Side effects and drug interactions of Common Heart Medicines - Anti-coagulants, Vasodialators, Inhibitors

Submitted by Dr S. Patel on 9 June 2020

If you have any heart condition, it is likely you will be placed on one of the cardiac medications listed below. Your doctor can tell you which medications or combination of are best suited for you. We have listed the commonly prescribed drugs, their side-effects and drug interactions in two parts.

The second part is here.

Remember this is not a complete list and if you are taking or planning to take any prescription, dietary, herbal or natural supplements, please consult your Cardiologist or Primary Practitioner first.

The tables below are best seen on a laptop or tablet.

The common cardiac drugs have been broadly categorised into the following classes. In part 1 we cover:

Anticoagulants
Antiplatelet Agents and Dual Antiplatelet Therapy
Vasodilators
ACE Inhibitors
Angiotensin II Receptor Blockers
Angiotensin Receptor-Neprilysin Inhibitors

Anticoagulants

Commonly referred to as Blood Thinners, these are a class of drugs that prevent and decrease size of clots in arteries and veins. They work by disrupting the factors that cause coagulation inside the blood vessels. The dosage is very carefully monitored by your doctor. They do this by measuring your Prothrombin time (PR) and International normalized ratio (INR) periodically. Both these tests indicate your clotting rate. Here are the side-effects seen with these drugs.

Common Anticoagulants	Side-effects
Warfarin is the most common anti-coagulant. Heparin is mostly used when in hospital. Newer drugs that cause less bleeding include Rivaroxaban, Edoxaban, Apixaban, and Dabigatran	Easy bruising Prolonged bleeding from a cut Blood in urine Black or bloody stools Nosebleeds Bleeding gums Vomiting or coughing of blood Heavy periods

Common Anticoagulants

Side-effects

Warfarin is the most common anti-coagulant.

Heparin is mostly used when in hospital.

Newer drugs that cause less bleeding include Rivaroxaban, Edoxaban, Apixaban, and Dabigatran

Easy bruising
Prolonged bleeding from a cut
Blood in urine
Black or bloody stools
Nosebleeds
Bleeding gums
Vomiting or coughing of blood
Heavy periods

Certain medications, foods and herbal remedies can interfere with anticoagulants. It is important you avoid all such possible and dangerous interactions.

Certain Medications	Consult your doctor before taking an over-the-counter medication. Antibiotics, anti-fungals, pain killers, reflux pills are known to increase risk of bleeding. If you are on oral contraception, you must inform you doctor about it. Antidepressants, Corticosteroids, anticonvulsants (for epilepsy) and NSAIDs (Ibuprofen)can all be counterproductive.
Vitamin K rich foods	Vitamin K is known to be a clotting factor. It can reduce the effectiveness of Warfarin. Intake of high levels of Vitamin K foods must be avoided. These include Broccoli, Asparagus, Cabbage, Kale, Lettuce, Spinach, Mustard or Collard greens, Turnips greens and Endives.
Vitamin E rich foods	Vitamin E is a natural clot buster. Food rich in Vitamin E are Spinach, Tomatoes, Mangoes, Peanut butter, Almonds, sunflower seeds and oils derived from olive, corn and soy.
Herbal remedies	Some herbs can interfere with the anti-clotting abilities of your medication. Always ask your doctor before using any herbal supplements (pills, teas etc)or remedies. Some herbs to watch out for are Chamomile, Echinacea, Licorice, Ginseng, Willow bark, Gingko biloba, and Evening Primrose oil.
Beverages	Alcohol and Cranberry juice are drinks that must be avoided.
Foods	Some food products are natural blood thinners. Make sure, you speak to your doctor if you regularly partake of these food items. They include garlic, ginger, aniseed, and celery seeds.

Antiplatelet Agents & Dual Antiplatelet Therapy

These are agents that prevent platelets from clumping together and forming clots. They work on both normal arteries and ones implanted with stents. When prescribed along with aspirin, it is known as dual anti-platelet therapy or DAPT. Here are the side-effects of anti-platelet drugs:

Anti-platelet drugs	Side-Effects
Acetylsalicylic acids (Aspirin, Asaphen, Entrophen, Novasen) P2Y12 inhibitors such asTicagrelor, Prasugrel, Dipyridamole and Clopidogrel	Bleeding from nose and cuts. Easy bruising Stomach pain or heartburn Vomiting with blood Blood in urine and stools Heavy bleeding during periods Clopidogrel can also cause nausea, headaches, dizziness, diarrhea or constipation. In some cases, Clopidogrel can cause an allergic reaction (swelling in mouth or throat, difficulty breathing, rash).

Anti-platelet drugs

Side-Effects

Acetylsalicylic acids (Aspirin, Asaphen, Entrophen, Novasen)

P2Y12 inhibitors such asTicagrelor, Prasugrel, Dipyridamole and Clopidogrel

Bleeding from nose and cuts.
Easy bruising
Stomach pain or heartburn
Vomiting with blood
Blood in urine and stools
Heavy bleeding during periods
Clopidogrel can also cause nausea, headaches, dizziness, diarrhea or constipation. In some cases, Clopidogrel can cause an allergic reaction (swelling in mouth or throat, difficulty breathing, rash).

Many drugs can interact negatively with antiplatelet drugs. These include:

Certain Medication	Over-the counter drugs like Acid suppressants and NSAIDS like Ibuprofen
Food	Vitamin K rich foods and green leafy vegetables
Alcohol	Is best avoided to prevent liver toxicity
Herbal agents	Ask your doctor before staring any herbal supplements or pills.

Precautions to be taken:

Before Surgery: Since both anti-coagulants and anti-platelets can cause bleeding, before embarking on any invasive or diagnostic procedure, you will be asked to stop taking these drugs for a few days. Your PT and INR tests will be done to check your clotting rates. For dental procedure, follow your Dentist’s instructions on taking your pills.
Pregnancy: If you find out you are pregnant, make sure you speak to your Gynecologist right away and stop medications. Birth defects and bleeding from the placenta are known adverse effects. The effects of anti-platelets are largely unknown, however in some cases low dose aspirin has been used.
Breastfeeding: Warfarin and Heparin are safe during breastfeeding; however other anti-coagulants are counter effective.
Avoid injuries: Even minor cuts and scrapes can lead to excessive blood loss. All types of falls and injuries must be averted. Avoid playing contact sports, take care while shaving and gardening or using tools for DIY.

Vasodilators

This group of medications help dilate or widen the blood vessel such that blood can flow more easily. There are three types of dilators viz Arterial, Venous and Mixed. As the name suggest, they work on arteries, veins or both respectively. This group include antihypertensives, nitrates, ACE inhibitors, ARBs and Calcium channel blockers.

Vasodilators	Side-effects
Nitrates: Isosorbide dinitrate Isosorbide mononitrate Nitroglycerin Anti-hypertensives: Minoxidil Hydralazine	Flushing Nasal congestion Nausea or vomiting Chest pain Heart palpitations (fluttering or pounding) Increased heart rate Fluid retention (edema) Dizziness Headache Excessive hair growth

Vasodilators

Side-effects

Nitrates:

Isosorbide dinitrate

Isosorbide mononitrate

Nitroglycerin

Anti-hypertensives:

Minoxidil

Hydralazine

Flushing

Nasal congestion

Nausea or vomiting

Chest pain

Heart palpitations (fluttering or pounding)

Increased heart rate

Fluid retention (edema)

Dizziness

Headache

Excessive hair growth

Precautions:

Avoid intake of alcohol with vasodilators
If you are or planning to get pregnant, speak to your doctor about it.
Beware of supplements which have Coenzyme Q10, L-arginine or Magnesium which are vasodilators.
Avoid excessive intake of certain foods that cause vasodilation such as Garlic, Niacin (B3), or Cocoa.
Caffeine such as in coffee causes vasoconstriction.

ACE (Angiotension Converting Enzyme) Inhibitors

As the name suggest, these drugs lower the levels of angiotension II in the body leading to expansion of blood vessels by decreasing resistance. This keeps the blood flowing easily and strains the heart less.

ACE Inhibitors	Common Side-effects	Rare Side-Effects
Benazepril Captopril Enalapril Fosinopril Ramipril Lisinopril Moexipril Perindopril Trandolapril Quinapril	Cough (it is likely that if one ACE inhibitor is causing cough, the others will too) Headache Dizziness Low BP High Potassium levels Drowsiness Weakness Change in taste (metallic or salty taste in mouth) Skin Rash and increased sensitivity to sun Chest pain High uric acid levels High BUN and creatinine levels	Allergic reaction Kidney failure Pancreatitis Decrease in White blood cells Changes in Liver functioning Angioedema (swelling of lower layer of skin and tissue)

ACE Inhibitors

Common Side-effects

Rare Side-Effects

Benazepril

Captopril

Enalapril

Fosinopril

Ramipril

Lisinopril

Moexipril

Perindopril

Trandolapril

Quinapril

Cough (it is likely that if one ACE inhibitor is causing cough, the others will too)
Headache
Dizziness
Low BP
High Potassium levels
Drowsiness
Weakness
Change in taste (metallic or salty taste in mouth)
Skin Rash and increased sensitivity to sun
Chest pain
High uric acid levels
High BUN and creatinine levels

Allergic reaction
Kidney failure
Pancreatitis
Decrease in White blood cells
Changes in Liver functioning
Angioedema (swelling of lower layer of skin and tissue)

All the ACE inhibitors work similarly, some more on the blood and some more in the tissues. Dosages of the different agents do vary depending on their absorption. Here are some drug interactions to be aware of:

Drugs	Lithium Aspirin and NSAIDs (Motrin, Ibuprofen, Naproxen etc). Diuretics (need close monitoring) Aliskiren (a drug used to treat high BP can cause adverse reactions).
Injections	Gold sodium aurothiomalate used to treat Rheumatoid Arthritis.
Potassium and Salt	Avoid both in food and supplement form.

Drugs

Lithium

Aspirin and NSAIDs (Motrin, Ibuprofen, Naproxen etc).

Diuretics (need close monitoring)

Aliskiren (a drug used to treat high BP can cause adverse reactions).

Injections

Gold sodium aurothiomalate used to treat Rheumatoid Arthritis.

Potassium and Salt

Avoid both in food and supplement form.

Angiotensin II Receptor Blockers (ARBs)

These group of drugs block the enzyme angiotensin from working on the blood vessels. Since they are similar acting to ACE inhibitors, they are used in people who cannot tolerate ACE inhibitors.

Types of ARBs	Common Side-effects	Rare Side-Effects
Azilsartan Losartan Candesartan Eprosartan Irbesartan Olmesartan Telmisartan Valsartan	Cough ( not as bad as with ACE inhibitors) Low BP especially on standing Headaches Dizziness Fatigue High Potassium levels Indigestion Flu-like symptoms Increase in blood glucose levels Upper respiratory tract infections Sinus infections Diarrhea Skin rash Metallic taste in mouth	Serious Allergic reaction Kidney failure (esp. if there is narrowing of renal arteries) Liver failure Decrease in White blood cells Decrease in platelet count Angioedema (swelling of lower layer of skin and tissue) Rhabdomyolysis (breaking of muscle fibers) Sexual dysfunction

Types of ARBs

Common Side-effects

Rare Side-Effects

Azilsartan

Losartan

Candesartan

Eprosartan

Irbesartan

Olmesartan

Telmisartan

Valsartan

Cough ( not as bad as with ACE inhibitors)
Low BP especially on standing
Headaches
Dizziness
Fatigue
High Potassium levels
Indigestion
Flu-like symptoms
Increase in blood glucose levels
Upper respiratory tract infections
Sinus infections
Diarrhea
Skin rash
Metallic taste in mouth

Serious Allergic reaction
Kidney failure (esp. if there is narrowing of renal arteries)
Liver failure
Decrease in White blood cells
Decrease in platelet count
Angioedema (swelling of lower layer of skin and tissue)
Rhabdomyolysis (breaking of muscle fibers)
Sexual dysfunction

Counter-interactions with other drugs include:

Drugs	Lithium Aliskiren (a drug used to treat high BP can cause adverse reactions). Rifampin reduces the effects of Losartan. When used with ACE inhibitors, it causes decrease in BP, increase in potassium and kidney problems.
Injections	gold sodium aurothiomalate Used to treat Rheumatoid Arthritis.
Potassium and Salt	Avoid both via food and supplement form.

Drugs

Lithium

Aliskiren (a drug used to treat high BP can cause adverse reactions).

Rifampin reduces the effects of Losartan.

When used with ACE inhibitors, it causes decrease in BP, increase in potassium and kidney problems.

Injections

gold sodium aurothiomalate Used to treat Rheumatoid Arthritis.

Potassium and Salt

Avoid both via food and supplement form.

ARBs are very unsafe for pregnant women and cause oligohydramnios, which is less amniotic fluid in the womb. This is a serious condition and can even be fatal for the fetus.

Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)

ARNIs are a combination drug of ARBs and a neprilysin inhibitor. Neprilysin is an enzyme that prevent widening of narrow arteries. Inhibiting its functions helps improve blood flow.

Common ARNIs	Side-effects
Sacubitril + Valsartan	Low BP especially on standing up Increase in Potassium levels Cough Dizziness Angioedema Hypersensitivity (rash, itching, anaphylaxis)

Contraindications:

Drugs to avoid	ACE inhibitors ARBs Potassium-sparing diuretics Aliskerenesp for Diabetic patients Can cause an allergic reaction NSAIDs Lithium

Drugs to avoid

ACE inhibitors

ARBs

Potassium-sparing diuretics

Aliskerenesp for Diabetic patients

Can cause an allergic reaction

NSAIDs

Lithium

Must be stopped immediately if you are pregnant. It can lead to oligohydramnios (decreased amniotic fluid), a dangerous and fatal condition for your fetus.

References: