Become A Champion for Heart Health

The numbers are stark: According to the Heart Disease and Stroke Statistics 2021 Update, compiled each year by the American Heart Association (AHA) and the National Institutes of Health, cardiovascular disease (CVD) accounts for more deaths every year than all forms of cancer and chronic lower respiratory disease, combined, and between 2015 and 2018, upward of 126 million American adults were living with some form of CVD.¹

Through an interdisciplinary approach—administering and educating the public about the importance of vaccines, performing medication therapy management (MTM) services, offering counseling tips to improve outcomes, and recommending lifestyle modifications—pharmacists can make a significant difference for people living with CVD. Million Hearts 2022, a national initiative to prevent 1 million heart attacks and strokes within 5 years, focuses on evidence-based priorities to improve cardiovascular health²—and evidence shows that pharmacist-led cardiovascular clinics improve patient health outcomes.³

Vaccination and Heart Health

Patients with CVD are at an increased risk of complications from influenza and COVID-19, and pharmacists play a vital role in ensuring this population is vaccinated against these diseases.^4,5 According to the CDC, patients with certain cardiovascular conditions—such as heart failure (HF), coronary artery disease (CAD), cardiomyopathies, and hypertension—are at a higher risk of severe COVID-19 that could result in hospitalization and death.⁴

Andrea Levin, PharmD, BCACP, assistant professor, Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, Fort Lauderdale, Florida, shared the importance of COVID-19 boosters for patients with CVD. “Everyone 18 years and older should be getting a COVID-19 vaccine booster if it has been at least 6 months after completing their second dose of Pfizer-BioNTech or Moderna [or] at least 2 months after a single dose of Johnson & Johnson,” Levin said. This is an important counseling pearl that Levin provides to both her ambulatory care patients and her pharmacy students during their clinical rotations.

According to a study that evaluated over 80,000 adults in the United States hospitalized with influenza across 8 flu seasons, acute cardiovascular events occurred in 1 of every 8 patients, approximately 12%.⁶ Patients with CVD can receive any flu vaccine except the live attenuated influenza vaccine (nasal spray).⁵ And, Levin added, patients with CVD can receive their COVID-19 and influenza vaccines at the same time.

MTM and Counseling Pearls

Pharmacists can improve patient health outcomes by providing MTM services to patients with CVD.⁷ There are 5 core elements of MTM that can be implemented by pharmacist-led services: medication therapy review, personal medication record, medication-related action plan, intervention or referral, and documentation and follow-up.⁷ These services can include identifying uncontrolled hypertension or educating patients on CVD and other cardiac medication therapies, including anticoagulants like apixaban (Eliquis), rivaroxaban (Xarelto), and warfarin (Coumadin), which are typically used for atrial fibrillation and to prevent deep vein thrombosis and pulmonary embolism.8 Counseling points include monitoring for signs of bleeding and the importance of a consistent diet—as well as a reminder for patients taking warfarin to avoid consuming large amounts of foods that contain high quantities of vitamin K, such as spinach and kale.

Secondary prevention of atherosclerotic cardiovascular disease (ASCVD) should include 81 mg to 162 mg per day of aspirin.⁹ Recent guidelines from the American College of Cardiology (ACC) and the AHA indicate that aspirin therapy should not be routinely used for primary prevention of ASCVD because of the lack of benefit and an increased risk of bleeding (Table 1).¹⁰

Table 1. ACC/AHA Aspirin Recommendations for Primary Prevention

Pharmacists can educate patients based on risk factors to determine whether they would benefit from aspirin for primary prevention. Other antiplatelet therapies such as clopidogrel (Plavix), prasugrel (Effient), and ticagrelor (Brilinta) are also used for secondary prevention.⁹ Prasugrel should be avoided in patients with a history of stroke or transient ischemic attack because of an increased risk of significant or fatal bleeding.⁹

First-line pharmacologic therapy for hypertension typically includes thiazide diuretics (hydrochlorothiazide, chlorthalidone), angiotensin-converting enzyme (ACE) inhibitors (benazepril, enalapril), angiotensin II receptor blockers (ARBs; valsartan, irbesartan), and calcium channel blockers (CCBs; amlodipine).⁸ Pharmacists should recommend ACE inhibitors or ARBs for patients with diabetes because these agents can prevent nephropathy, CAD, and HF. Evidence suggests that taking ACE inhibitors and ARBs at bedtime, rather than in the morning, may result in better blood pressure control and a decrease in CVD events.¹¹

Moderate- to high-intensity statin therapy (atorvastatin, simvastatin) to reach a low-density lipoprotein cholesterol goal of 50% reduction in patients with ASCVD can decrease the risk of CVD events.¹² Pharmacists should ensure that patients who have experienced a myocardial infarction (MI) receive β-blockers (carvedilol, metoprolol), while atenolol therapy should be avoided because it has not been shown to improve outcomes after MI.⁹

Primary prevention of CVD is also a critical component of patient care. Adults age 40 and 75 years who are being evaluated for CVD prevention should undergo a 10-year ASCVD risk estimation; pharmacists should educate these patients about pharmacological therapy including antihypertensives and statins, as well as the importance of lifestyle modifications such as diet and exercise.¹⁰

Blood Pressure Monitoring and Hypertension Management

Pharmacists can become champions of hypertension control by performing blood pressure (BP) screenings at point of care and providing education about the importance of self-measured blood pressure monitoring (SMBP) at home.^13,14 A tool kit provided by the Million Hearts initiative includes patient education resources to ensure that any SMBP monitoring product is a validated device through the American Medical Association—meaning that the device has been validated for clinical accuracy through an independent review process.¹⁴

Pharmacists can also educate patients about the importance of effectively controlling hypertension and the link between measuring BP and controlling high BP.¹⁴ This education can include SMBP device operation techniques and a suggestion to measure BP on the upper arm, which produces more reliable measurements than the wrist.¹⁴ Results are typically displayed digitally and some devices will store readings, calculate average BP, and submit results directly to health care providers.

Pharmacists can provide the following tips for getting the most accurate BP measurements¹⁴:

• Avoid drinking caffeinated beverages or exercising within 30 minutes of measuring BP.
• Make sure the cuff fits the arm.
• Sit upright with the back supported, feet flat on the floor, and arm supported at heart level.
• The bottom of the cuff should be directly above the elbow.
• Relax for about 5 minutes before taking BP.
• Avoid talking during the BP measurement.
• Wait 1 minute and retake the BP to get an additional measurement.
• Keep a log and bring to all pharmacy and physician appointments.
• Bring the device to appointments yearly to check the accuracy.

Uncontrolled hypertension is a major problem among minority groups—in particular, non-Hispanic Black men. In 2018, data from the Los Angeles Barbershop Blood Pressure Study (NCT02321618)¹⁵ enrolled over 300 Black adult men with systolic BP greater than 140 mm Hg from 52 US barbershops. These barbershops became nontraditional health care settings: Each shop was assigned to a pharmacist-led intervention or the active control group.
In the control group, barbers encouraged lifestyle modifications and doctor’s appointments; in the intervention group, barbers encouraged meetings in their shops between customers and specialty-trained pharmacists who prescribed medication therapy through a collaborative practice agreement with the customers’ physicians.

At 6 months, the mean reduction in systolic BP was 21.6 mm Hg greater with the intervention (95% CI, 14.7-28.4).¹⁵ This study further highlights the importance of pharmacists in a nontraditional setting for managing patients with hypertension.

Lifestyle Modifications

Adults should participate in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity per week.¹⁰ Routine exercise can help lower BP, maintain healthy body weight, reduce diabetes risk, strengthen muscles, lower stress, and reduce inflammation. Pharmacists should encourage patients to begin by setting an attainable goal and increase exercise time as they get stronger, particularly if patients have been sedentary. Exercise can also be broken up throughout the day by taking 10-minute brisk walks.

Examples of moderate-intensity aerobic activities include brisk walking, water aerobics, dancing, gardening, tennis (doubles), and biking (< 10 miles per hour). Aerobic activities like hiking uphill with a heavy backpack, running, swimming laps, aerobic dancing, heavy yard work, tennis (singles), cycling (> 10 miles per hour), and jumping rope are considered vigorous intensity. Consuming a healthy diet that includes vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish, and minimizing the intake of trans fats, red meat, refined carbohydrates, and sweetened beverages is an important counseling point pharmacists should provide patients for primary and secondary prevention of CVD.^9,10

Table 2. Five Major Steps to Intervention: "5 A's"¹⁶

Smoking cessation counseling is also important to prevent CVD complications, and pharmacists can assess patients’ willingness to quit smoking during MTM consults (Table 2).¹⁶ Levin generally recommends “nicotine replacement therapy that consists of a long-acting formulation (a nicotine patch) and short-acting product (gum or lozenges). Combination therapy usually provides patients with the most success.”

Jennifer Gershman, PharmD, CPh, is a drug information pharmacist and medical writer residing in South Florida.

View the rest of our February 2022 issue here.

References

1. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics-2021 update: A report from the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:10.1161.CIR.0000000000000950
2. Million Hearts 2022. Department of Health and Human Services. Updated November 22, 2021. Accessed January 3, 2022. https://millionhearts.hhs.gov/
3. People with certain medical conditions. CDC. Updated December 14, 2021. Accessed January 3, 2022. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
4. Flu & people with heart disease or history of stroke. CDC. Updated August 26, 2021. Accessed January 3, 2021. https://www.cdc.gov/flu/highrisk/heartdisease.htm
5. Chow EJ, Rolfes MA, O’Halloran A, et al. Acute cardiovascular events associated with influenza in hospitalized adults: a cross-sectional study. Ann Intern Med. 2020; 173(8):605-613. doi:10.7326/M20-1509
6. Community pharmacists and medication therapy management. CDC. Updated August 27, 2021. Accessed January 3, 2022. https://www.cdc.gov/dhdsp/pubs/guides/best-practices/pharmacist-mtm.htm
7. Types of heart medications. American Heart Association. Updated January 15, 2020. Accessed January 3, 2022. https://www.heart.org/en/health-topics/heart-attack/treatment-of-a-heart-attack/cardiac-medications
8. Jones R, Arps K, Davis DM, Blumenthal RS, Martin SS. Clinician guide to the ABCs of primary and secondary prevention of atherosclerotic cardiovascular disease. American College of Cardiology. April 2, 2018. Accessed January 3, 2022.https://www.acc.org/latest-in-cardiology/articles/2018/03/30/18/34/clinician-guide-to-the-abcs
9. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678
10. Dickman M. PURL: Is it better to take that antihypertensive at night? J Fam Pract. 2020;69(7):362-364.
11. Virani SS, Smith SC, Stone NJ, Grundy SM.Secondary prevention for atherosclerotic cardiovascular disease: Comparing recent US and European guidelines on dyslipidemia. Circulation. 2020;141(14):1121-1123. doi:10.1161/CIRCULATIONAHA.119.044282
12. Hypertension control change package, second ed. CDC, Department of Health and Human Services. May 2020. Accessed January 3, 2022. https://millionhearts.hhs.gov/files/HTN_Change_Package.pdf
13. Self-measured blood pressure monitoring (SMBP) implementation toolkit. Million Hearts. December 2020. Accessed January 3, 2022. https://www.nachc.org/wp-content/uploads/2020/12/SMBP-Toolkit_FINAL.pdf
14. US blood pressure validated device listing. American Medical Association. Accessed January 3, 2022. https://www.validatebp.org/
15. Victor RG, Lynch K, Li N, et al.A cluster-randomized trial of blood-pressure reduction in black barbershops. N Engl J Med. 2018; 378(14):1291-1301. doi:10.1056/NEJMoa1717250
16. Five major steps to intervention (The “5 A’s”). Agency for Healthcare Research and Quality. December 2012. Accessed January 3, 2022.https://www.ahrq.gov/prevention/guidelines/tobacco/5steps.html