Welcome, welcome to the module related to common cardiovascular pharmacologic therapies. What we want to do today is walk you through some of the common cardiovascular drugs, the medications that many of your patients will be on, and just start to familiarize you with the concepts behind the medicines, why we use certain medications, and get more comfortable with some of the terminology and the types of medicines that we use. So I wanted to start with just walking you through therapy goals. So when the clinicians, providers, physicians prescribe medications to the patients, we really are doing it through one of two reasons. The first one is to minimize disease progression. So patients been diagnosed with say atrial fibrillation or coronary artery disease or hypertension. Our goal with many of our medications is to minimize any progression of that disease process or potentially even eradicate it. So wherever we can take somebody's blood pressure and bring it down to a normal range, then they've got then better treated hypertension. The second reason is to manage cardiovascular symptoms. And so in some cases, we use medications to make patients feel better. See this typically in a heart failure patients where they may be feeling short of breath of too much volume, we call it, or too much fluid on their lungs, that kind of thing. We use medication to decrease that and improve their symptoms. So really a couple different reasons that we utilize medications in the cardiovascular space. In addition to that, though, I think it's really important that I want you to walk you through that there's more than one reasons or more than one type of therapy that we're going to recommend. And you're going to be key in many of these because the patients are going to have questions. And so just you are really understanding the construct in which we manage these patients and the sorts of recommendations that we make and the more that you can educate yourself on the way the different clinicians, providers, and physicians do things will be really important. There's really a couple of things that I want you to think about in addition to just pharmacologic therapies, which I'll walk you through in the rest of today's module. But in addition to that, oftentimes we will educate patients on nutrition changes. So dietary changes and the sorts of foods that they eat, activity levels and their ability to exercise and have a more active lifestyle. And then oftentimes weight management will be a key component. So again, I think it's just important to understand that for many of our diseases that you see with this patient population, like hypertension, diabetes, and even high cholesterol, a lot of times nutrition activity and weight management are really important in addition to the medications that we use. That being said, today's module is about pharmacologic therapies. And my goal is to really walk you through several different classes of drugs and why we use those drugs. And so we're going to talk about antihypertensive medications, antihyperlipidemia medications, and then we'll start to walk you through a couple others. There's also a couple of pearls. So you're really, one of your primary risk abilities is going to be taking a good medication history. And I know you learned about that in one of the other modules, but I can't tell you how incredibly important that role is because it's those that that medication history is going to tell the provider a lot about that patient's history and your ability to make sure that that's accurate is extremely important. So I wanted to walk you through kind of five different rules to keep in mind as you take that history. Number one, it is highly unlikely that a patient would be on more than one medication in the same class. So when we walk you through the rest of this module, and we will also provide a handout, anytime you see on the patient's list, two medications that are within the same class, that should be a red flag for you to escalate that to the physician or the APP that you're working with to address that and better understand that. Here's the challenge. We don't make it easy for our patients to kind of manage through and many of the patients that you're going to be helping to take care of are on multiple medications. And when medications change, they still have pill bottles in their homes of the previous medicine. So they oftentimes can get confused. And we use that medication history or medication reconciliation when they come back into the clinic to help make sure that they truly are on the medications they should be on. So if you ever find that there's a patient that's taking two of the same class of medicines, that's really important to escalate. The second one, there's a generic and a brand name for almost every drug, and I'm going to provide you both, but a patient should never be on the generic and then a second prescription for the brand name that doesn't make any clinical sense. So that's another time that you need to escalate that if you start to see something like that happen. The third one is never be afraid to ask questions or escalate anything that doesn't seem correct or is confusing. If the patient's confused about their medications, there probably is a problem and either you and or the clinician need to spend some more time. And if it doesn't make sense to you, as far as when you get that history, you need to escalate that to the provider. A key best practice is to have the patients bring in their pill bottles. So oftentimes we will tell patients as part of their reminder call, but if you're working with patients and when you talk to them about their next visit, encouraging them to bring in their actual pill bottles will be very helpful for you. And then when in doubt, call the pharmacy to make sure you know what medicines has really been prescribed for them. And also when you ask the patient around what pharmacy they use, make sure you understand if there's more than one pharmacy they use and you'll have to end up contacting all of them versus just one. And it's not uncommon for patients to use more than one pharmacy. It makes it complicated, but because of mail order and changes within pharmacies and formularies and drug plans, it's unfortunately not uncommon for patients to use more than one pharmacy. So when you take that history, make sure you garner all of that information so that you can ask appropriate questions and we understand where to go to get the information if it's not clear. All right. The categories I'm going to walk you through today include lipid management, hypertension, coronary disease or atherosclerotic cardiovascular disease, ASCDD, anticoagulation management and heart failure management. I would also say this is not an all-inclusive list of cardiovascular medications and the goal is not to make you a pharmacist, but really just to get through the more common drugs that you're going to see. And then as you kind of get comfortable and spend more time with patients, these will almost become second nature for you. But having a resource or a reference that you can go to will be really important. So the first section I want to walk through is lipid management and just a quick understanding of what is the goal when it comes to lipid management, because that will help you better understand why we use the medications that we use. But our overall goal is to increase HDL, decrease triglycerides and decrease LDL-C. And those are the sorts of medications that we use for our patients. I'm not going to walk you through all the numbers on this slide. You're actually going to have another module that talks about the different labs that we check on our patients and the different levels. But when it comes to lipid management, our pharmacologic therapy typically includes statins and then there are some add-on options that include azetamide and then the PCSK9 inhibitors along with phenylfibrates. So our overall goal with these patients is our triglycerides of less than 150, our HDL-C of greater than 40 for men or greater than 50 in women. And then our LDL-C, as you can kind of see here for patients with moderate risk, less than 100, for high risk, less than 70 and for very high risk, less than 55. And as I mentioned, there are several medications that we use for that. So the medications are statins, which is kind of one class of medications under the medications that we use for cholesterol. The two most common that we see under that statin classification are Lipitor, which is the brand name, and then Atorvastatin, which is the generic name, and then Crestor, which is the brand name, and Rosuvastatin, which is the generic name. There are several others, and you can typically remember them because a lot of them have OR on the end, but the two most common that you're going to see are the Lipitor and the Crestor. These are HMG-CoA reductase activity inhibitors, and they decrease hepatic cholesterol content. So contraindications in these patients are liver disease, pregnancy, or breastfeeding. And for surveillance, for patients that are on these medications, we typically recheck their lipids six to eight weeks after we initially start a statin, and then every four to six months to monitor their outcomes. And then in addition to that, we'll check their liver enzymes or their LFTs to make sure that there's no issues with their liver. They can have some side effects that include muscle complications. And so typically when patients are on these medications, we'll monitor them for any symptoms like muscle aches, that kind of thing. In addition to the statins, there's another medication that inhibits intestinal uptake of dietary and biliary cholesterol, and that is ezetimide or Zetia. Ezetimide is the generic name, Zetia is the commercial name. And really the contraindications are the same as the statin. The surveillance are the same as the statin, but they can be used in conjunction with each other. So sometimes patients can be on both. In addition, there's a PCSK9 inhibitor called Repatha. That is actually an injectable. So that kind of becomes more, you may ring a bell, but this is one that patients actually get an injection. Sometimes they inject themselves at home. Sometimes maybe their initial injection might be there in the office with you. And the goal is that this increases LDL receptors with the result of decrease in your serum LDL. So it decreases the LDL. In this case, again, we're going to do baseline lipids and then six to eight weeks initially, and then annually thereafter. And really side effects are typically related to injection site, maybe have some muscle pain and could potentially have some flu-like symptoms. And then finally, the last medication is phenylfibrate, which is meant to lower triglycerides, which by reducing the production of VLDL, which is very low density lipoprotein, and by speeding up the removal of triglycerides from the blood. Again, you can see contraindications there include liver disease, kidney disease, and our surveillance for these, this medication is the same as what we would see for the statin. And again, for side effects, typically doesn't happen often, but if you're going to see anything, it's an increase in those liver enzymes. So we would check those every four to six months. The next kind of area of medications I want to talk about are those that we use for hypertension. So in this case, our goal is for a blood pressure of less than 130 over 80. And we can use several different medication classes to potentially get there. So let me walk you through those. The first class of medications is called an ACE inhibitor. So ACE inhibitor, I just kind of gave you all the names. On the left-hand side, that is the commercial name and on the right-hand side, that is the generic name. And so the mechanism of action in this case is that they reduce sodium and water retention, and they also cause vasodilatation, which is actually expansion of the blood vessels themselves. When the blood vessels get bigger, the pressure goes down. Contraindications for these include high potassium. So hyperkalemia is another term for high potassium. Renal artery stenosis, pregnancy is a big contraindication. So we wouldn't use these in young women of childbearing age. And then a history of angioedema related to the use of an ACE inhibitor. So if that's ever occurred, it does not happen often, it's pretty rare. But if it happens once, you would never use this medication on those patients again. Surveillance-wise, we do check kidney function with these patients initially at baseline and then one to two weeks after dose change, and then thereafter based on risk. So the side effect is cough and then this angioedema, which is really kind of swelling of the facial area. The second class of medications are angiotensin receptor blocking agents, ARB. So with our ARBs, there's a couple of things. They have a very similar mechanism of action to the ACE inhibitor. So they reduce sodium and water retention, and they also develop or cause vasodilatation. The contraindications are the same. The surveillance is the same. And they do not have as much issues with the cough. So a lot of times when you start to work with patients and these medications, if they develop a cough with the ACE inhibitor, oftentimes the provider will change them to an ARB and they'll get the same blood pressure benefit, they just won't get the cough related to it. The next class of medications are called beta blockers. So for these medications, what we see is, again, you'll see several examples there, including Tenormin, Lopressor, Toprol XL, and Coreg are the most common ones. There are a few others that will be included in your handout, but these are the four most common. The mechanism of action for beta blocker include decreased myocardial contractility, which really is a lot of words to say. It's just that heart doesn't contract as hard. And by decreasing that contractility, it actually decreases the blood pressure, also decreases heart rate. So the heart rate, the heart does not pump as often. It just kind of slows everything down. Now the contraindications for these patients include a slow heart rate, bradycardia, slow heart rate, and then patients with asthma that have active wheezing. There's really no surveillance for these drugs when it comes to lab type checks, but just monitoring for side effects. And side effects include fatigue and sexual dysfunction. And then the next class are diuretics. So diuretics, the most common one we see here is Lasix or furosemide. And these are really meant to reduce volume through sodium and water loss. For contraindications with these, it's severe kidney disease and hypokalemia, which is really low potassium. So for that reason, we actually check their kidney function and their potassium levels at baseline, and then one to two weeks after we change a dose or based on risk. So if patients have previous kidney issues, we may check that more often. Side effects with these can be that it lowers blood potassium levels, and oftentimes patient needs to be on potassium replacement to go along with those. So it has to be monitored fairly closely. The next area of pharmacologic management is related to ASCVD or atherosclerotic cardiovascular disease, or another term for that would be coronary artery disease. So these are patients that maybe have had stents, have known coronary disease, maybe they've had bypass surgery. And so we put them on medications that really improve both progression of disease as well as symptoms of disease. And there's two classes of medications that we see or two different types of medications. The first one are the antiplatelet medications. We use these medications with a goal to decrease the risk of blood clot formation. And if you remember back to our previous module, I described where sometimes patients will have coronary artery plaque. When the plaque starts to fracture, blood clots can form. So what happens if we put patients on antiplatelet medications, it decreases the risk of those clots forming and decreases the risk of future heart attack. We often use these after stents have been placed as well. The second type of pharmacologic therapy that we use are anti-ischemic medications. The goal here is to dilate coronary arteries to allow more oxygen and control the symptoms of coronary artery disease or ASCVD, which really we would use the term angina or chest pain as a common symptom. So let's start with the antiplatelet medications. And I'm really gonna kind of show you two different classes. So the first one is aspirin. Aspirin just in and of itself decreases the reactivity of those platelets. Now the contraindications for aspirin include GI bleeding and allergies to aspirin. Really no surveillance as far as laboratory surveillance is required. And as far as potential other side effects, it's just gonna be things like bruising. They bruise a little bit easier or bleeding longer. Now we use low dose aspirin in these patients because over long-term, sometimes there can be issues with GI bleeding. So we've really minimized our use of aspirin over the years to try to manage the risk versus the benefit of the medication. The second class of medications include medications that are really antiplatelet inhibitors. And the three that we see most common are clopidogrel, which is Plavix, Prasugrel, which is Effient. And the third one is Hicagrelor or Berlinta. Berlinta is much easier to say. Mechanism of action for these are the same as the aspirin. They decrease the reactivity of the platelets. The contraindications are the same. No real surveillance. But the key piece with these is most patients take one of these medications for a short term after their stent, and then it's discontinued. So many patients are just on this for a short period of time as directed by the provider. The second type of medications I mentioned are those anti-ischemics. And I'm gonna actually include a couple of different ones here. So the first one is nitroglycerin, and you'll see SL-Nitro, so sublingual nitro. These are the little nitro pills that patients put under their tongues when they have chest pain. These little nitro pills vasodilate the arteries and the capillaries, including those in the heart arteries. And by vasodilating or dilating them open, they increase the blood flow to the heart muscle and oftentimes decrease that chest pain or improve the chest pain or the symptoms that the patient's feeling. Now, the contraindication for these is because they dilate those heart arteries, they dilate all the arteries and they can cause low blood pressure. So I always tell patients, make sure that you're sitting when they take it, but it can drop their blood pressure. We don't wanna use these in patients that have really low blood pressure to begin with. And these are a medication that's really used as needed when patients develop chest pain. But like I mentioned, it can cause them to feel lightheaded, dizzy. So I always tell patients, make sure you're seated when they take those. The second class of medications are very similar. They're still nitrates, but these are medications they take on a routine basis. And there's a couple of them. The first one is isosorbide dinitrite or Isordil or isosorbide mononitrate or Imdur. It's the same type of medication. It vasodilates those arteries and the capillaries. Same contraindication for patients that have low blood pressure. They should not be on these medications. They're typically dosed daily or twice daily. They can cause headaches or possibly dizziness. But the overall goal is to increase patients' risk of chest pain and actually improve their activity levels. If they have known coronary disease with some narrow heart arteries or some blockages in those arteries, this can improve their symptoms. All right, the next area of pharmacologic therapies that I want to talk about is anticoagulation medications. So our goal with these medications, again, is to decrease the risk of blood clot formation, but it works differently than those antiplatelets. And the other goal that we use these for is for stroke prevention. So for patients that have a heart condition that increases their risk for stroke, oftentimes we'll use these medications. Now, these medications require close monitoring and special dosing that can be very patient-specific. So let me talk to you about what that looks like. The first one is a medication called Coumadin with the generic name being warfarin. The mechanism of action of Coumadin is that it decreased the clotting through blocking a portion of the clotting cascade. So when you start to look at the science behind this, when our bodies create a blood clot, there's a number of different things that happen in order for that blood clot to occur. And the Coumadin affects one of those areas. And so being on the Coumadin will significantly decrease somebody's risk for clotting. Here's the challenge with the Coumadin. Everybody metabolizes that medicine a little bit differently. And so the dose is very patient-specific. And then in order to understand what dose patients need to be on, you have to monitor the PT and INR value, which is a blood test. Oftentimes this has to occur weekly. Once patients stabilize on a certain dose, it may move to monthly, but most of our organizations will manage these patients in something called a Coumadin clinic or an anticoagulation clinic. It's a very high risk, high touch medication. And so it's important that patients are getting their blood drawn on a routine basis and the dose is being adjusted accordingly. In addition, dietary changes and other medications can affect the metabolism or the breakdown of the drug. And so if you happen to find out with your patient that they recently started a new medication like an antibiotic or another type of new medicine to them, it's important that we let the anticoagulation clinic team be aware so that they can potentially monitor that patient's blood levels a little closer. Additional medications that fall into this class include Eliquis, Pradaxa, and Xeralto. Now, the difference between Coumadin and these medications is that these medications don't require the amount of surveillance that the Coumadin does. So the PT and the INR draws, these medications, the doses are much more of a single type dose. Now they do have to be dosed based on a patient's kidney function. And so it is important that when these medications are first started, that we monitor patient's kidney function and dose accordingly, but they don't have the issues or the challenges related to the dietary changes and the additional medications adjusting for the breakdown of the drug. So these have a lot less resource required in order to manage them. And then the final one is something called heparin or Lovenax. And you'll see LMWH, that's low molecular weight heparin, is what the Lovenax is. The Lovenax also decreases the clotting through blocking a portion of that clotting cascade. And these are both typically provided in a hospital setting. Heparin is given IV, the Lovenax is given through a subcutaneous injection. And we use these in patients that cannot be on the oral medications or maybe happen to be hospitalized. So I want you to be aware of them, but you'll be much less likely to see them in the office space setting. And the last group of medications I wanna talk about are those that you'll see for your patients that have heart failure. And there's a couple different classes of medications. The first one are the diuretics, which we've actually talked a little bit about already because we also use those medications in our patients with high blood pressure. But for our heart failure patients, our goal for the use of these medications is to decrease the swelling and improve the shortness of breath. In addition, you may see for some of these patients the use of a medication called Dajoxin. The Dajoxin's goal is to improve the quality of life by improving heart efficiency, improves physical endurance. And then in many cases for these heart failure patients, they may also be on a beta blocker or an ACE inhibitor or some sort of a combination drug. So the first one being that diuretic class, there's a number of these, and I provided you four different examples of those diuretics. The mechanism of action for these include increases in free water clearance by the kidney. So what it does is it gets rid of the fluid that's in the blood, not the blood cells, but the fluid that's in the blood. And by doing that, then the swelling that we see in our patients, the swelling in their feet, and we call it edema, that we see in other places will get reabsorbed into the vasculature. And so they'll lose that swelling and it'll improve the swelling. Now, as I mentioned before, when the kidneys get rid of that free water, the kidneys also tend to get rid of potassium. So these patients can have low potassium levels related to these drugs. And oftentimes we have to replace the potassium. So with these medications, our patients need to have their blood checked fairly often to check their kidney function and their potassium levels, and then replace the potassium as needed. I mentioned the digoxin. So another term for digoxin is digitalis, and it does increase heart contractility slightly. So it actually improves for many of our patients, their quality of life. Now, digoxin is cleared by the kidneys. So if they have poor kidney function, then it would be a contraindication for them to be on digoxin. Usually not a lot of surveillance required for these, but if there's any concern about their kidney function, then that usually will be monitored closely. So that really is the majority of the medications. Like I said, it's not all of them. There will be some other ones that a few of your patients may be on, but I wanted to cover the main ones that you're gonna see. And so a couple of key takeaways here. Number one, medications can be complicated. It's complicated for our patients. They oftentimes have their medications changed. We're sending in new prescriptions. They still have bottles at home, and it can become very confusing. So the more we can work with our patients, have them bring their bottles in, update that medication at every visit, and just to assure that they're on the right medications, the better. And then from your perspective, anytime you have a question or happen to be in doubt, don't be afraid to ask. And if you need to call the pharmacy, talk to the physician or the APP that you're working with. You're really a key role when it comes to helping the patients manage and keep their medications organized. And so the more that you can understand the names of the drugs, and the difference between the generics and the commercial names, and then even why we use these medications, the more informed you'll be when it comes to helping your patients when you take that history and assuring that you have an appropriate and accurate medication history for your patients. Again, thank you for joining us today. We appreciate your time. And your willingness to learn. If you have any questions, please reach out to not only your preceptor, but if you still have questions, reach out to us at academy at medaxine.com. Thank you.

cardiovascular medications

disease progression

nutrition

antihypertensive medications

antihyperlipidemia medications

medication history