Case Studies: Cardiovascular Health

Case 1: Mitral Valve Disease

Q: BC, a 68-year-old man, approaches the pharmacy counter looking for advice. Recently, he was seen by a cardiologist at the recommendation of his primary care physician, and after undergoing an electrocardiogram and an evaluation, he was told that he has mild mitral valve regurgitation. BC says that his doctor did not initiate any new drugs to treat this disorder, and he is not completely sure what self-care measures are necessary for this condition. BC is looking for advice on what lifestyle modifications, if any, he should consider making. Upon questioning, BC says that he is a cigarette smoker and has a history of hypertension and hyperlipidemia, managed on a combination of amlodipine, valsartan, hydrochlorothiazide, and atorvastatin. What information can you provide regarding self-care and nonpharmacologic approaches to manage this condition.

A: Mitral valve regurgitation, characterized by the backflow of blood through the mitral valve with each ventricular contraction, represents a common chronic cardiac condition. There are many interventions that BC can consider implementing to ensure optimal health, despite this new diagnosis. First and foremost, inquiring about his smoking history and identifying whether he has considered quitting represent an important intervention for ensuring optimal cardiac health. Smoking not only increases BC’s risk of heart attack and stroke but may also worsen his mitral valve disease. Numerous OTC and prescription smoking cessation options exist. Beyond smoking cessation, educate BC about the importance of a healthy diet, including consideration of the Dietary Approaches to Stop Hypertension diet, for optimizing blood pressure (BP) control and heart health, along with routine exercise and physical activity for managing his heart function, with the permission of his cardiologist. Although BC was not prescribed a medication specifically to treat his valve disease, reminding him about the importance of compliance with his antihypertensive medications is critical to controlling his BP and reducing the complications of heart disease. Finally, although it is reasonable to encourage BC to share a complete health history with all medical care providers, such as his dentist, it is important to recognize that antibiotic prophylaxis prior to dental procedures is no longer indicated in patients with mitral valve regurgitation.^1,2

Case 2: Aspirin for Primary Prevention of Heart Attack

Q: TW, a 54-year-old woman, is inquiring about a news story she recently read on the safety of low-dose aspirin. Her medical history is significant for diabetes, dyslipidemia, gout, and hypertension, and she says that she takes several medications, including allopurinol, aspirin, atorvastatin, lisinopril, metformin, and metoprolol, to treat these conditions. TW has never had a heart attack or a stroke and says that she started taking a low-dose aspirin each day at the recommendation of her primary care provider many years ago. Now, based on this new information, she is wondering whether it is safe for her to continue taking this aspirin or whether she should ask her physician for new advice. What recommendations can you provide?

A: According to the results of the recently published ASCEND trial, conducted in the United Kingdom, aspirin use, administered at a dose of 100 mg daily, versus a placebo was associated with a reduction in serious cardiovascular events, including myocardial infarction, stroke, and transient ischemic attack, when administered to patients with diabetes but no cardiovascular disease.³ This benefit, however, was offset by a significantly increased risk of major bleeding, including gastrointestinal and extracranial bleeding, seen in the aspirin group compared with the placebo cohort. This trial joins a number of newer studies reporting outcomes that question the efficacy or risk/benefit ratio of the use of aspirin in a population without underlying cardiovascular disease and for the primary prevention of a major cardiovascular event. Although the relationship between cardiovascular disease and hyperglycemia is established, this study has caused clinicians to pause and note other cardiac risk factors, beyond diabetes alone, when considering use of aspirin for primary prophylaxis. Most important, to reduce TW’s risk of the microvascular complications of diabetes, inquire about her glycemic control and compliance with lifestyle interventions and medication. Encourage TW to discuss these new findings with her physician to determine whether she should continue her use of aspirin prophylaxis.

Case 3: Supplementation with Coenzyme Q10 for Statin-Induced Myopathy

Q: YI, an 84-year-old woman, approaches the pharmacy counter looking for advice. She heard from a friend that supplementation with coenzyme Q10 could reduce her chances of developing muscle pain with use of her statin medication. Before purchasing this supplement, YI wanted to confirm that it is safe to take. Her medical history is significant for coronary artery disease, with 2 stents placed in 2017 and hypertension, and YI’s current medication list includes aspirin, clopidogrel, metoprolol, and rosuvastatin. She says that she was recently switched to rosuvastatin after having tried all the other statins because she developed an elevation in her muscle enzymes and muscle pains previously. After a discussion with YI’s cardiologist, the decision to try rosuvastatin was made, with close monitoring for potential adverse effects, including symptoms and blood work. What information can you provide regarding the uAse of coenzyme Q10?

A: Coenzyme Q10, also known as ubiquinone, is a fat-soluble nutrient similar in structure to vitamin K and found in dietary sources including liver, oily fish, and whole grains.⁴ The antioxidant effects of this nutrient, coupled with clinical evaluation of the efficacy of supplementation in patients with diseases known to deplete coenzyme Q10 levels, provide reason that supplementation may be beneficial in certain individuals.⁵ It is recognized that, according to their pharmacologic actions, statin medications inhibit 3-hydroxy-3-methylglutaryl coenzyme A, which results in not only cholesterol reduction but also a reduced rate of mevalonate production.⁶ This depletion of mevalonate, in turn, serves to inhibit coenzyme Q10 production, is hypothesized to lead to mitochondrial dysfunction, and represents a potential cause of myopathy in individuals treated with a statin. Supplementation with coenzyme Q10 in patients taking statins has been touted by some to offset the effects of myopathy.⁶ In YI’s case, it is worth mentioning that there are mixed data regarding the efficacy of coenzyme Q10 supplementation to prevent or treat statin-induced myopathy. Although results from several studies have demonstrated a benefit in taking up to 200 mg of coenzyme Q10 daily to reduce pain in patients experiencing statin myopathy, results from other studies have failed to show an improvement in muscle pain, tolerance of statin therapy, or an effect on creatine kinase blood levels.⁵ Given YI’s history of statin intolerance and myopathy, it is reasonable to consider a trial of coenzyme Q10 supplementation for this indication.

Case 4: Use of Fish Oil for Cardiovascular Health

Q: RT, a 70-year-old woman, is interested in learning whether fish oil supplementation could help lower her cholesterol. She reports no significant medical history but says she is interested in doing things that can keep her healthy. RT eats well, exercises regularly, and takes several supplements that, she has read, can promote her health. A friend introduced her to fish oil, saying it might improve her heart health and lower her cholesterol, but RT would like more information from her pharmacist before deciding whether there are real benefits. At RT’s last medical evaluation, her physician indicated that she had borderline high cholesterol and that he would give her a trial of dietary modification for 3 months to determine whether this alone might address her issue. What education aAbout the use of fish oil supplementation or recommendations can you offer?

A: Omega-3 fatty acids, found in fatty fish and some nuts and seeds, may have many beneficial effects, from reducing cholesterol and elevated triglycerides to improving symptoms of rheumatoid arthritis. Although fish oil products exist over the counter as dietary supplements, there are several FDA-approved fish oil products approved for use in treating hypertriglyceridemia. Fish oil may reduce elevated triglycerides, but the evidence regarding its efficacy in reducing low-density lipoprotein (LDL) and total cholesterol levels has been conflicting. Most tips for living with mitral valve regurgitation suggest that fish oil does not reduce elevated cholesterol and may even further increase elevated LDL levels in patients with hyperlipidemia.⁷ In RT’s case, emphasize the effects of her lifestyle in cholesterol reduction. A diet low in saturated and trans fats and high in fiber, as well as a regular exercise routine, can help reduce cholesterol levels.

Mary Barna Bridgeman, PharmD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.Rupal Patel Mansukhani, PharmD, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers Universityand a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

References

• Mitral valve regurgitation. Mayo Clinic website. mayoclinic.org/diseases-conditions/mitral-valve-regurgitation/diagnosis-treatment/drc-20350183. Accessed October 31, 2018.
• Oral health topics: antibiotic prophylaxis prior to dental procedures. American Dental Association website. ada.org/en/member-center/oral-health-topics/ antibiotic-prophylaxis. Updated June 25, 2018. Accessed October 19, 2018.
• ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of aspirin for primary prevention in persons with diabetes mellitus. New Engl J Med. 2018;379(16):1529-1539. doi: 10.1056/NEJMoa1804988.
• Saini R. Coenzyme Q10: the essential nutrient. J Pharm Bioallied Sci. 2011;3(3):466-467. doi: 10.4103/0975-7406.84471.
• Coenzyme Q10. In: Natural Medicines [Internet]. Stockton, CA: Therapeutic Research Center; 2018. naturalmedicines.therapeuticresearch.com.
• Tricarico PM, Crovella S, Celsi F. Mevalonate pathway blockade, mitochondrial dysfunction and autophagy: a possible link. Int J Mol Sci. 2015;16(7):16067-16084. doi: 10.3390/ijms160716067.
• Fish oil. In: Natural Medicines [insert]. Stockton, CA: Therapeutic Research Center; 2018. naturalmedicines.therapeuticresearch.com.