A SHARED DECISION-MAKING PROGRAM TREATMENT CHOICES FOR CORONARY HEART DISEASE

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1 A SHARED DECISION-MAKING PROGRAM TREATMENT CHOICES FOR CORONARY HEART DISEASE

2 This program content, including this booklet is copyright protected by Health Dialog Services Corporation (HDSC), a related entity of Bupa Health Dialog Pty Limited (Bupa Health Dialog), who is licensed to use the material in Australia. You may not copy, distribute, broadcast, transmit, perform or display this program or any part thereof, without permission from Bupa Health Dialog. You may not modify the contents of this program without permission from Bupa Health Dialog. You may not remove or deface any labels or notices affixed to the program package. Bupa Health Dialog Pty Limited 2012

3 FOREWORD As Bupa s Chief Medical Officer I m delighted to introduce Bupa s Treatment Choices for Coronary Heart Disease Shared Decision Guide. Making decisions about the steps needed to improve your health and make more informed choices can be complicated. This guide offers practical advice to help you better understand your condition and treatment choices, and support your discussion with your treating health professional. By keeping better informed you can be more confident that the care you receive is appropriate to your personal circumstances, priorities and preferences. We are grateful to Dr Leo Mahar,1 Director of cardiology at the Royal Adelaide Hospital and Professor Mark Harris2 and his team3 from the University of NSW who have reviewed this valuable tool. They have confirmed that it is based upon high quality, evidence based resources, and aligns with current Australian practice and guidelines. We hope this Shared Decision Guide will be useful to you and your health professional when you are needing to make decisions together about yours or your family s health and health care. Important instructions: The information in this program is not intended to be medical advice, a diagnosis of your condition, or a treatment recommendation. It is intended to help you learn about your symptoms, conditions, and various options so that you can participate more effectively in making decisions about your health with your doctor. Not all of the options discussed may be appropriate for your individual medical situation. Talk with your doctor about how the information presented relates to your specific condition. Bupa Health Dialog does not approve or authorise care or treatment. If you have questions about whether a particular treatment is covered by your private health insurance, please contact your private health insurer. For more information Visit bupa.com.au 1Leo Mahar has been practising cardiology for 30 years. He is currently the Clinical Director of the Cardiovascular Service at the Royal Adelaide Hospital and is a former president of the Cardiac Society of Australia and New Zealand. 2Mark Harris is foundation Professor of General Practice and Executive Director of the Centre for Primary Health Care and Equity at UNSW. 3Dr Nighat Faruqi, Centre for Primary Health Care and Equity at UNSW. 1

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5 TREATMENT CHOICES FOR CORONARY HEART DISEASE ABOUT THIS PROGRAM What is Shared Decision-Making TM? 6 Communicate openly with your healthcare provider About Shared Decision-Making TM Programs How can this program help you? 6 Are the options discussed in this program appropriate for you? Who made this program? 7 Who are the people in this booklet? How can you know if the information in this program is up-to-date? INTRODUCTION Be sure this information is right for you! WHAT IS CORONARY HEART DISEASE? Plaques narrow the coronary arteries 10 Two types of angina: stable and unstable What causes a heart attack? Heart procedures don t prevent most heart attacks What can help prevent heart attacks? 12 What is severe coronary heart disease WHEN TESTING LEADS TO IMMEDIATE TREATMENT How is an angiogram done? 14 Deciding whether to have an immediate angioplasty TREATMENT CHOICES Treatments often overlap 16 Weighing the benefits and risks of each treatment A note about the numbers comparing outcomes in this booklet MEDICAL THERAPY Medicines that lower your risk of heart attack and help you live longer Medicines that help manage angina 19 Possible benefits of medicines 19 Possible risks of medications 19 When medicines don t relieve syptoms

6 TREATMENT CHOICES FOR CORONARY HEART DISEASE HEART MEDICATIONS: BENEFITS AND SIDE EFFECTS Medicines are grouped by class 20 Dealing with side effects 20 Medicine classes: benefits and side effects Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARBs) 23 Anti-clotting medicines (including asprin) 23 Beta blockers 25 Bile acid binding resins 25 Calcium channel blockers 25 Ezetimibe 26 Fibric acid derivatives (fibrates) 26 ANGIOPLASTY AND STENTS Using angioplasty and stents to open arteries Possible benefits of angioplasty and stents Possible risks of angioplasty and stents Other complications 29 How many people will need another procedure? Comparing drug-eluting stents to bare-metal stents BYPASS SURGERY Possible benefits of bypass surgery 32 Possible risks of bypass surgery 32 Other possible risks 33 How many people will need another procedure? Nicotinic acid (niacin) 26 Nitrates 26 Statins 27 Other medicines for angina 27 4

7 COMPARING TREATMENT CHOICES A general comparison: symptom relief and possible risks Number of people with symptom relief Number of people who are heart-attack free Number of people who survive 36 Number of people with severe coronary heart disease who survive Number of people who need another heart procedure WORKING WITH YOUR DOCTOR LEADING A HEART-HEALTHY LIFESTYLE Doing your part 40 Start with a cardiac rehab program 40 DEFINITIONS OF MEDICAL TERMS 43 FOR MORE INFORMATION 45 RESEARCH PUBLICATIONS 46 5

8 ABOUT THIS PROGRAM ABOUT THIS PROGRAM WHAT IS SHARED DECISION-MAKING? Shared Decision-Making is working with your doctors and other healthcare professionals to make decisions about your care. In Shared Decision-Making, your doctor is the expert in medicine, but you are the expert on how you feel and what s important to you. Together you make up a decision-making team. Family, friends, and other healthcare providers may also be part of this team. Participating in healthcare decisions helps ensure that you are getting the care that best meets your needs. To do this, you ll need to be informed about your condition and the different ways to manage it. You ll also need to think about how each management approach can affect you so that you can choose what makes the most sense for you. COMMUNICATE OPENLY WITH YOUR HEALTHCARE PROVIDER Getting good care also requires good communication between you and your healthcare team. To get the right care, you and your doctor or other healthcare professional, need to talk about your health goals and what you re able to do to protect or improve your health. ABOUT SHARED DECISION-MAKING PROGRAMS This Shared Decision-Making program is provided through Bupa Health Dialog for your individual use. The program is designed to support your participation in an informed dialogue with your healthcare provider as you work together to make important decisions about your health. Shared Decision-Making programs are based on medical evidence researched and evaluated by the Informed Medical Decisions Foundation. The Informed Medical Decisions Foundation has been working for over two decades to advance evidence-based shared decision making through research, policy, clinical models and patient decision aids. Visit informedmedicaldecisions.org for more information. HOW CAN THIS PROGRAM HELP YOU? The information in this program can help you prepare to talk with your doctor so you are ready to ask questions and discuss how you feel about your healthcare options. Then you and your doctor can talk about which option may be best for you and make a decision together a shared decision. You might be wondering, is this information right for me? Where did it come from? How can I use it? In this program, you ll find answers to these and other questions you may have. 6

9 ARE THE OPTIONS DISCUSSED IN THIS PROGRAM APPROPRIATE FOR YOU? Some of the options in this booklet may not be appropriate for your individual medical situation. Talk with your doctor about how the information in this program relates to your specific health condition. Note that neither Bupa Health Dialog or any of its related entities approve or authorise care, treatments or tests. The care, treatments or tests described in this program may not be covered by your private health insurance. If you have questions about whether your private health insurance provides cover in respect of a particular treatment or test, speak with your private health insurer or your doctor. WHO MADE THIS PROGRAM? Bupa Health Dialog and the Informed Medical Decisions Foundation produced this program booklet. In accordance with the relevant requirements of the licence provided to Bupa Health Dialog, it has been adapted from the original version produced for use in the United States. Information regarding suitability for publication in Australia was provided by the University of New South Wales Centre for Primary Health Care and Equity. To ensure the content is appropriate and acceptable for Australian consumers and health professionals, Australian clinical practice guidelines have been reviewed and the Australian healthcare system, language and culture taken into account. Bupa Health Dialog does not profit from any of the treatments discussed in the program. WHO ARE THE PEOPLE IN THIS BOOKLET? The people who are quoted in this booklet are real. These people volunteered to share their stories about how they used various self care strategies to manage their condition. They received a fee to compensate them for their time and do not profit from any treatment or self care strategy they discuss. HOW CAN YOU KNOW IF THE INFORMATION IN THIS PROGRAM IS UP-TO-DATE? All booklets are reviewed regularly and updated. If you received this program some time ago, or if someone passed it along to you, do not use it. The information may be out of date. To make sure you have the most recent program, please visit bupa.com.au. Please use the product number located on the back of the booklet to determine if you have the most recent copy. Note: Italics are used in this program to emphasise key words or to identify medical terms. See the Definitions of medical terms section for a description of medical terms that are in italics. *Coronary heart disease is also called coronary artery disease. This booklet uses the term coronary heart disease. ABOUT THIS PROGRAM 7

10 INTRODUCTION INTRODUCTION BE SURE THIS INFORMATION IS RIGHT FOR YOU! This booklet program is intended for people who are considering treatment choices for coronary heart disease, including people who: have stable coronary heart disease with or without stable angina (chest pain) are about to have a coronary angiogram (cardiac or heart catheterisation). Coronary heart disease is also called coronary artery disease. This booklet uses the term coronary heart disease. The program is not intended for people who: are not candidates for medical therapy, angioplasty, or bypass surgery have had a heart attack in the past six weeks had bypass surgery, angioplasty, or stent(s) within the past six months have been in hospital because of heart-related chest pain (sometimes called unstable angina or acute coronary syndrome) in the last six weeks were born with heart defects have heart valve disease have cardiomyopathy not related to coronary heart disease are pregnant. 8

11 9 INTRODUCTION

12 WHAT IS CORONARY HEART DISEASE? WHAT IS CORONARY HEART DISEASE? Information in this chapter includes: Plaques narrow the coronary arteries Two types of angina: stable and unstable What causes a heart attack? Heart procedures don t prevent most heart attacks What can help prevent heart attacks? What is severe coronary heart disease? Plaques narrow the coronary arteries The heart gets its blood supply from blood vessels called coronary arteries. In people with coronary heart disease, deposits called plaques form within the walls of these arteries. The medical term for this condition is atherosclerosis. The coronary arteries supply the heart muscle with blood and oxygen. The right coronary artery supplies blood to the lower wall of the heart. The left main coronary artery divides into two branches. The left anterior descending artery supplies the front of the heart, and the circumflex artery supplies the back of the heart. Heart and coronary arteries If plaques get bigger, they can narrow the arteries and interfere with the blood supply to the heart. This can cause symptoms including pressure, pain, or discomfort in the chest, arm, shoulder, back, jaw, or neck, as well as nausea, cold sweat, dizziness, and shortness of breath. These symptoms usually get worse with exercise or emotional stress and typically improve after resting or taking short-acting nitrates by spray or tablet under your tongue. These symptoms are called angina. 10

13 Two types of angina: stable and unstable There are two types of angina: stable and unstable. Stable angina is predictable Stable angina is predictable. It happens at expected times, such as during exercise, emotional stress, or after a heavy meal. For people with stable angina, specific activities or emotions bring on the same amount of chest pain or discomfort each time. The symptoms usually go away with rest or medication. Unstable angina is unexpected and dangerous Angina is called unstable when it happens more often than it used to, or at unexpected times. If you used to get angina only with exercise, and you start to have angina pain at rest, your angina has become unstable. Angina that is new, different, or does not respond to rest and medication can signal a serious problem or a heart attack. If you have any angina symptoms that last for 10 minutes, are severe or are getting worse, call triple zero (000) immediately and ask for an ambulance. If dialling 000 does not work from your mobile phone, you can try calling 112. What causes a heart attack? A heart attack happens when the blood flow through a coronary artery is completely blocked. An artery can become completely blocked by: a blood clot that forms when a plaque, usually a small one, breaks open less often, by a plaque that gets so big that it stops blood from flowing through. In either case, the blockage prevents blood and oxygen from reaching a part of the heart muscle. As a result, part of the heart muscle can be damaged. Scientists used to think that most heart attacks happened when a plaque got so big that it completely blocked blood flow. It now appears that big plaques cause only about 15 out of 100 heart attacks. WHAT IS CORONARY HEART DISEASE? 11

14 WHAT IS CORONARY HEART DISEASE? Coronary plaques build up in artery walls Heart procedures don t prevent most heart attacks, but they can relieve symptoms (angina) In general, bypass surgery and angioplasty do not prevent heart attacks. This is because these procedures are usually not used to treat small plaques those most likely to cause heart attacks. What can help prevent heart attacks? The best way to prevent future heart attacks is to: quit smoking (if you smoke) take your prescribed medicines get regular physical activity eat a heart-healthy diet. Coronary arteries can become narrowed by deposits called plaque. If a plaque ruptures, it can trigger a blood clot that blocks the flow of blood through a coronary artery, causing a heart attack. Most heart attacks involve smaller plaques that do not completely block an artery. These unstable or vulnerable plaques can break open or rupture. When they do, it can trigger a blood clot that completely blocks the artery, causing a heart attack. This explains why most heart attacks occur in coronary arteries that are only partly blocked by plaque. It also helps explain why bypass surgery and angioplasty, which only treat large plaques, do not prevent most heart attacks. Heart procedures don t prevent most heart attacks Bypass surgery and angioplasty are used to treat arteries that have large plaques. For people who have angina that is not relieved by taking medicines, these procedures help reduce angina. In addition, they can help people with severe heart disease live longer. Depending on your situation, your doctor may recommend other things you can do. These measures can help you reduce your heart attack risk, feel better, and manage other health problems, such as arthritis or diabetes. What is severe coronary heart disease? A person with severe coronary heart disease may have one or more of the following: large plaques in the left main coronary artery large plaques in three important coronary arteries (the right coronary artery, the left anterior descending artery, and the circumflex coronary artery) large plaques and heart failure large plaques and diabetes. People with severe disease have a much higher risk of heart attack and death than people with milder forms of the disease. 12

15 13 WHAT IS CORONARY HEART DISEASE?

16 WHEN TESTING LEADS TO IMMEDIATE TREATMENT WHEN TESTING LEADS TO IMMEDIATE TREATMENT Information in this chapter includes: How is an angiogram done? Deciding whether to have an immediate angioplasty As part of diagnosing coronary heart disease, your doctor may use a test called an angiogram, sometimes called a cardiac catheterisation. How is an angiogram done? During an angiogram, a doctor threads a catheter, or thin tube, through an artery in your arm or leg and into the coronary arteries. A dye visible in x-rays is injected through the catheter so your doctor can see which coronary arteries have plaque and how much these arteries are narrowed. This information helps determine how much of the heart muscle is at risk of damage if a heart attack occurs. A plaque is considered large if it blocks 70% or more of the artery. Deciding whether to have an immediate angioplasty Although an angiogram and an angioplasty are two separate procedures, they are often done at the same time. This can make sense, because the catheter is already in place. On the other hand, you may not have a chance to talk with your doctor about whether an angioplasty is the best choice for your situation. In some cases, taking medicine may be just as effective as angioplasty, with fewer risks. In other cases, bypass surgery may be a better choice. Because it s difficult to participate in making decisions during an angiogram, talk to your doctor before the test. Be sure to answer these questions: Under what circumstances would you want an immediate angioplasty? When would it make more sense to wait and talk about the results before deciding on a treatment? If your doctor finds large plaques in one or more coronary arteries, he or she may suggest performing an angioplasty right away to open the blocked arteries. 14

17 15 WHEN TESTING LEADS TO IMMEDIATE TREATMENT

18 TREATMENT CHOICES TREATMENT CHOICES Information in this chapter includes: Treatments often overlap Weighing the benefits and risks of each treatment A note about the numbers comparing outcomes in this booklet Making decisions about how to treat coronary heart disease can be difficult. There is a lot of information to sort through, often in a short period of time. The three main treatment choices for coronary heart disease are: medical therapy (medicines) only angioplasty, which often involves the placement of one or more stents bypass surgery. Your treatment choices may differ depending on: your age your overall health the number, location, length, and severity of the plaques in your coronary arteries whether your heart function has been weakened from a heart attack (heart failure) the treatments you have already had. Weighing the benefits and risks of each treatment The goals of all three treatments are the same: relieve symptoms prevent heart attacks help you live longer. For many people with coronary heart disease, all three treatments provide similar benefits in preventing heart attacks and helping you live longer. The treatments differ in how well they relieve symptoms and in their possible risks now and in the future. The treatment decision often depends on how you feel about your symptoms and how much risk you are willing to take to reduce your symptoms. You need to take into account those many factors that are individual to you:... how old you are, how active you want to be, what other diseases do you have. How does that impact the risk of any of these interventions? Dr. William Nugent, Heart Surgeon Treatments often overlap Coronary heart disease treatments often overlap. People who have angioplasty or bypass surgery also take medicines. Some people have additional procedures over time. Others take medicines only, but do not have angioplasty or bypass surgery. 16

19 A note about the numbers comparing outcomes in this booklet To make it easier to compare outcomes for different treatments, each number is reported as out of 100 people, even when the outcome affects less than 1 in 100 people, or less than 1% of people. Different studies often have slightly different results. To show this variation for a risk or benefit, a range of numbers, such as 2 to 5, is used instead of a single number. TREATMENT CHOICES 17

20 MEDICAL THERAPY MEDICAL THERAPY Information in this chapter includes: Medicines that lower your risk of heart attack and help you live longer Medicines that help manage angina Possible benefits of medicines Possible risks of medications When medicines don t relieve symptoms There are two types of medicines used to treat coronary heart disease: medicines that lower your risk of heart attack and help you live longer medicines that help manage angina which help prevent and relieve symptoms and help you feel better. Some medicines lower your risk of heart attack and help you live longer as well as help relieve symptoms. Medicines that lower your risk of heart attack and help you live longer Medicines that lower your risk of heart attack and help you live longer include: statins angiotensin-converting enzyme (ACE) inhibitors angiotensin receptor blockers (ARBs), if you cannot tolerate ACE inhibitors beta blockers anti-clotting medicines, including aspirin (also called anti-platelet medicines) some calcium channel blockers. You can lower your risk of heart attack and death related to coronary heart disease by: 25% to 30% if you take a statin 25% or more if you take an ACE inhibitor, a beta blocker, or an anti-clotting medicine. If you take both a statin and another one of the medicines listed, you ll reduce your risks by some amount more, but it won t be by another 25%. You probably won t feel any different when taking these medicines. This doesn t mean they aren t working. Instead, these medicines have effects you can t feel. 18

21 Medicines that help manage angina For people with coronary heart disease who have angina (chest pressure, pain, or discomfort), especially during physical activity, doctors prescribe medicines to prevent and treat these symptoms. Possible risks of medications The possible risks of medicines include their side effects. For a list of the possible side effects of different medicines, see Heart Medicines: Benefits and Side Effects on page 20. MEDICAL THERAPY Medicines that help manage angina include: nitrates beta blockers calcium channel blockers. These medicines reduce chest discomfort, and can keep you from being limited by angina. Although studies have not shown that these medicines will prevent heart attacks or help you live longer, they are likely to make you feel better because they reduce your angina. Beta blockers can help your angina symptoms and lower your risk of heart attack and help you live longer. Possible benefits of medicines Out of 100 people who choose to take medicines, in the first year of starting treatment: 71 people will have symptom relief (29 will not) 96 people will not have a heart attack (4 will) 97 people will still be alive (3 will not). Medicines may also allow you to delay or avoid angioplasty or bypass surgery. When medicines don t relieve symptoms If medicines control your chest pain symptoms, you may not need angioplasty or bypass surgery unless you have severe coronary heart disease. But medicines do not relieve symptoms for everyone. Out of 100 people who take medicines for stable coronary heart disease: in the first year after starting medicines, about 10 people will have angioplasty or bypass surgery (90 will not) within five years of starting medicines, fewer than 50 people will have angioplasty or bypass surgery (more than 50 will not). Basically for a year I have had no angina pain at all. I can t recall a single occasion of having the kind of pain that I was having prior to the diagnosis and prior to going on the medicine. Kevin, chose medical therapy 19

22 HEART MEDICINES: BENEFITS AND SIDE EFFECTS HEART MEDICINES: BENEFITS AND SIDE EFFECTS Information in this chapter includes: Medicines are grouped by class Dealing with side effects Medicine classes: benefits and side effects Angiostensin-converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARBs) Anti-clotting medicines (including aspirin) Beta blockers Bile acid binding resins Calcium channel blockers Ezetimibe Fibric acid derivatives (fibrates) Nicotinic acid (niacin) Nitrates Statins Other medicines for angina This chapter lists common heart medicines and discusses some of their benefits and side effects. Keep in mind that this is not a complete list of heart medicines. You may be taking one or more medicines that are not listed. Medicines are grouped by class Medicines that contain similar chemicals and have similar effects are grouped into a class. Medicines in the same class may cause slightly different side effects. Most medicines have two names: the active ingredient and the brand name. The active ingredient is name of the chemical in the medicine that makes it work. The manufacturer of the medicine also gives it another name the brand name. There are often many brand names given to a single medicine; however, medicines with the same active ingredient are usually interchangeable. The medicines in this chapter are organised alphabetically by class names and active ingredients. All the medicines listed here are approved in Australia for managing angina symptoms or for lowering the risk of heart attacks and helping you live longer. The order does not reflect their importance in treating heart disease. As each medicine may be available under several brand names, only the active ingredients are listed. Dealing with side effects If you are bothered by a side effect that s not listed in this chapter, it is recommended you seek advice from your doctor. He or she may be able to lower your dose or switch you to another medicine. You can certainly have side effects from the medicines. So I want you to tell me if you re having any of these problems because there are a lot of different medicines we can use. Dr. Adolph M. Hutter, Jr.; Cardiologist Although doctors often have solutions to reduce or avoid side effects, it s not always possible to find a medicine that has no side effects. Talking with your doctor may help you understand and deal with the side effects you can t avoid. You may find that side effects bother you less over time, or that you learn to cope with them. Even if a side effect is bothersome, you may decide to live with it if the medicine can help you live longer. 20

23 21 HEART MEDICINES: BENEFITS AND SIDE EFFECTS

24 HEART MEDICINES: BENEFITS AND SIDE EFFECTS Medicine classes: benefits and side effects For each class of medicines, this section lists the expected benefits and the common side effects that have been shown in studies to be clearly related to medicines in the class. It also lists some rare but serious side effects. It is not a complete list of all possible side effects. More information about side effects is available in the Consumer Medicines Information leaflet that comes with your medicine. It can be hard to know if your symptoms are related to a specific medicine, especially if you are taking several medicines. Talk to your doctor if you are concerned. Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-converting enzyme (ACE) inhibitors lower blood pressure and reduce the risk of heart attack and heart-related death in people with coronary heart disease, heart failure, or diabetes. Possible side effects of ACE inhibitors Out of 100 people who take ACE inhibitors, between 5 to 20 will develop a dry, hacking cough. In rare cases, ACE inhibitors can cause swelling in the face, tongue, or throat. This condition, called angioedema, can be serious. It is more likely to occur in people of Black African or Caribbean heritage than in people of other races. If you develop swelling or difficulty breathing at any time while taking an ACE inhibitor, seek immediate medical care. ACE inhibitors include: captopril enalapril fosinopril lisinopril perindopril quinapril ramipril trandolapril. 22

25 Angiotensin receptor blockers (ARBs) Angiotensin receptor blockers (ARBs) are also known as angiotensin II antagonists, angiotensin receptor antagonists, and sartans. They can be an option for people who cannot take ACE inhibitors. Similar to ACE inhibitors, ARBs lower blood pressure and reduce the risk of heart attack and heart-related death in people with coronary heart disease, heart failure, or diabetes. Possible side effects of ARBs Common side effects of ARBs include dizziness and headache. ARBs can also cause cough and angioedema (swelling of the face, tongue, or throat), although they are much less likely to cause these symptoms than ACE inhibitors. ARBs include: candesartan eprosartan irbesartan losartan olmesartan telmisartan valsartan. Anti-clotting medicines (including aspirin) Medicines like aspirin are anti-clotting medicines (also called anti-platelet medicines). They prevent blood clots that can trigger heart attacks, and they reduce the risk of heart-related death. People who have had angioplasty and stents will often take both aspirin and another anti-clotting medicine, usually clopidogrel, for some time after the procedure. Possible side effects of anti-clotting medicines The anti-clotting medicines listed below, including aspirin, can cause bleeding and stomach pain. Anti-clotting medicines for coronary heart disease include: aspirin clopidogrel prasugrel. HEART MEDICINES: BENEFITS AND SIDE EFFECTS 23

26 HEART MEDICINES: BENEFITS AND SIDE EFFECTS 24

27 Beta blockers Beta blockers are used for preventing and treating angina. Beta blockers also reduce the risk of heart attack in people with coronary heart disease, lower blood pressure, and may be used to treat irregular heart rhythms. In people who have had a heart attack, beta blockers reduce the chance of death from future heart attacks. Possible side effects of beta blockers Beta blockers may cause dizziness and light-headedness, although these symptoms can decrease over time. Some people find that beta blockers make them more tired or less able to participate in sexual activity. People with asthma may also have more wheezing when taking beta blockers. Beta blockers include: atenolol bisoprolol carvedilol labetalol metoprolol nebivolol oxprenolol pindolol propranolol. Bile acid binding resins Bile acid binding resins help lower bad (LDL) cholesterol levels. They are usually used with statins and/or other cholesterol-lowering medicines. Possible side effects of bile acid binding resins Side effects can include stomach upset, nausea, bloating, and constipation. Bile acid binding resins include: cholestyramine colestipol. Calcium channel blockers Calcium channel blockers lower blood pressure and help relieve angina. They are often prescribed to people who cannot take beta blockers, but may also be used along with beta blockers. Possible side effects of calcium channel blockers Side effects can include ankle swelling and flushing (a feeling of warmth that comes from blood rushing to the surface of the skin). Calcium channel blockers include: amlodipine diltiazem felodipine lercanidipine nifedipine verapamil. HEART MEDICINES: BENEFITS AND SIDE EFFECTS 25

28 HEART MEDICINES: BENEFITS AND SIDE EFFECTS Ezetimibe Ezetimibe lowers bad (LDL) cholesterol, and is sometimes combined with a statin. It is not known whether it reduces the risk of heart attack. Possible side effects of ezetimibe Side effects can include stomach upset, diarrhoea and muscle aches. Ezetimibe is the only medicine in this class. Fibric acid derivatives (fibrates) Fibrates lower triglycerides and raise good (HDL) cholesterol. They may also lower bad (LDL) cholesterol. They are usually used for people with very high triglycerides, but sometimes they are used with statins and/or other cholesterol-lowering medications. Possible side effects of fibrates Side effects can include nausea, diarrhoea, stomach pain, gas, and heartburn. Fibrates include: fenofibrate gemfibrozil. Nicotinic acid (niacin) Nicotinic acid raises good (HDL) cholesterol and lowers bad (LDL) cholesterol. It is usually used with statins and/or other cholesterol-lowering medicines. Possible side effects of nicotinic acid Side effects can include flushing and stomach upset. Nitrates Nitrates improve blood flow to the heart and relieve angina. People can take nitrates regularly or as needed to help relieve chest pain. Nitrates can be short acting (sprays or tablets under the tongue) used to relieve or prevent angina immediately before an activity. Nitrates may also be long acting (patches or tablets) used to prevent angina in people with more frequent symptoms. If you use a long-acting nitrate, work with your doctor on a schedule for using it. Possible side effects of nitrates Side effects can include headache, dizziness or light-headedness, and flushing of the face and neck. If you take nitrates, do not take medicines to treat erectile dysfunction. Combining these two types of drugs can be fatal. Nitrates include: glyceryl-trinitrate (nitroglycerine) isosorbide dinitrate isosorbide mononitrate. 26

29 Statins Statins lower bad (LDL) cholesterol, raise good (HDL) cholesterol, and reduce the risk of heart attack and heart-related death in people with coronary heart disease or diabetes. Possible side effects of statins Side effects can include muscle pain and liver damage (rare). Statins include: atorvastatin fluvastatin pravastatin rosuvastatin simvastatin. Other medicines for angina If you are not able to take the medicines for angina described earlier, or if they cause bothersome side effects or do not work well enough to control your angina, one of the following medicines may be an option. Ivabradine Ivabradine reduces the heart rate and helps manage angina symptoms. Side effects can include mild problems with vision, such as seeing bright spots (which usually goes away over time) and dizziness. Nicorandil Nicorandil improves blood flow to the heart, which helps prevent angina. Side effects can include headache (especially when first starting to take the medicine) and flushing. HEART MEDICINES: BENEFITS AND SIDE EFFECTS Perhexiline Perhexiline helps manage angina symptoms. Due to serious possible side effects, regular blood tests are necessary. Serious side effects can include muscle weakness, numbness, and loss of appetite. Other side effects can include dizziness and unsteadiness when walking. 27

30 ANGIOPLASTY AND STENTS ANGIOPLASTY AND STENTS Information in this chapter includes: Using angioplasty and stents to open arteries Possible benefits of angioplasty and stents Possible risks of angioplasty and stents How many people will need another procedure? Comparing drug-eluting stents to bare-metal stents Using angioplasty and stents to open arteries In an angioplasty procedure, a doctor inserts a flexible tube, or catheter, into an artery in the arm or leg, and guides the tube into a coronary artery narrowed by plaque. The catheter carries a deflated balloon, which is inflated to compress plaque in the narrowed artery. The catheter can also carry a stent, a tiny expandable mesh tube that is placed in the artery and helps keep the artery open after the balloon is removed. Sometimes stents are placed without using a balloon. Stents are made of metal. The stents may be bare metal or have a coating. The ones with a coating, called drug-eluting stents, slowly release medication into the artery to help lower the chance that the artery will narrow again. If you have one of these stents, you will take anti-clotting medicines for a longer period of time than you would if you had a bare-metal stent. Doctors typically use angioplasty (with or without stents) only when an artery is blocked at least 70% by plaque. When the blocked artery is the left main coronary artery, doctors usually do bypass surgery and will do so for blockages of at least 50%. That s because this artery supplies blood and oxygen to a large amount of the important muscle on the left side of the heart that pumps blood to the entire body. After the angioplasty occurred, I had no problems at all and I felt wonderful. Richard, chose angioplasty Possible benefits of angioplasty and stents Out of 100 people who choose angioplasty with stent, in the first year after the procedure: 80 people will have symptom relief (20 will not) 94 people will not have a heart attack (6 will) 97 people will be alive (3 will not). 28

31 ANGIOPLASTY AND STENTS Possible risks of angioplasty and stents Serious problems can occur during or shortly after an angioplasty. The chance of some of these problems increases with age. People treated by angioplasty teams that perform at least 400 procedures a year and doctors who do at least 75 procedures per year have fewer complications than those that do fewer procedures. Chance of death Death as a result of angioplasty is rare. Out of 100 people: younger than 70, less than 1 person will die (more than 99 will not) 70 and older, 2 to 3 people will die (97 to 98 will not). Other complications Other more common but less serious complications of angioplasty include: bleeding or infection at the site where the catheter was inserted allergic reaction to the material that is injected through the catheter new or worsening kidney problems, especially in people who are older or who already have kidney disease damage to a coronary artery, requiring immediate bypass surgery. Chance of heart attack or stroke In rare cases, angioplasty can cause a heart attack or stroke. Out of 100 people: about 2 to 5 people will have a heart attack as a result of angioplasty (95 to 98 will not) less than 1 person will have a stroke (more than 99 will not). 29

32 ANGIOPLASTY AND STENTS 30

33 How many people will need another procedure? Even when stents are used, treated arteries can become narrowed or blocked again, or other arteries may become narrowed or blocked. If this happens, angina symptoms can return. Comparing drug-eluting stents to bare-metal stents This section discusses two important differences between drug-eluting stents and bare-metal stents. There may be other factors to consider. Talk to your doctor about which stent is right for you. ANGIOPLASTY AND STENTS If angina symptoms return and are severe even with medication another angioplasty or bypass surgery may be needed. a) Need for another procedure One important difference between the two types of stents is how often people who receive them need another heart procedure. Within the first year, arteries treated with drug-eluting stents are about half as likely to narrow again as arteries treated with bare-metal stents. b) Need for anti-clotting medicines Another difference between the two types of stents is how long people who receive them need to take anti-clotting medicines. If you receive a stent, usually you ll take two medicines to reduce the chance of blood clots in the blood vessels in your heart: aspirin clopidogrel or prasugrel. If you have a bare-metal stent, it is recommended that you take the two medicines for at least a month (ideally a year). If you have a drug-eluting stent, it is recommended that you take the two medicines for at least a year. It is very important to take your anti-clotting medicines for the full length of time recommended by your doctor. Stopping them early can increase the risks of a clot, which can cause a heart attack or death. Because anti-clotting medicines prevent clots, they also increase the risk of bleeding. Your doctor can help you decide whether the bleeding risks with these medicines outweigh their expected benefits for you. In general, it is recommended that you do not have any elective surgery (one that s not an emergency) while taking these medicines. Stopping the medicines before surgery increases the risks of having a heart attack due to a clot in the stent. As you compare the two types of stents, think about whether you plan to have surgery in the next year or so, and whether that surgery can be postponed. 31

34 BYPASS SURGERY BYPASS SURGERY Information in this chapter includes: Possible benefits of bypass surgery Possible risks of bypass surgery How many people will need another procedure? Coronary artery bypass surgery is a major operation. In bypass surgery, the surgeon takes healthy blood vessels from the leg or chest and uses them to redirect blood flow around portions of coronary arteries that have large plaques. Doctors typically perform bypass surgery or angioplasty only when an artery is blocked at least 70% by plaque. When the blocked artery is the left main coronary artery, doctors will use bypass surgery when there is blockage of at least 50%. That s because that artery delivers blood and oxygen to a large and important portion of heart muscle. Possible benefits of bypass surgery Out of 100 people who choose bypass surgery, in the first year after the procedure: 90 people will have symptom relief (10 will not) 95 people will not have a heart attack (5 will) 96 people will be alive (4 will not). Prior to surgery I could not climb more than one flight of stairs without stopping or having rather severe pain. After the surgery there was marked improvement. Lamar, chose bypass surgery Possible risks of bypass surgery Serious problems can occur during or shortly after bypass surgery. The chance of some of these problems increases with age. People treated by bypass teams that do many procedures each year have lower rates of death than people who are treated by teams that do fewer procedures. Death Death as a result of bypass surgery is rare for people younger than 80 years. Out of 100 people: younger than 80, about 1 to 2 people will die as a result of bypass surgery (98 to 99 will not) 80 and older, about 5 to 12 people will die (88 to 95 will not). People with lung disease, kidney disease, or diabetes have a higher risk of death from bypass surgery. 32

35 Heart attack Out of 100 people, 6 people will have a heart attack as a result of bypass surgery (94 will not). Stroke Out of 100 people: Other possible risks Other possible risks of bypass surgery include: infection at the chest or leg incisions numbness at the chest or leg incisions, which can last for some time. BYPASS SURGERY age 55 and younger, less than 1 person will have a stroke as a result of bypass surgery (more than 99 will not) age 56 to 65, about 1 person will have a stroke (99 will not) age 66 to 75, about 2 people will have a stroke (98 will not) older than 75, about 3 people will have a stroke (97 will not). Cognitive problems Cognitive problems for example, having a hard time concentrating or reading a map can make life difficult for people of any age. These problems can be especially hard for people who are older or who have health problems that limit their ability to function. Out of 100 people who have bypass surgery, about 10 to 30 people will still have difficulty concentrating six months after the surgery (70 to 90 will not). Cognitive difficulties can persist five years or longer. The risk of cognitive problems increases with age. Depression Out of 100 people, up to 33 people will experience depression after bypass surgery (67 will not). How many people will need another procedure? After surgery, bypass arteries or other arteries can become narrowed or blocked, and angina symptoms may return. If angina symptoms return and are severe even with medication another bypass surgery or an angioplasty may be needed. Within a year of bypass surgery, about 3 out of 100 people will have an angioplasty or another bypass (97 will not). 33

36 COMPARING TREATMENT CHOICES COMPARING TREATMENT CHOICES Information in this chapter includes: A general comparison: symptom relief and possible risks Number of people with symptom relief Number of people who are heart-attack free Number of people who survive Number of people with severe coronary heart disease who survive Number of people who need another heart procedure This chapter compares the effectiveness of the three treatment choices medical therapy, angioplasty and stents, and bypass surgery after one year, three years, and five years. The numbers presented are averages that reflect the combined experience of many people. Be sure to talk with your doctor to understand how these numbers apply to your situation. A general comparison: symptom relief and possible risks For many people with coronary heart disease, all three treatments provide similar benefits in preventing heart attacks and helping you live longer. After the first year, people with more severe disease may have better survival with bypass surgery or angioplasty than with medical therapy. The following summarises the chance of symptom relief and risk for serious side effects for the three treatments. Bypass surgery highest chance of symptom relief most risks for serious side effects. Angioplasty and stents higher chance of symptom relief some risk for serious side effects. Medical therapy high chance of symptom relief low risk for serious side effects. 34

37 35 COMPARING TREATMENT CHOICES

38 COMPARING TREATMENT CHOICES Number of people with symptom relief On average, bypass surgery provides the highest chance of symptom relief at one, three, and five years. While medical therapy provides the lowest chance of symptom relief, many people get symptom relief using only medicines. Symptom relief Number of people who survive Shortly after bypass surgery, survival is slightly lower than with medical therapy or angioplasty due to the risk of dying during or soon after surgery. But by the end of the first year, on average, all three treatments are equally successful at prolonging life. Survival Number of people who are heart-attack free On average, the number of people who do not have a heart attack is about the same for all three treatments. This is likely because all people, even those who have angioplasty or bypass surgery, are given the same medical therapy. Medical therapy reduces the risk of heart attack. No heart attack 36

39 Number of people with severe coronary heart disease who survive Studies that look specifically at people with severe coronary heart disease show differences in survival among the three treatments. For an explanation of severe coronary heart disease, see page 12. Bypass surgery helps people with severe disease live longer. To get the long-term benefits, however, people have to accept the short-term risks of surgery. Number of people who need another heart procedure People who have bypass surgery are less likely to need another procedure than people who choose medical therapy or angioplasty. People using medical therapy are more likely to need a procedure in the future than people who have already had angioplasty or bypass surgery. However, more than half of the people using medical therapy will not need a procedure within five years of starting the therapy. COMPARING TREATMENT CHOICES Survival: severe disease Need another procedure 37

40 WORKING WITH YOUR DOCTOR WORKING WITH YOUR DOCTOR Working with your healthcare providers to make decisions about your care and telling them about your preferences is called shared decision-making. There are many reasons for getting involved in your healthcare. Shared decision-making can help you: Get more out of conversations with your doctors Feel more satisfied with your healthcare Get the type of medical care you want Avoid treatments or side effects you don t want Gain a feeling of control over your life Shared goal Shared decision-making starts with a shared goal: keeping you healthy with care that s right for your needs. For your hip osteoarthritis, that means choosing from among different approaches to treatment. This information is designed to help you work with your doctor to choose the treatment that s best for you. It s not meant to be a substitute for talking with your doctor. Getting good care requires good communication between you and your doctor. You and your doctor need to talk about your personal health goals and what you re able and willing to do to protect or improve your health. Shared effort Shared decision-making also includes shared effort. Part of your doctor s job is to explain your condition and treatment choices, and listen carefully to your concerns. Your job is to prepare your questions, make sure you understand the answers, and speak up about what is important to you. Tips for working with your doctor: Learn about the medical conditions you have, as well as any health problems you may be at risk for in the future. Talk openly and honestly with your doctor about your health and habits. Ask questions until you understand the answers. Use your time with your doctor wisely. Work with your doctor to make your healthcare decisions. Follow through on the care plan you choose together. If you have trouble following through, be sure to let your doctor know so that you and your doctor can figure out an approach that works for you. 38

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