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 (see also Overview of Coronary Artery Disease).
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 medications to people with coronary artery disease:
To relieve chest pain by reducing the heart's workload and widening arteries (usually nitrates, sometimes morphine or fentanyl)
To prevent angina and acute coronary symptoms from occurring (beta-blockers, calcium channel blockers, and sometimes ranolazine)
To prevent and reverse coronary artery narrowing from atherosclerosis (statins and antiplatelet medications)
To decrease risk of progression of atherosclerosis by controlling blood pressure (angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers [ARBs])
To open a blocked artery (clot-dissolving medications, anticoagulants)
Often, oxygen is given through nasal prongs or a face mask. Providing more oxygen to the heart can help keep heart tissue damage to a minimum.
Medications 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 medications 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 (ARBs) | ||
Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan | Similar to ACE inhibitors, but cough is much less common | These medications have equivalent effects and benefits to those of ACE inhibitors. In people with severe high blood pressure or heart failure, these medications may be used in combination with an ACE inhibitor. |
Anticoagulants | ||
Argatroban Apixaban Bivalirudin Dabigatran Enoxaparin Fondaparinux Heparin Rivaroxaban Warfarin | Bleeding, especially when used with other medications that have a similar effect (such as aspirin and other nonsteroidal anti-inflammatory drugs) | These medications prevent blood from clotting. They are used to treat people who are having an acute coronary syndrome. They are also used after acute coronary syndromes for people with atrial fibrillation or blood clots in the heart or blood vessels. |
Antiplatelet medications | ||
Aspirin Clopidogrel Prasugrel Ticagrelor | Bleeding, especially when used with other medications that have a similar effect (such as anticoagulants) With aspirin, stomach irritation With clopidogrel, a small risk of reducing the white blood cell count | These medications 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. Combinations of these medications (aspirin with either clopidogrel, prasugrel, or ticagrelor) are used for 12 months after acute coronary syndromes to prevent clots from forming (though duration may be adjusted for bleeding concerns). |
Beta-blockers | ||
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 level of high density lipoprotein (HDL), which is the "good" cholesterol | These medications 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 microvascular angina 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 medications 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 medication) | ||
Abciximab Eptifibatide Tirofiban | Bleeding, especially when used with other medications that have a similar effect (such as anticoagulants or thrombolytic medications) Reduction of the platelet count | These medications prevent platelets from clumping and blood clots from forming. They may be used to treat people who have unstable angina, particularly those who are undergoing percutaneous coronary intervention after a heart attack. |
Nitrates and other antianginal medications | ||
Isosorbide dinitrate Isosorbide mononitrate Nitroglycerin | Flushing Headache Temporarily fast heart rate (tachycardia) | These medications 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 microvascular angina. For these medications to remain effective over the long term, people need to go 8 to 12 hours without taking the medication each day. |
Ranolazine | Dizziness, headache, constipation, and nausea | This medication is used to treat people who continue to have symptoms of angina despite treatment with other medications. |
Ivabradine | Blurred vision, chest discomfort, slow or fast heartbeat,headache, dizziness or fainting | This medication is used to treat symptoms of angina in some people who cannot take beta-blockers. |
Opioids | ||
Morphine Fentanyl | Low blood pressure when a person stands Constipation Nausea Vomiting Confusion (especially in older adults) | In some people who have had a heart attack, these medications are used to relieve anxiety and pain if the pain persists despite use of other medications. However, use is decreasing because these medications can interfere with the effectiveness of antiplatelet medications. |
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 medication | These medications lower cholesterol levels and help to heal damaged arteries, decreasing the chance of having a first or repeated heart attack or stroke. |
Cholesterol absorption inhibitors | ||
Ezetimibe | Diarrhea, fatigue, joint and muscle pain (especially if taken with a statin) | This medication is used to improve cholesterol levels if a statin alone does not work (or in people who cannot take a statin). |
PCSK-9 inhibitors | ||
Alirocumab Evolocumab | Few serious side effects | These medications are used to lower LDL-C, which is the "bad" cholesterol, in people not at target LDL-C levels. They are used alone or in combination with other lipid-lowering medications (eg, statins, ezetimibe) for the treatment of adults with primary hyperlipidemia (including familial hypercholesterolemia), including people who have trouble tolerating other medications that lower cholesterol. |
Mineralocorticoid receptor antagonists | ||
Spironolactone Eplerenone | Elevated potassium levels, dizziness, diarrhea, headache, breast enlargement and tenderness in men (with spironolactone) | Used for people with heart failure from damage caused by a heart attack. |
Sodium-glucose cotransporter 2 (SGLT2) inhibitors | ||
Empagliflozin Dapagliflozin | Urinary tract infections, fungal infections, dizziness, low blood sugar, kidney dysfunction | These medications are used in people with diabetes to decrease the risk of coronary artery disease, stroke, and heart failure. In people with diabetes, these medications are used after a heart attack to prevent future cardiovascular events. Sometimes these medications are also used in people without diabetes who have had a heart attack. |
Thrombolytic drugs | ||
Alteplase Anistreplase Reteplase Streptokinase Tenecteplase | Rarely, bleeding within the brain (intracerebral hemorrhage) or the digestive tract | These medications dissolve blood clots. They are used to treat people who have had a heart attack. |
Other medications | ||
Colchicine | Diarrhea, nausea, vomiting, abdominal pain, sore throat, headache | This medication is sometimes used after a heart attack to reduce the risk of a future heart attack. |
* Doctors may use different combinations of medications depending on the type of coronary artery disease the person has. | ||
† Also known as hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors. | ||
Antiplatelet medications
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 medications such as clopidogrel, ticlopidine, or ticagrelor taken by mouth, or glycoprotein IIb/IIIa inhibitors given by vein (intravenously).
Combinations of these medications (aspirin with either clopidogrel, prasugrel, or ticagrelor) are used for 12 months after acute coronary syndromes to prevent clots from forming. Sometimes the duration of treatment is adjusted due to concerns about bleeding.
Anticoagulants
Initially, most people with an acute coronary syndrome are also given an anticoagulant, such as enoxaparin or heparin, to help prevent the formation of additional blood clots.
After an acute coronary syndrome, people with atrial fibrillation or a blood clot will receive an oral anticoagulant, such as apixaban, rivaroxaban, dabigatran, edoxaban, or warfarin.
Nitrates
Most people are given nitroglycerin, which relieves pain by lowering blood pressure, which reduces the workload of the heart, and possibly by dilating arteries. Usually, it is first given under the tongue, then intravenously.
Opioids
Most people who have had a heart attack are experiencing severe discomfort and anxiety. Morphine and fentanyl have a calming effect and reduce the workload of the heart. One of these medications is given when nitroglycerin cannot be used or is not effective; however, some data suggest opioids may interact with antiplatelet medications and reduce their effectiveness and may slightly increase the risk of death.
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 medications, 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.
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 medications are usually given in the first few days after a heart attack and prescribed indefinitely.
Statins and other cholesterol medications
Statins have long been used to help prevent coronary artery disease, but 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. Other types of cholesterol medications include PCSK-9 inhibitors, such as alirocumab or evolocumab, and ezetimibe, which blocks cholesterol absorption in the intestine. They are used with statins if the statins are not improving cholesterol levels enough, or alone for people who cannot take statins. Finally, icosapent ethyl is a medication used to lower triglycerides, fats in the blood that are related to cholesterol.
Clot-dissolving medications
Clot-dissolving medications (thrombolytic medications) are given intravenously to open the arteries if percutaneous coronary interventions cannot be done within 90 minutes after the person arrives at the hospital.
Ranolazine and ivabradine
Ranolazine and ivabradine are alternative therapies for people with angina that does not respond to the usual therapies (for example, nitrates or morphine).
Drug Information for the Topic
