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CEAC 0874 July 2019 Regina Area

Table of Contents

Introduction ...... 3 Definitions ...... 4 ...... 5 ...... 6 (Eliquis ®) ...... 6 (Pradaxa ®)...... 7 (Lixiana®)...... 8 (Xarelto®)...... 9 (Coumadin® and others) ...... 10 Quick Guide to Warfarin...... 12 Valve Replacement Surgery ...... 13 Acute Coronary Syndrome...... 13 What causes an ACS?...... 14 What is Angina?...... 14 How is angina treated?...... 15 What is a heart attack?...... 15 How is a heart attack treated? ...... 15 How do I know if I’m having a heart attack?...... 16 Risk Factors ...... 17 Controllable Risk Factors ...... 17 Uncontrollable Risk Factors...... 17 High Pressure ...... 18 Blood Pressure Testing Tips...... 18 Do ...... 18 Do Not ...... 18 Cholesterol...... 19 Diabetes...... 20 Smoking ...... 21 Consumption ...... 21 Weight ...... 22 Non-Modifiable Risk Factors...... 23 What Can I Do To Reduce My Risk Factors?...... 23

CEAC 0874 July 2019 Page 1 of 35 Regina Area Antiplatelet Therapy...... 24 ASA (®, Novasen®, Entrophen®, and others) ...... 24 (Plavix®)...... 24 (Brilinta ®)...... 25 (Effient®)...... 25 Blood Pressure Medications ...... 26 Angiotensin Converting Enzyme (ACE) Inhibitors ...... 26 Angiotensin Receptor Blockers (ARBs)...... 26 Beta Blockers...... 27 Channel Blockers ...... 27 ...... 28 Aldosterone Blockers ...... 28 Nitrates (Nitroglycerin)...... 29 Fast Acting Nitrates ...... 29 Long Acting Nitrates ...... 29 Cholesterol Lowering Medications...... 30 “”...... 30 “”...... 30 Ezetimibe (Ezetrol®)...... 30 “PCSK9 Inhibitors” ...... 31 “Resins” or Bile Acid Sequestrants ...... 31 (Colesevelam- Lodalis® , Cholestyramine - Questran®) Herbal Therapy...... 32 Over the Counter Medications...... 32 Vaccinations...... 32 How to Take Your Medications ...... 34 Some Tips for Buying Your Medications...... 34 Money Matters...... 34 Conclusion...... 35

CEAC 0874 July 2019 Page 2 of 35 Regina Area Introduction

This booklet talks about medications used to treat heart problems, what they are for, how they work, what to expect from them, and how long to take them

Your doctor has prescribed you medications to improve your heart health. These medications have their own benefits and have been carefully chosen for you. Each person may react differently to a .

Although all medications may cause side effects, the benefits of using medications outweigh the risks and that is why your doctor has suggested you take them. In other words, the chance of having side effects from your medications is low while the benefit is high.

Follow the instructions for taking your medications. Never start or stop new ones without talking to your doctor or pharmacist first.

CEAC 0874 July 2019 Page 3 of 35 Regina Area Definitions

Acute Coronary Syndrome (ACS): a problem with the Heart Attack ( or MI): is vessels that bring blood to the heart. Heart attack (or damage (or death) to heart muscle, often (but not myocardial infarction, MI) and unstable angina are types always) due to a blockage (plaque) in an artery. of ACS. That is, the blockage cuts off the blood supply to the heart muscle and this causes heart cells and Aneurysm: arteries become weak and swell to form a muscle to die. pouch. This pouch can become filled with blood. When this happens, the artery wall is weakened more and Hypertension: high blood pressure. the area is more likely to burst. Hypertension raises the risk of heart disease, heart attacks, and . Anticoagulant: “anti” means against and “coagulant” is a term used in blood clotting. An anticoagulant makes it Hemorrhagic : occurs when a blood vessel less likely for clots to form in the blood. bursts in the brain. About 20% of all strokes are hemorrhagic. Artery: a blood vessel that takes blood away from the heart. Ischemic Stroke: occurs when a clot or plaque blocks a blood vessel in the brain. About 80% : beating of the heart that is a not strokes are ischemic. normal. Peripheral Vascular Disease: blood vessels are : “hardening of the arteries.” Fat and narrowed and this lowers blood flow. This is cholesterol builds up and can block arteries. This can usually due to atherosclerosis. affect blood vessels in all parts of your body, not just your heart. Atherosclerosis is one cause of heart : a part of the blood that helps to form disease and stroke. blood clots.

Atrial Fibrillation (AFib or AF): a type of arrhythmia in Primary Care Provider: the doctor or nurse who which the upper chambers of the heart “quiver” rather you see most regularly outside of the hospital. than pumping regularly. Since blood is not pumped out Stenosis: narrowing of a blood vessel. This is normally, a clot can form. People with AF are at usually due to atherosclerosis. increased risk of stroke. Stroke: when blood and oxygen cannot get to part Cardiovascular: the heart and blood vessels. of the brain. In the area around the stroke, the Cerebrovascular: the blood vessels that supply the brain cells are hurt. The effects of stroke depend brain. on where the brain damage is. The effects may not go away. There are two types of strokes: Congestive Heart Failure (CHF): when the heart is weak, ischemic and hemorrhagic. not enough blood can be pumped through the body. When the heart is not pumping as strongly as it should, : a blood clot. fluid can back up in the lungs, legs or ankles. This back Transient Ischemic Attack (TIA): symptoms are the up of fluid is called congestion. same as for stroke but usually last 24 hours or less. Coronary Artery: a vessel that brings blood to the heart Caused by temporary blockage of a blood vessel. It does not normally cause permanent brain damage. It is an muscle. important warning sign for a stroke. TIA is sometimes Embolus: “wandering clot.” A blood clot that travels called a mini stroke. through the bloodstream until it gets stuck in a small or narrowed vessel. This blocks blood and oxygen from getting to that part of the body.

CEAC 0874 July 2019 Page 4 of 35 Regina Area Atrial Fibrillation

What is it? The heart normally beats at a strong and steady rhythm. In atrial fibrillation, the two upper parts of the heart (the atria) beat in an irregular and often rapid pattern (somewhat like quivering, known as fibrillating) due to a problem with the heart’s electrical system.

This quivering can cause the lower parts of the heart, the ventricles, to beat fast and without a steady rhythm, which results in poor blood pumping to the rest of the body. In addition, blood can pool in the atria making it more likely to form clots. These clots can travel to the brain, block blood flow to the brain and cause a stroke.

Additional information is available from Canada: Afib and Stroke Video: https://www.youtube.com/watch?v=66cEqb5Owso&feature=youtu.be “You Have Atrial Fibrillation (AFIB)” information handout: http://thrombosiscanada.ca/wp-content/uploads/2016/10/M159-You-Have- Afib_Oct2016.pdf

Anticoagulant medications and occasionally antiplatelet medications help to prevent clots from forming. Most people with atrial fibrillation will need to take an anticoagulant agent long-term, occasionally antiplatelet agents may be used long term. These include: apixaban (Eliquis®), dabigatran (Pradaxa®), edoxaban (Lixiana®), rivaroxaban (Xarelto®), and warfarin (Coumadin®).

What causes it? Medical conditions that damage or strain the heart can cause atrial fibrillation. Some of these medical conditions include: high blood pressure, , heart attack, heart valve disease, high thyroid level, and pneumonia. Sometimes there is no known cause for atrial fibrillation.

What does it look and feel like (symptoms)? Some people feel the rapid beating of their heart as palpitations and/or become weak and short of breath. Other people will not feel any different.

Atrial fibrillation is not a life-threatening condition, but it requires treatment to prevent blood clots from forming which can lead to a stroke.

How is it treated? Treatment depends on the cause of your atrial fibrillation, your symptoms and your risk for stroke. Medications include:  Anticoagulant or antiplatelet, to prevent strokes  Rate-control medication to help slow your heart beat down, or rhythm-control medication to help your heart beat in a regular pattern CEAC 0874 July 2019 Page 5 of 35 Regina Area Anticoagulant Therapy

Apixaban (Eliquis ®) Apixaban is an anticoagulant that works by preventing blood clots from forming, which helps to prevent a stroke in people with atrial fibrillation. Most patients will need to be on apixaban long- term. Ensure you know why you are on apixaban and how long you should take it.

You do not need any blood tests to see how well apixaban is working. However, your primary care provider will conduct occasional blood tests (at least once a year and maybe more often) to be sure that the medication and dose are still right for you. Although you will not feel any different while taking this medication, it will help protect you from a stroke as long as you take the medication as prescribed.

If you were on warfarin before, this medication takes the place of warfarin.

How should I take this medication? Take this medication twice a day, in the morning and in the evening regularly at the same times each day. Apixaban can be taken with or without food.

If you miss a dose and it is 6 hours or more before your next scheduled dose, take the missed dose, and then take your next dose as you normally would. DO NOT take 2 doses to make up for a missed . If you are unsure of what to do, call your pharmacist.

Do not stop taking this medication without talking to your doctor. The medication does not stay in your body very long and stopping it could put you at a much higher risk for stroke.

Always tell any health care providers (doctor, dentist, nurse, pharmacist, etc.) that you are on apixaban before they write a prescription or perform a test or procedure. Talk to your pharmacist before buying non-prescription (over-the-counter) medications. ASA, (Motrin®, Advil®, and others), and (Aleve® and others) can increase when used in combination with apixaban. In most cases, these medications should not be taken with apixaban.

Side Effects Similar to other anticoagulants, apixaban can cause bruising or minor bleeding. You may notice that you more easily and that your cuts take longer to stop bleeding. This is expected, however if you notice dark or bright red blood in your stool, pink or dark colored urine, a cut that will not stop bleeding, a nose bleed that lasts a long time, a severe headache or an itchy rash, contact your doctor immediately.

It is very important that the people around you know that you are on apixaban. You may want to wear a medical alert bracelet or carry a card in your wallet that says you are taking apixaban, and who your primary care provider is.

Thrombosis Canada Handout: http://thrombosiscanada.ca/wp- content/uploads/2016/10/M159-Apixaban_Oct2016.pdf CEAC 0874 July 2019 Page 6 of 35 Regina Area Dabigatran (Pradaxa ®) Dabigatran is an anticoagulant that works by preventing blood clots from forming, which helps to prevent a stroke in people with atrial fibrillation. Most patients will need to be on dabigatran long- term. Ensure you know why you are on dabigatran and how long you should take it.

You do not need any blood tests to see how well dabigatran is working. However, your primary care provider will conduct occasional blood tests (at least once a year and maybe more often) to be sure that the medication and dose are still right for you. Although you will not feel any different while taking this medication, it will help protect you from a stroke as long as you take the medication as prescribed.

If you were on warfarin before, this medication takes the place of warfarin.

How should I take this medication? This medication comes in a capsule and should be taken twice a day, in the morning and in the evening regularly. The medication must be swallowed whole and cannot be crushed, chewed, or opened. Take dabigatran with food if it upsets your stomach.

If you miss a dose and it is 6 hours or more before your next scheduled dose, take the missed dose, and then take your next dose as you normally would. DO NOT take 2 doses to make up for a missed tablet. If you are unsure of what to do, call your pharmacist.

Do not stop taking this medication without talking to your doctor. The medication does not stay in your body very long and stopping it could put you at a much higher risk for stroke.

Always tell any health care providers (doctor, dentist, nurse, pharmacist, etc.) that you are on dabigatran before they write a prescription or perform a test or procedure. Talk to your pharmacist before buying non-prescription (over-the-counter) medications. ASA, ibuprofen (Motrin®, Advil®, and others), and naproxen (Aleve® and others) can increase bleeding when used in combination with dabigatran. In most cases, these medications should not be taken with dabigatran.

Side Effects One of the most common side effects with dabigatran is stomach upset/pain/heartburn. If this occurs, taking dabigatran with food (such larger meals) can help. Similar to other anticoagulants, dabigatran can cause bruising or minor bleeding. You may notice that you bruise more easily and that your cuts take longer to stop bleeding. This is expected, however if you notice dark or bright red blood in your stool, pink or dark colored urine, a cut that will not stop bleeding, or a nose bleed that lasts a long time, a severe headache or an itchy rash, contact your doctor immediately.

It is very important that the people around you know that you are on dabigatran. You may want to wear a medical alert bracelet or carry a card in your wallet that says you are taking dabigatran, and who your primary care provider is.

Thrombosis Canada Handout: http://thrombosiscanada.ca/wp- content/uploads/2016/10/M159-Dabigatran_Oct2016.pdf

CEAC 0874 July 2019 Page 7 of 35 Regina Area Edoxaban (Lixiana®) Edoxaban is an anticoagulant that prevents blood clots from forming, which helps to prevent a stroke in people with atrial fibrillation. Most patients will need to be on edoxaban long-term. Ensure you know why you are on edoxaban and how long you should take it.

You do not need any blood tests to see how well edoxaban is working. However, your primary care provider will conduct occasional blood tests (at least once per year and maybe more often) to be sure that the medication and dose are still right for you. Although you will not feel any different while taking this medication, it will help protect you from a stroke as long as you take the medication as prescribed.

If you were on warfarin before, this medication takes the place of warfarin.

How should I take this medication? When used for stroke prevention in atrial fibrillation, take this medication once per day with or without food at the same time each day. If you miss a dose, take the missed dose as soon as you remember on the same day. DO NOT take 2 doses or double up to make up for a missed tablet. Continue your regular dosing the following day. If you are unsure of what to do, call your pharmacist.

Do not stop taking this medication without talking to your doctor. The medication does not stay in your body very long and stopping it could put you at a much higher risk for stroke.

Always tell any health care providers (doctor, dentist, nurse, pharmacist, etc.) that you are on edoxaban before they write a prescription or perform a test or procedure. Talk to your pharmacist before buying non-prescription (over-the-counter) medications. ASA, ibuprofen (Motrin®, Advil®, and others), and naproxen (Aleve® and others) can increase bleeding when used in combination with edoxaban. In most cases, these medications should not be taken with edoxaban.

Side Effects Similar to other anticoagulants, edoxaban can cause bruising or minor bleeding. You may notice that you bruise more easily and that your cuts take longer to stop bleeding. This is expected, however if you notice dark or bright red blood in your stool, pink or dark colored urine, a cut that will not stop bleeding, or a nose bleed that lasts a long time, a severe headache or an itchy rash, contact your doctor immediately.

It is very important that the people around you know that you are on edoxaban. You may want to wear a medical alert bracelet or carry a card in your wallet that says you are taking edoxaban, and who your primary care provider is.

CEAC 0874 July 2019 Page 8 of 35 Regina Area Rivaroxaban (Xarelto®) Rivaroxaban is an anticoagulant that prevents blood clots from forming, which helps to prevent a stroke in people with atrial fibrillation. Most patients will need to be on rivaroxaban long-term. Ensure you know why you are on rivaroxaban and how long you should take it.

You do not need any blood tests to see how well rivaroxaban is working. However, your primary care provider will conduct occasional blood tests (at least once per year and maybe more often) to be sure that the medication and dose are still right for you. Although you will not feel any different while taking this medication, it will help protect you from a stroke as long as you take the medication as prescribed.

If you were on warfarin before, this medication takes the place of warfarin.

How should I take this medication? When used for stroke prevention in atrial fibrillation, take this medication once per day with food at the same time each day. It is important to take rivaroxaban with food to make sure that the full amount of the medication is absorbed. If you are using rivaroxaban for a reason other than atrial fibrillation the dose you take may be different and you should confirm with your doctor and pharmacist how to correctly take the medication and what to do if you miss a dose. If you miss a dose, take the missed dose as soon as you remember on the same day. take 2 doses or double up to make up for a missed tablet. Continue your regular dosing the following day. If you are unsure of what to do, call your pharmacist.

Do not stop taking this medication without talking to your doctor. The medication does not stay in your body very long and stopping it could put you at a much higher risk for stroke.

Always tell any health care providers (doctor, dentist, nurse, pharmacist, etc.) that you are on rivaroxaban before they write a prescription or perform a test or procedure. Talk to your pharmacist before buying non-prescription (over-the-counter) medications. ASA, ibuprofen (Motrin®, Advil®, and others), and naproxen (Aleve® and others) can increase bleeding when used in combination with rivaroxaban. In most cases, these medications should not be taken with rivaroxaban.

Side Effects Similar to other anticoagulants, rivaroxaban can cause bruising or minor bleeding. You may notice that you bruise more easily and that your cuts take longer to stop bleeding. This is expected, however if you notice dark or bright red blood in your stool, pink or dark colored urine, a cut that will not stop bleeding, or a nose bleed that lasts a long time, a severe headache or an itchy rash, contact your doctor immediately.

It is very important that the people around you know that you are on rivaroxaban. You may want to wear a medical alert bracelet or carry a card in your wallet that says you are taking rivaroxaban, and who your primary care provider is.

Thrombosis Canada Handout: http://thrombosiscanada.ca/wp- content/uploads/2016/10/M159-Rivaroxaban_Oct2016.pdf CEAC 0874 July 2019 Page 9 of 35 Regina Area Warfarin (Coumadin® and others) Warfarin is sometimes called a “blood thinner” or anticoagulant. It does not actually make the blood thinner. It makes blood clots less likely to form.

Warfarin is used to: 1) Prevent blood clots in the brain (stroke) in patients with an irregular heartbeat, called atrial fibrillation

2) Prevent blood clots from forming on valves or causing a stroke after valve replacement surgery

3) Prevent blood clots from forming, or to treat a clot already formed in your heart after a large heart attack

4) Treat blood clots that form in other parts of our bodies (legs and lungs)

How long you take warfarin will depend on why you are using it. Make sure you know why you are on warfarin and how long you should take it.

How should I take this medication? Warfarin is taken once a day, at the same time each day, usually around suppertime.

You will need to have your blood tested when you are on warfarin. The test (called an INR) tells your doctor, nurse practitioner or pharmacist how much warfarin you need to take. If your INR is above your target, you have an increased chance of bleeding. If your INR is below your target, you have an increased chance of developing a clot. This test may take place every day to every few days at first, and then it usually becomes less frequent over time as your dose becomes stable. You may only need to get your blood tested once per month or even less if you have been on warfarin at the same dose for several weeks or months.

Let the person managing your warfarin know if you miss a dose, since that will change your INR results. If you miss a dose, take the missed dose as soon as you remember on the same day. If it is near the time of your next scheduled dose, skip the missed dose and continue on your regular schedule. DO NOT take 2 doses at once to make up for a missed tablet. You should always keep a calendar record of both the doses you take and those you forget. Never stop taking or reducing the dose of warfarin unless the prescriber who ordered it tells you to do so. If you are unsure, contact your pharmacist.

The difference between a dose that is too high and too low is very small. Your dose may be different than someone else’s dose. Your dose may also change and you may have a different dose each day.

It is very important that the people around you know that you are on warfarin. You may want to wear a medical alert bracelet or carry a card in your wallet that says you are taking warfarin, and who your primary care provider is. Be sure to change the card if there are any changes. CEAC 0874 July 2019 Page 10 of 35 Regina Area Side Effects The most common side effect of warfarin is bleeding, since warfarin affects blood clotting. There are two types of bleeds:

Minor bleeds (more common) include bleeding from your gums when you are brushing your teeth or bleeding from shaving, and bruising easily. These types of bleeds can be minimized by using an electric toothbrush or razor and avoiding activities that can increase your chance of injury or bleeding.

Major bleeds (rare) include a cut that will not stop bleeding, vomiting blood or vomit that looks like coffee grounds, pink or dark colored urine, a nose bleed that lasts a long time, a severe headache, and blood in your stool (red or black, tarry stools). These types of bleeds are serious; you must seek medical attention immediately if you experience any signs of major bleeds.

Interactions with Food and other Medications - “DIME” D – Diet changes: green vegetables (such as broccoli, , kale) can affect your INR, so it is important to eat about the same amount each week.

I – Illness: your INR may change if you get sick with a cold, flu, nausea, vomiting, diarrhea, or another illness. Contact your doctor if you experience any stomach problems, vomiting, or diarrhea for more than one day.

M – Medications: changes in medications (including prescription medications, over-the-counter medications, , and herbal products), dose changes, or beginning can change the effect of warfarin. Always tell any health care professionals (nurses, doctors, dentists, pharmacists, etc.) that you are on warfarin before they write a prescription or perform a test. Talk to your pharmacist before buying non-prescription (over-the-counter) medications. ASA, ibuprofen (Motrin®, Advil®, and others), and naproxen (Aleve® and others) can increase bleeding when used in combination with warfarin. In most cases, these medications should not be taken with warfarin.

E – Error (missed dose): a missed dose can change your INR. Take the missed dose as soon as you remember, but do NOT double your dose to make up for the missed dose.

Contact the healthcare provider managing your warfarin for a plan for your warfarin dosing and when to check your INR if any of these changes occur.

Continue a healthy exercise program while on warfarin. Avoid contact sports or high-risk activities. Report any injuries to your primary health care provider.

Thrombosis Canada Handout: http://thrombosiscanada.ca/wp- content/uploads/2016/10/M159-Warfarin_Oct2016.pdf

Understanding Medications in Atrial Fibrillation: https://www.healthchoicesfirst.com/videos/how-a- pharmacist-can-help-af-patients-choose-the-right-blood-thinner

CEAC 0874 July 2019 Page 11 of 35 Regina Area Quick Guide to Warfarin

Check with your doctor, Take your warfarin exactly as pharmacist or nurse prescribed practitioner before you

change, start, or stop any medications

Get your blood tested as DO NOT double up on a missed required and record your dose (keep a record of missed dose and INR doses)

DO NOT make drastic changes Tell doctor and pharmacist all in your diet or lifestyle medications you are taking

DO NOT take warfarin if you

Take extra caution to avoid are pregnant or cutting yourself breastfeeding

DO NOT engage in contact Tell your doctor if you are sports where injury is sick common

Tell anyone giving you

medical care that you are on

warfarin DO NOT drink alcohol to excess (not more than 1 drink a day)

Carry a medical alert card or

wear a bracelet

CEAC 0874 July 2019 Page 12 of 35 Regina Area Valve Replacement Surgery

There are four valves in the heart. The valves make sure the blood flows in only one direction through the heart. The tissue of the valves is normally strong and thin. It may become scarred and thick, or fully destroyed from , birth defects, rheumatic fever, or the natural aging process. Each of the four valves is affected differently.

When the heart valves are damaged they are not able to open or close normally. This may result in blood leaking back through the valve. The heart then has to work harder to keep the blood moving in the right direction. Eventually heart failure may develop. When repairing the valve is not enough to correct the problem, valve replacement surgery may be needed.

The new valve can be mechanical or tissue. Mechanical valves are made from man-made materials like metal, plastic, or ceramic. Tissue valves usually come from human or pig sources.

Patients who have valve replacement surgery usually require warfarin and/or ASA. The length of warfarin and ASA treatment depends on the type and location of the valve replaced.

Acute Coronary Syndrome

Acute coronary syndrome (ACS) means there is a problem with the vessels that bring blood to the heart and they may be blocked partly or all the way. Heart attack (or myocardial infarction, MI) and unstable angina are types of ACS.

Blood brings food and oxygen to all cells in the body – even cells in the heart muscle. If blood does not get to the heart cells, they may stop working and may even die. The most common way that blood supply can be cut off from the heart muscle cells is if a blood vessel in the heart is blocked. The name for blocked blood vessels in the heart is coronary artery disease (CAD).

CEAC 0874

July 2019 Page 13 of 35 Regina Area What causes an ACS? Over many years, a sticky, yellow, fatty material called plaque can build up on the inside of blood vessels. One of the items in plaque is cholesterol.

Plaque builds up inside the blood vessel and makes it narrower. This means less blood can flow through the blood vessel. The plaque can break open and a clot can form to patch the hole. The clot can make the vessel narrower or even block the blood flow through the vessel.

The process of plaque building up in vessels is called atherosclerosis. This can affect blood vessels in all parts of your body, not just your heart. When plaque forms in the heart vessels it is called coronary artery disease (CAD) or coronary heart disease (CHD).

What is Angina? Angina is the feeling people get in their chest when areas of the heart are not getting enough oxygen. Angina is not the same as a heart attack. In a heart attack, an area of the heart is not getting any oxygen at all.

Angina can feel like: Pressure  Squeezing  Discomfort  Pain

Stable angin is expected: the pain comes with activity and goes away with rest or with medication.

Unstable angina is pain that does not have a pattern: it may not go away with rest or medication. Unstable angina is an important warning sign that you may be at risk of having a heart attack or a stroke in the future.

CEAC 0874 July 2019 Page 14 of 35 Regina Area How is angina treated? There are two goals when treating angina: getting rid of symptoms and lowering the risk of a heart attack. Doctors use medications or procedures to treat angina.

One procedure is called (coronary angiography, cardiac cath, or dye test). It uses a thin tube put inside the vessel to look for blocks in the blood vessel. If blocks are found, other procedures may be needed to help blood flow through the vessel or ways for blood to get around the block.

Balloon angioplasty, or percutaneous coronary intervention (PCI), is like a cardiac catheterization. At the end of the thin tube is a balloon which is blown up and presses the plaque or blockage against the blood vessel wall. Often, after the balloon is blown up, a tiny mesh or stent is put into the vessel to help keep it open. The tube and balloon are removed at the end of the procedure.

A type of open heart surgery, coronary artery bypass grafting (CABG, pronounced “cabbage”) may be needed. A blood vessel is taken from another part of the body and is connected before and after the block in the heart. This “bypass” is like a detour to avoid part of a road blocked by construction. You get to the same place but take a different path.

Medicines are needed after PCI or CABG to help keep the vessels open and help the heart heal.

What is a heart attack? In a heart attack, a part of the heart is not getting any oxygen. Without oxygen, that part of the heart muscle dies. Often it is a clot that blocks the blood flow.

A heart attack can be mild or very severe. If the block is in a main heart vessel, a bigger part of the heart dies. If too much of the heart dies, that person may die.

How is a heart attack treated? A heart attack can be treated the best right after symptoms start. It is very important to call an ambulance and go to an emergency room as soon as you first notice the symptoms of your heart attack. It is important that you do not drive yourself.

At the hospital, a doctor will take a blood sample and do an electrocardiogram (ECG). An ECG is a printed record of your heartbeat activity. You may be given medications to help your pain or .

The next step is to make the blood flow to your heart muscle by treating the blocked vessel. You may be treated with medications called “clot busters.” Heart doctors (cardiologists) may also do procedures to open the blocked heart vessel or let blood pass around the block.

After a heart attack, doctors will prescribe medications that help the heart heal and prevent another heart attack. Most of these medications need to be taken for the rest of your life. Taking them will lower your risk of dying from heart disease.

CEAC 0874 July 2019 Page 15 of 35 Regina Area How do I know if I’m having a heart attack? It is important to know the main warning signs of a heart attack so you can get to the hospital right away. The faster you get treatment, the better your chances of lowering the amount of damage to your heart and to having a good recovery.

 Sudden discomfort or pain that does not go away with rest  Pain that may be in the chest, neck, jaw, shoulder, arms or back Pain  Pain that may feel like burning, squeezing, heaviness or tightness  in women, pain may be more vague

Shortness of  Difficulty breathing breath

 Indigestion Nausea  Vomiting

Sweating  Cool, clammy skin

Fear  Anxiety

If you experience any of the warning signs of a heart attack, call 9-1-1 and get to a hospital emergency room right away. It is important to call an ambulance to take you to a hospital rather than driving yourself if possible.

CEAC 0874 July 2019 Page 16 of 35 Regina Area Risk Factors

Some things increase your risk of having a heart attack or stroke. The more of these things you have, the higher your risk. The risk factors that can be changed are called “controllable” and the ones that cannot be changed are called “uncontrollable.”

Controllable Risk Factors Uncontrollable Risk Factors

  High blood pressure Age   High cholesterol Gender  Diabetes Family history  Smoking Ethnicity  Being overweight Previous stroke or TIA Physical inactivity  Heart disease – atrial fibrillation  Stress and depression  Lack of vegetables & fruits

Although you can never completely get rid of your risk for a heart attack or stroke, you can reduce it by controlling or getting rid of risk factors.

CEAC 0874 July 2019 Page 17 of 35 Regina Area High Blood Pressure Blood pressure (BP) is the push of blood against the blood vessel walls. Enough pressure is needed to get blood from the heart to all the parts of the body. High blood pressure puts strain on the heart. It can also cause blood vessels in the brain to burst. This is called a stroke.

A blood pressure result has two numbers:   top: systolic pressure  bottom: diastolic pressure

Your blood pressure goal:  Most people with diabetes: less than 130/80 mmHg  Most people with heart disease: less than 140/90 mmHg

By getting to your blood pressure goal, the risk of a stroke is reduced by up to 40% and the risk of heart disease is reduced by up to 25%.

Blood Pressure Testing Tips Most of the time high blood pressure is not seen or felt. The only way to measure it is with the use of a blood pressure monitor. You may want to check your blood pressure at home using an approved blood pressure monitor. You can tell if a monitor is approved if it states: Recommended by Hypertension Canada.

To get an accurate blood pressure result:

DO DO NOT  Sit quietly for at least five minutes before  Take in caffeine (coffee, tea, cola, checking chocolate) one hour before checking  Sit comfortably with back supported, legs  Smoke for 15 to 30 minutes before uncrossed, and feet flat on the floor checking  Rest your arm on a table that is level with  Check right after a meal or physical the heart activity  Remain quiet while checking  Check if feeling anxious, stressed, or in  Be sure the bottom edge of the cuff is an pain inch above the curve of the elbow  Talk while checking  Follow the directions for using the blood  Wear tight clothing on the arm pressure machine

Some medications (including many cough and cold products) can increase blood pressure. Ask your doctor or pharmacist if any of your medications can do this. CEAC 0874 July 2019 Page 18 of 35 Regina Area Cholesterol Cholesterol is a type of fat in your body. Your body needs some cholesterol to make new cells and hormones. Cholesterol comes from two places: most is made in the liver (about 80%) and the rest comes from some foods such as meat and dairy products (about 20%). If cholesterol levels are too high, plaque can start to build up in the vessels (atherosclerosis or hardening of the arteries).

LDL (“bad” cholesterol):  can build up and clog your blood vessels.

HDL (“good” cholesterol):  prevents buildup in your blood vessels.

Non HDL Cholesterol:  tells how much of your cholesterol is “bad” cholesterol.

Cholesterol goals (after having a stroke, heart attack, or blocked vessel)  LDL: less than 2 mmol/L or at least a 50 % decrease from baseline o LDL for recent heart attack patients: less than 1.8 mmol/L   Non-HDL: less than 2.6 mmol/L

LDL cholesterol levels and Non HDL cholesterol levels can be lowered by changing the foods you eat and doing regular exercise. Dietary changes and exercise are not enough to get these to goal levels in most people. Your doctor may add medications while you keep exercising and following a healthy diet.

CEAC 0874 July 2019 Page 19 of 35 Regina Area Diabetes Diabetes is a disease where there is too much sugar in your blood. Cells need a hormone called insulin to use sugar the right way. There are two types of diabetes:

Type I: not enough insulin is made.

Type II: insulin is made but the body does not use it the right way or the body isn’t sensitive to it. About 90% of those with diabetes have the Type II form.

Over time high blood sugar levels can cause damage to blood vessels. Diabetes increases the risk of high blood pressure, atherosclerosis, stroke, and other heart diseases. When people learn they have Type II diabetes many already have high blood pressure.

Good control of blood sugar levels helps to lower the risk of damaging blood vessels and can help prevent eye problems, heart disease, and stroke.

Blood glucose (sugar) shows the current blood sugar level. Food and exercise can change blood glucose levels. Blood glucose can be tested at home with only a small drop of blood.

A1C shows how well blood glucose levels have been controlled over the past few months. A1C is checked at the lab by taking a blood sample from the arm.

Diabetes Goals for Most People:

 Fasting Blood Glucose (before meals) 4 to 7 mmol/L 5  Two hours after a meal to 10 mmol/L  A1C less than or equal to 7%  ACR Ratio less than 2

Together, many things are needed to get to the recommended blood glucose and A1C levels:  A good, balanced diet  Regular exercise  Keeping a healthy body weight  Taking medications that lower blood sugar

CEAC 0874 July 2019 Page 20 of 35 Regina Area Smoking Smoking or exposure to second hand smoke can lead to heart attack or stroke. Smoking nearly doubles your risk of having a heart attack or stroke.

The sooner you quit smoking, the faster your body can start to recover.

 In 48 hours your risk of a heart attack starts to fall   In 1 year your risk is cut in half  In 15 years your risk is the same as someone who never smoked

Quitting smoking can be difficult. Even if you have tried to quit smoking before it is important to try again. There are many people and groups ready and willing to help you.

For more information, support, tips, and tools to help you become smoke-free:  http://www.makeapact.ca/ www.smokershelpline.ca o 1-877-513-3333 http://www.healthycanadians.gc.ca/healthy-living-vie-saine/tobacco-tabac/index-eng.php o 1-800-622-6232 (1-800-O-CANADA)

Alcohol Consumption Alcohol in moderation may lower your risk of stroke or heart disease, however, excessive alcohol consumption increases your risk. If you drink alcohol—only have one or two standard drinks per day, to a maximum of 9 (for women) or 14 (for men) drinks per week.

One drink equals: - 1 bottle of (5% alcohol) - 5 oz (147.9 mL) of wine - 1 ½ oz of spirits (44.3 mL) (40% alcohol)

CEAC 0874 July 2019 Page 21 of 35 Regina Area Weight Being overweight is a major risk factor for heart disease and stroke. Your weight can also affect other risk factors such as blood pressure, cholesterol levels, and diabetes.

Two measures are used to see if your weight is putting your health at risk: BMI and waist circumference.

BMI (Body Mass Index) compares height and weight.  18.5 and 24.9: normal BMI  25 or greater: overweight and is linked to an increased risk of some health problems   You can check your own BMI: o http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Waist circumference (size) People with extra weight around the middle of their body are at the most risk for health problems. There is a normal waist size for different races or ethnic backgrounds. Waist size is not the same as pant size.

For European/Caucasian, Sub-Saharan Africans, Eastern Mediterranean, Middle Eastern

 Normal for men less than 102 cm (40 inches)  Normal for women less than 88 cm (35 inches)

For South Asian, Malaysian, Asian, Chinese, Japanese, Ethnic South and Central Americans

 Normal for men less than 90 cm (35 inches)  Normal for women less than 80 cm (32 inches)

Weight can be lost or controlled by making diet and lifestyle changes. If you cannot get within the normal range, weight loss of 5 to 10% will help lower your health risk. Keeping a steady, healthy weight and keeping off lost weight should be a long term plan.

You can find out more from the Heart and Stroke Foundation: www.heartandstroke.ca/healthywaists

CEAC 0874 July 2019 Page 22 of 35 Regina Area Non-Modifiable Risk Factors Age  Heart attacks and strokes can occur at any age. As you get older, your risk goes up.

Gender  Men over the age of 55 and women after menopause have a higher risk of heart disease.

Family History  If a close family member (a parent or sibling) had a heart attack or stroke before the age of 55 (or before menopause for women), your own risk is higher.

Ethnicity  Certain people such as First Nations, Africans, and South Asians are more likely to have high blood pressure and diabetes. The risk of a heart attack or stroke is higher because of these diseases.

Previous Heart Attack or Stroke/TIA (mini stroke)  Your risk is higher if you have had an event in the past.

What Can I Do To Reduce My Risk Factors?

There are many steps that you can take to lower your risk for heart disease.   Stop smoking  Maintain a healthy diet  Be physically active  Achieve an ideal body weight  Meet blood sugar targets (if you have diabetes)  Reach target blood pressure and cholesterol levels  Take medications which might be right for you and are prescribed by your doctor including: o Aspirin® (ASA) o Blood pressure medications o Cholesterol medications o Diabetes (blood sugar) medications

CEAC 0874 July 2019 Page 23 of 35 Regina Area Antiplatelet Therapy

ASA (Aspirin®, Novasen®, Entrophen®, and others) ASA can be used for pain, arthritis, and fever. It is also given to people with heart disease or stroke. ASA stops in your blood from clumping together. These clumps are called clots. Clots in the blood vessels can block the blood vessels and lead to a heart attack or stroke. Generally, taking ASA over the long term decreases your risk of further heart disease by about 20%.

The dose of ASA depends on each person. 81 mg once daily, or low dose ASA, is the usual dose if taken for heart health. ASA is usually taken for the rest of your life. Ensure you know why you are on ASA and how long you should take it.

Most people do not have side effects from ASA. Be sure to tell your doctor if you develop blood in your stool (bright red or black stool) as this could be a sign of a stomach bleed. ASA may upset your stomach. Taking it with food or milk may help.

ASA is considered first-line therapy for daily prevention of a heart attack and stroke in patients who have had a heart attack or stroke, or who have angina. ASA greatly reduces the risk of a heart attack and death in people who have angina, who are at risk for a heart event and who have already had a heart attack. ASA also lowers the risk of another stroke in people who have had a stroke or heart attack. In people who have not had an event, the benefits need to be weighed against the risks of use.

Clopidogrel (Plavix®) Clopidogrel stops platelets in your blood from clumping together like ASA, but it works in a different way. Your doctor may give you clopidogrel instead of ASA or may tell you to take both clopidogrel and ASA together. The combination of ASA and clopidogrel can result in a 10 to 30% decreased risk of heart disease or stroke as compared to ASA alone.

Make sure you know how long you are supposed to take clopidogrel. Most people take this medication for one year if they have had an ACS event, but sometimes the duration may be shorter or longer depending on your risk factors, such as if a stent is placed and the type of stent used. Stopping your antiplatelet medications early may lead to a stroke, heart attack, or death from cardiovascular disease. It is also important to let your other healthcare providers know that you are on this medication, especially if they are doing any procedure or providing any treatment that may cause bleeding. This includes any dentists or doctors that you may see in a clinic or an emergency room.

However, DO NOT STOP this medication unless your heart doctor (cardiologist) tells you to. It is very important that you continue to take your antiplatelet medication until directed to stop by your heart doctor (cardiologist).

Side effects caused by clopidogrel are uncommon. Be sure to tell your doctor if you develop a rash or blood in your stool (bright red or black stool) as this could be a sign of a stomach bleed.

CEAC 0874 July 2019 Page 24 of 35 Regina Area Ticagrelor (Brilinta ®) Ticagrelor stops platelets in your blood from clumping together like ASA, but it works in a different way. Ticagrelor is given in addition to ASA 81 mg once daily. When given with ASA, there was a 16% decrease in heart attack, stroke, and death from vascular causes compared to clopidogrel plus ASA.

Ticagrelor is used in patients who have experienced an acute coronary syndrome (ACS).

Ticagrelor is generally well-tolerated. Some patients may experience mild shortness of breath at night, at rest, or upon exertion. This side effect resolves on its own after continued use. See your doctor if the shortness of breath gets worse or is more than a minor nuisance. Do not stop ticagrelor without first speaking with your heart doctor (cardiologist).

The risk of bleeding is higher when taking this medication. Be sure to tell your doctor if you notice blood in your stool or urine (bright red or black), as this could be a sign of a stomach bleed.

Some medications may interact with ticagrelor. Be sure to tell your doctor or pharmacist all of the non-prescription and prescription medications you may be taking, starting, or stopping, and avoid nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen (Advil®) or naproxen (Aleve®) products.

Ticagrelor is taken twice daily usually for one year, but may be taken for longer or shorter periods of time in some patients based on individual risk factors. It is important for you to know how long you will be taking ticagrelor. Stopping anti-platelet medications can lead to blockage of the stent or coronary arteries. It is very important that you continue to take your antiplatelet medication until directed to stop by your heart doctor (cardiologist).

Prasugrel (Effient®) Prasugrel works in a similar way as clopidogrel to stop platelets in your blood from clumping together. Prasugrel is taken once daily in addition to ASA 81mg daily for up to one year. Prasugrel plus ASA was associated with a 19% decrease in heart attack, stroke, and death from cardiovascular causes when compared to clopidogrel plus ASA.

Prasugrel is used in patients who have ACS or who have undergone PCI. Patients with a known history of transient attack (TIA) or stroke should not take prasugrel.

Prasugrel is generally well-tolerated. Be sure to tell your doctor if you notice blood in your stool or urine (bright red or black), as this could be a sign of a stomach bleed. The risk of bleeding is higher in patients under 60 kg or aged 75 years or older. Avoid taking any products containing nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen (Advil®) or naproxen (Aleve®).

CCPN Dual Antiplatelet Therapy Video: https://www.facebook.com/CanadianCardiovascularPharmacistsNetwork/

CEAC 0874 July 2019 Page 25 of 35 Regina Area Blood Pressure Medications

Angiotensin Converting Enzyme (ACE) Inhibitors ACE Inhibitors have names that end in “pril.” This class of medications includes: Benazapril (Lotensin®), Cilazapril (Inhibace®), Fosinopril (Monopril®), Perindopril (Coversyl®), Ramipril (Altace®), Captopril (Capoten®), Enalapril (Vasotec®), Lisinopril (Prinivil® and Zestril®), Quinapril (Accupril®)

ACE Inhibitors are given to patients with high blood pressure, heart failure, coronary artery disease (CAD), kidney problems, or to prevent problems after a heart attack. Some ACE inhibitors can also protect the heart and kidneys. ACE inhibitors lower the risk of heart attack, stroke, and death in patients with heart disease by 20%. These medications work by relaxing blood vessels, lowering blood pressure, and making it easier for your heart to work. In heart failure, they slow down the progression of the disease and prevent changes in the heart. These medications even help people with normal blood pressure. These medications are usually given for the long term and you should continue taking your medication even if you do not feel any different or if your blood pressure is normal, because it will help protect you from a heart attack, stroke, and death.

Most people do not have any side effects from ACE inhibitors. One side effect a few patients may experience is a dry cough. The cough does not need urgent medical care but you should tell your doctor at your next visit. Your doctor may try a different ACE inhibitor or an ARB (Angiotensin Receptor Blocker). Another common side effect is dizziness or light headedness. If this occurs, get up slowly from a sitting or lying position and be careful when driving or operating machinery. These side effects go away as your body adjusts to the medication. Contact your doctor if these side effects worsen or interfere with your daily activities, but do NOT stop taking the medication son your own.

Your primary care provider may conduct occasional blood tests to check your potassium levels and kidney function to make sure the medication and dose are still right for you.

Angiotensin Receptor Blockers (ARBs) ARBs have names that end in “sartan.” This class of medications includes: Azilsartan (Edarbi®) Candesartan (Atacand®), Irbesartan (Avapro®), Telmisartan (Micardis®), Eprosartan (Teveten®), Losartan (Cozaar®), Olmesartan (Olmetec ®) and Valsartan (Diovan®)

ARBs can be used for all the same reasons that ACE inhibitors are used. They lower high blood pressure. They also help treat heart failure or prevent problems after a heart attack.

ARBs are often given to patients who get a dry cough with ACE inhibitors. Most people do not have any side effects. Though side effects are unlikely, if you develop headache, dizziness or tiredness you should tell your doctor. These medications are usually given for the long term.

CEAC 0874 July 2019 Page 26 of 35 Regina Area Beta Blockers Beta blockers have names that end in “lol.” This class of medications includes: Metoprolol (Lopressor®), Bisoprolol (Monocor®), Carvedilol (Coreg®), Atenolol (Tenormin®), Acebutolol (Sectral®, Monitan®), Betaloc®), Nadolol (Corgard®), Pindolol (Visken®), Sotalol (Sotacor®), Labetalol (Trandate®), Propranolol (Inderal®), Timolol (Blocadren®)

Beta blockers are used to treat many diseases: high blood pressure, chest pain, heart failure, and irregular heartbeats. They make the heart beat slower to decrease how hard the heart has to work. They also help to protect the heart and prevent another event after a heart attack.

People who have bypass surgery or valve surgery are at a high risk of getting after their surgery. Beta blockers are given soon after the procedure to prevent the irregular heartbeat. Some people will have their stopped several weeks to months after their heart surgery.

If you have diabetes and take beta blockers, it may be hard to tell the signs of low blood sugar (such as racing heart beat and tremor), with the exception of sweating. Beta blockers may cause breathing problems or shortness of breath in some people with asthma or other lung diseases. Let your doctor know if you have diabetes or a lung condition, since beta blockers may require special monitoring.

Some patients get side effects from beta blockers. Side effects from beta blockers usually go away with time. By starting at a low dose and increasing it slowly, your doctor is helping to lower the side effects you may have. Side effects which may occasionally occur with beta blockers include light headedness, especially when you stand up quickly from sitting or lying down. If this occurs, get up slowly and be careful when driving or operating machinery. Some patients experience tiredness, headaches, cold hands and feet, or stomach upset. You should contact your doctor if these side effects occur and get worse.

It is important that you do NOT stop taking a beta blocker without talking to your doctor first. Stopping this medication abruptly may cause the heart to beat abnormally. These medications are usually given for the long term, except for some people who have started them immediately after heart surgery.

Calcium Channel Blockers This class of medications includes: Amlodipine (Norvasc®), Felodipine (Plendil®, Renedil®), Nifedipine (Adalat®), Diltiazem (Cardizem®, Tiazac®), Verapamil (Chronovera®, Isoptin®, Veralan®)

Calcium channel blockers are used for high blood pressure, irregular heartbeats, and chest pain. They work by slowing the heart down and relaxing the blood vessels, letting more blood and oxygen reach the heart.

Calcium channel blockers help control high blood pressure, an important risk factor for heart attack. Diltiazem and verapamil also help with other health problems involving the heart (angina and irregular heartbeats). Ask your doctor about the reason you are taking a . These medications are usually given for the long term. Most people do not have any side effects. Some patients get headache, or dizziness while taking calcium channel blockers. In most cases, these medications are taken for the long term. CEAC 0874 July 2019 Page 27 of 35 Regina Area Diuretics

This class of medications include: Hydrochlorothiazide (Hydrodiuril®), Chlorthalidone (Hygroton®), Indapamide (Lozide®), Furosemide (Lasix®), Ethacyrinic acid (Edecrin®), Metolazone (Zaroxolyn®), Bumetanide (Bumex®)

Diuretics are sometimes called “water pills.” They are used for high blood pressure and heart failure. Diuretics work on the kidneys to make more urine. By lowering the amount of fluid and salt in the body, the heart does not have to work as hard.

Because diuretics cause you to make more urine, you may have to go to the bathroom more often. Take your in the morning so that you do not have to get up in the night. Do not to take any salt substitutes before talking first to your doctor or pharmacist.

In some people, these have to be taken for the long term, in others, short term use is all that is needed. It is important to talk to your doctor about how long you need to take these.

Aldosterone Blockers Spironolactone (Aldactone®, Novo-Spiroton®), Eplerenone (Inspra®)

Aldosterone blockers are a type of diuretic that are commonly used in heart failure, especially after a heart attack. They make it easier for your heart to pump, reduce shortness of breath and cough, and reduce swelling in your legs. They help to keep you out of the hospital and lower the risk of death by helping your heart heal and stay healthy.

You should take these medications in the morning with or without food.

These medications are generally well tolerated however, you may experience:  Dizziness or lightheadedness (to prevent this, stand up slowly from sitting or lying down)   Dry mouth (chew sugarless gum or suck on sugarless candies to help)  Upset stomach (try taking the medication with food to prevent this)   Increased hair growth and menstrual changes in females.  If these side effects become intolerable, tell your doctor  Spironolactone: swelling/growth of the breasts (both male and female) o If this occurs, eplerenone can be used as an alternative

Your doctor will order blood tests to check your sodium and potassium levels and your kidney function regularly, because these medications prevent your kidney from losing potassium in your urine.

CEAC 0874 July 2019 Page 28 of 35 Regina Area Nitrates (Nitroglycerin)

Nitrates relax blood vessels and help more oxygen get to the heart. They are used for patients who have angina.

Fast Acting Nitrates Some nitrates come in a fast acting form such as tiny pills or spray that is placed under the tongue (sublingual). If nitroglycerin was prescribed for you, carry it with you at all times.

These fast acting nitrates can be used for:

1) Angina attacks. You should STOP what you are doing and rest. Take one tablet or spray as soon as you feel an attack. If there is no relief after five minutes, call 9-1-1 or as directed by your cardiologist. While calling, you may continue to take nitroglycerin at 5 minute intervals two more times while sitting or lying down if the chest pain continues, for a maximum of 3 doses. Do not try to drive yourself to the hospital. Wait for the ambulance to come.

2) Given at time when chest pain is likely, such as before physical activity.

Long Acting Nitrates Long Acting Nitrates come as tablets or patches. They are used on a regular basis to prevent angina. Your pharmacist can show how to apply the patches. There should be about 10 to 12 hours per day when you do not receive nitrate products. This time without pills or patches helps to prevent “tolerance.”

The most common side effect is headache. This happens because nitrates cause blood vessels to open up in the head just like the vessels in the heart. The headache should go away in a few minutes.

CEAC 0874 July 2019 Page 29 of 35 Regina Area Cholesterol Lowering Medications “Statins” This class of medications includes: Atorvastatin (Lipitor®), (Crestor®), Simvastatin (Zocor®), Lovastatin (Mevacor®), Pravastatin (Pravachol®), Fluvastatin (Lescol®)

Statins are medications used to lower cholesterol. They work by preventing the liver from making LDL (“bad”) cholesterol. They also help break down LDL cholesterol. These medications have been shown to decrease the chance of having further heart attacks, strokes, and death by up to 40% or more. Although they lower your cholesterol in days to weeks, the true benefit occurs over months to years.

Statins are usually taken once a day. Since your body makes more cholesterol at night, some statins should be taken with your last meal or at bedtime. Statins control high cholesterol but do not cure it; therefore, to get the best results, statins should be taken for the rest of your life.

Statins are well tolerated by most people; however, some people have side effects. The most common side effect is muscle aches and pains and/or weakness, which are usually no more than a minor nuisance rather than a harmful side effect. Other side effects include stomach pain, nausea, heartburn, rash, and headache. Contact your doctor or pharmacist if any of these symptoms are severe or continue.

While taking a , your doctor will also check your blood occasionally to ensure that these medications are working and to make sure the medications are not causing side effects.

“Fibrates” This class of medications includes: Gemfibrozil (Lopid®), Fenofibrate (Lipidil®), Bezafibrate (Bezalip®)

Fibrates are medications that increase the breakdown and removal of cholesterol from the blood. They also lower the amount of cholesterol made in the liver. These medications tend to work by increasing your good cholesterol (HDL) and decreasing triglycerides.

Most people do not have any side effects from fibrates. The most common side effects usually involve the stomach tract such as nausea, diarrhea or constipation, and stomach pain. Skin rashes and muscle disease are rare. Muscle disease is more common for people who take both statins and fibrates.

Ezetimibe (Ezetrol®) Ezetimibe works in the gut to prevent the absorption of cholesterol. It can also decrease some cholesterol made by the body. Since it works in a different way to statins, ezetimibe and statins are often combined. Ezetimibe is not as effective as statins at decreasing cholesterol and preventing heart attacks, and so it is typically only used in patients who are intolerant to statins or have not met their cholesterol targets on statins alone. When ezetimibe and statins are combined, they lower cholesterol and other unhealthy types of cholesterol in the body.

Most people do not have any side effects from ezetimibe. CEAC 0874 July 2019 Page 30 of 35 Regina Area “PCSK9 Inhibitors” This class of medications includes: Alirocumab (Praluent®) and Evolocumab (Repatha®)

Alirocumab and evolovumab are injectable medicines that lower levels of LDL (“bad”) cholesterol in the blood. These medicines are monoclonal antibodies (a type of specialized protein designed to attach to a target substance in the body). They attach to PCSK9 which affects the liver’s ability to take in cholesterol. By attaching to, and mopping up PCSK9, the medicines increase the amount of cholesterol entering the liver and lower the level of cholesterol in the blood. In patients with heart disease, evolocumab has been shown to lower the risk of heart attack, stroke, hospitalization for angina, revascularization or cardiovascular death by 15% when added to statin therapy. Most patients will need to be on alirocumab or evolovumab long-term

Alirocumab and evolocumab may be used together with a statin or other cholesterol lowering medications, if the maximum dose of a statin does not lower levels of cholesterol sufficiently. Alternatively, they may be used when statins are not tolerated. Whenever possible, these agents should be used with statins if they are tolerated.

This medication is injected under the skin (subcutaneous) and each should be done in a different spot. Your dose depends on your underlying medical condition and will be taken every two weeks or once monthly. If your doctor decides that you are to start alirocumab or evolocumab, you or your caregiver should receive training on how to prepare, inject, and store correctly. Do not try to inject these medicines until you have been shown by your doctor, nurse, or pharmacist.

Most people do not experience concerning side effects. Some side effects that can occur are redness, swelling, pain, tenderness, itching, or bruising on the area that was injected. Contact your doctor if you experience any signs of an allergic reaction (severe rash, redness, severe itching, swollen face, trouble breathing), or if any of the side effects worsen or interfere with your daily activities.

“Resins” or Bile Acid Sequestrants (Colesevelam- Lodalis®, Cholestyramine - Questran®) Resins are used mainly in patients who are unable to tolerate statins. Resins are used along with lifestyle changes, to help to reduce LDL (bad) cholesterol & to increase HDL (good) cholesterol in the blood. These medications work by binding to substances in the intestine called bile acids, which contain cholesterol. Since these agents are not absorbed into the body, these bile acids (and cholesterol) pass out of the body without being absorbed.

These medications are usually taken from one to four times daily with meals. If you take it once daily, take with the heaviest meal. Tablet and powder forms of these medications are available. Ask your pharmacist for detailed instructions on proper administration of powder forms of this medication. Take other medications at least 1 hour before or 4 hours after you take resins, as they can attach to other medications & prevent them from being absorbed.

Side effects with these medications are mostly limited to the stomach or intestine because it is not absorbed into the blood. You may experience the following: constipation (drink lots of fluids, increase dietary fibre, increase exercise), bloating, heartburn, stomach upset or gas. These side effects usually get better as your body adjusts to the medication.

CEAC 0874 July 2019 Page 31 of 35 Regina Area Herbal Therapy

Some people may want to take herbal products. Herbals are medicines that come from plants. They can be bought without a prescription in health food stores, grocery stores, and some pharmacies.

Herbal products are not controlled like other medications. There is proof that some herbal products may be helpful. There are still many questions about how they work, interactions, and side effects. There are concerns that some herbals may make heart conditions worse. They can interact with medicines used for the heart and preventing strokes.

Even though they are natural, herbals can be harmful like any medication. It is best to talk to your doctor or pharmacist before taking a herbal or stopping a product you have used for a long time.

Over the Counter Medications

Over the counter medication and products (OTCs) do not need a prescription. Some OTCs may harm people taking some medications or with some health problems. For example, some patients may need to avoid OTC pain relievers such as ibuprofen (Advil®, Motrin®, and others) or naproxen (Aleve® and others).

Acetaminophen (Tylenol® and others) is often used for mild fever, pain, and headaches, and has no effect on the blood. may be unsafe for people with heart problems, high blood pressure, diabetes, thyroid disorder, and other diseases.

Let your pharmacist and doctor know what medications you are on (including herbals, vitamins, and supplements) so they can help you make the best choices.

Vaccinations

Why should you get vaccinated?  Heart conditions can make it harder for your body to fight off diseases

 Heart conditions can increase your risk of severe complications from diseases

 Vaccinations give you the safest and best protection against some preventable diseases  Side effects are usually mild and go away on their own; serious side effects are rare  Some diseases, such as the flu, can increase your risk of a heart attack or stroke

 Getting yourself vaccinated can also protect your family, friends, and those around you CEAC 0874 July 2019 Page 32 of 35 Regina Area Suggested : Influenza  Helps protect you from the seasonal flu (1 vaccine per season).

Pneumococcal Vaccine  Helps protect you from 23 types of pneumococcal bacteria. These bacteria can cause serious such as pneumonia, meningitis, and bloodstream infections (1 dose in a lifetime unless indicated*).

*Patients with certain health conditions are at high risk of getting pneumococcal disease and can receive a second vaccination at least 5 years after the first dose. These specific health conditions include: acquired complement deficiency, asplenia, congenital immunodeficiency, hematopoietic stem cell transplant recipient, human immunodeficiency virus (HIV), immunosuppressive medical treatment (e.g. , radiation, high dose steroids), liver disease (including cirrhosis, hepatitis B, hepatitis C), malignancies/, kidney disease, sickle cell disease and other hemoglobinopathies, solid organ or islet cell transplant candidate or recipient.

Zoster Vaccine  Helps protect you against shingles; recommended for adults 60 years old or older (1 dose in a lifetime).

Tdap Vaccine  Helps protect you from tetanus, diphtheria, and pertussis (whooping cough) (1 dose if not given at preteen or teen).

Ask your doctor or pharmacist for more information and to find out if these vaccines are right for you. Depending on your lifestyle, travels, and other circumstances, you may also need additional vaccines.

FAQ: Can I get the flu or other diseases from the vaccine? No, vaccines contain either the inactivated (killed) viruses, attenuated (weakened) viruses, or no viruses. Vaccines are designed in a way that they cannot cause illness.

What side effects may I experience from a vaccine? Soreness, redness, tenderness, or swelling on the area that the vaccine was given. Some people may experience a low-grade fever, headache, or muscle aches. These side effects are mild and go away on their own, and much less bothersome compared to the actual disease.

Where can I get vaccinated? Vaccinations can be given to you by your doctor, nurse practitioner, public health clinic, or pharmacist.

Do I have to pay for my vaccines? Some vaccines are given free of charge, while other must be paid for. However, your work, school, or personal health insurance may cover the cost. CEAC 0874 July 2019 Page 33 of 35 Regina Area Can I still get the flu, shingles, etc. if I get vaccinated?

Vaccines significantly lower your chance of getting the flu, shingles, etc. and help boost your . However, some people may still get the flu, shingles, etc., but their cases will be much less severe and may be a shorter duration compared to people who are not vaccinated.

Where can I find more information? Talk to your healthcare provider. You can also visit the Government of Saskatchewan Immunization Services website: https://www.saskatchewan.ca/residents/health/accessing-health-care- services/immunization-services

How to Take Your Medications

Different medications come with different instructions. There are suggestions for taking medications with food, other medications, and at specific times of the day. Your pharmacist can tell you how and when to take your medications.

If you take a pill at a certain time, make sure you take it at the same time every day.

Food and alcohol can affect the way a medication works in your body. For example, some medications are affected by eating and drinking grapefruit juice. Make sure you talk to your pharmacist about possible interactions between your medication and food or alcohol.

The end outcome of medical treatment is set by your commitment to taking your medications. Forgetting doses or taking them at the wrong time may lead to more broad and costly therapy in the long term. Getting into a routine will help you remember!

Some Tips for Buying Your Medications You should always try to go to the same pharmacy for your medications. It is important your pharmacist knows all of the medications you are taking so that they can monitor your progress, check for medication interactions, and ensure that your medications are correct. Your pharmacist should talk with you clearly and play an active role in your medical care.

Money Matters For many people, the cost of medications may be a problem. There are programs to help if you cannot afford your medications. Ask your pharmacist for more information on the assistance that is available.

Remember: the money you spend on your medications may save you the cost of a heart attack, stroke, or other problems. CEAC 0874 July 2019 Page 34 of 35 Regina Area Conclusion

You have already taken the first step in getting the best results from your medication – education!

The more you know about the medications you are taking, the more you can work with your health care team to make sure your therapy is the best it can be.

The medications given to patients with heart disease and stroke are used to help medical conditions, not cure them. That is why it is important for you to take them the way your doctor prescribed. Never stop taking your medications without talking to your doctor first. Stopping all of a sudden can lead to serious problems in some cases.

This book is to give you some basic ideas about your medications and what you can do to help your heart and brain health. Ask your doctor or pharmacist if you would like more details.

CEAC 0874 July 2019 Page 35 of 35 Regina Area

CEAC 0874 July 2019 Regina Area