Commonly used preventive drugs for heart disease

All drugs have clear applicable groups and are by no means "health drugs that everyone should take." They must be used after personal cardiovascular risk stratification and underlying disease conditions are evaluated by a doctor.

Last week, I met an Internet practitioner who was just over 30 years old at the outpatient clinic. His physical examination showed that his low-density lipoprotein was 3.9mmol/L and he weighed 20 pounds. He had no high blood pressure or diabetes, and no family history of premature heart disease. The first thing he said when he came in was, "Doctor, should I take aspirin to prevent myocardial infarction?" ”——This is really not an exception. I meet two or three people almost every week who take the initiative to prescribe preventive medicine. Either they read popular science on the Internet and think that "you have to take aspirin as you get older", or someone around you has a myocardial infarction and is so scared that you want to take medicine in advance to "safeguard".

To be honest, aspirin is the most abused preventive drug now, and even the academic community has been adjusting its indications for primary prevention. Ten years ago, there were indeed guidelines recommending that people over 50 years old can eat it without contraindications. However, in recent years, as more and more data are related to bleeding risks, both the American ACC and China's cardiovascular disease prevention guidelines have made the indications much stricter: only people with a 10-year risk of cardiovascular disease ≥10%, no peptic ulcer, history of bleeding, negative Helicobacter pylori, and low overall bleeding risk are recommended to use aspirin for primary prevention. If you have already suffered from coronary heart disease, missed a stent, or had a cerebral infarction, you must eat it as long as there are no contraindications. This is not controversial. Two months ago, I admitted a 62-year-old man with a history of high blood pressure and smoking. He was indeed eligible to take aspirin, but he secretly bought it at the drugstore and took it without checking for Helicobacter pylori. He suffered gastrointestinal bleeding after eight months of taking it and was sent to the emergency room. He almost had an accident. Later, he was found to be positive for Helicobacter pylori. He sterilized and protected his stomach first, and then switched to clopidogrel. This is a lesson in taking medicine without evaluation.

Many people may not have heard of SGLT2 inhibitors, but many diabetic patients are familiar with “dapagliflozin” and “empagliflozin” drugs. In the past, everyone thought it was a simple hypoglycemic drug that only diabetics could take. In fact, it is now a first-line drug for the prevention of heart disease. I have a 48-year-old patient who does not have diabetes, but has a family history of coronary heart disease. His low-density lipoprotein has not been lowered to the target value, and he still has a little proteinuria. Last year, he started to add a small dose of dapagliflozin. This year, not only did the proteinuria disappear, but his blood lipids were also stable, and he even lost 6 pounds in weight. Of course, there are different opinions on this usage. Many senior doctors will think that "what anti-diabetic drugs should be used without diabetes" for fear of hypoglycemia. However, more than a dozen large-scale clinical studies have been published so far and have confirmed that even people with normal blood sugar will not suffer from hypoglycemia when using regular doses of leucoxide. On the contrary, it can reduce the risk of cardiovascular events by about 30% and protect kidney function. Especially for patients with heart failure, the effect is particularly obvious.

Let’s talk about the most controversial statins. A search on the Internet all shows the statement “Don’t take statins because they damage the liver and kidneys.” To be honest, I have met many patients who had obviously let go of stents but secretly stopped statin after reading online posts. After half a year, the blood vessels were rechecked and the blood vessels were blocked again. The side effects of statins do exist. About 1% of people will experience a mild increase in transaminase, and a very small number of people will experience muscle soreness. However, the vast majority of people are completely tolerant, and even if there is an increase in transaminase, as long as it does not exceed 3 times the upper limit of the normal value, there is no need to stop taking the drug, just reduce the dosage or change the type. I had a patient who had high transaminases after taking 20mg of atorvastatin. Later, he switched to 10mg of rosuvastatin plus ezetimibe. Not only did his LDL drop to the target value of 1.4mmol/L, but his transaminases were also completely normal. He had no problems at all after taking it for three years. There is still a small controversy in the academic community about whether the lower the LDL, the better. The latest guidelines recommend that ultra-high-risk groups should lower it to less than 1.4, and some scholars even recommend that it be lowered to less than 1.0. Some people are worried about whether too low will affect the normal function of the body. So far, long-term follow-up data has not found any clear harm, but individual adjustments are still needed. There is no need to blindly pursue extremely low values.

As for beta-blockers such as metoprolol and bisoprolol, many patients feel slow heartbeat and fatigue after taking them, so they secretly stop taking them. This is especially risky for patients who have already had myocardial infarction. This type of drug seems to lower heart rate and blood pressure, but in fact it can reduce the sudden death rate of patients after myocardial infarction by more than 30%. It is a must-use drug for secondary prevention. As long as your resting heart rate can be maintained above 55 beats/min, and you don't feel dizzy or have dark eyes, you don't have to worry at all. If you feel weak when you first take it, you can reduce the amount by half first and slowly get used to it. Most people will have the side effects disappear after a week or two.

There are also the commonly mentioned "Pril" and "Satan" types, including the latest sacubitril-valsartan. Many people think that this is an antihypertensive drug and they don't need to take it if the blood pressure is not high. In fact, the role of this type of drug goes far beyond lowering blood pressure. It can improve myocardial remodeling and delay heart enlargement. Whether it is patients who have already suffered from coronary heart disease or heart failure, or high-risk groups with diabetes or kidney disease, as long as the systolic blood pressure can be maintained above 100mmHg, small doses can significantly reduce the risk of cardiovascular events. This effect is independent of blood pressure reduction. If you can't stand the dry cough that comes with taking the Prilim type, you can just switch to the Sartan type without having to bear it hard.

Finally, I can honestly say that I have been working in clinical practice for more than ten years. There is no magic medicine for preventing heart disease that is “applicable to everyone”. I have met many people who spend a lot of money to buy Coenzyme Q10 and deep-sea fish oil to prevent heart disease. In fact, if you meet the medication indications, a bottle of statins costing a few yuan is much more effective than health products costing thousands of yuan. ； If your risk is low, eating well, staying up less late, and exercising more are better than taking any medicine. If you really want to take preventive medicine, you should first go to a cardiologist for a risk assessment. Don’t just buy and take it blindly. After all, medicines are only three parts poisonous. What works for others may not be suitable for you.