Pharmaceutical Care and Cardiovascular Diseases

  • Martin SchulzEmail author
  • Katrin Krueger
  • Nina Griese-Mammen
  • Ross Tsuyuki


Cardiovascular diseases (CVDs) are often accompanied with comorbidities and, therefore, with multiple drug regimens. Drug-related morbidity and mortality due to drug-related problems (DRPs) represent a serious problem in these patients. Pharmacists’ intervention can detect and solve or prevent DRPs. However, DRPs in CVDs are currently not a validated surrogate outcome. Nevertheless, suggested interventions are medication reconciliation and reviews, patient education and counseling (to improve self-care and medication adherence), additional written information (medication plan) and pillboxes (weekly dosing aids) to improve adherence, and monitoring of clinical parameters, among others. Apart from hypertension and CVD risk reduction, randomized controlled trials (RCTs) with robust designs, studying large populations, adequate follow-up periods, and sufficiently powered to detect clinical relevant differences in endpoints are needed. The evidence gained will provide standards for the interventions and outcome measures, both to compare studies and approaches to implement them reimbursed in daily pharmaceutical practice.


Pharmaceutical care Cardiovascular diseases Medication adherence Hypertension Angina pectoris Myocardial infarction Heart failure Cerebrovascular diseases 

29.1 Introduction

Cardiovascular diseases (CVDs) are the number one cause of death globally. The World Health Organization (WHO) reports that 17.5 million people die each year from CVDs, an estimated 31% of all deaths worldwide. Four out of five CVD deaths are due to heart attacks and strokes. Over 75% of CVD deaths occur in low-income and middle-income countries [1].

CVDs are caused by disorders of the heart and blood vessels, such as raised blood pressure (BP; hypertension (HT)) and coronary heart disease (CHD). They include angina, acute coronary syndromes (ACS) including myocardial infarction (MI), heart failure (HF), cerebrovascular diseases (stroke and transient ischemic attacks (TIA)), peripheral artery disease (PAD), rheumatic heart diseases, and congenital heart diseases. Individuals at risk of CVD often have hypertension, dysglycemia, and dyslipidemia as well as overweight/obesity. These can all be easily measured and monitored by pharmacists. Identifying those at highest risk of CVDs and ensuring they receive appropriate treatment can prevent premature deaths. The major lifestyle risk factors of CVD are tobacco use, physical inactivity, an unhealthy diet, and harmful use of alcohol [1].

It is possible to prevent CVD by addressing these behavioral risk factors. People with CVD or at high CV risk need early detection and management including counseling and pharmacotherapy [1, 2, 3]. The WHO identified cost effective interventions for prevention and control of CVD, e.g., comprehensive tobacco control policies, taxation to reduce the intake of foods that are high in fat, sugar and salt, building walking and cycle paths to increase physical activity, and individual healthcare interventions to be targeted to those at high CVD risk. For secondary prevention of CVD in those with established disease, treatment with medications like aspirin (ASA), beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEI), and lipid-lowering drugs (mostly statins) is necessary [1].

The complexity of the guideline-recommended therapies increases as the disease progresses due to increasing comorbidities requiring additional treatment by different specialists. This increases the probability of drug-related problems (DRPs) such as drug/drug and drug/food interactions, contraindications, duplicate medications, and adverse effects (AE). Moreover, actual medication intake by patients often differs from the recommendations made by healthcare professionals. Medication nonadherence is, hence, another major issue. For many patients, it is difficult to self-manage their many pharmacological and non-pharmacological treatments. More on medication adherence can be found in Chap.  5.

So, multidisciplinary approaches to treatment and care are promising to reduce hospitalizations and mortality, eventually [1]. The benefits of these interventions are largely independent, but when used together with smoking cessation, nearly 75% of recurrent vascular events are potentially preventable. Currently there are, however, major gaps in the implementation of these interventions particularly at the primary healthcare level [1].

29.2 Disease Characteristics

Hypertension and dyslipidemia are the most common CVD risk factors, and CHD and HF are by far the most common CVD. Therefore, this section covers these four conditions.

29.2.1 Dyslipidemia

Dyslipidemia is a major risk factor for CVD including stroke [1, 2, 3, 22]. The most common dyslipidemia is elevated low-density lipoprotein cholesterol levels, which directly relate to risk of atherosclerotic vascular disease.

Dyslipidemia targets recommended by major cardiovascular guidelines are all based upon calculation of an individual’s risk for CV events (see the guidelines for various CV risk calculators). The approach to LDL-C targets vary by guideline, and either call for a 50% reduction in LDL-C, targets based upon CV risk (e.g., a target of <2.0 mmol/L in those at high CV risk) (see and, or simply to use high-dose statins in all patients at high CV risk (see

29.2.2 Hypertension

Hypertension is a condition in which the blood vessels have persistently raised pressure. Raised BP is one of the leading risk factors for CHD, HF, both ischemic and hemorrhagic stroke, and subsequently, for global mortality. In some age groups, the risk of CVD doubles for each increment of 20/10 (systolic/diastolic) mmHg of BP, starting as low as 115/75 mmHg [1].

29.2.3 Coronary Heart Disease (CHD)

CHD, as a result of coronary artery disease (CAD), causes exercise- and stress-related ischemic symptoms due to narrowing of ≥50% in the left main coronary artery and ≥70% in one or several of the major coronary arteries. CHD is characterized by episodes of reversible myocardial supply mismatch, related to ischemia or hypoxia commonly associated with transient chest discomfort and pain (angina pectoris).

The various clinical presentations of CHD are associated with different underlying mechanisms that mainly include (i) plaque-related obstruction of epicardial arteries, (ii) focal or diffuse spasm of normal or plaque-diseased arteries, (iii) microvascular dysfunction, and (iv) left ventricular dysfunction (LVD) caused by prior acute myocardial necrosis and/or hibernation (ischemic cardiomyopathy) [2].

29.2.4 Heart Failure (HF)

HF is a highly morbid and costly condition with a growing impact on public health affecting approximately 1–2% of the adult population in developed countries. Hospitalizations for acute decompensated HF (ADHF) are common, and the mortality is high despite guideline-directed treatment [3]. HF is characterized by typical symptoms (e.g., breathlessness (various degrees of dyspnea), ankle swelling, and fatigue) that may be accompanied by signs (e.g., elevated jugular venous pressure, pulmonary crackles, and peripheral edema). It is caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output. Before clinical symptoms become apparent, patients can present with asymptomatic structural or functional cardiac abnormalities. Identification of the underlying cardiovascular problem(s), mostly undiagnosed or poorly managed hypertension or CAD, is crucial.

HF is categorized by the percentage of the left ventricular ejection fraction (LVEF). There are patients with normal LVEF (≥50%; HF with preserved EF (HFpEF)), with reduced LVEF (<40%; HF with reduced EF (HFrEF)), and with an LVEF in the range of 40–49% (HF with midrange EF (HFmrEF)) [2].

29.3 Treatment Goals

29.3.1 Hypertension

BP-lowering drugs are strongly recommended to reduce the risk of CV outcomes (e.g., stroke, ACS/MI, and HF) in all individuals with HT [2]. Treating systolic and diastolic BP to a target below 140/90 mmHg is associated with a reduction in CV complications [1]. Treatment includes lifestyle modifications which is first line. The introduction of pharmacotherapy is linked to overall CVD risk: diuretics (including thiazides, chlorthalidone, and indapamide), BB, calcium channel blockers (CCBs), and ACEI or angiotensin receptor blockers (ARBs) are all suitable for the initiation and maintenance of antihypertensive treatment [2].

29.3.2 Coronary Heart Disease

Management of CHD aims to reduce symptoms, improve prognosis, as well as prevent CV events. It includes lifestyle modifications like healthy diet and increased/appropriate physical activity, control of risk factors (like smoking, overweight/obesity, high lipids, high BP), evidence-based pharmacological therapy, and patient education. Anti-ischemic drugs like nitrates and molsidomine, BB, CCB, and ivabradine (an inhibitor of the “funny channel” reducing only the heart rate in patients in sinus rhythm) are used.

To prevent CV events (like MI or acute thrombotic events), pharmacological or lifestyle interventions are used which: (i) reduce plaque progression; (ii) stabilize plaque by reducing inflammation, and (iii) prevent thrombosis. Therefore, antiplatelet agents like low-dose aspirin and P2Y12-inhibitors such as clopidogrel, prasugrel, or ticagrelor, lipid-lowering agents (statins), and renin-angiotensin-aldosterone system (RAAS) blockers like ACEI are recommended [2].

29.3.3 Heart Failure

The goals of guideline-recommended therapies for heart failure (HF) are: improvement of symptoms (dyspnea, fatigue, and exercise tolerance), slowing of disease progression, improvement in quality of life (QoL), and decrease in hospitalizations and mortality, requiring a long-term therapy with multiple drugs [4]. Neurohormonal antagonists (ACEI or ARB, BB, and mineralocorticoid receptor antagonists (MRA)) have been shown to improve overall survival (all-cause mortality) in patients with HFrEF. In addition, a first-in-class composite angiotensin receptor–neprilysin (NEP) inhibitor (ARNI; valsartan+sacubitril) reduces the risk of HF-related hospitalizations and mortality in patients with HFrEF. Ivabradine reduces the elevated heart rate often seen in HFrEF and has also been shown to improve outcomes in HFrEF.

The use of diuretics, especially loop diuretics, should be modulated according to the patient’s clinical status. Treatment of hypertension is recommended to prevent or delay the onset of HF. Also counseling on appropriate fluid/sodium intake, appropriate physical activity, smoking cessation, and reduction in alcohol intake is recommended [2].

29.4 Common Drug-Related Problems Often Encountered in Patients with CVD

CVDs are often accompanied with comorbidities and, therefore, with multiple drug regimens. One study found that nearly 30% of CVD patients taking ≥5 drugs (a common threshold for polypharmacy) had at least one DRP. Inappropriateness of the drug (especially inappropriate drug combinations) or the dose was the most common drug-related problems (DRPs). A need of additional drug therapy and lack of therapeutic monitoring are common risk factors causing DRPs [5].

The most inappropriate drug class for CVD patients is nonsteroidal anti-inflammatory drugs (NSAIDs, ibuprofen, diclofenac, naproxen, among others) including COX-2 inhibitors (coxibs). Whenever possible, NSAIDs should be avoided in combination with ACEI, ARB, or diuretics due to the risk of raised BP and worsening of renal function. NSAIDs or coxibs are not recommended (contraindicated) in patients with HF, as they increase the risk of HF worsening and HF hospitalization [6].

Many antihypertensives are associated with clinically significant drug interactions which may affect BP-lowering or result in adverse drug reactions (ADR). BB may mask signs and symptoms of hypoglycemia when used with insulin or oral antidiabetics and may impair glucose tolerance leading to poorer glycemic control. Drug/drug interactions resulting in increased plasma levels of statins increase the risk of ADRs such as myopathies.

In HF, drug classes causing many DRPs include ACEI, ARB, BB, MRA, diuretics, potassium supplements, and digoxin [6]. Regular monitoring of both potassium levels and renal function is recommended. Moreover, thiazolidinediones (glitazones) and the CCBs diltiazem and verapamil are not recommended in patients with HF, as they increase the risk of HF worsening and HF hospitalization [2].

Pharmacists’ intervention can help to monitor and prevent the risk of developing DRPs, and contribute to improve clinical outcomes in patients with or at risk of CVD [5]. In one non-randomized study without a control group, 94% of the DRPs in HF patients were classified as preventable. During the 6-months follow-up, pharmacist interventions solved or prevented the health problem in 83% of the cases [6]. It should also be emphasized that many patients with, or at risk for CVDs are undertreated for their risk factors—these are DRPs that should be a target for pharmacist interventions.

29.5 Interventions in Patients with or at Risk of CVD

There are few studies evaluating pharmacists´ intervention in patients with or at risk of CVD, and randomized controlled trials (RCTs) are rare. However, RCTs in pharmaceutical care are often challenging to conduct. Most studies have investigated the impact of interventions in hypertension, followed by HF, and CHD.

Pharmacists’ intervention may improve the clinical management of major risk factors for CVD, can detect, solve, or prevent DRP, and may increase medication adherence. In one RCT with 723 patients, and after adjusting for baseline values and center effect, there was a 21% difference in change in risk for CVD events (p < 0.001) between the intervention and usual care groups. The intervention group had greater improvements in LDL-C (−0.2 mmol/L; p < 0.001), systolic BP (−9.37 mmHg; p < 0.001), glycosylated hemoglobin in those with diabetes (−0.92%; p < 0.001), and smoking cessation (20.2% reduction; p = 0.002) [7].

A systematic review and meta-analysis identified the following interventions: patient education, patient reminder systems, measurement of CVD risk factors, medication management and feedback to physician, or education of other healthcare professionals [8]. Pharmacist care was associated with a significant reduction in systolic/diastolic BP (19 studies [10,479 patients]: −8.1 mmHg, 95% CI [−10.2 to −5.9]/−3.8 mmHg [−5.3 to −2.3]); total cholesterol (TC) (9 studies [1121 patients]: −17.4 mg/dL [−25.5 to −9.2]; LDL-C (7 studies [924 patients]: −13.4 mg/dL [−23.0 to −3.8], and a reduction in the risk of smoking (2 studies [196 patients]: relative risk, 0.77 [0.67–0.89]) [8].

Another systematic review of studies, which evaluated the impact of pharmaceutical care on patients with CVD, showed that 20 of 24 included RCTs resulted in significantly improved risk factors, i.e., high BP, elevated LDL-C or blood glucose levels, or CV risk in general—with high BP and elevated cholesterol levels as the most common surrogate outcomes with significant differences after the intervention [9]. Interventions with significant results were medication reviews, patient education and counseling, additional written information, pillboxes (weekly dosing aids), and monitoring of clinical parameters [9]. More on medication review and counseling can be found in Chaps.  4 and  7 of this book.

29.5.1 Hypertension

The control of BP is a major challenge in primary care. The primary outcomes of studies evaluating pharmaceutical care in patients with hypertension are, apart from BP, medication adherence and QoL with systolic BP as the outcome most positively impacted by pharmaceutical intervention [10].

There is very strong evidence that pharmacist intervention improves BP control in outpatients compared with usual care. In a large systematic review, pharmacist intervention—for example, patient education and counseling about lifestyle, medication use and adherence, feedback to physician (including DRP identification and recommendations for medication change), and medication management (e.g., drug monitoring)—showed a reduction in systolic BP (−7.6 mmHg, 95% CI [−9.0 to −6.3]; I2 = 67%), and diastolic BP (−3.9 mmHg [−5.1 to 2.8]; I2 = 83%) when compared with usual care [11]. The effect tended to be larger if the intervention was led by the pharmacist and was delivered at least monthly.

Moreover, a recent study demonstrated better BP outcomes and cost savings with a pharmacist prescribing intervention for patients with hypertension in Canada [12].

29.5.2 Coronary Heart Disease

For CHD, a systematic review of RCTs evaluated the impact of pharmaceutical care interventions on cardiovascular events, hospitalizations, and mortality [13]. Secondary outcomes were medication adherence, BP, and lipid management. The authors found only one study that assessed the primary outcomes with no significant effects; and four that assessed secondary outcomes—with significant effects on medication adherence, BP, and lipid management. Interventions delivered by pharmacists included patient education, medication management (e.g., medication review, tools to improve/measure medication adherence, monitoring therapy), feedback to other healthcare professionals, and disease management (e.g., assessment of targets for medication therapy such as BP) [13].

29.5.3 Heart Failure

For HF, a recent systematic review identified three important fields for primary (ambulatory/community) pharmacist care: (I) medication reconciliation and reviews, (II) self-care and symptom control, and (III) medication adherence. Eight RCTs were included and seven systematic reviews were analyzed additionally [14]. Pharmacist interventions consisted of a structured interview with the patient (e.g., guided and documented by an assessment tool such as “The One Minute Clinic for Heart Failure” (TOM-CHF) [15] where drug use and reasons for medication nonadherence were discussed as well as a follow-up of the supply with electronic devices (MEMS®), regular communication with the patient about the therapy, monitoring with MEMS® and written instructions, medication reconciliation, and reviews to optimize medical treatment according to guidelines and to improve medication safety, written information for the patient and instructions for self-care, home visits including a medication review as well as advice on symptom self-management and lifestyle [14]. Primary outcomes were a combination of the 2 min walk test, BP, body weight, pulse, forced vital capacity (FVC), and QoL, medication adherence, adverse drug events (ADE) and medication errors, hospital admission, as well as a composite of hospital admission and death [14].

Six RCTs found statistically significant effects on primary outcomes, whereas two studies found no significant differences [14]. This systematic review showed an improvement in CV risk factors due to pharmacist intervention, a reduced risk of hospitalizations due to collaboration between pharmacists and physicians including medication reviews, as well as due to pharmacists’ monitoring for contraindications and drug interactions. Moreover, educational and counseling interventions including instructions on self-monitoring, recommendations to physicians, and adherence aids were identified as promising interventions.

Two meta-analyses of RCTs in HF have reported reductions in all-cause hospitalizations of 21% and 29%, respectively, when the multidisciplinary intervention contained elements of pharmacist care [16, 17].

With a largely static therapeutic armamentarium in HF, maximal application of existing RCT-proven therapies is increasingly important. The dangers of deferring HF therapy are obvious: “Drugs can’t work in patients who don’t receive them”. A structured medication review offers the opportunity not only to reconcile the medication but to identify undertreatment of HF both in terms of drug classes and doses prescribed/used. Pharmacists can play a critical role in addressing the ever-growing complexity of polypharmacy for HF, incorporating medications for comorbid conditions, and orchestrating dose titration of cardiovascular medications as well as integrating newer medications such as sacubitril–valsartan or ivabradine [18, 19].

29.6 Disease Management Programs

Adequate patient education, with special emphasis on adherence and self-care are common components of management programs for patients with HF. These programs should employ a multidisciplinary approach (cardiologists, primary care physicians, pharmacists, nurses) [2]. The 2017 update of the German national guideline on chronic heart failure (CHF) included a specific statement supporting the integration of pharmacists in the care of HF patients. A further statement recommends a standardized medication plan (a complete list of prescribed and OTC drugs) for every HF patient. Physician and pharmacist should coordinate issuing and updating the medication plan with the main aims to improve patient safety and medication adherence [20]. A consolidated medication plan shall be a result of a coordinated medication review. However, assuring that patients understand the standardized medication plan and can transfer the given information into practice is necessary. In addition to aid the patient, a complete and up-to-date medication plan also informs healthcare professionals about a patients’ current medication. Hence, bridging the gap between providers and settings. It, therefore, can help to detect, solve, and prevent DRPs and to support medication reconciliation [21].

29.7 Outcomes that Matter

Evidence of cost-effectiveness of pharmaceutical care on major and patient-centered outcomes in CVDs is currently not strong enough to draw firm conclusions. Possible issues are the diversity of pharmaceutical care interventions, a lack of precision in defining the scope of the intervention, the size of the study population, and the lack of RCTs which have investigated relevant clinical endpoints. Clinical endpoints such as hospitalizations and mortality are often not captured. Most often, surrogate parameters like BP or LDL-C levels have been evaluated (although that may be appropriate). The detection and resolution of DRPs and the presentation of the number of DRPs need to be put into the context of patient outcomes. Most studies have investigated the number of DRPs, but had no control group to compare relevant patients´ outcomes. Hence, DRPs in CVDs are currently not a validated surrogate outcome. Often, the study population is small, and therefore the studies are underpowered to detect significant differences in usual composite endpoints in CVD, hence morbidity (CV- or HF-related hospitalizations, MI, or stroke) and CV or all-cause mortality. In addition, the follow-up period is too short to assess mortality as an outcome.

A review further criticized the low quality of study designs according to the Jadad scale [10]. Differences in the design quality as well as differences in interventions and measurements have made it difficult to compare studies, and the conduct of meta-analyses. This does not apply to pharmacists’ intervention studies in hypertension, however.

In addition to hospitalizations and mortality, health-related QoL (HRQoL) of CVD patients is widely considered to be of increased importance as an outcome measure. It is included in Health Technology Assessments (HTA), and a number of validated instruments are available. For example, the Minnesota Living with Heart Failure questionnaire (MLHF) or the Kansas City Cardiomyopathy Questionnaire (KCCQ) is widely used in HF trials. In CHD, the Seattle Angina Questionnaire (SAQ) or the Quality of Life after Myocardial Infarction (QLMI)/MacNew Heart Disease Quality of Life Questionnaire (MacNew) are valid and accepted instruments.

For all CVD patients, HRQoL is noticeable and influences the entire daily routine. Therefore, future, preferably randomized controlled CVD trials of pharmacist care interventions should assess both generic (e.g., EuroQoL/EQ-5D) and disease-specific QoL as secondary (patient-related) outcome measures. Economic analyses should also be conducted to determine value for the money spent on pharmacist care interventions.

Case Scenario

Hypertension and Dyslipidemia → CAD  Myocardial infarction (MI)  HF

Patient Mr. X, male, 69 years old, 179 cm, 87 kg (BMI: 27.2 kg/m2)

Medical history-I (<2011)

Diagnoses: COPD, psoriasis, gout, ulcerative colitis

Pharmaceutical care-I

Check elderly patients for CV risk factors i.e., measure weight and height and calculate BMI, assess smoking history, and measure blood pressure (BP), heart rate (HR), and lipids (at least total (TC) and low-density lipoprotein cholesterol (LDL-C)).

Note: BP measurement should be performed according to standards: patients/clients should be seated quietly in a chair with back support, with both feet flat on the floor for at least 5 min prior to obtaining a measurement. BP should be checked in both arms at the first examination, at least, and the arm with the higher pressure should be used for subsequent monitoring assessments. It is recommended that the average of at least two readings should be taken at an interval of at least 1 min to represent the patient’s/client’s BP. If the difference between the first two readings is more than 5 mm Hg, one or two additional readings should be obtained, and the average of the multiple readings should be used.

CV risk factors screened by pharmacists: slightly elevated BMI, current smoker (>40 years), high BP (150/92 mmHg), and elevated LDL-C level (185 mg/dL [4.8 mmol/L], non-fasting).

Offer structured smoking cessation program including nicotine replacement therapy (NRT). Refer to GP with documented CV risk factors.

GP diagnosis of CV risk conditions: hypertension and dyslipidemia.

CV-Medication prescribed (Rx): enalapril 10 mg b.i.d. (bis in die = twice a day), atorvastatin 20 mg daily.

Pharmaceutical care-II

Monitor for medication nonadherence and potential AE/ADR; intervene as appropriate.

Medical history-II (2012)

Large anterior MI; single vessel disease.

CV-Medication: ASA 100 mg daily, bisoprolol 10 mg daily, enalapril 10 mg b.i.d., atorvastatin 20 mg daily.

Medical history-III (2016)

Hospitalization for decompensated HF.

New diagnoses: Heart failure (NYHA III-IV, re-compensated), type 2 diabetes. BP: 105/70 mmHg (right arm sitting).

HR: 85 bpm (sinus rhythm (SR)).

Lab: K+ 4.8 mEq/L; eGFR: 45 ml/min/1.73 m2

CV-Medication: ASA 100 mg daily, furosemide 40 mg b.i.d., bisoprolol 10 mg daily, enalapril 10 mg b.i.d., atorvastatin 20 mg daily. Other: metformin 500 mg b.i.d.

Pharmaceutical care-III

Medication review (3 weeks following discharge).

Make an appointment for a medication review and ask patient to bring his entire medication (Rx and OTC) in a “brown bag”.


GP file (Rx)

Pharmacy dispensed (Rx/OTC)

Patient interview including brown bag and dose according to patient

Drug-related problem (DRP)


Bisoprolol 10 mg

Bisoprolol 10 mg


Missing drug; only used sporadically and if HR is high

Inform GP and suggest a starting dose of 1.25 mg and up-titrate every 14 days, if tolerated, to at least 5 mg

Enalapril 10 mg b.i.d.

Enalapril 10 mg b.i.d.

Enalapril 10 mg b.i.d.


Furosemide 20 mg b.i.d.

Furosemide 20 mg

Furosemide 20–40 mg

Frequent awakening for urination

Take 20 mg in the morning and 20 mg not later than 4 pm. Counsel on appropriate fluid intake and regular monitoring of weight

ASA 100 mg

ASA 100 mg

ASA 100 mg


Atorvastatin 20 mg

Atorvastatin 20 mg

Atorvastatin 20 mg

Check LDL-C level

LDL-C 105 mg/dL (2.7 mmol/L)

Metformin 500 mg b.i.d.

Metformin 500 mg b.i.d.

Metformin 500 mg b.i.d.

Renal function and HbA1c?

Ask GP


Allopurinol 100 mg

Allopurinol 100 mg

GP unaware of this drug

Inform GP


Diclofenac 25 mg b.i.d.

NSAIDs may worsen HF and drug/drug interaction with ACE inhibitor

Switch to non-NSAID analgesic


Simvastatin/Ezetimibe 10/40 mg


medication; prescribed by other physician

Clarify with both physicians

Document drug-related problems (DRPs) and intervene as mentioned above.

Follow-up (mid 2017)


BP: 115/78 mmHg

HR: 82 bpm (SR)

CV-Medication: ASA 100 mg daily, furosemide 20 mg daily, bisoprolol 1.25 mg daily (+ 1.25 mg every 14 days) 5 mg daily (if tolerated), enalapril 10 mg b.i.d., atorvastatin 40 mg daily.

Other: Metformin 500 mg b.i.d., allopurinol 100 mg daily, COPD medication.

OTC: Paracetamol 500 (acetaminophen) 1000 mg prn (max. 3 g daily).

Pharmaceutical care-IV

Check inhalation technique (metered dose (MDI) and dry powder inhaler (DPI)) and intervene as needed.

Check HR during and after up-titration of bisoprolol (goal 60–70 bpm).

Offer follow-up medication review (as above).

One result of this medication review is a medication plan for Mr. X, consolidated by Mr. X, his GP, and his pharmacist (see below).

Medication Plan for Mr. X (as of 6 September 2017)

(insert) Rx name

Generic name





2.5 mg (for next 14 days; than increase to 5 mg)

Heart failure



10 mg b.i.d.

Heart failure



10 mg early morning and

10 mg between 2 and 4 pm



Acetylsalicylic acid (ASA)

100 mg

Prevention myocardial infarction (MI)



40 mg

Prevention MI, high cholesterol



100 mg




500 mg b.i.d.

Type 2 diabetes


Fenoterol/ipratropium 50/20 (MDI)

Daily 3–4 times 1 puff

Chronic obstructive pulmonary disease (COPD)


Tiotropium 18 (DPI)




Paracetamol (acetaminophen) 500

1000 mg (2 caplets) prn (up to 3 g per day = 6 caplets)


b.i.d. = bis in die (twice daily); DPI = dry powder inhaler; HR = heart rate; MDI = metered dose inhaler; OD = once daily; prn = pro re nata; SR = sinus rhythm

Make sure that Mr. X has fully understood his medication plan!


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Martin Schulz
    • 1
    Email author
  • Katrin Krueger
    • 2
  • Nina Griese-Mammen
    • 2
  • Ross Tsuyuki
    • 3
  1. 1.Department of MedicineFederal Union of German Associations of PharmacistsBerlinGermany
  2. 2.Scientific EvaluationFederal Union of German Associations of PharmacistsBerlinGermany
  3. 3.Division of Cardiology, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonCanada

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