PHARMACEUTICAL CARE
ISSUES IN CARDIOLOGY
BY: BASARIAH BT NAINA
B.PHARM(HONS)M.PHARM(CLINICAL)
Medication Appropriateness
Index
1. Is there an indication for the drug?
2. Is the medication effective for
the condition?
3. Is the dosage correct?
4. Are the directions correct?
5. Are the directions practical?
6. Are there clinically significant
drug-drug interactions?
7. Are there clinically significant
drug-disease/condition interactions?
8. Is there unnecessary duplication with
other drugs(s)?
9. Is the duration of therapy acceptable?
10. Is this drug the least expensive alternative
compared with others of equal utility?
INTRODUCTION
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Types of heart disease: angina, heart
attack (myocardial infarction),
atherosclerosis, heart failure,
cardiovascular disease, and cardiac
arrhythmias (abnormal heart
rhythms).
Other forms of heart disease :
congenital heart defects,
cardiomyopathy, infections of the
heart, coronary artery disease, heart
valve disorders, myocarditis, and
pericarditis.
Treatments for Heart disease
Aspirin - low-dose aspirin may be used to
avoid heart attacks. However, because of side
effects and risks it is not usually
recommended for healthy individuals. Mainly
for those with existing heart problems or
previous conditions.
 Digitalis - makes the heart pump harder, also
helps some heart rhythm problems.
 ACE inhibitors
 Beta-blocker
 Nitrate (including nitroglycerine)

Treatment of advanced or critical types of heart
disease, such as heart attack, heart Failure or
serious abnormal heart rhythms, requires
hospitalization. Treatment includes :
administration of oxygen aimed at increasing the
amount of oxygen that is delivered to the heart
tissue. Also involves intensive monitoring and
stabilization of vital signs, which may require CPR
and/or intravenous medications. Breathing may
need to be supported by mechanical ventilation.
Heart rhythm and cardiac enzymes are also
monitored.
 Abnormal heart rhythms need treatment with
medications & possibly electrical defibrillation.
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In a heart attack, nitroglycerin, used to improve
blood flow to the heart.
morphine, to reduce pain and anxiety and lower the
amount of oxygen the heart needs.
aspirin or heparin, may be used.
Angioplasty -the blood clot is removed from the
artery and the artery is widened using a balloon
device and a stent is placed in the artery to keep it
open.
coronary artery bypass : new graft arteries are placed
to bypass the blocked coronary artery or arteries.
Blood flow is then redirected through healthy new
graft arteries to the affected heart tissues
MI
HEART
Balloon Catheter
Rare Types of Heart disease:
 Atrial myxoma
 Long QT syndrome
 Wolff Parkinson White syndrome
 Supraventricular tachycardia
 Atrial flutter
 Constrictive pericarditis
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Curable Types of Heart disease:
Valvular heart disease
Infective endocarditis
Congenital heart diseases
Coronary heart disease
Atrial myxoma
Long QT syndrome
Wolff Parkinson White syndrome
Supraventricular tachycardia
Atrial flutter
Constrictive pericarditis

ASPIRIN
75 mg /day would decrease rates of GI
bleeding by 40 % compared to 300
mg/day.
Digitalis after MI?
Should not be given to pts with MI who are
not in cardiac failure-may increase infarct
size.
DIGOXIN
IM severe pain-IV preferred
IM dose is 80 % of previous oral dose
Decrease digoxin level
Antacid
Cancer chemotherapy
Cholestyramine
Cholestipol
Kaolin Pectin
Laxatives
Sulfasalazine
Increase Digoxin level
Erythromycin
 Omeprazole
 Alprazolam
 Amiodarone –decrease digoxin 50 %
 Calcium channel blockers
 Captopril
 Quinidine- decrease digoxin 50 %
 Tioconazole
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Digoxin Dosage:
Loading Dose:
-Lower range (0.01 mg/kg) for mild CHF.
-Higher range (0.02 mg/kg) to control
ventricular rate in atrial fibrillation.
Oral LD= (Vd)(Cp)
(F)
Factors alter response to Digoxin
Compliance
 Bioavailability
 Malabsorption
 Altered metabolismhypocalcemia,hyperthyroidism
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DIGITALIS TOXICITY
Arrythmia
Tx
IV lidocaine
Phenytoin
IV Propranolol
Procainamide & Quinidine ( ) :IV use
can cause hypotension and
cardiotoxicity
CHF
DIURETICS
 Responsiveness to loop diuretics
diminishes as HF progresses.
 So-combination of thiazides and
loop diuretics are useful as these
drugs work synergistically
to improve diuresis.
In patients with a GFR below
30ml/min, thiazides are not effective
alone but may be used
synergistically with loop diuretics
The combination of i.v. nitrate and
low dose frusemide is more
efficacious than high dose diuretic
LAB INVESTIGATION
Hyponatremia
 Hypochloremia: can cause
hypochloremic acidosis
 Hypokalemia
 Hypomagnesemia
Can cause cardiac arrythmias

alkaline phosphatase /AST in HF
pt :result of hepatic congestion from
right sided HF

Patient on DIURETIC
Increase BUN but normal serum
creatinine.
 BUN:creatinine ratio 10-20:1
 Prerenal Azotemia: cause is
decreased RBF secondary to
uncompensated CHF.

Hyperuricemia
1-2 mg/dl common
If > 10 mg/dl /Hx of gout – should
treat.
ACE INHIBITOR
Monitor blood urea, creatinine and
serum potassium at 7-14 days,
especially in patients with impaired
renal function.
If the rise in serum creatinine level
is >20% compared to baseline, then
ACEI therapy may need to be
stopped.
Severe HF the combination of ACEI
and an ARB may be considered
to reduce hospitalization due to HF.
ACE INHIBITOR
Captopril-short acting drug, start first
to monitor side effect then change.
Common s/e: dry cough
Severe s/e:
Angioedema(facial & neck swelling)
CI : Pregnancy –esp 2nd & 3rd
Trimester
ARRYTHMIAS
Classification :
Supraventricular Arrythmias:
Originating above bundle of HIS.
Include: Sinus Bradycardia,sinus
tachycardia,paroxysmal supraventricular
tachycardia,atrial flutter,atrial
fibrillation,wolff-Parkinson-White (WPW)
syndrome
VENTRICULAR ARRYTHMIAS:
Below bundle if HIS. Include premature
ventricular contraction(PVCs),VT &
ventricular fibrillation(VF)
ANGINA
NITRATE:
Oral nitrates with extended duration
Of action –prone to induce tolerance.
Must devise a nitrate free dosing
schedule.
Transdermal Ointment-3 x/day
Transdermal Patches-no tolerance if
<12hrs/day
Transmucosal -nitrate free interval at
night,no tolerance
Isosorbide Mononitrate
Adv of ISMO –less dosage
fluctuation because of absence of
presystemic clearance
 Extended release(Imdur) can
provide effective control as once
daily –alternative is Isosorbide
Dinitrate(less expensive) 3 x/day
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B Blockers
Metoprolol (lipophilic) can cause CNS
s/e so change to atenolol(hydrophilic).
Cannot stop abruptly – can cause
rebound Phenomenon.
B blockers may worsen asthma
substitute with CCB or long acting
nitrates.
CombinationTherapy for Angina

Nitrate,B blocker,CCB , ACEI &
Anti platelet
Myocardial Infarction
Thrombolytic – up to 1 hr from
onset of chest pain.
 Readministration of Thrombolytic
agents:
Streptokinase (antibodies formation
and allergic) for 1st infarction,if 2nd
attack within same yr alteplase or
reteplase.
> 70 yrs pt should receive
Streptokinase cause tPA can cause
intracranial hemorrhage
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VASODILATORS
NTG vs Nitroprusside
 NTG preferred over Nitroprusside cause
Nitroprusside increase ST segment
elevation. NTG decrease ST segment
elevation.
 Sodium Nitroprusside would be useful in
patients not responsive to nitrates
&useful in cases of uncontrolled
hypertension, acute mitral or aortic
regurgitation.
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Morphine
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Causes peripheral venous & arterial
vasodilation
reduce preload &
afterload
reduce myocardial
Oxygen demand.
CASE 1
72 yrs old male
 Develops substernal,crushing pain
associated with diaphoresis.
 At ED:
ST segment elevation MI
Troponin 3.65
95 % stenosis in left anterior artery,then
drug eluting stent placed with reduction
in stenosis to less than 25 %
Stabilized & discharge home on day 5
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Discharge medication
Clopidogrel
Prior to this admission:
Aspirin and lansoprazole daily for GERD
Based upon the info provided,any concern
on medication profile?
DISCUSSION
Clopidogrel for 9-12 mths
Ix between clopidogrel & PPI
Clopidogrel requires activation by
cytochrome P450.PPI inhibitor of P450.
- decrease clopidogrel activation &
reduction in antiplatelet effects.
Pt with GERD alternative drug : H2
blockers or pantoprazole for pt
absolutely require PPI
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Case 2
56 yrs old male
 12 yrs of idiopathic Parkinson’s ds.
 Medication:
Levodopa,pramipexole and just started
clozapine 6.25 mg and titrated up to 50
mg/day over 1st mth of starting therapy.
Patient subsequently presented with
fever,dyspnea,tachycardia & chest pain
persisted for the last 8hrs.
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Lab result: normal only serum troponin T
was elevated.
 EKG showed diffuse T wave flattening&
elevated QTc interval.
 Echocardiography revealed severely
depressed left & right ventricular
contractility & reduced injection fraction
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DIAGNOSIS?
CLOZAPINE INDUCED MYOCARDITIS
Myocarditis –inflammation of the heart and
myocardial destruction that lead to
dilated cardiomyopathy.
Rare –estimated incidence 0.3
cases/100,000 pt.
Appears rather quickly,within 2 mths in
90% of cases.
Immediate discontinuation of clozapine.
CASE 3
AG is an 80-year-old woman who reports
to the ED complaining of dizziness,
weakness and nausea for about 7 days.
Her past medical history is significant for
chronic renal insufficiency, chronic
obstructive pulmonary disease,
intermittent atrial fibrillation,
osteoarthritis, coronary artery disease,
mild-to-moderate anxiety, and
hypertension.
Her medications on admission are:
Digoxin 0.25 mg daily
Triamterene 37.5 mg/HCTZ 25 mg, 2
capsules daily
Quinidine gluconate 324 mg 3x daily
Lisinopril 20 mg daily
Simvastatin 20 mg daily
Triamcinolone inhaler 2 puffs 3-4x daily
Formoterol inhaler one inhalation 12 hrly
Ticlopidine 250 mg twice daily
Chlordiazepoxide 10 mg 3 xdaily
Multivitamin
During osteoarthritis disease flares
she often self-medicates with
indomethacin that her husband uses
for gout.
She states that she usually takes 2-3
capsules of the 25 mg indomethacin
daily until symptoms subside.
Upon evaluation in ED
-the physical exam unremarkable
-vital signs within normal limits.
-The EKG shows a junctional rhythm.
Abnormal laboratory values
identified:
Potassium 6.0 (normal, 3.5 -5.0
mmol/L)
BUN 40 (normal, 10 - 26 mg/dL)
SCr 2.0 (normal, 0.6-1.3 mg/dL)
Serum digoxin level 5.1 nmol/L
(normal, 0.6 – 2.8 nmol/L)
Some medication therapy
management issues include:
Hyperkalemia related to digoxin
toxicity
Decreased clearance of renally
eliminated drugs
Hyponatremia
Potential management:
Consider lower dose digoxin if
needed (digoxin toxicity,
hyperkalemia)
Change ticlopidine(renal &geriatric)
to other agent (aspirin)
Remove chlordiazepoxide
(accumulation)
Lower ACE inhibitor dose
(hyperkalemia)
Consider different antihypertensive
Consider change in diuretic/dose
(hyperkalemia)
Refrain from taking
indomethacin(cardio risk & renal),
and choose a short-acting NSAID
Monitor electrolytes more closely