Common Blood Pressure Medications
Angiotensin-converting enzyme inhibitors (ACE-i) — these medications, which typically have generic names ending in “pril”, do not only lower blood pressure. They can improve endothelial function and protect sensitive blood vessels in the kidneys, eyes and brain. They have also been shown to improve heart function in patients with heart failure.
Some people can develop a cough with these medications and need to be switched to an ARB (see below). Very rarely a specific type of allergic reaction can occur involving swelling of the lips and tongue followed later by difficulty breathing — in the unlikely event that these symptoms occur a patient must go to their nearest emergency department for treatment. Routine allergy treatments do not work (adrenaline, steroids, anti-histamines) and a combination of supportive care (airway management) and intravenous administration of fresh frozen plasma (which contains enzymes that metabolise bradykinin) can be considered.
Angiotensin receptor blockers (ARBs) — with generic names ending in “sartan” these are alternatives to ACE inhibitors for blood pressure control and protection of endothelial function. Some evidence suggests they may be superior to ACE-inhibitors, though this is not widely accepted. ACE-inhibitors and ARBs should not be used together.
Calcium channel blockers (CCBs) — generic names usually end in “pine”. Effective blood pressure medication, particularly in some ethnicities. When used along with an ACE-i or ARB there is a synergistic effect on blood-pressure lowering so this combination is useful.
Beta-blockers (BBs) — generic names ending in “olol”. Combined blood-pressure lowering and heart rate lowering effects. These medications can help lower blood pressure but are particularly useful for heart rate control in patients with arrhythmia and for heart failure management.
Verapamil is a special type of calcium channel blocker which also helps reduce heart rate. It is generally not used along with a BB as dangerously low heart rates can result.
Diuretics — the two most commonly used ones are bendrofluazide and indapamide (the latter is now preferred due to a slightly better side-effect profile).
Common Diabetes Medications
Metformin — this is considered the first-line type 2 diabetic medication for patients with normal kidney function. It is safe (very little chance of causing low blood sugar) and has been shown to improve cardiovascular outcomes and overall mortality in diabetics.
DPP-4 inhibitors — often called “gliptins” (how the generic names all end). These drugs are typically used alongside metformin.
SGLT2 inhibitors — the “flozins” increase urinary excretion of glucose to improve diabetic control and lower body weight. They are effective treatment for patients with symptomatic heart failure and improve cardiovascular outcomes. These drugs can be particularly helpful in patients with reduced kidney function. Possible downsides include a potential risk of urinary tract infections, dehydration and acidosis, so avoiding dehydration and stopping these medications during any severe infection is prudent (immediately seek medical attention if concern arises).
GLP-1 agonists — all generics end in “tide”. These drugs improve diabetic control and promote weight loss. They have also been shown to improve cardiovascular outcomes in patients with heart failure. There are a number possible side-effects and long-term effects are still poorly understood, so detailed discussion is prudent before considering a GLP-1 agonist, particularly when used solely for weight loss.
Common Cholesterol Medications
Statins — when used in combination with regular exercise and healthy diet the statin drugs permit significant reduction in ApoB concentration. This results in stopping or slowing the formation of coronary plaque, a reduced risk of heart attack and improved overall cardiovascular outcomes, including reduced mortality. These drugs work by inhibiting cholesterol production and increasing LDL-cholesterol uptake by the liver and skeletal muscle, but they also have less-understood pleiotropic benefits, including improved endothelial function, reduced inflammation and an anti-thrombotic effect (preventing blood clots). They are the first-line treatment in patients with elevated ApoB (atherogenic cholesterol).
Side effects with these drugs may be less frequent than typically thought but can still occur. Most common is muscle aches, particularly in the thighs, calves or upper arms. Sometimes stopping the statin and later restarting at a reduced dose or with a different type of statin can prevent this problem. Even a small dose of a statin taken on alternate days can have a big impact on harmful cholesterol particle levels and meaningfully impact cardiovascular risk while minimising the incidence of adverse effects.
All patients on a statin should have their liver function checked after starting and then once yearly. Patients prone to diabetes can have issues with glycemic control, particularly if taking a large statin dose, so HbA1C is typically also monitored. As with most medications, in the unlikely event that severe symptoms are experienced after starting a statin stop the drug and seek medical attention.
The three most commonly used statins in Trinidad are rosuvastatin, atorvastatin and simvastatin.
Ezetimibe — this drug blocks cholesterol reabsorption in the gastrointestinal tract. Although dietary cholesterol does not contribute significantly to serum cholesterol levels (saturated fat and excess calorie intake do!) cholesterol made by your own body is excreted by the liver and biliary system into the gut and gets reabsorbed — ezetimibe blocks this reabsorption. With less “recycled” cholesterol coming from the gut the liver takes up more LDL-cholesterol from the blood and apoB serum levels drop.
Ezetimibe works well in combination with a statin because statin use can lead to increased cholesterol reabsorption from the gastrointestinal tract.
Common Heart Failure Medications
Furosemide — this is a diuretic designed to increase urine production. In heart failure fluid retention occurs. Fluid leaks out of blood vessels causing oedema and the increased vascular volume puts strain on the cardiovascular system, worsening heart function. Getting rid of the retained fluid improves symptoms of heart failure.
Eplerenone — this diuretic has multiple effects aside from getting rid of excess fluid. In heart failure aldosterone levels rise and lead to a cascade of harmful effects — eplerenone blocks aldosterone and has been shown to reduce mortality in heart failure.
Sacubitril/valsartan — this has been shown to reduce the risk of hospitalisation and cardiovascular death in heart failure patients.
Ivabradine — this is a safe heart-rate lowering medication which does not cause a drop in blood pressure and will not decrease heart rates to dangerously low levels. It is useful in treating heart failure as well as angina caused by myocardial ischaemia in patients with known coronary disease.
Anti-anginal medications
Sublingual or patch nitroglycerin — in Trinidad the GTN tablet and Nitromint sublingual spray are common. These medications can help increase coronary flow in patients with angina (chest pain) or other symptoms of coronary ischaemia. Patients taking these drugs should not use the erectile dysfunction/pulmonary hypertension drugs sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra).
Isosorbide dinitrate — commonly “Isordil” in Trinidad, typically used three times daily. This is essentially a long-acting form of the short-acting nitroglycerin treatments listed above. Patients taking these drugs should not use the erectile dysfunction/pulmonary hypertension drugs sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra).
Trimetazidine — branded as Vastarel in Trinidad, this drug reduces anginal (cardiac ischaemic) symptoms by improving myocardial glucose use. It has also shown promise in reducing heart failure symptoms.
Blood thinners
Low-dose aspirin — previously given for routine primary prevention of heart attack and stroke, low-dose aspirin is now reserved only for those with high risk of a coronary event or those who are known to have coronary disease, such as patients who have suffered a heart attack or who have had an angiogram showing coronary disease. In these patients the reduction in heart attack risk outweighs the increased risk of bleeding.
Clopidogrel, prasugrel, ticagrelor — these drugs are typically reserved for heart attack patients, patients with a very high risk of heart attack or patients who have had angioplasty and coronary artery stenting.
Warfarin — this drug is used for patients found to have a blood clot in the main ventricle of the heart or who have a metallic heart valve replacement. Using this drug is complicated because levels have to periodically checked using blood testing, sometimes as often as weekly and typically at least every couple months. Complex dietary advice should be followed as certain foods can affect warfarin’s efficacy.
Rivaroxaban, dabigatran, apixaban, edoxaban — powerful blood thinners typically used for patients with the arrhythmia atrial fibrillation and patients with a blood clot in their legs or their lungs. Low doses are sometimes also used following a heart attack in order to reduce the risk of another event. Unlike warfarin these drugs do not typically require blood tests to monitor levels and no dietary restrictions are required.
Anti-inflammatory
Colchicine — in patients with known coronary disease who have persistently elevated hsCRP despite statin use there is possible added benefit with the anti-inflammatory medication colchicine. In those with many risk factors for coronary disease and unexplained persistently elevated hsCRP low-dose colchicine may help reduce cardiovascular risk.
Foods — evidence exists of mild anti-inflammatory effects on the endothelium with use of turmeric, ginger, garlic as well as many types of nuts, fruits and veggies — so eat healthily!