If you’ve been diagnosed with silent heart disease or coronary heart disease or have experienced a heart attack or another heart event, your treatment will most likely include one or more medications that you may take for the rest of your life.
Medications, along with lifestyle changes, are the most common form of treatment for cardiovascular diseases. Hundreds of drugs have been developed over the last five decades for the treatment of heart patients. There are many ways to classify these medications, but for our purposes, we will categorize these drugs according to the four main cardiac problems they are designed to treat:
1.Cholesterol
2.Blood clots
3.Blood pressure
4.Chest pain
Every heart patient is different, so you’ll need to work with your physician to create a regimen of medications specific to your condition. For example, you may take drugs to lower your cholesterol and manage your blood pressure but not for blood clots or chest pain. Your best friend or spouse could have another diagnosis and need another category of drug or perhaps three or all four of them.
Heart disease is not the same for everyone, so it may be treated differently in each individual. As a patient, expect your physician to adjust dosages of your medication(s) to find the right level for you and to minimize side effects. Coronary heart disease is a chronic disease; there is no cure for it. However, much can be done to delay or limit its progression and to treat symptoms and complications. So, it’s important to never stop taking a medication and never change your dosage or frequency without first consulting your doctor.
In the following discussion of the various types of medications, I will list their generic names followed in parentheses by their commercial brand names. We’ll conclude this chapter with a discussion of other cardiac treatments beyond pharmaceuticals, notably surgical options and implantable devices.
High cholesterol levels in your blood can cause atherosclerotic plaque to build up and lead to narrowed or blocked blood vessels. This is one of the leading causes of heart attack, stroke, and other serious heart problems. Cholesterol medications help lower your levels of low-density lipoprotein (LDL), or “bad” cholesterol, and raise your levels of high-density lipoprotein (HDL), or “good” cholesterol.
Statins are the most widely used drugs to lower bad cholesterol. Since their introduction in 1987, statins have evolved into seven different kinds for patients to use, depending on their needs. Generally statins are effective in lowering cholesterol levels by 20 to 60 percent, as well as reducing cardiovascular inflammation. Most people who have had a heart attack or stroke, bypass surgery, stents, or diabetes should be taking statins, as should patients with a high LDL level with or without heart disease. Some physicians prescribe statins for patients with multiple risk factors (e.g., advanced age, poor diet, sedentary lifestyle) to try to prevent the progression or onset of coronary heart disease with or without symptoms.
Common types of statin drugs are atorvastatin (Lipitor), pravastatin sodium (Pravachol), and simvastatin (Zocor). While statins remain the drug of choice for most physicians, there are other kinds of drugs that can lower cholesterol for patients who might be allergic to statins, including bile acid resins such as cholestyramine, cholesterol absorption inhibitors such as ezetimibe (Zetia), fibric acid derivatives such as fenofibrate (Tricor), and nicotinic acid such as niacin (Niacor), although these drugs tend to be less effective in lowering cholesterol levels.
In addition to a statin, your doctor may prescribe a drug to prevent a buildup of plaque in the blood vessels. The buildup of plaque can lead to blood clots, which in turn can cause serious problems when they break free of the plaque and partly or completely block blood flow to the heart and cause a heart attack. If the blood clot travels to the lungs, a pulmonary embolism could result. And if a clot travels to the brain, a stroke could occur.
While colloquially knowns as blood thinners, it’s important to note that anticoagulants don’t actually make the blood less concentrated or dissolve existing blood clots. Anticoagulants work by preventing blood clots from forming. Some do this by preventing your body from making substances called clotting factors. Others keep the clotting factors from working or prevent other chemicals from forming so that clots can’t develop.
Aspirin, one of the oldest drugs known, is an over the counter anticoagulant used by millions of Americans for its painkilling effects. The ancients used as a painkiller the extract of willow bark—which naturally contains the anti-inflammatory ingredient salicin, a chemical component of modern-day aspirin. The synthesized form of the active chemical ingredient in aspirin, acetylsalicylic acid, was developed and first marketing by the Bayer pharmaceutical company in 1899. Its cardiovascular benefits were discovered in the 1960s. Aspirin can help to keep arteries open because of its anticlotting and antiplatelet effects. A standard dosage for heart patients is eighty-one milligrams per day, which is one baby aspirin. Aspirin makes sense for people who already have heart disease but not necessarily for people who just have risk factors, although many patients with high-risk profiles take daily aspirin preventively. Examples of other anticoagulants are enoxaparin (Lovenox), heparin (many brand names, including Fragmin and Lovenox), and warfarin (Coumadin).
Like anticoagulants, antiplatelet medications help prevent blood clots, but they work in a different way by preventing your body from making a substance, called thromboxane, that tells platelets to stick together to form a clot. Antiplatelet medicines include clopidogrel (Plavix), prasugrel (Effient), and ticagrelor (Brilique). They are prescribed with, or instead of, aspirin by some physicians.
You usually need antiplatelet medicines if you’ve had coronary angioplasty and stent implantation or have had recurring heart attacks or angina. Aspirin is both an anticoagulant and an antiplatelet drug. Other leading antiplatelet drugs are clopidogrel (Plavix) and prasurgel (Effient).
As we learned earlier, one in three Americans suffers from hypertension or high blood pressure, a leading cause of silent heart disease and coronary heart disease. Well over thirty drugs or drug combinations are available for the treatment of elevated blood pressure.
ACE (angiotensin converting enzyme) inhibitors have been used for the treatment of hypertension for more than twenty years. They lower blood pressure by altering a biological control mechanism, the renin-angiotensin system. Renin is a hormone-like material produced by the kidneys that stimulates the production of angiotensin, a substance that tends to elevate blood pressure. ACE inhibitors lower the blood pressure by “inhibiting,” or blocking, the actions of angiotensin. Examples of these drugs are captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril, Prinivil), benazepril (Lotensin), and ramipril (Altace).
For those individuals who are unable to tolerate the ACE inhibitors, an alternative group of drugs, called angiotensin receptor blockers (ARBs), may be used. These drugs act on the same hormonal pathway as ACE inhibitors but instead block the action of angiotensin II at its receptor site directly. A small, early study of one of these agents suggested a greater survival benefit in elderly congestive heart failure patients as compared to an ACE inhibitor. However, a larger follow-up study failed to demonstrate the superiority of ARBs over ACE inhibitors. Further studies are underway to explore the use of these agents in congestive heart failure both alone and in combination with ACE inhibitors. Commonly prescribed ARBs are candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), losartan (Cozaar), telmisartan (Micardis), and valsartan (Diovan).
Beta-blockers, which belong to the class of drugs that act upon nerve receptors, also can be useful in the treatment of high blood pressure. Beta-blockers can slow your heartbeat and lower your blood pressure and risk of a heart attack. You may sometimes be given a beta-blocker for arrhythmias (abnormal heart rhythms) or angina (see below).
This class of drugs not only slows your heart rate and reduces blood pressure but also limits or reverses some of the damage to your heart if you have systolic heart failure. Beta-blockers may reduce signs and symptoms of heart failure, improve heart function, and help you live longer. Commonly prescribed beta-blockers include acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), bisoprolol/hydrochlorothiazide (Ziac), bisoprolol (Zebeta), metoprolol (Lopressor, Toprol XL), nadolol (Corgard), propranolol (Inderal), and sotalol (Betapace).
Vasodilators are another class of drugs found to be very effective in controlling blood pressure. These drugs “dilate,” or open, the peripheral blood vessels. Initially, the vasodilators most widely used were hydralazine (Apresoline) and minoxidil (Rogaine—yes, the same drug used as a topical ointment to promote hair growth), but in recent years a new class of drugs, called calcium channel blockers, have been found to be particularly effective in treating not only high blood pressure but also problems associated with silent heart disease and coronary heart disease. Calcium is needed for all muscles to move, including the heart. Calcium channel blockers work by regulating the amount of calcium that enters muscle cells in your heart and blood vessels. This makes your heart beat less forcefully and helps blood vessels relax.
Your doctor may prescribe a calcium channel blocker if you have high blood pressure, chest pain, or a heart arrhythmia. Commonly prescribed calcium channel blockers include amlodipine (Norvasc), diltiazem (Cardizem), and nifedipine (Procardia).
Angina pectoris literally means “choking in the chest.” Earlier, we learned that symptom-free, high-risk patients with silent heart disease may have a much higher mortality rate from heart attacks and sudden death than other patients with coronary heart disease. Patients who have previously suffered angina and a heart attack and also have a history of silent heart disease are at very high risk for a recurrent heart attack and even death. In short, the successful management of angina is a matter of life and death for anyone but especially those who have suffered silent heart disease in the past.
Among the most widely prescribed antianginal medicines are nitrates, which have been used in one form or another since 1867. They act by relaxing the muscular walls of both arteries and veins, thereby (1) opening up the coronary arteries and permitting more oxygen-rich blood to flow to the heart muscle itself, and (2) dilating arteries in the periphery (the arms and legs), diminishing the amount of work done by the heart and reducing its oxygen requirements. Nitroglycerine, a rapidly acting nitrate administered under the tongue, is the treatment of choice for acute anginal chest pains. (This is the one of the drugs you’re likely to get at an ER if you’re experiencing chest pains.) Nitrates reduce both symptomatic and symptom-free episodes of inadequate coronary blood flow (ischemia). Intravenous nitroglycerine infusions are used to eliminate all episodes of silent heart disease. Some commonly prescribed forms of nitrates are isosorbide dinitrate (Dilatrate-SR, Isordil), isosorbide mononitrate (ISMO), and nitroglycerin (Nitro-Dur, Nitrolingual, Nitrostat).
Beta-blockers and calcium channel blockers are also used to treat angina.
Now, earlier in the chapter, I explained how cardiac treatment is highly individualized. What works for Jane might not work for Joe or June, John or Janice. Still, that doesn’t mean research hasn’t been conducted on what combination of cardiac medications is the best on average.
Researchers from the William Harvey Research Institute at Queen Mary University of London in the United Kingdom recently conducted a large long-term study that looked at the efficacy of different treatments in keeping cardiovascular disease at bay. The question that they hoped to answer in the Anglo-Scandinavian Cardiovascular Outcomes Trial was, Which treatments work best for preventing cardiovascular events?
Their test subjects were 8,580 UK participants who had high blood pressure as well as several risk factors for developing cardiovascular disease. One group received “traditional” treatment with a blood pressure drug and a diuretic, which is a drug often prescribed for high blood pressure. A diuretic increases the amount of water and salt expelled from the body as urine, which in turn decreases the amount of fluid flowing through the blood vessels, reducing pressure on the vessel walls. The other group received an “innovative” treatment consisting of a blood pressure drug and a statin (the go-to drug for lowering cholesterol).
The results, published in 2018, were unequivocal: the group receiving the innovative treatment had markedly better cardiovascular health. In fact, the new treatment was so successful that the study was stopped midstream. So many more lives were being saved with the new protocol that the researchers in good conscience could not continue with the traditional treatment. In fact, after five years with the new treatment, the subjects had on average nearly a 30 percent better chance of not succumbing to fatal heart disease.
While previous studies had shown that statins conferred long-term survival benefits, this study was among the first to confirm the importance of a regimen that aims to lower blood pressure and cholesterol together. Since high blood pressure and high cholesterol are two of the most common risk factors for silent heart disease, the findings could be relevant to tens of millions of Americans.
For most patients diagnosed with coronary heart disease, including silent heart disease, treatment will consist of one or more medications. However, in some instances, their doctors might recommend surgery to treat an underlying problem that led to heart symptoms. Among the surgical options are those required to implant devices in selected cases. The following are some of the most widely used procedures.
•Coronary bypass surgery: This procedure is meant to correct severely narrowed or completely blocked coronary arteries. It’s the most common type of heart surgery, with more than two hundred thousand operations performed annually in the United States.
•Heart valve repair or replacement: If a faulty heart valve is causing your heart failure, your doctor may recommend repairing or replacing the valve to eliminate backward blood flow. Surgeons can also repair the valve by reconnecting valve leaflets, by removing excess valve tissue so that the leaflets can close tightly, or by tightening or replacing the ring around the valve (annuloplasty). Once requiring open-heart surgery, today certain types of heart valve repair or replacement can be done with either minimally invasive surgery or by using cardiac catheterization techniques.
•Implantation of a cardioverter-defibrillator: An implantable cardioverter-defibrillator (ICD) is a device similar to a pacemaker, which is implanted under the skin of the chest with wires leading through the veins to the heart. If your heart starts beating at a dangerous rhythm or stops, the ICD is designed to shock it back into normal rhythm. An ICD can also function as a pacemaker and speed your heart up if it is going too slow.
•Cardiac resynchronization therapy (CRT) or biventricular pacing: A device is implanted next to the heart to send timed electrical impulses to both of the heart’s lower chambers (the left and right ventricles), so that they pump in a more efficient, coordinated manner, thus preventing heart failure from worsening. Often the CRT is combined with an ICD.
•Implantation of a ventricular assist device (VAD): This implantable mechanical pump, which is attached to a failing heart muscle, facilitates the pumping of blood from the lower chambers of the heart (the ventricles) to the rest of the body. This device is often used in lieu of heart transplant surgery. About thirty-five hundred VADs are implanted in patients every year.
•Heart transplant: Some people have such severe heart failure that surgery or medications don’t help enough, and they will need their compromised heart replaced with a healthy donor heart. The most common reason is that one or both ventricles are no longer functioning properly, and severe heart failure is present. Once a rare and exotic procedure, today approximately thirty-five hundred heart transplants are performed every year around the world, more than half of them in the United States. Still, because of the complexity of the surgery and the long wait time required for a donor heart, this is usually the procedure of last resort. There’s no question that remarkable progress has been made since the first human heart transplant was performed more a half century ago by Dr. Christiaan Barnard. Today, the National Institutes of Health estimate that the procedure extends the average heart transplant patient’s life by ten years.
In the next chapter, we’ll get a preview of what medical science already has planned for the new generation of diagnostics and treatments.