Warnings – and hope – from new heart disease treatment guidelines

By American Heart Association News

THURSDAY, July 20, 2023 (American Heart Association News) — New guidelines detailing how to care for people with heart disease come with easy-to-understand warnings for patients.

The chronic coronary heart disease guidelines from the American Heart Association and the American College of Cardiology, published Thursday in the journal AHA Circulation, are not an additional update, said Dr. Salim Virani, chair of the expert panel that rewrote them.

“This is actually a new guideline in that everything that needed to be assessed in terms of evidence has been reviewed and all recommendations have been rewritten,” said Virani, vice-rector for research and professor of medicine at the Aga Khan University in Karachi, Pakistan.

Coronary artery disease includes various conditions that can be traced back to the buildup of plaque in the walls of arteries that restricts blood flow to the heart. This includes coronary artery disease, angina, heart attack, and care after a procedure to open a blocked heart artery.

The guidelines cover topics ranging from exercise to cholesterol management to bypass surgery. “It brings everything together into a one-stop shop for providers caring for these types of patients,” said Dr. Kristin Newby, vice chair of the editorial board.

From that ‘one-stop-shop’, here are six warnings for people with coronary heart disease – plus a general message to embrace.

“Trans fats aren’t good for anyone,” said Newby, a professor of medicine and cardiology at Duke University in Durham, North Carolina. But people with coronary heart disease should be extra careful.

Of all the fats and oils used in cooking, Newby said, trans fats are the most likely to cause plaque in the arteries. In people with existing disease, trans fats have been linked to a higher risk of heart attack and stroke, higher death rates from these problems, and a higher risk of premature death.

Artificial trans fats are liquid oils that have been turned into solids. Margarine and shortening are common examples. The Food and Drug Administration has banned food manufacturers from using a once common source of trans fat: partially hydrogenated vegetable oils. But in some places, trans fats are still present in restaurant fryers and elsewhere.

Trans fats also occur naturally in beef, lamb, and butter fat, but guidelines say they pose less of a risk than artificial trans fats.

Companies are allowed to say a food is trans fat free even if they contain up to half a gram. To avoid trans fats, check nutrition labels and avoid fried foods, processed baked goods, and refrigerated dough. And look for terms like “partially hydrogenated oils” in the ingredient list.

Watch out for second-hand smoke

Smoking is a well-known cause of heart disease. But even if you don’t smoke, you need to be careful.

“Every effort should be made to avoid second-hand smoke, as it contains many of the same chemicals and irritants that we think lead to coronary heart disease,” Newby said.

It’s a question of accumulation of risk, Virani said. “If you have heart disease and then add second-hand smoke to whatever is going on, the risk really increases.” For people who have had a heart attack, this includes a higher risk of having another one.

Avoiding second-hand smoke can be difficult if you work in a place where smoking is allowed. But if you have a family member who smokes, Virani said, “at a minimum,” you should ask them to smoke outside.

Be careful with common medications, including ibuprofen

“A lot of times we all have this misperception that if something is available over the counter, it’s safe,” Virani said. “Patients who have heart disease have to be very careful, even if it’s vitamins.”

The guidelines offer a specific warning about nonsteroidal anti-inflammatory drugs, also called NSAIDs. These drugs include ibuprofen and naproxen sodium.

“What we’re talking about here isn’t some kind of one-time use because your muscles are sore post-workout,” Newby said. “What we’re talking about is using them every day.”

NSAIDs pose two problems for people with coronary heart disease, Virani said. First, prolonged use has been linked to cardiovascular problems, including a second heart attack.

Second, NSAIDs can cause bleeding in the stomach and intestines. A heart patient may take one or even two blood thinners, Virani said. Combine them with NSAIDs, and “your risk of bleeding increases enormously”.

Occasional use isn’t a problem, he says. But he and Newby recommend acetaminophen as an alternative.

Do not combine erectile dysfunction drugs with nitrates

Nitrates – including nitroglycerin – are prescribed for angina or chest pain. Phosphodiesterase type 5 inhibitors – including sildenafil and tadalafil – are used for erectile dysfunction.

Their mixture can cause a life-threatening drop in blood pressure.

“It’s not about not use them,” Newby said. “It’s just about being careful.

Tadalafil, for example, can stay in the system for up to 48 hours, and some nitrates are also long-acting. Men should talk to their doctor about how long medications last in the system and seek alternatives if necessary, experts said.

Do not use these weight loss drugs

Sympathomimetic weight-loss drugs such as phentermine and benzphetamine work by suppressing appetite. They also increase your heart rate and blood pressure, which can put a strain on a heart already suffering from compromised blood flow, Virani said. The drugs could also cause irregular heartbeats, he said.

One drug in this class, sibutramine, was removed from the US market in 2010 but may be available outside the country or sold illegally.

Avoid them all, says Virani. “We have much better and safer weight loss drugs.”

Be careful with post-menopausal hormone therapy

Estrogens and progestins are given to women to relieve postmenopausal symptoms such as hot flashes. Against the background of heart disease, he has problems.

First, Newby said, although hormones have been studied extensively in hopes of showing that they protect against heart disease, intensive research has found no benefit. But hormone therapy increases the risk of venous thromboembolism, a blood clot in a deep vein or lung.

“What we suggest for patients with chronic coronary artery disease is to have this conversation with their treating clinician to see what other alternatives exist,” Virani said. Given their already high risk, “they have to be very careful.”

And now the good news…

The management of chronic coronary heart disease may seem like a list of limitations. Virani said he should also be seen as a wealth of opportunities.

“You know, 30 or 40 years ago, having chronic coronary heart disease was really like, ‘OK, you’re just going to have another heart attack one of these days, and you may or may not survive,'” he said. But even in the past four to five years, new treatments have made it more manageable than ever if people work with their healthcare professionals and take their medications.

“So there is also a lot of hope,” he said. “It’s not a death sentence anymore. You can have a fairly normal lifespan and good quality of life if you actually follow the recommendations.”

News from the American Heart Association covers heart and brain health. Any opinions expressed in this story do not reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved.

By Michael Merschel, American Heart Association News

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