You may have noticed something curious about the previous six strategies for taking charge of your heart disease: most of them don’t involve taking drugs, at least not as the first line of treatment. For many of the key risk factors of heart disease high blood pressure, cholesterol, excess weight, excess blood sugar (though not necessarily smoking) the first steps are the same: diet, exercise, and weight control.

Medications have a role if these first steps fail to bring the condition under control, but most doctors don’t turn to them right at the outset of a treatment program. But for heart disease itself, several medications are absolutely critical and can mean the difference between life and death right from the beginning:

• Aspirin and other so-called “blood thinners.”
• Beta-blockers.
• ACE inhibitors.
• Statins or other cholesterol-lowering medications for selected patients.

Each of these drugs has different purposes. For example, aspirin and other blood thinners work to keep blood flowing through arteries clogged by heart disease. Beta-blockers and ACE inhibitors help those who have had a heart attack from having another.

And there are other combinations of these drugs to suit specific conditions. Exactly what combination will work best for you is something you’ll work out with your doctor, in part as a safeguard against negative drug interactions or allergic reactions. But if you have heart disease, these are drugs you will need to know about.

Aspirin and Other Blood Thinners

The ability of blood to clot is what keeps us from bleeding to death when we’re cut and, conversely, what makes ordinary life dangerous for people who have conditions that keep their blood from clotting. But in people with heart disease, clots can slow or stop the flow of blood in coronary arteries, starving the heart of oxygen and triggering heart attacks.

That’s why medicines that inhibit the ability of blood to clot called “blood thinners” are a key weapon in the battle against heart disease. Aspirin, highly effective and inexpensive, tops the list of blood-thinning drugs used for this purpose, but there are others as well.

Aspirin: The “New” Wonder Drug for Heart Disease. Healers at least since the ancient Egyptians have known there was something in the bark of willow trees and wintergreen plants that reduced pain. Centuries later, the “something” was identified as salicylic acid.

It was a remarkably effective pain-reliever and fever-reducer, but taken in its pure form it had some pretty nasty side effects it caused nausea and severe stomach irritation. Scientists in a number of countries tried to formulate less toxic derivatives, but it wasn’t until the late 1890s that a German chemist, whose father had rheumatoid arthritis, came up with a compound acetylsalicylic acid that worked without causing harm.

The chemist worked for Bayer and Company, and they named the compound “aspirin.” Labeled the “wonder drug,” it has been the leading non-narcotic painkiller ever since. It wasn’t until quite recently, however, that researchers discovered that aspirin was also a wonder at preventing heart problems.

During the past thirty years, roughly 150 studies have demonstrated repeatedly and conclusively that taking just a single aspirin tablet a day can reduce your risk of a heart attack by as much as 30 percent, and reduce your risk of having a stroke as well.

And that’s not all. Taking aspirin at the first sign of a heart attack greatly reduces your risk of complications and death. After bypass surgery, angioplasty, or stenting, aspirin helps keep arteries from becoming blocked again. Indeed, aspirin protects more than just the heart.

After bypass surgery, for example, it lowers the risk of stroke, kidney problems, and bowel problems; in addition, daily aspirin use is associated with a significantly lower risk of developing precancerous growths in the colon; and long-term use of aspirin or other anti-inflammatory medications may reduce the risk of Alzheimer’s disease.

How Does It Work? The truth is, we don’t completely know. But a couple of things are clear. Aspirin is a “blood thinner.” During the 1960s, researchers found that a dose of aspirin could inhibit the normal process by which platelets form clots. By keeping clots from forming, aspirin keeps blood flowing to the heart.

More recently, researchers have begun to understand that inflammation of the arteries can also lead to heart disease. Aspirin calms inflammation and thus may also help to prevent heart disease in this way.

What The Guidelines? The American Heart Associa-tion/American College of Cardiology guidelines are clear: take one aspirin tablet per day for the rest of your life. Unlike other medications, where different doses have different effects, studies show that any dose from 75 to 325 mg (the most common tablet strengths), taken once a day, will have about the same effect.

If you’ve recently had a heart attack, you should take another medication, clopidogrel (discussed below) in addition to aspirin for at least nine months. If you can’t tolerate aspirin’s side effects, take clopidogrel or warfarin instead.

What Are Aspirin’s Side Effects? Aspirin is one of the safest drugs on the market today. That’s why you can buy it “over the counter,” without a prescription. Still, even aspirin can have side effects.

It can damage the lining of the stomach and, occasionally, cause ulcers that can bleed. But these risks are fairly small; studies have shown that only one in a hundred people who take aspirin for two years will experience stomach or intestinal bleeding.

If you’ve been taking aspirin and develop stomach pain, and especially if your stool turns black sometimes (indicating the presence of blood), you should stop taking it and contact your doctor. In addition, because it inhibits clotting, aspirin sometimes can keep clots from forming in places where they’re needed, increasing the tendency to bleed.

This can cause minor problems, like an increased vulnerability to bruising, or serious problems, including a major hemorrhage. The most catastrophic complication may be bleeding that occurs in the brain, a condition called hemorrhagic stroke. But this condition is very rare. Research has demonstrated that only one in 1,000 people who take aspirin for three years will be affected in this way.

The benefits far outweigh the risks: of every 1,000 people treated with aspirin, there will be fourteen fewer heart attacks and four fewer non-bleeding strokes. Finally, as with any medication, there are a small number of people who cannot tolerate aspirin. But if you notice what you think is any allergic reaction, consult your doctor immediately.

Who Should Avoid Aspirin? Obviously, anyone who’s truly allergic to aspirin should avoid taking it. And because aspirin is a blood thinner, anyone who suffers from a bleeding disorder, such as hemophilia, should avoid aspirin as well.

For the same reason, patients scheduled for some kinds of surgery may be told to avoid aspirin for a few days before the operation and for a period afterward as well although a recent study suggests that aspirin may be beneficial for bypass-surgery patients.

Finally, if you are already taking other blood-thinning medications, you should consult with your doctor before adding aspirin. These concerns aside, however, the bottom line is that aspirin’s benefits far outweigh its risks.

It is cheap, readily available, and safe for the vast majority of heart disease sufferers at the dosages recommended by the American Heart Association/American College of Cardiology guidelines. For every ten people who are saved from a heart attack or stroke by aspirin, only one will suffer any major aspirin-related complications.

Frequently Asked Questions

DO other pain relievers protect the heart like aspirin does?

Among all the commonly used over-the-counter pain relievers acetaminophen (Tylenol), ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), indomethacin (Indocin) only aspirin has been proven definitively to protect the heart.

Like aspirin, some pain relievers such as ibuprofen, naproxen, and indomethacin also have antiinflammatory properties and can inhibit platelets (which are important for clotting), though their effect is temporary, while as-pirin’s is permanent. Although some studies suggest that these other medications may also help to protect the heart, these studies are not definitive.

And acetaminophen (Tylenol), for example, is not believed to have any effect on the heart. Because so much research has been done on aspirin, it is the only over-the-counter pain reliever that has the support of cardiology experts. Some experts believe that ibuprofen should not be taken with aspirin, but this position is still controversial.

Taking some of the other pain relievers (except Tylenol) with aspirin may increase your risk of stomach irritation; it is not clear that it helps or hurts the protective effects of aspirin. Of note, Vioxx (rofecoxib) was recently withdrawn from the market because of evidence that it increases the risk of heart attacks and strokes.

Is it better to take bufferd or coated aspirin instead of plain tablets?

No. Drug companies claim that “buffered” or “enteric-coated” aspirin helps protect against stomach irritation, but the research that has been done on these claims is inconclusive and even contradictory. Indeed, a study that examined all research to date on these forms of aspirin concluded that they do not reduce the risk of stomach or intestinal bleeding. They simply tend to cost more.

Will a higher-dose aspirin tablet be more effective than a lower one?

Again, no. Research shows that aspirin provides the same heart protection benefit whether you take a low-strength tablet (at least 75 mg) or a higher one. Baby aspirin is usually 81 mg. Some people prefer the 325 mg dose because, ironically, it’s often less expensive than tablets with smaller dosage; they simply cut the higher dose tablets in half. However, there is no clear evidence that a lower dose reduces your risk of stomach irritation.

Is grape juice a substitute for aspirin?

A few studies have suggested that substances called flavonoids, contained in purple grape juice, can inhibit platelets from forming clots. Other juices orange, white grape, grapefruit can’t do this because they are low in this substance. But it hasn’t been demonstrated that purple grape juice can decrease the risk of heart disease, so it cannot be used as a substitute for aspirin.

Can chocolate substitute for aspirin?

Some scientists are actually doing research on the ability of chocolate to inhibit platelets (and clotting) and promote blood flow. Chocolate contains the same flavonoids as grape juice. One study showed that drinking a cocoa drink for four days had a similar, though less strong effect, as taking a baby aspirin.

Wouldn’t it be fun for doctors to start prescribing chocolate for your heart? Unfortunately, that is not going to happen anytime soon. This research may provide insight into new ways of treating heart disease, but no one is suggesting that any food that contains flavonoids, including chocolate, should substitute for aspirin. By the way, green and black tea also have an abundant amount of flavonoids.

Are some people resistant to the effect of aspirin?

Yes. Recent research indicates that for perhaps one in ten people aspirin will not prevent platelets from forming clots. The test that can indicate who will be aspirin-resistant is not yet in wide use, though some researchers want all patients taking aspirin to have this test.

What about combining aspiring and ibuprofen?

Some researchers have raised concerns that ibuprofen (and perhaps some other drugs like it) may blunt the benefit of aspirin for patients with heart disease. This issue is important because many people are taking both of these medications. For now, it is far from clear whether this concern has any merit.

Studies have not consistently supported the concern but the methods of the different studies make them hard to compare. For now, it seems prudent to combine them only if you really need both (good advice for any medication). This topic is likely to remain controversial for some time.

Clopidogrel (brand name: Plavix) Like aspirin, clopidogrel is a blood thinner that affects the ability of platelets to form clots. If you are unable to take aspirin, research suggests that clopidogrel is at least as effective as aspirin in reducing your risk of a heart attack or stroke.

Indeed, one study of more than 10,000 people who suffered from heart disease, stroke, or narrowing of the arteries showed that clopidogrel might work slightly better than aspirin at lowering a patient’s risk of suffering another heart attack or stroke, and of dying. Clopidogrel’s potential side effects stomach irritation and bleeding are the same as aspirin’s.

Clopidogrel can cause a rash in rare cases and, in even rarer instances (affecting only a few people for every 1,000 treated), can adversely affect white blood cells. Consequently, the American Heart Association/American College of Cardiology guidelines recommend that anyone with heart disease who is unable to take aspirin take clopidogrel instead.

For patients who have just suffered a heart attack, clopidogrel is typically prescribed in addition to aspirin for at least nine months (see the section After a Heart Attack, on pages 103–105).

Frequently Asked Questions

If clopidogrel is so effective, why do doctors recommended aspirin first?

While clopidogrel may be slightly more effective than aspirin, it is expensive and requires a prescription; aspirin is cheap and doesn’t. Also, although one study has suggested that clopidogrel may be better than aspirin, experts tend to be conservative with the results of just a single study, no matter how impressive those results may be. Consequently, at this point clopidogrel is not recommended first.

Warfarin Warfarin (brand name: Coumadin) is a potent anticoagulant (blood thinner) commonly prescribed after major surgery and for people who have mechanical heart valve replacements, as well as for patients with atrial fibrillation (also called an “irregular heartbeat”) to prevent the formation of dangerous blood clots.

The benefit of warfarin is the prevention of stroke this blood thinner can dramatically reduce your risk of stroke if you have atrial fibrillation. It is particularly important for you to ask your doctor about warfarin if you have atrial fibrillation and are not taking this drug many people in this country with atrial fibrillation who could benefit from warfarin are not receiving it.

Research has shown that warfarin also can have benefits for patients with heart disease similar to those of aspirin and clopidogrel, and so it has been recommended for patients who can’t tolerate those drugs. A study from Norway suggests that it may even be better at reducing the risk of future heart problems.

But warfarin is a more powerful blood thinner than the others and, as a result, has a higher risk of causing internal bleeding. It is so powerful that patients taking it must have a regular blood test to keep track of how well it’s working. The test, called an International Normalized Ratio (or, INR), measures certain aspects of the clotting process.

The best level for you depends on your condition. However, the risk of bleeding increases markedly when the INR level rises above 3.0 seconds, and that’s the most common concern with this medication. Minor bleeding can be common bruising, nosebleeds, cuts when shaving that bleed excessively, among others.

These effects occur in one of every six people taking the medication. (Heavier menstrual bleeding is rare.) Major bleeding is less common, though more dangerous when it occurs. The INR level is related to the dose of warfarin taken, but it can also be affected by diet and other medications. That’s one reason why it is monitored carefully and regularly.

Frequently Asked Questions

If warfarin is such a potent blood thinner, why isn't it the preferred drug for portecting againts heart damage?

Warfarin has the same disadvantages as clopidogrel: it costs more than aspirin (though not as much as clopidogrel) and requires a prescription. But it has the additional disadvantage of needing to be monitored frequently through blood tests, which are also costly, and inconvenient as well. Moreover, if not monitored closely it can cause severe bleeding.