Although lifestyle changes are an essential first step in treating coronary heart disease, you may need to take medication to keep your symptoms controlled. Most people with heart disease need to take more than one medication.

The specific combination of drugs depends upon the symptoms and risk factors. The medications for coronary heart disease can be broken down into 3 broad categories - (1) Medications which reduce the Blood Pressure (2) Medication which help reduce Cholesterol (3) Medications which dilate the vessels and/or help prevent clots 

(1) Blood Pressure Medications

Blood pressure, which is a risk factor for developing heart disease, is treated using one medication or a combination of medications. The following are some of the most common medications used to control blood pressure.

Diuretics -

Diuretics for many years have treated high blood pressure. Thiazide diuretics such as chlorthalidone (Clorpres,Thalitone) and hydrochlorothiazide (Microzide, HydroDiurill) are the most commonly used diuretics. These medications are very effective in reducing high blood pressure, which is why they’re recommended as an initial treatment method for most people with hypertension, used alone or in combination with another blood pressure medication. 

Diuretics are also inexpensive. What’s more, they also boost the effectiveness of other antihypertensive medications. However, it’s not suitable for people who have trouble urinating because it may aggravate the problem. It can also lower potassium levels, although potassium-sparing diuretics are available. Other problems include fatigue and raised blood sugar, which increases the risk of diabetes. In spite of having some drawbacks, diuretics form the base for treating high blood pressure.

Angiotensin-Converting-Enzyme (ACE) inhibitors -

ACE inhibitors work by blocking the body’s production of a protein called angiotensin, which constricts the blood vessels. This dilates the blood vessels and lowers the pressure. In addition to that, ACE inhibitors are also prescribed for heart failure cases. They help to preserve heart function after heart attacks, protect the kidneys of diabetic people and slow the progress of atherosclerosis. Some of the commonly used ACE inhibitors are benazepril (Lotensin), captopril (Capoten), and lisinopril (Prinivil, Zestril). The side effect of this medication is a persistent cough, which makes some people to stop taking it.

Angiotensin-receptor blockers (ARBs) -

ARBs are the alternate medication to ACE inhibitors. ARBs work in a slightly different manner than ACE inhibitors by preventing angiotensin from exerting its blood vessel constricting effects on the body. Thus, the normal blood flow is undisturbed. ARBs are good alternatives for those who cannot take an ACE inhibitor. Examples of ARBs include candesartan, valsartan, irbesartan (Avapro), and losartan (Cozaar).

Beta-blockers -

Beta-blockers are one of the most commonly used medications for controlling cardiac ischemia and heart failure. Beta-blockers obstruct the working of epinephrine (adrenaline), a hormone that normally stimulates the heart to beat faster and stronger. They slow down the heart rate, reduce the cardiac output and lower the blood pressure thus decreasing the workload of the heart. Lowering the oxygen needs of the heart prevents or relieves ischemia.

Some of the side effects of beta-blockers are erectile dysfunction and fatigue. People with asthma, heart failure or diabetes should be extra careful while taking these medications since they can make the condition worse. However, taking “partially selective” beta-blockers that act selectively on the heart rather than other parts of the body minimizes this problem. Some examples are atenolol (Tenormin) and metoprolol (Lopressor, Toprol XL). 

In spite of having some side effects, beta-blockers are preferred for the treatment of heart failure and coronary artery disease because their benefits outweigh the potential risks.

Calcium-channel blockers (CCB) -

CCB are vasodilators, meaning they dilate the coronary arteries, thereby increasing the blood flow to the heart and reducing its workload, by lowering the blood pressure and the force of the heart’s contractions. Some studies suggest that the older generation of calcium-channel blockers is hazardous in some people with heart disease because these medications are short-acting. The newer medications are long-acting and seem safe and effective in controlling high blood pressure. This is the reason why calcium-channel blockers are now recommended as the first-line treatment for controlling blood pressure.

People who do not get adequate relief from using beta blockers or nitrates can use calcium-channel blockers, which are more effective than beta blockers in preventing angina that results from a coronary spasm. It also has fewer side effects than diuretics and is more convenient because a single dose is enough for the day.

(2) Cholesterol Medications

Cholesterol is another risk factor that needs to be taken care of in order to prevent coronary artery disease. There are various medications that can be used for lowering the blood cholesterol, especially the harmful LDL cholesterol.

Statins -

Medically known as HMG-CoA reductase inhibitors, lower the LDL levels and also improve the overall cholesterol profile by lowering total cholesterol, slightly boosting the levels of HDL and slightly lowering triglycerides. The liver makes a majority of the cholesterol circulating in our body and the enzyme HMG-CoA reductase decides how much cholesterol the liver should make. Statins work by preventing the liver from making cholesterol and forcing it to draw LDL cholesterol from the blood.

There are many benefits to having statins since they stabilize the cholesterol plaque in the walls of the artery, promote growth of new blood vessels and soothe away the inflammation. These actions further help to reduce the risk for CHD and heart attack, and that is the reason why statins are regarded as one of the most important recent advances in drug therapy. Atrovastin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pitavastatin (Livalo), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor) are some of the commonly used statins. 

Fibric acid derivatives -

These are prescribed mainly for people who have high levels of triglycerides in their blood. They reduce triglyceride levels by 20 to 50 percent and raise HDL (good cholesterol) levels by 10 to 15 percent and also have a minimal effect on LDL levels. These drugs block the production and activity of the protein that transports cholesterol in the blood.

Gemfibrozil and fenofibrate, which are pills, are the two most commonly prescribed fibric acid derivatives. They are taken once or twice a day with meals. Some of the side effects of these drugs can be dyspepsia, dizziness or changes in sensations such as touch and taste. 

Niacin -

Also known as nicotinic acid, is an essential vitamin B found in many of the healthy food products such as fish, nuts, lean meat and dairy products. At 14 mg for women and 16 mg for men, niacin works as a vitamin but at doses of 1500 mg to 4500 mg, the crystalline form of nicotinic acid works as a drug.

Niacin on its own can reduce LDL levels by 15 percent or so, lower triglycerides and boost the levels of HDL by as much as 20 percent. If taken in combination with a statin, it further lowers the LDL level by 10 percent. Niacin works by cutting the liver’s production of VLDL, which is ordinary converted into LDL.

Niacin is a fairly safe and inexpensive medicine. However, it can be unsafe for people with chronic liver disease, diabetes, peptic ulcer and certain other heart conditions. One of the side effects of the medication is rashes; it can also, aggravate conditions like gout, diabetes or peptic ulcers. A sustained-release preparation of niacin (Niaspan) has fewer side effects, but it can cause liver damage if combined with a statin.

Bile acid binders -

These are synthetic resins. These resins bind themselves chemically to the cholesterol-rich bile acids, preventing their reabsorption. The body then draws from the stored cholesterol to replace the bile acids that were lost, thus lowering the levels of cholesterol in the blood. These medications are capable of lowering the LDL cholesterol levels by 15 to 30 percent, depending on the daily dose and whether they’re combined with a statin. Cholestyramine, colesevelam and colestipol are some of the commonly used bile acid binders.

There are many side effects and problems associated with bile acid binders so it’s a rarely used medication. Some of the side effects are constipation, heartburn and a bloated feeling. It can also interfere with the working of other drugs such as digitalis, thiazide diuretics, beta-blockers, warfarin, anticonvulsants and the thyroid hormone thiazide, which cause further problems. Bile acid binders can also elevate the levels of triglycerides in people who already have high levels of triglycerides.

Ezetimibe (Zetia) -

Ezetimibe is a great alternative for those who haven’t benefitted at all from the statins. Ezetimibe works by preventing the cholesterol in food from crossing the intestinal wall and getting into the bloodstream. On its own, it’s capable of reducing LDL levels by 20 percent and when combined with a statin, it lowers LDL by another 15 to 23 percent. The benefit of combining a statin and ezetimibe is still under question as several studies have raised concerns over its inability to lessen the cholesterol-laden plaque in the carotid arteries. 

In spite of such reports, ezetimibe is considered a backup for people who cannot take a statin or who need a bigger cholesterol-lowering push.

(3) Cardiovascular Medications

Cardiovascular medicationsfunction as anti-platelet drugs, preventing the formation of blood clots, and also help in dilating the blood vessels. 

Aspirin -

Aspirin is the most common inexpensive drug used to prevent subsequent heart attacks and death in people who already had a heart attack or stroke. Although aspirin is best known as an anti-platelet drug, it can also reduce the inflammation that is common in coronary artery disease. A low-dose of aspirin, a dose of 81mg a day, found in a baby aspirin, reduces the risk for heart disease by about 25 percent and causes fewer problems. 

Aspirin might have some serious side effects such as gastrointestinal bleeding and hemorrhagic stroke in both men and women. The risk of aspirin-induced bleeding is higher in men, in people who have a history of uncontrolled high blood pressure, ulcers, bleeding problems and those who regularly take ibuprofen or warfarin. However, if the benefits outweigh the risks, aspirin is considered for the treatment.

Apart from aspirin there are several other anti-platelet medications to consider. These include dipyridamole, clopidogrel and the newly approved prasugrel. All these medications are more expensive than aspirin and are not as well-studied, so the possible side effects are still unknown.

Nitrates

Nitrates remain one of the most important medications for treating coronary artery disease even after the introduction of many heart drugs. They help prevent or stop ischemia by relaxing the muscles in the walls of the blood vessels, causing them to dilate and thereby increasing the supply of blood to the heart. They also reduce the heart’s work by lowering the body’s blood pressure and the pressure within the heart’s chambers. The heart, then, requires less oxygen and doesn’t put the coronary arteries under stress. 

Due to the properties of nitrates to dilate blood vessels throughout the body, side effects such as headache, dizziness and fainting spells are quite common. Therefore, it’s advised that before taking these medications the patient should sit down to avoid falling, and if there is a feeling of lightheadedness or dizziness, he/she can also lie down after taking the drug.

It’s also important to know that nitrates can cause a life-threatening drop in blood pressure in people who also take erectile dysfunction medications. 

Combination medications

Combination medications are another possible option available for treating coronary artery disease. Such medications aim to control high blood pressure by combining a diuretic with a beta-blocker, calcium-channel blocker, ACE inhibitor, ARB or even a different type of diuretic. Caduet, an example of combination medication, aims at lowering the blood pressure as well as cholesterol.

Combination drugs are best suited for those who take a stable dose of two different medications or those who routinely miss doses or get confused about which medication they’ve taken. It’s also more cost-effective because you have to pay for only one drug instead of two However, at times it can also prove to be expensive if you pay for the medication yourself or your health plan charges a higher copayment for brand-name drugs than for generics.