What follows is basic information about some of the more commonly used medicines. The information provided has been selected for patient use. It is not intended to be comprehensive.

Aspirin

Whenever a blood vessel wall is damaged, certain cells (called platelets) collect around the area of the damage and clump together to form a clot. If the clot becomes too large it can block the blood vessel and prevent blood from reaching the heart muscle. This is what happens when you have a heart attack. Aspirin (in low doses) helps stop platelets sticking together, which prevents clots forming and prevents your new stent or bypass graft from blocking.

Aspirin can sometimes cause stomach irritation or heartburn. To reduce the risk of irritation, it is important that you take your aspirin with or just after food and dissolve it in water before taking it. If you do get indigestion with aspirin, you may find that the coated form of aspirin is better.

If you need to take a painkiller, avoid painkillers that contain aspirin, ibuprofen, naproxen or any other non-steroidal anti-inflammatory drug (NSAID). Paracetamol or Co-Codamol can be used instead. If you would like some help with choosing a suitable painkiller, ask your Pharmacist or local chemist.

Antiplatelets (e.g. Clopidogrel, Ticagrelor, Prasugrel)

Antiplatelets are similar to Aspirin as they also help to prevent platelets sticking together and forming a clot. Patients who have undergone an angioplasty with stenting, or who have had a heart attack will be given both Aspirin and one other, either Clopidogrel, Ticagrelor or Prasugrel. The Aspirin will usually be continued indefinitely and the Clopidogrel, Ticagrelor or Prasugrel for a set period of time; this will be stated on an antiplatelet card which will be given to you before discharge.

If you have a stent and there is any question of the Clopidogrel, Ticagrelor or Prasugrel being stopped by anyone, it must first be confirmed with your Cardiology Consultant at the hospital.

Notify your dentist if you are taking Clopidogrel/Ticagrelor/Prasugrel.

Please note: Whilst taking Aspirin/Clopidogrel/Ticagrelor/Prasugrel you may notice that you bruise more easily or if you cut yourself it takes slightly longer than usual to stop bleeding. This is quite normal but you are advised to see your GP if you have any concerns or develop any other unusual bleeding from any other areas, e.g. bowels.

Proton Pump Inhibitors (e.g. Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, Rabeprazole)

Proton Pump Inhibitors reduce the production of acid in the stomach, preventing or relieving irritation of the stomach lining.

Aspirin combined with another antiplatelet can irritate the lining of the stomach and, due to this action on platelets, may lead to blood loss. Omeprazole or a similar agent has been prescribed to reduce the likelihood of this happening. (see sheet on page 73 for secondary prevention guidelines)

The omeprazole (or similar agent) will usually be stopped on stopping your clopidogrel, ticagrelor or prasugrel. You may however continue on omeprazole (or similar agent) despite stopping clopidogrel, ticagrelor or prasugrel if you are likely to have or have previously had stomach trouble. This will be guided by your GP.

Statins (e.g. simvastatin, atorvastatin, pravastatin, rosuvastatin, fluvastatin)

Cholesterol is produced in the liver with the help of an enzyme. Statins block the effect of this enzyme and reduce the production of cholesterol. Statins reduce the levels of bad cholesterol (LDLs) and increase the levels of good cholesterol (HDLs).

It is recommended that people who have coronary artery disease take lipid-lowering drugs such as statins to reduce their blood cholesterol. Even if your cholesterol is not high, reducing it will lessen the chance of you having another heart attack or stroke.

Statins can cause stomach pain, wind, constipation or diarrhoea. If this happens to you, tell your doctor because reducing the dose may make this better. A rare but serious side effect of statins is inflammation of the muscles (myositis). You must tell your doctor if you have any unexpected muscle pain, tenderness or weakness.

Drinking grapefruit juice or eating grapefruit should be avoided if you are taking a statin drug called simvastatin. However, if you are taking another statin, such as atorvastatin, then grapefruit juice (or the grapefruit) can be taken in small quantities.

ACE Inhibitors (e.g. lisinopril, ramipril, perindopril, captopril, enalapril)

ACE inhibitors (Angiotension converting enzyme inhibitors) have several actions. They reduce blood pressure by dilating blood vessels and reducing fluid retention. Your heart is a muscle and after a heart attack will have suffered some damage, the heart will have to start to work harder to pump blood around your body. ACE inhibitors allow the blood vessel walls to relax and widen, reducing the work the heart has to do which reduces your changes of heart failure or a further heart attack.

Whilst you are taking ACE Inhibitors your GP will routinely arrange a blood test to check your kidneys are working well. This is particularly important when you first start this medication.

A dry, tickly cough can sometimes develop when taking ACE inhibitors. This is quite common and you should not worry about it. If it becomes troublesome you should speak to your doctor who can change you to a similar drug, called an angiotensin II receptor antagonist (or an ARB). The cough you had with the ACE inhibitor may take 3 or more weeks to disappear once the ACE inhibitor has been stopped. It is important NOT to stop taking them suddenly. Discuss any concerns with your GP.

Angiotensin II Antagonists (e.g. Candesartan, Valsartan, Losartan)

Angiotensin II receptor antagonists work in a very similar way to ACE inhibitors, reducing blood pressure and fluid retention, but do not cause the persistent dry cough that ACE inhibitors can sometimes cause.

Beta-blockers (e.g. atenolol, bisoprolol, nebivolol, carvedilol, metoprolol)

These drugs work by reducing the effects of adrenaline in the body. Adrenaline normally increases the heart rate and causes a rise in blood pressure. By blocking these effects, beta-blockers lower the work the heart has to do and therefore reduce the chance of you having angina, abnormal heart rhythms or experiencing a further heart attack.

Minor side effects are common and include tiredness and cold hands and feet. Other less frequent effects include nausea, diarrhoea, skin rashes, impotence or other sexual disorders, nightmares and pins and needles in the fingers.

It is important NOT to stop taking them suddenly as this may bring on angina and/or an increase in your blood pressure. Discuss any concerns with your GP.

Diuretics 'water tablets' (e.g. furosemide, bumetanide, bendroflumethiazide and others)

Diuretics control the amount of water in the body. They get rid of extra water and salt in your urine, and relieve congestion in your circulation.

You will need to use the toilet frequently for a few hours after taking these tablets so find a time of day that suits you. It is best to take diuretic tablets in the morning but if you are directed to take them twice a day, take your second dose at lunchtime or early afternoon.

If you have a special occasion to attend, where frequently visiting the toilet would be a nuisance, you can take the tablet at a different time that day.

It is important not to stop taking diuretic tablets without first consulting your GP, as missing even one dose could lead to fluid building up within the body.

Potassium Sparing Diuretics (e.g. eplerenone, spironolactone)

These are weak diuretics that increase the output of water, but prevent too much potassium being lost at the same time. This helps maintain the balance of salts within the blood. They do this by inhibiting the action of aldosterone, a substance produced within the body which controls your blood pressure and heart function.

Diuretics and potassium sparing diuretics are used to help manage the symptoms of heart failure.

Before you are started on diuretics or potassium sparing diuretics a blood test will check your potassium level and kidney function. Further blood tests should be repeated within the first week of starting,after a month, or after a change in dose.

Nitrates (e.g. glyceryl trinitrate tablets and spray, isosorbide mononitrate)

These work by widening coronary arteries and increasing blood flow through them, allowing the heart to get more oxygen.

Glyceryl trinitrate (GTN) comes as tablets or a spray and is used to relieve symptoms of angina.

How to use your GTN:

1. If you get angina symptoms, stop what you are doing and rest. Sit down if possible
2. If your pain does not ease within a minute spray one or two puffs, or place one to two tablets, under the tongue
3. If after 5 minutes your pain has not resolved take a second dose
4. If after 10 minutes (2 doses) you still have pain you should call an ambulance. You can continue to take your GTN every 5 minutes until the ambulance arrives
5. With GTN tablets, once the pain has resolved either spit out, or swallow, the tablet. If you need to take a second dose, spit out the tablet and place another one under the tongue.
6. If using GTN spray, once the pain has resolved rinse your mouth with water to remove excess spray (if possible).

Always carry your GTN with you. If you do not use your GTN very often, SIT DOWN before you take a spray as it can cause a rapid dilation of blood vessels making you feel lightheaded. Other side effects include facial flushing, dizziness or headaches. These will subside as the drug wears off. Paracetamol can be used to relieve the headache (do not use ibuprofen or aspirin).

If you find that you are increasing the amount of times you are using GTN, (on average greater than four separate occasions a day) make an appointment to see your GP as soon as possible. It may be helpful to make a note of what, if anything brought the angina on and if anything relieved it. This will help you give an accurate description of your symptoms to the doctor, thereby assisting their diagnosis. An angina/symptom record sheet may be found on page 74.

If you have been prescribed Sildenafil (Viagra), Tadalafil (Cialis) or Vardenafil (Levitra) leave at least 12 hours between taking one of these and using your spray, or if you take nitrate tablets, allow at least 24 hours (48 hours for Cialis).

Long-acting Nitrates (e.g. Isosorbide mononitrate, Isosorbide dinitrate)

These are tablets taken either once daily or twice a day to prevent attacks of angina. If you are prescribed this medication twice daily then the second dose should be taken no later than 4pm, this allows your body to have a 'nitrate free period' and reduces the likelihood of intolerance.

Initially they may give you headaches, but this usually settles as the body adjusts to the medication. If it is particularly troublesome problem then discuss this with your GP.

Do not take Sildenafil (Viagra), Tadalafil (Cialis) or Vardenafil (Levitra) whilst you are prescribed Isosorbide Mononitrate or Isosorbide dinitrate unless advised appropriately by your Cardiologist.

Anticoagulant medicines

Blood clots are made up of platelets (tiny blood cells clumped together) and a protein called fibrin. If a clot is not treated, it could travel to the brain and cause a stroke, or travel to the lung and block a main artery (known as a pulmonary embolism). Anticoagulants help to prevent such harmful blood clots from forming.

They are most commonly prescribed for people who have an abnormal heart rhythm, such as atrial fibrillation, or for those who have an artificial heart valve. Both of these conditions increase the risk of a blood clot forming inside the heart, which can then increase the risk of having a stroke.

Anticoagulants are particularly valuable for treating clots that have already formed, such as those that develop in the veins of the legs (deep vein thrombosis).

Whilst taking an oral anticoagulant it is important to carry an anticoagulation card with you and inform any health care professionals, of your treatment.

You will only be prescribed one of the following: Warfarin or a Direct Oral Anticoagulant (DOAC).

Warfarin

Warfarin has been prescribed as an anti-coagulant for many years. It acts on vitamin K, an essential factor for the formation of various clotting factors in the body.

Warfarin can be prescribed to prevent clots forming for a number of different reasons. You may be prescribed warfarin if you have an abnormal heart rhythm, if you have a certain type of artificial heart valve or if you have had a clot in the leg or lungs.

There is no standard dose for Warfarin. The dose is guided by your blood clotting time, which is known as your "INR" (International Normalised Ratio). The only way of knowing the correct dose of warfarin for someone is to measure the INR regularly. Once the correct level is found these blood tests will become less frequent.

The main risk with warfarin is bleeding. Usually this is a minor problem but if you are worried about any bruising, observe dark stools, blood in the urine or unusual bleeding, speak to your doctor immediately.

Always tell any health professional that you are taking Warfarin. Warfarin interacts with other medications so if you start or stop other medications you may need to have a blood test to ensure that your INR stays within the desired range.

Interactions with food:

Some foods can also affect Warfarin. The most noticeable one is cranberry juice, which should be avoided as it can increase the effect of the warfarin. Dark-leaved greens can be eaten in small portions, as large amounts taken infrequently can alter the INR. Alcohol can also affect your INR. It is recommended that if you drink alcohol, to drink the same small amount every day. i.e. 1-2 units a day for men and women (see page 61).

If you are taking Warfarin and require further advice about it, then please speak to your anticoagulation clinic or your community pharmacy.

Direct Oral Anticoagulants (DOACs) - Dabigatran, Apixaban, Edoxaban and Rivaroxaban

These anticoagulant medicines have been approved for use for people who have atrial fibrillation, to reduce the risk of having a stroke, for treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE). You cannot take them if you have a heart valve problem or if you have had heart valve surgery.

The main benefit of these anticoagulant medicines is that you don't need to have the regular blood tests that you would need if you were taking warfarin.

These medicines are not affected by the amount of vitamin K in your diet. This means that vitamin K will not reverse the effects of any bleeding that may occur. If there is any bleeding, your doctor will tell you to stop taking the medicine, in order to reduce the level of the medicine in your blood.

These medicines may affect the way that other medicines you are taking work. Your doctor should discuss this with you. It is important that your doctor discusses with you the risks and benefits of taking any of these medicines rather than warfarin.

Dabigatran

Dabigatran helps to reduce the risk of blood clots forming by thinning the blood. It does this by working on an enzyme called thrombin. Dabigatran needs to be taken twice a day as its effects wear off quickly. This means that missing a dose increases the risk of having a stroke. There is an antidote (Praxbind) that can reverse the effect of Dabigatran, if needed in an emergency.

Rivaroxaban and Edoxaban

Rivaroxaban and edoxaban cause your blood to become thinner by affecting the blood clotting process. They need to be taken once a day. It is very important not to miss a dose.

Apixaban

This works in a similar way to Rivaroxaban and Edoxaban, but it should be taken twice a day as its effects will quickly wear off. This means that missing a dose increases the risk of having a stroke.

Side effects of anticoagulants

The main side effect of taking any anticoagulant medicine is bleeding. This happens because the anticoagulant affects the blood-clotting process, helping to prevent blood clots from forming. The anticoagulant may cause internal bleeding, or make bleeding from a minor injury worse.

Any of the following symptoms could mean that your dose of anticoagulant may need to be checked.

• Cuts which bleed for longer than usual.
• Bleeding that does not stop by itself.
• Nose bleeds that last for more than a few minutes. (If a nose bleed lasts for more than 20 minutes, you must go to your GP surgery or to the accident and emergency department of a hospital.)
• Bleeding gums.
• Severe bruising.
• Red or dark-brown urine.
• Red or black bowel movements.
• For women, heavier bleeding during periods, or other vaginal bleeding that is not caused by periods.

If you receive a hard blow to the head or to another part of the body, you should seek medical help without delay to make sure you don't have internal bleeding as this may not be noticeable straight away. If you are worried, contact your GP or anticoagulant clinic, or go to the accident and emergency department at your local hospital. Take with you your anticoagulation treatment booklet and any other medicines you are currently taking.

If you are taking an oral anticoagulant and require further advice about it, then please speak to your anticoagulation clinic or your community pharmacist.

Amiodarone

Amiodarone is used to treat an irregular heart rhythm; it works by correcting this rhythm and slowing the heart rate if it is beating too fast. It is usual to start taking amiodarone three times a day, reducing to twice a day after 7 days, then once a day after a further 7 days. It is then continued once a day.

Side effects associated with amiodarone include:

• Feeling sick
• Blurred vision, it is recommended to have an eyesight test each year as you may develop deposits in the eyes. These should not affect your vision but you may find that you are dazzled by car headlights if you drive at night.
• Feeling either extremely tired and weak, or extremely restless and agitated; either of these can be caused by changes in thyroid function. It is important to have you thyroid function checked every 6 months.
• Blue or grey marks on areas of skin exposed to the sun due to increased sensitivity to the sun. It is advisable to use a high factor sunscreen (at least factor 15, that protects against UVA and UVB) to protect any exposed areas of skin whilst taking amiodarone.
• Changes in the way things taste, feeling shaky, nightmares and difficulty sleeping.

If you are experiencing any of these side effects and they persist or become troublesome speak to your doctor or pharmacist.

Amiodarone can stay in the body for a number of weeks after taking the last dose, so side effects may continue even after stopping the drug.

If you experience any of the following rare but possibly serious symptoms contact your doctor for advice straightaway:

• Breathing difficulties or unexplained cough.
• Yellowing of skin or whites of your eyes that could be a sign of jaundice.
• A severe skin rash that could be a sign of an allergic reaction

Other medications can interact with amiodarone so always check with a pharmacist when buying medicines that they are safe to take together. Grapefruit juice can increase the level of the drug in the body so it is best to avoid this whilst taking amiodarone.

Buying Medicines online, or from health food shops

These sources may not be reliable in terms of the drug's content. Generally it is not safe to buy from sites unless they are registered with the Royal Pharmaceutical Society of Great Britain and displaying this logo.

If you use herbal remedies or supplements, it is wise to check with your pharmacist that there is no interaction between these and your prescribed medication.

Paying prescription charges

If you pay for your prescriptions a pre-payment prescription certificate(PPC) may help with the cost. If you need more than 13 prescribed medicines each year, you could save money with a 12-month PPC. You can also buy a three-month PPC, which will save you money if you need more than three prescribed medicines in three months.

To buy a PPC go to: https://apps.nhsbsa.nhs.uk/ppcwebsales/

Or for telephone assistance call: 0300 330 1341.