Chapter 12

Cardiovascular Drugs

Chapter 12 Topics
Arrhythmias Congestive Heart Failure Myocardial Infarction Angina Pectoris Hypertension Blood Clotting Hyperlipidemia

Learning Objectives
Understand the cardiovascular system Differentiate arrhythmias, congestive heart failure, myocardial infarction, angina and hypertension Know the drugs and treatment of each separate aspect of heart disease

Learning Objectives
Recognize anticoagulant and antiplatelet drugs and know their functions Discuss stroke and the drugs used to treat it Identify hyperlipidemia and explain its role in heart disease and stroke

Predetermined Factors for Cardiovascular Disease

Heredity Gender

Increasing Age

Factors Influenced by Lifestyle Modification

Cigarette Smoking High Blood Pressure High Blood Cholesterol Levels Obesity Diabetes

Arrhythmias
Variation from normal heart rhythm

Normal Rhythm
Generated by SA node at a rate of 70-80 beats per minute

Normal Rhythm
Generated by SA node at a rate of 70-80 beats per minute When the SA node is suppressed or damaged, it may lead to premature contractions resulting in:
Tachycardia, flutter, or fibrilation

ECG records the conduction cycle of the heart

Premature Ventricular Contraction

Abnormal Heart Rhythms

Arrhythmia tachycardia bradycardia atrial flutter atrial fibrilation prem. atrial cont. prem. vent. cont. vent. fibrilation BPM 150-250 <60 200-350 >350 variable variable variable

Abnormal Heart Rhythms

Caused by:
ischemia, infarction, alteration of body chemicals

Abnormal Heart Rhythms

Caused by:
ischemia, infarction, alteration of body chemicals

Symptoms:
palpitations, syncope, lightheadedness, visual disturbances, pallor, cyanosis, weakness, sweating, chest pain, hypotension

Pharmaceutical Treatment
Aimed at preventing life-threatening conditions by restoring normal rhythm Acts on the myocardium where the impulses are conducted Some drugs influence heart rate, others influence movement of ions (Na and Ca)

 Depressant closes the gate Stimulant opens the gate

Membrane Stabilizing Agents (Class I)

Slows the movement of Na ions into myocardial cells A stronger signal is needed for action potential

Drug List
Antiarrhythmic Agents Membrane-Stabilizing Agents (Class I)
disopyramide (Norpace) flecainide (Tambocor) lidocaine (Xylocaine) mexiletine (Mexitil) moricizine (Ethmozine)

Drug List
Antiarrhythmic Agents Membrane-Stabilizing Agents (Class I)
phenytoin (Dilantin) procainamide (Procanbid, Pronestyl) propafenone (Rythmol) quinidine tocainide (Tonocard)

phenytoin (Dilantin)
Used on resistant arrhythmias
Also used for seizures

Beta Blockers (Class II)

Decreases heart rate, myocardial contractility, blood pressure, and myocardial oxygen demand More beta-1 blocking, rather than beta-2, is preferred for heart conditions

Beta Blockers Side Effects

Heart depression Bronchoconstriction Impotence Depression Fatigue May mask symptoms of hypoglycemia and cause bradycardia

Drug List
Antiarrhythmic Agents Beta Blockers (Class II)
acebutolol (Sectral) esmolol (Brevibloc) propranolol (Inderal) sotalol (Betapace)

Potassium Channel Blockers (Class III)

Delays repolarization by blocking the flow of potassium across cell membranes

Drug List
Antiarrhythmic Agents Potassium Channel Blockers (Class III)
amiodarone (Cordarone) bretylium

Calcium Channel Blockers (Class IV)

Prevents movement of calcium to reduce cell contractility Relaxes coronary vascular smooth muscle causing vasodilation Agent of choice for tachyarrhythmias

Calcium Channel Blockers Side Effects

Bradycardia Hypotension Heart block Cardiac failure Nausea Constipation Headache Dizziness Fatigue

Drug List
Antiarrhythmic Agents Calcium Channel Blockers (Class IV)
diltiazem (Cardizem, Dilacor XR) verapamil (Calan, Covera HS, Isoptin, Verelan)

Drug List
Antiarrhythmic Agents Other Agents
atropine digoxin (Lanoxicaps, Lanoxin) isoproterenol (Isuprel)

digoxin (Lanoxicaps, Lanoxin)

Most important drug in managing atrial flutter and fibrilation Slows ventricular rate and treats cardiac failure

Congestive Heart Failure (CHF)

Heart pumps less blood than it receives, so excess blood pools in the chambers and stretches the walls of the heart

Discussion
Why is it dangerous for blood to pool in the chambers of the heart?

Discussion
Why is it dangerous for blood to pool in the chambers of the heart?
Answer: decreased oxygen supply to tissues; risk of blood clot formation and movement throughout the body

CHF
Occurs in 10% of the population over 75 Can result in death through progressive heart damage or sudden death Overworking of the heart leads to cardiomegaly and myocardial hypertrophy

Causes of Congestive Heart Failure

Primary causes:
Cardiomyopathy Coronary artery disease Hypertension Side effects of drug therapy Kidney failure Stress Infection and inflammation Cigarette smoking Obesity

Secondary causes:
High salt intake Noncompliance with treatment

Drug List
Agents for CHF
Antiarrythmic: digoxin (Lanoxicaps, Lanoxin) Antidote for digoxin toxicity: digoxin immune Fab (Digibind)

digoxin (Lanoxicaps, Lanoxin)

Increases force of contraction Increases effective refractory period Affects SA node, causing direct stimulation

digoxin Dispensing Issues

Warning!
dig toxicity
Systemic accumulation Symptoms: nausea, vomiting, arrhythmias

Drug List
Agents for CHF Vasodilators
milrinone (Primacor) nitroprusside (Nitropress)

ACE Inhibitors
Inhibits conversion of angiotensin I to angiotensin II Lowers blood pressure and lowers the stress on the heart

ACE Inhibitors Side Effects

Dry, nonproductive cough Dizziness during first few days

ACE Inhibitor Dispensing Issues

Warning!
Stand slowly to prevent orthostatic hypotension Avoid salt substitutes Do not take potassium supplements

Drug List
Agents for CHF ACE Inhibitors
benazepril (Lotensin) captopril (Capoten) enalapril (Vasotec) fosinopril (Monopril) lisinopril (Prinivil, Zestril)

Drug List
Agents for CHF ACE Inhibitors
moexipril (Univasc) perindopril (Aceon) quinapril (Accupril) ramipril (Altace) trandolapril (Mavik)

Angiotensin II-Receptor Antagonists

Blocks the action of angiotensin II Works as well as ACE inhibitors with less coughing and better toleration

Angiotensin II-Receptor Antagonist Dispensing Issues

Warning!
Look-alike and Sound-alike Drugs:
losartan (Cozaar) valsartan (Diovan)

Drug List
Agents for CHF

Angiotensin II-Receptor Antagonists Human B-type Natriuretic Peptide (hBNP) nesiritide (Natrecor)

Myocardial Infarction
AKA heart attack Leading cause of death in industrialized nations Heart muscle is deprived of oxygen and muscle cells die If healing occurs, scars form, and there is less contractility of the heart muscle

Causes of MIs
Prolonged decrease in oxygen supply Occurs if one or more of the 3 major arteries is narrowed by 70% or more Risk factors:
History of angina, alcohol consumption, reduced pulmonary vital capacity, cigarette smoking, atherosclerosis

Lifestyle Changes
To reduce the risk of an MI:
Eliminate smoking Control diabetes Reduce hypertension Exercise moderately Achieve and maintain ideal body weight Decrease alcohol consumption Use aspirin therapy Reduce dietary cholesterol/triglycerides

Symptoms of a Heart Attack

Oppressive or burning tightness or squeezing in the chest Feeling of choking Sense of impending doom Substernal pain with radiations to the neck, throat, jaw, shoulders, and one or both arms Pain can last 30 mins to several hours

Myocardial Drug Therapy

Aimed at allowing the heart to rest and undergo normal healing Slow the heart (Beta Blockers) Reduce blood clot formation (Aspirin Therapy)

Drug List
Beta Blockers Used after an MI
acebutolol (Sectral) atenolol (Tenormin) betaxolol (Kerlone) bisoprolol (Zebeta) carvedilol (Coreg)

Drug List
Beta Blockers Used after an MI
esmolol (Brevibloc) labetalol (Normodyne, Trandate) metoprolol (Lopressor, Toprol XL) nadolol (Corgard) pindolol (Visken)

Drug List
Beta Blockers Used after an MI
propranolol (Inderal) sotalol (Betapace) timolol (Blocadren)

carvedilol (Coreg)
First beta blocker approved for mild to moderate CHF Slows the heart and improves left ventricular function

Angina Pectoris
Chest pain due to imbalance of oxygen supply and demand
Oxygen demand is related to heart rate, strength of contraction, and resistance to blood flow

3 Types of Angina
Stable
Unstable Variant

3 Types of Angina
Stable
Effort-induced pain from physical activity or emotional stress Relieved by rest Predictable and reproducible

Unstable Variant

3 Types of Angina
Stable Unstable
Pain occurs with increasing frequency Diminishes patients ability to work Has decreasing response to therapy May signal an oncoming MI

Variant

3 Types of Angina
Stable Unstable Variant
Pain due to coronary artery spasm Pain may occur at certain times of the day, but is not stress induced

Symptoms of Angina
Severe chest discomfort (heaviness, pressure, tightness, choking, squeezing) Sweating Dizziness Dyspnea

Risk Factors for Angina

Advanced age Coronary artery disease Hypertension Increased serum glucose levels (diabetes) Increased serum lipoprotein levels Obesity Smoking Type A personality

Initiating Factors of an Attack

Cold weather Emotions Heavy meals Hypoglycemia Pain Smoking

Discussion
Explain why some of these factors may initiate an angina attack: cold weather, emotions, heavy meals, hypoglycemia, pain, smoking.

Discussion
Explain why some of these factors may initiate an angina attack. Answer: cold weather tension in the muscles, possible decrease in blood flow.

Nitrates
Most commonly used drugs for angina Relax vascular smooth muscle and cause vasodilation Helps with pulmonary edema in CHF

Drug List
Agents for Angina Nitrates
isosorbide dinitrate (Dilatrate-SR, Isordil) isosorbide mononitrate (Imdur, Ismo) nitroglycerin (Minitran, Nitrolingual, Nitrostat)

nitroglycerin (Minitran, Nitrolingual, Nitrostat)

Drug of choice for acute attacks
Spray and tablets taken sublingually

May also be used as a prophylaxis If using a patch, it should not remain on the skin for a full 24 hours, there needs to be free time

nitroglycerins Side Effects

Severe headache Orthostatic hypotension Flushing

nitroglycerin Dispensing Issues

Warning!
Tablets must be dispensed in the original amber glass bottle Medication should be refilled every 3 months and discard any remaining drug

Calcium Channel Blockers

Relaxes vascular smooth muscle
Some of these drugs should be taken with food and caffeine should be limited

Constipation is most common side effect

Drug List
Agents for Angina Calcium Channel Blockers
amlodipine (Norvasc) bepridil (Vascor) diltiazem (Cardizem, Dilacor XR) felodipine (Plendil) isradipine (DynaCirc)

Drug List
Agents for Angina Calcium Channel Blockers
nicardipine (Cardene) nifedipine (Procardia) nisoldipine (Sular) verapamil (Calan, Covera HS, Isoptin, Verelan) Beta Blockers Table 12.5

verapamil (Covera HS)

Timed-release product designed for bedtime dose Drug is pumped out of 2 holes in the tablet Patients may see a ghost tablet in the stool

Beta Blockers and Angina

Effective in slowing the heart rate, decreasing myocardial contractility, and lowering blood pressure

Hypertension
Product of cardiac output (CO) and total peripheral resistance (TPR) Vasoconstriction increases TPR CO has 3 aspects
Preload blood delivered to the heart Afterload shortening of the cardiac muscle Contractility capacity of the muscle to shorten

Blood Pressure
Systolic Pressure
Measures pressure during the filling of the heart Cardiac output is a major determining factor

Blood Pressure
Systolic Pressure
Measures pressure during the filling of the heart Cardiac output is a major determining factor

Diastolic Pressure
Measures pressure after the heart has emptied TPR largely determines diastolic pressure

Staging of Blood Pressure

Category
Normal

Systolic
<120

Diastolic
<80 80-89

Prehypertension 120-139 Hypertension Stage 1 Stage 2

140-159 >160

90-99 >100

Factors Leading to Hypertension

Family history Cigarette smoking High fat diet Kidney disease Decreased pressure peripherally Truncal obesity Adrenal tumor Medications: OC, corticosteroids, NSAIDs, nasal decongestants, appetite suppressants

Untreated Hypertension
Cardiovascular disease develops
Enlargement of the heart Cardiac hypertrophy Thickening of the cardiac wall Cardiac output is reduced

CHF results in cold extremities, edema, and accumulation of fluid in the lungs

Untreated Hypertension
Renal insufficiency can occur due to an increased pressure causing a reduction in renal blood flow and function
Accelerated cardiac and peripheral vascular disease can occur
Higher the pressure, the greater the risk

Regimen for Reducing Blood Pressure

Step 1 Lifestyle Modifications
Step 2 - Monotherapy Step 3 Add a diuretic Step 4 Add a third agent

Regimen for Reducing Blood Pressure

Step 1: Modify Lifestyle Factors
High sodium intake to Excess consumption to of calories Physical inactivity to Excess ETOH to Nicotine usage to High stress to Moderate sodium intake Weight reduction Regular aerobic activity Moderate ETOH Nicotine cessation Control stress

Regimen for Reducing Blood Pressure

Step 2: Monotherapy
Use a single drug, usually a diuretic, beta blocker, ACE inhibitor, angiotensin II-receptor antagonist, or calcium channel blocker

Regimen for Reducing Blood Pressure

Step 2: Monotherapy
Use a single drug, usually a diuretic, beta blocker, ACE inhibitor, angiotensin II-receptor antagonist, or calcium channel blocker

Step 3:
Add a diuretic if it was not the drug used to begin therapy in Step 2 of the regimen

Regimen for Reducing Blood Pressure

Step 4:
Add a third agent that will be synergistic with the other two in reducing blood pressure

Pharmacologic Antihypertensive Therapies

See Table 12.9 for an overview of the action of each class of antihypertensive

Drug List
Antihypertensives
Selective Aldosterone Blocker epierenone (Inspra) Calcium Channel Blockers ACE Inhibitors

Drug List
Antihypertensives Angiotensin II Antagonists
candesartan (Atacand) eprosartan (Teveten) irbesartan (Avapro) losartan (Cozaar) olmesartan (Benicar)

Drug List
Antihypertensives Angiotensin II Antagonists
telmisartan (Micardis) valsartan (Diovan)

Beta Blockers

Drug List
Antihypertensives CNS Agents
clonidine (Catapres, Catapres-TTS, Duraclon) guanfacine (Tenex) methyldopa (Aldomet)

Drug List
Antihypertensives Alpha Blockers
alfuzosin (Uroxatral) doxazosin (Cardura) phentolamine (Regitine) prazosin (Minipress) terazosin (Hytrin)

terazosin (Hytrin)
Blocks impulses at vascular smooth muscle

Drug List
Antihypertensives Vasodilators
epoprostenol (Flolan) fenoldopam (Corlopam) hydralazine (Apresoline) minoxidil (Loniten, Rogaine) treprostinil (Remodulin)

Drug List
Antihypertensives Combination Drugs
amlodipine-benazepril (Lotrel) benazepril-HCTZ (Lotensin HCT) enalapril-diltiazem (Teczem) enalapril-HCTZ (Vaseretic)

Drug List
Antihypertensives Combination Drugs
irbesartan-HCTZ (Avalide) losartan-HCTZ (Hyzaar) trandolapril-verapamil (Tarka) valsartan-HCTZ (Diovan HCT)

Blood Clotting
Blood clots are also called thrombi Develop from abnormalities with:
Blood coagulation Blood flow Platelet adhesiveness Vessel walls

Blood Clotting
Anticoagulants
Prevent clot formation by inhibiting clotting factors

Blood Clotting
Anticoagulants
Prevent clot formation by inhibiting clotting factors

Antiplatelets
Reduce risk of clot formation by inhibiting platelet aggregation

Blood Clotting
Anticoagulants
Prevent clot formation by inhibiting clotting factors

Antiplatelets
Reduce risk of clot formation by inhibiting platelet aggregation

Fibrinolytics
Dissolve clots already formed

Clotting Cascade

Clotting Cascade
If any factor in the cascade is missing, blood will not clot (hemophilia)

Venous Thrombi
Usually form in areas of slow blood flow, surgical or vein injuries, large venous sinuses, or pockets formed by valves in deep veins If the clot breaks off, it can travel to the lung causing pulmonary embolism (PE)

DVT
Deep vein thrombosis above the knee is the most serious and may be fatal

Risk Factors for DVT

Age over 40 Bed rest over 4 days Estrogen combined with nicotine High dose estrogen therapy Major illness Obesity Parturition Pregnancy Previous DVT Surgery Trauma Varicose veins

Laboratory Testing
Certain lab tests must be done on patients who are on anticoagulant therapy

Laboratory Testing
Partial thromboplastin time (PTT) affected by heparin Prothrombin Time (PT) affected by warfarin International Normalized Ration (INR) Hematocrit

Drug List
Anticoagulant Agents
argatroban bivalirudin (Angiomax) fondaparinux (Arixtra) heparin lepirudin (Refludan) warfarin (Coumadin)

Drug List
Anticoagulant Agents
Low-Molecular-Weight Heparins: dalteparin (Fragmin) enoxaparin (Lovenox) tinzaparin (Innohep)

heparin
Inhibits thrombin formation preventing clots from forming Only anticoagulant that does not cross the placenta Given for prophylaxis of DVT in postoperative, bedridden, obese patients, and others

warfarin (Coumadin)
Prevents production of vitamin K-dependent clotting factors Prevents future clots with no effect on existing clots Should not be taken with ASA or NSAIDs

Drug List
Antiplatelet Agents
aspirin clopidogrel (Plavix) ticlopidine (Ticlid)

Drug List
Antiplatelet Agents
Glycoprotein Antagonists: abciximab (ReoPro) eptifibatide (Integrilin) tirofiban (Aggrastat)

Drug List
Fibrinolytic Agents
alteplase (Activase) reteplase (Retavase) streptokinase (Streptase) tenecteplase (TNKase) urokinase (Abbokinase)

Stroke
The brain is the most oxygen-rich organ If cerebral circulation is stopped, the brain runs out of oxygen within 10 seconds, tissue dies and does not regenerate A stroke is an interruption of oxygen supply

Types of Strokes
Ischemic Stroke

Cerebral Hemorrhage

Types of Strokes
Ischemic Stroke
Results from obstruction of blood flow due to a thrombus or emboli lodging in the blood vessel

Cerebral Hemorrhage

Types of Strokes
Ischemic Stroke
Cerebral Hemorrhage
Involves primary rupture of a blood vessel Signs: sudden severe headache, stiff neck, stupor, or a combination of these Effects are long-lasting and irreversible

Stroke Risk Factors

Modifiable: Cigarette smoking Coronary artery disease Diabetes Excessive alcohol intake
Hyperlipidemia Hypertension Obesity Physical inactivity

Stroke Risk Factors

Non Modifiable Age Gender Genetic predisposition Prior stroke Race

Stroke Management
Emphasis is on prevention
Antiplatelet therapy

Stroke Management
Emphasis is on prevention
Antiplatelet therapy Anticoagulant therapy

Stroke Management
Emphasis is on prevention
Antiplatelet therapy Anticoagulant therapy Fibrinolytic intervention

Stroke Management
Emphasis is on prevention
Antiplatelet therapy Anticoagulant therapy Fibrinolytic intervention Cerebrovascular surgery

Stroke Management
Emphasis is on prevention
Antiplatelet therapy Anticoagulant therapy Fibrinolytic intervention Cerebrovascular surgery Nonpharmacologic therapy

Stroke Management
Emphasis is on prevention
Antiplatelet therapy Anticoagulant therapy Fibrinolytic intervention Cerebrovascular surgery Nonpharmacologic therapy Poststroke management

Stroke Management
Emphasis is on prevention
Antiplatelet therapy Anticoagulant therapy Fibrinolytic intervention Cerebrovascular surgery Nonpharmacologic therapy Poststroke management

It is imperative to know the cause of the stroke to determine treatment

Antiplatelet Agents
Prevent platelet activation and formation of platelet plug
Can interfere with platelet aggregation induced by ADP or Interfere with synthesis of thromboxane

Anticoagulant Agents
Interfere with the synthesis and activation of the bloods coagulation factors May prevent existing clots from expanding Does not reduce existing clots

Fibrinolytic Agents
Dissolve existing emboli or thrombi Indications:
DVT Acute peripheral occlusion Acute MI with embolization PE Coronary embolus

Drug List
Agents for TIAs and Stroke Prevention
aspirin aspirin-dipyridamole (Aggrenox) clopidogrel (Plavix) dipyridamole (Persantine) pentoxifylline (Trental) ticlopidine (Ticlid)

clopidogrel (Plavix)
Blocks ADP receptors and prevents platelet adhesion and aggregation Used to prevent MI and stroke Major side effect is bleeding

Hyperlipidemia
High blood cholesterol is a major risk factor in heart attacks and strokes Cholesterol is present in animal food products, but not from plant origin Some cholesterol is good and needed for the body to function correctly

Hypercholesterolemia
Can be inherited or come from environmental factors
Out of the three types of cholesterol; saturated, monounsaturated, and polyunsaturated; saturated is the most problematic

Lipoproteins
Packages containing triglycerides, cholesterol, and carrier proteins 4 types of lipoproteins:
Chylomicrons Very-low-density lipoproteins Low-density lipoproteins High-density lipoproteins

Lipoproteins
Chylomicrons
90% triglycerides and 5% cholesterol Absorbed into the lymphatic system

Very-low-density lipoproteins Low-density lipoproteins High-density lipoproteins

Lipoproteins
Chylomicrons Very-low-density lipoproteins
60% triglycerides and 12% cholesterol Fatty acids are produced and deposited in adipose tissue Remnants are changed into LDL

Low-density lipoproteins High-density lipoproteins

Lipoproteins
Chylomicrons Very-low-density lipoproteins Low-density lipoproteins
6% triglycerides and 65% cholesterol Takes cholesterol to the cells

High-density lipoproteins

Lipoproteins
Chylomicrons Very-low-density lipoproteins Low-density lipoproteins High-density lipoproteins
5% triglycerides, 25% cholesterol, 50% protein Remove cholesterol from cells HDL is good cholesterol

Lipoproteins
LDL not used by the cell may be deposited in the artery walls causing atherosclerosis Can result in stroke, MI, or limbs lost to gangrene High HDL levels lower the risk of atherosclerosis

Hyperlipidemia
Reduction in the amount of saturated fats ingested is needed Total fat intake should not exceed 30% of total calories Goal is to decrease total cholesterol levels, but specifically LDL levels

HMG-CoA Reductase Inhibitors

Inhibit the enzyme responsible for cholesterol biosynthesis Side effects include GI upset and headache These drugs should be taken at night because most cholesterol is formed at night Avoid drinking grapefruit juice within several hours of taking statins

HMG-CoA Reductase Inhibitors Dispensing Issues

Warning!
These drugs should be taken at night because most cholesterol is formed at night Avoid drinking grapefruit juice within several hours of taking statins

Drug List
Lipid-Lowering Agents HMG-CoA Reductace Inhibitors
atorvastatin (Lipitor) fluvastatin (Lescol) lovastatin (Altocor, Mevacor) pravastatin (Pravachol) rosuvastatin (Crestor) simvastatin (Zocor)

simvastatin (Zocor)
Take with meals Report muscle pain accompanied by fever

atorvastatin (Lipitor)
Lowers LDL levels significantly and lowers triglycerides

Statin Equivalency Chart

Generic Name
atorvastatin rosuvastatin fluvastatin lovastatin pravastatin simvastatin

Brand Name
Liptor Crestor Lescol Mevacor Pravachol Zocor

Equiv. Dose
20 mg 5 mg 160 mg 80 mg 80 mg 40 mg

Drug List
Lipid-Lowering Agents Fibric Acid Derivatives
clofibrate fenofibrate (TriCor) gemfibrozil (Lopid)

fenofibrate (TriCor)
Increases the breakdown of VLDLs Should be used with dietary modification Primary side effects are GI disturbances

gemfibrozil (Lopid)
Lowers triglyceride and VLDL levels while increasing HDL levels

gemfibrozils Side Effects

Abdominal pain Diarrhea Nausea Vomiting Vertigo Headache Alteration in taste Skin rash

Drug List
Lipid-Lowering Agents Bile Acid Sequestrants
cholestyramine (Questran) colesevelam (WelChol) colestipol (Colestid)

Drug List
Lipid-Lowering Agents Others
ezetimibe (Zetia) niacin (Niacor) psyllium (Fiberall, Metamucil)

niacin (Niacor) (Vitamin B3)

Inhibits synthesis of VLDL and lowers triglyceride and LDL levels May cause extreme skin flushing, preventatives are available This is the most effective drug to increase HDL levels

ezetimibe (Zetia)
Lowers total cholesterol by inhibiting absorption in the small intestine Also increases HDL levels

Drug List
Lipid-Lowering Agents Combinations
amlodipine-atorvastatin (Caduet) niacin-lovastatin (Advicor) pravastatin-buffered aspirin (Pravigard PAC)

Discussion
Name some ways people can lower their cholesterol levels.

Discussion
Name some ways people can lower their cholesterol levels.
Answer: Inject less fat, particularly saturated fat; exercise, take medications as directed