Common Cardiac Conditions and Medication Treatment Options

Cardiac conditions and their treatment with medications is a huge topic.  Below, we will discuss some of the most common cardiac conditions in brief and also list (by category) the ever growing compendium of cardiac medications.  It is important to see the entire list so that you have somewhat of an idea of all the choices that go through the mind of your physician when they are evaluating you for medication treatment. 

Each category of medications has its own set of side effects, adverse reactions, drug interactions, monitoring parameters, food interactions and cautions and precautions to be aware of.  Further, within each category, the profile is somewhat different for each medication.  When picking up your prescriptions, always take the time to discuss your medication with your pharmacist, even if you have already discussed the process with your physician. 

The goal of this handout is to help educate you about your condition, your medication options and raise some questions for you so you may then engage your own health care practitioner in an educated discussion about your medication therapy.

Always ask your pharmacist if any of the medications you are taking have a
Black Box Warning.

 
Blood Pressure

If high blood pressure is left untreated, the blood vessels will harden and this will eventually lead to a heart attack or a stroke. Increased blood pressure will damage the vessels that supply the retina with blood and lead to vision problems. Furthermore, the filtering cells in the kidneys will become damaged and lead to kidney failure. Lastly, the heart will tire from pumping against the increased pressure and eventually lead to heart failure.

Atherosclerosis & Cholesterol

The buildup of cholesterol on a blood vessel wall causing the development of plaque is known as atherosclerosis.   Over time, this plaque will build up on the inside of the blood vessel and minimize the space for the blood to flow through.  Two bad things can happen here. First, as the blood vessel narrows because of the plaque buildup, the blood vessel downstream will have a decrease supply of blood and because of this, the tissues will get less oxygen. This can be very dangerous when the blockage leads to your heart or brain.  Second, if the plaque breaks free, it can scratch a blood cell and start the blood clot cascade which may lead to either a stroke or a heart attack.

Heart Rhythm

Quite often, heart arrhythmia's are harmless. Occasionally, people will have an irregular heartbeat that causes a bit of fluttering or temporary racing heartbeat. On the other hand, arrhythmia's have the potential of causing significant and life threatening complications. An irregular heartbeat is one of the conditions that predispose an individual to developing a blood clot which may get stuck in the legs, lungs, heart or brain. As we know, blood clots may be life threatening.

Acute Coronary Syndrome (ACS)

Acute Coronary Syndrome is brought on by decreased blood flow to the heart. This can be described as the crushing pain one feels during a heart attack, or the light chest pain one may feel while at rest or performing light physical activity.  In management of ACS, the focus is on three main therapies. First, the patient needs to be stabilized, second, the chest pain needs to be relieved, and third, anti-thrombotic therapy needs to be provided to prevent a clot.
 

Blood Pressure Control

In general, taking medications that lower your blood pressure may make you feel a little light headed, dizzy or tired.  Take it slow when you go from a sitting to standing position.  Balance yourself for 10 seconds to make sure you are stable before taking a step.  If you are dizzy when you stand up and the lightheadedness does not clear up within 30-60 seconds, have a seat.  If the dizziness continues, please let your doctor know as soon as possible. 

Angiotensin Converting Enzyme Inhibitors (ACEI’s) work by inhibiting a portion of the renin-angiotensin-aldosterone system which in turn relaxes pressure on the blood vessels and allows the blood to flow more smoothly.

  • Benazepril (Lotensin-TM)
  • Enalapril (Vasotec-TM)
  • Lisiniopril (Prinivil-TM, Zestril-TM)
  • Quinapril (Accupril-TM)
  • Ramipril (Altace-TM)

Angiotensin Receptor Blockers (ARB’s) work by inhibiting a different portion of the renin-angiotensin-aldosterone system which in turn also relaxes pressure on the blood vessels and allows the blood to flow more smoothly.

  • Candesartan (Atacand-TM)
  • Irbesartan (Avapro-TM)
  • Losartan (Cozar-TM)
  • Olmesartan (Benicar-TM)
  • Valsartan (Diovan-TM)

Renin Inhibitors work by inhibiting yet another different portion of the renin-angiotensin-aldosterone system which in turn also relaxes pressure on the blood vessels and allows the blood to flow more smoothly.

  • Aliskiren (Tekturna-TM)

Alpha Blockers-(peripheral) work to block the body’s natural chemicals that affect blood vessels and the heart. This medication may decrease blood pressure by relaxing blood vessels and decreasing the strain on the heart.

  • Doxazosin (Cardura-TM)
  • Prazosin (Minipres-TM)
  • Terazosin (Hytrin-TM)

Alpha Agonists-(centrally acting) work in your brain to block the stimulation that constricts your blood vessels.  By decreasing this stimulation, your blood vessels are relaxed and blood pressure is decreased.

  • Clonidine (Catapres-TM)
  • Guanfacine (Tenex-TM)

Beta Blockers work to block the body’s natural chemicals that affect blood vessels and the heart. This medication may decrease blood pressure by relaxing blood vessels, slowing heart rate and decreasing the strain on the heart.

  • Atenolol (Tenormin-TM)
  • Carvedilol (Coreg-TM)
  • Carvedilol (Coreg CR-TM)
  • Metoprolol (Lopressor-TM)
  • Metoprolol XR (Toprol XR-TM)
  • Nadolol (Corgard-TM)
  • Nebivolol (Bystolic-TM)
  • Propranolol (Inderal-TM)
  • Propranolol LA (Inderal LA-TM)

Calcium Channel Blockers work by relaxing the blood vessels in both the vascular system and in the heart. By doing this, the resistance that the heart needs to pump against is decreased, heart rate is decreased, and the heart does not need to work as hard to pump blood.

  • Amlodipine (Norvasc-TM)
  • Diltiazem ER (Cardizem CD-TM, Dilacor XR-TM, Taztia XT-TM and others)
  • Felodipine (Plendil-TM)
  • Isradipine (Dynacirc CR-TM)
  • Nifedipine ER (Procardia XL-TM, Adalat CC-TM, and others)
  • Nisoldipine (Sular-TM)
  • Verapamil SR (Calan SR-TM, Isoptin SR-TM, and others)

Diuretics, sometimes called water pills, increase the volume of urine eliminated from your body. Taking a diuretic helps the body rid itself of excess water and salt, thereby, decreasing blood pressure and excess strain on the heart.

  • Bumetadine (Bumex-TM)
  • Furosemide (Lasix-TM)
  • Hydrochlorathiazide (Esedrix-TM)
  • Metolazone (Zaroxolyn-TM)
  • Torsemide (Demadex-TM)

Blood Clot Treatment and Prevention

In general, you will have a tendency to bleed easily while taking this category of medication.  If you notice any unusual bleeding, such as bleeding from the gums while brushing your teeth, a constant nose bleed, or prolonged bleeding from a cut, you should notify your health care provider.  In the unusual event that you  notice any blood in your urine or stool, or are vomiting or coughing up blood, please notify your doctor and report to the nearest emergency room.  Not everyone who takes these medications will experience side effects, however, if you notice any unwanted effect, please talk about it with your doctor of pharmacist.

Vitamin K antagonists blocks the production vitamin K which in turn inhibits the production of clotting factor.   This decreases the potential for the body to develop a clot.

·         Warfarin (Coumadin-TM)

Anti-Thrombin medications interfere with thrombin and inhibit the extensive clotting cascade at one point or another.   This helps to treat and block the development of a blood clot.

·         Apixaban (Eliquis-TM)
·         Dabigatran (Pradaxa-TM)
·         Enoxaparin (Lovenox-TM)
·         Rivaroxaban (Xarelto-TM)

Anti-Platlet medications act on the platelets,(which are a type of blood cell that help damaged arteries by forming a plug to prevent bleeding). The anti-platelet medications work to inhibit platelet aggregation in patients who are at risk for developing blood clots in their arteries.

·         Aspirin/Dipyridamole (Aggrenox-TM)
·         Clopidogrel (Plavix-TM)
·         Prasugrel (Effient-TM)


Heart Rhythm Maintenance

In general; while taking anti-arrhythmic medications you may experience some nausea, vomit or diarrhea.  You may also experience some dizziness, headache, constipation, anxiety and maybe a little tiredness.  Please, if these, or any other unwanted side effect persists, call your doctor or pharmacist to discuss it with them.

Anti-arrhythmic medications work by slowing the transmission of the chemicals the heart uses for electrical conduction of the heart rhythm. This process prolongs the conduction time of the contraction in all areas of the heart which significantly decreases the chances for irregular heartbeats. This category of medication helps maintain a regular and steady heartbeat.

  • Amiodarone (Cordarone-TM, Pacerone-TM)
  • Disopyramide CR (Norpace CR-TM)
  • Dronedarone (Multaq-TM)
  • Flecanide (Tambacor-TM)
  • Propafenone (Rythmol-TM)
  • Propafenone (Rythmol SR-TM)
 
Cholesterol Medications

An infrequent side effect associated with the Statins is muscle pain, which may rarely lead to a condition known as rhabdomyolysis.  This is characterized by muscle weakness, tenderness and an unusual tiredness, possibly with a fever.  This may be damaging to the muscles and liver if not acted upon.  If you notice any of these symptoms, or any symptoms of liver difficulty such as yellowing eyes, dark urine or a persistent nausea or abdominal pain, please do not hesitate, let your doctor know immediately.

Statins work by blocking an enzyme in the liver that is necessary for the production of cholesterol

  • Atorvastatin (Lipitor-TM)
  • Lovastatin (Mevacor-TM)
  • Rosuvastatin (Crestor-TM)
  • Simvastatin (Zocor-TM)
Please remember, this is a general reference, specifically prepared with the goal that it will be utilized to help stimulate educated questions and discussions between patients and their health care practitioners.  If you have any questions, please contact your Community Pharmacist or your Primary Health Care Practitioner. 

To learn more about any of the medications discussed in this blog, please www.AudibleRx.com and listen to the Medication Specific Counseling Session you are interested in.

Thanks
Steve

Copyright AudibleRx (TM), all rights reserved.

Pharmacy Customer Service

Pharmacy customers are not made through coupon cards, price matching, drive through windows and 10 minute prescription guarantees.  Customers are made and retained through real and meaningful attention to service.  Is the customer recognized when they walk into the pharmacy?  Does the customer feel as if they may approach their pharmacist with questions and is their pharmacist available to discuss their medical conditions with them?

I practice in an outpatient clinic pharmacy located next to a community hospital.  Yes, we do fill discharge prescriptions; however, our customer base comes from the local population.  These people have the option of utilizing one of the local Big Box pharmacies; however, for one reason or another, they go out of their way to come to our little store. 

Today I was fortunate to be present and experience my pharmacist partner provide a level of customer service indicative of a community pharmacy whose sole existence is dependent upon the provision of unparalleled customer service.

Last summer my partner attended a pharmacy trade show.  He always comes back with many different ideas on how we may better increase our front end sales with different devices and products.  This past year he brought back a functional and incredibly inexpensive blood glucose meter.  The beautiful thing about this particular meter, other than its complete ease of operation, was the fact that the test strips are very inexpensive.

Over the months we have sold quite a few of these devices and patients regularly come back to our store to purchase the test strips.  Today, one of our regular customers came in and was looking to purchase another one of these particular machines because he had misplaced his and, after looking everywhere, couldn't find it and thought he would just stop by and get another one. 

It just so happened that my partner took this particular situation (we are good about taking equal turns handling customer service issues that show up in the store).   After a brief discussion with the patient he realized that we were out of this machine on the shelf.  The patient still had a full box of test strips at home so he wasn't interested in another machine, besides, he really appreciated how he had been sold the first one and liked how it works.

After researching the issue on our wholesaler's website, we realized that the machine was no longer listed as an available product.  My partner got on the phone and called the manufacturer of the machine.  After a lengthy discussion about availability and options, the manufacturer stated that our wholesaler was still listed as a distributor of this particular machine.  He then called the wholesaler who, after another lengthy discussion about availability and options, stated that in fact this machine was no longer a product that they were carrying.

At this point he could have given up, let the patient know that it wasn't available, and then sold him another machine.  This isn't what happened.  My partner then persisted with the wholesaler, describing that he had been sold the machine at their trade show last summer, had purchased quite a few units, and had been selling them to patients.  He asked if perhaps one of the other divisions may still stock these blood glucose units.

After a bit of research, the wholesaler found another division that does stock these units and they would have a few of them shipped to us within a couple days from the other division.  The patient left the store satisfied that his needs had been met, with an increased trust that only comes from a satisfied customer experience.  This is what keeps patients coming back, not discount/transfer cards!

During this time, which was about 20 minutes start to finish, the customer was pleasantly sitting in the waiting area watching the pharmacy flow.  Patients would come and go, drop off and pick up prescriptions; we were answering other phone calls and still had time for counseling patients. 

Not only did my pharmacist partner provide fantastic customer service to this patient, we did it without interrupting the daily flow of the pharmacy. 

Thanks
Steve
Copyright AudibleRx (TM), all rights reserved.

Medication Adherence and Heart Patients

Really, how important is it to maintain adherence to your medication profile?
 

I have a friend whose heart stopped beating due to a massive heart attack over ten years ago. His wife found him unresponsive, called 911 and performed CPR on him until the paramedics arrived. He was taken to the hospital for an extended stay in the intensive care unit where doctors and nurses performed multiple procedures, infused him with many different medications and monitored him constantly in an effort to stabilize his now beating heart. When discharged from the hospital, my grateful friend did one important thing; he followed his doctor's directions.

1.       First of all, he quit smoking. He had smoked daily and regularly for many years. He has not smoked a single cigarette since he left the hospital.

2.       He signed up with a health club, and began a regular course of aerobic and resistance training.

3.       He followed his doctor's orders about taking his new medications.  He is 100% adherent to his medication profile.

 
So, why is adherence important?

·         Adherence is described as "the degree to which patients correctly follow prescription instructions."

·         The most recent adherence statistics state that:

·         Of the over 3.2 billion prescriptions (yes, 3.2 billion) dispensed each year in the United States, over half are non-adherent.

·         An astounding 32 million Americans use 3 or more medications on a daily basis.

·         Over 75% of adults are not adherent in one way or another to their medication.

·         Mortality data shows that over 125K deaths per year in United States are related to non-adherence to medication therapy.

·         Estimates show that over 69% of all medication related hospital admissions and 40% of all medication related nursing home admissions are due to medication adherence issues.

·         So again, why is adherence important, well, the best estimates put the cost of non-adherence at somewhere between 100 and 300 billion dollars per year.  Now those are some significant health care dollars!

 
Now, why, specifically, is adherence important with cardiac patients?

·         The 10/13 issue of the American Heart Journal reviewed the medication adherence in post-heart attack patients.

·         Most medication adherence studies review WHY patients are non-adherent to their medication profile.  This study was different. 

·         This particular study examined the long term clinical outcome of the patients compared to how often they were adherent to their medications.

·         The results are more than convincing.  This study shows that post-heart attack patients, who are at least 80% adherent to their medications, are significantly more likely to have a long term positive outcome of therapy.

·         So, with results like these, why would anyone not be adherent to their medications?

 
There are many different barriers to medication adherence, here; we will discuss a few of the most common.

·         COST of medications:  Yes, many medications are expensive.  What happens is a patient cannot afford their medication and then decide on their own that it is better to take it every 2 or 3 days and save some money rather than not take the medication at all.  Then, a couple months go by and they may just stop all together.  Please, talk to you pharmacist or doctor.  Quite often there is a generic medication that is much less expensive that your doctor may feel appropriate in this particular situation.   Your pharmacist will be happy to discuss the situation with your doctor or insurance company.

·         Forgetfulness:  WOW, the idea of going from not taking any medications to taking 3 or more medications up to 3 times daily is a huge issue.  Again, take a moment and ask your pharmacist what recommendations they may have for you on how to organize your medications in order to help you maintain adherence.

·         HEALTH LITERACY:  The ability to explain your diagnosis, what you are doing to treat it, and the consequences of not treating it.  A recent study in the New England Journal of Internal Medicine described that over 72% have some limitation in their health literacy.  Over half of these patients were not adherent to their medications.  Why would you think you need to take your medication if you don't understand why you are taking it, how it works, and what will happen if you don't take it?

Again, talk with your pharmacist.  Your community pharmacist is a valuable Medication Information and Health Literacy resource.  The 3/14 issue of Consumer Reports wrote an article titled "The top 10 reasons you may want to change pharmacies".  The number one reason was to make sure you were able to establish a relationship with a pharmacist.

Do yourself a favor and visit three or four local pharmacies. Include an independent pharmacy, chain store, supermarket and big box retail store. Stand back and watch the pharmacy for 5 or 10 minutes and take in what you see. Do the pharmacists look like they have enough time do the work in front of them, is there a patient counseling area that appears relatively private, are the clerks at the front counter pleasant with the customers, and how many patients are in line or waiting for their prescriptions?

Next, step up to the counter and ask to speak with the pharmacist. Explain to the pharmacist that you are considering transferring prescriptions to their store and you would like to know what sort of service they offer. Believe me; if you visit four different pharmacies and follow through with this little exercise, you will have a clear idea of which pharmacy is the one for you.

Thanks
Steve

Copyright AudibleRx (TM), all rights reserved.

Pharmacy Report Card


Establishing a good relationship with a pharmacist you trust is the No. 1 reason to choose a drugstore, says Lucinda Maine, CEO and executive vice president of the American Association of Colleges of Pharmacy. “You can and should expect your pharmacist to be both accessible and knowledgeable,” she says. “If he or she is not, then you should take your business elsewhere.”

How long have you been using your pharmacy for and why have you given them such loyalty?  We, as humans, are creatures of habit.  We have all been there.  We have been doing some particular thing for an extended period of time.  It may not be the easiest or best way to do it; however, it is what we are comfortable with and we know what to expect.  We all have busy lives and the simple act of considering and evaluating a new method brings on an uncomfortable feeling of the unknown.

As a pharmacist, I am here to tell you, today is the day to evaluate your pharmacy and your pharmacist.  Consumer Reports just posted an interesting and well researched survey which offers 10 reasons why you may want to switch drug stores.  

As of 2009, there were over 56,000 pharmacies in the United States.  While many pharmacies are independently owned or hospital/clinic pharmacies, the overwhelming majority (upwards of 70%) are in a retail setting such as a chain pharmacy (i.e.; CVS, Walgreen, Rite Aid), supermarket (i.e.,; Safeway, Raleys, Albertsons), or big-box retail outlet (i.e.; Costco, Wal-Mart). 

While I am not going to discuss all 10 reasons you may want to switch pharmacies, (they are outlined and ranked quite well in the Consumer Reports article), I think it is important to review the #1 reason you may want to consider changing pharmacies. 

If your pharmacist is not readily available for discreet and educated consultation about your prescription and over-the-counter medications, you should consider taking your business to another pharmacy.  As noted in the Consumer Reports survey, “Customers at independents were much more likely than others to have discussed prescriptions with their pharmacist”.   

Maintaining a relationship with your pharmacist is important so that you have a medication information resource that is also familiar with your medical history.  This knowledge of your medical profile will help your pharmacist answer your prescription and over-the-counter medication questions, taking into consideration your entire medication history.  Your pharmacist will look out for drug and food interactions, missed refills, cost saving issues, and will gladly call your doctor for you to discuss your clinical situation whenever necessary.

Take a moment and review the Consumer Reports survey on “Finding the right pharmacy, 10 reasons why you may want to switch drugstores”.

Then, do yourself a favor and visit three or four local pharmacies.  Include an independent pharmacy, chain store, supermarket and big box retail store.  Stand back and watch the pharmacy for 5 or 10 minutes and take in what you see.  Do the pharmacists look like they have enough time do the work in front of them, is there a patient counseling area that appears relatively private, are the clerks at the front counter pleasant with the customers, and how many patients are in line or waiting for their prescriptions?

Next, step up to the counter and ask to speak with the pharmacist.  Explain to the pharmacist that you are considering transferring prescriptions to their store and you would like to know what sort of service they offer.  Believe me; if you visit four different pharmacies and follow through with this little exercise, you will have a clear idea of which pharmacy is the one for you.

Thanks
Steve

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