Appendix Medication Guide: Heart Disease

Table 10: Blood pressure medications

ACE inhibitors

Generic name

Brand name

Use

Side effects

Comments

captopril

Capoten

Inhibit angiotensin-converting enzyme (ACE) from activating the hormone angiotensin. Angiotensin signals the body to constrict blood vessels, thereby raising blood pressure. ACE inhibitors dilate arteries, decrease the resistance to blood flow in vessels, and lower blood pressure.

Persistent dry cough, altered taste sensation, rash and other allergic reactions; may cause kidney damage and, rarely, decrease the number of white blood cells.

May take several weeks to achieve the full effect; kidney function should be monitored; usually taken two or three times per day.

enalapril

Vasotec

Usually taken once or twice a day; may be used alone or in combination with other medications.

lisinopril

Prinivil, Zestril

quinapril

Accupril

benazepril

Lotensin

fosinopril

Monopril

moexipril

Univasc

ramipril

Altace

trandolapril

Mavik

Angiotensin-receptor blockers (ARBs)

Generic name

Brand name

Use

Side effects

Comments

candesartan

Atacand

Prevent angiotensin from exerting its blood vessel–constricting effects, thereby lowering blood pressure.

Persistent cough, elevated potassium levels, dizziness, headache, drowsiness, diarrhea, abnormal taste sensation, rash.

May be an alternative for people who can't take ACE inhibitors.

irbesartan

Avapro

losartan

Cozaar

valsartan

Diovan

Beta blockers

Generic name

Brand name

Use

Side effects

Comments

propranolol

Inderal

Lowers demand on heart by slowing heart rate, decreasing force of contractions, and reducing blood pressure.

Can worsen or provoke asthma or pain in legs due to narrowed arteries; can also worsen congestive heart failure, or provoke Raynaud's phenomenon (spasm of blood vessels to hands); sometimes cause fatigue or depression, impotence, hallucinations, or bad dreams; elderly people are more prone to these latter side effects.

Available in short-acting and extended-release forms.

nadolol

Corgard

Long-acting drug usually taken once per day; do not stop taking suddenly.

timolol

Blocadren

Usually taken twice per day.

metoprolol

Lopressor, Toprol XL

Less likely than propranolol to cause wheezing and spasm of arteries outside of the heart.

Metoprolol and other "cardioselective" beta blockers can be used with caution by people with asthma. Although they are safer for these people than propranolol, cardioselective agents can still cause side effects.

atenolol

Tenormin

Similar to metoprolol; often taken once per day.

Other beta blockers not included in this table include pindolol (Visken), acebutolol (Sectral), labetalol (Normodyne, Trandate, others), penbutolol (Levatol), carteolol (Cartrol), betaxolol (Kerlone), bisoprolol (Zebeta), and combination medications with a beta blocker as one ingredient. Although most of these medications are often used to treat hypertension, not all of them have been evaluated in large, randomized trials for their ability to help people who have coronary disease.

Calcium-channel blockers

Generic name

Brand name

Use

Side effects

Comments

diltiazem

Cardizem, Dilacor XR

Dilates blood vessels and lowers oxygen demands on the heart by slowing heart rate and decreasing the force of the heart's contractions.

Headache, flushing, nausea, weakness, drowsiness, fluid retention, constipation, excessively slow heart rate.

Low rate of side effects in most people; available in long-acting preparations.

nifedipine

Procardia, Adalat

Dilates blood vessels but does not slow heart rate.

Headache, swelling of legs (edema), flushing, palpitations, dizziness, constipation.

Long-acting preparation; may reduce side effects, but swelling of legs and ankles remains a problem with both short- and long-acting formulations.

nicardipine

Cardene

Dilates coronary arteries more than other blood vessels.

amlodipine

Norvasc

Lower blood pressure and dilate coronary vessels.

Higher doses cause similar side effects to those caused by nifedipine.

Can be taken once daily; with less than the highest doses, possibly fewer side effects than from nifedipine.

felodipine

Plendil

verapamil

Calan, Isoptin, Verelan

Of available drugs in this class, is most likely to slow heart rate.

Constipation, excessively slow heart rate, worsened heart failure.

Available in long-acting preparations; constipation limits use in some people.

Table 11: Cholesterol-lowering medications

Statins (HMG-CoA reductase inhibitors)

Generic name

Brand name

Use

Side effects

Comments

lovastatin

Altoprev, Mevacor

Blocks the main liver enzyme that promotes LDL cholesterol production. Lowers LDL and triglycerides; raises HDL.

Abdominal pain, constipation, diarrhea, indigestion, nausea, flatulence, heartburn, dizziness, fatigue, headache, rash, blurred vision, muscle pains, damage to muscle or liver, sleep disturbances.

Should not be taken by heavy drinkers or by people with active or chronic liver disease, and should be used with caution by those taking gemfibrozil, cyclosporine, clofibrate, erythromycin, or niacin. Can increase the effect of warfarin. FDA advises that Crestor be given at lowest starting doses to people over age 65, those who have hypothyroidism or kidney disease, and Asian Americans, to reduce risk for severe muscle damage and kidney failure.

pravastatin

Pravachol

simvastatin

Zocor

atorvastatin

Lipitor

fluvastatin

Lescol

rosuvastatin

Crestor

Bile acid binders

Generic name

Brand name

Use

Side effects

Comments

cholestyramine

Questran

Binds to and prevents absorption of bile acids in the gut. Lowers LDL; raises HDL; elevates triglycerides.

Constipation, heartburn, "bloated" feeling, nausea, flatulence, tendency to bleed easily; decreased absorption of certain drugs and vitamins A, D, and K.

Should not be taken by people with familial dysbetalipoproteinemia, a very high triglyceride level, or history of severe constipation, and should be used with caution by those with moderately elevated triglycerides. Other medications should be taken at least one hour before or four hours afterward. Vitamin supplementation may be necessary.

colestipol

Colestid

colesevelam

WelChol

Ezetimibe

Generic name

Brand name

Use

Side effects

Comments

ezetimibe

Zetia

Works by preventing cholesterol in food from reaching bloodstream. Lowers LDL and triglycerides.

Uncommon but may include fatigue, gastrointestinal problems, muscle pain, fever, headache, runny nose, sore throat.

Helpful for people who have not responded to statins. Also boosts effectiveness of statins.

Fibric acid derivatives (fibrates)

Generic name

Brand name

Use

Side effects

Comments

fenofibrate

TriCor

Increases liver's breakdown of VLDL, and blocks the activity of proteins involved in transporting cholesterol. Lowers triglycerides; variable effect on LDL cholesterol.

Nausea, vomiting, diarrhea, indigestion, flatulence, abdominal pain, headache, cardiac arrhythmias, dizziness, fatigue, muscle pain and weakness, rash, hair loss, abnormal liver and/or muscle enzymes.

Should not be taken by people with either liver problems or severe kidney problems or by those with gallbladder disease. Usually should not be taken in combination with any of the statins. Can increase the effects of warfarin. Liver functions and blood counts should be checked before and throughout therapy.

gemfibrozil

Lopid

Niacin

Generic name

Brand name

Use

Side effects

Comments

Niacin (nicotinic acid)

Niacor, Nicolar, others

Reduces liver's production of VLDL. Lowers total cholesterol, LDL, and triglycerides; raises HDL.

Flushing (especially with crystalline preparations), rash, headache, nausea, vomiting, diarrhea, flatulence, indigestion, low blood pressure, elevated blood levels of uric acid, high blood sugar, activation of peptic ulcer, cardiac arrhythmias, dry skin, abnormal liver enzymes (especially with sustained-release preparations).

Especially effective in combination with bile acid binders. Should not be used by people with chronic liver disease, active peptic ulcer, or arterial bleeding, and should be taken only with great caution by those with gallbladder disease, diabetes, severe gout, or high blood levels of uric acid. Tests of blood glucose, uric acid, and liver functions need to be done regularly.

Table 12: Other cardiovascular medications

Anticoagulants

Generic name

Brand name

Use

Side effects

Comments

heparin

Calciparine, Liquaemin

Given to hospitalized people following a stroke, transient ischemic heart attack, or unstable angina to reduce risk for blood-clot formation.

Bleeding from any tissue or organ, pain and redness at the injection site, thrombocytopenia (abnormal reduction in number of platelets).

Unsafe for people with bleeding problems. Bleeding complications more likely in older people, especially women, who may be more sensitive to the drug's effects.

warfarin

Coumadin

Used for long-term anticoagulation by people who have been discharged from the hospital and are at high risk for recurrent stroke; especially effective for reducing stroke risk in people with atrial fibrillation.

Bleeding from any tissue or organ.

Not recommended for people who have active ulcers. Prothrombin time must be measured regularly. Certain medications including antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and barbiturates may boost the effects of warfarin.

Nitroglycerin and long-acting nitrates

Generic name

Brand name

Use

Side effects

Comments

nitroglycerin

Nitrocot, Nitrostat, others

Lowers demand on heart by dilating blood vessels.

Headache, flushing, low blood pressure.

Placed under tongue to provide relief from or to prevent angina attack; a short-acting preparation.

nitroglycerin spray

Nitrolingual

One to two squirts onto or under the tongue to treat or prevent angina.

Isosorbide mononitrate

Imdur, Ismo

Long-acting nitrate preparation; taken periodically during the day to decrease the frequency of angina.

Nitroglycerin ointment

Nitrobid, Nitrol

Placed on the skin and covered with a dressing, allowing slow absorption of the medication over several hours; removal of ointment recommended for several hours each day to provide a period without exposure to nitroglycerin.

Nitroglycerin patch

Deponit, Minitran, others

Convenient; removal of patch recommended for several hours each day to provide a period without exposure to nitroglycerin.

Platelet aggregation inhibitors

Generic name

Brand name

Use

Side effects

Comments

clopidogrel

Plavix

Antiplatelet drug that inhibits platelet aggregation. This effect persists for the life of the platelet. Used for the treatment of unstable angina and/or prevention of heart attacks; also used to prevent blood clots following angioplasty and stent procedure.

In a comparison with aspirin, rash and diarrhea occurred slightly more frequently with clopidogrel than with aspirin. But the risk for a reduction in white blood cell count is small and no different than with aspirin.

This drug's effect on platelets begins shortly after the drug is administered but subsides within several hours, even in people taking aspirin. Clopidogrel has been found to be slightly but significantly superior to aspirin in preventing ischemic vascular events.

abciximab

ReoPro

Inhibits the ability of platelets to clump and form blood clots by binding to the site where fibrinogen, a blood protein, attaches to the platelet. Fibrinogen normally forms a web between platelets, "gluing" them together, or causing them to clump. Used with aspirin and heparin during angioplasty to prevent sudden heart attack in people at high risk for this complication.

Minor side effects include nausea, vomiting, slowed heartbeat, swelling in the arms and legs, vision changes, and fluid buildup in the lungs. The most serious side effect is the risk for major bleeding in other parts of the body, specifically the brain, gastrointestinal tract, abdomen, urinary tract, and the site where the PTCA catheter entered the body. Platelet counts may fall and require transfusion of these blood cells.

Unsafe for people with recent bleeding episodes, bleeding problems, or recent surgery. People particularly prone to bleeding problems when taking this drug include those who:

• weigh less than 165 pounds

• are older than 65 years

• have a history of gastrointestinal disease

• are taking other anticlotting drugs.

Thrombolytic agents

Generic name

Brand name

Use

Side effects

Comments

Recombinant tissue-plasminogen activator (tPA)

Activase

Dissolves blood clots following a myocardial infarction or ischemic stroke.

Bleeding from any tissue or organ.

Must be given intravenously within three hours of ischemic stroke that has been confirmed by a CT scan; can be life-threatening for people who have had a hemorrhagic stroke; unsafe for people who've had a previous stroke or head injury or who have uncontrolled hypertension, a bleeding disorder, aneurysm, or arteriovenous malformation.

streptokinase

Streptase

Experimental stroke treatment used only in clinical trials; may be delivered via a catheter directly to the blood clot; unsafe for people who've had a previous stroke or head injury or who have uncontrolled hypertension or a bleeding disorder.

urokinase

Abbokinase