The controversy surrounding statins really does not affect people who have proven coronary artery disease-every guideline in the world acknowledges the importance for people with coronary artery disease having a statin. They do not work solely through lowering cholesterol but have other effects that are probably important in preserving long-term good health.
The controversy is really about people who are not currently diagnosed with coronary artery disease but have a higher than normal risk of a heart attack or stroke over the next 10 years. The guidelines vary around the world NICE recommend starting a statin if someone’s risk is greater than 10% over the next 10 years. In the USA the threshold is 7.5%.
As well as reducing the risk of heart attacks and strokes in people who are found to have vascular disease. It does not lower mortality in people without vascular disease, and so assessment for vascular disease can be very useful.
There is also evidence that aspirin is anti-cancerous. It reduces the risk of colon cancer (the second most common cancer in most people) by 27%. It also probably reduces oesophageal, stomach, and pancreatic cancers by 20-40%-these are all cancers with very high mortality. However, aspirin can cause bleeding and so should only be started following a consultation with a doctor when the risks and benefits can be explained to you. Most patients over the age of 70 years old on aspirin should be on stomach acid-suppressing medication. There is recent evidence that the effect of aspirin on cancer incidence may be age-dependent with an increase in cancer with aspirin in people older than 75 years.
There are now 6 different families of anti-anginal medication, each with its own benefits and risks. Nicorandil can cause ulcers and so should be used sparingly.
Warfarin is not as safe as the new anticoagulants and so should only be used in a small percentage of patients with particular medical conditions.
Blood Pressure Lowering Medication
Beta-blockers should ideally no longer be used to lower blood pressure. There are many excellent medications to choose from. Blood pressure control is one of the most important health interventions in lowering the risk of poor health in later life and can tremendously lower the risk of a stroke.
Heart Failure Medication
The core medication consists of ACE inhibitors, angiotensins II blockers, specialised beta-blockers, aldosterone antagonists (eg spironolactone) and loop diuretics. Ivabradine can also be helpful.
In addition, the following should be considered-
Entresto (Sacibutril/Valsartan) has been a breakthrough medication for the treatment of heart failure. It is the first Neprilysin inhibitor and in a very difficult to treat a group of patients with severe heart failure; it lowers mortality by 16% and makes some patients feel very much better.
SGLT2 inhibitors such as Dapagliflozin have also been shown to lower mortality in heart failure.
Medication for Palpitations
Beta-blockers remain the mainstay for the treatment of palpitations. They block the effect of adrenaline on the heart and make it less excitable. Beta-blockers are safe with few serious side effects. However, they are not suitable for everyone eg asthmatics and they can make some people feel slowed down. There are additional medications such as Flecainide, which may be helpful.
However, most other antiarrhythmics have significant and sometimes serious side effects.