Medication for the long-term treatment of coronary artery disease

Antiplatelets make sure that the blood platelets do not clump so quickly to form blood clots. Regularly taking antiplatelets reduces the risk of things such as heart attack or stroke in people with CAD, and increases life expectancy. Antiplatelets are also referred to as platelet function inhibitors or platelet aggregation inhibitors.

Two antiplatelet drugs are used for the long-term treatment of CAD: acetylsalicylic acid (ASA) and clopidogrel.

• ASA is the drug found in painkillers like Aspirin. Low-dose ASA has been used in the prevention of heart disease for many decades. People with CAD typically take one 100 mg ASA tablet per day.
• Clopidogrel is mostly used by people who don't tolerate ASA well or can't take it for other reasons. One 75 mg tablet of clopidogrel is taken per day.

ASA is a well-studied drug: Expressed in numbers, studies that lasted five years came to the following conclusion: If 100 people with CAD take ASA permanently, a heart attack or stroke will be prevented in an average of 5 to 10 of them. Just how much someone benefits from this medication will very much depend on their personal risk.

A large study compared ASA and clopidogrel directly. Both medications were found to offer equally good protection.

People may start bleeding more easily because antiplatelets slow down blood clotting. That means people can bruise more easily. Bruising and other minor bleeding events like nosebleeds are no cause for alarm. Dark red or black stool and vomit with blood in it, on the other hand, may be signs of bleeding in the stomach and need medical attention.

If 100 people with CAD take ASA over a period of five years, it leads to gastric bleeding that requires treatment in about 2 to 3 of them. But most of these cases can be easily treated and do not have any long-term effects. Stomach ulcers are another possible side effect of antiplatelets.

It can make sense for people who have had gastrointestinal bleeding or a stomach ulcer to also take medication to protect their stomach. These drugs include omeprazole and pantoprazole (known as proton-pump inhibitors). They inhibit stomach acid production and protect the stomach's mucous lining. That prevents stomach ulcers and gastric bleeding.

Statins lower cholesterol levels and protect the blood vessel walls. Large studies show that they increase the life expectancy of people with CAD and reduce the risk of heart attacks and strokes.

The following statins have been approved for use in Germany: atorvastatin, fluvastatin, lovastatin, pravastatin and simvastatin. So if someone does not tolerate a particular statin, they can switch to a different statin.

Research on the use of statins for people known to have CAD has found the following: If people with CAD take statins over a period of five years, medical conditions like heart attacks, strokes and other forms of blood vessel blockages will be prevented in an average of about 5 out of 100 of them. The positive effect may be bigger or smaller, depending on individual risk.

If cholesterol levels have to be lowered more, statins can also be combined with another medication such as ezetimibe.

Statins are usually well tolerated. A few studies suggest that these drugs can cause muscle pain in a small group of people. But muscle problems can be caused by many other things, too. So it doesn't make sense to stop treatment at the first sign of a possible side effect. It’s best to talk to your doctor about any intolerances you might have.

Rhabdomyolysis is an extremely rare but serious side effect where the muscle tissue in certain muscles gradually breaks down. This causes paralysis, and the breakdown products that are released from the muscles can severely damage the kidneys. In studies, this side effect occurred in 1 out of 10,000 people who had long-term treatment with statins. Its signs include quickly tiring or cramping muscles and reddish or dark urine. It's important to seek medical advice if you have these symptoms. No damage is to be expected if you stop taking the statin in good time.

If exertion with CAD causes chest tightness (angina), other medications might be taken to relieve the symptoms. A difference is made between:

• Preventive medication (in particular beta blockers)
• Medication to treat acute angina attacks (fast-acting nitrates)

Preventive medication is taken over the long term to lower the risk of angina symptoms. Beta blockers are mainly used here. They slow down the heart rate (pulse) and lower blood pressure, taking strain off the heart. Calcium channel blockers are another option for people who don’t tolerate beta blockers, can’t take them or need another medication. They widen your blood vessels, and some also slow your heart rate. That lowers blood pressure and takes the strain off the heart.

Acute symptoms can be relieved using fast-acting nitrates. They quickly widen the blood vessels, supplying more blood to the heart. That relieves the tightness and pain in the chest. There are different kinds of nitrates, such as sprays ("nitro spray") and capsules ("nitro capsules"). Nitrates start working after 2 to 5 minutes, and last for up to half an hour.

People who have angina symptoms often carry nitrate medication with them to be taken as needed.

Fast-acting nitrates can also be used as a preventive measure, like just before activities involving exertion such as doing sports, mowing the lawn or going for a walk in very cold weather, that would otherwise cause symptoms.

People can feel worn-out and fatigued if beta blockers lower the heart rate or blood pressure too far. But this can often be avoided by adjusting the dose of the medication. Other possible side effects of beta blockers include reduced sexual desire and erection problems. But fewer than 1 out of 100 people have these problems as a result of taking this medication. Beta blockers are usually well-tolerated.

The possible side effects of calcium channel blockers include headache, drowsiness, hot flashes, constipation and water retention in the legs.

Nitrates can cause short-term headaches and reddening of the face. They can also cause blood pressure to drop. That is why doctors recommend sitting down before taking nitrates.

Men who take potency medicines such as sildenafil (Viagra) should talk to their doctor. It is important that there’s a big enough time gap between taking those kinds of medications and nitrates to avoid too big a drop in blood pressure.

Other or additional medications might be an option for people who have other conditions as well as CAD, such as high blood pressure, heart failure or atrial fibrillation. Treatment with various antiplatelets is usual for a while if a stent has been fitted.

Tolerance and possible interactions with other medications are also important factors when selecting the right treatment.

People who have CAD usually take several different medications over a long period of time. It can be hard to keep track of everything. Various things can help make it easier to take the medication, though. The following have proven especially useful:

• Keeping your medicine schedule as simple as possible.
• Using medicine dispensers with small compartments for each day, making it easy to see whether a tablet has been forgotten.
• Seeing your doctor regularly so that questions about the treatment can be addressed.

Many people are afraid of taking medication regularly for a long period of time, for instance because they might worry about the build-up of medication in their body over time. But these worries are unfounded. Our bodies continuously break down medications and get rid of them without any trace with the help of various mechanisms. All of the medications described here have also been carefully tested in studies.

All medications can have side effects. Yet it’s often possible to avoid them by adjusting the dose or by choosing a different medication in the same group of drugs. The side effects often go away after a while too, once the body has got used to the medication. It is best to talk to your doctor if you don’t tolerate a medication.

The risk of side effects may increase when several medications are taken together, because they may interact. It is therefore important to tell your doctor what medication you are already taking, including any herbal or other over-the-counter medication. It can help to keep a list of medication. People with statutory health insurance in Germany who take three or more prescription medications are entitled to request a "standardized medication schedule." This schedule is normally put together by your family doctor and should be kept up to date by all treating practices and pharmacies.