Pharmaceutical Care of CV community 1

Question 1

list the Red Flag Symptoms for Cardiovascular Conditions

Answer 1

1) Chest pain- crushing, central, radiating down arm
2) Breathlessness- with no signs of infection
3) Oedema-swollen ankles
4) Fast heart rate
5) Dizziness/collapse

Question 2

what symptoms are indicative of cardiac pain?

Answer 2

1) Central or band like radiation to jaw ,arms or back
2) Fast pulse
3) May be relieved by GTN/rest
4) Other risk factors: older age, male gender, smoking, hypertension, diabetes mellitus etc.
- Also check no recent trauma to chest

Question 3

what symptoms are indicative of Respiratory

problems?

Answer 3

1) Fast respiratory rate
2) Persistent localised pain
3) Pain worsens on breathing deeply or coughing
4) “knifelike”

Question 4

what symptoms are indicative of Gastro-intestinal

problems?

Answer 4

1) Sub-sternal “burning” pain
2) Often after food or at night
3) Relieved by antacid
4) Difficulty swallowing
5) Tenderness

Question 5

what symptoms are indicative of an infection

problems?

Answer 5

1) High temperature
2) Previous viral illness
3) Fast pulse
4) Infected sputum

Question 6

when would you refer a patient?

Answer 6

1) Any of red flag symptoms
2) Any condition that could cause their current condition to deteriorate
3) Drug-disease interactions for RTS condition

Question 7

outline which Drugs should be avoid in patients with cardiovascular disease

Answer 7

1) High sodium content
2) Drugs that increase blood pressure
3) Drugs that increase risk of falls
4) Drugs that cause fluid retention
5) Drugs that increase heart rate

Question 8

what are the OTC treatment options for Indigestion in Patients with CVD?

Answer 8

1) Check it is indigestion first!
2) Low sodium antacids – Maalox, Mucogel, Topal, Asilone
3) H2 antagonists – ranitidine, famotidine (avoid cimetidine)
4) Proton pump inhibitors – omeprazole, pantoprazole watch interactions with other drugs e.g. warfarin)

Question 9

why should NSAID’s not be recommended for pain relief in Patients with CVD?

Answer 9

1) Cause fluid retention, renal impairment and interfere with platelet effect of low dose aspirin
2) Triptans – cauise vasoconstriction

Question 10

what OTC medicines are recommended for pain relief in Patients with CVD?

Answer 10

1) Paracetamol- For more severe pain, take regularly for best control
2) Low dose opioids- Avoid if can – increased risk of falls in elderly
- Is muscle pain caused by statins Opioids better than NSAIDS

Question 11

outline the treatment options for Colds and Flu in Patients with CVD. Focus on how you would relieve the following symptoms:

1) fever
2) blocked sinuses
3) cough

Answer 11

1) fever - Paracetamol
2) blocked sinuses- Steam inhalation, Avoid decongestants
3) cough- Steam inhalation, Simple linctus, Pholcodine linctus – if insistent

Question 12

outline the treatment options for Headaches/Migraines in Patients with CVD. Also provide a list of medicines that should be avoided

Answer 12

1) Paracetamol- Often been tried already by patient
2) Codeine- Good for headaches, watch with the elderly
3) Migraleve- OK (as above)
4) avoid: Triptans, NSAID’s, Midrid

Question 13

why are some Cardiac Patients put on a fluid restricted diet?

Answer 13

1) When you have heart failure, your heart does not pump out enough blood. This causes fluids to build up in your body.
2) If you drink too many fluids, you may get symptoms such as swelling, weight gain, and shortness of breath. Limiting how much you drink and how much salt (sodium) you take in can help prevent these symptoms.

Question 14

outline the OTC treatment options for Constipation in Patients with CVD who are NOT on fluid restriction.

Answer 14

1) Bulk forming laxatives
2) Lactulose
3) Encourage fluid intake
4) Encourage fresh fruit and vegetables, high fibre

Question 15

outline the OTC treatment options for Constipation in Patients with CVD who are on fluid restriction

Answer 15

1) Use stimulant laxatives short term e.g. senna, docusate sodium
2) Encourage fresh fruit and vegetables, high fibre

Question 16

what OTC products should not be recommended for patients on Warfarin?

Answer 16

1) Glucosamine
2) NSAIDs
3) Miconazole gel
4) St Johns Wort
5) Many cold and flu preparations
6) Omeprazole

Question 17

discuss why you need to be more ready to refer CV patients who for example, have a suspected chest infection, diarrhoea and vomiting?

Answer 17

Presenting condition may exacerbate underlying cardiovascular condition such as angina, atrial fibrillation and heart failure

Question 18

what are some of the conditions cardiovascular patients may present with in the pharmacy?
- for each condition state what it could be caused by

Answer 18

1) Tiredness: Drug related e.g. beta blockers, verapamil
- Worsening of symptoms e.g. heart failure
- Anaemia caused by G.I bleed (aspirin)
2) Constipation: Drug related e.g. verapamil, diuretics
- Dehydration – fluid restriction
3) Nausea (reffer) : Side effects of drugs e.g. digoxin
- General malaise associated with condition e.g. heart failure, atrial fibrillation
4) Cough:Drug related e.g. ACEi
- Pink frothy sputum
- Crackles in lungs even after coughing

Question 19

list the Cardiovascular drugs to watch out for with regards to interactions

Answer 19

1) Digoxin
2) Amiodarone
3) Warfarin
4) Drugs that slow heart rate
5) Drugs affecting electrolytes

Question 20

why should antihistamines be avoided in CV patients?

Answer 20

Avoid antihistamines – prolong QT interval and may lead to arrhythmias

Question 21

discuss how pharmacists can support patients with cardiovascular disease

Answer 21

1) MUR’s and NMS
2) Support medication adherence
3) Offer lifestyle advice
4) Provide advice on recognising and responding to symptom deterioration/ medicines optimisation
5) Providing self management advice on side effects

Question 22

how can pharmacists improve medication Adherence in CV patients?

Answer 22

1) Simplify regime
2) Multi-compartment Aids
3) Counsel the patient on correct use of drugs e.g. GTN
4) MURs should be based around compliance

Question 23

Preventing or reducing development of cardiovascular disease is a national priority. outline what health advice pharmacists should provide to CV patients.

Answer 23

look for opportunities to make interventions to reduce a patient’s risk of developing/worsening their CVD

1) Smoking- risk of CVD begins to decline within a few months of stopping. For CHD risk declines in 2-3 years to that of someone who has never smoked.
2) Obesity – losing weight decreases CVD risk and reduces cholesterol, blood pressure and blood sugars. Aim for BMI of less than 25
3) Exercise-regular exercise assists weight loss and reduces blood pressure.
4) Diet - Unsaturated fats, low salt and increased fruit/veg/ Mediterranean diet
5) Alcohol – men and women

Question 24

two other factors that can influence CVD are environmental and social. discuss how these two factors can influence CVD

Answer 24

1) Environmental-are they exposed to smoke/pollution, are they able to walk/cycle safely in order to exercise. Are there swimming pools/leisure centres. Does weather allow exercise- extremes of heat. Taxes on bad food. Prices of healthy food. Availability of fast food
2) Social- stress increases CVD. Social environment – influences diet, smoking, drinking. Depression/mental health more at risk – reach for”comfort” foods, cigarettes, alcohol

Question 25

what questions should be asked when optimising therapy in angina sufferers?

Answer 25

1) Does the patient have good control of their symptoms?

2) Are they using their GTN correctly?

Question 26

what questions should be asked when optimising therapy in MI patients?

Answer 26

1) Is the patient experiencing symptoms e.g. angina, heart failure?
2) Have their doses been up titrated?
3) Can they discontinue their clopidogrel / ticagrelor?
4) Is their cholesterol in the normal range?

Question 27

discuss how a pharmacist could optimise therapy in heart failure patients.

Answer 27

1) Currently there are no recommendations on ensuring optimal doses in heart failure
2) Target doses may not be being prescribed so patients may not be getting a full benefit.
3) MURs with heart failure patients should be based around compliance and a discussion of why doses may be increased even if the patient feels well
4) Evidence shows that pharmacist involvement can increase the number of patients receiving optimal doses of ACE inhibitors.

Question 28

Describe Symptom Deterioration in patients with Heart Failure

Answer 28

1) Increased SOB with decrease in exercise tolerance
2) Weight gain of more than 2kg in 2 days
3) New orthopnoea ( discomfort in breathing that is brought on or aggravated by lying flat)
4) Paroxysmal nocturnal dyspnoea ( sudden and severe shortness of breath at night)
5) Development or worsening of peripheral oedema or ascites

Question 29

outline the Common side effects of the following CV drugs:

1) Beta-blockers
2) Statins
3) Nitrates
4) Calcium channel blockers
5) ACEi

Answer 29

1) Beta-blockers: Tiredness, fatigue, impotence, coldness of extremities
2) Statins: Myalgia (pain in muscle), Myopathy
3) Nitrates: Headache
4) Calcium channel blockers: Ankle swelling, headache
5) ACEi: Cough, Dizziness