Looking out for your heart: medical therapy with common side effects and intolerances!

 

On diagnosis of a cardiovascular condition, medical therapy is usually the first line of treatment in cardiac care. Therefore, it is essential to address the patient’s past medical history, and to note any allergies and intolerances to previous medicines. When starting patients on any new medication, it is important to give advice and information about the medicines, dosages, frequency, effects of the drug, and common side effects. In order for patients to comply with therapy, they need to understand the reason for taking them in the first place.

It is equally important to monitor the patient for compliance, as well as effectiveness of the medical therapy. While compliance is crucial to treatment, the patient will need to be followed up at regular intervals for sensitivity, side effects and intolerances.

 

The standard regime of drugs given to patients diagnosed with coronary artery disease (CAD), myocardial infarction and revascularisation (PCI, PPCI):

Anti-platelets:          Aspirin, clopidogrel, ticagrelor

ACE inhibitor:          Ramipril, Lisinopril

Beta-blocker:           Bisoprolol, atenolol, carvedilol

Anti-anginals:           Isosorbide mononitrate, nicorandil, ranolazine, glyceryl trinitrate

Statin:                       Atorvastatin, Simvastatin

 

The standard regime of drugs for treating patients with atrial arrhythmias such as atrial fibrillation:

Beta-blocker:            Bisoprolol

Anti-coagulant:        Warfarin, apixaban, rivaroxaban, dabigatran, edoxaban

Anti-arrythmic:         Amiodarone, flecainide, digoxin

 

The standard regime of drugs for treating patients with heart failure and arrythmia:

Anti-coagulant:         Warfarin, apixaban, rivaroxaban, dabigatran, edoxaban

Beta-blocker:            Bisoprolol, atenolol, carvedilol, metoprolol

Ace-inhibitor:                      Ramipril, Lisinopril

Aldosterone antagonist:   Eplerenone, spironolactone

Diuretics:                             Fursemide, bumetanide, bendroflumethiazide

Anti-arrythmic:                   Amiodarone, digoxin

Anti-anginal:                        Ivabradine

 

Dual anti-platelet therapy (DAPT) is initiated in acute coronary syndrome and percutaneous coronary intervention (PCI), in the prevention of platelet aggregation and thrombus formation in the coronary arteries. Aspirin is initiated in conjunction with ticagrelor or clopidogrel after revascularisation, and caution should be taken with patients with previous history of dyspepsia, gastro-intestinal and intra-cranial bleeds, haemorrhage, anaemia and haemophilia. To reduce the risk of gastric irritation and bleeds, consider prescribing proton pump inhibitor, for example omeprazole and lansoprazole. Monitor for reduce platelet count, bleeding, anaemia, dyspepsia. It is advisable to take DAPT after or with a meal to reduce episodes of dyspepsia.

 

An ACE-inhibitor will also be included as prophylaxis to keep the blood pressure under control. This acts on the renin-angiotensin system, therefore rigorous monitoring is necessary for liver and renal function. Patients commonly report symptoms of coughing whilst on Ramipril. In this instance if symptoms persist, consider switching to angiotensin II receptor antagonist, for example candesartan.

Beta-blockade is initiated in all cardiovascular conditions to slow the heart down eg bisoprolol. It blocks the beta-adrenoceptor in the heart, liver, pancreas, bronchi and peripheral vasculature. It prevents excitation within the heart muscle and allows for more efficient filling within the chambers, at a slower heart rate. Normally aiming to keep the heart rate to around 60 beats per minute. Patients may present with bradycardia, dyspnoea and cold extremities. Start with lower doses and monitor for hypersensitivity, titrating as necessary.

 

Calcium channel blockers e.g. diltiazem, should be considered for patients who are hypersensitive or intolerant to beta-blockers. Calcium channel blockers interfere with the calcium ions through the channels within the active cell membranes, thus affecting the rate of heart muscle contractions. The most common complaint is ankle oedema and dizziness.

 

Anti-anginals such as isosorbide mononitrate and glyceryl trinitrate (GTN) may also be prescribed to treat symptoms of myocardial ischaemia. These are potent vasodilators that interfere with venous return, thus reducing the work of the left ventricle. GTN is quick acting and can last for up to 20-30 minutes. Patients requiring frequent use of GTN should be prescribed oral nitrate for angina relief. However, nitrates have a tendency to cause hypotension, dizziness and headaches. Advise not to overuse and patient should be seated when taking GTN. Paracetamol can be taken to relieve headaches.

Amiodarone used to control atrial arrhythmias can affect the thyroid gland leading to either hyperthyroidism or hypothyroidism, phototoxicity, skin discoloration and jaundice. Digoxin can cause dizziness and blurred vision. There is also a risk of digitalis toxicity, therefore rigorous monitoring is required for plasma-digoxin concentration assay, serum electrolytes and renal function.

There are many other combinations of medical therapy which can be used to treat various cardiac conditions, requiring up or down titration according to symptoms. The table below consists some of the more common medicines used in the treatment of angina, revascularisation, atrial arrhythmia and heart failure.

 

***Table of medicines commonly used in cardiovascular conditions. Please see our upcoming newsletter for the table of medicines. Nadia will be teaching a session on Managing Heart Failure and Hypertension in Primary Care on 5 March 2018.

 

 

AF and other arrhythmias, elderly, consider stopping if no improvement in symptoms after 3 months

 

 

References:

British National Formulary: September 2017-March 2018. Royal Pharmaceutical Society.

 

National Institute for Health and Care Excellence (2011) Stable angina: management. Clinical guideline (CG 126).

National Institute for Health and Care Excellence (2013) Anaemia – iron deficiency. Clinical knowledge summaries.

National Institute for Health and Care Excellence (2014) Atrial Fibrillation: Management. Clinical guideline (CG 180).

Ramrakah, P and Hill, J. (2006) Oxford handbook of cardiology. New York: Oxford university press

Yao, X; Abraham; Abraham, N. S; Sangaralingham, L. R; Bellolio, M. F (2016) Effectiveness and safety of dabigatran, rivaroxaban, and apixaban versus warfarin in non-valvular atrial fibrillation. Journal of the American Heart Association. Vol. 5(5), pp. 1-19

 

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