Yvette C. Terrie, BSPharm, RPh

Cardiovascular disease (CVD) continues to be the leading cause of death among men and women in the United States and worldwide, accounting for an estimated 655,000 deaths annually in the United States.

The most recent statistics from the American Heart Association indicate that in 2017, an estimated 17.8 million deaths were attributed to CVD globally, a surge of 21.1% from 2007.

 Annually, 805,000 individuals have a myocardial infarction, and 18.2 million adults 20 years and older have some degree of coronary artery disease.

 Among deaths attributable to CVD, coronary heart disease is the main contributor to mortality, accounting for 43.8% of deaths, followed by stroke, hypertension, and heart failure.

 Many of the classic risk factors for CVD, such as cigarette smoking, obesity, poor nutrition, and a sedentary lifestyle, are thought to increase inflammation and oxidative stress, thus influencing the development of atherogenesis.

Research has shown that micronutrients, including many vitamins and minerals, such as selenium and zinc, are involved in pathways that can modulate inflammation and oxidative damage and therefore are thought to play a role in diminishing the risk of CVD.

Pharmacists are in a pivotal position to expand awareness regarding the critical nature of being proactive about cardiovascular health. They can educate patients about both modifiable risk factors, such as diabetes, hyperlipidemia, hypertension, obesity, and smoking, and nonmodifiable cardiovascular risk factors, such as age, ethnicity, gender, and genetics/ familial history of CVD. Pharmacists can also encourage patients to discuss these risk factors with their primary health care providers.

 Results from a study show that an estimated 50% of deaths related to CVD are because of key modifiable CVD risk factors.

 Health experts indicate that implementing early-life interventions for cardiovascular health, before the occurrence of clinical manifestations, could assist in lessening the global burden of CVD.

As some of the most accessible health care providers, pharmacists are likely to encounter patients seeking advice on the various nutritional supplements marketed for cardiovascular health and can guide them on the proper selection and use.

Studies show that men are more likely than women to use supplements for heart health or to lower cholesterol.

There is a host of nutritional supplements marketed for the promotion of cardiovascular health and protective effects against CVD, which are available as combination or single-entity products in several dosage forms. Some foods are even fortified with omega-3 fatty acids and plant sterols for cardiovascular health. Manufacturers of some specialty mineral/multivitamin supplements are also marketing formulations specifically targeting a blend of essential nutrients for cardiovascular health. The most common supplements marketed for promotion of cardiovascular health include coenzyme Q10 (CoQ10), garlic, omega-3 fatty acids, and plant sterols.

There are many studies exploring the use of nutritional supplements in cases of CVD, and there is still debate about the issue.

For instance, in a 2019 publication, researchers indicated that low vitamin D levels have been associated with atrial fibrillation, heart failure, and coronary artery disease, and deficiency of CoQ10 has been linked with myocardial dysfunction and to statin myopathies.

They also indicated that multivitamin supplementation has been shown to diminish cardiovascular events, and the use of probiotics has been proposed to lower both blood pressure and circulating lipids.

Another study explored how multivitamin use is associated with the risk of CVD in initially healthy men at baseline. Researchers concluded that in initially healthy men, multivitamin use for 20 years or fewer years was correlated with a lesser risk of major CVD events.

In a 2019 publication, researchers examined evidence about the effects of dietary interventions and nutritional supplements on cardiovascular events and mortality in adults. They concluded that the use of omega-3 long-chain polyunsaturated fatty acids and folate supplementation could lessen risk for some cardiovascular outcomes in adults.

 aimed to explore the literature supporting the use of minerals/multivitamins and oral multivitamins for treatment and prevention of CVD. They concluded that despite the popular use of supplements by patients, there is no evidence to support the routine supplementation of minerals/multivitamins and oral multivitamins for CVD prevention or treatment.

A recent study published noted that the pesco-Mediterranean diet, which consists of moderate amounts of dairy, extra virgin olive oil, plants, and fish and seafood as the principle sources of animal protein, with daily time-restricted eating within a window of 8 to 12 hours, is proposed as an ideal cardioprotective diet.

Poor diet quality has surpassed all other risk factors for death, accounting for 11 million deaths and about 50% of cardiovascular deaths globally, according to the 2017 Global Burden of Disease Study, a comprehensive report on the health impact of diet in 195 countries around the world.

In August 2020, the American Heart Association (AHA) issued a new scientific statement recommending the implementation of a rapid diet screening tool that can be incorporated into electronic health record platforms across all health care settings.

Before recommending any supplement marketed for cardiovascular health, it is imperative that pharmacists ascertain the appropriateness of use and screen for potential contraindications and drug interactions. Patients with preexisting medical conditions and those taking other medications should always consult their primary health care providers before using supplements. During counseling, advise patients that the use of supplements is not intended to be a replacement for a healthy diet or for any prescription antihyperlipidemia agents or other prescription drugs for CVD. The AHA indicates that an estimated 80% of CVD is preventable via controlling diabetes, hyperlipidemia, and hypertension, along with implementing healthy lifestyle behaviors, such as smoking cessation.

, is a consulting pharmacist and a medical writer in Haymarket, Virginia.

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Articles

Pharmacists must ascertain the appropriateness of use and screen for potential contraindications and drug interactions.

Nutritional Supplements Can Help Prevent and Reduce Cardiovascular Disease

The coronavirus disease 2019 (COVID-19) pandemic continues to put an immense burden on the nation’s health care system and has altered the delivery and practice of health care in many ways.

Health care professionals, including pharmacists, are overcoming those challenges with dedication and ingenuity and continuing to provide quality care to patients. Pharmacists are, for example, addressing concerns from especially anxious, fearful patients amid the cold and influenza season.

The CDC indicates that an estimated 90% of Americans live within 5 miles of a community pharmacy, providing easy access to patients.

 In a July 2020 report, the CDC indicated that despite the challenge of dealing with the pandemic, pharmacists have maintained the delivery of critical health services to patients, including those patient populations at greater risk for COVID-19—related complications.

 The CDC report also noted that pharmacists are in a vital position to deliver priority pandemic responses, including COVID-19 testing, point-of-care testing for chronic disease management, and vaccinations.

Pharmacists have also been instrumental in providing patients with reliable information about the prevention, detection, treatment, and management of COVID-19.

The American Pharmacists Association (APhA) indicates that the scope of practice for pharmacists has broadened during the pandemic, with more patients seeking care from pharmacists and more pharmacies anticipating increased point-of-care testing and expanded immunization services.

A recent survey conducted by the National Community Pharmacists Association (NCPA) explored how the pandemic is modifying community pharmacy practice. Respondents said that the pandemic may result in more pharmacies offering point-of-care testing (61.3%) and immunizations (52.1%) and expanding their scope of practice (56.9%).

 The majority (61%) also said the pandemic increased consumer demand for online products and availability.

 Additionally, the respondents have increased curbside delivery or extended delivery services (82.4%) and increased their online presence or social-media advertising (37.5%) in recent months. Respondents also noted that these changes are expected to continue even after the pandemic, as will pharmacy employees’ use of personal protective equipment, such as gloves and masks.

In April 2020, the US Department of Health & Human Services (HHS) issued new guidance under the Public Readiness and Emergency Preparedness Act (PREP) allowing licensed pharmacists to order and administer COVID-19 tests that are FDA authorized.

 On September 9, 2020, HHS issued guidance under the PREP Act authorizing state-licensed pharmacists to order and administer—and state-licensed or registered pharmacy interns acting under the supervision of the qualified pharmacist to administer&mdash;COVID-19 vaccinations to individuals 3 years or older, subject to certain requirements.

Several major pharmacy organizations, including the American Association of Colleges of Pharmacy, the APhA, the American Society for Clinical Pathology, the American Society of Health-System Pharmacists, the College of Psychiatric and Neurologic Pharmacists, the Hematology/Oncology Pharmacy Association, the National Alliance of State Pharmacy Associations, the National Association of Chain Drug Stores, the NCPA, and the National Pharmaceutical Association, have advocated for expanding the role of pharmacists and released a set of policy recommendations to address the challenges associated with combating the virus. The 4 key suggested policy recommendations are: Address continuity and shortage of care; authorize tests, immunize for, and treat, infectious diseases, such as COVID-19; ease operational barriers to address workflow and workforce issues; and reimburse for services and remove barriers.

Despite being integral members of the health care team in disease management and patient care, pharmacists are the only providers who do not have full provider status at the federal level.

 As of October 2020, just 37 states allow pharmacists to qualify as medical providers under the rules of Medicare Part B, and as a result, pharmacists encounter administrative obstacles when seeking reimbursement for clinical services offered.

The APhA has indicated it is working to obtain provider status for pharmacists for Medicare coverage and support for fundamental payment reform for pharmacists’ service.

Granting provider status to pharmacists is associated with numerous clinical benefits, including delivery of telepharmacy services, medication management, vaccinations without restrictions, and testing and treating patients.

 Granting provider status to pharmacists would eradicate financial, logistical, and regulatory barriers to vaccination and improve vaccination rates and patient outcomes.9 Moreover, provider status would allow pharmacists to improve patient care through disease management services, including counseling, screening, and treatment.

Pharmacists can act as patient identifier, advocate, and educator. Throughout the pandemic, pharmacists have continued to deliver quality care to patients, and their valuable role in patient care continues to evolve. As the gatekeepers of proper drug use, pharmacists provide clinical interventions and patient support that improve outcomes. They are also well trained and positioned to provide a variety of clinical services to patients, such as counseling about the efficacy and safety of vaccines, including the COVID-19 vaccine when it becomes available; disease education and support; medication management and monitoring; patient education; and point-of-care administration and testing.

 Pharmacists can also help dispel misconceptions and myths about vaccinations and provide patients with facts. Their accessibility can augment rates of vaccinations among all patient populations and help patients make informed decisions about their health. The importance of pharmacists in health care delivery is indispensable and should never be taken for granted.

, is a consulting pharmacist and a medical writer in Haymarket, Virginia. 

Strand MA, Bratberg J, Eukel H, Hardy M, Williams C. Community pharmacists’ contributions to disease management during the COVID-19 pandemic. 

Tanzi MG. Community pharmacies have an even bigger role during COVID-19. American Pharmacists Association. August 18, 2020. Accessed November 10, 2020. https://www.pharmacist.com/article/communitypharmacies- have-even-bigger-role-during-covid-19

Weitzman D. Provider status for pharmacists: it’s about time. 

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HHS statements on authorizing licensed pharmacists to order and administer COVID-19 tests. News release. US Department of Health & Human Services. April 8, 2020. Accessed November 9, 2020. https:// www.hhs.gov/about/news/2020/04/08/hhs-statements-on-authorizinglicensed- pharmacists-to-order-and-administer-covid-19-tests.html

Pharmacists as front-line responders for COVID-19 patient care. American Pharmacists Association. Accessed November 15, 2020. https:// www.pharmacist.com/sites/default/files/files/APHA%20Meeting%20 Update/PHARMACISTS_COVID19-Final-3-20-20.pdf

Pharmacist advocacy groups call for new action to enhance COVID-19 patient care News release. American Pharmacists Association. March 20, 2020. Accessed November 10, 2020. https://www.pharmacist.com/ press-release/pharmacist-advocacy-groups-call-new-action-enhancecovid- 19-patient-care

Billingsley A. Yes, pharmacists are healthcare providers. GoodRx. June 15, 2020. Accessed November 9, 2020. https://www.goodrx.com/blog/ yes-pharmacists-are-healthcare-providers/

American Pharmacists Association comments on the presidential election. News release. American Pharmacists Association. November 9, 2020. Accessed November 10, 2020. https://www.pharmacist.com/ press-release/american-pharmacists-association-comments-presidential- election

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They have maintained delivery of critical health services to patients, Including those at greater risk for COVID-19–related complications.

Pharmacists Rise to the Challenge of Expanded Roles

Vulvovaginal candidiasis (vvc), also known as a yeast infection, is one of the most common vaginal infections affecting an estimated 75% of women, who report at least 1 episode in their lifetime.

Self-treatment with OTC antifungal therapy is appropriate in women with infrequent, mild, and uncomplicated infections, according to the CDC.

Recurring episodes may be an indication of an underlying issue, so encourage patients to pursue further medical care from their primary health care providers, as there is a potential for inappropriate therapy.

 For example, research shows that many women have difficulty identifying a VVC episode, and 2 of 3 who purchase OTC VVC antifungals do not really have a yeast infection.

Although any woman can develop VVC, certain factors may increase the risk, especially in terms of recurring infections. Factors that may augment the risk of developing VVC include estrogen replacement therapy, high-dose estrogen oral contraceptives, pregnancy, and uncontrolled diabetes.

 Some patients also report developing a VVC infection during or after completing treatment with broad-spectrum antibiotics. Moreover, patients taking systemic antineoplastic drugs, corticosteroids, or immunosuppressant agents also have reported developing VVC infections.

Classic signs and symptoms of VVC may include abnormal vaginal discharge, ranging from a slightly watery, white discharge to a thick white discharge with no odor; inflammation of the vulvar skin; intense burning, especially when urinating; itching; a pH greater than 4.5; and soreness.

Patients with a history of recurring episodes of VVC, those with severe symptoms, and women with preexisting medical conditions should be referred for further medical evaluation and treatment.

 In general, the goals of therapy for vaginal fungal infections are resolution of infection, restoration of normal vaginal flora, and symptomatic relief. To date, the FDA-approved treatment OTC options for uncomplicated VVC include clotrimazole, miconazole,

and tioconazole, which are available in vaginal creams, suppositories, and tablets.

 Some formulations are available in 1-, 3- and 7-day treatments. Pharmacists should advise patients to adhere to the manufacturer directions and always ask questions about any concerns. Some manufacturers of OTC VVC products also have useful patient education resources, including symptom assessment tools on their websites and other resources about vaginal health.

It is important to remind patients to complete the full course of therapy as indicated by the manufacturer instructions on the selected product, even if symptoms appear to improve. Failure to complete therapy for the recommended duration is considered the leading cause of recurring VVC episodes.

 Patients whose symptoms show no signs of improving or worsen should seek immediate medical attention. During counseling, pharmacists should ensure that patients understand the proper use of OTC products indicated for VVC.

Pharmacists can advise patients to always wash their hands before and after application of the antifungal product; complete the full course of therapy, even during menstruation; insert the product once daily, ideally at bedtime, because lying down can minimize product leakage; not to douche or use tampons when using vaginal antifungals; refrain from intercourse during treatment; and seek medical care if symptoms persist or worsen. They can also let patients know that symptoms typically improve 24 to 48 hours after initiating therapy.

Pharmacists can educate patients about recommended preventive measures and self-care for VVC. They can also encourage and remind patients to consult their primary health care providers to confirm diagnosis, especially if this is the first occurrence of VVC, and urge those with recurring episodes to seek further medical care to avoid additional complications and rule out other possible causes. Pharmacists can also inform patients about populations who should not self-treat and advise them to seek medical care. These include patients who are pregnant; have a fever or pain in the lower abdomen, back, pelvic area, or shoulder; take pharmacological agents that predispose them to VVC, such as chemotherapy and steroids; and are younger than age 12. It also includes patients with a history of VVC episodes that have occurred more than 3 times per year or in the past 2 months and those with a history of medical conditions that predispose them to VVC, such as an HIV infection or uncontrolled diabetes.

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Vulvovaginal candidiasis, also known as a yeast infection, is one of the most common vaginal infections affecting an estimated 75% of women, who report at least 1 episode in their lifetime.

Help Patients Recognize and Self-Treat Vulvovaginal Candidiasis

Many people experience the discomfort associated with dyspepsia and heartburn at some point, but others unfortunately experience gastric discomfort on a regular basis.

Dyspepsia and heartburn are common complaints that if left unresolved can negatively affect quality of life, interrupt sleep, and restrict or limit the ingestion of certain foods.

 Patients may experience both dyspepsia and heartburn.

An estimated 60 million individuals in the United States experience heartburn at least once a month, and more than 15 million experience it daily, according to the American College of Gastroenterology.

The upper gastrointestinal (GI) tract consists of the duodenum, esophagus, and stomach, and there are numerous causes for upper gastric pain.

 Some sources are minor and amenable to self-treatment, but others may necessitate further and immediate medical treatment. Examples of possible causes of upper gastric pain include appendicitis, bowel obstruction, diverticulitis, dyspepsia, flatulence, gallstones, gastritis, gastroenteritis, heart burn, liver or pancreatic issues, and muscle pain.

 In many cases, a condition may cause another complication, and it is critical to recognize when to pursue further medical care and evaluation.

 For example, gallstones can cause liver dysfunction, and ulcers can cause indigestion.

 Depending upon the severity and types of symptoms, upper gastric pain can be a minor inconvenience or so intense that it makes functioning difficult.

Because pharmacists are likely to encounter patients seeking guidance on nonprescription products to prevent and treat mild or moderate cases of dyspepsia and heartburn, they should be prepared to counsel patients about the efficacy and safety of these products. Available OTC products to treat dyspepsia, gastroesophageal reflux disease (GERD), and heartburn include antacids and histamine2-receptor agonists (H2RAs) for patients with infrequent, mild dyspepsia and heartburn. There are also proton pump inhibitors that can be used for treating frequent heartburn (occurring more than 2 days per week) or for those who do not respond to OTC H2RAs.

Before recommending any nonprescription product for dyspepsia and heartburn, a pharmacist should determine whether self-treatment is appropriate. Pharmacists can identify patients at increased risk for developing dyspepsia and heartburn, due to certain lifestyle habits, medical conditions, or pharmacological agents, as well as direct patients with symptoms not amenable to self-treatment to immediately seek further medical evaluation. During counseling, patients should be advised that heartburn that is frequent, persistent, or lasts longer than 3 months is the most common symptoms of GERD, which can cause long-term complications, such as Barrett’s esophagus, esophageal cancer, esophagitis, and GI bleeding, if left untreated.

Chronic heartburn may increase an individual’s risk of throat cancer, according to the American Cancer Society. Therefore, it is important that individuals with frequent heartburn receive appropriate treatment as soon as possible.

Patients with dyspepsia and heartburn may present with a bitter or sour taste in the mouth; choking or coughing, especially while lying down; excessive burping; frequent sleep interruptions caused by indigestion; a hoarse, sore throat; painful burning sensation in the chest, just behind the sternum, characteristically within 1 to 4 hours after eating; and regurgitation of food.

 Several factors are often considered when selecting a nonprescription agent for the self-treatment of dyspepsia and heartburn, such as contraindications; cost; dosage form and intervals; duration, frequency, and severity of symptoms; and potential drug/drug interactions. Pediatric patients, those with preexisting medical conditions, and women who are lactating or pregnant should consult with their primary care physicians (PCPs) before using any of these products. Patients with persistent and recurring episodes of heartburn or those exhibiting atypical or severe symptoms should be immediately referred to their PCPs for additional medical evaluation. If symptoms show no signs of improvement or worsen after 14 days of self-treatment, patients using OTC products should seek immediate medical care from their PCPs.

Pharmacists also can recommend nonpharmacological strategies for averting or diminishing the prevalence of dyspepsia and heartburn, such as avoiding greasy or spicy foods or late-night eating, consuming larger meals, losing weight, and stopping smoking.

An excellent patient resource on GERD is the American Gastroenterology Association (AGA) website (https://patients.gi.org/topics/acid-reflux/). The AGA also has an online test for GERD on its website (https://gi.org/topics/acidreflux/). 

What is GERD. American Gastroenterological Association. Accessed September 4, 2020. https:// gastro.org/practice-guidance/gi-patient-center/topic/gastroesophageal-reflux-disease-gerd/

Whetsel T, Zweber A. Heartburn and dyspepsia. In: Krinsky D, Berardi R, Ferreri S, et al, eds. 

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Educate patients about the appropriate and safe use of gastrointestinal products and direct them to seek further medical care when warranted.