This is a broad topic. Many different types of medication are prescribed for patients with heart disease. These include anticoagulants, antiplatelet agents, ACE inhibitors, angiotensin II receptor blockers, angiotensin-receptor neprilysin inhibitors, beta-blockers, calcium channel blockers, cholesterol-lowering medications, digitalis preparations, and diuretics. They are used following a heart attack or stroke. They are also used to treat or prevent deep vein thrombosis, pulmonary embolism, blood clots within catheters, and stent thrombosis.
- Anticoagulants and antiplatelet agents: These are commonly called blood thinners, but that is a misnomer. They do not actually thin the blood. Antiplatelet medication interferes with the binding of platelets. Anticoagulants interfere with the different “factors” (which are proteins in your blood) that are involved with coagulation. Different anticoagulants interfere with different factors to prevent clotting.
There are several kinds of anticoagulant medication. Heparin and LMWHs are given by injection in the hospital. Vitamin K antagonists include warfarin and coumarins. As the name implies, they reduce the action of vitamin K. Often the patient is told to avoid foods containing vitamin K. Non-VKA oral anticoagulants (NOACs) work on different anticoagulant factors in the blood. Rivaroxaban, Edoxaban, and Apixaban work by inhibiting Factor Xa. Dabigatran is a NOAC that is a direct inhibitor of thrombin.
For a very long time, warfarin (Coumadin) was the main anticoagulant medication prescribed. Levels had to be monitored and there were dietary restrictions. NOACs do not need monitoring or dietary restrictions. Since the full anticoagulant effect of warfarin is not achieved for several days, heparin is preferred for initial rapid anticoagulation. Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, which include Factors II, VII, IX, and X, and the anticoagulant proteins C and S. Patients are often told to avoid foods that are high in vitamin K while on the drug. During initial therapy with warfarin, the interference with heparin anticoagulation is of minimal clinical significance.
The main side effect of these medications is bleeding. Patients need to be aware of any signs of excessive bleeding, including black and tarry stools, blood in urine or phlegm, nosebleeds, severe bruising, nosebleeds, bleeding gums, or vomiting blood. Other side-effects include diarrhea, constipation, nausea, indigestion, dizziness, headaches, rashes, itchy skin, jaundice, or hair loss.
- Antiplatelet medication: Where anticoagulant medication interferes with fibrin formation, antiplatelet drugs keep platelets from adhering to each other. They are used for patients with a history of heart disease or stroke. They are also used after angioplasty, stent replacement and after bypass surgery or valve replacement. They also prevent the formation of blood clots in patients with atrial fibrillation. Aspirin is used as an antiplatelet medication. It may be worth mentioning that omega-3 fatty acids can decrease the cohesiveness of platelets.
Common antiplatelet medications include: clopidogrel (Plavix), ticagrelor (Brilinta), prasugrel (Effient), ticlopidine (Ticlid), and eptifibatide (Integrilin). There is a possibility of severe adverse reactions to these drugs. These include cardiac failure, stroke, heart attack, dyspnea, and severe allergic reactions.
The different anticoagulant drugs work on various chemical pathways and enzymes. Different classes of these drugs have different side effects. ADP inhibitors (one example is clopidogrel, sold under the brand name, Plavix) may have the following side effects: bleeding (and bruising), dyspnea, nosebleeds, cough, bradycardia, hypertension, back pain, peripheral edema, abdominal pain, indigestion, nausea, diarrhea, constipation, itching, rash, vertigo, and fatigue. Phosphodiesterase inhibitors (eg sildenafil, vardenafil, and tadalafil) can have the following side effects: headache, dizziness, vertigo, paresthesia, tachycardia and heart palpitations, diarrhea, indigestion, nausea, vomiting, abdominal pain, flatulence, myalgia, leg cramps, back pain, sore throat, dyspnea, rash, and jaundice. Protease-activated 1 antagonists (eg vorapaxar, sold under the brand name Zontivity) can have the following side effects: bleeding, anemia, rashes, double vision, and retinal disorder. Glycoprotein IIB and IIIA inhibitors (eg abciximab, sold under the brand name ReoPro and eptifibatide sold under the brand name Integrilin) can have the following side effects: serious bleeding, chest pain, palpitation, nausea, vomiting, indigestion, diarrhea, vision disturbances, dizziness, anxiety, confusion, muscle contractions, coma, myalgia, muscle contractions and increased tone, and hypersensitivity reactions.
- ACE inhibitors: ACE stands for “angiotensin-converting enzyme” These drugs inhibit the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, blood vessels relax and dilate, thereby reducing blood pressure. Examples of ACE inhibitors include benazepril (Lotensin), enalapril (Vasotec), perindopril (Aceon), Ramipril (Altace), and trandolapril (Mavik). These drugs are used to treat high blood pressure and coronary issues (heart failure and coronary artery disease). They are also given to patients with certain chronic kidney diseases, migraines, scleroderma, and diabetes.
These drugs may increase potassium levels. Side effects can include dizziness, drowsiness, headache, dry cough, or fainting. Signs of high potassium levels include muscle weakness, sexual dysfunction, and a slow, irregular heartbeat. Although used to treat some kidney problems, it can adversely affect the kidneys (especially if there is stenosis of the renal arteries), causing new problems or making old ones worse. There is a rare possibility of liver damage, and the patient may experience jaundice, dark urine, extreme fatigue, severe abdominal pain, nausea, and vomiting. Not to be taken during pregnancy, may cause birth defects.
- Angiotensin II receptor blockers: These are used to treat kidney disease, high blood pressure, and heart failure. Angiotensin II is a hormone that works to narrow the arteries and to retain salt and water. Like ACE inhibitors, they act on angiotensin II. ACE inhibitors block the formation of angiotensin II, these drugs block the receptors of it. The drugs block this action, allowing the blood vessels to dilate. These include azilsartan (Edarbi), candesartan (Atacand), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), and valsartan (Diovan). Side effects include dizziness, headache, fatigue, vomiting, diarrhea, elevated potassium levels, and angioedema. Not to be taken during pregnancy; may cause birth defects.
- Angiotensin-receptor neprilysin inhibitor: This is a new drug, used for chronic heart failure. It works on the renin-angiotensin system. Sacubitril/valsartan, sold under the brand name Entresto, is a combination drug for use in heart failure. It consists of the neprilysin inhibitor sacubitril and the angiotensin receptor blocker valsartan. It is meant as a substitute for ACE inhibitors in heart failure patients with a reduced ejection fraction. Neprilysin also removes amyloid beta and may be of use to Alzheimer’s patients. Common adverse effects in the initial study included cough, high serum potassium levels, kidney dysfunction, and low blood pressure.
- Beta-blockers: Beta-blockers work by blocking the effects of the epinephrine (adrenaline). They cause the heart to beat slowly and with less force as well as causing the blood vessels to relax. Some beta-blockers mainly affect your heart, while others affect both your heart and your blood vessels. Examples of beta-blockers include acebutolol (Sectral), bisoprolol (Zebeta), atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL), propranolol (Inderal LA, InnoPran XL), nadolol (Corgard) and nebivolol (Bystolic).
Conditions treated by beta-blockers include high blood pressure, arrhythmia, heart failure, migraine, angina, and certain types of tremor. Beta-blockers generally aren’t used in people with asthma because of concerns that the medication may trigger severe asthma attacks. In people who have diabetes, beta-blockers may block signs of low blood sugar, such as rapid heartbeat. They can also cause an increase in LDL and in triglycerides.
Side-effects of beta-blockers include fatigue, cold hands and feet, weight gain, sleep disturbance, depression, and shortness of breath. A patient taking the medication should not abruptly stop.
- Calcium channel blockers: Calcium channel blockers prevent calcium from entering cells of the heart and blood vessel walls. This causes the vessel walls to relax and lowers blood pressure. They are used for high blood pressure, angina, heart disease, and poor circulation. Examples of these include amlodipine (Norvasc), diltiazem (Cardizem), felodipine, nifedipine (Adalat CC), and verapamil (Calan). Some calcium channel blockers intact with grapefruit and patients are told to avoid it. Side effects can include headache, nausea, constipation, palpitations, dizziness, and swelling in the extremities.
- Cholesterol-lowering medication: Cholesterol-lowering medication is a $25 billion/year business. Statins ultimately prevent the production of coenzyme Q 10. Statins work by inhibiting the enzyme methylglutaryl coenzyme A (HMG-CoA) reductase. They prevent the production of mevalonate from HMG-CoA. The body converts mevalonate to cholesterol and a variety of other products. One of the things that mevalonate produces is Coenzyme Q10. CoQ10 is important for energy production in the cell. Patients taking these drugs commonly do not tolerate exercise well and tend to get sore with activity. If general muscle pain is experienced, it is a serious side effect and a doctor should be consulted. Studies show that these drugs have the potential to cause myopathies (muscle pain) and rhabdomyolysis (muscle damage) with kidney failure. The FDA has warned about liver failure in conjunction with these drugs. These more serious side effects occur in about 1% of the population taking the drugs. Most chiropractors and physical therapists can tell you that almost everyone on the drugs has some kind of pain.
A study published in the journal Diabetes Wellness (May 2005;11(5):4) showed that giving coenzyme Q10 to patients who take statins reduces muscle pain. Subjects received either 400 IU of vitamin E or 100 mg. of coenzyme Q10. Eighteen of the 21 subjects receiving the coenzyme Q10 (90%) experienced pain relief; this compared to three patients out of 20 in the vitamin E group. Coenzyme Q 10 levels decrease after taking a statin drug. In the June 2000 issue of Archives of Neurology, a study was published that showed a reduction in coenzyme Q 10 levels after the subjects took 80 mg. of a statin drug. The mean blood level of coenzyme Q 10 in the 34 participating subjects went from 1.2 mcg/ml to .62 mcg/ml.
The heart contains high levels of coenzyme Q 10 and these levels are found to be lower in people suffering from congestive heart failure. According to an article appearing in The Lancet (1998;352(Suppl. 1):39-41) notes that the incidence of heart failure has dramatically increased in the last three or four decades. The prevalence of heart failure had increased by 70% between 1990 and 2000.
Research on pravastatin appearing in the Journal of the American Medical Association (December 18, 2002;288:1998-3007,3042-3044) shows that the drug does indeed lower cholesterol but does not reduce the risk of death or heart disease in those with moderately high cholesterol and high blood pressure.
There are a number of studies that show that statin drugs may affect behavior, leading to aggressive behavior or depression. Research appearing in the journal Psychosomatic Medicine (1994 Nov-Dec;56:479-84) links aggressive behavior and depression to low cholesterol It has been postulated that there may be a connection between cholesterol and serotonin.
There are nearly 130 million patients taking statins, and many having serious side-effects. It is worthwhile to look at what these drugs do and to take the simple step of giving patients on these drugs coenzyme Q10.
- Digoxin: Digoxin belongs to the class of medicines called digitalis glycosides. It is used to treat congestive heart failure, usually in combination with a diuretic and an ACE inhibitor. It is also used to treat atrial fibrillation. Digoxin It is used to control the rate and rhythm of the heartbeat. Brand names include Digitek, Digox, Lanoxicaps, and Lanoxin. Side effects include dizziness, fainting, irregular heartbeat. Other, less common, side effects include unusual bleeding or bruising (tarry stools, bleeding gums, blood in urine or stools, bloody vomit), and severe stomach pain.
- Diuretics: The kidneys control the amount of water retained by the body by controlling the retention of sodium and chloride. Diuretics are used to increase the flow of urine by removing sodium and chloride from the body. They are used for edema caused by congestive heart failure, cirrhosis of the liver, renal dysfunction (nephrotic syndrome, acute glomerulonephritis, and chronic renal failure), and for edema caused by corticosteroid and estrogen therapy. They are also used to treat high blood pressure. Other uses include treatment of glaucoma and off-label treatment of osteoporosis and diabetes insipidus.
There are several types of diuretics, each working with a different mechanism. Common side effects of these drugs include dry mouth, thirst, weakness, lethargy, muscle pains (cramps), drowsiness, confusion, seizures, low blood pressure, rapid heart rate, and GI disturbances. Diuretics can also deplete magnesium, thiamin, and potassium. In congestive heart failure patients, loss of these nutrients can make the condition worse and they should be supplemented (as they should with anyone taking these drugs). Patients taking digoxin (Lanoxin) may experience extremely low levels of potassium, which can result in weakness, cramps, and irregular heartbeats.
Loop diuretics are the most potent. The word “loop” refers to the loop of Henle in the kidney, where they increase the elimination of sodium and chloride by preventing reabsorption. It also causes decreased excretion of lithium. These may cause lithium toxicity in patients taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs). Lithium levels need to be monitored in these patients.
Thiazide diuretics work in the distal convoluted tubules of the kidney, also preventing reabsorption of sodium and chloride. These include chlorothiazide (Diuril), chlorthalidone (Hygoroton), indapamide (Lozol), hydrochlorothiazide (Lozol), methyclothiazide (Enduron), metolazone, (Zaroxolyn, Diulo, Mykrox). Along with the other common side effects of other diuretics, thiazide diuretics may cause an increase in uric acid and may be a problem for patients with a tendency to develop gout. Thiazide diuretics may cause extremely low sodium levels in the elderly and may cause neurologic damage and even death. When thiazides are given to patients taking diabetic medication, they may decrease levels of diabetic medication. Watch blood sugar levels in these patients. It also causes decreased excretion of lithium. These may cause lithium toxicity in patients taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs). Lithium levels need to be monitored in these patients.
Potassium-sparing diuretics reduce sodium reabsorption (not chloride) at the distal tubules, thus sparing potassium. These include amiloride hydrochloride, spironolactone (Aldactone), and triamterene (Dyrenium). These are not very powerful and are often given with other diuretics. When they are given to patients taking ACE (angiotensin-converting enzyme) inhibitors, potassium levels may increase, and hyperkalemia is possible. This may present as bradycardia, muscle weakness, and fatigue. Patients taking NSAIDs may also experience hyperkalemia.
Carbonic anhydrase inhibitors work by increasing the excretion of sodium, potassium, bicarbonate, and water from the renal tubules.
Natural diuretics: Nigella sativa (black cumin, black seed or black caraway) increases urine output and reduces sodium and potassium levels. Hibiscus sabdariffa prevents the body from getting rid of potassium. Other natural diuretics include parsley, ginger, and dandelion. When giving these, realize that you are changing mineral and fluid balance; monitor your patient for symptoms.