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MEDICATIONS OFTEN PRESCRIBED FOR PATIENTS WITH HEART DISEASE: ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACE INHIBITORS)
These drugs lower blood pressure, and decrease the amount of work the heart needs to do to pump blood. The consequence of having a weak heart muscle (heart failure) is that sensors in the large blood vessels such as the aorta and the kidneys receive low blood flow. The body counteracts this consequence of poor cardiac performance by manufacturing a variety of hormones and other circulating substances that constrict blood vessels, raise blood pressure, and cause the kidneys to retain salt and water. This reaction is very similar to the sudden and massive “fight or flight response,” which occurs during severe physical stress such as major injury or bleeding.
The defense mechanisms called into play when the heart is pumping weakly, normally intended to defend the body against sudden severe stresses, are inappropriate, and even harmful, when dealing with long-term continuous stresses, such as those caused by permanent weakness of the heart’s pumping action.
These defense mechanisms result in overactivity of the hormone angiotensin, which causes blood vessels to constrict and raises blood pressure. With a healthy heart, this would not be much of a problem, but in a patient with a weak heart muscle, an increase in blood pressure causes the heart to work excessively hard and fail more rapidly. Other defense mechanisms include increased stickiness of blood platelets, and activation of the blood-clotting mechanism, all of which makes it more likely that clotting will occur inside blood vessels. The kidneys retain salt and water, and therefore there is an excess of salt and water in the body. This causes an increase in the amount of blood to be pumped by the heart, and also increases the heart’s workload. A failing heart has difficulty pumping this extra amount of blood, and hence the need to restrict salt intake and use “water pills” (diuretics), to allow the kidneys to get rid of extra salt and water in heart failure.
ACE inhibitors are drugs that directly prevent an excess of the active form of angiotensin. This drug is very effective at lowering blood pressure, and is particularly effective in patients with heart failure. There is now excellent evidence from a large number of research studies that blood-pressure lowering with ACE inhibitors preserves the heart’s pumping functions, reduces death rates and improves quality of life in patients with heart failure. The drug should probably be used by most patients with either substantial heart muscle weakness or a recent heart attack. Although it is not intuitive, even to some doctors, that “low blood pressure” is better than “normal blood pressure” in patients with heart failure, most patients with moderate or substantial heart damage in fact feel better and live longer if their blood pressure is lower than the average. Patients and families thus need to be aware that their blood pressure while taking these drugs may be as low as 100/70 (the higher number is the systolic and the lower number the diastolic pressure). The normal average blood pressure is about 120/80, although this tends to climb with age, so most sixty- or seventy-year-olds in Western society have blood pressure in the range of 140-150/80?90 mmHg (millimeters of mercury). The desirable blood pressure on ACE inhibitors is thus a fair bit lower than average. (Remember, there is no harm, but there is benefit, when patients with heart failure have blood pressure at this level.)
In patients who cannot take ACE inhibitors (as is very occasionally the case because of kidney malfunction or cough caused by these medications), other drugs that lower blood pressure, known as “afterload reducing agents” (drugs that lower blood pressure by dilating blood vessels), can be used. These drugs include angiotensin 2 receptor antagonists, varying forms of nitroglycerin (nitrates, see below) and hydralazine.
Importantly, habitual physical exercise also lowers blood pressure by helping blood vessels relax, and thus makes the job of the heart easier.
If a patient takes more ACE inhibitors or similar drugs than necessary, blood pressure may fall too low and cause dizziness or lightheadedness, especially on standing up quickly. This is not dangerous, but may indicate the need to cut back on the dose. Patients with heart diseases require very careful regulations of their medications. The medications discussed in this section are all helpful, and many are literally life-saving or life-prolonging. However, their use requires careful monitoring and a certain amount of expertise in the selection of the best drug and the best dose for a particular patient. For this reason, there are advantages to patients to seeing, at least on occasion, physicians expert in the care of heart disease, including particular complications of heart disease, such as cardiologists who have special expertise and experience in the treatment of heart failure.
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