also in your mind and spirit. You can have this care along with treatment to cure your illness.

Palliative care providers will work to help control pain or side effects. They may help you decide what treatment you want or don't want. And they can help your loved ones understand how to support you.

If you're interested in palliative care, talk to your doctor.

End-of-life care

Treatment for a heart attack is increasingly successful at prolonging life and reducing complications and hospitalization. But a heart attack can lead to problems that get worse over time, such as heart failure and abnormal heart rhythms (arrhythmias).

It can be hard to have talks with your doctor and family about the end of your life. But making these decisions now may bring you and your family peace of mind. Your family won't have to wonder what you want. And you can spend your time focusing on your relationships.

You will need to decide if you want life-support measures if your health gets very bad. An advance directive is a legal document that tells doctors how to care for you at the end of your life. You also can say where you want to have care. And you can name someone who can make sure your wishes are followed.