TREATMENT

What is there, apart from medication, to treat angina?

Relief measures other than medication include angioplasty and surgery. First, there are some general self-help measures. These have been discussed before but to summarise:

• stop smoking;

• lose weight;

• cut down on alcohol;

• take exercise;

• Take life easier by reducing stress.

Table 3.2 Drugs for angina

Generic name Trade name

Nitrates

Isosorbide mononitrate

Elantan, Imdur, Ismo, Isotard

Glyceryl trinitrate

(tablets or spray)

Beta blockers

Atenolol

Tenormin, Totamol

Acebutolol

Sectral

Bisoprolol

Monocor, Emcor

Metoprolol

Betaloc, Lopresor

Nadolol

Corgard

Oxprenolol

Trasicor

Pindolol

Visken

Propranolol

Inderal, Beta-Prograne

Timolol

Betim, Blocadren

Calcium antagonists

Amlodipine

Istin

Diltiazem

Adizem, Dilzem, Tildiem

Felodipine

Plendil

Nicardipine

Cardene

Nifedipine

Adalat, Adalat LA, Cardilate MR, Coracten XL

Nisoldipine

Syscor MR

Verapamil

Cordilox, Securon, Univer

Potassium channel activators

Nicorandil

Ikorel

Sinus node slowers

Ivabradine

Procoralan

The use of aspirin as a preventative drug has been discussed a lot in the media recently. What does aspirin do?

Aspirin helps stop blood clotting. It reduces by 25% the risk of a heart attack and helps prevent strokes in people with angina or who have had a heart attack. You only need 75 mg a day and should not take more, unless specified by your doctor; 75 mg is a quarter of an adult 300 mg tablet. It occasionally upsets the stomach and a small number of people with asthma or bronchitis may be sensitive to it (it worsens the wheezing). Overall it is cheap, safe and very effective. Special types of coated aspirin are available for those who get indigestion but they are not always helpful. Taking a compound like Alka-Seltzer is another way of taking aspirin and reducing the chances of a stomach upset; it contains 324 mg aspirin, so you will need to take only a quarter.

I get indigestion on aspirin - is there an alternative?

Plopidogrel (Plavix) 75 mg daily thins the blood to the same degree as aspirin and is used as an alternative. It is only available on prescription. It still may cause indigestion and it may be best to stay on aspirin and use a drug that blocks stomach acid such as omeprazole.

Medication

What relieves the pain of angina? Do I have to take medication?

Angina is relieved after 1-2 minutes by slowing down or stopping activity, or using a nitrate tablet or spray, usually GTN, short for glyceryl trinitrate. If you get pain on walking after a meal and stop to take an indigestion tablet, it will seem as if the tablet has helped. In fact it was the stopping that relieved the pain: this is often how angina and indigestion get confused.

Several drugs are available to stop angina occurring or to deal with an attack. We have already discussed cholesterol-lowering diets and tablets in Chapter 2 and it is essential that people with angina have a cholesterol test and know the result.

Anyone with angina should be prescribed and told how to use sublingual (under the tongue) nitrates and aspirin or clopidogrel. The other medications - oral nitrates, beta-blockers, calcium antagonists and potassium channel activators (discussed below) - are prescribed as necessary. See Table 3.2 for a list of currently available medications. Check the trade name against the generic name.

Nitrates

How do the nitrates work?

Nitrates open up the arteries by relaxing the muscle in the artery wall. They relax the coronary arteries to improve the blood flow; by relaxing the peripheral arteries (such as in the legs) and veins, they reduce the work the heart has to do. As the problem is one of too much demand and too little supply, nitrates attempt to rectify the situation by improving supply (by dilating the artery) and reducing demand (the heart pumps against less resistance as the arteries are relaxed).

My mother has been given sublingual nitrates but seems unclear what to do. As I am her carer, what do I need to know?

Sublingual nitrates are taken in tablet or spray form and are absorbed via the veins under the tongue. They are effective in 12 minutes and last 20-30 minutes. They relieve attacks and can be used when your mother fears an attack; for example, she can use them at the bottom of a hill before she starts to climb. Headache is the main side effect.

After you collect them from the chemist, the tablets last only about 8 weeks and have to be stored correctly.

• Keep the tablets in the airtight bottle in which they have been dispensed.

• After use, close the bottle tightly

• Do not put cotton wool, other tablets, or anything else in the bottle with these tablets.

• Store the tablets in a cool place. When your mother carries them with her, tell her not to put them too close to the heat of her body - she could keep them in a purse or handbag (other people can carry them in a briefcase).

• If she does not use the tablets within 8 weeks of opening the bottle, get a fresh supply and discard the old tablets. An active tablet produces a slight burning sensation when placed under the tongue. If this does not happen, you should get a fresh supply for her.

The spray lasts 2-3 years but is more expensive. It is useful when attacks are infrequent as it lasts longer in storage. Tablets can be bought over the counter without prescription whereas the spray needs a doctor's prescription.

I have been given nitrate tablets to swallow. Are these different from the sublingual ones?

Yes, nitrates also come as tablets that are swallowed once or twice daily and can be taken on a regular basis to reduce your angina attacks and improve your ability to take exercise. The commonest are isosorbide mononitrate which are taken twice daily, or in slow release formulations (Imdur, Elantan, Ismo) once daily. They must not be taken more often or the body gets used to them - known as tolerance - and they are then ineffective in relieving angina. Sublingual tablets are only taken when you have, or fear, an angina attack coming on.

There are also nitrate patches which are effective when placed on the skin like a plaster; they have to be taken off after 12 hours or your body again develops tolerance. Used 12 hours on and 12 hours off, they act as a back-up and can be helpful overnight if put on in the evening and taken off in the morning. They should not be used on their own because, with 12 hours off, no angina protection is provided for that period.

Since I have been taking nitrates for my angina, I seem to get headaches. Is this due to my medication and are there any other side effects?

Headache is certainly the most frequent side effect. Occasionally you may get palpitations (see Chapter 6) or flushing and sometimes the tablets under your tongue make your breath smell. Rarely, and particularly if the tablets are taken within a short while of drinking alcohol or when starving, you might get a dizzy attack, caused by a temporary lowering of blood pressure. If headaches are a problem, the nitrates will be stopped and other drugs substituted.

 
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