Mr Lenard Kek attends the cardiac rehabilitation programme at Singapore Heart Foundation every week. ST PHOTO: DESMOND FOO

SINGAPORE – Mr David Teo was 47 when he suffered his first heart attack in 2010. He was about to leave home to play golf when he felt a tightness in his chest and cold sweat dripping down his forehead. 

Thinking it was due to the hot weather, he rested for a while before leaving home.

While he was driving, the sweating stopped, but when he reached the driving range, it started again.

"This time, I knew something was not right, as the air-con in my car was blowing at me," says the 61-year-old, who runs a small business in the medical industry.

He went to the hospital for a check-up and found out he was having a heart attack.

He had to undergo surgery to insert two stents in his coronary artery, which was almost 100 per cent blocke. A stent is a small mesh-like tube inserted into the artery to help keep it from narrowing or closing again. 

"Initially I was shocked, but I realised my smoking habit and unhealthy diet could have been the main causes of heart attack," says Mr Teo, who is married and has two sons. He has a family history of heart disease, which puts him at a higher risk of developing a heart condition.

After the heart attack, he found out he had high cholesterol and has been on medication since. 

He gradually stopped smoking and started brisk-walking two to three times a week. He also gave up eating fried food like french fries, curry puffs and chicken wings.

In 2016, however, he suffered another heart attack, which required him to undergo stent surgery again. “This time, I was determined to do even more to take care of my health,” says Mr Teo.

Since 2017, he has been attending the Singapore Heart Foundation’s (SHF) cardiac rehabilitation programme, which is supervised and includes exercise and education on healthy living. He has also adopted a healthier diet by cutting down on carbohydrates and beverages laden with sugar.

More surviving heart attacks

SHF chairman Tan Huay Cheem says: “More people are getting heart attacks, but more are surviving. So it is important that survivors know how to manage their risks, as studies have repeatedly shown that they are at an increased risk of getting another heart attack.”

According to the Singapore Myocardial Infarction Registry annual report in 2021, more people in Singapore are getting heart attacks, with the number rising from 8,014 in 2011 to 12,403 in 2021.

The number of deaths due to heart attacks was 1,000 in 2021, a slight increase compared with 907 in 2011.

However, the age-standardised mortality rate of heart attacks declined significantly from 22.5 to15.3 per 100,000 population during this period. The age-standardised rate takes into account the age of the population. The mortality rate measures the frequency of deaths over a given period in a defined population.

The report stated that the decreasing trend in the age-standardised mortality rate was likely due to the higher rates of medical treatment and medication administered, and a drop in time between the onset of the heart attack and the administration of treatment.

The incidence of heart attacks is also expected to rise, partly due to the increasing prevalence of several cardiovascular risk factors, including hypertension and obesity, notes Professor Tan, who is also a senior consultant cardiologist at the National University Heart Centre.

White paper to combat heart disease

A white paper released in March by the SHF, Singapore Cardiac Society and the Academy of Medicine, Singapore, supported by global biotechnology company Amgen, has highlighted the need for greater efforts to prevent cardiovascular disease in Singapore, including recurrent heart attacks in survivors.

This includes a collaborative patient education programme between healthcare professionals and community partners.

The programme highlights eight steps to manage the five main controllable cardiovascular risk factors. They include keeping cholesterol levels and blood pressure within the healthy range, clocking at least 150 minutes of exercise a week, and avoiding smoking and vaping.

Survivors at risk of another attack

Assistant Professor Jeffrey Lau, a senior consultant at National Heart Centre Singapore’s department of cardiology, says a person who has had a heart attack should tackle the underlying risk factors.

“Unless something fundamentally changes, such as improvements in blood sugar, cholesterol and blood pressure, the risk of recurrence will remain high for the person,” he adds.

A second heart attack is often more severe, with 10 to 15 per cent of patients facing a higher risk of death and heart failure. PHOTO: ISTOCKPHOTO

Dr Pinakin V. Parekh, a consultant cardiologist at The Harley Street Heart and Vascular Centre, Singapore, says not taking medications is also a major contributing factor to recurrent heart attacks.

A second heart attack is often more severe, with 10 to 15 per cent of patients twice as likely to have heart failure and die, says Prof Tan.

Some people experience a second heart attack shortly after the first, while others may have one weeks to even years later, says Dr Pinakin.

Depending on the type of heart attack, Prof Lau says the chance of recurrence can be different.

For example, broken heart syndrome – where the heart muscle becomes suddenly weakened due to extreme emotions – tends to be a one-off occurrence, whereas a heart attack due to coronary artery disease in a chronic smoker or diabetic tends to recur.

Stress and diet a factor

Dr Pinakin often sees young busy professionals who eat out more frequently, which has led to them having higher low-density lipoprotein (LDL) levels, often referred to as “bad” cholesterol.

“The earlier and longer you experience high LDL levels, the higher your risk for a cardiovascular event. Conversely, the earlier and longer you can maintain low LDL levels, the better your cardiovascular risk profile,” he notes.

Stress is another significant risk factor. People tend to eat more foods which are high in sugar and trans fats when they are stressed, which can impact blood pressure and LDL levels, says Dr Pinakin.

“For those who already have coronary artery plaque build-up, the surge of adrenaline during a stressful event can cause the rupture of previously stable plaques, leading to a heart attack,” he adds.

Operations planner Lenard Kek, who has high cholesterol and was highly stressed at work, suffered a heart attack in 2022.

The 49-year-old bachelor had chest pain that became progressively worse throughout the day.

“I thought it was just muscle pain, but when I went to the hospital, I found out it was a heart attack,” says Mr Kek, who is overweight. He had a blocked blood vessel and required stent surgery to restore blood flow to the heart.

He has been taking medication for hypertension since the heart attack.

“Even though I maintained a relatively healthy diet, I was stressed at work and slept four to five hours every night, which could have contributed to the heart attack,” he says.

It was a wake-up call to take better care of himself, says Mr Kek, who is aware that he is at higher risk of getting another heart attack.

Symptoms of subsequent attack tend to be the same

The symptoms of a recurrent heart attack tend to be similar to the first one, highlights Prof Lau.

Mr Teo had chest tightness and cold sweat on both occasions.

Prof Lau says the classic symptom of a heart attack is the Levine’s sign, which refers to the clutching of the left chest. However, he adds, studies have shown that only about 11 per cent of patients do this during a heart attack.

The symptoms of a heart attack are also not the same for everyone.

Besides chest tightness and pain, some may experience excessive sweating, breathlessness, or pain down the left arm, or up the left neck to the left jaw.

“This is why heart attacks can be missed, because some patients may think it’s just a queasy stomach,” says Prof Lau.

Fears of second heart attack

Patients are typically fearful of getting a second heart attack and can become stressed and develop depression, much like post-traumatic stress disorder, says Prof Tan.

However, this can be managed if patients undergo cardiac rehabilitation. It is a supervised programme that includes exercise, education on healthy living, and counselling to reduce stress and help patients return to an active life.

Both Mr Kek and Mr Teo take part in SHF’s cardiac rehabilitation programme every week.

Prof Tan says clinical research has shown that regular participation in cardiac rehabilitation reduces cardiac-related death by over 50 per cent and re-hospitalisations by 25 per cent, and improves chronic disease control and well-being.

Joining a patient support group or talking to other heart attack survivors can provide emotional support and valuable insights into coping strategies and living with heart disease, he adds.

“The fear can be garnered into positive energy to change one’s lifestyle and look after oneself better,” he notes.

Seven ways to prevent heart attacks

Preventing heart attacks involves managing risk factors and promoting heart health, say
cardiologists. Here are some ways to do so.

1. Quit smoking
Smoking is the largest preventable risk factor for heart disease, says Dr Pinakin. “The risk of another heart attack can be reduced by half simply by quitting smoking,” he adds.

2. Manage cholesterol level, adopt heart-healthy diet
The biggest impact on the reduction of heart attack recurrence is the “intensive, aggressive lowering of ‘bad’ cholesterol, also known as LDL cholesterol”, says Prof Tan.

“Studies have shown that lowering the LDL cholesterol level to 1.4 mmol/L (25mg/dL) as early as possible in patients with heart attack, with a combination of oral medications and injections, can help prevent the recurrence of cardiac events,” he notes.

To lower bad cholesterol and triglyceride levels, Dr Pinakin also recommends cutting down on foods high in saturated fats and trans fats, such as margarine and snacks like cookies and crackers.

He suggests following a heart-healthy diet known as Dash, which stands for Dietary Approaches to Stop Hypertension. It is low in salt and rich in fruit, vegetables, whole grains, low-fat dairy and lean protein.

3. Exercise regularly
Regular physical activity strengthens the heart muscle and improves cardiovascular fitness. This enhances the heart’s ability to pump blood efficiently, reduces strain on the heart, and lowers the risk of heart attacks and other cardiovascular events, says Dr Pinakin.

Aim for at least 150 minutes of moderate-intensity exercise a week, such as 30 minutes a day for five days of the week.

4. Maintain a healthy weight
Obesity and excess body weight can increase strain on the heart and are associated with an increased risk of heart attacks, says Dr Pinakin. Reduce the risk by staying within a healthy body mass index range of 18.5 to 22.9.

5. Control blood pressure, blood sugar levels
Hypertension and diabetes are risk factors for heart disease and recurrent heart attacks, notes Dr Pinakin.

A heart-healthy diet and regular exercise can help manage one’s blood pressure, while controlling blood sugar levels can reduce inflammation and prevent coronary artery damage, reducing one’s risk of a heart attack, he says.

6. Take medications as prescribed
Non-compliance with or non-adherence to medications is a major contributing factor to recurrent heart attacks, highlights Dr Pinakin. Take heart, cholesterol and blood pressure medications as prescribed by your physician to maintain heart health, he advises.

7. Manage mental health
Chronic stress and poor mental health are associated with an increased risk of heart disease and adverse cardiac events, so it is important to address emotional issues like depression, stress and anger that can impact heart health, says Dr Pinakin.

“Engaging in regular exercise and adopting a nutritious diet can not only promote cardiovascular health but also reduce stress levels, improving overall mental health,” he adds.