Kicking back after a heart bypass

About 7,000 people die every year in Ireland due to heart attacks. Some 2,000 more survive their initial heart attack or narrowly escape having one and go on to have heart bypass surgery. Although no longer a high-risk operation, bypass surgery is one of the most feared medical interventions.

"It's very overwhelming to have a heart attack. You think you are immortal and then you're faced with bypass surgery. In hospital, you become a child again. You get used to being looked after and then you are kicked out five days later," says Prof Ian Graham, cardiologist at the Adelaide and Meath Hospital (Tallaght Hospital) and professor of cardiology at Trinity College Dublin.

Sent home from hospital - or to a nursing home for initial recuperation - patients must then begin to reclaim their lives. Good physical and psychological recovery is strongly linked to participation in a cardiac rehabilitation programme. Attending group classes in the hospital sets patients steadily on the road to recovery. Although the mortality rates are down to about 2 per cent (1.7 per cent in men and 3 per cent in women), each procedure carries some risk and certain side-effects which must be dealt with in rehabilitation.

"Following a bypass, most patients think they are fixed. But they still have cardiovascular disease which also has to be looked after for the rest of their lives," explains Irene Byrne Byrne, the senior respiratory physiotherapist on the cardiac rehabilitation team at the Mater Hospital.

"Patients are shell-shocked following bypass surgery. They are so delighted to be alive. Yet they face anxiety and depression afterwards, memory or sensory disturbances, taste and sleep disturbances as well as pain from their chest or leg wounds and shoulder and neck stiffness," says Shirley Ingram, the cardiovascular nurse specialist at the Adelaide and Meath Hospital. A period of depression, which may last for up to six months, is quite common among those who have had heart bypass surgery. Forgetting people's names and phone numbers is also not uncommon. This is usually attributed to the fact that the heart has been temporarily stopped and the patient's blood circulated through a bypass machine during heart surgery. Informing patients about these symptoms is one of the initial tasks of the cardiac rehabilitation team. Cardiac rehabilitation is carried out by a multi-disciplinary team which includes cardiologists, cardiovascular nurse specialists, physiotherapists, a dietitian and social worker/psychologist. According to recent figures from the Irish Cardiac Surgery Register, the average age of patients undergoing bypass surgery has increased from late 50s to early 60s. However, this does not preclude certain pockets of younger patients in some places.

"Our patients are younger and very high-risk people who are overweight, with high blood pressure, a high-fat diet, high levels of cholesterol and lacking in exercise," says Prof Ian Graham. There is also an increased incidence of heart attacks and subsequent heart bypass operations in pre-menopausal women who were deemed previously to be protected from heart attacks by their reproductive hormones. The cardiac rehabilitation team at the Mater Hospital have also noted an increased number of younger women among their patients recently. While younger people will usually recover better physically, it can be much more difficult psychologically.

Spending time in the hospital gym doing aerobic exercises is a major component of initial physical retraining and overall confidence-building.

"After an uncomplicated heart bypass, it is safe to exercise within two to three weeks," says Ingram. "Sometimes, patients have felt so unwell before their operation that their bodies get very deconditioned to exercise. We tell them that their hearts are working better now and the rest of their bodies have to catch up with it." A patient's blood pressure is monitored before and after each exercise period and heart monitors are worn during exercise. "The purpose of rehabilitation is to get the patient back in control of their own health. Often, in the beginning, we see relatives staring into the gym, seeing their partner on the treadmill and anxiously thinking he won't be able for that," says Ingram. Stop-smoking programmes and education on diet are other aspects of a cardiac rehabilitation programme. Some patients are ready to re-appraise their lifestyle, others go back to their old habits - usually drinking or smoking too much or not exercising enough.

Sexual dysfunction is quite common following heart bypass surgery. "Usually someone in the group will mention Viagra, and that gets a bit of a laugh. Sexual dysfunction due to psychological reasons or due to medication is common enough and, yes, we have prescribed Viagra for some men," says Ingram. Relationships with partners also undergo change. "Often, the partners will want to wrap the patient up in cotton wool, and it is important for them not to suffocate them," says Ingram.

Social worker Tim Norton runs the stress management component of the Adelaide and Meath's rehabilitation programme. He says that a lot of people who have heart bypass surgery will take stock of their lives and question their workloads. "In the group, we do a lot of breathing and stretching techniques, but if we discover something like free-floating hostility, there are opportunities to explore these issues on an individual basis," he says.

Currently there are about 12 hospitals in the Republic offering cardiac rehabilitation. The recent report of the cardiovascular health strategy group, Building Healthier Hearts, aims to increase this number to 40 over the next 10 years. "Substantial funds are becoming available so that every hospital which has a coronary care unit will have cardiac rehabilitation," says Ann Gallagher. Declan Sugrue, cardiologist at the Mater, says that the biggest foreseeable change in terms of bypass surgery is that of the patient profile. "We will see older and sicker people having bypass surgery in the future. They may also have other concurrent medical problems such as diabetes and kidney problems which may complicate things. And their cardiac rehabilitation needs will be different. There will be a greater need for education for everyday living," he says.