Healthpharmablog. About Health & Medicine

ACE inhibitors

Angiotensin-converting enzyme inhibitors, such as captopril (Capoten) and enalapril (Vasotec), along with many others, are a recent class of drugs used in the treatment of coronary heart disease. Research shows they extend life and reduce the chances of heart failure after heart attack. They act by preventing angiotensin from causing constriction of smaller arteries, which reduces “afterload” and allows the heart to work less hard. They also treat hypertension as do beta-blockers and calcium antagonists. Side effects include low blood pressure, kidney dysfunction, and more minor problems such as persistent cough, taste alterations, and rash.

Aspirin

No review of drugs used for angina would be complete without a mention of aspirin. In these circumstances, aspirin is not being prescribed for its well-known effect on pain, but for its effect on the platelets in the bloodstream. In low doses—half a standard aspirin tablet per day—aspirin prevents platelets from sticking together or from adhering to the surface of atheromatous plaques.

As this is the first step to thrombosis at the site of a plaque, aspirin should, in theory, prevent the thromboses within the coronary arteries at stenotic sites that are thought to be the main cause of heart attacks. The whole medical world now accepts, after many trials have shown its effects, that one aspirin should be given at the time of an acute heart attack to minimize the damage, and thereafter to prevent a further attack.

It is a very small step from giving such a low dose of aspirin during a heart attack to its use to prevent one in people with angina. I advise all my patients with angina to take half an aspirin a day. The very .few who cannot tolerate this dose of the drug because it gives them indigestion may have to do without it, but it is possibly a lifesaver for the rest. It has no obvious effect on the angina, but it may well prevent the angina from becoming a full-blown heart attack.

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Five years ago, I was advising people that they had a choice in stopping: they could stop suddenly or gradually. Now I’m convinced that the first is the only way, and I advise the “General de Gaulle” method.

General de Gaulle announced to the whole French nation, on television, that he had stopped smoking. After that, he could hardly light up in case a member of the press caught him and exposed him as a fraud or backslider! Most people could do something similar, in front of friends. Today’s antismoking climate will ensure their sympathy and support, rather than sneers or sniggers.

I advise people to take all the cigarettes they possess, in pockets, handbags, at home, or anywhere else, to scrunch them up, and throw them in the trash. They should then resolve never to buy another cigarette, and always say “no” immediately, without even thinking about it, to anyone who offers them one. If they do not wish to argue with smoking friends, a nonsmoking sticker in the car and on the front window of the home can help.

People contemplating suddenly stopping smoking often fear withdrawal symptoms. These symptoms can include agitation, irritability, sleeplessness, and nervousness, but such things may be completely absent. I have found that people who have to give up for serious medical reasons, such as angina, hardly ever have withdrawal symptoms. If you have decided to stop because of your angina, odds are that you will have no bother with withdrawal. You may still have a desire to smoke, but that will subside in a week or two, as your new feeling of well-being, caused by the elimination from the bloodstream of carbon monoxide, nicotine, and tar-linked chemicals takes over. People suffering from depression should be treated before cigarette cessation.

If you must do something else to take your mind off cigarettes, then chew low-calorie gum or, better still, eat pieces of carrot or celery. Get a friend to support you in the effort.

If you find you cannot stop the first time, don’t despair. Try again. Many people find that they have to stop several times before they can do it permanently. You can try acupuncture or hypnosis if you wish, but they do not have any magical properties. They only support your own determination, and cannot overrule weak willpower. If you have angina, you should not use nicotine chewing gum or patches. They work by supplying nicotine to your bloodstream, on the principle that it will stop any craving for tobacco. However, that nicotine can still narrow your arteries, and may even promote a heart attack if you backslide and start smoking again. The combination of nicotine from the cigarettes and from the gum or patches may be too much for your heart.

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I would like to plug (yet again) the Mediterranean way of eating. The ideal is to “go Italian”! Italian food is not only among the best in the world, but it is among the healthiest, too. Italians cook mainly in olive oil, eat plenty of high-quality vegetables and fruit, their fish is superb, and they eat meat sparingly.

Pasta is starchy rather than sugary, so that your glucose level rises slowly after a meal, if at all (starch takes longer to digest down to glucose than does sugar). That is all to the good. Even the garlic used in Italian cooking helps. Garlic contains substances that help to prevent blood clotting. Eating garlic every day may not make you popular with close friends (unless they are eating it, too!), but it may help you live longer.

The most important aspect of this change of eating habit (I deliberately do not call it a diet) is that it is a positive one. It is not a question of cutting down on food intake, but of shifting to a more varied, tastier, and healthier way of eating. You can be just as satisfied after an Italian meal than after a burger and fries.

The new tastes you encounter on the way to your new style of living will be a revelation. Experiment with spices, and use less salt, so that you can taste these new flavors. As desire for salt diminishes, your sensitivity to other tastes will be enhanced—and you will not put on weight.

• Not everyone wants to eat Italian-style all the time, though. There are alternatives, such as a baked potato instead of pasta, or onions instead of garlic. Now that you have made fish and poultry your main source of protein, grill them or shallow-fry them in oil. For extra taste and interest, try frying them in oatmeal. However, do not use the cooking oil more than three times: repeated frying can turn unsaturated oils into saturated fats.

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A blood pressure measurement has two readings: the systolic and the diastolic pressures. Systole is the contraction of the heart that pumps the blood into the main arteries, and diastole is the relaxation phase, in which the heart fills up again with blood entering from the veins and the lungs. (Refer back to figure 2 in chapter 3 for an illustration.) during diastole, valves close to stop the blood in the arteries rushing back into the heart, and the arteries tense, exerting a further pressure on the blood inside them, so that it continues on its way.

Pressures are measured in millimeters of mercury (mm Hg). The systolic pressure is the pressure exerted on the blood in systole, the normal being around 110-130 mm Hg, and the diastolic pressure, measured during diastole, is around 60-80 mm Hg. Blood pressures are noted down as the systolic/diastolic reading, for example, 125/80 mm Hg.

As blood pressure rises, so does the risk of a heart attack. The British Regional Heart Study revealed that at a systolic pressure equal to or higher than 148 mm Hg, the heart attack risk was twice normal. There was a raised risk, too, if the resting diastolic pressure was, on repeated measuring, above 93 mm Hg, but even those with diastolic pressures above 72 mm Hg appeared to carry some extra risk. This result was similar to those in studies conducted in the U.S., which suggest that the lower the diastolic blood pressure, the better it is for the heart.

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Angina is simply the medical word for pain. Angina pectoris means pain in the chest, and the two words have slipped into common usage as meaning heart pain.

However, many pains in the chest are not connected to the heart. They may arise from cramping or bruising in the muscles of the chest wall, or from inflammation of the surface of the lung, or from spasm or acid in the esophagus. A common chest pain arises from the ribs, which can be inflamed at the junction between their bony back two-thirds and their cartilaginous front third. Coughing can bruise the muscles between the ribs, causing pain upon deep breathing. Pain in the chest can even come from the stomach, as in indigestion—though it should never be diagnosed as such until heart pain has been ruled out. The precise site of the pain is very relevant. The heart is just left of center in the chest, but heart pain is not confined to this area. It mainly occurs behind the breastbone (in the center of the chest) and around and above the left nipple, but it can spread up to the left shoulder, into the left half of the jaw, down into the left arm, into the back, and even into the upper abdomen. It is less likely to cross over into the right-hand side of the chest, and it is very rare for it to be entirely right-sided. (However, I did once meet a patient with entirely right-sided angina pectoris. He was a “mirror-image” twin, whose organs were on the opposite side of the body as normal, so that his heart was right-sided, and his liver and appendix were on his left side. His twin had his organs on the normal side of the body—they had developed from a single egg that had split early on in the pregnancy.)

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