Medications in This Chapter the Medicines That You Have Been Given Are an Important Part H General Guidelines

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Medications In This Chapter The medicines that you have been given are an important part h General Guidelines ...... H1 of the treatment plan. This chap- h Angiotensin Converting ter provides guidelines and Enzyme (ACE) information about many heart Inhibitors...... H4 medications. It is important for you to follow h Angiotensin Receptor Blockers ...... H5 the medication regimen your doctor has prescribed. Let your Antiarrhythmics...... H6 h doctor or the Cardiac Rehab staff h Anticoagulants...... H7 know if you have any concerns about taking your medications. h Antiplatelets...... H9 Beta Blockers...... H10 h SECTION 1 h Calcium Channel Blockers ...... H12 h General Guidelines For Taking Medication h Digitalis...... H13 The following guidelines are meant to help prevent mistakes in taking med- Diuretics...... H14 h ication. Please follow them carefully. Never take medication in the h Combination Drugs...... H16 dark. Lipid Lowering h Always read the labels on your Agents ...... H16 medication bottles. Nitrates...... H19 Take exactly as ordered by your h doctor. Do not skip doses or take h Potassium extra. Bad effects can happen Supplements...... H22 from taking too much or too little of a medication. Pain Relievers...... H23 h Do not give your medication to someone else and do not take any h Over-The-Counter Medications...... H24 medication not prescribed for you. Make sure to tell all doctors or H2 MEDICATIONS

dentists what medications you are have any allergies and the reac- taking. tion. This can be very important Some medications should be in an emergency. The Cardiac taken with food and some should Rehab staff can provide you with be taken on an empty stomach. a medication wallet card and help Know how your medication needs you fill it out. to be taken. Refill your medication before you If you are taking a long-acting or are completely out. Plan ahead for sustained release form of a med- weekends and holidays. ication, you must swallow it Have all your prescriptions filled whole. Do not break, chew, or at the same pharmacy. This will crush before swallowing. allow your pharmacist to better For liquid medications use a mea- screen for drug interactions. suring spoon or specially marked If you are worried you might for- device. Do not use your silver- get to take your regular medicine, ware. a medicine chest (pillbox) can help Check with your doctor or phar- you remember when to take your macist before taking any over-the- medication. counter or non-prescription medications. What you should know about each of your medications Know what side effects or reac- 1. Name & strength of each medications to report to your doctor. tion. Always carry a list of medications 2. Why are you taking each medica- with you. Include the name, tion? strength, and dose of both pre- 3. How much and how often do you scription and non-prescription need to take it? medications, including natural or 4. How long will you need to take it? herbal drugs. Also include if you 5. Possible side effects or reactions. What do you do if side effects CAUTION occur? Do not discontinue 6. Does the medication interact or your medications without contacting interfere with any of your other your doctor, even if medicines, over-the-counter prod- you feel better. ucts or alcohol? 7. Are there any special instructions? 8. How should you store your medication? MEDICATIONS H3 Grapefuit Juice/Drug Interactions Grapefruit juice can interact with some prescription medications. If you are taking any of the following medications, it is recommended that you decrease or eliminate grapefruit in your diet. Medications that can Interact with grapefruit juice

Medication name Possible effects Diazepam (Valium) Increased sedation Triazolam (Halcion) Lovastatin (Mevacor) Headaches, muscle pain Atorvastatin (Lipitor) gastrointestinal complaints Simvastatin (Zocor) Amlodipine (Norvasc) Increased adverse effects Felodipine (Plendil) Nicardipine (Cardene) Nifedipine (Procardia, Adalat) Nimopidine (Nimotop) Nisoldipine (Sular) Verapamil (Isoptin, Calan, Verelan, Covera HS) Cyclosporine Increased gastrointestinal (Sandimmune, Neoral) complaints (Nausea, stomach pain Tacrolimus (Prograf) Prednisone Carbamazepine (Tegretol) Estinyl Estradiol (Estiny) Itraconazole (Sporonox) Quinidine (Cardioquin, Quinaglute, Quinidex) Caffeine Viagra (Sildenafil) Cialis (Tadalafil) Cilostazol (Pletal) Amiodarone (Cordarone) Colchicine Bupropion (Zyban, Wellbutrin) Losartan (Cozaar) Propafenone (Rythmol) H4 MEDICATIONS

9. What do you do if a dose is missed? SECTION 2 10. Does the medication require any Angiotensin Converting monitoring (i.e. blood tests)? h Enzyme (ACE) Inhibitors Storage of Medications Angiotensin is a substance in the KEEP OUT OF REACH OF CHIL- body that causes blood vessels to nar- DREN row. ACE inhibitors reduce the produc- Store in a cool, dry place. tion of angiotensin by blocking the Keep away from heat or sunlight. enzyme, angiotensin converting Keep in the original container, enzyme. This allows the blood vessels tightly capped. Do not mix differ- to relax, for a reduction in blood pres- ent medications in one bottle. sure and increase in blood and oxygen Do not remove labels, these will supply to the heart. contain directions and any special Uses for ACE Inhibitors include treat- information. ment of high blood pressure (hyperten- Do not store in the refrigerator sion), congestive heart failure, and to unless directed by your pharma- protect the kidneys of diabetic patients. cist or doctor. Examples of ACE Inhibitors Do not keep in the bathroom, • Benazepril (Lotensin) near a sink, or in any damp place. • Captopril (Capoten) Heat or moisture may cause the • Enalapril (Vasotec) medication to break down. • Fosinpril (Monopril) Discard any medication that you • Lisinopril (Prinivil, Zestril) have been instructed not to take • Moexipril (Univasc) any more or any medication that • Perindopril (Aceon) is expired. • Quinapril (Accupril) What to do if you miss a dose? • Ramipril (Altace) If you’ve missed a dose, take it as • Trandolapril (Mavik) soon as possible. If several hours have Things to Remember passed or if it is nearing the time for DO NOT take other medications the next dose, DO NOT DOUBLE unless you discuss them with your THE DOSE IN ORDER TO “CATCH doctor or pharmacist. This espe- UP,” just skip the missed dose and cially includes over-the-counter continue your usual schedule. If you medications for appetite control, miss more than one dose or you have asthma, colds, cough, hay fever, or questions call your doctor. sinus problems since they may increase your blood pressure. MEDICATIONS H5

DO NOT take salt substitutes or M Dizziness or lightheadedness medications containing potassium M Skin rash while taking ACE inhibitors, unless prescribed by your doctor. CAUTIONS Tell your doctor if you are taking ACE inhibitors may cause your body to retain potassium. Signs of captopril or fosinopril. These medica- too much potassium are: confu- tions may interfere with some medical sion, irregular heart/beat, ner- tests. vousness, weakness, heaviness of Notify your doctor immediately if the legs, and numbness or tin- any of the following occur: fever and gling in the hands, feet or lips. chills, hoarseness, trouble in breathing Check with your doctor if any of or swallowing, or swelling of the face, these signs occur. mouth, hands or feet. You may become dizzy or lightheaded while taking ACE inhibitors. Make sure you know SECTION 3 how you react to this medication h Angiotensin II Receptor before driving an automobile or Blockers (ARBs) operating machinery. Alcohol may Angiotensin Receptor Blockers make this effect stronger. (ARBs) are similar to ACE Inhibitors. Dizziness, lightheadedness, or They block the action of angiotensin fainting may occur if you exercise by blocking the binding of angiotensin or if the weather is hot. Heavy to the receptor. This results in a relax- sweating may cause you to lose too much water and lower your ation of blood vessels and a reduction blood pressure. Use extra care in blood pressure. during exercise in hot weather. ARBs are used to treat high blood pressure and may have benefit in If you are taking captopril or moexipril, take on an empty stom- patients with congestive heart failure ach one hour before meals. and to protect the kidneys of diabetic patients. Possible Side Effects Examples of Angiotensin M Dry cough Receptor Blockers M Loss of taste • Candesartan (Atacand) M Nausea or vomiting Headache • Eprosartan (Teveten) M • Irbesartan (Avapro) Unusual tiredness M • Losartan (Cozaar) M Diarrhea • Olmesartan (Benicar) H6 MEDICATIONS

• Telmisartan (Micardis) M Change in how much or how • Valsartan (Diovan) often you urinate Chest pain Combination products with a diuret- M ic such as hydrochlorothiazide are also M Fast or slow heartbeat available. M Lightheadedness or fainting • Irbesartan + Hydrochlorothiazide M Swelling in the hands, ankles or feet (Avalide) • Losartan + Hydrochlorothiazide SECTION 4 (Hyzaar) • Valsartan + Hydrochlorothiazide h Antiarrhythmics (Diovan HCT) When your heart has an irregular Things to Remember rhythm your body may not receive all the blood and nutrients it needs. Don’t use potassium supplements or salt substitutes containing Antiarrhythmics help correct irregular potassium without checking with rhythms and increase your heart’s effi- your physician first. ciency. You may take these medicines Examples of Antiarrhythmics with or without food. • Amiodarone (Cordarone) This medication may make you • Disopyramide (Norpace, Norpace CR) dizzy or drowsy. Avoid driving, • Dofetilide (Tikosyn) using machines, or doing anything • Flecainide (Tambocor) else that could be dangerous if • Mexiletine (Mexitil) you are not alert. • Moricizine (Ethmozine) Possible Side Effects • Procainamide (Pronestyl, Procan) M Back pain • Propafenone (Rhythmol) M Cough, stuffy or runny nose, sore • Quinidine (Quinidex, Quinaglute) throat • Tocainide (Tonocard) M Headache Things to Remember M Dizziness Do not miss taking a dose and do M Notify your physician if you have not take more than what is any of these side effects: ordered. M Allergic reaction: itching, hives, Take at evenly spaced times at the swelling in face or hands, swelling same time every day. or tingling in mouth or throat, Do not stop taking unless ordered tightness in chest, trouble swal- by your doctor. lowing MEDICATIONS H7

Do not confuse quinidine with in chest), joint pain, blurred quinine. These are different med- vision, incoordination, ringing in ications with different uses. ears. Quinine is a medication used to M Moricizine: Palpitations, dizzi- treat nighttime leg cramps. ness, nausea, trouble breathing, It is best to take these medica- headache. tions with meals unless otherwise M Propafenone: Stomach pain, dry directed so by your doctor of mouth, anxiety, drowsiness, inco- pharmacist. ordination, palpitations (pounding Sensitivity to sunlight may occur in chest), blurred vision, edema, while you are taking Amiodarone. weakness. Use sunscreen and protective M Procainamide: Fever, chills, joint clothing until tolerance is deter- pain, skin rash, sore mouth, gums, mined. or throat, unusual tiredness or Possible Side Effects weakness, trouble breathing. Quinidine: Bitter taste, flushing, M All Antiarrhythmics: Nausea, vom- M iting, diarrhea, constipation, wors- stomach pain or cramping, ening of heart rhythm, dizziness, blurred vision, severe headache, fainting, fatigue, confusion, loss of ringing in ears, appetite, rash. trouble breathing, fainting. Tocainide: Tingling, tremor, M Amiodarone: Halos around lights, M sensitivity to lights, blurred blurred vision, sweating, drowsi- vision, dry eyes, blue-gray skin ness, confusion, headache. color, numbness and tingling in hands and feet, hair loss, short- SECTION 5 ness of breath, coughing. M Disopyramide: Difficult urination, h Anticoagulants chest pain, dry mouth or throat, Anticoagulants interfere with the muscle weakness, rapid weight clotting ability of your blood. They are gain, decreased sexual ability. often called blood thinners, but they M Flecainide: Headache, tremor, don’t really thin the blood. They abdominal pain, ringing in ears, lengthen the time it takes your blood edema, change in taste, dry to clot. They are used to prevent clot mouth, blurred vision, difficulty formation in arteries, veins, heart focusing, depression, incoordina- chambers, and on artificial heart tion. valves. They will not dissolve blood M Mexiletine: Stomach pain, tremor, clots that have already formed, but depression, palpitations (pounding they do prevent clots from enlarging. H8 MEDICATIONS

Dosing of anticoagulants varies wide- Aspirin increases the blood thin- ly between individuals. Your dose is ning action of anticoagulants, so determined by a blood test called the it is very important to take the prothrombin time (protime or PT), same dose every day. which measures how fast your blood Limit your alcohol intake. clots. The PT is then converted to a Drinking too much alcohol may standardized ratio and reported at the change the way your anticoagu- International Normalized Ratio (INR). lant works. If you have questions Your INR will be determined during about drinking alcohol, please ask regular visits to your doctor. your physician. Dosage changes may occur based on CAUTION the results of this blood test. Tell your 1. Anticoagulants can interact with doctor if you have missed any doses, many other medications, resulting which could affect the test results. in an increase or decrease in effec- The most widely used anticoagulant tiveness. Do not start or stop tak- is: Warfarin (Coumadin) ing any other medication without Things to remember consulting your doctor or pharma- Take your anticoagulant exactly cist. This includes common over as prescribed, and at the same the counter medications such as time every day. It may be helpful aspirin, ibuprofen (Advil), and to keep a daily record of the time naproxen (Aleve). you take it. 2. The effect of your anticoagulant Inform all of your doctors, den- depends on the amount of vitamin tists, pharmacists, and nurses that K in your body. Vitamin K is you are taking an anticoagulant. found in meats, dairy products, If you are having dental work or and green leafy vegetables (like other procedures done, special broccoli, cabbage, collard greens, precautions may be necessary to kale, lettuce, and spinach) as well prevent bleeding. as in some multiple vitamins and Carry identification stating which nutritional supplements. It is best anticoagulant you are taking and to have about the same amount of your dosage. vitamin K in your diet every day. If your doctor prescribes aspirin Do not make radical changes in along with your anticoagulant, it your diet. Also check with your is important to take the same doctor if you are unable to eat for dose of aspirin every day. Do not several days or if you have contin- take additional aspirin for pain or uing stomach upset, diarrhea, or fever, use acetaminophen instead. fever. MEDICATIONS H9

3. If you miss a dose and realize it that same day, take it as soon as SECTION 6 possible. If you don’t remember Antiplatelets until the next day, do not take the h Platelets are components of the missed dose and do not double blood that clump together to help the next one. Doubling doses form blood clots. Antiplatelet medica- could cause bleeding. tions interfere by preventing platelets 4. Do not begin taking warfarin dur- from sticking together. They help pre- ing pregnancy, and do not become vent the formation of blood clots with- pregnant while taking it. It may in the heart or blood vessels. cause birth defects. Antiplatelets are often used after heart Possible Side Effects surgery. Notify your doctor immediately if Examples of Antiplatelets any of the following occur: • Dipyridamole (Persantine) M Red or black tarry stools • Aspirin (Ecotrin, Ascriptin, Red or dark brown urine M Bufferin, Bayer, etc.) Back pain, abdominal pain or M • Dipyridamole + Asprin (Aggrenox) swelling • Ticlopidine (Ticlid) M Dizziness • Clopidogrel (Plavix) M Unexplained nosebleeds Things to remember M Severe or constant headaches Check with your doctor to see if M Vomiting of blood or material that you can take aspirin for other rea- looks like coffee grounds sons (headache, fever). This M Excessive bleeding from gums applies whether you are pre- when brushing teeth, or excessive scribed aspirin, dipyridamole or bleeding or oozing from cuts. ticlopidine. Unexplained bruising or purplish M Store aspirin in a tightly closed areas on the skin. bottle in a cool, dry place. If M Unusually heavy or unexpected aspirin has a strong vinegar small, menstrual bleeding. it has broken down and should be M Skin rash or itching discarded. If aspirin upsets your stomach, The Cardiac Rehab staff can show you a take it with food or an antacid. video and give you additional information Buffered or enteric coated aspirin on what you need to know while you are can also be used. taking Warfarin (Coumadin). H10 MEDICATIONS

Dipyridamole is most effective taken on an empty stomach with SECTION 7 a full glass of water. If this Beta Blockers method upsets your stomach, this h drug may be taken with food. Beta blockers work by affecting the response of various parts of the body If you are on ticlopidine, this medication should be taken with a to nerve impulses. The heart’s meal or snack. response is to reduce heart rate and the strength of muscle contraction. By Clopidogrel can be taken without lowering the heart’s need for blood regard to meals. and oxygen, the heart can work more CAUTION efficiently. Ticlopidine may lead to increased bleeding. Beta blockers are used to treat high Report an unusual bleeding or dark-colored blood pressure (hypertension), relieve stools to your doctor. Make sure your doc- chest pain (angina), correct irregular tors and dentists are aware you are on this medication. Lab tests are required during heart rhythms (arrhythmias), and pre- treatment with ticlopidine. These may vent additional heart attacks in include blood counts and liver function patients who have had a heart attack. tests. Examples of Beta blockers Possible Side Effects • Acebutolol (Sectral) Dipyridamole, Ticlopidine • Atenolol (Tenormin) and Clopidogrel • Betaxolol (Kerlone) M Dizziness, light-headedness, • Bisoprolol (Zebeta) or fainting • Carteolol (Cartrol) M Stomach cramping, nausea, • Carvedilol (Coreg) vomiting, diarrhea • Labetalol (Trandate, Normodyne) M Weakness • Metoprolol (Lopressor, Toprol XL) M Headache • Nadolol (Corgard) M Flushing, skin rash, itching • Penbutolol (Levatol) • Pindolol (Visken) Aspirin • Propranolol (Inderal, Inderal LA) M Abdominal pain, nausea, vomiting • Sotalol (Betapace) M Bloody or black tarry stools • Timolol (Blocadren) M Vomiting of blood or material resembling coffee grounds Things to Remember DO NOT stop taking this medica- Skin rash, hives, itching M tion without first checking with M Ringing in the ears your doctor. Some conditions MEDICATIONS H11

(such as chest pain) may become CAUTION worse when the medication is 1. You may become dizzy, drowsy, or stopped suddenly. lightheaded while taking this medication. This side effect often goes When getting up from a lying or sitting position, you may become away after the first few weeks of dizzy or faint. If this occurs, get- therapy. Make sure you know how ting up slowly may help. Alcohol you react to this medication may make this effect worse. before driving an automobile or operating machinery. You may become more sensitive to cold temperatures, especially if 2. This medication may reduce or you have blood circulating prob- prevent chest pain resulting from lems. Dress warmly during cold exercise or physical exertion. This weather and be careful during may tempt you to “over do” it. prolonged exposure to cold. Make sure you discuss with your doctor a safe level of exercise for Ask your doctor about checking your pulse or heart rate. If it is you. much slower than your usual rate 3. If you are a diabetic, beta blockers (or less than 50 beats per may cause your blood sugar levels minute), check with your doctor. to fall. This medication may also cover up signs of low blood sugar, If you are taking the extended- release capsule or tablet form of and changes in the heart rate. metoprolol or propranolol, swal- 4. DO NOT take other medications low the capsule or tablet whole. unless you discuss them with your DO NOT crush, break, or chew doctor or pharmacist. This espe- before swallowing. cially includes over-the-counter medications for appetite control, If you are taking sotalol, take on an empty stomach one hour asthma, colds, cough, hay fever, or before meals. sinus problems since they may increase your blood pressure. Labetalol, metoprolol, and propranolol are most effective taken Possible Side Effects with a meal or a snack. M Difficulty breathing Acebutolol, atenolol, betaxolol, M Chest pain bisoprolol, nadolol, and pindolol M Cold hands or feet may be taken without regard to Unusually slow heart rate food. M M Depression M Nightmares M Skin rash H12 MEDICATIONS

M Swelling of ankles, feet, or lower Examples of Calcium legs Channel Blockers M Decreased sexual arousal or • Amlodipine (Norvasc) impotence • Bepridil (Vascor) M Dizziness or lightheadedness • Diltiazem (Cardizem, Cardizem M Drowsiness SR, Cardizem CD, Dilacor XR, M Nausea of vomiting Tiazac) • Felodipine (Plendil) Alpha/Beta Blocker • Isradipine (Dynacirc) Carvedilol (Coreg) is a drug that has • Nicardipine (Cardene, Cardene SR) both the properties of a beta-blocker • Nifedipine (Adalat, Adalat CC, and an alpha-blocker. Both actions Procardia, Procardia XL) decrease blood pressure. Carvedilol • Nimodipine (Nimotop) can be used to treat high blood pres- • Nisoldipine (Sular) sure or in combination with other • Verapamil (Calan, Calan SR, medications to treat congestive heart Isoptin, Isoptin SR, Verelan) failure. Carvedilol must be taken with food to reduce the risk of too low Things to Remember blood pressure. DO NOT stop taking this medication without first checking with your doctor. Some conditions SECTION 8 (such as chest pain or irregular heart rhythms) may become worse h Calcium Channel Blockers when the medication is stopped Calcium Channel Blockers affect the suddenly. movement of calcium into the cells of DO NOT take other medications the heart and blood vessels. As a unless you discuss them with your result, they relax blood vessels and doctor or pharmacist. This espe- increase the amount of blood and oxy- cially includes over-the-counter gen delivered to the heart, while medications for appetite control, reducing the heart’s work load. asthma, colds, cough, hay fever, or Calcium Channel Blockers are used sinus problems since they may to relieve and control chest pain (angi- increase your blood pressure. na), treat high blood pressure (hyper- If you are taking diltiazem or ver- tension), and correct irregular heart apamil, ask your doctor about rhythms (arrhythmias). checking your pulse or heart rate. If it’s much slower than your usual rate (or less than 50 beats MEDICATIONS H13

per minute), check with your doc- M Dizziness or lightheadedness tor. M Flushing or feeling of warmth You may get a headache during M Nausea the first week or two of taking Skin rash this medication. This effect is M more common if you are taking nifedipine. This should become SECTION 9 less noticeable after a while. If it continues, see your doctor. h Digitalis Digitalis medication is used to When getting up from a lying or sitting position, you may become improve the strength and pumping dizzy or faint. If this occurs, get- action of the heart or to control the ting up slowly may help. Alcohol rate and rhythm of the heart. Digitalis may also make this effect worse. helps your heart beat stronger and keeps it from beating too fast. This If you are taking the extended- release capsule or tablet form of will lead to better blood circulation. diltiazem, nicardipine, nifedipine, Examples of Digitalis nisoldipine, or verapamil, swallow the capsule or tablet whole. DO • Digoxin (Digitek, Lanoxin, NOT crush, break or chew before Lanoxicaps) swallowing. • Digitoxin Avoid taking nisoldipine with Things to Remember grapefruit products. Take exactly as your doctor has ordered it and at the same time CAUTION every day. Do not stop taking it Chest pain resulting from exercise or because you feel better. physical exertion is reduced or pre- If you miss a dose and remember vented with this medication. This may within 12 hours, take as soon as tempt you to “over do” it. Make sure you remember. However, if it is you discuss a safe level of exercise more than 12 hours after your with your doctor. scheduled dose, do not take the Possible Side Effects missed dose and do not double the next dose. Continue your M Difficulty breathing usual schedule. If you have any M Irregular or unusually fast or slow heart rate questions or miss more than one dose, call your doctor. M Chest pain Ask your doctor about checking M Swelling of ankles, feet, or lower your pulse or heart rate. Your legs H14 MEDICATIONS

doctor may want to know if your M Fatigue, muscle weakness rate is slower or faster than usual. These side effects may be signs that Your doctor may recommend a there is too much medication in your low-sodium (low salt) diet and a potassium supplement. Choose body. Contact your doctor immediate- foods that are low in sodium and ly. Your dose may need to be changed. high in potassium and emphasize Once you and your doctor have deter- them in a well-balanced diet. mined the correct dose, you usually will not experience side effects if you Your doctor may check the amount of Digoxin in your body take Digoxin exactly as prescribed. with a blood test. Check with your doctor or phar- SECTION 10 macist before taking any over-the- counter medications. They could h Diuretics (“Water Pills”) change the way your digitalis Diuretic medication reduces the works. amount of water in the body by increasing the flow of urine. Along Possible Side Effects with water, there is a loss of sodium in Irregular heartbeat or changes in M the urine. Sodium can cause your pulse (slow heart rate) body to retain extra water which can M Loss of appetite cause your hands and feet to swell. M Nausea/vomiting Your heart has to work harder to M Lower stomach pain pump the extra water throughout your M Diarrhea body, which can raise your blood pres- M Unusual tiredness or weakness sure. By losing the extra water, your heart will not have to work as hard M Slow or irregular heartbeat and your blood pressure can be con- M Vision changes such as flashes or flickering of light, sensitivity to trolled. light, seeing things larger or Diuretics will not cure your high smaller than they are, blurring, blood pressure but will help control it. color changes (yellow or green) You must continue to take it, even if and seeing halos or borders on you feel well, if you expect to keep objects your blood pressure down. Diuretics are sometimes combined M Drowsiness Confusion with other medications used to treat M high blood pressure into a single pill. Depression M Potassium-depleting diuretics allow M Headache potassium to be excreted in urine. MEDICATIONS H15

Examples of To keep this from affecting sleep: potassium-depleting diuretics A. If you are to take a single dose • Acetazolamide (Diamox) each day, take it in the morn- • Benedroflumethiazide (Naturetin) ing after breakfast. • Bumetamide (Bumex) B. If you are to take more than • Chlorthalidone (Hygroton) one dose a day, take the last • Chlorothiazide (Diuril) dose no later than 6 p.m. • Ethacrynic Acid (Edecrin) There is no need to change how • Furosemide (Lasix) much fluid you drink while taking diuretics. • Hydrochlorothiazide (Hydrodiuril, HCTZ, Esidrex) If you take a potassium-depleting • Hydroflumethiazide (Diucardin) diuretic, your doctor may want • Indapamide (Lozol) you to eat or drink foods that have a high potassium content, or • Methylclothiazide (Enduron) instruct you to take a potassium • Metolazone (Zaroxolyn) supplement. • Polythiazide (Renese) • Torsemide (Demadex) If you take a potassium-sparing diuretic, it will probably not be • Trichlormethiazide (Naqua) necessary for you to take extra Potassium-sparing diuretics do not potassium medication. Check with allow potassium to be lost in urine. your doctor first. Examples of Dizziness, or lightheadedness may potassium-sparing diuretics occur, especially when getting up • Amiloride HCI (Midamor) from a sitting or lying position. • Eplerenone (Inspra) Getting up slowly may help. • Spironolactone (Aldactone) Alcohol may make this effect • Triamterene (Dyrenium) worse. Sensitivity to sunlight may occur. Examples of combination diuretics Use sunscreens and wear protec- • Amiloride/Hydrochlorothiazide tive clothing until tolerance is (Moduretic) determined. • Spironolactone/Hydrochlorothiazide Do not take other medications (Aldactazide) without your doctor’s approval. • Triamterene/Hydrochlorothiazide This includes nonprescription (Dyazide, Maxzide) medicines for appetite control, asthma, colds, cough, hay fever or Things to remember: sinus problems. You may notice an increase in urine or frequency of urination. H16 MEDICATIONS Possible side effects Beta Blocker + Diuretic M Dry mouth* Atenolol + Chlorthalidone (Tenoretic) M Thirst* Bisoprolol + HCTZ (Ziac) M Irregular heart beat* Metoprolol + HCTZ (Lopressor HCT) M Nausea, vomiting* Nadolol + Bendroflumethazide (Corzide) Propranolol + HCTZ (Inderide) M Mood changes* Timolol + HCTZ (Timolide) M Muscle cramps or pain* M Unusual weakness or tiredness* Calcium Channel Blocker M Loss of appetite + ACE Inhibitor M Joint pain Amlodipine + Benazepril (Lotrel) M Impotence Felodipine + Enalapril (Lexxel) Verapamil + Trandolapril (Tarka) M Sensitivity to sunlight M Skin rash or hives M Unusual bleeding or bruising SECTION 12 *Signs of potassium loss. Notify your doctor. h Lipid Lowering Medications High levels of cholesterol and/or SECTION 11 triglycerides in the blood may block blood vessels and increase the risk of h Combination Drugs developing heart or blood vessel dis- Combination drugs are pills that con- ease. Lipid lowering agents work best tain two or more medicines in one when used along with a low-choles- tablet. They offer the advantage of terol, low-fat diet. decreasing the number of pills that one takes and decreasing cost. Below How they work is a list of some combination drugs. HMG-COA reductase inhibitors are used to lower the levels of cholesterol ACE Inhibitors + Diuretics and triglycerides in the blood. They do Benazepril + HCTZ (Lotensin HCT) this by reducing the production of Captopril + HCTZ (Capozide) cholesterol by the body and by increas- Enalapril + HCTZ (Vaseretic) ing the rate at which the body Lisinopril + HCTZ (Prinzide, Zestoretic) removes cholesterol from the blood. Moexipril + HCTZ (Uniretic) MEDICATIONS H17

Examples of Lipid level, liver function tests, and eye Lowering Medications exams (for lovastatin only). A. HMG-COA Reductase Inhibitors CAUTION Do not take these medications if you • Atorvastatin (Lipitor) are pregnant. • Lovastatin (Mevacor) • Pravastatin (Pravachol) Possible Side Effects • Simvastatin (Zocor) M Nausea, vomiting, diarrhea, consti- • Fluvastatin (Lescol) pation, gas, indigestion • Rosuvastatin (Crestor) M Headache, dizziness, weakness, sleeplessness Things to remember Cold or flu-like symptoms, cough You should follow a proper diet M and exercise program in addition M Rash, itching to taking your medication. M Muscle pain, chest pain, fever, Lovastatin should be taken with blurred vision your evening meal. If you are tak- B. Bile Acid Sequestrants ing it twice a day, it should be taken with the morning and How they work evening meals. These drugs are used to lower cholesterol. They do this by binding to Simvastatin should be taken once daily in the evening (without bile acids in your intestines and pre- regard to meals). venting their absorption. Your body must replace these bile acids by con- Atorvastatin or Rosuvastatin can be taken any time of the day with- verting cholesterol to bile acids. out regard to meals. Examples Fluvastatin and Pravastatin • Cholestyramine (Questran) should be taken at bedtime with- • Colestipol (Colestid) out regard to meals. • Colesevelam (Welchol) Notify your doctor if you develop unexplained headache, muscle Things to remember pain, tenderness or weakness, Bile acid sequestrants are most nausea, vomiting, or diarrhea, par- effective when used with a low ticularly if accompanied by a fever cholesterol, low saturated fat diet. or general body discomfort. They may interfere with the action of other drugs taken at the same Lab tests may be required during treatment. These tests may time. Take other medications either include blood counts, cholesterol 1 hour before or 4 to 6 hours after the bile acid sequestrants. H18 MEDICATIONS

They should be taken just before These drugs lower blood levels of eating or with meals. triglycerides and cholesterol by They may cause constipation. A decreasing the production of triglyc- laxative, stool softener or drinking erides by the body and by increasing liquids may be helpful. the rate of excretion of cholesterol. Periodic lab tests will be required Things to remember during treatment. Tests may Take gemfibrozil 30 minutes before include blood count, triglycerides, the morning and evening meals. and cholesterol. They are most effective when used DO NOT take the powder or gran- with a low cholesterol, low satu- ules in the dry form. It must be rated fat diet. mixed with any beverage, very liquid soups or cereals, or pulpy fruits It may cause dizziness or blurred (applesauce or crushed pineapple). vision - use caution when driving. Lab tests may be required during Increase your daily intake of liquids while taking this medicine. treatment. These may include blood counts, cholesterol and Possible Side Effects triglycerides, liver function tests, M Severe constipation, fatty or black and blood glucose levels. stools, gas, belching, nausea, vom- Take Fenofibrate once daily with iting, heartburn, diarrhea, loss of food. appetite Possible Side Effects M Headache, anxiety, dizziness, fatigue M Stomach upset, vomiting, nausea, diarrhea, constipation M Asthma, wheezing M Headache, dizziness, fatigue M Itching, hives M Rash, itching, eczema M Unusual bleeding from gums or rectum M Sore throat, fever, chills, muscle pain or soreness M Deficiencies of fat soluble vitamins A and D D. Zetia C. Fibric Acid Derivatives Zetia is a medication that lowers cholesterol. It works by blocking the Examples absorption of cholesterol from your • Gemfibrozil (Lopid) intestines during digestion. It lowers • Fenofibrate (Antara, Lofibra, total cholesterol and LDL, but is most Tricor) effective when added to another cholesterol medication. MEDICATIONS H19

Examples aspirin a half hour before each • Zetia + Zocor (Vytorin) dose of niacin may help prevent this. Check with your doctor Things to remember before trying this. You should follow a heart-healthy Take niacin with meals. diet and exercise program in addition to taking your medication. Take extended release niacin at bedtime. Lab tests will be required during treatment. These tests may When getting up from a lying or include cholesterol and triglyceride sitting position, you may become levels and liver function tests. dizzy or faint. If this occurs, getting up slowly may help. Vytorin should be taken in the evening without regard to meals. Possible Side Effects Flushing, itching, tingling, sensa- Possible Side Effects M tion of warmth. M Diarrhea, abdominal pain Abdominal pain, nausea, vomiting, Fatigue, dizziness, headache M M diarrhea Muscle pain, chest pain, joint M Dizziness, headache pain, back pain M M Sore throat, cough SECTION 13 E. Nicotinic Acid (Niacin) Niacin (in large doses) reduces cho- h Nitrates lesterol and triglyceride levels. Nitrates are useful in either relieving the pain of angina (chest pain) attacks Examples or reducing the number of such • Niaspan attacks. Nitrates relieve chest pain by • Niacor improving the supply of blood and Things to remember oxygen to the heart by widening the Skin flushing and a sensation of walls in your blood vessels. warmth, especially of the face and The most common nitrates are nitro- upper body, may occur. Itching, glycerin and isosorbide. They are avail- tingling, and headache may also able in the following forms: occur. These effects usually last 30 to 60 minutes after taking a Nitroglycerin dose and usually decrease as you • Sublingual tablets (Nitrostat) continue to take the medication. • Long-acting tablets and capsules (Nitro-bid) If you have persistent or bother- some flushing, taking 325mg of H20 MEDICATIONS

• Ointment, topical (Nitro-bid, Storage: Keep in the original Nitrol) container. Keep the container • Spray, translingual (Nitrolingual) closed tightly. Store at room • Transdermal patch (Minitran, temperature. Protect from Nitro-Dur, Transderm-Nitro, moisture. Unused nitroglycerin Nitrodisc, Deponit) tablets should be discarded 6 months after the original bot- Isosorbide tle is opened. Do not put any • Sublingual tablets (Isordil) other medications in the nitro- • Chewable tablets (Sorbitrate) glycerin bottle. • Oral tablets (Isordil Titradose, 2. Translingual spray — Nitroglycerin Sorbitrate, ISMO, Monoket) Spray onto or under the tongue. • Long-acting tablets/capsules Do not inhale spray. At the (Isordil Tembinds, Sorbitrate SA, onset of an angina attack, spray Imdur) 1 or 2 doses onto oral mucosa. No more than 3 doses are rec- Things to remember ommended within 15 minutes. If 1. Sublingual tablets — Nitroglycerin you still have pain after 3 doses, or Isosorbide call 911 or your local emergency When you start to feel an angi- number. Do not drive yourself to na attack, sit down, then place the hospital. a tablet under your tongue and It may be used 5 to 10 minutes let it dissolve. Do not crush, before you begin an activity chew or swallow. If angina is that normally causes your angi- not relieved in 5 minutes, dis- na. solve a second tablet under 3. Sustained release capsule or your tongue. If pain is not tablet — Nitroglycerin or relieved within another 5 min- Isosorbide utes, dissolve a third tablet. If These forms are used to pre- you still have pain after taking vent angina attacks. They will three tablets, call 911 or your not relieve chest pain that has local emergency number. already started. Long-acting Do not drive yourself to the forms should be taken on a hospital. regular schedule. If you miss a Take the medication before dose, take it as soon as you activity that normally causes remember if your next dose is your angina. not scheduled within six hours. It may cause stinging or tin- Do not double the dose in gling when it touches under order to “catch up.” the tongue. MEDICATIONS H21

Swallow whole. Do not break, not subject to excessive move- crush or chest long-acting ment. Do not apply patch to the tablets or capsules. forearms or below the knees. 4. Topical nitroglycerin ointment Avoid cuts or irritations. Rotate Nitroglycerin ointment is used application site slightly each to prevent angina. It works too time to avoid skin irritation. slowly to relieve pain that has Your physician may have you already started. Occasional use apply or remove patch at spe- of sublingual tablets may be cific times of the day. necessary. CAUTION Carefully read the instructions Patients who use nitrates must talk before using. to their doctor before using any of the The ointment comes with mea- suring papers. Use them to erectile dysfunction drugs (Viagra, measure the length of the oint- Cialis, Levitra). There are several med- ment and to apply the oint- ical conditions that prevent a person ment to the skin. Do not use from using these medications safely. your fingers. Using these medications together The ointment can be applied to (even hours or days apart) can lower any area on the skin (not just blood flow to the heart arteries, caus- the chest). Preferably, apply it ing a heart attack. If you have symp- to an area of skin with little or toms of angina or a heart attack and no hair. Do not rub or massage have used any of these drugs, you ointment into the skin. When should not use your nitroglycerin. Go reapplying ointment, remove to the nearest Emergency Room for any ointment remaining from treatment. the previous dose. Rotate appli- You must always tell your doctor all cation sites to prevent contact the medications you are taking dermatitis. (including over-the-counter medicines) 5. Transdermal nitroglycerin patches so that problems can be avoided. Nitroglycerin patch is used to prevent angina attacks. It will Possible side effects not relieve chest pain that has M Nitrates may cause headaches, a already started. Occasional use feeling of fullness in the head, of sublingual tablets may be flushing or redness of the skin. necessary. Carefully read the These side effects are usually tem- instructions before using. porary and disappear on their Apply the patch once each day own. If they persist, consult your to a skin site free of hair and doctor. H22 MEDICATIONS

M You may feel dizzy, light-headed Things to remember: or faint, especially when getting Some people find that potassium up from a lying or sitting posi- supplements taste unpleasant or tion. Remember to get up slowly. cause stomach discomfort. Taking Alcohol may also make this effect this medication after meals or worse. with food and a full glass of water will lessen stomach upset. M Other effects: blurred vision, dry mouth, appetite loss, skin Do not chew or crush tablets, rash/itching, rapid heartbeat, nau- always swallow them whole. Oral sea, vomiting, restlessness. liquids, soluble powders and effer- vescent tablets should be mixed or dissolved in 4 to 8 ounces of SECTION 14 cold water or juice. Drink the mix- ture slowly. h Potassium Supplements Potassium supplements are used to Tell your doctor or pharmacist if treat or prevent low potassium blood you are taking or if you are plan- levels when dietary intake is too low. ning to take any over-the-counter or prescription medications with Low potassium levels may also be potassium supplements. cause by illness or treatment with cer- tain drugs (diuretics, or “water pill,” The following drugs and drug for example). Potassium is most fre- classes may interact with potassium supplements: quently supplied as: • Salt substitutes Examples of • Anticholinergics (Banthine) potassium supplements • Spironolactone (Aldactone) • Slow-K • Triamterene (Dyrenium) • K-Tab • Amiloride (Midamor) • K-lyte • Captopril (Capoten) • K-Dur • Lisinopril (Prinivil, Zestril) • Kor-Con • Enalapril (Vasotec) • K-lor • Benazepril (Lotensin) • Klotrix • Quinapril (Accupril) • Fosinopril (Monopril) • Micro-K • Ramipril (Altace) • Kaon-Cl • Moexipril (Univasc) • Ten-K Notify your doctor if you experi- Potassium chloride is available in liq- ence tingling of the hands and uid, powder, capsule and tablet form. feet, unusual tiredness or weakness, a feeling of heaviness in the MEDICATIONS H23

legs, severe nausea, vomiting, • Vicodin abdominal pain or black stools. • Vicodin ES Possible side effects: Oxycodone and acetaminophen: M Nausea, vomiting, diarrhea • Percocet M Stomach discomfort, pain, or gas • Roxicet M Skin rash • Endoct M Confusion • Tylox M Irregular heartbeat • Oxycet M Unusual tiredness or weakness • Propoxyphene and aceta- M Numbness or tingling in hands minophen: Darvocet-N 50, or feet Darvocet-N 100, Wygesic Things to remember: SECTION 15 Take exactly as prescribed by your physician. If you think that your h Pain Relievers Combination medicine containing medicine is not relieving pain, check with your doctor before narcotic analgesics and acetaminophen increasing the dose. (Tylenol) are used to relieve pain after heart surgery. When used together, Take with food to avoid possible nausea or vomiting. this combination may relieve pain better than either medication used alone. A stool softener or fiber laxative may be helpful since narcotic anal- Examples of oral gesics (especially codeine) may analgesic combinations cause constipation. If you feel dizzy or faint when get- Codeine and acetaminophen ting up from a sitting or lying • Tylenol #2 position, get up slowly. Other • Tylenol #3 sedating medicines may make this • Tylenol #4 effect worse. • Phenaphen #2 DO NOT drink alcoholic bever- • Phenaphen #3 ages while taking a narcotic anal- • Phenaphen #4 gesic. Hydrocodone and acetaminophen: DO NOT take other pain medication unless you discuss them first • Lorcet with your doctor. Avoid taking • Lortab any medicines that contain aceta- • Hydrocet minophen or a narcotic. H24 MEDICATIONS

CAUTIONS Please ask your doctor or pharmacist You may become dizzy, drowsy, or which medications are acceptable for lightheaded, or feel an exaggerated you to take. Show them a list of the sense of well-being while taking this prescription medications you are tak- medication. Make sure you know how ing. you react to this medicine before dri- The most commonly purchased OTC ving a car or before operating machin- products are pain relievers, antacids, ery. cold/allergy products and vitamin sup- Notify your doctor immediately if plements. Below is a list of various any of the following occur: severe con- OTC products and instructions on fusion, drowsiness or weakness, their use with your heart medications. seizures, diarrhea, prolonged nausea or vomiting, shortness of breath or Pain Medications trouble breathing, increased sweating, The most commonly used pain med- skin rash, or cold, clammy skin. ications are aspirin, acetaminophen and ibuprofen. Through each of these Possible side effects medications will relieve pain, you M Dizziness or lightheadedness should use caution in selecting one to M Drowsiness use. M Nausea or vomiting Acetaminophen (Tylenol) is a good choice for the occasional M Loss of appetite relief of pain, headache or fever. If Weakness M you have a need for regular pain M Blurred vision control, such as the pain from M Constipation arthritis, talk to your doctor. M Dry mouth Limit total daily doses to 4000mg. M Nightmares Aspirin (Anacin, Bayer, Bufferin, Ecotrin, Empirin) is used to treat fever, pain and inflammation. You SECTION 16 may already be taking a low dose of aspirin to prevent the forma- h Over-The-Counter Medications tion of blood clots. Your doctor may tell you to avoid taking addi- As a patient with heart disease, you tional aspirin. Some OTC prod- should use care when choosing an ucts contain aspirin as an ingredi- over-the-counter (OTC) drug. An inap- ent, such as Alka-Seltzer. You propriate OTC product may worsen should read an OTC product’s your heart disease by interfering with label or ask your pharmacist if your prescribed medications or diet. aspirin is an ingredient. The MEDICATIONS H25

Cardiac Rehab staff can provide unless you’ve discussed it first with you with a list of common medica- your doctor. If you need temporary tions that contain aspirin. relief of sinus pressure, a nasal decon- Ibuprofen (Advil, Bayer Select, gestant (Afrin, Dristan, Duration, Neo- Motrin OB, Nuprin) is a non- Synephrine) may be used. Follow the steroidal anti-inflammatory drug product’s directions closely. (NSAID) that is also used to treat fever, pain, and inflammation. Antacids Ibuprofen, and the newer NSAIDS You may already use an antacid to naproxen (aleve) and ketoprofen relieve indigestion or heartburn. (Orudis KT), may increase your However, an antacid may interact with blood pressure or decrease the your prescribed medications or diet amount of urine you eliminate. If restrictions. When selecting an you are taking a diuretic, beta- antacid, you should choose a “low blocker, or angiotensin converting sodium” or “sodium free” product to enzyme inhibitor (ACEI), you avoid increasing the amount of sodium should use acetaminophen instead in your diet. Antacids that contain of a NSAID. either no sodium or only small CAUTION amounts are: Aluminum hydroxide, Di- If you are taking Warfarin Gel, Gas-X, Gelusil, Milk of Magnesia, (Coumadin), you should avoid using Mylanta, Riopan, Rolaids Sodium Free, aspirin or NSAID products. These Trilacac, and Tums. Avoid any antacids medications may increase the blood that have sodium bicarbonate as an thinning action of Warfarin and can ingredient. Products you should not increase the risk of bleeding. use are: Alka-Seltzer, Bromo-Seltzer, Gaviscon and Sodium Bicarbonate. If Allergy/Cold Medications you’re unsure about the sodium con- Care in choosing an appropriate tent of an antacid, check with your allergy or cold medication is impor- pharmacist. tant. Many oral preparations contain a decongestant to help clear a stuffy CAUTION nose or head. Decongestants, like Antacids may reduce the absorption phenylephrine, pheylpropanolamine, of other medications when taken and pseudoephedrine, may increase together by binding to them or chang- your heart rate or blood pressure by ing the acidity of the stomach. narrowing the blood vessels. You need Medications that may be affected by to avoid using a combination cold antacids are: Allopurinol, Atenolol, product that contains a decongestant, Digoxin, Iron supplements and H26 MEDICATIONS

Quinidine. If you need to take an The following lists examples of vita- antacid while on one of these prescrip- mins and their actions: tion medications, you should separate Examples of vitamins each dose by two hours or more. and their actions Herbal and Natural Supplements Vitamin C and Vitamin A — may Some supplements sold as natural promote wound healing and herbal products can contain ingre- Folic Acid, Vitamin B6 , and dients that may interfere with the Vitamin B12 lowers the level of medications you are taking. It is not a homocysteine in the body. Too good idea to take over-the-counter or much homocysteine may con- health food supplements without tribute to heart disease. checking with your doctor or pharma- Do not use over-the-counter cist first. niacin as a substitute for prescription niacin. Fish Oil Capsules In some people, part of having high lipid levels includes having high triglycerides. Fish oil capsules have been shown to lower high triglycerides. It is important to talk with your doctor before taking fish oil capsules. Taking the proper dose is required to lower triglycerides. The only side effects reported are “fish” burps and mild stomach upset. Omacor is a fish oil supplement available only by prescription. Many others are available without a prescription. Vitamins Some vitamin supplements may be prescribed by your physician. They may or may not require a prescription. Always follow the directions your doctor gives you. Do not take more that the recommended amount each day.