bleeding, but at the wrong place and wrong time— inside an artery, they can trigger a heart attack. A daily aspirin reduces this risk and prevents heart attacks in those with heart disease. Everyone with coronary disease should take it unless there are strong reasons to avoid it (allergy, excessive bleeding).

At the Lown Center, we promote the value of effective medications in the management of coronary disease in its stable phase. Using aggressive management with medicines, many of our patients have lived long and productive lives without resorting to the unnecessary risk and expense of surgeries or stents. In our practice we have found that using surgery as a last resort for most patients yields excellent results both in terms of longevity and quality of life. Recent large clinical trials have confirmed the approach we have advocated and practised for over 30 years. —VS

Living with Heart Disease
If you are already afflicted with a heart condition, here’s our series on secondary prevention for you to stay well

Whether you are on one type of medication or other, make sure to follow diet restrictions and exercise regularly as advised by your physician to keep safe.


DR VIKAS SAINI is a clinical cardiologist and researcher at Harvard Medical School and Harvard School
of Public Health. He is president of the Lown Cardiovascular Research Foundation in Boston. Write to him at



PREVENTION takes many forms. Primary prevention is certainly the best: to avoid the condition completely. In the case of heart disease, the build-up of atherosclerotic plaque can indeed be prevented through diet, exercise and stress reduction, though in our modern life this is difficult and requires diligence and focus. However, after heart disease strikes, what we call ‘secondary prevention’ becomes key. When plaque builds up, heart attacks and death may follow. But in recent decades mortality from cardiac disease has declined in the West. Why? The list includes changes in diet (especially in the composition of dietary fats), healthy habits (exercise, smoking cessation), and the improved ability of hospitals to treat heart attacks and other ‘unstable events’. New and better procedures, such as

emergency stents, have their role too. But drugs play a critical part. Researchers have developed medications that are quite effective in stabilising coronary disease. Indeed, one estimate is that up to 40% of the reduction in mortality we have seen in recent years can be attributed to various drugs. What are the important medications if one has known coronary heart disease? Four broad classes are central: anti-platelet agents, beta-blockers, cholesterol-lowering statins and ACE inhibitors.


These block the effects of adrenalin, a hormone that stimulates the body for ‘fight or flight’. In heart disease, this otherwise useful function can increase complications and death. Betablockers reduce heart rate and BP and stabilise the electrical system.


Anti-platelet agents

One of the longest-used and best-known medicines, aspirin is an excellent example. Well known for its role in the reduction of fever and pain, in heart disease aspirin prevents clots. Clots are useful to stop wounds from

These are well known for their cholesterol-lowering effects. While doctors debate their role in primary prevention, there is no doubt that almost all those with coronary artery disease (CAD) should take a statin if they can tolerate it. While the mechanism by which they work has not been fully identified, they clearly lower rates of death and heart attack in those with CAD.

ACE inhibitors

A family of BP medications, these stabilise the heart after damage from a heart attack. There is also some evidence suggesting they may prevent recurrent attacks. Moreover, their mechanism of action involves important cellular pathways linked to mechanisms of ageing. They are thus an important addition to most

medical programmes for heart disease. Each of these classes of medications reduces risk significantly. In combination, they have led to remarkable improvements in longevity. Compared to the dismal prognosis when I was in medical school, today’s patients can enjoy healthy, active lives even after a diagnosis of heart disease.