Sadly, there’s no cure for CAD. Instead, those who suffer from this disease are told to modify their lifestyles in the ways we’ve mentioned up to this point. Sometimes, though, lifestyle modification isn’t enough to reduce a person’s risk of a heart attack. Those who suffer from abnormal cholesterol and blood pressure levels, diabetes, stable or unstable angina, or a previous heart attack, for instance, will likely need to add medication to their treatment plan.
In addition to using medications to slow the heart, dilate arteries, and lower cholesterol and blood pressure, some invasive procedures may be recommended. In cases where damage to the heart is severe, for instance, the best option may be to undergo an invasive procedure such as a bypass to help clear blockages and restore blood flow to normal levels.
No matter which route your doctor suggests, all treatments (medical or natural) are designed to help improve the quality of life and reduce or eliminate symptoms by improving the blood’s ability to flow to the heart. Ultimately, your doctor wants to stop or slow the progression of CAD.
Taking medication doesn’t preclude the mission to adopt healthy or healthier lifestyle patterns. There’s no room for bad habits when you’re trying to keep your heart in working condition. Plus, it’s proven that the drugs work better when you lose weight, exercise regularly, quit smoking, and eat nutritious foods.
Lipid-Lowering Medications
There are many options when it comes to drugs that help regulate blood lipid levels. They lower total cholesterol, LDL, and triglycerides and raise HDL. Statins are the most widely used of these lipid-lowering drugs. However, a newer medication called PCSK9 inhibitors are more powerful. Other helpful drugs include cholesterol absorption inhibitors, niacin, fibrates, and bile acid sequestrants.
Statins
Statins stop cholesterol from forming in the liver. While they work best at lowering LDL (usually by 20 to 60 percent in several weeks), they also can reduce triglyceride levels by 25 to 30 percent but have a negligible impact on raising HDL levels. Statins are even more successful when boosted by the addition of soluble fiber (such as Metamucil or psyllium), which can be purchased in health food and vitamin stores.
Statins are effective regardless of gender or history of a heart attack. Although statins have a minor risk of causing kidney damage and a small increased risk of hemorrhagic stroke (in those with a history of ischemic stroke who take high doses of atorvastatin), they significantly reduce the risk of ischemic stroke.
And the benefits of statins far outweigh their risks, according to a 2018 study published in the European Heart Journal. Researchers found no evidence of adverse effects on cognitive function or link to dementia or Parkinson’s disease in statin users.
No two statins are the same. Some lower cholesterol further than others, and certain statins have additional beneficial properties. For instance, researchers found that maximum doses of rosuvastatin and atorvastatin are similarly effective in reversing the buildup of cholesterol plaques in the coronary artery walls after 24 months of treatment. Your doctor will decide which statin and dose is most appropriate for you.
Overwhelmingly positive results from large, well-designed clinical trials show that statins reduce fatal and non-fatal heart attacks, strokes, and the need for revascularization in people with CAD. They’ve also been shown to have a wide range of other beneficial effects. Studies found that every 40 mg/dL reduction in LDL achieved with statins is associated with a 19 percent reduction in cardiac death and a 12 percent reduction in all-cause mortality and fewer strokes, heart attacks, and revascularization procedures.
How much a person benefits from statin therapy depends on the individual risk of having an event and the lowest level of LDL that’s achieved. The lower the LDL, the greater the benefit, particularly when blood pressure levels are normal (less than or equal to 120 mmHg).
Statins also benefit healthy patients with elevated cholesterol by preventing a first heart attack. They’re thought to do this by stabilizing the core of soft atherosclerotic plaques, making them less likely to rupture.
How Safe are Statins? Overall, statins have been deemed safe and their many positive effects are enduring. Side effects are generally minimal and include muscle pain or weakness (myalgia). When these occur, most simply stop taking the drug. However, the risk of heart attack increases exponentially when statin therapy is discontinued.
Statins are so valuable in reducing the risk of heart attack and stroke that European experts issued a consensus statement advising physicians on how to treat patients who struggled with their use. Their advice was to stop the drug for two to four weeks, then try a different statin. One study found 70 percent of patients who couldn’t tolerate two types of statins were able to tolerate a third. A different study found that 92 percent of patients were still taking the second statin one year later.
Patients who experience muscle pain when taking statins should visit their doctor to make sure the pain is related to statin treatment. They typically will take a blood test that rules out rhabdomyolysis, a rare but serious disease that causes muscle tissue to break down. Some patients find that muscle pain can be controlled by taking high doses of coenzyme Q10, which is available over the counter at pharmacies. Again, talk to your doctor before making any changes.
Important Facts About Statins. In the past, statin users required routine periodic monitoring of their liver enzymes. Today, these tests are performed only before starting statin therapy and if indicated thereafter.
Statin labels carry a warning about the potential for generally non-serious and reversible cognitive side effects such as memory loss and confusion, as well as reports of increased blood sugar and glycosylated hemoglobin (HbA1c) levels.
There are some situations in which lovastatin either shouldn’t be used or should be used in limited doses (for example, when taken with certain medicines that can increase the risk for muscle injury).
Statin-takers should limit their alcohol intake and inform a doctor if they start an antibiotic or anti-fungal medication; these may adversely affect the liver if taken with a statin. If you have any questions or concerns about statins, ask your physician.
PCSK9 Inhibitors
Unlike statins, which block the production of cholesterol in the liver, PCSK9 inhibitors block the enzyme of the same name, allowing more LDL cholesterol to be removed from the blood. It does so by binding to LDL receptors, resulting in a decrease in “bad” cholesterol levels.
The FDA has approved two PCSK9 inhibitors: alirocumab (Praluent) and evolocumab (Repatha). Unlike statins, which are generally taken daily, PCSK9 inhibitors are given as injections once every two to four weeks.
PCSK9 inhibitors are so powerful that when they’re combined with statins, they can lower LDL cholesterol to rock-bottom levels. In a 2017 trial known as FOURIER, those who added evolocumab to statin therapy noticed a 15 percent lower risk of heart attack, stroke, coronary death, need for revascularization, and unstable angina requiring hospitalization. This makes the PCSK9 inhibitor highly valuable for those with LDL levels that are much higher than normal due to genetic conditions. It also gives patients with genetically high cholesterol a chance to prevent heart disease.
PCSK9 inhibitors also can be used in patients who can’t achieve adequately low LDL levels on statins alone and in patients who can’t tolerate the side-effects caused by statins.
Now for the downside: Despite their excellent LDL-lowering ability, PCSK9 inhibitors are expensive and some patients have difficulty getting their prescription covered.
Cholesterol Absorption Inhibitors
Ezetimibe (Zetia), a cholesterol absorption inhibitor, works by reducing the amount of cholesterol absorbed through the digestive tract. This drug was developed for use in addition to statins, but it isn’t as effective as a statin if used alone.
In studies, patients who were unable to reach their LDL goal on statins were able to reduce their LDL level an additional 25 percent by adding ezetimibe. Research showed that ezetimibe can reduce total cholesterol by about 13 percent, LDL by 18 percent, and triglycerides by 8 percent. Plus, it will slightly increase HDL.
A clinical trial known as IMPROVE-IT compared the combination of simvastatin and ezetimibe (Vytorin) to simvastatin alone in 18,144 patients admitted to the hospital with heart attack. The addition of ezetimibe resulted in a small but significant decrease in cardiovascular events.
Niacin
Niacin, or nicotinic acid, is a component of the vitamin B complex (vitamin B3), which has been used since the 1950s to modify cholesterol levels. When taken in large doses, niacin may lower LDL by as much as 25 percent—an effect similar to that of the lower-potency statins.
Cardiologists used to prescribe niacin to raise HDL. However, a large-scale, NIH-funded clinical trial (AIM-HIGH) was halted early in May 2011 when the addition of niacin to a statin did not reduce the risk of heart attack or stroke over treatment with a statin alone.
Another recent large trial (HPS2-THRIVE) yielded similarly discouraging results. As a result, niacin is no longer used to raise HDL, but it can be combined with a statin to lower LDL to its desired goal.
That said, niacin can be used safely without statins. The downside: Its side effects (namely skin flushing and itching) can be bothersome enough that up to one-third of patients stop taking it. These uncomfortable symptoms can be largely avoided by using extended-release formulations such as Niaspan or by taking low-dose aspirin 30 to 60 minutes before niacin. Also, avoiding alcoholic beverages or hot beverages such as coffee or tea two to three hours before taking niacin will help reduce flushing. It’s best to take niacin with food or at bedtime.
Although over-the-counter niacin formulations may be attractive to many patients seeking a “natural” alternative to cholesterol treatment, remember that such brands are considered dietary supplements and aren’t subject to the same federal regulations as prescription drugs like Niaspan.
Preparations listing “nicotinic acid” in the contents have the active ingredient you want. If the label says “no-flush” or “flush-free” niacin, or if the contents list “inositol hexaniacinate” as an ingredient, don’t buy it. These products have no detectable biological effect in humans and won’t alter cholesterol levels.
Fibrates
Fenofibrate (Tricor, Antara) and gemfibrozil (Lopid) are more effective at lowering triglycerides and raising HDL than they are at lowering LDL. Fibrates are generally used only in selected patients, particularly those with mixed hyperlipidemias (elevations in both triglycerides and LDL).
Fibrates have been shown to lower the risk of cardiovascular events by 10 percent and coronary events by 13 percent. Studies included both primary and secondary prevention patients with and without cardiovascular disease. The trials also found that fibrate therapy reduced coronary events and was well tolerated.
The downside: Combining statins and fibrates can increase the likelihood of muscle pain three- to five-fold.
Bile Acid Sequestrants
Bile acids are made by the liver and help break down fats. They’re stored in the gallbladder for release following a meal and are necessary for the absorption of lipids from food.
Our bodies can’t break down cholesterol, and since it’s eliminated in our stool, most bile acids are absorbed and reused. Bile acid sequestrants such as colestipol (Colestid), colesevelam (Welchol), and cholestyramine (Questran) bind bile acids in the intestine, boosting their excretion in the stool.
The result is a reduction in the amount of bile acid that’s reused and returned to the liver. The liver then has to produce more bile acids to make up for those lost in the stool. To do so, it must convert more cholesterol into bile acids, thus lowering the level of LDL cholesterol and triglycerides and increasing HDL.
Since bile acid sequestrants aren’t as potent as statins, niacin, or ezetimibe, they’re normally used only in patients who are intolerant to more effective drugs or to those who require a third or fourth agent to reach their LDL goal.
BP‑Lowering Medications
High blood pressure is a risk factor for the development of CAD. Consistent use of blood pressure medications to lower blood pressure to normal levels can reduce the chance of heart attack and stroke. For this reason, major medical societies recommend maintaining a systolic blood pressure of 140 mmHg or less.
A major clinical trial known as SPRINT found that lowering systolic blood pressure to less than 120 mmHg in patients at high risk of coronary artery disease may lower the combined risk of heart attack, stroke, heart failure, and cardiovascular death an additional 25 percent. When these endpoints were examined individually, the benefits were even more striking.
While achieving a systolic blood pressure as low as 120 mmHg may have benefits, the corresponding drop in diastolic blood pressure has risks. Doctors are now being warned that patients’ diastolic blood pressure should avoid dropping below 70 mmHg, and never below 60 mmHg.
Many antihypertension medications are available. If one drug doesn’t do the job, your doctor may try another. A combination of two or more different types is common when blood pressure resists control. A few months of trial and error may be needed to find the right drug or combination that works best for you and has the fewest side effects.
Diuretics
Diuretics cause the kidneys to excrete more salt. Since water tends to follow the salt, more water is also excreted. Diuretics enhance the effectiveness of other antihypertension drugs. Many diuretics are available in generic form.
Beta-Blockers
This class of drugs prevents the hormone adrenaline (also called epinephrine) and related compounds from raising heart rate and cardiac output. They do this by preventing adrenaline from interacting with one of its cellular receptors, called a beta-adrenergic receptor. As a result, blood pressure drops and stress on the heart is relieved.
Whether a beta-blocker is right for you depends on your medical history. Since beta-blockers can sometimes cause fatigue, weight gain, depression, and erectile dysfunction, they aren’t first-line drugs for all patients with hypertension.
Calcium-Channel Blockers
For muscle cells to contract, dissolved calcium must quickly enter cells through protein channels in the cell membrane. Restricting or blocking calcium hinders the muscles’ ability to contract. When the muscle is surrounding an artery, the artery can’t constrict as much, which prevents blood pressure from increasing. Calcium-channel blockers (CCBs) “plug” the calcium channel, lowering blood pressure and controlling angina.
Beware: If you take a CCB, the antibiotics clarithromycin, erythromycin, and telithromycin may increase the risk that your blood pressure will drop to dangerously low levels.
ARBs and ACE Inhibitors
Angiotensin-converting enzyme (ACE) inhibitors reduce the production of a compound in the blood called angiotensin II, which constricts arteries and raises blood pressure.
Angiotensin II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors on blood vessels. They are as effective as ACE inhibitors at lowering blood pressure and may have the unique quality of preventing dementia.
An analysis of multiple clinical trials published in 2012 showed that ACE inhibitors were associated with a 10 percent reduction in all-cause mortality over four years in patients with hypertension. Patients taking other blood pressure-lowering drugs didn’t experience this advantage.
For patients diagnosed with peripheral artery disease and intermittent claudication (pain in the calf that occurs while walking and disappears with rest), 24 weeks of treatment with the ACE inhibitor ramipril (Altace) has proven to be effective in improving and physical health. In one small pilot study, ramipril was associated with a 77 percent increase in average pain-free walking time and a 123 percent increase in maximum walking time.
Those who take ACE inhibitors or ARBs should ensure that their kidney function is closely monitored. Even small rises in creatinine levels are associated with increased risk of end-stage kidney disease, heart attack, heart failure, or death.
Beware: Multiple pharmaceutical companies have recalled ARBs like irbesartan, as well as valsartan- and losartan-containing drugs, due to an increased risk of cancer.
Combination Drugs
Taking medication can be cumbersome, especially when you have to keep track of multiple pills. Luckily, several combinations of antihypertension drugs and hypertension medicines along with other heart medications are available in a single tablet, making it easier to keep track of what you’re taking. These combinations can be highly effective in preventing heart attack and stroke while simplifying pill taking.
Diabetic Risk-Reducing Medications
People with diabetes are at a greatly increased risk for cardiovascular disease. The good news: Certain medications prescribed to control diabetes also may lower the risk of heart failure and could prevent cardiac death.
People taking drugs to control glucose levels should take statins and aspirin, even if their lipid profile is normal or close to normal. High blood pressure should also be treated aggressively.
Drugs to Manage Angina
Most heart attacks don’t come with a warning. In fact, only 20 percent of them are accompanied by angina symptoms (e.g., chest pain brought on by exertion or anxiety and relieved by rest). Plus, about 50 percent of men and 64 percent of women who die suddenly from CAD have no symptoms of the disease.
Since those with any risk factor for CAD are in danger of atherosclerosis, it’s important to take steps to stop or slow the progression before symptoms develop. By the time you experience signs, you may already be having a heart attack.
If you do experience symptoms, your doctor may order a battery of tests. The results will help determine your treatment. If your symptoms aren’t too severe, relatively infrequent, relieved by rest, and predictable based on the level of exertion, then you’ll likely be diagnosed with chronic stable angina.
Chronic Stable Angina
As described in Chapter 1, chronic stable angina—chest pain that occurs during times of exertion and then disappears with rest—affects about 6.4 million Americans. Every year, some 400,000 new cases are diagnosed. Fortunately, many who suffer from chronic stable angina lead long lives after diagnosis—and even after a heart attack. Although the angina may not disappear completely, many learn how to prevent it from interfering with their activities.
If you’ve been diagnosed with chronic stable angina, your doctor will first try to determine your level of risk, which will dictate your treatment regimen. Invasive treatments such as an angioplasty or stenting aren’t usually suggested, since they haven’t been shown to improve survival any better than taking medicine. Many with chronic stable angina are prescribed nitrates, a beta-blocker, or a calcium-channel blocker, aspirin, and a statin. Some doctors may prescribe ranolazine (Ranexa), which is approved for patients with chronic angina who don’t respond to other anti-angina medications.
Nitrates. These important and useful drugs prevent and relieve angina by rapidly relaxing and dilating the coronary arteries and veins throughout the body. They cause resistance to blood flow to diminish, thereby increasing blood and oxygen delivery to the heart muscle and decreasing the heart’s workload. The result: Reduced angina.
There are several nitrates from which to choose. Among them are nitroglycerin, isosorbide dinitrate (Isordil), and isosorbide mononitrate (Imdur). All are available in oral, extended-release capsules and transdermal patches for absorption through the skin.
The most rapidly acting nitrate is nitroglycerin. A pill dissolved under the tongue, nitroglycerine provides quick angina relief. A metered spray known as Nitrolingual Pumpspray also is available to spray nitroglycerin under the tongue. Nitroglycerin degrades rapidly on exposure to air, so it must be kept in a cool, dark place and replaced when it reaches its expiration date.
Relief should begin to occur within one or two minutes, but the effect lasts only about an hour. Nitroglycerin also can be taken in anticipation of angina—usually five or 10 minutes before any physical activity or emotional stress that might spark an episode.
Beta-Blockers. Beta-blockers are used to treat hypertension, but they also are effective in preventing angina during exercise, reducing the incidence of cardiac events, and improving survival rates after a heart attack in people with stable angina.
Beware: Certain medical conditions can make beta-blockers risky. Patients with stable angina should avoid beta-blockers if they also have:
- A very slow heart rate (severe bradycardia), including a condition that blocks the transmission of electrical signals from the atria to the ventricles called high-degree atrioventricular block.
- Atria that beat abnormally or irregularly (sick sinus syndrome).
- Severe, decompensated left ventricular heart failure.
- Severe asthma or chronic obstructive pulmonary disease (emphysema or chronic bronchitis).
Calcium-Channel Blockers. Another family of antihypertension medications, calcium-channel blockers are used in patients who can’t take beta-blockers or for whom beta-blockers are ineffective in managing their angina.
Nitrates plus beta-blockers or calcium-channel blockers can be more effective when used together. The most efficient combination appears to be a slow-release or long-acting calcium-channel blocker of the dihydropyridine type—for example, amlodipine (Norvasc)—plus a beta-blocker.
However, a beta-blocker in combination with one of the nondihydropyridine calcium-channel blockers, such as diltiazem (Cardizem) or verapamil (Covera-HS), can cause bradycardia (slow heart rate) and low blood pressure, which can result in fatigue. Note: Diltiazem and verapamil may be effective in treating stable angina when beta-blockers cannot be tolerated.
Aspirin. Inexpensive, accessible, and generally well-tolerated, aspirin outperforms newer heart medications in some patients. An antiplatelet medication, aspirin prevents platelets from sticking together and forming blood clots, which can block blood flow in coronary arteries during unstable angina and heart attack. Aspirin has been shown to be useful in preventing angina from evolving into something more serious and life threatening and unequivocally has been shown to reduce deaths from heart attack in multiple large studies.
Beware: Although aspirin is available over the counter, it’s a powerful medication, and taking too much of it may increase the risk of major bleeding.
If you have stable angina, your doctor will likely prescribe low-dose daily aspirin unless you have stomach distress, are prone to heartburn, or have had an ulcer. If so, a medication to block the release of stomach acid may be needed for aspirin to be tolerated.
For people with aspirin allergies, clopidogrel (Plavix), ticagrelor (Brilinta) or prasugrel (Effient) are alternatives. Anyone at higher risk for heart attack may benefit from taking one of these drugs in addition to aspirin.
In some patients, aspirin fails to prevent platelets from sticking together. The term “aspirin resistance” has been coined to explain this phenomenon. Other patients are resistant to clopidogrel. This may occasionally occur, but new findings show that some patients simply need higher doses of these medications to prevent blood clots. In too many cases, blood clots occur because patients stop taking these medications without their doctor’s permission. (See “The Great Aspirin Debate” in Chapter 2.)
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