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• Peripheral adrenergic antagonists Peripheral adrenergic antagonists widen blood vessels and lower blood pressure by blocking the effects of the stress hormone epinephrine. They may be used with diuretics. They can cause drowsiness when taken in high doses.

Cholesterol-lowering medications

If your cholesterol levels are high or if you have heart disease, your doctor may prescribe cholesterol-lowering medication to reduce your risk of developing heart disease or of having a heart attack. You may need to take this medication for the rest of your life. Cholesterol-lowering medications include the following:

• Statins Statin drugs (HMG CoA reductase inhibitors) block the action of an enzyme called HMG CoA reductase in the liver, causing the liver to produce less cholesterol. Possible side effects include occasional muscle aches and nausea. In rare cases, liver damage may result. Currently available statin drugs include lovastatin, simvastatin, provastatin, fluvastatin, and atorvastatin.

• Bile acid binding resins Bile acid binding resins prevent absorption of cholesterol into the blood and stimulate the liver to remove cholesterol from the bloodstream. Possible side effects include bloating, cramping, and diarrhea. Examples of bile acid binding resins include cholestyramine, colestipol, and colesevelam.

• Fibrates Fibrates (also called fibric acid derivatives) decrease blood levels of triglycerides (a type of fat in the blood). These drugs can also decrease LDL (bad) cholesterol and mildly increase HDL (good) cholesterol. People who take fibrates have a slightly increased risk of developing gallstones (see page 793) and gallbladder disease. Examples include clofibrate, fenofibrate, and gemfibrozil.

• Niacin Niacin (nicotinic acid) is a vitamin that decreases production of LDL (bad) cholesterol in the liver. Depending on the dosage, it can also increase HDL (good) cholesterol. Possible side effects include bloating, cramping, or diarrhea. In rare cases, niacin may cause liver damage. A number of nonprescription niacin supplements are available over the counter.

Surgery for heart disease

A number of surgical procedures can be performed to treat heart disease, primarily by rerouting blood vessels around a blockage or reopening a blocked artery. These procedures include coronary artery bypass surgery, balloon angioplasty, and stent placement.

Coronary artery bypass surgery

Coronary artery bypass surgery is very effective for people who have angina and whose heart muscle has not been damaged by a heart attack. Bypass surgery is the procedure most widely used to treat heart disease caused by atherosclerosis (see page 557). The procedure can improve endurance, reduce symptoms, and decrease the amount of medication a person needs to take. Bypass surgery is most likely to benefit people who have severe angina that cannot be controlled with medication, who have a normally functioning heart, and who have not had a heart attack. About 85 percent of people who have bypass surgery experience complete or significant relief from their symptoms.

Bypass surgery involves grafting veins or arteries from another part of the body onto the coronary artery to reroute blood flow around the obstruction. The surgeon usually uses veins from the person’s leg. Most surgeons also use at least one artery, usually taken from the person’s chest wall. Atherosclerosis seldom develops in the treated arteries, and most treated arteries stay open for at least 10 years after the surgery. However, if the grafted veins become obstructed, the procedure may need to be repeated.

For bypass surgery you are given general anesthesia, your heart is stopped, and you are placed on a heart-lung machine, which takes over your circulation and breathing. The machine oxygenates your blood and pumps it throughout your body. If necessary, more than one bypass can be performed during the same procedure.

Coronary artery bypass surgery

This illustration shows blood vessels that were taken from other