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Treatment of acute stroke.

reassurance to those without ST segment changes is fatuous; it is action and not words which is needed to show a patient that he or she can walk, bicycle, swim, or even tie shoe laces without danger. ST segment behaviour and drop in morale are not related to each other. Some patients do not want to join formal exercise courses. Most wish to get back to active life, however, and need proper advice about how to do so, whether they have been in hospital or looked after at home. Many hospitals do not provide any exercise rehabilitation facilities for patients with coronary disease, and the doctor in charge of such patients has to give them sensible advice about how to get fitter on their own. This takes time, but it is time well spent. The simplest start is with a walking campaign, and patients need to be told that in the absence of angina, uncomfortable breathlessness, or profound fatigue they are not doing too much. Some patients prefer a routine based on how far they get in their daily walk in a certain time and improve their fitness by going a bit further each day, or by walking a set distance and reducing the time. Once they can achieve four miles an hour with comfort most prefer to proceed to other things such as slow running, swimming, or bicycling. Patients need to be told that exercise should be enjoyable and that sprinting and marathon running are not an essential part of any programme; they often also appreciate knowing that both these activities have been safely performed by patients who have had an infarction. The important feature is to increase the exercise gradually. Symptoms are a reason to cut back on the intensity, and they should be reported if they continue. Exercise may be beneficial in many chronic illnesses: obesity, diabetes, asthma, coronary disease, hypertension, and probably osteoporosis.1 This form of treatment is cheap, not accompanied by side effects other than muscle stiffness, which wears off in time, and it actually makes people feel better. It is surprising how reluctant our profession is to accept this. "Whenever I feel the desire to take exercise I lie down until the feeling passes off," allegedly said for the first time by Bernard Shaw, several American presidents, and innumerable doctors is beginning to sound as silly and outdated as "one for the road." After a myocardial infarction patients feel very vulnerable and most listen to, and often act on, whatever advice is given. Doctors should be wary about blanket advice on things such as early retirement, avoidance of stress, and changes in diet. For some people such advice may be correct since it may make them happier, but there is no good evidence that it improves the prognosis for the majority. As in the primary prevention of coronary disease, we can confidently condemn smoking.7 Advice on increasing exercise for those without limiting angina or heart failure may now be added to the condemnation of tobacco, not for a reduction in mortality, which remains uncertain, but for improvement in the sense of wellbeing which is frequently so lacking after a heart attack.