CVD: Get to the Heart of the Matter

Cardiovascular disease (CVD) is the leading cause of death for men and women in the United States and claims more lives annually than all forms of cancer and chronic respiratory disease combined.¹

Typically, women experience a sharper increase in CVD risk during and after menopause than during premenopause.² CVD accounted for 836,546 deaths in the United States, representing an estimated 1 in 3 deaths, according to 2018 statistics from the American Heart Association.¹ Additionally, CVD is the foremost global cause of death, accounting for more than 17.9 million deaths in 2015, and this number is expected to rise to more than 23.6 million by 2030.¹

CVD imposes a substantial burden on our health care systems. The estimated global cost of CVD was $863 billion in 2010, and that is expected to increase to $1044 billion by 2030.³ Despite large declines in CVD mortality in the late 20th century attributed to advances in public health and health care, improvements in US life expectancy have slowed for some patient populations, and CVD mortality is no longer improving.^4,5 Various health care organizations have tried to increase CVD awareness, as well as provide educational resources for clinicians and patients.

In 2017, the US Department of Health and Human Services launched the Million Hearts 2022 initiative to decrease CVD via community-based strategies aimed at diminishing combustible tobacco use, physical inactivity, and sodium intake, as well as enhancing health care for those at risk for and with CVD through clinical strategies that improve appropriate aspirin use, blood pressure control, cholesterol management, participation in cardiac rehabilitation, and tobacco cessation.^6,7 Million Hearts 2022 is also focused on selected priority populations at risk, including adults who have had a previous myocardial infarction (MI) or stroke, African Americans with hypertension, individuals with mental health or substance abuse disorders who use tobacco, and those aged 35 to 64 years for whom CVD mortality rates are increasing.^6,7 Moreover, Million Hearts 2022 has set clinical quality measure targets of 80% performance on the “ABCS” of CVD prevention^6,7:

• Aspirin when appropriate
• Blood pressure control
• Cholesterol management
• Smoking cessation

NEWS ABOUT CVD

In November 2018, the American Heart Association and the American College of Cardiology updated their national lipid guidelines to feature an algorithm for when to prescribe a PCSK9 inhibitor and revised their risk assessment for primary prevention.⁸

Fewer than 50% of patients receiving therapy for diabetes, dyslipidemia, or hypertension in primary-care practices mainly in Europe meet guideline treatment targets for primary prevention of CVD, according to the results of a new analysis from the EUROASPIRE V survey.⁹

Results from another recent publication showed that metabolomics-based biomarkers offer a unique tool in identifying those at risk for CVD and with a new diagnosis.¹⁰ The study showed that metabolomics-based biomarkers can also be used to identify those at risk for major adverse cardiac events, independent of traditional risk factors. The discovery of metabolomics-based biomarkers has shown great potential in cardiovascular research, including evaluating disease risk, diagnosing the disease, defining pathological mechanisms, and detecting therapeutic targets.¹⁰

Results from a cohort study published in a 2018 issue of JAMA showed that women who followed a Mediterranean diet had up to a 25% relative reduction in CVD events, including in adiposity, biomarkers of inflammation, glucose metabolism, and insulin resistance, than those who did not follow this diet.¹¹

Research published in JAMA conducted by O’Brien et al indicates that higher cardiovascular risks were linked with the use of sulfonylureas or basal insulin compared with newer classes of antidiabetic agents.¹²

Although aspirin is well established as secondary prevention of CVD, its role in the primary prevention of CVD is still unclear, especially in the geriatric patient population at increased risk. McNeil et al conducted the ASPREE trial involving 19,114 individuals, in which 9525 were assigned to receive aspirin and 9589 to receive a placebo. Researchers concluded that the use of low-dose acetylsalicylic acid (ASA) as a primary prevention strategy in older adults resulted in a substantially greater risk of major hemorrhage and did not result in a meaningfully lower risk of CVD than a placebo.¹³ Other studies have explored the effects of ASA for primary prevention, such as the ASCEND trial, which found that aspirin use was associated with a modest increase in major bleeding risk and modest reduction in cardiovascular events.¹⁴

IDENTIFYING CVD RISK FACTORS

Pharmacists can help identify patients at risk for CVD and encourage them to discuss their risk factors with their primary health care providers. Risk factors for CVD can be classified as modifiable or nonmodifiable. Modifiable risk factors include alcohol and tobacco use, diabetes, dyslipidemia, hypertension, obesity, and a sedentary lifestyle.¹⁰ Nonmodifiable risk factors include advancing age, ethnic characteristics (African Americans, Latinos, and non—Latino Caucasians are at greater risk for CVD), and a family history of CVD.¹⁰ Failure to control modifiable-risk CVD factors accounts for an estimated 61% of cardiovascular deaths, according to the World Health Organization.^15-17

PHARMACIST’S ROLE

Because pharmacists are frontline health care providers, they are intricately involved in patient care. As a result, they have indispensable roles in increasing optimal therapeutic outcomes as clinician and patient advocates and educators. As drug experts, pharmacists are in a pivotal position to work with prescribers to make recommendations for pharmacotherapy for CVDs such as heart failure, hyperlipidemia, and hypertension. They can also identify patients at risk for CVD. In addition, pharmacists have a critical role in educating patients about CVD and the clinical benefits shown in numerous studies regarding the impact of early diagnosis and clinical intervention. They can also ensure that patients understand the need to be continually monitored by their primary health care providers, as well as the critical nature of adherence to drug therapy, if warranted, and lifestyle modifications.

Research shows that poor medication adherence is common among those with CVD; an estimated 33% of patients were nonadherent as early as 90 days after an MI, and 25% to 30% of those with hyperlipidemia failed to pick up medications within 1 to 2 weeks after receiving the prescription.^18,19

The role of the pharmacist is continually evolving and being recognized as a critical one in patient care. In collaboration with the Million Hearts 2022 initiative, the CDC published a guide in 2018, Best Practices for Cardiovascular Disease Prevention Programs: A Guide to Effective Health Care System Interventions and Community-Clinical Links. The new guide stresses the role of the pharmacist as an integral team member in the identification of patients at risk for CVD and in the management of CVD.²⁰ One of the emphasized strategies in the publication includes promoting pharmacists’ involvement in patient care.²⁰ The guide also recommends a collaborative effort among clinicians, encouraging patient involvement through self-management, reducing out-of-pocket costs for medications, and patient education.²⁰ The complete guide can be found at cdc.gov/dhdsp/pubs/guides/best-practices/index.htm

Yvette C. Terrie, BSPharm, RPh, is a consulting pharmacist and a medical writer in Haymarket, Virginia.

References

• Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67-e492. doi: 10.1161/CIR.0000000000000558.
• Campos H, McNamara JR, Wilson PW, Ordovas JM, Schaefer EJ. Differences in low density lipoprotein subfractions and apolipoproteins in premenopausal and postmenopausal women. J Clin Endocrinol Metab. 1988;67(1):30-35.
• Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation, 2015;131(4):e29-322. doi: 10.1161/CIR.0000000000000152.
• Global Burden of Cardiovascular Diseases Collaboration Roth GA, Johnson CO, et al. The burden of cardiovascular diseases among US States, 1990-2016. JAMA Cardiol. 2018;3(5):375-389. doi: 10.1001/jamacardio.2018.0385.
• O’Flaherty M, Buchan I, Capewell S. Contributions of treatment and lifestyle to declining CVD mortality: why have CVD mortality rates declined so much since the 1960s? Heart. 2013;99(3):159-162. doi: 10.1136/heartjnl-2012-302300.
• Wright JS. Million Hearts 2022: focusing action for impact. Presented at CDC Public Health Grand Rounds, Atlanta, GA; February 20, 2018. cdc.gov/grand-rounds/pp/2018/20180220-million-hearts-2022.html. Accessed December 21,2018.
• Wall HK, Ritchey MD, Gillespie C, Omura JD, Jamal A, George MG. Vital signs: prevalence of key cardiovascular disease risk factors for Million Hearts 2022 - United States, 2011-2016. MMWR Morb Mortal Wkly Rep. 2018;67(35):983-991. doi:10.15585/mmwr.mm6735a4.
• Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 Nov pii: S0735-1097(18)39034-X. doi: 10.1016/j.jacc.2018.11.003.
• Busko M. Most patients don’t meet CV primary prevention treatment targets: EUROASPIRE V. Medscape. December 20, 2018. medscape.com/viewarticle/906868. Accessed December 21, 2018.
• Dang VT, Huang A, Werstuck GH. Untargeted metabolic in the discovery of novel biomarkers and therapeutic targets for atherosclerotic cardiovascular diseases. Cardiovasc Hematol Disord Drug Targets. 2018;18(3):166-175. doi: .10.2174/1871529X18666180420170108.
• Ahmad S, Moorthy MV, Demler OV, et al. Assessment of risk factors and biomarkers associated with risk of cardiovascular disease among women consuming a Mediterranean diet. JAMA Netw Open. 2018;1(8):e185708. doi: 10.1001/jamanetworkopen.2018.5708.
• O’Brien MJ, Karam SL, Wallia A, et al. Association of second-line antidiabetic medications with cardiovascular events among insured adults with type 2 diabetes. JAMA Netw Open. 2018;1(8):e186125. doi: 10.1001/jamanetworkopen.2018.6125.
• McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med. 2018;379(16):1509-1518. doi: 10.1056/NEJMoa1805819.
• Finnegan J. An aspirin a day? Doctors need to consider new evidence. Fierce Healthcare website. fiercehealthcare.com/practices/aspirin-a-day-doctors-need-to-consider-new-evidence. Published November 27, 2018. December 21,2018.
• Good L. Hypertension highlights; blood pressure targets, global risk factors and diabetes: the latest data are not encouraging. Medscape. medscape.com/viewarticle/715584. Accessed December 22, 2018.
• Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 2004;364(9438):937-952.
• Stewart J, Manmathan G, Wilkinson P. Primary prevention of cardiovascular disease: A review of contemporary guidance and literature. JRSM Cardiovasc Dis. 2017; 6:2048004016687211. Published 2017 Jan 1. doi:10.1177/2048004016687211.
• Faridi KF, Peterson ED, McCoy LA, Thomas L, Enriquez J, Wang TY. Timing of first post discharge follow-up and medication adherence after acute myocardial infarction. JAMA Cardiol. 2016;1(2):147-155. doi:10.1001/jamacardio.2016.0001
• Derose SF, Green K, Marrett E, et al. Automated outreach to increase primary adherence to cholesterol-lowering medications. JAMA Intern Med. 2013;173(1):38-43. doi: 10.1001/2013.jamainternmed.717.
• CDC includes pharmacists in proven models for heart disease prevention. American Pharmacists Association website. pharmacist.com/article/cdc-includes-pharmacists-proven-models-heart-disease-prevention. Published February 13, 2018. Accessed December 21, 2018.