Are You Getting Optimal Medical Therapy?

So you got a stent in an artery of your heart......hopefully your doctor talked to you about the changes to your life you will need to make moving forward, and the five medications that we know to save lives after a heart attack. Here are my thoughts on caring for your heart - note that this blog does not replace the advice of your doctor. Nor does this blog constitute medical advice. These are general principles I use to discuss with my patients. There are always unique situations where some of these principles will not apply so always discuss with YOUR OWN doctor before taking these words as the gospel. .

With a stent in your coronary artery, you should be on five medications, all of which have been proven to prolong life in those with heart disease.

1. Aspirin 81mg daily. Brand is irrelevant. Get the coated variety. Any generic works. to be exact, Originally we thought that you need 2mg for every kilogram of body weight. for the average 80 kg person, need 160mg daily, but we found that the 81mg dose provided similar benefit from stroke and heart attack, with a lower risk of bleeding ulcers and gastric erosions. We know that SOME people will develop GI bleeding from aspirin. But we also know, from a public health perspective that far greater number of people will prevent a heart attack by taking a baby aspirin than those who will develop a GI bleed. So you must weigh the benefits against the risks before starting aspirin therapy.

2. Plavix OR Effient (we have begun using Effient rather than Plavix due to a better efficacy and lower risk of bleeding). Plavis is available as a generic, and is cheaper, but we know that certain people (about 30% will not adequately metabolize the plavix, and it will be like they are not taking it at all). Effient does not have these type of genetic variations, so pretty much all people who take Effient will get the benefit of the drug. Insurance companies, who are in the business of making profits by not paying for your care, will balk at the higher priced Effient (or the equally pricey Brilinta) so we try to document high risk status to increase the success rate of getting the newer better drugs paid by your drug plan.

3. A beta blocker - metoprolol, carvedilol, atenolol, or another drug that ends in -lol. Metoprolol ER (extended release) is a good generic that you only have to take once a day. The BHAT trial, way back decades ago, showed that after a heart attack, beta blockers reduced mortality.

4. An ACE inhibitor - lisinopril, ramipril, fosinopril, trandolapril, or another drug that ends in -pril. I prefer ramipril simply because all the major studies of heart protection like the HOPE trial used ramipril. it is generic, and reduces risk of stroke and heart attacks. Some people develop a dry cough with this class of drugs - in a small percentage, the cough is bad enough to change the drug to an ARB, a cousin of the ACE inhibitor.

5. A statin - rosuvastatin, atorvastatin, simvastatin, etc...

depending on your insurance, they will try to steer you towards generics - cheaper for them, but generally less effective than the newer drugs on the market (generics are the older drugs, that have lost their patent). I take rosuvastatin (crestor) myself and don't have much difficulty with muscle aches or fatigue.

You need to have your cholesterol and liver enzymes checked prior to beginning statin therapy, at the two month point to check liver enzymes and to see if the LDL cholesterol is down to goal of 70, and every six months afterwards. if you ever change dose or change the drug, then recheck liver enzymes after 2 months again. if you experience SEVERE muscle aches or "coca cola" colored urine at any time while on a statin, stop taking the drug immediately, call your cardiologist and have muscle enzymes checked in your bloodstream (LDH, aldolase, CPK, myoglobin) and drink a whole lotta water for a few days.

If you got a drug eluting stent (cypher, taxus, promus, endeavor, xience) then you absolutely positively NEED a platelet blocking agent (plavix, effient, brilinta) not just for a year, but possibly for the rest of your life.

You should consider getting annual stress testing with nuclear imaging, and an echocardiogram, to provide yearly surveillance of your stented artery, and try to prevent a new blockage from going undetected.

The ACC also recommends a sub-maximal stress test 6-21 days after your stent, or a maximal (HR of 85% max predicted) stress test six weeks after your stent.

You may benefit from cardiac rehab, unless you are already physically active.

I would advise limiting your salt intake and exercising daily. Also, look into a Mediterranean diet. it works.

Limit your alcohol to two drinks a day. More than two is generally considered harmful. All wines contains flavonoids, the anti-oxidants that everyone seems to be trying to increase in our diets. Acai juice is good, flax seed oil is good, and pomegranate juice seems to be good.

Avoid grapefruit juice since it interferes with your statin. Also, if you take Prilosec (omeprazole) or Nexium (esomeprazole) for gastric reflux, these two drugs interfere with Plavix (but not Effient), and should be stopped.

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