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If you have an LDL level of 130 mg/dL or greater, you will generally need to take an LDL-lowering medicine. If your LDL level is 100 to 129 mg/dL, your doctor will consider all the facts of your case in deciding whether to prescribe medication for further LDL lowering or for high triglycerides and/or low HDL if they are present. If you have been hospitalized for a heart attack, your doctor will likely start you on a medication at discharge if your LDL-cholesterol is 130 mg/dL or greater. If your LDL-cholesterol is between 100 and 129 mg/dL during your hospitalization, your doctor may choose to start you on an LDL-lowering medication before you are discharged. Also, if your LDL-cholesterol is far above the goal level of less than 100 mg/dL when first measured, your doctor may choose to start a cholesterol-lowering medication together with diet and physical activity right from the beginning of treatment. If your doctor prescribes medicine, you also will need to:
· Follow your cholesterol-lowering diet.
· Be more physically active.
· Lose weight if overweight.
· Control all of your other heart disease risk factors, including smoking, high blood pressure and diabetes.
Taking all these steps together may lessen the amount of medicine you need or
make the medicine work better — and that reduces your risk for a heart attack.
The following is a description of cholesterol-lowering medicines.
Statins
There are currently five statin drugs on the market in the United States: lovastatin, simvastatin, pravastatin, fluvastatin and atorvastatin (cerivastatin was withdrawn from the market by the manufacturer in August 2001). The major effect of the statins is to lower LDL-cholesterol levels, and they lower LDL-cholesterol more than other types of drugs. Statins inhibit an enzyme, HMG- CoA reductase, that controls the rate of cholesterol production in the body. These drugs lower cholesterol by slowing down the production of cholesterol and by increasing the liver's ability to remove the LDL-cholesterol already in the blood. Statins were used to lower cholesterol levels in the 4S, CARE and LIPID studies. The large reductions in total and LDL-cholesterol produced by these drugs resulted in large reductions in heart attacks and heart disease deaths. Thanks to their track record in these studies and their ability to lower LDL-cholesterol, statins have become the drugs most often prescribed when a person with heart disease needs a cholesterol- lowering medicine.
Studies using statins have reported 20 to 60 percent lower LDL-cholesterol levels in patients on these drugs. Statins also reduce e elevated triglyceride levels and produce a modest increase in HDL-cholesterol.
The statins are usually given in a single dose at the evening meal or at bedtime. It is important that these medications be given in the evening to take advantage of the fact that the body makes more cholesterol at night than during the day.
You should begin to see results from the statins after several weeks, with a maximum effect in four to six weeks. After about six to eight weeks, your doctor can do the first check of your LDL-cholesterol while on the medication. A second measurement of your LDL-cholesterol level will have to be averaged with the first for your doctor to decide whether your dose of medicine should be changed to help you meet your goal.
Statins are well tolerated by most patients, and serious side effects are rare. A few patients will experience an upset stomach, gas, constipation, and abdominal pain or cramps. These symptoms usually are mild to moderate in severity and generally go away as your body adjusts. Rarely a patient will develop abnormalities in blood tests of the liver. Also rare is the side effect of muscle problems. The symptoms are muscle soreness, pain and weakness. If this happens, or you have brown urine, contact your doctor right away to get blood tests for possible muscle problems.
Bile Acid Sequestrants
Bile acid sequestrants bind with cholesterol-containing bile acids in the intestines and are then eliminated in the stool. The usual effect of bile acid sequestrants is to lower LDL-cholesterol by about 10 percent to 20 percent. Small doses of sequestrants can produce useful reductions in LDL-cholesterol. Bile acid sequestrants are sometimes prescribed with a statin for patients with heart disease to increase cholesterol reduction. When these two drugs are combined, their effects are added together to lower LDL-cholesterol by over 40 percent. Cholestyramine, colestipol and colesevelam are the three main bile acid sequestrants currently available. These drugs are available as powders or tablets. They are not absorbed from the gastrointestinal tract, and 30 years of experience with the sequestrants indicate that their long-term use is safe.
Bile acid sequestrant powders must be mixed with water or fruit juice and taken once or twice (rarely three times) daily with meals. Tablets must be taken with large amounts of fluids to avoid gastrointestinal symptoms. Sequestrant therapy may produce a variety of symptoms including constipation, bloating, nausea and gas.
The bile acid sequestrants are not prescribed as the sole medicine to lower your cholesterol if you have high triglycerides or a history of severe constipation. Although sequestrants are not absorbed, they may interfere with the absorption of other medicines if taken at the same time. Other medications therefore should be taken at least one hour before or four to six hours after the resin. Talk to your doctor about the best time to take this medicine, especially if you take other medications.
Nicotinic Acid
Nicotinic acid or niacin, the water-soluble B vitamin, improves all lipoproteins when given in doses well above the vitamin requirement. Nicotinic acid lowers total cholesterol, LDL-cholesterol and triglyceride levels, while raising HDL-cholesterol levels. There are three types of nicotinic acid: immediate release, timed release and extended release. Most experts recommend starting with the immediate-release form; discuss with your doctor which type is best for you. Nicotinic acid is inexpensive and widely accessible to patients without a prescription but must not be used for cholesterol lowering without the monitoring of a physician because of the potential side effects. (Nicotinamide, another form of the vitamin niacin, does not lower cholesterol levels and should not be used in the place of nicotinic acid.)
All patients taking nicotinic acid to lower serum cholesterol should be closely monitored by their doctor to avoid complications from this medication. Self-medication with nicotinic acid should definitely be avoided because of the possibility of missing a serious side effect if not under a doctor's care.
Patients on nicotinic acid are usually started on low daily doses and gradually increased to an average daily dose of 1.5 to 3 grams per day for the immediate release form, and 1.5 to 2 grams per day for the other forms.
Nicotinic acid reduces LDL-cholesterol levels by 10 percent to 20 percent, reduces triglycerides by 20 percent to 50 percent, and raises HDL-cholesterol by 15 percent to 35 percent.
A common and troublesome side effect of nicotinic acid is flushing or hot flashes, which are the result of blood vessels opening wide. Most patients develop a tolerance to flushing and, in some patients, it can be decreased by taking the drug during or after meals or by the use of aspirin or other similar medications prescribed by your doctor. The extended release form may cause less flushing than the other forms. The effect of high blood pressure medicines may also be increased while you are on niacin. If you are taking high blood pressure medication, it is important to set up a blood pressure monitoring system while you are getting used to your new niacin regimen. A variety of gastrointestinal symptoms including nausea, indigestion, gas, vomiting, diarrhea and the activation of peptic ulcers have been seen with the use of nicotinic acid. Three other major adverse effects include liver problems, gout and high blood sugar. Risk of the latter three increases as the dose of nicotinic acid is increased. Your doctor may possibly not prescribe this medicine for you if you have diabetes, because of the effect on your blood sugar.
Fibrates
The cholesterol-lowering drugs called fibrates are primarily effective in lowering triglycerides and, to a lesser extent, in increasing HDL-cholesterol levels. Gemfibrozil, the fibrate most widely used in the United States, can be very effective for patients with high triglyceride levels. However, it is not very effective for lowering LDL- cholesterol. It is used in some patients with heart disease for whom a goal of treatment is lowering triglycerides or raising HDL. One study found that patients with heart disease, somewhat elevated triglycerides, and low HDL who took fibrates had reduced risk for a heart attack. Fibrates are usually given in two daily doses 30 minutes before the morning and evening meals. The reductions in triglycerides generally are in the range of 20 percent to 50 percent with increases in HDL-cholesterol of 10 percent to 15 percent.
Fibrates are generally well tolerated by most patients. Gastrointestinal complaints are the most common side effect and fibrates appear to increase the likelihood of developing cholesterol gallstones. Fibrates can increase the effect of medications that thin the blood, and this should be monitored closely by your physician.
Other Drugs
Hormone Replacement Therapy
The risk of heart disease is increased in
postmenopausal women, whether the menopause is natural, surgical or premature.
This increasing risk may be related to the loss of estrogens after menopause.
Hormone therapy (HT) is treatment with estrogen, either alone or with another
hormone called progestin. HT may be prescribed when women experience symptoms
from menopause.
A recent study examined whether postmenopausal women with CHD who take HT experience fewer CHD events than women who have CHD and do not take HT. The Heart and Estrogen/Progestin Replacement Study (HERS) found that:
· In the first year of the study, women receiving HT had more CHD events than those not taking it, despite a modest drop in their LDL-cholesterol and a rise in their HDL-cholesterol levels.
· By the fourth and fifth years of the study, women in the HT group experienced fewer events than women not taking HT.
Women in the HT group experienced more blood clots and gallbladder disease. Overall, HERS found that women taking HT did not benefit from a lower rate of CHD events. Furthermore, results of the Women's Health Initiative postmenopausal hormone therapy trials among healthy women have shown that hormone therapy should not be used to prevent heart disease. Postmenopausal women who are judged by their physician to need drug treatment to reduce their risk for a heart attack should consider cholesterol-lowering drugs instead of HT, since cholesterol-lowering drugs have been shown to be safe and effective in lowering cholesterol and reducing CHD risk in such women.
Combination Drug Therapy
your goal LDL level is not reached after
three months with a single drug, your doctor may consider starting a second
medicine to go with it. Combination therapy can increase your cholesterol
lowering, reverse or slow the advance of atherosclerosis, and further decrease
the chance of a heart attack or death. The use of low doses of each medicine may
help reduce the side effects of the drugs.
Other Medications Commonly Prescribed for Heart Disease
In addition to cholesterol lowering and control of the other risk factors, including diabetes, there are other treatments to help lower your risk from heart disease. Aspirin, a drug that has been used for centuries to relieve pain and reduce fever, has been shown to reduce the risk of future heart attacks in patients who have already had one. Guidelines for the use of aspirin in people who are at high risk for developing heart disease have not been set. Aspirin seems to work by reducing the stickiness of the platelets (the cells that cause blood clotting) so that blood clots do not form as readily. After bypass surgery, patients treated with aspirin have fewer early closures of the newly grafted blood vessels in their hearts.
Beta-blockers, another type of drug, have been shown to reduce death rates in patients who have heart disease. Beta-blockers slow the heart and make it beat with less contracting force — so blood pressure drops and the heart works less hard. Many patients with heart disease, and those at high risk for developing it, have high blood pressure. Other drugs may be needed to reach a normal blood pressure.
The amount of risk reduction shown by aspirin and beta-blockers is similar to that of cholesterol lowering, making all three important in the treatment of heart disease.