PHARMACEUTICAL CARE ISSUES IN CARDIOLOGY

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PHARMACEUTICAL CARE ISSUES IN CARDIOLOGY

• BY BASARIAH BT NAINA
• B.PHARM(HONS)M.PHARM(CLINICAL)

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Medication Appropriateness Index

• 1. Is there an indication for the drug?
• 2. Is the medication effective forthe
  condition?
• 3. Is the dosage correct?
• 4. Are the directions correct?
• 5. Are the directions practical?

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• 6. Are there clinically significant
  drug-drug interactions?7. Are there clinically
  significantdrug-disease/condition
  interactions? 8. Is there unnecessary
  duplication withother drugs(s)?9. Is the
  duration of therapy acceptable?10. Is this drug
  the least expensive alternativecompared with
  others of equal utility?

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INTRODUCTION

• Types of heart disease angina, heart attack
  (myocardial infarction), atherosclerosis, heart
  failure, cardiovascular disease, and cardiac
  arrhythmias (abnormal heart rhythms).
• Other forms of heart disease congenital heart
  defects, cardiomyopathy, infections of the heart,
  coronary artery disease, heart valve disorders,
  myocarditis, and pericarditis.

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Treatments for Heart disease

• Aspirin - low-dose aspirin may be used to avoid
  heart attacks. However, because of side effects
  and risks it is not usually recommended for
  healthy individuals. Mainly for those with
  existing heart problems or previous conditions.
• Digitalis - makes the heart pump harder, also
  helps some heart rhythm problems.
• ACE inhibitors
• Beta-blocker
• Nitrate (including nitroglycerine)

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• Treatment of advanced or critical types of heart
  disease, such as heart attack, heart Failure or
  serious abnormal heart rhythms, requires
  hospitalization. Treatment includes
  administration of oxygen aimed at increasing the
  amount of oxygen that is delivered to the heart
  tissue. Also involves intensive monitoring and
  stabilization of vital signs, which may require
  CPR and/or intravenous medications. Breathing may
  need to be supported by mechanical ventilation.
  Heart rhythm and cardiac enzymes are also
  monitored.
• Abnormal heart rhythms need treatment with
  medications possibly electrical defibrillation.

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• In a heart attack, nitroglycerin, used to
  improve blood flow to the heart.
• morphine, to reduce pain and anxiety and lower
  the amount of oxygen the heart needs.
• aspirin or heparin, may be used.
• Angioplasty -the blood clot is removed from the
  artery and the artery is widened using a balloon
  device and a stent is placed in the artery to
  keep it open.
• coronary artery bypass new graft arteries are
  placed to bypass the blocked coronary artery or
  arteries. Blood flow is then redirected through
  healthy new graft arteries to the affected heart
  tissues

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MI
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HEART
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Balloon Catheter
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• Rare Types of Heart disease
• Atrial myxoma
• Long QT syndrome
• Wolff Parkinson White syndrome
• Supraventricular tachycardia
• Atrial flutter
• Constrictive pericarditis

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• Curable Types of Heart disease
• Valvular heart disease
• Infective endocarditis
• Congenital heart diseases
• Coronary heart disease
• Atrial myxoma
• Long QT syndrome
• Wolff Parkinson White syndrome
• Supraventricular tachycardia
• Atrial flutter
• Constrictive pericarditis

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• ASPIRIN
• 75 mg /day would decrease rates of GI bleeding
  by 40 compared to 300 mg/day.

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Digitalis after MI?

• Should not be given to pts with MI who are
• not in cardiac failure-may increase infarct
• size.

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DIGOXIN

• IM severe pain-IV preferred
• IM dose is 80 of previous oral dose

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Decrease digoxin level

• Antacid
• Cancer chemotherapy
• Cholestyramine
• Cholestipol
• Kaolin Pectin
• Laxatives
• Sulfasalazine

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Increase Digoxin level

• Erythromycin
• Omeprazole
• Alprazolam
• Amiodarone decrease digoxin 50
• Calcium channel blockers
• Captopril
• Quinidine- decrease digoxin 50
• Tioconazole

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Digoxin Dosage

• Loading Dose
• -Lower range (0.01 mg/kg) for mild CHF.
• -Higher range (0.02 mg/kg) to control ventricular
  rate in atrial fibrillation.
• Oral LD (Vd)(Cp)
• (F)

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Factors alter response to Digoxin

• Compliance
• Bioavailability
• Malabsorption
• Altered metabolism-hypocalcemia,hyperthyroidism

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DIGITALIS TOXICITY

• Arrythmia
• Tx
• IV lidocaine
• Phenytoin
• IV Propranolol
• Procainamide Quinidine ( ) IV use
• can cause hypotension and
• cardiotoxicity

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CHF

• DIURETICS
• Responsiveness to loop diuretics diminishes as HF
  progresses.
• So-combination of thiazides and loop diuretics
  are useful as these drugs work synergistically
• to improve diuresis.
• In patients with a GFR below 30ml/min,
  thiazides are not effective alone but may be used
  synergistically with loop diuretics

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• The combination of i.v. nitrate and low dose
  frusemide is more efficacious than high dose
  diuretic

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LAB INVESTIGATION

• Hyponatremia
• Hypochloremia can cause hypochloremic acidosis
• Hypokalemia
• Hypomagnesemia
• Can cause cardiac arrythmias
• alkaline phosphatase /AST in HF pt result
  of hepatic congestion from right sided HF

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Patient on DIURETIC

• Increase BUN but normal serum creatinine.
• BUNcreatinine ratio 10-201
• Prerenal Azotemia cause is decreased RBF
  secondary to uncompensated CHF.

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• Hyperuricemia
• 1-2 mg/dl common
• If gt 10 mg/dl /Hx of gout should treat.

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ACE INHIBITOR

• Monitor blood urea, creatinine and serum
  potassium at 7-14 days, especially in patients
  with impaired renal function.
• If the rise in serum creatinine level is gt20
  compared to baseline, then ACEI therapy may need
  to be stopped.
• Severe HF the combination of ACEI and an ARB
  may be considered
• to reduce hospitalization due to HF.

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ACE INHIBITOR

• Captopril-short acting drug, start first
• to monitor side effect then change.
• Common s/e dry cough
• Severe s/e
• Angioedema(facial neck swelling)
• CI Pregnancy esp 2nd 3rd Trimester

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Tx of systolic HF

• Carvedilol better than metoprolol
• cause produce greater improvements in LVEF
  stroke work.

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ARRYTHMIAS

• Classification
• Supraventricular Arrythmias
• Originating above bundle of HIS.
• Include Sinus Bradycardia,sinus
  tachycardia,paroxysmal supraventricular
  tachycardia,atrial flutter,atrial
  fibrillation,wolff-Parkinson-White (WPW) syndrome

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• VENTRICULAR ARRYTHMIAS
• Below bundle if HIS. Include premature
  ventricular contraction(PVCs),VT ventricular
  fibrillation(VF)

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ANGINA

• NITRATE
• Oral nitrates with extended duration
• Of action prone to induce tolerance.
• Must devise a nitrate free dosing
• schedule.
• Transdermal Ointment-3 x/day
• Transdermal Patches-no tolerance if lt12hrs/day
• Transmucosal -nitrate free interval at
• night,no tolerance

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Isosorbide Mononitrate

• Adv of ISMO less dosage fluctuation because of
  absence of presystemic clearance
• Extended release(Imdur) can provide effective
  control as once daily alternative is Isosorbide
  Dinitrate(less expensive) 3 x/day

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B Blockers

• Metoprolol (lipophilic) can cause CNS
• s/e so change to atenolol(hydrophilic).
• Cannot stop abruptly can cause
• rebound Phenomenon.
• B blockers may worsen asthma
• substitute with CCB or long acting
• nitrates.

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CombinationTherapy for Angina

• Nitrate,B blocker,CCB , ACEI Anti platelet

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Myocardial Infarction

• Thrombolytic up to 1 hr from onset of chest
  pain.
• Readministration of Thrombolytic agents
• Streptokinase (antibodies formation and
  allergic) for 1st infarction,if 2nd attack within
  same yr alteplase or reteplase.
• gt 70 yrs pt should receive Streptokinase cause
  tPA can cause intracranial hemorrhage

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VASODILATORS

• NTG vs Nitroprusside
• NTG preferred over Nitroprusside cause
• Nitroprusside increase ST segment elevation.
  NTG decrease ST segment
• elevation.
• Sodium Nitroprusside would be useful in patients
  not responsive to nitrates useful in cases of
  uncontrolled hypertension, acute mitral or aortic
  regurgitation.

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Morphine

• Causes peripheral venous arterial vasodilation
  reduce preload afterload
  reduce myocardial Oxygen demand.

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CASE 1

• 72 yrs old male
• Develops substernal,crushing pain associated
  with diaphoresis.
• At ED
• ST segment elevation MI
• Troponin 3.65
• 95 stenosis in left anterior artery,then
  drug eluting stent placed with reduction in
  stenosis to less than 25
• Stabilized discharge home on day 5

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Discharge medication

• Clopidogrel
• Prior to this admission
• Aspirin and lansoprazole daily for GERD
• Based upon the info provided,any concern
• on medication profile?

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DISCUSSION

• Clopidogrel for 9-12 mths
• Ix between clopidogrel PPI
• Clopidogrel requires activation by cytochrome
  P450.PPI inhibitor of P450.
• - decrease clopidogrel activation reduction
  in antiplatelet effects.
• Pt with GERD alternative drug H2 blockers or
  pantoprazole for pt absolutely require PPI

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Case 2

• 56 yrs old male
• 12 yrs of idiopathic Parkinsons ds.
• Medication
• Levodopa,pramipexole and just started
  clozapine 6.25 mg and titrated up to 50 mg/day
  over 1st mth of starting therapy.
• Patient subsequently presented with
  fever,dyspnea,tachycardia chest pain persisted
  for the last 8hrs.

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• Lab result normal only serum troponin T was
  elevated.
• EKG showed diffuse T wave flattening elevated
  QTc interval.
• Echocardiography revealed severely depressed left
  right ventricular contractility reduced
  injection fraction

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• DIAGNOSIS?

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• CLOZAPINE INDUCED MYOCARDITIS
• Myocarditis inflammation of the heart and
  myocardial destruction that lead to dilated
  cardiomyopathy.
• Rare estimated incidence 0.3 cases/100,000 pt.
• Appears rather quickly,within 2 mths in 90 of
  cases.
• Immediate discontinuation of clozapine.

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CASE 3

• AG is an 80-year-old woman who reports to the ED
  complaining of dizziness, weakness and nausea for
  about 7 days. Her past medical history is
  significant for chronic renal insufficiency,
  chronic obstructive pulmonary disease,
  intermittent atrial fibrillation, osteoarthritis,
  coronary artery disease, mild-to-moderate
  anxiety, and hypertension.

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• Her medications on admission areDigoxin 0.25
  mg dailyTriamterene 37.5 mg/HCTZ 25 mg, 2
  capsules dailyQuinidine gluconate 324 mg 3x
  dailyLisinopril 20 mg dailySimvastatin 20 mg
  dailyTriamcinolone inhaler 2 puffs 3-4x
  dailyFormoterol inhaler one inhalation 12
  hrlyTiclopidine 250 mg twice dailyChlordiazepoxi
  de 10 mg 3 xdailyMultivitamin

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• During osteoarthritis disease flares she often
  self-medicates with indomethacin that her husband
  uses for gout.
• She states that she usually takes 2-3 capsules
  of the 25 mg indomethacin daily until symptoms
  subside.

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• Upon evaluation in ED
• -the physical exam unremarkable
• -vital signs within normal limits.
• -The EKG shows a junctional rhythm. Abnormal
  laboratory values identifiedPotassium 6.0
  (normal, 3.5 -5.0 mmol/L)BUN 40 (normal, 10 - 26
  mg/dL) SCr 2.0 (normal, 0.6-1.3 mg/dL)Serum
  digoxin level 5.1 nmol/L (normal, 0.6 2.8
  nmol/L)

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Some medication therapy management issues include

• Hyperkalemia related to digoxin toxicity
  Decreased clearance of renally eliminated
  drugsHyponatremiaPotential managementConsider
  lower dose digoxin if needed (digoxin toxicity,
  hyperkalemia)

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• Change ticlopidine(renal geriatric) to other
  agent (aspirin)Remove chlordiazepoxide
• (accumulation)Lower ACE inhibitor dose
  (hyperkalemia)Consider different
  antihypertensive Consider change in
  diuretic/dose (hyperkalemia)Refrain from taking
  indomethacin(cardio risk renal), and choose a
  short-acting NSAID Monitor electrolytes more
  closely

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THANK YOU