Pharmacy
This booklet gives information about different medicines used for patients:
- following a heart attack
- following stent insertion
- with angina
- with heart failure
It does not replace the advice that your doctors, pharmacists or nurses may give you, based on their knowledge of your condition, but it should help you to understand what they tell you.
Medicines are an important part of your treatment, alongside other lifestyle changes such as stopping smoking, taking more exercise and watching what we eat. There are different groups of medicines used in the treatment of heart disease.
The team decides which combination of drugs is best for you, so you may find that you are not on all the usual medicines for good reasons; you are an individual and therefore your medicines are individualised!
This information is to help you to better understand the medicines you have been prescribed. It also contains information about other commonly used heart medicines that many people take.
It contains the following information about your medicines:
How they work and what they do
What are the likely side-effects
How to take them
When you are discharged from hospital you will be given up to a four-week supply of medicines. The team will tell you which medicines you should be taking and how to take them.
You will receive a copy of the prescription for your records. The team will also inform your GP about the medicines you should be taking and any changes made whilst you have been in hospital.
In general, if you have had a heart attack then you are likely to take the following medicines: Aspirin, a beta-blocker, an ACE inhibitor, a statin and one of the following: prasugrel, ticagrelor or clopidogrel).
If you have heart failure then you are likely to take the following: An ACE inhibitor, a beta-blocker, an MRA, an SLGT2 inhibitor and, a diuretic.
Medicines sick day rules
If you are unwell with any of the following: fevers, sweats and shaking, vomiting or diarrhoea (unless minor) then consider temporarily stopping the medicines listed below.
- ACE inhibitors – For example; ramipril, perindopril, enalapril, lisinopril, captopril
- ARBs – For example; candesartan, losartan, valsartan, irbesartan, olmesartan
- Diuretics (“water tablets”) – For example; furosemide, bumetanide, bendroflumethiazide
- Sacubitril valsartan (Entresto)
- Eplerenone or spironolactone
- NSAIDs – For example; ibuprofen, naproxen, diclofenac
- Metformin
- SGLT-2 Inhibitors – For example; Dapagliflozin, Empagliflozin
Antiplatelet medicines
Aspirin, ticagrelor, clopidogrel and prasugrel are antiplatelet medicines. Ticagrelor, clopidogrel and prasugrel are more potent (stronger) than aspirin.
What do they do:
Platelets are blood cells that, when you cut yourself, stick together to form a clot and stop you bleeding. Sometimes, these platelets form a clot inside damaged blood vessels supplying the heart (arteries).
These medicines make platelets less ‘sticky’ which helps to reduce the chance of a blood clot forming. This helps to lower the risk of having a further heart attack or a clot in your stented area.
Aspirin is frequently used in combination with ticagrelor (or clopidogrel or prasugrel) in what we call “Dual Antiplatelet Therapy”.
Combining two antiplatelets is the recommended treatment for most patients after a heart attack.
Aspirin
How to take:
Take 75mg once a day. Take it with food (usually breakfast) to reduce the risk of upset stomach. Swallow the tablets whole (but they can be mixed with water if necessary).
Side-effects: Some people may get some heartburn, indigestion or nausea (feeling sick). In a small number of people it can provoke or worsen bleeding in the stomach. Tell your GP if you have any unexplained bleeding or bruising, blood in the urine or black and tarry bowel motions.
Other information: Aspirin should be taken for life, unless your doctor advises otherwise. Do not take any additional aspirin or anti-inflammatory pain relief (for example ibuprofen).
Ticagrelor (‘Brilique’)
This is used, along with aspirin to prevent your blood clotting too easily. This is to reduce the chances of you having a heart attack or getting clots in your stent(s).
How to take:
Take one 90mg tablet twice a day. You should aim to take the tablets 12 hours apart – one in the morning and one in the evening.
Try to take them at the same time each day. Perhaps store them next to your toothbrush as a visual reminder. It can be taken with or without food. The doctor or nurse will tell you how long the course will be and will provide a ‘dual antiplatelet therapy’ (DAPT) card.
Side-effects: It can cause some minor bruising and, or minor bleeding such as a nosebleed or bleeding more than usual if you cut yourself. If you experience any severe bruising, blood in the urine, black tarry stools or any other prolonged unexplained bleeding please report this to your GP.
You may feel short of breath or gasp or sigh occasionally, which could be a side-effect of taking ticagrelor. Contact your GP if this occurs.
If you are experiencing any side-effects please do not stop taking your ticagrelor until you have spoken to your GP or the Interventional Cardiology team, Telephone: 01642 854922
Please remember
It is vitally important that you DO NOT stop taking this tablet or aspirin before the course is finished. In exceptional circumstances it may be necessary to interrupt treatment but this should only be done after discussion with your cardiologist (see your DAPT card for contact details).
Clopidogrel
This is used, along with aspirin to prevent your blood clotting too easily. This is to reduce the chances of you having another heart attack or getting clots in your stent(s).
How to take:
Take one 75mg tablet once a day with food (usually with breakfast). The doctor or nurse will tell you how long the course will be and will provide a ‘dual antiplatelet therapy’ (DAPT) card.
Side-effects: It can cause some minor bruising or minor bleeding such as a nosebleed, bleeding around the gums, or bleeding more than usual if you cut yourself.
Some people may complain of heartburn, indigestion, or nausea. In a small number of people it can provoke or worsen bleeding in the stomach. Tell your doctor if you have any unexplained bleeding or bruising, blood in the urine or black / tarry bowel motions.
If you are experiencing any side-effects please do not stop taking your clopidogrel until you have spoken to your GP or the Interventional Cardiology team on Telephone: 01642 854922
Please remember
It is vitally important that you DO NOT stop taking this tablet or aspirin before the course is finished. In exceptional circumstances it may be necessary to interrupt treatment but this should only be done after discussion with your cardiologist (see your DAPT card for contact details).
Prasugrel (‘Efient’)
This is used, along with aspirin 75mg once daily, to prevent your blood clotting too easily. This is to reduce the chances of you having another heart attack or clots forming in your stent(s).
How to take:
Take one 5mg or 10mg tablet with food (usually breakfast). The doctor or nurse will tell you how long the course will be and will provide a ‘dual antiplatelet therapy’ (DAPT) card. A dose of 5mg or 10mg is decided based upon your age and weight.
Side-effects: It can cause some minor bruising or minor bleeding such as a nosebleed, some bleeding around the gums or bleeding more than usual if you cut yourself.
Some people may complain of heartburn, indigestion, or nausea. In a small number of people it can provoke or worsen bleeding in the stomach. Tell your doctor if you have any unexplained bleeding or bruising, blood in the urine or black and tarry bowel motions.
If you are experiencing any side-effects please do not stop taking your prasugrel until you have spoken to your GP or the Interventional Cardiology team.
Please remember
It is vitally important that you DO NOT stop taking this tablet or aspirin before the course is finished. In exceptional circumstances it may be necessary to interrupt treatment but this should only be done after discussion with your cardiologist (see your DAPT card for contact details).
Beta-blockers
For example: bisoprolol, atenolol, metoprolol, carvedilol
Beta-blockers ease the workload of the heart. They slow the heart rate, reduce blood pressure and are effective in preventing angina attacks. They reduce the risk of further heart attacks. They can be used to improve the symptoms of heart failure. They can be used to control abnormal heart rhythms and to treat high blood pressure.
How to take:
Normally taken once a day. Your doctor may sometimes ask you to take them twice a day (usually to help lessen side-effects).
Side-effects: Their side-effects may come on at first and then go. If they become troublesome, tell your doctor.
They can cause some light-headedness or dizziness when first started. If this persists the dose may be split or reduced. Occasionally, people feel more tired, get cold fingers and toes, or experience vivid dreams. They can worsen erectile dysfunction in some men.
Other information: These are started at a low dose and your doctor should gradually increase the dose to the maximum that you can tolerate. DO NOT stop taking suddenly as this may cause palpitations or more severe chest pains.
ACE inhibitors
For example, ramipril, perindopril, lisinopril
These block an enzyme called Angiotensin Converting Enzyme (ACE) from working in the body. As a result they cause a widening of the blood vessels, reduce blood pressure, and make it easier for the heart to pump. They can help to lessen the damage to heart muscle caused by a heart attack and reduce the risk of another heart attack occurring. If you have heart failure they can prevent it from getting worse and help you be more active.
How to take:
Taken once a day. When you first start them we may ask you to take them before bedtime to reduce the chance of them causing dizziness. Your doctor may sometimes ask you to take them twice a day (usually if you are getting light-headed).
Side-effects: They can cause some light-headedness or dizziness when first started. If this persists, taking the dose before bedtime, reducing the dose, or splitting into two doses during the day may help.
Other side-effects include: dry, tickly cough, a skin rash, and sometimes altered taste. Rarely they cause swelling of the face, tongue or neck. Contact your doctor if this happens.
Other information: Your doctor will take regular blood tests while slowly increasing the dose, to check your kidney function and potassium levels. It is worth making the appointment yourself if your doctor does not arrange this.
Angiotensin II receptor blockers
For example, losartan, candesartan, valsartan
These block the effect in the body of a hormone called angiotensin II. As a result they cause a widening of the blood vessels, reduce blood pressure, and make it easier for the heart to pump. They can help to lessen the damage to heart muscle caused by a heart attack and reduce the risk of another heart attack occurring. If you have heart failure, they can prevent it from getting worse and help you be more active.
How to take:
Take them once a day. When you first start them we may ask you to take them before bedtime to reduce the chance of them causing dizziness. Your doctor may sometimes ask you to take them twice a day (usually if you are getting light-headed).
Side-effects: They can cause some light-headedness or dizziness when first started. These may improve after a few days. If this persists the dose may be taken at night or split or reduced.
Other information: Your doctor will take regular blood tests while slowly increasing the dose, to check your kidney function and potassium levels. It is worth making the appointment yourself if your doctor does not arrange this. Please avoid salt substitutes because these can cause your potassium levels to get dangerously high.
Lipid-lowering drugs
For example; atorvastatin, simvastatin, pravastatin, rosuvastatin) (cholesterol-lowering drugs) (‘statins’)
These reduce the amount of cholesterol in your blood, which can help to reduce the further build-up of ‘fatty’ deposits in the coronary arteries. They also stabilise any existing deposits, making them less likely to break and cause a heart attack. They are often prescribed after a heart attack or if you have angina, no matter what your cholesterol level is, because they offer long term protection from heart attacks and stroke.
These medicines will work better if you follow the advice given to you on a healthy diet, stopping smoking and taking up regular exercise.
How to take:
Simvastatin and pravastatin should be taken at night. Atorvastatin and rosuvastatin may be taken at any time of day. Taking them with some food may reduce the risk of upset stomach and diarrhoea.
Side-effects: Most people experience no side-effects from statins. Feeling sick (nausea), stomach upset (for example; diarrhoea, bloating, flatulence), headache and tiredness can occur.
Muscular aches and pains can occur. We all get muscle aches from time to time, so it’s difficult to know if they are due to medication or just to do with everyday life. For some, though, they are an issue. If this is the case, ask your doctor about trying a different statin.
An exceptionally rare, but serious, side effect is severe muscle damage, producing pain and weakness in the muscles. It can be reversed if treatment is stopped and most people who develop it make a rapid recovery.
Other information: You should avoid grapefruit or grapefruit juice if you are taking a statin. Statins act on the liver so, for a few people, they can affect its function but, again, this is rare.
Any side-effects need to be weighed against the positives in that statins are generally safe to take and dramatically reduce the risk of heart attacks and strokes, which could be fatal.
If you find you cannot tolerate any statin or you have had cholesterol tests and it is above certain levels, lipid specialists may recommend additional cholesterol-lowering drugs; such as ezetimibe, bempedoic acid or the injectable medication: inclisiran.
Glyceryl Trinitrate
Often known as ‘GTN’
This widens blood vessels which increases the blood supply to the heart. It is used to relieve angina symptoms and can be used prior to doing any activity that you know might trigger an angina attack.
How to take:
Spray one or two doses under the tongue and close your mouth. Can be repeated if necessary – see ‘GTN card’
Side-effects: Can cause headache, dizziness and flushing.
Other information: Also called GTN, trinitrate or nitroglycerin. GTN can cause a drop in blood pressure, it is best to sit or lie down when using GTN.
Isosorbide mononitrate
GTN spray is fast-acting and used to relieve chest discomfort whereas these tablets are taken regularly and used to prevent it.
How to take:
The tablets should be taken twice daily (at 8am and 2pm). This allows a “nitrate-free” period later in the day and means that the effect of the drug does not lessen over time. This can be a problem with these medicines.
Side-effects: The most common side-effects of nitrates include headaches, dizziness or light headedness, flushing or a warm feeling in the face.
Medicines for erectile dysfunction
GTN and Isosorbide mononitrate can cause a large drop in blood pressure if treatments for erectile dysfunction are also being taken.
If you take sildenafil (Viagra), tadalafil (Cialis) or other medicines for erectile dysfunction please let a member of the team know. We can provide further information
Other medicines that may be used
MRAs
For example, Spironolactone, Eplerenone
These medicines are called Mineralcorticoid Receptor Antagonists. They help to reduce the effects of a hormone (called aldosterone) on the heart and circulation. Aldosterone causes the body to hold onto water and salt and also can cause inflammation of the heart muscle.
They are used when the heart is not pumping effectively and can help to reduce symptoms. They help the body get rid of excess salt and water and reduce the effects of the inflammation. This means they can prevent heart failure from getting worse and so can help you to be more active and live longer.
How to take: Take them once a day in the morning.
Side-effects: They can cause diarrhoea. Some people can feel sickly (nauseous). They can affect kidney function. Spironolactone sometimes causes tender and slightly enlarged breasts in men.
Other information: When first starting eplerenone or spironolactone you will need blood tests every one to four weeks to begin with, and then once every three to six months. It is worth making the appointment yourself if your doctor does not arrange this.
SGLT-2 Inhibitors
For example, dapagliflozin, empagliflozin
Their full name is Sodium-glucose co-transporter-2 inhibitors. These medicines were originally used in diabetes but have been found to be very beneficial in managing and preventing heart failure.
They help remove excess water and sugar and may also improve heart function by reducing the workload of the heart and reducing any inflammation.
How to take: Take them once a day in the morning.
Side-effects: They can cause low blood sugar, particularly if taken alongside other diabetes medicines and can cause some people to feel thirsty.
Because of there being more sugar in the urine, there is a slightly higher chance of a urinary tract infection or thrush. This risk is reduced with normal hygiene and washing but please tell your doctor if you notice any redness, pain while urinating, tenderness or swelling in your genital region.
Entresto
Sacubitril and Valsartan
This medicine combines two drugs into one tablet to have a stronger combined effect, it is often started as a step up from an ACEi or ARB.
Valsartan is an ARB (Angiotensin II receptor blocker) which reduces effect of the hormone angiotensin II on the body. Angiotensin causes narrowing of blood vessels and increased blood pressure.
Sacubitril is an Neprilysin inhibitor which reduces the effect of the enzyme neprilysin. This enzyme breaks down protective natriuretic peptides which would otherwise cause relaxation of blood vessels and an overall lower blood pressure.
By blocking the effect of angiotensin and increasing the amount of natriuretic peptides, Entresto can cause a much greater relaxation of the blood vessels than if you were just taking one or the other. This can help prevent worsening of heart failure and help you be more active.
How to take: Take them twice a day
Side-effects: They can cause some light-headedness or dizziness when first started. These may improve after a few days. If this persists the dose may be taken at night, split or be reduced.
Your doctor will take regular blood tests while slowly increasing the dose, to check your kidney function and potassium levels. It is worth making the appointment yourself if your doctor does not arrange this.
Diuretics
For example, furosemide, bumetanide
These are commonly called ‘water tablets’. They remove excess water from the body and make you pass more urine for a few hours after taking. Do not take them after 4pm, as you are then likely to need to go to the toilet during the night.
Calcium channel blockers
For example, amlodipine, diltiazem, verapamil
These prevent calcium from entering heart muscle and blood vessel cells. They cause the arteries to relax and widen which reduces blood pressure and improves blood supply to the heart allowing it to work more efficiently. Verapamil and diltiazem are sometimes used to control irregular heart rhythms.
You may experience flushing of the face, headache, dizziness and swollen ankles. These side-effects tend to settle and go away.
Anti-arrhythmics
For example; amiodarone or digoxin
Arrhythmias are abnormal heart rhythms. Anti-arrhythmic drugs are designed to treat this abnormality. They may be used to terminate the abnormal rhythm, prevent it happening or slow the heart rate during the abnormal rhythm to make it more tolerable.
Amiodarone:
Amiodarone is usually prescribed by the heart specialist after a number of tests have been performed to ensure that it is suitable for you. It takes a few weeks for amiodarone to build up to the right level in the body, so it is prescribed at a higher dose at first and then reduced over a few weeks.
Certain medicines can interact with amiodarone so let your doctor know all the medicines you are taking (including over the counter medicines and herbal remedies).
Some side-effects of amiodarone are not serious and only temporary, such as feeling sick
(try taking it after food) and headaches. More serious (but rare) side-effects affecting the eyes, thyroid gland and lungs can occur and your doctor will keep a close eye on your treatment.
Some people on amiodarone find that their skin is more sensitive to the sun than usual. To reduce the chance of burning it is sensible to keep your arms and legs covered, wear a hat to protect your face and neck and apply total sun block. The sensitivity can persist for several months after stopping the amiodarone. If you are prescribed amiodarone, you will be given separate, written information.
Digoxin:
Digoxin is occasionally used as an alternative to or, if necessary, alongside beta blockers (see earlier in booklet) to manage arrythmias. It is also sometimes used to help manage heart failure.
If it is started in hospital, you are often given a large ‘loading’ dose to get a good amount in your body quickly so you receive the benefits faster, you are then put on a smaller ‘maintenance’ dose to keep the amount in your body at a good level.
It is possible to have too much digoxin in your body which can cause loss of appetite, nausea, vomiting, diarrhoea or vision problems. If you experience these effects when starting digoxin, let your doctor know so they can check your levels are safe.
You will have blood tests when starting digoxin to check your electrolyte levels (such as Sodium, Potassium and Calcium) as they can change the effect of digoxin. Should levels be found to be low, you may also be prescribed supplements to get them back into the target normal range.
Anticoagulants
Clots are made up of platelets (tiny blood cells) clumped together with a protein called fibrin.
By reducing how much fibrin can be produced by the body, anticoagulant medicines make the blood take longer to clot.
They help to prevent strokes specifically caused by atrial fibrillation (AF), which is a common abnormal heart rhythm in the UK. AF increases the risk of stroke as it can lead to blood pooling in the heart, which increases the risk of clots forming. If these clots are ejected by the heart, they can block a blood vessel in the brain and cause a stroke.
If you are commenced on an anticoagulant, you will be given additional written information about these medicines.
Warfarin:
This has been used for many years to prevent clotting of the blood and is most often used for people who have an irregular heart rhythm such as atrial fibrillation. It is also used in people with disease of the heart valves, especially those who have been given an artificial heart valve.
You will need regular blood tests (called an INR) to ensure you are on the correct dose.
Direct oral anticoagulants
For example; apixaban, rivaroxaban, edoxaban or dabigatran
These work in a slightly different way to warfarin which means that people who take them do not need regular INR blood tests. However, you will need regular, but less frequent, blood tests to check your kidney function.
Changes that have been made to your medicines:
| Medicine | Started, stopped, dose changed | Reason |
|---|---|---|
Please remember
- Always follow the instructions on taking medications and never exceed the recommended dose
- Don’t share your medicines with anybody else
- Never stop taking them without contacting your doctor or nurse.
- If you are unhappy about any of your tablets, you must discuss this with your doctor, nurse, or pharmacist who will advise you
- Speak to your pharmacist before buying any other medicines
- You should keep an up-to-date list of all your tablets and dosages with you at all time.
Further information
For further information you can visit the British Heart Foundation website.
Contact the Interventional Cardiology Specialist Team
Telephone: 01642 854922
Email: [email protected]
| You can use this space to note down any questions you may have. The doctor, nurse or pharmacist may also write additional information here. |
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