Pharmacotherapy for Cardiovascular Disorders
Cardiovascular disease (CVD) is the leading cause of death in the United States. CVD is a group of disorders of the heart and blood vessels, and they include coronary heart disease, cerebrovascular disease, peripheral arterial disease; and rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism (Hajar, 2016). This week’s post will examine the pharmacotherapy for cardiovascular disorders.
Case Study #3
Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following:
- Glipizide 10 mg po daily
- HCTZ 25 mg daily
- Atenolol 25 mg po daily
- Hydralazine 25 mg qid
- Simvastatin 80 mg daily
- Verapamil 180 mg CD daily
Risk Factors and Associated Health Issues
Heart attacks and strokes are usually acute events and are mainly caused by arteriosclerosis involving heart or brain. The cause of heart attacks and strokes is usually the presence of a combination of risk factors, such as age, gender, ethnicity, tobacco use, birth weight, unhealthy diet and obesity, physical inactivity, alcohol abuse, hypertension, diabetes, and hyperlipidemia. CVD becomes more common with age, and are in fact diseases of aging. Around 83 million Americans are estimated to have one or more types of CVD, and 42 million of them are age 60 or older (Alliance for Ageing Research, 2017). At age 80 and older, 83% of women and 87% of men have some type of CVD (Alliance for Aging Research, 2017). Age is a continuous risk factor for the occurrence of stroke, with an increase in the incidence and prevalence rates for each successive 5 years after age 65 years (Arboix, 2015). Men show a higher incidence of stroke than women. Regarding ethnicity/race, it has been demonstrated that black patients have a higher incidence of stroke vs white patients (Arboix, 2015). Intracranial atherosclerotic disease is more frequent in patients of Asian. Birth weight is inversely associated with coronary heart disease and stroke
The patient in the scenario selected is presenting with serious cardiovascular issues and risks. CB’s current medication needs to be reviewed along with his compliance regarding CB’s health plan and goals. The Nurse Practitioner (NP) needs to examine the patient’s comorbidities as they relate to pharmacokinetics or pharmacodynamics. The case study states “CB has a history of stroke.” The question is that did the stroke occur within the last few days, few weeks or months. Also, what type of stroke did the patient have? Regardless of the timeframe or the type of stroke, there is concern that the patient is not taking any antithrombic or anticoagulant medication as part of the stroke core measures. Stroke patients are at increased risk of developing venous thromboembolism (VTE), and so it is recommended that the patient be on some sort of anticoagulant or antithrombic therapy for prophylaxis. The patient’s lifestyle and food habits, and medical conditions need to be considered. This patient is on a combination of anti-diabetic, diuretic, beta-blockers, vasodilators, statins and calcium-channel blockers (Drugs.com, 2017).
Pharmacokinetics and Pharmacodynamics
Altered pharmacokinetics and pharmacodynamics are characteristic in older patients. Decreased volume of distribution and creatinine clearance lead to significant changes in drug effect profiles and drug concentration. Much of the increased risk of adverse drug effects in older adults can be attributed to medication overdosing. Renal impairment is often missed on routine laboratory studies because the decrease in muscle mass that accompanies normal aging leads to a lower serum creatinine level than in younger patients with the same level of kidney function. All elderly patients should have their glomerular filtration rate checked routinely, and renal-excreted drugs should be dosed accordingly. Also, elderly patients are often on multiple prescription medications which should be carefully screened for interactions. Comorbid conditions may also increase the risk of adverse drug effects.
Cardiac medications frequently stimulate or block a signaling receptor. For example, the b-adrenergic receptor is stimulated by dobutamine, thus termed an agonist, while medications that block the action of b-adrenergic receptor such as atenolol are called antagonists. Antagonists can be further qualified as competitive, taking the place of a naturally occurring ligand (e.g. epinephrine) to block activity, or noncompetitive, which bind elsewhere on the receptor and thus are less affected by the concentration of the usual ligand. Another common type of cardiovascular drug, which has a pharmacodynamic effect by inhibiting the action of an ion channel is the calcium-channel blockers, which inhibit the influx of calcium into cardiac and other muscle cells, which in the cardiac pacemaker cells reduces chronotropic activity, in other myocardium can result in reduced inotropy, and in vascular smooth muscle can lead to vasodilatation.
Recommendations
Adjusting the patient’s drug therapy is not the only issue that should be addressed. An in-depth talk and genuine concern for the patient and their health needs to be addressed. The NP should always review patient’s medications and reconcile them. It is important to routinely check renal functions with the elderly. The NP should discuss diet, disease process, exercise, and the importance of compliance to these goals and the medication prescribed. One-half of patients do not take their chronic disease medications as prescribed, and only 1 in 10 patients follow recommended guidelines for lifestyle changes, such as smoking cessation or weight loss (Willard–Grace et al., 2015).
Recent studies have suggested that patients are likely to adhere to treatment regimen using combination drugs; thus, reducing the amount of drugs the patient must remember to take (e.g. combining atenolol with HCTZ). Also, health coaching and/or case management can bridge the gap of understanding and compliance with these patients. It also addresses the gap by equipping people with the knowledge, skills, and confidence to manage their chronic conditions (Willard-Grace et al., 2015).
Conclusion
The normal process of aging is associated with progressive deterioration in structure and function of the heart and vasculature that likely contribute to the development of CVD, including stroke, coronary heart disease, hypertension, and heart failure. As an NP, it is our responsibility to recommend appropriate treatment options for patients with CVD and ensure the safety and effectiveness of drug therapy. Since elderly is one of the fastest growing segments of the population, it is of vital importance that we have a thorough understanding of the physiological changes that occur with aging, and its influence on pharmacokinetic and pharmacodynamic processes such as medical history, other drugs currently prescribed, and individual patient factors that affect the elderly population with CVD.
References
Alliance for Aging Research (2017). Geriatric Cardiovascular Disease.
Retrieved from http://www.agingresearch.org/geriatricCVD
American Heart Association (2015). Stroke Fact Sheet. Retrieved from
https://www.heart.org/idc/groups/heart-public/@wcm/@gwtg/documents/downloadable/ucm_310976.pdf
Arboix, A. (2015). Cardiovascular risk factors for acute stroke: Risk profiles in
the different subtypes of ischemic stroke. World Journal of Clinical Cases: WJCC, 3(5), 418–429. http://doi.org/10.12998/wjcc.v3.i5.418
Drugs.com (2017). Prescription Drug Information, Interactions & Side Effects.
Retrieved from http://www.drugs.com
Hajar, R. (2016). Framingham Contribution to Cardiovascular Disease.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966216/
Sleder, A. T., Kalus, J., & Lanfear, D. E. (2016). Cardiovascular
Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics for the Clinical Practitioner. Journal Of Cardiovascular Pharmacology & Therapeutics, 21(1), 20-26. doi:10.1177/1074248415590196
Willard-Grace, R., et al. (2015). Health coaching by medical assistants to
improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Annals Of Family Medicine, 13(2), 130-138. doi:10.1370/afm.1768
