Category:Cardiovascular agents

A cardiovascular agent is a medicine used in the management of disease of the heart, the blood vessels, or the blood that they carry. The category is one of the broadest in pharmacology and includes the medicines that lower the arterial blood pressure, that lower the circulating lipoproteins for atherothrombotic-event prevention, that relieve the chest pain of myocardial ischaemia, that suppress cardiac arrhythmia, that prevent or treat clot formation, that improve the survival of patients with heart failure, and that manage the small but important class of pulmonary-circulation diseases. The umbrella is large because the cardiovascular system is the leading cause of mortality in the developed world, and the pharmacology of its management has been the subject of more outcome-trial evidence than any other field of contemporary medicine.

The clinical history of cardiovascular medicine has been the gradual displacement of symptomatic therapy by mortality-reducing prevention. In 1900 the United States physician facing a patient with hypertension, ischaemic heart disease, or congestive heart failure had, at best, digitalis, nitroglycerin, and bed rest; in 2026 the same patient is offered a panel of medicines that, collectively, have reduced cardiovascular mortality in the developed world by approximately two-thirds from its 1950s peak. The pharmacological history is, in outline, the history of the major umbrellas indexed below: the antihypertensives from the Veterans Administration trials of Edward Freis in 1967 forward; the lipid-lowering agents from the discovery of compactin by Akira Endo in 1976; the antianginals from the amyl-nitrite trials of Lauder Brunton in 1867; the antiarrhythmics from the Vienna observation of Karel Wenckebach in 1914; the anticoagulants from the dog-liver accident of Jay McLean in 1916; the antiplatelet agents from the demonstration that aspirin reduced acute myocardial infarction mortality in ISIS-2 in 1988; and the heart failure medications from William Withering's foxglove monograph in 1785.

The contemporary practice of cardiovascular medicine is organised around a small number of large outcome trials that define the standard of care for the major conditions. In hypertension, the SPRINT trial of 2015 established that a more aggressive blood-pressure target of less than 120 mm Hg systolic reduced cardiovascular events and mortality in a high-risk population, although at the cost of more hypotension, syncope, and acute kidney injury (see antihypertensives). In secondary prevention of atherothrombotic cardiovascular disease, statin therapy reduces cardiovascular events by approximately one-third in trials of secondary prevention (4S in 1994 onward) and by one-quarter to one-fifth in primary prevention of high-risk patients (WOSCOPS, JUPITER, HOPE-3). In heart failure with reduced ejection fraction, the "four pillars" of an angiotensin receptor / neprilysin inhibitor (or ACE inhibitor or ARB), a beta-blocker, a mineralocorticoid antagonist, and an SGLT2 inhibitor reduce mortality and hospitalisation each by approximately 20 to 30 percent; the combined effect of all four is sufficient to halve the long-term mortality of patients receiving them (see heart failure medications). In atrial fibrillation, anticoagulation with a direct oral anticoagulant or warfarin reduces stroke by 65 to 70 percent at the cost of approximately 0.5 percent per year of major bleeding (see anticoagulants). In the post-myocardial-infarction setting, dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor reduces recurrent ischaemic events; the duration of the dual therapy has been progressively refined.

The clinical pharmacology of the contemporary cardiovascular patient is, in consequence, a complex polypharmacy. The patient with established atherosclerotic cardiovascular disease, hypertension, type 2 diabetes, and chronic kidney disease (a profile that describes a substantial fraction of contemporary primary-care attendees) may take aspirin, a high-intensity statin, an ACE inhibitor or angiotensin receptor blocker, an SGLT2 inhibitor, a beta-blocker, a calcium channel blocker, ezetimibe, and (in selected cases) a PCSK9 inhibitor or icosapent ethyl. The pill burden, the additive bleeding and hypotension risks, the cumulative interaction profile, the cost, and the difficulty of monitoring are clinical pharmacology problems in their own right, and the fixed-dose combination tablets described under fixed-dose combinations address part of the burden. The clinical-pharmacology research direction has been toward better risk stratification (which patient will benefit most from intensification, and which is at higher bleeding or hypotension risk) and toward outcome trials of regimens rather than of individual medicines.

The category is divided by indication and mechanism into:

• Antihypertensives: medicines used in the management of arterial hypertension
  • ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, beta-blockers, the thiazide diuretics and thiazide-like diuretics in this indication, alpha-1 blockers, the centrally acting sympatholytics, the direct vasodilators
• Lipid-lowering agents: medicines used in atherothrombotic-event prevention through circulating-lipoprotein reduction
  • Statins, fibrates, PCSK9 inhibitors, cholesterol absorption inhibitors, omega-3 fatty acids in pharmacological doses, niacin
• Antianginals: medicines used for symptomatic relief of myocardial ischaemic chest pain
  • Organic nitrates, calcium channel blockers, beta-blockers, ivabradine, ranolazine
• Antiarrhythmics: medicines used to suppress cardiac arrhythmia (Vaughan Williams classes I-IV plus the unclassified agents)
• Anticoagulants: medicines that interfere with the coagulation cascade
  • Vitamin K antagonists, the heparins, the direct oral anticoagulants including the direct factor Xa inhibitors
• Antiplatelet agents: medicines that inhibit platelet activation and aggregation
  • P2Y12 inhibitors including the thienopyridines, aspirin in low-dose antiplatelet use, the glycoprotein IIb/IIIa antagonists, the PAR-1 antagonist vorapaxar
• Heart failure medications: medicines that reduce mortality and hospitalisation in heart failure with reduced or preserved ejection fraction
  • The four pillars of HFrEF therapy, the loop diuretics for congestion, the inotropes for acute decompensation
• Pulmonary-vasculature medicines (when this category page is built): the endothelin receptor antagonists (bosentan, ambrisentan, macitentan), the PDE5 inhibitors for pulmonary arterial hypertension (sildenafil, tadalafil), the prostacyclin analogues (epoprostenol, iloprost, treprostinil, selexipag), the soluble guanylate cyclase stimulator riociguat
• Inotropes and vasopressors (the acute-care side): digoxin, dobutamine, milrinone, the sympathomimetics norepinephrine, dopamine, phenylephrine, epinephrine, vasopressin
• Vascular smooth muscle and other: vasodilators (described separately), vasopressors (where built), direct vasodilators hydralazine and minoxidil

The boundary of this category is "medicine whose principal indication is a disease of the heart, the blood vessels, or the systemic circulation it serves." Medicines whose primary indication is endocrine, metabolic, or otherwise non-cardiovascular but which have important cardiovascular effects (the SGLT2 inhibitors for heart failure across the ejection-fraction spectrum, the GLP-1 receptor agonists for cardiovascular event prevention, the COX-2-selective NSAIDs for their cardiovascular thrombotic risk) are listed under their primary indication and cross-indexed here where the cardiovascular indication is established. Surgical and procedural treatments (percutaneous coronary intervention, coronary bypass grafting, valve replacement, ablation, cardiac transplantation, ventricular assist devices) are not medicines and are referenced on the medicine pages but not collected in this category. The medicines used for cardiac arrest in the immediate resuscitation setting (intravenous epinephrine, vasopressin, the antiarrhythmics amiodarone and lidocaine) are listed under their primary classes and are cross-referenced to advanced cardiac life support protocols on the individual medicine pages.

This category page is an encyclopedia article about its subject. The actual index of medicines belonging to the category is generated automatically by the wiki engine, from category-membership declarations on the individual medicine pages, and appears at the foot of the page below the references.