Treating Cardiovascular Disease Means Making Choices
Encourage patients to adhere to medication and recommendations, but also deprescribe when warranted, ensure that immunizations are up-to-date, and share new information.
Most pharmacists know that antihypertensives, weight loss, smoking cessation, and statins are the cornerstones of treating cardiovascular disease (CVD). Other successful strategies include maintaining good dental care, identifying and treating depression early, following a low-sodium diet that includes plenty of fish and roughage, limiting alcohol, getting regular and sustained exercise, and managing stress.1 These facts are well known among health care providers and often promoted in public health campaigns, so why do many Americans have poor cardiovascular health? Unfortunately, many are aware of these recommendations but have trouble implementing them.
Lowdown on Aspirin
For years, clinicians advised taking low-dose aspirin daily to prevent CVD. But healthy individuals should not take daily aspirin to prevent heart disease. Guidance on daily low-dose aspirin use changed in 2019. The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend daily aspirin only for patients who have had a heart attack, open heart surgery, or a stroke.1 Routine low-dose aspirin use in individuals without CVD appears to lower the incidence of heart attack or stroke by 17%, which is significant. But it increases the risk of gastrointestinal bleeding by 47% and the risk of intracranial bleeding by 34%.2 The news that aspirin’s anticoagulation effects and the risk of major bleeding outweigh its CVD preventive benefit may not have filtered down to the millions of Americans who are not at risk and have not had CVD. In addition, individuals with risk factors for CVD who have not experienced an event benefit more from lowering blood pressure and cholesterol levels, losing weight, and quitting smoking.1
Statin Therapy: When to Stop
As mentioned, statins are essential in CVD management in individuals with elevated low-density lipoprotein cholesterol levels (≥ 190 mg/dL), patients aged 40 to 75 years with diabetes mellitus, and those at cardiovascular risk. However, statins need not be a lifelong commitment.3 As patients age, especially past 75 years, those with no CVD symptoms may not need statins.4 This issue is receiving more attention as the proportion of individuals
in this age group grows. The results of one study showed that discontinuing statins in patients older than 75 years with life expectancies of less than a year significantly improved quality of life, lowered medication costs by $3.37 per day, and reduced the medication burden.5
Although controversy surrounds the issue of discontinuing statins in older adults, evidence is accumulating. Older adults who have had a heart attack, ischemic attacks, or stroke should continue their medications. Clinicians should remember that a small increase in geriatric-specific adverse effects could offset the cardiovascular benefit. Table 1 lists considerations for deprescribing.6,7
Let's Talk Immunization
Patients with CVD need to stay up-to-date with adult immunizations (Table 2.)8,9 They also will have questions about the coronavirus disease 2019 (COVID-19) vaccines. The message they need to hear is simple: Individuals who have CVD risk factors, had a heart attack or stroke, or have heart disease are at much greater risk from adverse effects of COVID-19 than they are from the vaccine. Patients with CVD may be concerned that their weakened immune systems are a contraindication. The vaccines for COVID-19 do not contain live virus, so patients with CVD need not worry.10
Although the ACC/AHA updated their joint guide- line in 2019, the bulk of their recommendations remained the same.1 As pharmacists encourage patients with CVD to adhere to medications and well-known recommendations, they should also deprescribe when warranted; disseminate new information, such as stopping use of unnecessary low-dose aspirin; and ensure that adult immunizations are up-to-date.
About the Author
Jeanette Y. Wick, MBA, RPH, FASCP, is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73(24):e285-e350. doi:10.1016/j.jacc.2018.11.003
- Veronese N, Demurtas J, Thompson T, et al. Effect of low-dose aspirin on health outcomes: an umbrella review of systematic reviews and meta-analyses. Br J Clin Pharmacol. 2020;86(8):1465-1475. doi:10.1111/bcp.14310
- Krishnaswami A, Steinman MA, Goyal P, et al. Deprescribing in older adults with cardiovascular disease. J Am Coll Cardiol. 2019;73(20):2584-2595. doi:10.1016/j.jacc.2019.03.467
- Bonnet F, Bénard A, Poulizac P, et al. Discontinuing statins or not in the elderly? study protocol for a randomized controlled trial. Trials. 2020;21(1):342. doi:10.1186/s13063-020-04259-5
- Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691-700. doi:10.1001/jamainternmed.2015.0289
- Odden MC, Pletcher MJ, Coxson PG, et al. Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years and older in the United States. Ann Int Med. 2015;162(8):533-541. doi:10.7326/M14-1430
- Lin L, Teng M, Zhao YJ, et al. Long-term cost-effectiveness of statin treatment for primary prevention of cardiovascular disease in the elderly. Cardiovasc Drugs Ther. 2015;29(2):187-197. doi:10.1007/s10557-015-6584-7
- Heart disease, stroke, or other cardiovascular disease and adult vaccination. CDC. Updated February 3, 2021. Accessed February 19, 2021. https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/heart-disease.html
- Vaccinations for adults with heart disease. Immunization Action Coalition. Accessed January 15, 2021. https://immunize.org/catg.d/p4044.pdf
- COVID-19 vaccines and therapeutics. American Hospital Association. Accessed January 15, 2021. https://www.aha.org/covid19vaccine