Helping Patients Manage Cardiovascular Disease

LaTonya Menefee, PharmD Resident; Yvonne Knox, PharmD Resident; and Justin Sherman, PharmD
Published Online: Thursday, November 1, 2007
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Drs. Menefee and Knox are PharmD residents, and Dr. Sherman is an associate professor of pharmacy practice, at the University of Louisiana at Monroe College of Pharmacy.


More than 1.4 million Americans die of cardiovascular disease each year, which is 1 death every 36 seconds, and more than 79 million Americans currently live with a cardiovascular disease, including hypertension, coronary artery disease, heart failure, myocardial infarction, and stroke.1 In addition to certain lifestyle factors, such as diet and exercise, diabetes mellitus is especially important when looking at increased risk of target-organ damage caused by cardiovascular disease.

Risk Factors for Cardiovascular Disease

Common risk factors for cardiovascular disease include the following: age >65 years, male, genetic predisposition, African American race, smoking, high cholesterol, high blood pressure, physical inactivity, overweight, and diabetes. Smoking, diet, blood pressure, and diabetes are modifiable risks, while race, age, and genetics are not. Risk increases proportionally with the number of risk factors. Two major independent risk factors are high blood pressure and high blood cholesterol. A 10% decrease in total cholesterol levels in the US population overall, for example, may result in an estimated 30% reduction in the incidence of coronary heart disease.1 Thus, community pharmacists should encourage reducing modifiable risk factors.

Reducing Modifiable Risk

Long-standing hypertension, uncontrolled diabetes, and high cholesterol can lead to many complications, such as kidney damage, heart attack, stroke, limb amputation, and blindness. An important consideration in cardiovascular disease is that many complications can occur together and lead to others. Education and prevention provide pharmacists with an important opportunity to help patients reduce their risk of cardiovascular events.2

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the American Heart Association Guidelines, and the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ ATP III), a nutritious diet helps to reduce occurrence of cardiovascular disease. Heart failure, hypertension, stroke, and myocardial infarction risk can be decreased with weight reduction, smoking cessation, and increased physical activity.3-5 Teaching patients how to read food labels, choose alternative salt and sugar sources, and participate in local fitness programs could have a major impact on their health care. Eliminating sodas, high fructose fruit drinks, bread, and table salt and simply walking for 30 minutes a day in 10-minute blocks could help with weight, blood pressure, and cholesterol reduction. The benefits of lowering blood pressure alone equal a 40% reduction in stroke occurrence, a 25% decrease in myocardial infarction, and a 50% decrease in heart failure.6

To help reduce cardiovascular disease, pharmacists should encourage modest weight reduction (approximately 10%); a diet rich in fruits, vegetables, and low-fat dairy products; reduced sodium (≤2.4 g per day); limited alcohol consumption; smoking cessation; and increased physical activity (Table 1). To maximize the reduction of low-density lipoprotein (LDL) cholesterol through diet, NCEP?s Therapeutic Lifestyle Change (TLC) Diet recommends consumption of <200 mg of cholesterol per day.5 Although many patients expect medications to be the cure-all, they are not; rather, they should be used along with lifestyle modifications for optimal results.

Table 1


Medication Management

Pharmacists can have a tremendous impact on the treatment of cardiovascular disease. Adherence to evidencebased therapies and risk-factor management improves cardiac-patient survival and quality of life.7 Angiotensin-converting enzyme inhibitors (ACEIs) are effective in the treatment and prevention of many cardiovascular events. An ACEI or an angiotensin receptor blocker (ARB) should be prescribed to all patients with left ventricular dysfunction (heart failure) and/or post myocardial infarction.7 Clinical trials have demonstrated the benefits of antiplatelet, beta-adrenergic blocker (BB), ACEI, and statin therapy in cardiovascular disease.1 According to the American Diabetes Association guidelines, aspirin as a primary and secondary therapy prevents cardiovascular events in diabetic and nondiabetic individuals.4

Nearly 1 in 3 adults in the United States has high blood pressure. For each 20-mm increase in systolic readings and 10-mm increase in diastolic above 115/75 mm Hg, there is a twofold increase in cardiovascular disease.6 Recommended medication therapies for hypertension and other cardiovascular comorbidities from the JNC 7 are listed in Table 2.

Table 2


Pharmacists also should remind patients to stay current with their vaccinations and have blood pressure, blood glucose, and cholesterol levels checked routinely. Influenza vaccine has been shown to reduce diabetes-related hospital admission by as much as 79% during flu epidemics. Also, tight glycemic control helps to delay or diminish microvascular complications.4 Reduced blood pressure and cholesterol decrease morbidity and mortality for patients with hypertension and hyperlipidemia, respectively. Prevention is the best means of treatment for cardiovascular disease.

Conclusion

Compliance and creating the ideal environment for medications to work can help prevent and treat cardiovascular disease. Inform patients of the importance of taking their medications as directed. Although many patients expect a quick fix at the doctor?s office or neighborhood pharmacy, encourage them to take responsibility for their own health care and make this a priority. Exercising, eating right, and following their prescribed treatment regimens are for their own benefit.

References

  1. Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention. Addressing the Nation's Leading Killers-At a Glance 2007. Available at: www.cdc.gov/nccdphp/publications/AAG/dhdsp.htm.
  2. American Heart Association. Risk Factors and Coronary Heart Disease. Available at: www.americanheart.org/presenter.jhtml?identifier=4726.
  3. National Heart Lung and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Available at: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm.
  4. American Diabetes Association. Standards of Medical Care in Diabetes-2007. Diabetes Care. 2007;30(suppl):S4-S33.
  5. National Heart Lung and Blood Institute. Third Report of the Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Executive Summary. Available at: www.nhlbi.nih.gov/guidelines/cholesterol/atp_iii.htm.
  6. Spencer AP. Outpatient Cardiology. In: Updates in Therapeutics: The Pharmacotherapy Preparatory Course. American College of Clinical Pharmacy; 2007:581-607.
  7. Hertz KT. The continuum of cardiovascular care: championing guideline adherence, optimizing the "teachable moment." Physicians Weekly. June 21, 2004. Available at: www.physiciansweekly.com/index.asp?issueid=143.



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