Heart Disease

Treatment

• Regular exercise 
• Healthy Diet
• Medication

Common High Blood Pressure Medications:

Some people can rely on exercise, losing weight, changing their lifestyle, or changing their diet to control their blood pressure. Although these changes are an important aspect of treatment without medication those changes alone may not be sufficient. Your doctor will determine if you need to take medication.

High blood pressure is a lifelong disease. If patients are required to take medication, they should take their medication according to their doctor’s instructions in order to enjoy a long healthy life. By controlling their high blood pressure, they will also prevent: damage to the heart vessels; heart attacks; stroke; blood clots; kidney failure; and other complications.

Useful information about taking blood pressure medications:

• Medications should be taken at the same time daily to be effective
• If you tend to forget to take your medication(s), place the medication bottle(s) next to things you use daily, like breakfast plates
• Most medications require up to 6 weeks to be fully effective, so be patient
• Do not start a new medication before bedtime in case your blood pressure becomes too low over night
• Long-acting medications (such as CR, SR, CD, XL) should be taken whole on a daily basis; you should never cut the pills into smaller pieces
• Taking a variety of low dose combination drugs rather than a single high dose drug is more effective and has less side effects
• Many patients require 2 or 3 types of medications at the same time to effectively keep their blood pressure within the ideal range
• Do not hesitate to use a few different types of medications, the most important thing is to protect the blood vessels and prevent complications from developing
• Do not take / exchange other patients’ medications; everyone’s health and reactions to medications are different, so let your physician decide the best combination for you

Current medical treatment for high blood pressure can be categorized as:

Diuretics

Lowers sodium and water content in the body which lowers the volume of blood going through the heart and decreases blood pressure

•   Function: diuretic, eliminate edema, lower blood pressure
•   Appropriate for: congestive heart failure, edema 
•   Not appropriate for: gout, kidney failure 
•   Side effects: long term effects are on blood fat, blood sugar, uric acid, blood electrolyte imbalance, and especially loss of Potassium and Sodium which will require food consumption to replenish 
•   Examples: Thiazides (HCTZ); HCTZ/ Amiloride (Moduret); Idapamide (Lozide); Spironolactone (Aldactone); Loop diuretics (Furosemide) 

Beta Blocker

•   Function: lowers blood pressure, treats arrhythmia and angina, slows heart rate 
•   Appropriate for: post heart attack, teenager with fast heart rate 
•   Not appropriate for: people with slow heart rate, asthmatic patients, chronic obstructive pulmonary disease, and severe peripheral arterial disease  
•   Side effects: fatigue, slow heartbeat, dizziness
•   Note: people at the age of 60+ should not take this medication alone; these medications should not be discontinued abruptly as they need to be tapered off gradually.
•   Examples: Atenolol (Tenormin); Metoprolol (Lopressor SR); Bisoprolol (Monocor); Propranolol (Inderal); Acebutolol (Sectral); Pindolol (Visken); Nadolol (Corgard)

Calcium Channel Blockers

•   Function: lowers blood pressure, treats angina and arrhythmias 
•   Appropriate for: angina, high blood pressure 
•   Not appropriate for: congestive heart failure 
•   Side effects: swelling in the feet, headache, flush 
•   Note: should always use the long acting (CD, SR, XL) version rather than the short acting CCB, only requires to be taken once a day. Some CCB will slow down the heart rate as well (eg. Diltiazem, Verapamil). Taking Beta Blocker at the same time may cause dizziness because of decreasing heart rate and lowering blood pressure too much.
•   Examples: Nifedipine (Adalat XL); Amlodipine (Norvasc); Felodipine (Renedil, Plendil); Diltiazem (Cardiazem CD, Tiazac); Verapamil (Isoptin SR)

ACEI-Angiotensin Converting Enzyme Inhibitors

•   Function: lowers blood pressure, protects the heart, blood vessels, and kidney. 
•   Appropriate for: diabetics, congestive heart failure patients, post myocardial infarction, enlarged left heart and proteinuria patients, 
•   Not appropriate for: Black people, Renal Artery Stenosis, Kidney function failure, women trying to get pregnant 
•   Side effects: severe coughing (especially in Asians) 
•   Examples: Ramipril (Altace); Perindopril (Coversyl); Captopril (Capoten); Enalapril (Vasotec); Fosinopril (Monopril); Lisinopril (Prinivil, Zestril); Quinapril (Accupril); Trandolapril (Mavik); Benazepril (Lotensin)

ARBs-Angiotensin II Receptor Blockers 

•   Function: this type of medication has similar function as ACE inhibitors, it can protect the heart, blood vessel, and kidneys without causing coughing or other adverse reactions. This is a newer drug than ACE inhibitors. 
•   Appropriate for: Patients that cannot take ACE inhibitor 
•   Examples: Valsartan (Diovan); Irbesartan (Avapro); Candesartan (Atacand); Losartan (Cozaar); Telmisartan (Micardis); Eprosartan (Teveten)

Alpha Blockers

•   Function: lowers blood pressure, treats enlarged prostate
•   Appropriate for: older men with an enlarged prostate 
•   Side effects: Postural hypotension and fainting, especially during first dose syncope. Drug dose should be increased gradually. Be extra cautious and move slowly when getting out of bed. Avoid driving at the first 24 hours. This drug should not be taken alone for the first time.  
•   Examples: Prazosin (Minipress); Doxazosin (Cardura); Terazosin (Hytrin)

Direct Renin Inhibitor

This is one of the newest drugs for lowering blood pressure 

•   Function: prevents the body from releasing angiotensin II which cause blood vessel to contract. As a result, blood vessels will be relaxed, lowering blood pressure.  
•   Not appropriate for: Pregnant women and anyone that’s below the age of 18years old 
•   Examples: Aliskiren (Rasilez) 

Blood pressure Medication Combinations

These are drugs that combine two separate drugs into one pill to make it more convenient to use.

ACEI-Angiotensin Converting Enzyme Inhibitors + Diuretic  

Ramipril + HCTZ (Altace-HCT)

Perindopril + Indapamide (Coversyl-Plus)

Lisinopril + HCTZ (Zestoretic, Prinzide)

Quinapril + HCTZ (Accuretic)

Enalapril + HCTZ (Vaseretic)

ARBS + Diuretic 

Candesartan + HCTZ (Atacand-plus)

Valsartan + HCTZ (Diovan HCT)

Losartan + HCTZ (Hyzaar)

Irbesartan + HCTZ (Avalide)

Telmisartan + HCTZ (Micardis Plus)

Beta blocker + Diuretic

Atenolol + HCTZ (Tenoretic)

Propranolol + HCTZ (Inderide)

With the current available blood pressure medication, blood pressure can be effectively controlled with the correct pairing of medication and lifestyle. For patients that have high blood pressure, you should always take your medication on time and you should provide your doctor with your blood pressures for their reference. Measure your blood pressure two to three times a week after resting for 10 mins.  

For hypertensive patients, the following factors may affect the effectiveness of the blood pressure medications: 

• Did not take medications regularly or forgot to take medications
• Medication dose is too low 
• Combination of medications being taken is inappropriate 
• Poor diet and excessive amount of salt in diet
• Being overweight 
• Smoking or excessive drinking 
• Sleep apnea 
• Psychiatric patients with other medications that interact negatively with hypertension drugs, e.g. Anti-inflammatory: NSAID, Cox-2 inhibitor, steroid drugs, contraceptive, decongestant, etc. 
• Other disease that affects blood pressure, e.g. kidney failure, kidney blood vessel disease, adrenal tumor, pheochromocytoma, etc. 

Hypertension patients on long term medication for lowering blood pressure should always carry their list of medication in case of emergency. Most importantly they should keep in touch with their doctor and return for periodic checkups. With the joint effort of the patient and doctor, hypertensive patients’ can enjoy a healthy life with controlled blood pressure. 

Content by Dr. Thomas Ho, Family Physician

Exercise

Before starting any new exercise regime, make sure to check with your doctor.

Exercise helps prevent or control cardiovascular disease in many ways. It helps to control the impact of many of the risk factors of heart disease, such as: high cholesterol, high blood pressure, obesity, stress and diabetes. There is also strong evidence that frequent exercise strengthens the heart and prevents heart attacks.

How do you exercise the heart effectively? You must engage in sports with a lot of physical activity. This will significantly accelerate your heartbeat and strengthen the heart. Such activities are called “aerobics activities” . Examples include: cycling, swimming, brisk walking, stair climbing, running and jogging. Some activities that also have a lot of benefits but are not aerobic activities are working in the garden, walking leisurely, bowling and weightlifting. . Ideally, in order to stay healthy a person should exercise 5-7 times a week, with each time lasting 30–60 minutes.

Your heart rate is the number of times your heart beats each minute. The goal of aerobic exercising is to reach 50–75% of your “maximum heart rate” while you exercise. This is your target heartbeat range. To calculate your target range, first calculate your maximum heart rate. One quick way of calculating this is to subtract your age from 220. For example, a forty year old person calculates their maximum heart rate as: 220 – 40 = 180.  Then to get your target heartbeat range divide the result by 2 to get the lower number and divide your maximum by 4 and multiply that by 3 to get the higher number. For example, a 40-year-old doing aerobic exercise would aim for between 90 -135 heartbeats per minute (180/2 = 90 and 180/4=45*3=135). When you initially start exercising, set you target at the lower end of the range, for example 60%. As you increase your fitness, you can set your target higher, for example 85%. 

The best exercise is something you like and can stick with. Walking is one of the best exercises because it is simple, easy, safe and inexpensive. The amount of calories burned with brisk walking is similar to running, but the risk of injury is much less. Walking does not require special training or equipment. You just need a pair of good shoes. It is also an aerobic and weight-bearing exercise and so is beneficial for your heart while at the same time it helps prevents osteoporosis.

 Tips:

• Choose a sport that you enjoy.
• Exercise 30 minutes daily. If necessary split your exercise into 3 sessions of 10 minutes each.
• Gradually build up your routine to allow your body to adapt to the exercise.
• Before starting actual exercise do preparation exercise and stretch your limbs.
• Choose an exercise with an appropriate pace 
• Gradually slow down towards the end of your exercise.
• After the exercise routine loosen up and stretch your limbs.
• If you do not exercise for a few days, don’t jump right into intense activity.
• If you find yourself bored, switch to another form of exercise.
• If you want to lose weight, it is important to have a balanced diet as well as regular exercise 

Content by Dr. Anthony Fung, Cardiologist

Diet

Eat a heart healthy diet which includes watching your:

• Salt intake
• Dietary fat

Diagnosis

Coronary disease is best diagnosed by a person’s medical history and a medical check-up by their doctor. If a patient exhibits any of the symptoms listed and/or has several of the risk factors, the patient should go for a heart check-up. Currently there are several ways to help diagnose the presence of coronary disease. 

Commonly used methods for heart check-ups are:

Electrocardiogram (ECG) 

ECG measures the electrical activity of the heart to test how well your heart is functioning. Electrodes are placed on the skin of the chest and of the arms and legs. On the electrocardiogram, the pulse beats of the heart are shown as waves. Each time the heart beats, it produces the wave shown in the image.

ECG can be used to determine:

•   Heartbeat
•   Irregular or abnormal heartbeats (arrhythmia)
•   Decrease in blood or oxygen supply to the heart
•   Previous heart attacks
•   Damage to heart tissues

Exercise Stress Test

If a patient has chest pains and the doctor suspects it is due to coronary disease, the doctor will usually suggest an exercise endurance test. Electrodes connected to an ECG machine will be attached to the patient while the patient walks on a treadmill. The treadmill is slightly tilted to simulate going up a hill and it gradually increases in speed during the test which requires the patient to walk faster.

As the body exerts more effort to walk and then run faster, the heart will require more blood and the heart beats faster.  As the heart beats faster, the blood pressure will go up. If the blood supply to the heart is not enough for the faster speeds, the ECG will display irregularities.

Through the exercise stress test, the doctor can diagnose problems with the heart blood vessels being blocked and also more accurately determine what level of exercise is most suitable for the patient.

Myocardial Perfusion Scan (MIBI)

When the doctor wants to know more about the heart’s blood supply and suspects the narrowing of coronary arteries, a nuclear scan may be required. The patient will be injected with a small amount of radioactive material (called thallium or MIBI). The patient lies on a special bed with a camera above (gamma camera) which takes pictures of radioactive activity. If a portion of the heart does not receive normal blood supply it will show as a blank space in the scanned image.

The first set of images is taken while the patient is at rest. Then the patient does the exercise stress test. A second set of images is taken after the patient completes the exercise. If the patient cannot perform the exercise due to muscle of skeletal problems, the patient may be prescribed dipyridamole (Dipyridamole or Persantine) to simulate the effect of actual exercise.

Echocardiogram

An echocardiogram is a test that uses sound waves to record the heart’s motion This test allows the doctor to check the functioning of the heart and its valves. When the patient has abnormal heart murmurs, has previously had a heart attack, or is suspected of having valve issues, an echocardiogram is required.

Computer Tomography (CT Scan)

CT scans use x-ray and sophisticated computer technology to obtain “the most conclusive” image. During the scan, the patient lies down on a narrow table and the body is pushed into the machine. Usually, a pigmented substance is injected into the veins of the patient to enable the doctor to see the vascular network of the heart. Some patients may have a sensitivity to this pigment and the scan can be done without it in this case. If you belong to this group, inform your doctor when he schedules the scan.

CT scans allows the doctor to clearly see the heart’s arteries, intravascular fat deposits, and any damage or death in the heart tissues.

Magnetic Resonance Imaging (MRI)MRI machine

MRI uses magnetic fields and radio waves of different frequencies to take high quality images of the heart. It does not use x-ray. MRI is very useful for people with congenital heart problems or for determining the extent of heart damage in people who have had heart attacks.

Coronary Angiography (Cath)

Coronary angiography enables the doctor to observe the heart and its blood vessels. Although other tests (such as MIBI or CT scan) can assist the doctor in diagnosing blockage in coronary arteries, coronary angiography is the most effective method. It is done in the hospital. The doctor usually threads a small tube from the patient’s femoral artery or wrist artery into the coronary arteries. X-ray dye is injected into the coronary arteries and flows into the smaller arteries of the heart. The path of the dye and any interruptions is recorded.

If the heart has severe blockages, a balloon angioplasty or a stent placement can be done. If a heart bypass surgery is required, it can also be done after this procedure.

Content by Dr. Anthony Fung, Cardiologist

Treatment

Lifestyle changes:

•   Quit smoking: Not only does this reduce the chance of you getting heart disease or if you already have heart disease then having it get worse, it also reduces the risk of stroke and lung cancer.
•   Control high blood pressure: The usual goal is to keep blood pressure below 140/90 mmHg. In certain cases (for patients with diabetes, kidney failure or heart failure) the doctor will set an even lower goal.
•   Control cholesterol levels: For people with coronary disease and diabetes, doctors will have stricter guidelines than for the general public. Borderline levels of cholesterol are definitely not good enough. Patients must ask their doctors for an acceptable cholesterol level for them since it is dependent on their coronary situation. To get a patient’s cholesterol level to where it should be usually requires both a controlled diet and medication.
•   Control diabetes: Maintaining a healthy glucose level decreases the risk of diabetic complications, including the risk of cardiovascular disease complications.
•   Control body weight: Patients should maintain a reasonable weight based on their gender and height. The waistline is also an important guide for preventing vascular diseases. A reasonable waistline for Asian men is less than 35 cm and for Asian women is less than 31 cm.

Exercise regularly:  Exercise at least four times a week for 30 minutes each time.

Medication for Coronary Disease

Nitroglycerin

•   Nitroglycerin mouth sprays and nitroglycerin tablets placed under the tongue can be used for quick relief of chest pains. Those who frequently experience chest pains should always carry either the spray or tablets.  If these do not help the chest pain the patient should go to the Emergency room.
•   Oral nitroglycerin tablets or skin patches are used to prevent the return of chest pains (note: skin patches should stay on for 12 hours)

Blood thinners (Anti-platelet drugs)

•   These drugs help prevent blood clots from forming in the blood and blocking the blood vessels. This reduces the risk of heart attacks.
•   Aspirin is the most common drug of this type. If the patient has adverse reactions to aspirin, Clopidogrel (Plavix) may be used instead. In more severe cases Warfarin can be used.
•   After a procedure such as balloon angioplasty or stent placements the patient is usually prescribed aspirin and Clopidogrel (Plavix).  The medication is required from anywhere between a month to a year depending on the type of balloon or stent inserted. Failure to continue with medication can increase the risk of sudden blood vessel blockages and heart attacks.

B-blocker

•   Helpful in the treatment of chest pains
•   Helps prevent another heart attack
•   Used to treat heart failure (weakened hearts)
•   Used to treat irregular heart beats

ACEI-Angiotensin Converting Enzyme Inhibitors

•   Used to treat heart failure (shows good results when taken with B-blockers)
•   Used to treat high blood pressure
•   Used to treat kidney failure especially when related to diabetes
•   One side effect observed among Chinese people is a dry cough. In this case another group of drugs unlikely to cause a cough can be substituted (ARBs: Angiotensin Receptor Blockers)

Content by Dr. P.K. Lee, Cardiologist