“ACE Inhibitors” and “ARBs” To Protect Your Heart?

Is This Guide Right for Me?

This Guide Is for You If:

• You have coronary heart disease, a disease affecting the arteries of your heart. You may have had a heart attack or suffer from chest pains with exercise, but your symptoms are not changing.
• Your coronary heart disease is in “stable” condition. This means that your symptoms have not changed or become worse.
• Your doctor recommends adding a medicine called an ACE Inhibitor or an ARB.
• You do not take medicine for high blood pressure (also called "hypertension").

This Guide Will Not Help You If:

• You are making decisions about the other medicines that you may be taking for your coronary heart disease.

This guide was created by reviewing the many research studies done on this topic. The information is provided here to help you make a decision about your choices based on the available evidence.

Understanding Your Disease

What Is Coronary Heart Disease?

This picture shows what your coronary heart disease may look like. The arteries that bring blood to your heart muscle have become narrowed or blocked. When that happens, it is hard for blood and oxygen to get to your heart. When the vessel is blocked, you may feel chest discomfort (such as pain, pressure, or tightness) when you do any physical effort or exercise. Doctors call this chest discomfort “angina.”

What Are the Possible Problems?

People with coronary heart disease are at risk for serious problems, including:

• Heart attack
• Heart failure
• Stroke

Each of these problems can cause death or can take a long time for recovery and keep you from working or doing other activities.

Understanding Treatment for Coronary Heart Disease

How Can I Protect Myself From Possible Problems?

Although there is no cure for coronary heart disease, some medicines can help protect you from heart attack, heart failure, or stroke.
Your doctor may ask you to take one or several medicines, such as:

• Low-dose aspirin or drugs that keep platelets in the blood from sticking together.
• Medicines to lower your cholesterol level.
• Medicine that helps reduce heart rate and blood pressure, such as beta-blockers.
• Medicines to prevent your blood from clotting, such as warfarin.
• Other medicines for high blood pressure or diabetes.

What About ACE Inhibitors and ARBs?

Two other medicines ­— ACE Inhibitors and ARBs — have been studied to see if they can also help people with stable coronary heart disease from developing other problems. Both of these medicines lower your blood pressure and have been used to treat heart failure.

• ACE Inhibitors. Your doctor may also call these medicines "angiotensin-converting enzyme inhibitors" or "ACEIs."
• ARBs. Your doctor may also call these medicines "angiotensin II receptor blockers."

Understanding Your Choices

You and your doctor can decide whether you should add an ACE Inhibitor or an ARB to your other medicines by:

• understanding and comparing the benefits of the medicine, and
• deciding if the benefits outweigh the possible side effects from the medicine.

Is an ACE Inhibitor Right for Me?

You and your doctor might want to add an ACE Inhibitor to your other medicines for coronary disease because:

• Doctors know more about the benefits and side effects of ACE Inhibitors than ARBs.
• ACE Inhibitors are available in generic form, making them cost less than ARBs.
• Most people who take ACE Inhibitors experience only minor side effects.

What Are the Benefits of Adding an ACE Inhibitor?

There are four possible benefits to patients who add an ACE Inhibitor to their other medicines for coronary disease:

• It reduces your risk of dying from a heart attack or heart failure.
• It reduces your risk of having a nonfatal heart attack.
• It reduces your risk of being hospitalized because of heart failure.
• It reduces your risk of needing surgery or other procedures to increase blood flow to your heart muscle. This is called “revascularization” (pronounced ree-VASK-you-lar-iz-A-shun).

How Much Benefit Can I Expect?

The two charts below compare the results over a 4-year period for 100 people who did and did not add an ACE Inhibitor to their other medicines.

Without an ACE Inhibitor, what can I expect?

For every 100 people taking other medicines for coronary disease without an ACE Inhibitor, 92 people will not die from a heart attack or heart failure over 4 years (  ); 8 will die from these causes (  ).

With an ACE Inhibitor, what can I expect?

For every 100 people who add an ACE Inhibitor to their other medicines for coronary disease, 93 will not die from a heart attack or heart failure over 4 years (  ); 7 will die from these causes (  ).

That means that 1 additional person out of every 100 people ( ) will avoid dying of a heart attack or heart failure by adding an ACE Inhibitor to their other coronary disease medicines over 4 years. The amount of benefit is about the same for avoiding a heart attack, being hospitalized with heart failure, or needing surgery or another procedure to increase blood flow to your heart muscle.

What are the possible side effects?

Some people who take an ACE Inhibitor have these problems:

• A cough.
• Sudden fainting.
• Too much potassium in their blood. This may cause problems with the heart beat or the heart’s rhythm. These problems are not common.

Some people who take an ACE Inhibitor and then have surgery to open a blocked blood vessel have more risk of:

• Another surgery to open up a different blocked blood vessel.
• Low blood pressure.

WARNING: Some studies have found that ACE Inhibitors can cause a sudden swelling of the tongue, lips, throat, hands or feet. This is called "angioedema" (pronounced an-gee-o-uh-DEE-mah). Call your doctor right away if this happens. ACE Inhibitors can also cause serious birth defects. If you are or think you may become pregnant and are taking an ACE Inhibitor, tell your doctor and ask what you should do.

Should I Add an ARB?

You may be someone who does experience one or more of the side effects from an ACE Inhibitor. In that case, you and your doctor may decide to add an ARB to your other medicines instead.

What are the benefits of adding an ARB?

Studies show that patients who add an ARB to their other medicines (because they cannot take an ACE Inhibitor) have a lower risk of either dying from a heart-related cause or having a nonfatal heart attack or stroke.

What are the possible side effects?

Some people who take ARBs can get too much potassium in their blood. This may cause problems with the heart beat or the heart’s rhythm. These problems appear to not be common. ARBs can cause angioedema and birth defects as well.

Do I need an ACE inhibitor and an ARB?

A research study has shown that taking both of these medicines does not help you any more than taking only an ACE Inhibitor. Adding both medicines can also cause more serious side effects, including:

• Fainting.
• Low blood pressure.
• Kidney problems.

Deciding What Is Best for You

Which ACE Inhibitor or ARB Is Best for Me?

There are many ACE Inhibitor and ARB medicines. These medicines are made by different companies. There are no major chemical differences among the ACE Inhibitor medicines or among the ARB medicines, but dose amounts and costs will vary.

What Is the Cost?

The amount you will have to pay will depend on:

• Whether you are taking a generic or a brand-name medicine.
• The amount of medicine that you are taking.
• The amount of your copay through your insurance plan.

Most ACE Inhibitors come in a generic form. Generic medicines usually cost less than brand-name medicines. There are no generic forms of ARBs.
Ask your doctor to help you choose a medicine that is most effective for you and best fits your budget.

Common Generic and Brand Names for ACE Inhibitors and ARBs

ACE Inhibitors

• benazepril (Lotensin)
• captopril (Capoten)
• enalapril (Vasotec)
• fosinopril (Monopril)
• lisinopril (Prinivil, Zestril)
• perindopril (Aceon)
• quinapril (Accupril)
• ramipril (Altace)
• trandolapril (Mavik)

Angiotensin II Receptor Blockers (ARBs)

• candesartan (Atacand)
• eprosartan (Tevetan)
• irbesartan (Avapro)
• losartan (Cozaar)
• olmesartan (Benicar)
• telmisartan (Micardis)
• valsartan (Diovan)

Your Doctor Can Help You Decide

Ask your doctor:

1. Will an ACE Inhibitor or an ARB reduce my risk of death, heart attack, or stroke?
2. Do the possible harms or side effects from taking these medicines outweigh the benefits for me?
3. Do I need to have an operation to open up the vessels around my heart? How does this change any decisions we might make about the use of these two medicines?
4. Will an ACE Inhibitor or an ARB interact with the other medicines I’m taking?

Other Ways To Help Reduce Your Risk of Heart Problems

You can lower your risk of heart attack, heart failure, or a stroke, if you:

• Lose weight.
• Exercise regularly.
• Eat foods that are low in fat and cholesterol.
• Do not smoke.

Abnormal heart rate turbulence is associated with an increased risk of heart disease

 Study finds new possible risk factor of heart disease

Abnormal heart rate turbulence is associated with an increased risk of heart disease death in otherwise low-risk older individuals, according to a study funded by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health.
This study appears in the Feb. 15 edition of the Journal of Cardiovascular Electrophysiology.
Among the nearly 1,300 study participants, heart rate turbulence, which reflects how well the heart reacts to occasional premature contractions, was an even stronger heart disease risk factor than elevated levels of C-reactive protein. CRP is a potential heart disease biomarker that has emerged in recent years.
Study participants considered at low risk of heart disease based on traditional risk factors were on average 8 to 9 times more likely to die of heart disease during the roughly 14-year follow-up period if they had abnormal heart rate turbulence values. Traditional risk factors include age, gender, high blood cholesterol, high blood pressure, obesity, diabetes, and smoking. Low-risk individuals with elevated CRP in their blood were about 2.5 times more likely to die than those with normal or low CRP.
"These findings suggest that apparently healthy people might be at increased risk of death from cardiovascular disease, and heart rate turbulence may help us identify them," said Susan B. Shurin, M.D., acting director of the NHLBI. "It will be important to see if we can replicate this finding in other populations."
This study followed 1,272 adults aged 65 and older as part of the NHLBI's Cardiovascular Health Study. Participants were categorized as healthy (no sign of heart disease risk except possibly diabetes), subclinical (some signs of heart disease) or clinical (had a cardiovascular event, such as a heart attack). At the onset, participants underwent 24-hour monitoring of their hearts’ electrical activity through a small electrocardiographic, or ECG, device called a Holter monitor attached to their skin.
Abnormal heart rate turbulence and CRP levels both appeared to independently correlate with an increased likelihood of dying of heart disease in the group that was categorized as healthy, even after controlling for other risk factors. Abnormal heart rate turbulence — present in about 7 percent of the study participants — also predicted an increased likelihood of heart disease death in the subclinical and clinical groups, though these results were not as pronounced.
Heart rate turbulence refers to how smoothly the heart rate returns to normal after a premature ventricular contraction, a fairly common event in which the second portion of a heart beat is triggered too soon. Due to the improper timing between the atrial and ventricular contractions, the ventricles haven’t fully filled with blood and therefore do not push out enough blood to the body. The brain detects this sub-optimal release of blood and instantly increases the heart rate to pump more blood. However, this overcompensation raises blood pressure, causing the brain to react again and lower the heart rate until blood pressure returns to normal.
By analyzing the heart's electrical signals, physicians can measure the magnitude of the initial heart rate jump (turbulence onset) and the speed at which heart rate returns to normal (turbulence slope), and then determine if the heart rate turbulence response is normal or abnormal.
"A heart rate turbulence measurement is insightful because it offers a sign of how well the autonomic, or subconscious, nervous system is functioning," said study author Phyllis K. Stein, Ph.D., a research associate professor of medicine and director of the Heart Rate Variability Laboratory at Washington University School of Medicine in St. Louis. "If someone's heart doesn't react well to these uncoordinated beats that might mean it's not good at reacting to other issues like sudden stress or severe arrhythmias."
Researchers don't yet know if abnormal heart rate turbulence can be treated or prevented. In the meantime, said Stein, interest might grow within the medical community in measuring heart rate turbulence in clinical practice. Currently, this type of measurement is not widely available.

Basic facts about muscles

Healthy Muscles Matter

Did you know you have more than 600 muscles in your body? These muscles help you move, lift things, pump blood through your body, and even help you breathe.
When you think about your muscles, you probably think most about the ones you can control. These are your voluntary (VOL-uhn-ter-ee) muscles, which means you can control their movements. They are also called skeletal (SKEL-i-tl) muscles, because they attach to your bones and work together with your bones to help you walk, run, pick up things, play an instrument, throw a baseball, kick a soccer ball, push a lawnmower, or ride a bicycle. The muscles of your mouth and throat even help you talk!
Keeping your muscles healthy will help you to be able to walk, run, jump, lift things, play sports, and do all the other things you love to do. Exercising, getting enough rest, and eating a balanced diet will help to keep your muscles healthy for life.

Different kinds of muscles have different jobs

• Skeletal muscles are connected to your bones by tough cords of tissue called tendons (TEN-duhns). As the muscle contracts, it pulls on the tendon, which moves the bone. Bones are connected to other bones by ligaments (LIG-uh-muhnts), which are like tendons and help hold your skeleton together.

A joint showing muscles, ligaments, and tendons. (Representation)
• Smooth muscles are also called involuntary muscles since you have no control over them. Smooth muscles work in your digestive system to move food along and push waste out of your body. They also help keep your eyes focused without your having to think about it.

• Cardiac (KAR-dee-ak) muscle. Did you know your heart is also a muscle? You have no control over this muscle. It pumps blood through your body, changing its speed to keep up with the demands you put on it. It pumps more slowly when you’re sitting or lying down, and faster when you’re running or playing sports and your skeletal muscles need more blood to help them do their work.

Why healthy muscles matter to you

Healthy muscles let you move freely and keep your body strong.

Healthy muscles let you move freely and keep your body strong. They help you to enjoy playing sports, dancing, walking the dog, swimming, and other fun activities. And they help you do those other (not so fun) things that you have to do, like making the bed, vacuuming the carpet, or mowing the lawn.
Strong muscles also help to keep your joints in good shape. If the muscles around your knee, for example, get weak, you may be more likely to injure that knee. Strong muscles also help you keep your balance, so you are less likely to get hurt by slipping or falling.
And remember—the exercises that make your skeletal muscles strong will also help to keep your heart muscle strong!
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What can go wrong?

Injuries

Almost everyone has had sore muscles after exercising or working too much. This is known as muscle strain (streyn). Muscle strains can be mild (the muscle has just been stretched too much) to severe (the muscle actually tears). Maybe you lifted something that was too heavy and the muscles in your arms were stretched too far. Lifting heavy things in the wrong way can also strain the muscles in your back. This can be very painful and can even cause an injury that will last a long time and make it hard to do everyday things.
The tendons that connect the muscles to the bones can also be strained if they are pulled or stretched too much. If a ligament (remember, they connect bones to bones) is stretched or pulled too much, the injury is called a sprain (spreyn). Most people are familiar with the pain of a sprained ankle.
Contact sports like soccer, football, hockey, and wrestling can often cause strains. Sports in which you grip something (like gymnastics or tennis) can lead to strains in your hand or forearm.

Diseases

Muscles that are not used will get smaller and weaker. This is known as atrophy.

A number of diseases can affect your muscles. Some, like muscular dystrophy (DIS-truh-fee) and Pompe (POM-pay) disease, affect the muscles directly. Other diseases, like polio (POH-lee-oh) and multiple sclerosis (MUHL-tuh-puhl skli-ROH-sis), attack the nerves that control the muscles, so that the muscles become weak or paralyzed.
Muscles that are not used can get smaller and weaker. This is known as atrophy (A-truh-fee). If you have ever had a cast on your arm or leg, you might have noticed that the muscles in that arm or leg were smaller when the cast came off. It’s important to exercise your muscles after an injury like this, so that they will grow back to the right size and work the way they should.

How do I keep my muscles healthy?

Exercise

When you make your muscles work by exercising, they respond by growing stronger. They may even get bigger by adding more muscle tissue. This is how bodybuilders get such big muscles, but your muscles can be healthy without getting that big.
There are lots of things you can do to exercise your muscles. Walking, jogging, lifting weights, playing tennis, climbing stairs, jumping, and dancing are all good ways to exercise your muscles. Swimming and biking will also give your muscles a good workout. It’s important to get different kinds of exercise to work all your muscles. And any exercise that makes you breathe harder and faster will help exercise that important heart muscle as well!

Try to get 60 minutes of exercise every day.

Try to get 60 minutes of exercise every day. It doesn’t have to be all at once. You can exercise several times during the day, as long as you get 60 minutes worth of exercise by the end of the day.

Eat a healthy diet

You really don’t need a special diet to keep your muscles in good health. Eating a balanced diet will help manage your weight and provide a variety of nutrients for your muscles and overall health. A balanced diet:

• Has a lot of fruits, vegetables, whole grains, and fat-free or low-fat milk and dairy products.
• Includes protein from lean meats, poultry, fish, beans, eggs, and nuts.
• Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars.

Prevent injuries

To prevent sprains, strains, and other muscle injuries:

• Warm up and cool down. Before exercising or playing sports, warm-up exercises, such as stretching and light jogging, can make it less likely that you’ll strain a muscle. They are called warm-up exercises because they really do make the muscles warmer—and more flexible. Cool-down exercises loosen muscles that have tightened during exercise.
• Wear the proper protective gear for your sport, for example pads or helmets. This will help reduce your risk for injuring your muscles or joints.
• Remember to drink lots of water while you’re playing or exercising, especially in warm weather. If your body’s water level gets too low (dehydration), you could get dizzy or even pass out. Dehydration can cause many medical problems.

Don’t try to “play through the pain.”
• Don’t try to “play through the pain.” If something starts to hurt, STOP exercising or playing. You might need to see a doctor, or you might just need to rest the injured part for a while.
• Be careful when you lift heavy objects. Keep your back straight and bend your knees to lift the object. This will protect the muscles in your back and put most of the weight on the strong muscles in your legs. Get someone to help you lift something heavy.

Start now

Keeping your muscles healthy will help you have more fun and enjoy the things you do. Healthy muscles will help you look your best and feel full of energy. Start good habits now, while you are young, and you’ll have a better chance of keeping your muscles healthy for the rest of your life.

Definitions

Atrophy (A-truh-fee). Wasting away of the body or of an organ or part, as from defective nutrition, nerve damage, or lack of use.
Cardiac (KAR-dee-ak) muscle. The heart muscle. An involuntary or smooth muscle over which you have no control.
Dehydration (dee-hahy-DREY-shun). A condition that occurs when you lose more fluids than you take in. Your body is about two-thirds water. When you get dehydrated, it means the amount of water in your body has dropped below the level needed for normal body function.
Ligament (LIG-uh-muhnt). Tough cords of tissue that connect bones to other bones at a joint.
Multiple sclerosis (MUHL-tuh-puhl skli-ROH-sis) (MS). A nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS.
Muscular dystrophy (DIS-truh-fee) (MD). A group of more than 30 inherited diseases that cause muscle weakness and muscle loss. Some forms of MD appear in infancy or childhood, while others may not appear until middle age or later. Most people with MD eventually lose the ability to walk.
Polio (POH-lee-oh). A disease caused by a virus that attacks your nervous system. It most commonly affects young children. In rare cases, polio infection can cause paralysis. Polio vaccination will protect most people for life. The United States and most other countries eliminated polio decades ago, except for rare cases.
Pompe (POM-pay) disease. A rare genetic disorder that results in profound muscle weakness. The heart and skeletal muscles are most affected.
Skeletal (SKEL-i-tl) muscle. Muscles that attach to bones.
Sprain (spreyn). A stretched or torn ligament. Ankle and wrist sprains are common. Symptoms include pain, swelling, bruising, and being unable to move the joint.
Strain (streyn). A stretched or torn muscle or tendon. Twisting or pulling these tissues can cause a strain. Strains can happen suddenly or develop over time. Back and hamstring muscle strains are common. Many people get strains playing sports.
Tendon (TEN-duhn). Tough cords of tissue that connect muscles to bones.
Voluntary (VOL-uhn-ter-ee) muscles. Muscles that you can control.