Which drugs reduce the risk of heart attack

[surfdevl02]

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Hello smart med students, I am doing some research into drugs that reduce the risk of heart attacks and i am a little confused. If you have a 62 year old gentleman coming to you with only hypertension, which medications (from below) reduce the risk of heart attacks in this man and which are contraindicated. Please help, there are so many conflicting studies out there that i can't keep them straight!:

aspirin
folic acid, 1 mg
vit E
spironolactone
pravastatin
ramipril
Beta blockers
thiazide diurectics
nifedipine
clonidine

 

[ChiefToma]

are you a first year student doing this stuff?

 

[SpiritiualDuck]

Captopril first line choice. Arguably, Lorsartan is better because of the diminished side effects, i.e., cough, angioedema. Still the same, go with an ACE inhibitor.

Also, Aspirin therapy would be well advised. It has a relatively safe profile and the benefits are innumerable. Low dose, 81mg, is the trick. take with food.

 

[skypilot]

First treat the hypertension.

 

[Uncle Izzy]

Hello smart med students, I am doing some research into drugs that reduce the risk of heart attacks and i am a little confused. If you have a 62 year old gentleman coming to you with only hypertension, which medications (from below) reduce the risk of heart attacks in this man and which are contraindicated. Please help, there are so many conflicting studies out there that i can't keep them straight!:

aspirin
folic acid, 1 mg
vit E
spironolactone
pravastatin
ramipril
Beta blockers
thiazide diurectics
nifedipine
clonidine

Depends on the degree of his hypertension... First line is HCTZ. You can add a 2nd and third agent if that doesnt bring him down to goal. If he has no contraindications (which from what you say he doesnt) he should be on daily aspirin, 81MG. The others should not be added until indicated, especially if his HTN responds to HCTZ. If his cholesterol is WNL, no statin.

Remember, as a first line, you also have to counsel him regarding lifestyle, diet, etc.. You can bring your BP down significantly by dropping just 5-10% of your body weight and exercising daily.

 

[Uncle Izzy]

http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

Follow this link and go to the pharm management section.. This is the consensus JNC7 report. Hope it helps. It's very straight forward with easy tables and recommendations.

 

[Jason_AZCOM]

Hello smart med students, I am doing some research into drugs that reduce the risk of heart attacks and i am a little confused. If you have a 62 year old gentleman coming to you with only hypertension, which medications (from below) reduce the risk of heart attacks in this man and which are contraindicated. Please help, there are so many conflicting studies out there that i can't keep them straight!:

1) Past medical Hx? allergies? lipids?
2) Fam Hx?
3) Vitals? (i.e. systolic HTN? diastolic? how high? for how long?)
4) Physical and exam normal?


If it's mild HTN, start ASA and HCT. If it's more then +20 sys and/or +10 diastolyic elevation, use an ace inihibitor (or ARB) plus HCT, and ASA.

CHECK lipids and get pt to ATP-III goals.

I would also suggest looking at the JNC-7 guidelines. As far as studies, ALLHAT (which JNC-7 is largely based upon).

 

[PickyBicky]

1) Past medical Hx? allergies? lipids?
2) Fam Hx?
3) Vitals? (i.e. systolic HTN? diastolic? how high? for how long?)
4) Physical and exam normal?


If it's mild HTN, start ASA and HCT. If it's more then +20 sys and/or +10 diastolyic elevation, use an ace inihibitor (or ARB) plus HCT, and ASA.

CHECK lipids and get pt to ATP-III goals.

I would also suggest looking at the JNC-7 guidelines. As far as studies, ALLHAT (which JNC-7 is largely based upon).

Very well said. Stage II HTN deserves 2 meds. I agree, you should read the JNCVII guidelines.

 

[souljah1]

You have to be careful about interpreting studies when thinking about an individual patient. From what you describe, this is someone how does not have a history of MI, nor does he have a myocardial infarction equivalent, i.e. DMII.

Usually the first line of therapy in a patient with hypertension, once lifestyle modifications have been attempted without success, is to start HCTZ. If someone has diabetes, you may think about starting an ACEI initially given its protective renal effects for the development of nephropathy.

A lot of you are saying that ASA should be started in this patient. Questions to think about:

What is the number needed to treat (or screen) in patients taking ASA for prophylaxis against MI?

What is the number needed to harm in patients taking ASA for prophylaxis against MI (GI bleeds for example)?

What symptoms or signs, when present, increase your confidence for starting ASA in someone who has not had an MI, does not have angina/chest pain/ecg changes/etc., and does not have DMII?

ASA is not benign.

Below is an abstract that kind of gets at what I'm saying. This patient does have hypertension so the following paper doesn't exactly get at this example, but worth thinking about.

Aspirin for the prevention of cardiovascular disease: calculating benefit and harm in the individual patient.

Loke YK, Bell A, Derry S.

Department of Clinical Pharmacology, University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE. [email protected]

AIMS: To estimate the absolute reduction in the risk of cardiovascular events and absolute increase in gastrointestinal haemorrhage associated with aspirin for individuals with different baseline risks. METHODS: Calculation of absolute treatment effects from estimates of: (i) baseline risks for cardiovascular event and gastrointestinal haemorrhage; and (ii) relative risks of these events with treatment. Baseline cardiovascular risks were derived from existing risk scores, and baseline risk of gastrointestinal haemorrhage from an observational cohort study. Changes in relative risks were obtained from clinical trial data. The effects of aspirin treatment were calculated in examples of two individuals with very different baseline risks. RESULTS: Treatment of a healthy 74-year-old man (blood pressure 144/88 mm Hg and no history of gastrointestinal disorder) would reduce his annual risk of a cardiovascular event from 2% to 1.74% (absolute risk reduction 0.26%, number needed to treat 385), but increase the gastrointestinal haemorrhage risk from 0.3% to 0.51% (absolute risk increase 0.21%, number needed to harm 476). In a 66-year-old obese man, following a transient ischaemic attack, and with a history of hospital treatment for a peptic ulcer, the annual risk of a cardiovascular event would be reduced from 5% to 4.35% (absolute risk reduction 0.65%, number needed to treat 153), but the risk of gastrointestinal haemorrhage would increase from 1.08% to 1.83% (absolute risk increase 0.75%, number needed to harm 133). CONCLUSIONS: Estimating benefit and harm by taking into account the baseline risks in each individual allows patients and doctors to judge for themselves the magnitude of the trade-offs involved in taking aspirin.

 

[Strength&Speed]

I think the short answer is:
1. Treat the hypertension with available agents--HCTZ, Ace-I. Hypertension is associated with more heart attacks.

2. Modify other risk factors if present--diabetes, hyperlipidemia. Both of these associated with more heart attacks.

3. Start aspirin. Unless contraindicated. I.E. History of GI bleed. There is NOT super exciting evidence for aspirin however. We are talking about preventing 3-4 MI's out of 1000 that would have happened anyway. And raising your risk of dying from GI bleed to 1-2 out of 1000. So we are talking small benefit, very small.

For some background on the drugs (because I feel like typing today):No drug: BBlockers, Ca Channel Blockers, Ace-Inhibitors, HCTZ, or others (except aspirin) have been shown to independently reduce a person's chances of having a heart attack. (Independent from effects on hypertension).

The reason beta blockers are used more often is because bblockers have usefulness in myriad heart conditions (arrhythmias, chf, hypertrophic cardiomyopathy, aortic stenosis, etcetera). Ace-inhibitors are used more frequently as well because they reduce proteinuria (a common cause of renal failure in diabetics) and also help with congestive heart failure.

Calcium channel blockers are not used quite as much due to slight increase in risk of arrhythmia post myocardial infarction (of the cardiac-specific medications). Also, they don't have many beneficial effects outside of just lowering hypertension. They aren't useful in CHF, arrhythmias, most cardiac conditions. Moreover, they are expensive, and can cause lower extremity edema, and other side effects. Not necessarily worse than the side effects from any of the other drugs however.

Hydrocholorothiazide is useful because it is dirt cheap. And all these drugs lower blood pressure more or less equally. However, it causes minor elevations in glucose, uric acid, lipids, so is somewhat downgraded a bit because of that. Also, it doesn't have umbrella effects on other conditions as do Ace-inhibitors, and BBlockers.

Ace-inhibitors and ARB's are the same. Only difference is ARB's don't cause cough.

Statins are being found to have usefulness in a ton of diseases. Primary and Secondary prevention of stroke, Primary prevention of MI (when hypercholesterolemia or CAD is present), secondary prevention of MI, prevention of heart stent/bypass graft stenoses, reduction in peripheral vascular disease complications (I think), among others. Some studies suggest it reduces onset of dementia as well. It is likely useful for a ton of conditions--and probably should be put in the water supply. 🙂 The major side effects are rhabdomyolysis and liver toxicity. Most common reason for discontinuation is myalgias and muscle pain.

 

[Strength&Speed]

Continuing:

Folate not shown to be useful in preventing Mi's. New evidence actually suggests hyperhomocyteinemia is not independent risk factor for MI's.

Neither has Vit E. In fact some new evidence suggests high dose Vit E actaully has more cardiac events. Wouldnt take this one.

Clonidine has some nasty side effects, but lowers blood pressure well initially. Until you want to discontinue the drug, then you have problems. Not a good choice unless you have really bad hypertension.

Of the statins, the best evidence is for Atorvastatin. Pravastatin has the least amount of side effects but is a weaker drug. Any statin is better than no statin however.