FAFP2 Pharmaceutical care II Lecture: Cardiovascular system I. - hypertension Pharmacist's role in providing pharmaceutical care to patients with arterial hypertension Blood pressure measurement 4. 3. 2020 PharmDr. Bc. Dana Mazánková, Ph.D. mazankovad@vfu.cz Hypertension • sustained increase in systemic arterial pressure above 140/90 mmHg Blood pressure (BP) goals: • all patients with hypertension decrease BP: < 140/90 mm Hg • patients with diabetes decrease BP: < 140/85 mm Hg • patients with hypertension with high total cardiovascular (CV) risk: patiets with diabetes mellitus, metabolic sy, patients after myocardial infarction, patients after ictus, renal impairment, proteinuria decrease BP: < 130/80 mm Hg • the elderly patients (over 65 years): ▫ systolic BP goal of 140-150 mm Hg Definitions and classification of office blood pressure levels (mmHg) WHO, European Society of Hypertension (ESH) Category Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Optimal <120 <80 Normal 120-129 80-84 High normal (prehypertension) 130-139 85-89 Grade 1 hypertension 140-159 90-99 Grade 2 hypertension 160-179 100-109 Grade 3 hypertension ≥180 ≥110 Isolated systolic hypertension ≥140 <90 Pharmaceutical care to patients with hypertension 1. Primary prevention of hypertension 2. Detection of hypertension 3. Management of hypertension treatment 1. step: Primary prevention of hypertension – pharmacist's role Providing information about health life style, non-pharmacological treatment (regimen intervention) Contacts to organizations: • Centres for weight loss • Centres for quit smoking • Supporting smoking cessation in pharmacies Recommendations for the non-pharmacological treatment of arterial hypertension a) Excess of calories b) Excess of saturated fats c) Excess of alcohol d) Excess of salt e) Lack of physical activity f) Smoking a) (Dyslipidemia) b) (Diabetes mellitus) Body weight control Maintain BMI < 25 kg/m 2 up to 65 years of age Maintain BMI < 27 kg/m 2 after 65 years of age Moderate alcohol consumption Limit daily alcohol consumption to: 1 dose for women and low-weight individuals - max 20g/day 2 doses for men – max 30g/day Moderate salt consumption Salt (portion/day): 6 g NaCl (3 000 mg of sodium) - the DASH diet (Dietary Approach to Stop Hypertension) Fruits (portions/day) 4-5 Vegetables (portions/day) 4-5 Milk and dairy products < 1% fat (portions/day) 2-3 Lean meat, fish and poultry (g/day) < 180 Oils and fats (portions/day) 2-3 Seeds and nuts (portions/week) 4-5 Added sugars (portions/week) < 5 Whole grains (portions/day) 6-8 Dietary patterns Physical activity For all hypertensives – population recommendation – physical activity practice: - moderate, continuous (1 x 30 min) or cumulative (2 x 15 min or 3 x 10 min) physical activity (similar to walking) - at least 30 min/day, 5 to 7 days/week Aerobic training - at least 3 times/week (ideally 5 times/week) - minimum of 30 min (ideally 40 to 50 min) Positive factor: Kalium (K) - potassium Role of pharmacist: • ask, if patiet use drugs, that can cause hypocalemia ▫ thiazid diuretics • ask, if patiet use drugs, that can cause hypercalemia ▫ ACE- inhibitors, angiotensin II receptor antagonists (ARBs) • detect, if any organ impairment can increase risk of hypercalemia ▫ in decreased renal function • detect, if physician control blood-kalium level • recommendation of food with higl level of kalium / potassium High-potassium foods (more than 200 mg per serving) - fruit, vegetables, others • 1 medium banana (425) • ½ of a papaya (390) • ½ cup of prune juice (370) • ¼ cup of raisins (270) • 1 medium mango (325) or kiwi (240) • 1 small orange (240) or ½ cup of orange juice (235) • 1 medium pear (200) • 1 medium baked potato, with skin (925) • 1 baked medium sweet potato, with skin (450) • ½ cup of tomato or vegetable juice (275), or 1 medium raw tomato (290) • ½ cup of mushrooms (280) • ½ cup of cooked zucchini (220) or winter squash (250) • ¼ of a medium avocado (245) • ½ cup of broccoli (230) • ½ cup of cooked pinto beans (400) or lentils (365) • 1 cup of soy milk (300) • 3 ounces of baked or broiled salmon (319) • 6 ounces of yogurt (260 to 435) • 1 cup of nonfat, low-fat, or whole milk (350 to 380) Positive factor: calcium (Ca), magnesium (Mg) • risk patient for high income of Ca, Mg: ▫ patient with decreased renal functions • high income of chrome in food can prevent: ▫ diabetes mellitus ▫ atherosclerosis Positive factor: chrome (Cr) 2. step: Detection of hypertension – pharmacist's role Blood pressure measurement • hypertension must be diagnosed by physician ! • pharmacist can support patient's compliance by assisting in blood pressure measurement: ▫ BP measurement in pharmacy ▫ providing advice for correct patient's BP measuremet in home Frequency of BP measuremet  beginning of BP measurement, in each change of drugs, before visit a physician: ▫ 2 x morning and 2 x evening ▫ in interval: 1 – 2 minutes ▫ 1 week  BP measurement between visit a physician: ▫ 1 week (quarterly) ▫ or: always 1 – 2 days per a week, constantly • 30 min before measuring do not: ▫ consume caffeine, alcohol ▫ smoke ▫ exercise ▫ use drugs Tonometers • validated, calibrated devices, with cuff size adequate to arm circumference • fully automatic devices • recommendation of validation: once per 2 years  www.dableducational.org Devices for self blood pressure measurement (SBPM) according to various characteristics: • more suitable devices upper arm devices than wrist devices • more suitable devices with history than without history • more suitable devices devices with 2 principles of measurement of BP than only with 1 principles • e. g. Tensoval Duo Tonometers – cuff selection Arm circumference (cm) Cuff size (cm) Designation 22 – 26 12 x 22 Small adult 27 – 34 16 x 30 Adult 35 – 44 16 x 36 Large adult 45 - 52 16 x 42 Adult tight Types of tonometres Blood pressure measurement - technique • to allow the patients to sit for 3–5 minutes before beginning BP measurement • do not talk during measurement • always use the same tonometer • sitting, supported back, arm supported at heart level • cuff at heart level - left hand, 1-2 cm above elbow (cubital) fossa • measured at least 2x (ideally 3x) a 2-minute break • count average from all measurements (2nd and 3rd) • repeat - if measured values of each differed by> 5 mmHg • measurement at the end drug of dose-interval • avoid the influence of „white coat syndrome“ BP levels – pharmacist's interventions Systolic and diastolic BP (mmHg) Pharmacist's interventions SBP < 120 or DBP < 75 BP is optimal. No interventions needed. Repeat BP measurement after 2 years, in patients over 75 years after 1 year. SBP < 120-130 or DBP < 75-85 BP is normal Repeat BP measurement after 1 year. SBP < 130-139 or DBP < 85-89 High normal BP Repeat BP measurement after some months. Provide patient with non-pharmacological treatment recommendations. SBP < 140-199 or DBP < 90-109 Elevated BP Recommend visit physician. Provide patient with non-pharmacological treatment recommendations. SBP < 200-219 or DBP < 110-119 High elevated BP Recommend immediate visit physician. SBP > 220 or DBP > 120 Recommend immediate visit physician or call rescue service. 3. step: Management of hypertension treatment – pharmacist's role 3. 1. Patient's pharmacotherapy monitoring • Communication with patient in pharmacy: a) reason of treatment b) patient's benefit of proper BP value c) asymptomatic process of hypertension d) side effects of antihypertensive drugs e) whole-life antihypertensive treatment f) regiment intervention g) self BP measurement Drugs, that can induce or deteriorate hypertension • nonsteroidal anti-inflammatory drugs (NSAIDs) • corticosteroids • antidepressants • estrogens • sympathomimetics • sibutramin • Panax Ginseng extractum • mineral waters with lots of minerals (natrium) 3. 2. Non-pharmacological treatment (lifestyle changes) • Salt restriction • Moderation of alcohol consumation ▫ 140 g per week for men ▫ 80 g per week for women • Other dietary changes ▫ vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources ▫ fresh fruits ▫ restriction of fat income - saturated fats replace by non-saturated fats  daily income of saturated fats: max 33 %  daily income of cholesterol: max 300 mg • Weight reduction • Regular physical exercise • Smoking cessation 3. 3. Proper recommendation of OTC, food supplements • omega-3 polyunsaturated fatty acids ▫ daily dose: 3 g • eicosapentaenoic acid (EPA) recommended daily dose: 1 g • docosahexaenoic acid (DHA) recommended daily dose: 1 g • dietary and soluble fibre Antihypertensive drugs • monotherapy vs. drug combination strategies ? Monotherapy Combination therapy • fixed-dose / single-pill combinations • preferring drug combinations that are effective in reducing CV outcomes: ▫ CV morbidity ▫ CV mortality Monotherapy vs. drug combination strategies to achieve target BP ESH 2013 guidelines for the management of arterial hypertension G Preferred drugs in hypertension therapy • angiotensin-converting enzyme inhibitors (ACE-inhibitors) • angiotensin II receptor blockers, AT1-receptor antagonists (sartans, AT1-inhibitors) • calcium antagonists • diuretics • beta-blockers ________________________________________________________________________ • alpha receptor blockers and centrally acting agents ▫ combination therapy • direct renin inhibitor: aliskiren Renin-Angiotensin-Aldosterone system Angiotenzinogen Kininogen Angiotensin I Bradykinin Angiotensin II inactive metabolite Renin ACE (Angiotensinconverting enzyme) + + + Renin inh. - ACEI AT1 inh. arteriolar vasodilatation decreased BP Aldosteron secretion: Na+ reabsorption K- excretion water retention ADH secretion vasodilatation sympathetic activation vasoconstriction increased BP AT II rec. AT I rec. PG synthesis Preferred drug combinations Fixed-dose combinations of two drugs • ACE-inhibitor / AT1-inhibitor + diuretics • ACE-inhibitor / AT1-inhibitor + calcium antagonist • diuretics + calcium antagonist ______________________________________________________________________ • ACE-inhibitor + AT1-inhibitor • ACE-inhibitor / AT1-inhibitor + beta-blocker • diuretics + beta-blocker • calcium antagonists (verapamil / diltiazem) + beta-blocker Fixed-dose combinations of three drugs • combination with diuretics: • ACE-inhibitor / AT1-inhibitor + calcium antagonist + diuretics • combination with hypolipidemic agent: • ACE-inhibitor + calcium antagonist + statin • perindopril + amlodipin + atorvastatin (LIPERTANCE)