Statins are the first-line drugs for lowering high LDL ("bad" cholesterol) levels, and reducing the risk for heart attack and stroke. Current joint guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend statin therapy for patients with existing atherosclerotic heart disease and people at risk for heart disease.
The ACC/AHA has designed a special "risk calculator" to compute cardiovascular disease risk percentage. A doctor enters into the calculator a patient's gender, age, race, total cholesterol, HDL ("good" cholesterol), blood pressure, diabetes status, and smoking status. If the formula indicates a 7.5% or higher risk for having a heart attack or stroke within the next 10 years, treatment with a statin drug is recommended.
Statin drugs approved in the United States are lovastatin (Mevacor, generic), pravastatin (Pravachol, generic), simvastatin (Zocor, generic), atorvastatin (Lipitor, generic), fluvastatin (Lescol), pitavastatin (Livalo), and rosuvastatin (Crestor).
Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either antiplatelets or anticoagulants. Both antiplatelets and anticoagulants prevent blood clots from forming. But they work in different ways. Antiplatelets prevent blood platelets from sticking together. Anticoagulants are "blood thinners" that reduce blood clotting. Both of these therapies carry the risk of bleeding, which can lead to dangerous situations, including stroke.
For most patients with CAD, antiplatelet drugs are preferred over anticoagulants. Anticoagulants may be prescribed for patients with atrial fibrillation or prosthetic heart valves. Some patients need both.
Current guidelines recommend that patients with CAD receive antiplatelet therapy with either aspirin or clopidogrel. Other antiplatelet drugs such as prasugrel (Effient), ticagrelor (Brilinta), or ticlopidine (Ticlid) may be recommended. Sometimes two anti-platelet drugs (one of which is almost always aspirin) are prescribed for patients with unstable angina, acute coronary syndrome (unstable angina or early signs of heart attack), or those who have received a stent during PCI.
Aspirin. Aspirin is known as a nonsteroidal anti-inflammatory drug (NSAID). It stops blood platelets, which are major clotting factors, from sticking together to form a blood clot. Aspirin therapy is extremely beneficial for patients with coronary artery disease or history of stroke.
If you have been diagnosed with CAD, your doctor may recommend that you take a daily dose (from 75 to 162 mg) of aspirin. A daily dose of 81 mg is recommended for patients who have undergone PCI (angioplasty). Aspirin can reduce the risk of heart attack and ischemic stroke. However, prolonged use of aspirin can increase the risks for stomach bleeding.
A daily low-dose aspirin (75 to 81 mg) is usually the first choice for preventing heart disease or stroke in high-risk individuals. Daily aspirin is not recommended for prevention in healthy people who are at low risk for heart disease. A doctor needs to consider a patient's overall medical condition and risk factors for heart attack before recommending aspirin therapy. Discuss with your doctor whether aspirin therapy is appropriate for you.
Clopidogrel. Thienopyridines are antiplatelet drugs. Clopidogrel (Plavix, generic) is the standard thienopyridine for patients with CAD.
For heart disease primary and secondary prevention, daily aspirin is generally the first choice for antiplatelet therapy. Clopidogrel is prescribed instead of aspirin for patients who are aspirin allergic or who cannot tolerate aspirin. For most patients, clopidogrel is not taken in combination with aspirin because the two drugs combined can increase the risk of bleeding. However, the combination is common in patients who have had a heart attack or who have received a stent.
Clopidogrel and aspirin is recommended for patients who are undergoing angioplasty with or without stenting. Patients who receive drug-coated stents require prolonged clopidogrel therapy, while those who receive bare-metal stents can often go back to aspirin alone after a shorter period of time. Patients having coronary bypass surgery should not take clopidogrel for at least 5 days prior to surgery because of a significant bleeding risk.
Aspirin and thienopyridine antiplatelet drugs like clopidogrel can increase the risk for upper gastrointestinal bleeding, especially for patients who have pre-existing ulcers or other risk factors. For this reason, some doctors recommend that patients who are at high risk of gastrointestinal bleeding take a proton pump inhibitor (PPI) drug along with antiplatelet therapy.
PPI drugs help suppress gastric acid production, which in turn helps heal ulcers. However, certain PPI drugs may interfere with clopidogrel's antiplatelet effects. Discuss with your doctor the risks and benefits of taking a PPI drug along with clopidogrel and whether this is right for you.
Beta blockers are useful for preventing angina attacks and reducing high blood pressure. They reduce the heart's oxygen demand by slowing the heart rate and lowering blood pressure. They can help reduce risk of death from heart disease and from heart surgeries, including PCI and coronary bypass.
Beta blockers are used or recommended in a number of situations:
- They are started in nearly all patients who have just had a heart attack or acute coronary syndrome and are continued for at least 3 years.
- They are the drugs of choice for older patients with stable angina and may also be beneficial for people with silent ischemia.
- They may be used alone or with other medications for management of rhythm disturbances or high blood pressure.
Beta blockers include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc). All of these drugs are available in generic form. A nasal spray form of propranolol may be helpful in reducing exercise-induced angina attacks.
If beta blocker therapy is not appropriate or not effective, a calcium channel blocker, nitrate, or ranolazine are alternative options.
Side Effects. Beta blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL ("good") cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. These beta blockers may need to be avoided by patients with asthma, emphysema, or chronic bronchitis.
Patients should never abruptly stop taking these drugs. The sudden withdrawal of beta blockers can rapidly increase heart rate and blood pressure. The doctor may advise a patient to slowly decrease the dose before stopping completely.
Angiotensin Converting Enzyme (ACE) Inhibitors
Angiotensin converting enzyme (ACE) inhibitors are important heart-protective drugs, particularly for people with diabetes, high blood pressure, and heart failure. They reduce the production of angiotensin, a chemical that causes arteries to narrow, and so are commonly used to lower blood pressure. They may also reduce risk for heart attack, stroke, complications of diabetes, and death in patients at with or at high risk for heart disease.
ACE inhibitors are indicated for most patients who have had heart attacks. They are particularly helpful for patients with coronary artery disease who also have diabetes or who have heart failure or left ventricular dysfunction (when the heart's main chamber does not pump as well as it should).
ACE inhibitors include captopril (Capoten, generic), ramipril (Altace, generic), enalapril (Vasotec, generic), quinapril (Accupril, generic), benazepril (Lotensin, generic), perindopril (Aceon, generic), and lisinopril (Prinivil, Zestril, generic).
Side Effects. Side effects of ACE inhibitors may include an irritating dry cough. More serious side effects are uncommon, but may include excessive drops in blood pressure, allergic reactions, and high blood potassium levels. If you cannot tolerate the side effects of ACE inhibitors, your doctor may prescribe an angiotensin receptor blocker (ARB) as an alternative high blood pressure drug with similar benefits.
Nitrates are used to control angina symptoms. Nitrates have been used in the treatment of angina for over 100 years. These drugs are vasodilators; they release nitric oxide, which relaxes the smooth muscles in blood vessels and allows blood to flow more easily. Many nitrate preparations are available. The most common are nitroglycerin, isosorbide dinitrate, and isosorbide mononitrate. Nitrates can be absorbed from the gastrointestinal tract (oral tablet), skin (ointment or patch), or from under the tongue (sublingual tablet or spray).
Rapid Acting Nitrates. Rapid-acting nitrates are used to treat acute angina symptoms. Nitroglycerin is the most widely used drug for this purpose. It can be administered under the tongue (sublingually or as a spray) or pocketed between the upper lip and gum (buccally) and can relieve angina within minutes. The procedure for taking nitroglycerin during an attack is as follows:
- At the onset of an angina attack, the patient sits or lies down and then administers one sublingual or buccal tablet or one metered dose of the spray.
- If the pain is not relieved within 5 minutes the patient takes a second dose; a third can be taken after another 5 minutes if symptoms persist.
- If pain continues after a total of three doses in 15 minutes, the patient should go immediately to the nearest emergency room or call 911 (they should not drive themselves).
Nitroglycerin is very unstable so its potency can be easily lost. Patients should take the following precautions:
- Keep no more than 100 tablets on hand, stored in their original container.
- When first opened, the cotton filler should be discarded, and the cap screwed on tightly immediately after each use.
- A supply should always be kept close at hand in case of an attack, with the rest kept in a cool dry place.
Intermediate to Long-Term Nitrates. Sublingual tablets of isosorbide dinitrate have a slower onset of action than nitroglycerin and are useful for preventing exertional (activity-induced) angina. Ointments, skin patches, and oral tablets are used for longer-term prevention of angina attacks:
- Transdermal skin patches are applied in the morning to any hair- or injury-free area on the chest, back, stomach, thigh, or upper arm. Hands should be washed after each patch or ointment application, and sites of application should be rotated to avoid skin irritation.
- Nitroglycerin ointment is applied by measuring out an even amount on an applicator paper and then placing, not rubbing or massaging, it on the chest, stomach, or thigh. Any ointment that remains from the previous application should be removed.
Long-acting forms may lose their effectiveness over time, so doctors generally schedule nitrate-free breaks to prevent tolerance.
Side Effects. Nitrates can have many side effects, some of which can be serious.
Common side effects of nitrates include headaches, dizziness, nausea and vomiting, blurred vision, fast heartbeat, sweating, and flushing on the face and neck. Low blood pressure and dizziness can be relieved by lying down with the legs elevated. These effects are significantly worsened by alcohol, beta blockers, calcium channel blockers, and certain antidepressants.
The doctor may prescribe medicines to lessen these side effects. Patients should contact their doctor if these side effects are persistent or severe. Patients who take nitrates in any form should never take medications for erectile dysfunction, such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra).
Serious side effects requiring immediate medical help include fever, joint or chest pain, sore throat, skin rash (especially on the face), unusual bleeding or bruising, weight gain, and swelling of the ankles.
Withdrawal. Withdrawal from nitrates should be gradual. Abrupt termination may cause angina attacks.
Calcium Channel Blockers (CCBs)
Calcium channel blockers reduce heart rate and slightly dilate the blood vessels of the heart, thereby decreasing oxygen demand and increasing oxygen supply. They also reduce blood pressure. However, CCBs vary chemically. Although some are helpful, others may even be dangerous for certain patients with CAD.
Click the icon to see an image of heart arteries.
- Long-acting nifedipine (Adalat, Procardia, generic) and nisoldipine (Sular, generic) and newer CCBs, such as amlodipine (Norvasc, generic) and nicardipine (Cardene, generic), are used to treat angina symptoms. They may be used alone for patients who cannot tolerate beta blockers, or in combination with a beta blocker.
- Short-acting CCBs, including short-acting forms of verapamil, diltiazem, nifedipine, and nicardipine, are helpful for treating Prinzmetal's angina. However, short-acting forms of certain CCBs, such as nifedipine and nisoldipine, can cause severe and even dangerous side effects, including an increase in heart attacks and sudden death in patients with stable or unstable angina. Short-acting CCBs are, therefore, not used for treating stable or unstable angina.
Side Effects. Patients with heart failure have a higher risk for death with these drugs and should not take them. No one should abruptly stop taking calcium channel blockers because sudden withdrawal can dangerously increase the risk of high blood pressure. Note: Grapefruit and Seville oranges boost the effects of certain CCBs, sometimes to toxic levels. (Regular oranges do not pose any hazard.)
Ranolazine (Ranexa) is used to treat chronic angina in patients who have not responded sufficiently to other angina drugs. Ranolazine is usually taken in combination with a calcium channel blocker, beta blocker, or nitrate drug.