Before a heart attack, many people “were kind of normal functioning, did the yard work, walked the dog, maybe took some casual walks,” says Richard Andrews, an exercise physiologist and coordinator of the cardiac rehab program at University of Southern California Verdugo Hills Hospital in Glendale, California. “And then suddenly they’re shuffle-gait walking out of the hospital and out of breath just getting dressed.” Many people only realize after they’ve had a heart attack the importance of their doctor’s advice on managing cholesterol years before.

Made by your liver and also found in foods derived from animals, cholesterol is a waxy substance that’s important for many functions in the body, including building new cells. But when there’s too much of it in your blood, it can contribute to the buildup of plaque — a hard coating of cholesterol and other substances — on the inside of your blood vessels, known as atherosclerosis. When an area of plaque in an artery supplying blood to your heart becomes unstable and breaks off, a blood clot can form that completely blocks blood flow to that region of the heart, depriving it of oxygen. This causes a heart attack, which often causes lasting damage to your heart muscle. “When you have a heart event, it’s a signal that you are vulnerable to more of this,” says Elizabeth Klodas, MD, a cardiologist in Minneapolis and the chief medical officer at Step One Foods, a company that makes science-based food products to help manage cholesterol levels. “It’s not a one-and-done if you don’t change how you live.” According to the American Heart Association (AHA), one in five people who have a heart attack will experience a second one within five years. They note that you can take steps to reduce your risk of recurrence, including controlling your cholesterol.

How to Lower Your Cholesterol

The good news is that even if you had unhealthy levels of cholesterol for years before your heart attack, there is evidence that lowering your cholesterol can still have real benefits. “We can actually undo some of this stuff,” Dr. Klodas emphasizes. “With aggressive lifestyle and medication treatment plans, you can actually see regression of atherosclerosis.” Here are some ways to lower your cholesterol and reduce your risk of another heart attack, as well as some precautions for what not to do.

1. Do take your medications as prescribed.

While following a healthy lifestyle is important, so is taking your prescribed cholesterol medication . “If you have atherosclerotic disease, you should be on a statin,” says Klodas, referring to the most commonly prescribed type of cholesterol-lowering drug. “Statins have been shown to reduce recurrent events — heart attacks and strokes — and reduce the risk of dying from atherosclerotic disease.” The goal, Klodas says, is to get your levels of “bad” low-density lipoprotein (LDL) cholesterol as low as possible, using the combined effects of drugs and lifestyle measures. Talk to your doctor about which medication, or combination of medications, may be right for you. Other cholesterol-lowering medications include PCSK9 inhibitors, selective cholesterol absorption inhibitors, bile acid sequestrants, fibrates, and niacin.

2. Do attend cardiac rehab.

Cardiac rehab programs help people become physically active after a heart attack, building up their strength while teaching them a safe, effective exercise program that they can eventually continue on their own. Not all doctors refer patients to cardiac rehab, possibly because they’re skeptical that people who weren’t serious about exercise in the past will suddenly change their lifestyle following a heart attack. And unfortunately, “Most people don’t know what cardiac rehab is,” says Andrews. “They may not ask their doctor.” A typical program involves three hour-long sessions per week for up to 12 weeks, with at least half of each session devoted to aerobic exercise. The remaining time may be spent giving guidance on exercise, nutrition, and other aspects of a heart-healthy lifestyle. When developing a program for someone, “We try to cater it to the individual’s needs as much as possible,” says Andrews. “Too many changes at once can be overwhelming, so we might just make this initial drive to establish the habit of exercise.” According to an article published in February 2015 in the Journal of the American College of Cardiology, exercise-based cardiac rehab programs have been found to reduce the risk of a second heart attack by 47 percent, based on an analysis of 34 randomized controlled trials.

3. Do get enough aerobic exercise.

Whether or not you attend cardiac rehab, it’s important to get enough aerobic exercise, which includes activities such as walking, swimming, and biking. “Exercise is medicine,” says Andrews. “We’re built to move, and we ought to move.” The AHA recommends getting at least 150 minutes of moderate aerobic exercise each week, or 30 minutes at least 5 days a week. But Klodas believes people should be moving even more when possible, getting an hour a day of aerobic activity if they’re otherwise sedentary for most of the day. “It doesn’t have to happen all at once,” Klodas emphasizes. “This is not about extreme physical activity, but it is about regular daily physical activity.”

4. Do aim for a healthy weight.

If you exercise enough and follow a healthy diet, you may lose excess body weight even without aiming to do so. If you’re overweight, weight loss has also been shown to separately reduce the risk of cardiovascular events, such as a heart attack. Weight loss is one of the topics covered in cardiac rehab, according to Andrews. But he emphasizes that the behaviors that may lead to weight loss — eating well and exercising — are more important than reaching a weight-loss goal and carry benefits even if you don’t lose weight.

5. Do eat mostly plant-based foods.

“We encourage largely eating a plant-based diet as much as possible,” says Andrews. In particular, your diet should be “low in animal products with saturated fat content, such as meat and full-fat dairy.” Plant-based foods, especially those high in fiber, can lower cholesterol in the body, according to Klodas. That’s because high-fiber foods help prevent the reabsorption of bile — a cholesterol-rich liquid that aids in digestion — which is then excreted from the body. As a result, Klodas explains, “The liver is going to pull more cholesterol from the blood to make more bile for the next meal, and your cholesterol levels will fall.”

6. Do choose healthy fats over unhealthy fats.

You don’t have to eliminate all fat from your diet, but you do need to be careful about the ones you choose. Healthy fats “are liquid at room temperature. Those are the unsaturated fats,” says Klodas. Examples of foods rich in unsaturated fats include olive oil, nuts and seeds, avocados, and fatty fish. According to the AHA, unsaturated fats can help improve cholesterol when eaten in place of saturated and trans fats. Unhealthy saturated fats are solid at room temperature and have been shown to raise LDL (bad) cholesterol levels. Examples include butter, cheese, and the fat in meat and poultry. Trans fats, found in baked goods, fried foods, and shortening, can both raise LDL and lower high-density lipoprotein (HDL), “good” cholesterol that picks up excess cholesterol in your blood and brings it back to your liver. The AHA recommends limiting saturated fats to 5 to 6 percent of your daily calories and minimizing your intake of trans fats.

7. Don’t focus on meat as a protein source.

“Everyone is obsessed with protein these days,” says Klodas, but, “It’s actually pretty rare to run into someone who is protein deficient.” You can get plenty of protein from a plant-based diet, says Klodas. Protein-rich plant foods include beans, nuts, and seeds. If you do include animal protein in your diet, it should be a lean cut/variety of meat, poultry, or fish.

8. Don’t drink too much alcohol.

Alcohol turns into a simple form of carbohydrate in the body, which may contribute to weight gain. But it also appears to raise levels of HDL, which may be protective against cardiovascular disease. In addition, red wine contains antioxidants that may help protect against harmful inflammation that increases the risk of heart disease. Alcohol is “a double-edged sword,” says Klodas. “It seems that one drink a day — maybe two for larger individuals — is probably most beneficial. Less than that and you don’t get the benefit; more than that and it’s harmful.” Drinking too much alcohol can raise levels of triglycerides, a type of fat that, in combination with high LDL or low HDL levels, can contribute to plaque buildup, according to the AHA. If you drink, talk to your doctor about the benefits and risks of drinking in moderation.

9. Don’t smoke.

It’s very simple: Smoking greatly increases your risk of cardiovascular disease, including heart attack. It raises levels of LDL cholesterol and triglycerides and lowers levels of HDL cholesterol. “If you’re a smoker, quit,” says Klodas. Talk to your doctor about getting help to quit smoking if you think you need it.

10. Don’t stress out.

Stress, especially chronic stress, has been shown to increase the risk of cardiovascular events, such as heart attack. That’s why many cardiac rehab programs have a stress-reduction component, in which specialists talk to participants about identifying sources of stress in their life and how to deal with it. But you can also tackle stress on your own by taking an inventory of what causes it for you and figuring out ways to avoid or deal with stressors. Many people find yoga, meditation, and guided imagery to be helpful.

11. Don’t ignore your emotions.

Depression is common in older people with cardiovascular disease, as noted in a review published in October 2017 in the Journal of Clinical Neuroscience. What’s more, depression is associated with worse outcomes related to cardiovascular events — and deatth. If you’re struggling with feelings of hopelessness or anxiety after your heart attack, reach out to your doctor or a mental health professional. You may benefit from joining a support group for heart attack survivors or from the social engagement that comes with a cardiac rehab program.

12. Don’t go it alone.

While a heart attack can make you feel scared, vulnerable, or even angry, there’s no reason it should make you feel alone, since there are likely many people in your community who have gone through the same experience. Andrews notes that many people who participate in his cardiac rehab program transition to an unmonitored maintenance program, which is sort of like a gym membership. These people, he says, “make our jobs a lot easier, because they’re very welcoming and accommodating to the new patients.” In addition to providing a platform for exercise, Andrews says that ongoing programs let heart attack survivors “develop social bonds that are equally important to their long-term health.” “When someone says, ‘I had this happen to me five years ago, and look at me now, I’m doing great, but I know you’re struggling now,’ that carries way more weight than a 30- or 40-year-old who doesn’t have heart disease telling them, ‘This is good for you,’” says Andrews.