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Millions of Americans will have a myocardial infarction in their lifetime and 20% will have a recurrent fatal or non-fatal coronary heart disease event. Several modifiable risk factors, including elevated blood pressure, cholesterol, and glucose as well as tobacco use, can and should be addressed to reduce the risk of recurrent cardiovascular events. Systemic inflammation has also been associated with poor CV outcomes. Is systemic inflammation a modifiable CV risk factor? And if so, should an anti-inflammatory agent be added to the recommend post-MI drug cocktail to reduce the risk of morbidity and mortality?  That's the question that the COLCOT Study attempted to answer.

Guest Authors:  Jessica Wearden, PharmD and Augustus (Rob) Hough, PharmD, BCPS, BCCP

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Until recently, glucagon-like-peptide-1 (GLP-1) receptor agonists were only available as injectable products. Some clinicians and patients are reluctant to use injectable agents because they require additional patient education and can be intimidating.  If a GLP-1 receptor agonist were available in an oral dose form, it would be welcomed treatment option. But would the cardiovascular safety and benefits of oral GLP-1 receptor agonists be better, similar, or worse than their injectable siblings?

Guest Authors:  Sally Earl, PharmD, BCPS and Megan Supple, PharmD, BCACP

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Vitamin D and fish oil (aka omega-3 fatty acids) were the most widely used vitamin and nutritional supplement in 2011-2012.  Both have been commonly touted for their potential benefits in reducing cancer and cardiovascular disease. While vitamin D and omega-3 fatty acid supplements are wildly popular, the evidence supporting their health benefits is inconclusive and inconsistent. The VITAL study sought to determine whether vitamin D and/or marine omega-3 fatty acids can prevent cardiovascular disease (CVD) and cancer when used by the general population.

Guest Authors:  Anthony M Todd, PharmD; Sean E Smithgall, PharmD, BCACP; and Nicole A Slater, PharmD, BCACP

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The American Heart Association / American College of Cardiology (AHA/ACC) Task Force recently published the 2018 Guideline on the Management of Blood Cholesterol. The guidelines writing committee had representation from 12 organizations, including the National Lipid Association, American Diabetes Association, and the American Pharmacists Association — all of whom endorsed the guidelines. The previous guidelines (published in 2013) were intended to answer some specific clinical questions and significantly changed our approach to treatment. The 2018 guidelines provide a more comprehensive set of recommendations, akin to the (older) National Heart, Lung, and Blood Institute Adult Treatment Panel (ATP) III guidelines last published in 2002!

Guest Authors:  Dawn Fuke, Pharm.D., BCPS, and Zach Conroy, PharmD, BCACP

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Daily low-dose aspirin has long been considered a “wonder drug” for its cardioprotective effects, particularly in patients with pre-existing cardiovascular and cerebrovascular disease; however, despite decades of research, the use of aspirin to prevent a first event is less certain. In 2014, the Food and Drug Administration (FDA) responded to a citizen petition requesting the labeled indications for low dose aspirin be updated to include primary prevention. The FDA concluded that the evidence “fail[ed] to establish that aspirin reduces the risk of primary myocardial infarction (MI) in patients with a coronary heart disease (CHD) risk of 10% or more for over 10 years.” The Asprin to Reduce Risk of Initial Vascular Events (ARRIVE) study is intended to address this gap in our knowledge.

Guest Authors:  Amy St. Amand, PharmD, BCPS and Christine Borowy, PharmD, BCPS

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Aspirin is no doubt beneficial in patients with overt vascular disease for the secondary prevention of myocardial infarction, stroke, or cardiovascular death. However, evidence supporting use of aspirin for primary prevention in patients who have not had a cardiovascular event is far less compelling. The clinical uncertainty of aspirin use for the primary prevention of CV events in patients with diabetes is reflected in the different recommendations in current guidelines. The investigators of the ASCEND (A Study of Cardiovascular Events in Diabetes) trial set out to determine the safety and efficacy of daily aspirin use in patients with diabetes without known occlusive arterial disease.

Podcast Case:  ASA Use in DM - Evidence ASCENDing?

Guest Author:  Kirstie Perry, Pharm.D.

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We interview Eric MacLaughlin, Joseph Saseen, and Kristin Rieser about the ACC/AHA Guidelines for the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in Adults released in November 2017.  Dr. MacLaughin, a member of the Guideline Writing Committee, gives a insiders view of the guidelines development process and explains the rationale for lower blood pressure goals.  Drs. Saseen and Rieser talk about some of the practical considerations that we all must consider as we move forward to making these recommendations a reality.

Guests:  Kristin Rieser, Pharm.D., Joseph Saseen, Pharm.D, and Eric MacLaughlin, Pharm.D.

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Statins reduce atherosclerotic cardiovascular disease (ASCVD) risk. However, the utility of statin therapy in older adults — particularly in those age 75 years and older — remains controversial. The need for additional evidence to guide clinical practice is underscored by the fact that one-in-three older Americans report taking a statin.  Given the paucity of prospective data, a post-hoc analysis of the ALLHAT-LLT (Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial - Lipid Lowering Trial) was recently published.  Does this new analysis really help inform the decision?

Guest Author:  Leo Buckley, Pharm.D.

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For the acute treatment of venous thromboembolism, the direct oral anticoagulants (DOACs) have increasingly replaced injectable anticoagulant therapy followed by warfarin.  For patients with an unprovoked deep vein thrombosis or pulmonary embolism who may benefit from long-term extended prophylaxis for the secondary prevention of VTE, the choice is less clear. Should a DOAC be used?  If so, which one and what's the best dose?  What about low-dose aspirin? Is extended therapy needed at all?  The EINSTEIN CHOICE study adds important new insights to the growing body of literature.

Guest Author: Sarah Anderson, PharmD, BCPS

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More than 15 million Americans have coronary heart disease and most should be taking aspirin daily.  Given aspirin’s ubiquity in cardiovascular medicine and patients’ pill boxes, it is shocking that there are still so many unanswered questions about aspirin use. Which dose and dosage forms should be prescribed?  How common is aspirin resistance?  What is the relationship between platelet inhibition and clinical outcomes?

Guest Author:  Daniela Valencia, Pharm.D.

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