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Drug Treatment of Coronary Artery Disease

By Jonathan G. Howlett, MD, Clinical Professor of Medicine;President, University of Calgary;Canadian Heart Failure Society

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The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which branch off the aorta just after it leaves the heart, deliver this blood. Coronary artery disease that narrows one or more of these arteries can block blood flow, causing chest pain (angina) or an acute coronary syndrome. In an acute coronary syndrome, sudden blockage in a coronary artery greatly reduces or cuts off the blood supply to an area of the heart muscle (myocardium). The lack of blood supply to any tissue is termed ischemia. If the supply is greatly reduced or cut off for more than a few minutes, heart tissue dies. A heart attack, also termed myocardial infarction (MI), is death of heart tissue due to ischemia.

There are many different reasons doctors give drugs to people with coronary artery disease:

  • To relieve chest pain by reducing the heart's workload and widening arteries (nitrates, morphine)

  • To prevent angina and acute coronary symptoms from occurring (beta-blockers, calcium channel blockers, sometimes a newer drug, ranolazine)

  • To prevent and reverse coronary artery narrowing from atherosclerosis (angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers, statins, and antiplatelet drugs)

  • To open a blocked artery (clot-dissolving drugs, anticoagulants)

Nitrates

Most people are given nitroglycerin, which relieves pain by reducing the workload of the heart and possibly by dilating arteries. Usually, it is first given under the tongue, then intravenously.

Morphine

Because most people who have had a heart attack are experiencing severe discomfort and anxiety, morphine is often used. This drug has a calming effect and reduces the workload of the heart.

Beta-blockers

Because decreasing the heart’s workload also helps limit tissue damage, a beta-blocker is usually given to slow the heart rate. Slowing the rate enables the heart to work less hard and reduces the area of damaged tissue.

Calcium channel blockers

Calcium channel blockers prevent blood vessels from narrowing (constricting) and can counter coronary artery spasm. All calcium channel blockers reduce blood pressure. Some of these drugs, such as verapamil and diltiazem, may also reduce the heart rate. This effect can be useful to many people, especially those who cannot take beta-blockers or who do not get enough relief from nitrates.

Ranolazine

Ranolazine is a drug used to treat angina in people who continue to have symptoms despite taking all other antianginal therapy. It may be more effective in women than in men.

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) can reduce heart enlargement and increase the chance of survival for many people. Therefore, these drugs are usually given in the first few days after a heart attack and prescribed indefinitely.

Statins

Statins have long been used to help prevent coronary artery disease, but doctors have recently found that they also have short-term benefit for people with an acute coronary syndrome. Doctors give a statin to people who are not already taking one.

Antiplatelet drugs

People who think they may be having a heart attack should chew an aspirin tablet immediately after calling an ambulance. If aspirin is not taken at home or given by emergency personnel, it is immediately given at the hospital. This therapy improves the chances of survival by reducing the size of the clot (if present) in the coronary artery. People may also be given other types of antiplatelet drugs such as clopidogrel or glycoprotein IIb/IIIa inhibitors. Some people are given both aspirin and clopidogrel.

Clot-dissolving drugs

Clot-dissolving drugs (thrombolytic drugs) are given by vein (intravenously) to open the arteries if percutaneous coronary interventions cannot be done within 90 minutes after the person arrives at the hospital.

Anticoagulants

Most people are also given an anticoagulant drug, such as heparin, to help prevent the formation of additional blood clots.

Often, oxygen is given through nasal prongs or a face mask. Providing more oxygen to the heart helps keep heart tissue damage to a minimum.

Drugs Used to Treat Coronary Artery Disease*

Examples

Some Side Effects

Comments

Angiotensin-converting enzyme (ACE) inhibitors

Benazepril

Captopril

Enalapril

Fosinopril

Lisinopril

Moexipril

Perindopril

Quinapril

Ramipril

Trandolapril

Cough, usually dry and metallic

Rash

Rarely, a severe allergic reaction (angioedema)

Possibly worsening of kidney function when people already have kidney disease or when the artery to one of the kidneys is greatly narrowed

These drugs lower blood pressure and treat heart failure and prevent kidney damage in people with high blood pressure or diabetes. They also benefit people who have had heart attacks.

People who have high blood pressure, heart failure, or prior heart attacks and who are treated with an ACE inhibitor live longer than people who do not take an ACE inhibitor.

Angiotensin II receptor blockers

Candesartan

Eprosartan

Irbesartan

Losartan

Olmesartan

Telmisartan

Valsartan

Similar to ACE inhibitors, but cough is much less common

These drugs have equivalent effects and benefits to those of ACE inhibitors. In people with severe high blood pressure or heart failure, these drugs may be used in combination with an ACE inhibitor.

Other drugs

Ranolazine

Dizziness, headache, constipation, and nausea

This drug is used to treat people who continue to have symptoms of angina despite treatment with other drugs.

This drug may be more effective in women than in men.

Anticoagulants

Argatroban

Bivalirudin

Dalteparin

Enoxaparin

Fondaparinux

Heparin

Tinzaparin

Warfarin

Bleeding, especially when used with other drugs that have a similar effect (such as aspirin and other nonsteroidal anti-inflammatory drugs)

These drugs prevent blood from clotting. They are used to treat people who have unstable angina or who have had a heart attack.

Antiplatelet drugs

Aspirin

Clopidogrel

Prasugrel

Ticagrelor

Ticlopidine

Bleeding, especially when used with other drugs that have a similar effect (such as anticoagulants)

With aspirin, stomach irritation

With ticlopidine and less so with clopidogrel, a small risk of reducing the white blood cell count

These drugs prevent platelets from clumping and blood clots from forming. They also reduce the risk of a heart attack. They are used to treat people who have stable or unstable angina or who have had a heart attack.

Aspirin is taken as soon as a heart attack is suspected. People with an allergy to aspirin may take clopidogrel or ticlopidine as an alternative.

Beta-blockers

Acebutolol

Atenolol

Bisoprolol

Carvedilol

Metoprolol

Spasm of airways (bronchospasm)

Abnormally slow heart rate (bradycardia)

Heart failure

Cold hands and feet

Insomnia

Fatigue

Shortness of breath

Depression

Raynaud syndrome

Vivid dreams

Hallucinations

Sexual dysfunction

With many beta-blockers, an increase in the triglyceride level and a decrease in the HDL level

These drugs reduce the workload of the heart and the risk of a heart attack and sudden death. They are used to treat people who have stable or unstable angina or syndrome X or who have had a heart attack.

Calcium channel blockers

Amlodipine

Diltiazem

Felodipine

Nifedipine (sustained-release only)

Verapamil

Dizziness

Fluid accumulation (edema) in the ankles

Flushing

Headache

Heartburn

Enlarged gums

Abnormal heart rhythms (arrhythmias)

With verapamil, constipation

With short-acting, but not long-acting, calcium channel blockers, possible increased risk of death due to heart attack, especially in people who have unstable angina or who have had a heart attack recently

These drugs prevent blood vessels from narrowing and can reverse artery spasm. Diltiazem and verapamil reduce the heart rate. Calcium channel blockers are used to treat people who have stable angina.

Glycoprotein IIb/IIIa inhibitors (a type of antiplatelet drug)

Abciximab

Eptifibatide

Tirofiban

Bleeding, especially when used with other drugs that have a similar effect (such as anticoagulants or thrombolytic drugs)

Reduction of the platelet count

These drugs prevent platelets from clumping and blood clots from forming. They are used to treat people who have unstable angina or who are undergoing percutaneous coronary intervention after a heart attack.

Nitrates

Isosorbide dinitrate

Isosorbide mononitrate

Nitroglycerin

Flushing

Headache

Temporarily fast heart rate (tachycardia)

These drugs relieve angina, prevent episodes of angina, and reduce the risk of a heart attack and sudden death. (However, risk reduction is much less than that with beta-blockers.) They are used to treat people who have stable or unstable angina or syndrome X. For these drugs to remain effective over the long term, people need to go 8 to 12 hours without taking the drug each day.

Opioids

Morphine

Low blood pressure when a person stands

Constipation

Nausea

Vomiting

Confusion (especially in older people)

In people who have had a heart attack, these drugs are used to relieve anxiety and pain if the pain persists despite use of other drugs.

Statins

Atorvastatin

Fluvastatin

Lovastatin

Pravastatin

Rosuvastatin

Simvastatin

Occasionally, muscle aches and pains, but rarely severe muscle pain (myositis)

Rarely, liver damage, but not more commonly than in people who are not taking the drug

These drugs lower cholesterol levels and help to heal damaged arteries, decreasing the chance of having a first or repeated heart attack or stroke.

Thrombolytic drugs

Alteplase

Anistreplase

Reteplase

Streptokinase

Tenecteplase

Rarely, bleeding within the brain (intracerebral hemorrhage) or the digestive tract

These drugs dissolve blood clots. They are used to treat people who have had a heart attack.

*Doctors may use different combinations of drugs depending on the type of coronary artery disease the person has.

Also known as hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors.

HDL = high-density lipoprotein.

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