 Hello and welcome to Texas Heart Institute. I am Brianna Castello. I am an interventional and general cardiologist here. I will be bringing you today, Cardio Pharmacology and Cardiac Rehab, an overview. Let's start off with a little laugh here on the right. To prevent a heart attack, take one aspirin every day. Take it out for a run, take it to the gym, then take it for a bike ride. So what are we going to learn today or what are we going to kind of generally review? What medications are used for each cardiac condition, the common cardiac conditions that you all know probably most about? Why are certain medications so important in maintaining or improving cardiac health? What side effects are most common in cardiac medications that you should know about? And what role does cardiac rehab play in cardiovascular health? So the first question that many of us get as physicians or care providers, why so many medications doc? Well the truth is if we're giving you a medication there's probably a reason that we pick that particular medication for you. Medications target many systems in the cardiovascular system including other organs, not only the heart but the kidney etc. And different drugs affect these organs differently. Additionally, some different drugs target certain symptoms. So there's a reason for our craziness about picking certain meds most of the time. Medications are generally chosen that either one make you feel better, two make you live longer, or three do both. So let's start off with one of the most common things that we encounter in our clinic visits, hypertension, also known as high blood pressure. First what's our goal? What do the physicians want to achieve when they're treating you with these medications? The answer to that is the blood pressure of less than 120 over 80 for the most part. So what are some of the medications and how do they work and why do they pick, why do we pick them? A common medication that you might encounter is a calcium channel blocker. That's a lot of words for the medications that you might have in your cabinet such as amlodipine, nifetapine or diltiazum. So how does this medication work? It relaxes the smooth muscles of your arteries and the arteries are what kind of dictate your blood pressure. So in turn relaxing these muscles can decrease your blood pressure. A beta blocker, that's a pretty common one used for many cardiac conditions, but in particular for high blood pressure or hypertension it decreases the heart rate but also has effect on the smooth muscle. Metoprolol, Nibibolol, Atenolol, there's a few other ones but these are the common ones that target just that beta receptor. The beta receptor also again as mentioned decreases your heart rate so this is a wanted effect for many cardiac conditions but for you that's something you might notice. So if you notice a slow heart rate or you notice your heart rate's not going up as much when you're exercising this is the medicine that's doing that. Core egg or Carvetalol is another medicine that has beta blocker properties. It also has an alpha blocker property. Those alpha receptors they live on your blood vessels and those alpha receptors when they are attacked by this drug they relax. So again like the calcium channel blocker, relaxing the smooth muscle in the arteries can decrease your blood pressure. One of our favorites diuretics. What do diuretics do? Those are the ones that make you pee a lot. In general they decrease your blood volume, they encourage your kidneys to excrete water and decrease by decreasing the blood volume they decrease your blood pressure. So what are a couple of the classes of diuretic that we use? In general we have loop diuretics which are your Lasix or Fiorosamide, Torsamide or Bumetanide which is Bumex. So those drugs are pretty potent diuretics and if you're on those your doctor might tell you expect to be going to the bathroom a lot more. They're pretty effective and a lot of the times they're using another condition called heart failure. Another type of diuretic which is more common and generally one of the first line or most common drugs that we use for new high blood pressure is a thiazide. Hydrochlorothiazide or chlorhthalodone are two of these. Hydrochlorothiazide you may have heard your doctor refer to as HCTZ. The next class that we'll talk about is an ACE inhibitor. This is a very common medicine especially for those diabetics or if you're a diabetic and you have high blood pressure. These drugs work in a multitude of ways but in general they decrease your kidney so your renal, vasoconstriction and therefore decrease your blood pressure. It's a complex mechanism so at this point just know that it helps decrease your blood pressure by working with your kidneys. Lycinopril and Ramapril are two of the common ones that we use of the ACE inhibitors. An angiotensin receptor blocker is very similar to an ACE inhibitor and it mechanistically works pretty similarly. It just affects a little bit lower on the cascade. Belsartan, low-sartan and ulma-sartan are a couple of the most common angiotensin receptor blockers. Last on the list and perhaps maybe one of the least favorites of us cardiologists is quantity. This is a central alpha receptor blocker so it actually central means works in your brain. By doing this the brain receptors decrease the peripheral meaning the arteries in your arms your legs and the rest of your body. The smooth muscle is relaxed so if you decrease or you increase the relaxation you decrease the blood pressure. So those are the most common blood pressure medicines that we'll talk about today. You'll see a few of these repeated in the other classes or the other cardiac conditions shortly. So coronary artery disease also known as blocked arteries. What first is our goal? Our goal in any coronary artery disease or atherosclerosis or blocked arteries is to stabilize the plaque that's been built up in the arteries, decreased any chest pain that you're getting from having the plaque in the arteries or to keep your sense open. So again we have a beta blocker. The beta blocker for coronary artery disease works in a way by decreasing the heart rate which we talked about but this helps to decrease the demand on the heart. Imagine it like your heart's going for a marathon and the heart rate is a hundred sixty all the time. That's like your heart if you had a very severe blockage. So how can you decrease the stress on your heart? You decrease the heart rate. So the beta blocker for coronary artery disease decreases the heart rate which decreases the demand on your heart which can also help with your symptoms of chest pain. Aspirin. This is a very common one. Aspirin is a platelet inhibitor. What does that mean? It attaches to the platelet and it blocks its ability to clot or form little clots. So you can imagine if you have blockages in the arteries you want to decrease the chance of clots happening or any more plaque buildup and aspirin helps do this. P2Y12 letters and numbers which mean it's another platelet inhibitor. P2Y12 is a certain receptor on a platelet and it also just helps so that little microclots and clots don't happen in the arteries. A lot of people will have this prescribed as an aspirin and a platelet inhibitor P2Y12 inhibitor after they have a stent placed. Some of these come in P2Y12 or the three that we use most are platyx or clopidogrel, prasagrel or effiant, antikagrel or berlinta. Those are the brand names. So the next on the list another very common one that we'll talk about a little bit more briefly. Staten is to decrease the cholesterol because cholesterol is intimately involved with blocked artery disease or coronary artery disease. Our goal as physicians and cardiologists and primary doctors is if you have coronary artery disease or any sort of artery disease we need to drive down your cholesterol. So the medicines that we commonly prescribe for this are torvastatin, resuvastatin, pravastatin and simastatin. Last but not least nitrates. So many people will know these as the sublingual nitro that they carry around if they're having chest pain and they put one under their tongue. The reality is there are some long-acting nitrates that we also use for people who have chest pain or ongoing chest pain with coronary artery disease. A few of these are isosorbide mononitrate, isosorbide dinitrate and nitrostat which is a sublingual form. The first two are more of the daily medicines that are longer-acting. So next on the list a very common disorder that many patients especially as they age will encounter or be diagnosed with. So dyslipidemia also known as high cholesterol. What is our goal? Our goal is to generally decrease the LDL, low density lipoprotein. That's the bad cholesterol that most of your doctors will talk about. The goal of this is to decrease the risk of heart attack, stroke and other vascular disease. So here in the center you can see it's just a cross section or a longitudinal section. They picked an artery and that top A says normal artery. We want your arteries to look like that. No plaque clear of any disease. Second on the list you start to see that plaques building up. And then third more. The goal of statins is to decrease the cholesterol so that the cholesterol doesn't deposit in that wall and make that little yellow film. So what drugs do we have to fix your cholesterol? Statins of course as mentioned. It decreases the ability of the liver to actually synthesize or make the cholesterol. Again atorvastatin, resuvastatin, pravastatin, simvestatin are of some of the options that we have. Next on the list is Zetamib or as many patients know Zetia. This actually decreases the ability of your gut to absorb cholesterol. So that's one way to drive down the LDL. One of the newer therapies that we have that we actually love because it's very efficacious is a PCSK9 inhibitor. It's a lot of letters. For a drug that's an injectable it's a monoclonal antibody that actually helps with the body to not absorb LDL or to get rid of LDL. Most of these drugs have taken can decrease your bad cholesterol by more than 50%. That's huge. As a comparison atorvastatin or servastatin maybe on the order of 20 to 30%. So PCSK9 inhibitors are largely efficacious and especially used in the patients who have resistant LDL or LDL that doesn't respond well just to statins. Next on the list is icosapent aka vasipa, much easier to say. Vasipa is an EPA ester that reduces VLDL and triglycerides. All that means is it's a drug that really helps us drive down triglycerides for the most part which we know as physicians is linked with worsened cardiac outcomes. Next is pretty, it's a newer drug, Bempadilic acid. This drug actually works by inhibiting the cholesterol synthesis in the liver via a different mechanism than a statin but it's quite efficacious. Newer on the market. Newer on the market for patients might might also mean a little more expensive so always good to talk about the cost of these things with your doc and what you can do to decrease the cost. Last on the list is fibrates. These are generally not used very often and it's because reality has shown us that it doesn't improve outcomes. As physicians and clinicians and scientists we're always looking for drugs that are going to make you live longer or feel better like we talked about at the beginning and fibrates don't seem to make you live much longer and certainly don't make you feel better so we don't use these very often. Next on the list, atrial fibrillation also known as shorthand aphib. What is our goal in aphib? Well there are really two main goals. We either want to keep you in normal rhythm or slow you down meaning make your heart rate normal heart rate so between 60 to 100. Additionally the therapy for aphib a lot of the times is focused on decreasing your stroke risk. Aphib increases your risk for stroke. So what are the drugs that we have? There's generally two main categories. We have anti-arrhythmics which means we don't want to be in the wrong rhythm. So this keeps you in the normal rhythm or tries to and maintains your heart rate at the same time. Amiodarone or dronetarone. Dronetarone is the it's a very similar to amiodarone drug with a few changes in its chemistry. It works on many receptors in the heart to keep you in normal sinus rhythm. Sodium channel blockers often use in patients who really don't have structural heart disease which means you have a normal squeeze of the heart and you don't have any significant valvular disease. Flecanide, myxilatine, propanone. These are some of the drugs that your doc might might prescribe. Beta blockers again pops up. It's a drug that decreases your heart rate so again it can also help maintain normal rhythm. Metoprolol, tenolol, propanolol, some of the drugs that we've mentioned earlier. Potassium channel blockers work on the potassium channel in the heart and these drugs are Soda Law and Dofetalide. Dofetalide is a drug that your doc might want you to come to the hospital for to be loaded meaning to start you on it in the hospital so we can monitor your EKG. Last on the list of anti-rhythmic drugs, calcium channel blockers. These have been mentioned before in high blood pressure or hypertension. These rapamell ditism can also work on the cardiac channels in the heart to maintain sinus rhythm or slow your heart down most of the time. So the heart rate. So next huge topic that we often spend a lot of time discussing with our patients is anticoagulants or blood thinners. The whole goal of these blood thinners is to prevent a stroke and a fib. You see on the bottom picture here a normal heart, the top chambers beat and then the bottom chambers beat and it's in synchrony. So top bottom and a fib the top chambers are kind of wiggling around having a party while the bottom chambers are kind of dancing to their own beat. So the top chambers wiggling around with this discordant contraction have static flow which means that there's stasis in the blood in those top chambers and any stasis of blood can promote coagulation which means promote clots in the heart. Those clots can travel from the top chamber to the bottom chamber and ultimately the brain. So that's why we want to thin your blood. So if you're wondering why the doc wants you on those nasty drugs that make you bruise easy, this is a good reason for it. There are three general classes that we use. Vitamin K antagonist also known as Coumadin or Warfarin. That was a standard back many years ago and really the only option we had. Now fortunately we have new drugs, factor 10A inhibitors and direct thrombin inhibitors that kind of, they jump in on the clotting cascade at different parts and they block the ability to clot. The 10A inhibitors, Riveroxaban, also known as Zeralto or Epixaban also known as Alakwis your doctors might say and then direct thrombin inhibitors which is Pradaxa also the generic as Dibigatran. All right, congestive heart failures are next topic. This is also known as congestive heart CHF. A lot of patients will be told that they have CHF but really understanding what kind of heart failure you have is important. Do you have heart failure because your blood pressure has been uncontrolled for too long? Do you have heart failure because you've had a heart attack in the past or do you have heart failure for some other reason? The treatment goal of this, of all heart failure, is truly to improve the heart function by using medications generally or to control your symptoms meaning keep your fluid balance, meaning your water balance pretty even. So again we see Beta Blocker, he's kind of the jack of all trades. So he decreases or she decreases the heart rate and the oxygen demand and stress on the heart. Same drugs we talked about before, diuretics again we talked about before and heart failure it's a disorder, it's really a disorder of your balance of fluid with a lot of involvement of your kidneys but it decreases blood volume the diuretics and promotes water loss when we give you a diuretic which hopefully makes you feel better. If you feel short of breath and we know you have heart failure and you're storing fluid in your lungs the diuretics will help get rid of that fluid. Similarly if you have swelling in your legs the diuretics are what are going to help you pee out some of that fluid. ACE inhibitors as we've talked about are good blood pressure medicines but also have been proven in studies to help with heart function. So improve the muscle, the muscle of the heart remodeling and truly you know prolong your life. Lycinoprol, Ramaprol again are a couple of those. Angiotensin receptor blockers are similar to ACE inhibitors when we give them in heart failure. There is a new kid on the block the angiotensin receptor neprolycin inhibitor or ARNI, A-R-N-I. This is secubitrol balsartan also known as intresto. We often use the brand name because it's easier to say and easier for everyone to kind of remember. So this drug has been shown to certainly decrease hospitalizations for patients with heart failure so that's why we really love it and generally for many patients we see an improvement in their function of their heart, the squeeze of their heart. So now that we did a whirlwind tour, some of the drugs used for cardiac conditions, what are some of the most common cardiac drugs with side effects? So in the clinic often beta blockers as they slow your heart rate, which is the goal of why we're giving you this medicine, often people will complain of fatigue or lightheadedness and this can be because sometimes we drive your heart rate down too low but also this can be because you know as you decrease your heart rate your cardiac output does go down a little bit. So you may or may not feel a little more fatigued. It's an easy fix by backing off, decreasing your dose of the beta blocker. Another less common side effect is hair loss in women which a lot of docs might not even realize but this is an interesting, they're not quite sure on the mechanism, but it is common in women more than anything. Stattons. Everyone has the patients who just say they can't tolerate statins and muscle aches is the biggest complaint. The reality is a lot of this can be avoided if you start lower on the statin and kind of ramp up the dose. So if you tell your doc, hey I'm having muscle aches, do you think you can maybe cut my dose in half or try you know a lower dose for a little while until I can tolerate it? That's a good approach. Next, amiodarone. So this one is more of a side effect, the side effects that we really try to avoid. This drug can affect your liver, your lungs and your thyroid gland. These are uncommon but can be very serious so worth talking about it with your doc. Next, diuretics. Well they get rid of water so the only real way to get rid of water with drugs is making you pee a lot. So this increases urination and oftentimes is so bothersome for patients. A way to circumvent this annoyance is to dose the diuretics earlier in the day meaning in the morning when you wake up and maybe early afternoon so that you're not up all night. Amlodipine. Another drug with common side effect of lower extremity edema meaning swelling. This stops when you stop the medicine. Again, common in women. Some quote about one in five people women will have this side effect. Aspirin P2I12, anti-coagulants. Again, it's working to decrease your ability to clot so it does of course increase your risk of bleeding. And again, this is kind of the goal of the medicine but also can be a nuisance. Worth talking to your doc about if there's any way to manage this a little bit better. Alright, we did a whirlwind tour of all the drugs and their side effects or some of the most common side effects. So now let's talk about a different aspect. Cardiac rehab. If your doctor hasn't talked with you about cardiac rehab and you've had a stent or you've had bypass or perhaps you've just been diagnosed with heart failure, this is something you should talk about. What is it? So it's a medically supervised program for rehab. It includes exercise, diet and stress counseling. So it kind of goes through your lifestyle and how you can make your heart healthy. Who should have it? Again, anyone really with a following. Heart failure, prior angioplasty, which is a fancy term for stent or ballooning in the arteries of your heart. And of course, cardiac surgery. This cardiac rehab, you can find centers near your home. It's not only in the Med Center that we have rehab programs but Med Center, rehab centers can be found just about anywhere in the cities, even close to your house. Alright guys, thank you so much for joining me today. I hope that this whirlwind tour helped you understand some of the medications you're on. And here at Texas Heart, our goal is for you to understand why you're on medicine so we can work together as a team to make you feel better and live longer.