Kelsey Giara, PharmD

The body depends on heart to pump blood and deliver nutrients and oxygen to the body’s cells.

Heart failure (HF), the heart’s inability to maintain its workload, leads to inadequate circulating blood supply.

 About 6.2 million American adults have HF, leading to considerable health care costs, ill health, and mortality.

Patients with HF experience coughing, fatigue, shortness of breath, and a decreased capacity to complete activities of daily living, such as climbing stairs or even walking.

HF is chronic and progressive. The heart tries to compensate for its inability to pump enough blood by developing more muscle mass, enlarging, and/or pumping faster. Blood vessels also narrow to maintain blood pressure, and the body diverts blood away from organs, such as the brain, heart, and kidneys, and “less important” tissues.3 These measures mask, but don’t solve, the problem. Eventually, usually years after HF begins, the body and heart fail to keep up and patients will experience the aforementioned symptoms.

When providers diagnose HF, almost 10% of patients are hospitalized emergently with worsening symptoms within 1 year.

 Readmission rates within 1 month are as high as 25%.

 Identifying decompensation in HF patients before emergency department admission is warranted. Technological advances in recent decades allow more intensive community-based monitoring to identify decompensation early; prompt intervention, such as changes to diuretic dosage, in those who are no longer euvolemic; and support lifestyle and medication adherence.

Bureaucratic, economic, and geographic barriers often hinder in-person multidisciplinary care.

 The HF team can provide structured telephone support for patients as part of disease management or postdischarge services.

Telemedicine, such as telehealth, embraces electronic communication via mobile wireless device, phone, and/or smartphone, with or without video to diagnose or treat patients remotely.

Telemedicine’s main HF goals are to prevent and treat disease exacerbations and promote patient self-empowerment.

 With technology, patients can help providers make care decisions from afar by capturing data that signal decompensation and include blood pressure, body weight, heart rate and rhythm, and oxygen saturation.

The American Heart Association recommends that patients have an action plan for when symptoms arise.

 Its Self-Check Plan for HF Management, summarized in 

, uses a stoplight-type pattern to categorize symptoms. It empowers patients to reach out to providers early.

The direct-to-consumer health technology industry is booming. Nearly 20% of Americans use fitness monitors to track their health statistics.6 Although marketed for general fitness and health purposes, these wearable devices are becoming gradually more accurate and sophisticated and can be considered biological sensors.

 Telemedicine is largely focused on predicting acute decompensation associated with fluid congestion, including a warning alert when a patient gains more than 2 lbs in a day. However, body weight variability is not always an accurate indicator of total body water or decompensation.

Researchers are investigating devices that can recognize other indicators of worsening HF. These include:

 In HF, fluid accumulates in the lower body, leading to edema. No mechanism exists to measure lower-extremity swelling except visual inspection.

 For this reason, researchers have pilot-tested wearable technology called SwellFit. Worn around the ankle, SwellFit monitors the ankle’s curvature. Preliminary data showed that it successfully differentiated swelling from motion artifacts, such as change in values caused by external force or sensor rotation.

 The device’s creators plan to test SwellFit on hospitalized patients with HF to demonstrate feasibility and reliability.

The first implantable monitor the FDA cleared for HF monitoring is the CardioMEMS HF System, consisting of an implantable sensor, delivery system, and Patient Electronics System.

 The FDA cleared the device for patients with class 3 HF who were hospitalized in the past year. A provider implants the paper clip—sized sensor into the pulmonary artery via the delivery system (catheter) and it measures and monitors pulmonary artery pressure and heart rate. Patients take daily readings using the Patient Electronics System, which transmits the results electronically to their providers.8 This remote monitoring aims to reduce HF-related hospitalizations.

 Left untreated, atrial fibrillation can precipitate HF, so at-home ECG monitoring is helpful. The FDA cleared a self-administered ECG called Kardia.

 Patients simply open the Kardia application on their smartphones, place their fingers on 2 electrodes, and receive ECG results instantly.

Theoretically, monitoring these physiological signals could permit a more empowered and personalized experience for patients living with HF. Technology could promote more appropriate and frequent therapy adjustments and detect warning signals ahead of decompensation. 

, is a staff pharmacist at CVS Health in Pelham, New Hampshire.

American Heart Association. What is heart failure? Updated May 31, 2017. Accessed December 14, 2020. https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure

Brahmbhatt DH, Cowie MR. Remote management of heart failure: an overview of telemonitoring technologies. 

. 2019;5(2):86-92. doi:10.15420/cfr.2019.5.3

CDC. Heart failure. Updated September 8, 2020. Accessed December 14, 2020. https://www.cdc.gov/heartdisease/heart_failure.htm

Gensini GF, Alderighi C, Rasoini R, Mazzanti M, Casolo G. Value of telemonitoring and telemedicine in heart failure management. 

. 2017;3(2):116-121. doi:10.15420/cfr.2017:6:2

American Heart Association. Heart failure tools and resources. Accessed December 14, 2020. https://www.heart.org/en/health-topics/heart-failure/heart-failure-tools-resources

Singhal A, Cowie MR. The role of wearables in heart Failure. 

. 2020;17(4):125-132. doi:10.1007/s11897-020-00467-x

Kim S, Iravantchi Y, Gajos KZ, Grosz B. Swellfit: a wearable sensor for patients with congestive heart failure. Accessed December 14, 2020. https://www.eecs.harvard.edu/~kgajos/papers/2016/kim16SwellFit.shtml

FDA. CardioMEMS HF System-P100045. Updated January 11, 2016. Accessed December 14, 2020. http://wayback.archive-it.org/7993/20170112091357/http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm400550.htm

Kardia Mobile. AliveCor. Accessed December 14, 2020. https://www.alivecor.com/kardiamobile

Articles

Telemedicine and remote monitoring advancements can help prevent hospitalizations for the condition.

Spot Heart Failure a Mile Away

Erectile dysfunction (ED), the inability to develop or keep an erection, is men’s most common sexual problem, and it affects about 30 million Americans. ED often occurs when blood flow to the penis is limited or nerves are damaged, often by consistent hyperglycemia in diabetes. ED can signal serious illness, such as atherosclerosis, diabetes, heart disease, and hypertension. Other risk factors include alcohol or tobacco use, an enlarged prostate, psychological factors, sleep disorders, and stress.

Other sexual problems are often mistaken for ED, which is not a decreased interest in sex, occasional trouble having an erection, or structural problems that affect ejaculation.

 Age alone does not cause ED, but the condition is most common in middle-aged and older men.

The figure describes normal erections and what prevents them from occurring.

 Successful erections require a balance of contracting and relaxing agents. About 95% of ED cases are treatable.

The most common medications used for ED are phosphodiesterase type 5 (PDE5) inhibitors, which enhance endogenous nitric oxide levels. Of note, an erection occurs only if natural stimulation happens in conjunction with the drug. Four PDE5 inhibitors are FDA approved (see table

). They are a mainstay of therapy and are effective and well tolerated in more than 70% of men.

PDE5 inhibitors’ most common adverse effects (AEs) are back pain, dyspepsia, flushing, headache, flushing, and nasal congestion. Patients need medical attention for erections lasting longer than 4 hours (priapism) or for sudden vision loss in 1 or both eyes. Patients should avoid alcohol when taking PDE5 inhibitors because of the risk of severe hypotension.

Patients can take PDE5 inhibitors with or without food.

 Cytochrome P450 3A4 inducers and inhibitors can affect their hepatic metabolism. Combination with nitrates, such as isosorbide dinitrate and nitroglycerin, can create dangerous, sustained vasodilation.

 Of note, combining vardenafil with drugs affecting the QTc interval or in patients with a history of arrhythmia is discouraged.

Vardenafil is available as an orally disintegrating tablet (ODT) that patients place on top of the tongue to disintegrate. Patients should not take it with liquid. Vardenafil ODT tablets contain phenylalanine, which can harm patients with phenylketonuria.

 Patients with difficulty swallowing large amounts of liquid, impaired swallowing, or preexisting nausea may prefer the ODT formulation.

Men who respond poorly to or are intolerant of PDE5 inhibitors may benefit from alprostadil, available as an intracavernosal injection (ICI) or a urethral suppository. Alprostadil, a synthetic prostaglandin E1, activates a cascade that reduces cytoplasmic calcium, binds to smooth muscle cell surface prostaglandin receptors, and causes penile vascular smooth muscle relaxation, or erection.

Patients self-inject alprostadil ICI into the corpus cavernosum on the side of the penis. Its onset of action is 3 to 5 minutes, with subsequent erections lasting 30 minutes to 12 hours. Alprostadil ICI is effective in 70% to 87% of patients. Its discontinuation rate is 2% to 4%, usually because of penile burning or pain. Patients can use alprostadil ICI 3 times weekly, with at least 24 hours between doses.

Intraurethral alprostadil improves erectile function in 59% to 78% of men with ED. After the suppository is inserted into the urethra, the drug passes through the urethra and into the corpus cavernosum. Onset is about 5 minutes, resulting in a 30- to 60-minute erection. This formulation’s most frequent AEs are penile or urethral bleeding or pain. Priapism is less common than with ICI alprostadil, but systemic AEs, such as flushing and hypotension, are more common.

Several regenerative or restorative treatments are under investigation for ED.

 These include extracorporeal shock wave therapy, which involves low-intensity shock waves that aim to fix erectile tissues and help restore natural erections; intracavernosal injection of stem cells to help cavernous tissue regrowth; and intracavernosal injection autologous platelet rich plasma, to help cavernous tissue regrowth.

 is a community pharmacist and a freelance writer in New Hampshire.

 is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

Men & diabetes. Centers for Disease Control and Prevention. Updated April 1, 2019. Accessed March 21, 2020. https://www.cdc.gov/diabetes/library/features/diabetes-and-men.html

What is erectile dysfunction? Urology Care Foundation. Updated June 2018. Accessed March 21, 2020. https://urologyhealth.org/urologic-conditions/erectile-dysfunction(ed)

Mitidieri E, Cirino G, d’Emmanuele di Villa Bianca R, Sorrentino R. Pharmacology and perspectives in erectile dysfunction in man. 

. 2020:208:107493. doi:10.1016/j.pharmthera.2020.107493

Stendra. Prescribing information. VIVUS Inc; 2012. Accessed May 18, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202276s000lbl.pdf

Viagra. Prescribing information. Pfizer Inc; 1998. Accessed May 18, 2020. https://labeling.pfizer.com/ShowLabeling.aspx?id=652

Cialis. Prescribing information. Eli Lilly & Co; 2003. Accessed May 18, 2020. http://pi.lilly.com/us/cialis-pi.pdf

Levitra. Prescribing information. GlaxoSmithKline; 2014. Accessed May 18, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/021400s017lbl.pdf

Staxyn. Prescribing information. Merck & Co Inc; 2010. Accessed May 18, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/200179lbl.pdf

Hanchanale V, Eardley I. Alprostadil for the treatment of impotence. Expert Opin Pharmacother. 2014;15(3):421-428. doi:10.1517/14656566.2014.873789

Medications are remarkably effective at addressing men's most common sexual problem.