CARDIAC MEDICATIONS

Strengthen the heart, decrease heart rate, decrease blood pressure, decrease fluid retention, improve symptom control

 

  1. HOW DOES THE MEDICATION WORK? (Mechanism of action)

  2. WHAT IS THE REASON FOR THE MEDICATION? (Indications)

  3. PATIENT ADVICE (Administration, Side-effects, Interactions, Monitoring – as applicable)

 

Anticoagulants

e.g. warfarin, rivaroxaban (Xarelto), apixaban (Eliquis), enoxaparin

  • Prevent the blood from clotting as quickly or as effectively as normal (decrease clotting tendency of the blood)

  • Warfarin blocks the effects of Vitamin K which is needed to make some blood clotting factors; blocking Vitamin K prevents blood clots from forming so easily by increasing the time it takes to make the solid protein fibrin (strands of fibrin form a meshwork and trap blood cells and platelets which form a solid clot)

  • Rivaroxaban and apixaban stop a blood chemical called thrombin from being made, which in turn prevents fibrin from being made

  • Used to treat and prevent harmful clots that may form in your blood vessels (arteries or veins) and prevent clots from becoming larger and causing more serious problems (heart attack, stroke, deep vein thrombosis or pulmonary embolism)

  • Most common side-effect of all anticoagulants is bleeding

  • Look out for and report to your doctor any signs and symptoms of bleeding: easy and severe bruising, passing blood in your urine, bloody or dark stools, prolonged nosebleeds, bleeding from the gums, vomiting blood

  • With warfarin, regular blood tests are required to measure how quickly the blood clots, and the dose will be adjusted accordingly – always keep your appointments and you should never adjust a dose without consulting your doctor

  • Never double a dose because you missed a dose

  • You should always tell the healthcare professional looking after you (including dentist) that you are taking an anticoagulant (always carry an anticoagulation identification card/tag with you, especially for warfarin)

  • If you have surgery or an invasive test, you may need to temporarily stop taking the anticoagulant – consult your doctor

  • Take extra care when brushing teeth or shaving to avoid cuts and bleeding gums; Consider using a soft toothbrush, electric razor

  • Some foods and beverages may interact with warfarin (avoid consuming large amounts of certain foods or drinks, including; kale, spinach, brussels sprouts, broccoli, asparagus, green tea, cranberry juice, alcohol)

  • Do not start new medications, herbals, or supplements without consulting your doctor/pharmacist

  • Rivaroxaban should be taken with food

  • Avoid taking ibuprofen or other painkillers in the same family since they can increase your risk of bleeding if taken together

  • It is important that you attend to your scheduled outpatient visits for follow-up and monitoring

 

Antiplatelets

e.g. aspirin, clopidogrel, dipyridamole, prasugrel (Effient)

  • Prevent blood clots from forming by inhibiting blood platelets from sticking together

  • Help to prevent clotting in patients who have had a heart attack (myocardial infarction) to reduce the chance of having another one, and in unstable angina to prevent a heart attack from occurring

  • Help to prevent clotting in patients who have had an ischaemic stroke or transient ischaemic attack

  • Help to prevent clotting in patients with peripheral vascular disease

  • May be prescribed preventively when plaque buildup is evident but there is not yet a major blockage in the artery

  • Patients are usually prescribed aspirin combined with another antiplatelet drug (dual antiplatelet therapy), such as after percutaneous coronary intervention (angioplasty), to decrease the risk of thrombotic complications

  • Antiplatelets can irritate the lining of the stomach, hence gastrointestinal side-effects such as indigestion and stomach aches may occur à it is important to take with food

  • Avoid taking ibuprofen or other painkillers in the same family since they can increase your risk of bleeding if taken together

  • Inform your doctor if you experience side-effects such as severe bruising, blood in urine or stools, prolonged nosebleeds

  • It is important that you attend to your scheduled outpatient visits for follow-up

Angiotensin-converting enzyme (ACE) inhibitors

e.g. enalapril, perindopril, lisinopril

  • Reduce the activity of angiotensin-converting enzyme, which is an enzyme responsible for hormones that help to control your blood pressure

  • ACE inhibitors inhibit or limit this enzyme, making your blood vessels relax and widen; this lowers your blood pressure and improves blood flow to your heart muscle

  • By making the heart’s work easier or more efficient, ACE inhibitors also improve the efficiency of the kidneys

  • Commonly used to treat or improve symptoms of high blood pressure (hypertension) and heart failure, and are often prescribed following a heart attack to limit further damage

  • Help in reducing hospital admissions and improving life expectancy in patients with heart failure

  • ACE inhibitors are generally well-tolerated, but they may cause unwanted effects upon starting the medication, including dizziness, headache and fatigue, which usually improve after a few days. Consult your doctor if they do not improve.

  • A possible side-effect is a dry, irritating cough; If you develop this side-effect, let your doctor know as soon as possible, and an alternative medication may need to be prescribed (ARBs are available alternatives and studies have shown that ARBs have similar beneficial effects as ACE inhibitors in lowering blood pressure and helping to manage heart failure, but without causing patients to develop a cough)

  • Take first doses sitting down, preferably at bed time, due to the risk of hypotension

  • ACE inhibitors are often prescribed with other medications for a synergistic effect, such as with diuretics and beta-blockers; Together these medications have an enhanced effect at lowering blood pressure, hence it is important to report to your doctor as soon as possible if you feel dizzy

  • You should persist with taking your medication even if your blood pressure is controlled (adherence) - stopping the medication will cause your blood pressure to increase

  • It is important that you attend to your scheduled outpatient visits for routine blood tests and follow-up monitoring, such as to monitor kidney function

  • If you become pregnant, the medication should be stopped as soon as possible under the guidance of your doctor

 

Angiotensin II receptor blockers (ARBs)

e.g. valsartan

  • ARBs reduce the action of the hormone angiotensin II by blocking receptors that the hormone acts on

  • Angiotensin II has a powerful constricting effect on blood vessels, increasing blood pressure and also stimulates salt and water retention in the body, which further increases blood pressure à Blocking the action of angiotensin II helps to lower blood pressure and prevent damage to the heart and kidneys

  • Used to treat or improve symptoms of high blood pressure (hypertension) and heart failure, and may be prescribed following a heart attack to limit further damage

  • Help in reducing hospital admissions and improving life expectancy in patients with heart failure

  • ARBs are generally well-tolerated, but they may cause some unwanted effects upon starting the medication, including dizziness, headache and fatigue, which usually improve after a few days. Consult your doctor if they do not improve.

  • ARBs are often prescribed with other medications for a synergistic effect, such as with diuretics and beta-blockers. Together these medications have an enhanced effect at lowering blood pressure, hence it is important to report to your doctor if you feel dizzy

  • You should persist with taking your medication even if your blood pressure is controlled (adherence) – stopping the medication will cause your blood pressure to increase

  • It is important that you attend to your scheduled outpatient visits for routine blood tests and follow-up monitoring, such as to monitor kidney function

  • If you become pregnant, the medication should be stopped as soon as possible under the guidance of your doctor

 

 

Angiotensin receptor neprilysin inhibitors (ARNIs)

Sacubitril/valsartan (Entresto)

  • ARNIs are a drug combination of a neprilysin inhibitor and an ARB

  • Neprilysin is an enzyme that breaks down natural substances in the body that open narrowed arteries. By limiting the effect of neprilysin, the effect of these substances is increased and artery opening and blood flow are improved, sodium (salt) retention is reduced, and the strain on the heart is decreased

  • Used for the treatment of heart failure

  • May cause dizziness, headache, hypotension, nausea

  • Is important that you attend to your scheduled outpatient visits for routine blood tests and follow-up monitoring, such as blood pressure, renal function

 

 

Beta-blockers

e.g. atenolol, carvedilol, metoprolol, sotalol, labetolol

  • Block the release of the stress hormones adrenaline and noradrenaline in certain parts of the body

  • This results in slowing of the heart rate and reduces the force at which blood is pumped around your body

  • Used to lower blood pressure (hypertension)

  • Used to treat chest pain (angina) and decrease the frequency of angina attacks by reducing the oxygen demand of the heart and heart rate

  • Used to help prevent future heart attacks in patients who have had a heart attack

  • Used to treat heart failure

  • Used to control the irregular heart rhythm in people with atrial fibrillation (by slowing the heart rate, symptoms particularly palpitations and fatigue, are often improved)

  • Help in reducing hospital admissions

  • Beta blockers are usually well-tolerated without significant side-effects

  • Can cause lethargy and fatigue, which can be more noticeable with the first few doses and often settle with time

  • They may cause cold hands and feet, particularly in older people

  • Erectile dysfunction is occasionally a problem for some men who take beta-blockers

  • If you think you are experiencing side-effects, speak to your doctor

  • Do not stop taking a beta-blocker suddenly without consulting your doctor. This is important because when you take a beta-blocker regularly, your body becomes used to it. Stopping it suddenly could cause problems such as palpitations, a recurrence of chest pain or a rise in blood pressure

  • It is important that you attend to your scheduled outpatient visits for follow-up

Calcium channel blockers

e.g. amlodipine, diltiazem, verapamil

  • Interrupt the movement of calcium into the cells of the heart and blood vessels. Calcium is necessary to contract the muscular linings of blood vessels throughout your body. Calcium passes into these cells through special pores in the surface of these cells (ion channels). These channels are blocked by CCBs, thereby reducing the amount of calcium entering the cells of the heart and blood vessel walls. As a result, the blood vessels relax and the heart muscle receives more oxygenated blood, which is how they are able to lower blood pressure and treat chest pain (angina)

  • Some calcium channel blockers also block calcium going into the conducting cells in the heart and have the added effect of slowing the heart rate

  • Used to treat high blood pressure (hypertension), chest pain (angina) caused by reduced blood supply to the heart muscle, and some arrhythmias (abnormal heart rhythms)

  • Most common side-effects are headache, ankle swelling, flushing and palpitations

  • Calcium channel blockers may cause your blood pressure to decrease suddenly, which may result in dizziness

  • If you experience any symptoms, talk to your doctor as soon as possible. Do not stop taking your calcium channel blocker without discussing with your doctor since this could result in a flare-up of your angina.

  • Verapamil may cause constipation

  • It is important that you attend to your scheduled outpatient visits for follow-up

 

 

Lipid regulating drugs/cholesterol lowering medications

 

Statins e.g. simvastatin, atorvastatin, rosuvastatin

Fibrates e.g. fenofibrate, bezafibrate

Ezetimibe (Cholesterol absorption inhibitor)

 

  • Statins disrupt production of cholesterol by blocking an enzyme inside the liver cells; this results in less cholesterol being released into the blood

  • Statins are the most common medications to lower LDL (‘bad’) blood cholesterol levels

  • Drugs other than statins are usually used for patients in whom statins are not effective or who have serious side-effects from statin therapy

  • Take at night as this is when most of your cholesterol is produced

  • Most patients experience no side-effects with statins

  • Muscular aches and pains may be experienced à Report any unexplained muscle pain, tenderness or weakness to your doctor

  • Headache, gastro-intestinal effects (abdominal pain, flatulence, constipation or diarrhoea, nausea and vomiting) may be experienced

  • The benefits of statins are great, so consult your doctor as soon possible if you experience side-effects since the dose may be reduced or the medication may be changed. Do not stop taking your medication without discussing with your doctor.

  • If you take simvastatin, you should not consume grapefruit, grapefruit juice, pomegranate and pomegranate juice as they increase the concentration of the drug in the blood, increasing the risk of side-effects. If you take another type of statin, limit your intake to very small quantities or avoid.

  • It is important that you attend to your scheduled outpatient visits for routine blood tests and follow-up monitoring, such as liver function

 

 

Digoxin

  • Increases the force of the heart's contractions, slows heart rate and improves the filling of the heart ventricles with blood

  • Can be beneficial in treating heart failure and slows certain types of irregular heartbeat (arrhythmias), particularly atrial fibrillation

  • Digoxin can have side-effects if you take the wrong (higher) dose

  • Symptoms that suggest there is too much digoxin in your blood include; nausea, vomiting, diarrhoea, tiredness, insomnia, visual disturbances, palpitations and fainting. Consult a doctor as soon as possible.

  • If you experience heart rhythm disturbances, you must go to the emergency department for an ECG and further monitoring

  • It is important that you attend to your scheduled outpatient visits for routine blood tests and follow-up monitoring

 

Diuretics

e.g. bumetanide, bendroflumethiazide, furosemide

  • Help to remove excess fluids and sodium from the body through urination

  • Help to reduce the heart's workload

  • Decrease the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs

  • Used to help lower blood pressure

  • Improve symptom control in heart failure, such as decreasing swelling (oedema) from excess buildup of fluid in the body

  • Do not take at bedtime to avoid inconvenient urination during the night

  • Caution: hypokalaemia – may need to be prescribed potassium supplementation (signs of hypokalaemia include fatigue, weakness, bilateral calf pain, palpitations, gastrointestinal upset)

  • Caution: dehydration (signs include tachycardia, dizziness upon standing up, thirst, postural hypotension, decreased skin turgor)

  • Consult your doctor if you experience any pain in the joint of the big toe

  • Consult your doctor as soon possible if you experience side-effects since the dose may need to be reduced. Do not stop taking your medication without discussing with your doctor

  • Consult your doctor if you experience any shortness of breath, cough or if you observe swelling in your body such as in the legs, since these symptoms may indicate that the effectiveness of treatment needs to be reviewed

  • It is important that you attend to your scheduled outpatient visits for routine blood tests and follow-up monitoring

 

 

Nitrates

e.g. isosorbide mononitrate, isosorbide dinitrate, glyceryl trinitrate (GTN)

  • Relax blood vessels and decrease blood pressure

  • Increase the supply of blood and oxygen to the heart while reducing the stress on the heart which can ease chest pain (angina)

  • If you use GTN tablets/spray, keep it on you at all times, especially during activity (can be used preventively when chest pain can be expected, such as before exercise, after a meal, emotional stress, sexual activity and in colder weather)

  • GTN tablets/spray should be administered under the tongue (sublingual fast-acting) and are absorbed into the lining of the mouth

  • GTN spray has an expiry date of up to three years, whereas GTN tablets expire 8 weeks after opening; store the tablets in their original container away from sunlight and write the date you opened them to remind you when they need to be replaced; expired tablets will not work as effectively

  • With sublingual (fast-acting) nitrates, when chest pain is experienced, the patient should rest sitting and take 1 tablet every 5 minutes (maximum 3 tablets in 15 minutes) – if pain does not subside with maximum 3 tablets in 15 minutes it is important to seek medical advice

  • If you are prescribed nitrate patches, the recommendation is to only wear them for 12 hours to allow a nitrate-free interval of 8 to 12 hours; this minimises the risk of tolerance

  • Any changes to the dosage or times will need to be discussed with your doctor; inform your doctor if you feel your medication is not effective anymore

  • Most common side-effects include headaches, dizziness, flushing or a warm feeling in the face. These side-effects are not experienced by all patients, however if side-effects are a problem for you, always discuss with your doctor before you stop taking the medication

 

 

Mineralocorticoid receptor antagonists

e.g. spironolactone, eplerenone

  • help the kidneys send unneeded water and salt from your tissues and blood into your urine to be released

  • can ease swelling and water buildup to improve heart health

  • lower blood pressure

  • used in heart failure

 

Antiarrhythmic drugs

e.g. amiodarone, flecainide

  • Have the ability to terminate an arrhythmia and are usually given to prevent abnormal rhythm from occurring or to reduce its frequency or duration

  • Amiodarone has a number of potential side-effects

  • It is important that you attend to your scheduled outpatient visits for routine blood tests and follow-up monitoring, such as liver function, eye examination, thyroid function (for many patient, amiodarone-related thyroid effects can be treated with medication to control thyroid function, but some may need to stop taking the drug. If this happens, dronedarone (Multaq), which is structurally similar to amiodarone, may be substituted as it has no adverse effects on thyroid function)

  • Amiodarone requires use of a high-factor wide-spectrum sunscreen to protect against both long-wave ultraviolet and visible light since the skin may become more sensitive to sunlight (phototoxicity)

  • Flecainide is usually well tolerated but can cause stomach upset (nausea, vomiting)

®© Mario Scicluna
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