CLINICAL
NEWS JACC in a FLASH
chronic disease, making them well
positioned to identify patients at high
risk for CVD and to assist with disease
management.
In the RxEACH study, Ross T.
Tsuyuki, PHARMD, MSC, and colleagues examined adult patients who
were at a high risk for cardiovascular
events—those with diabetes, chronic
kidney disease, atherosclerotic vascular disease, coronary artery disease—
or primary prevention patients with
multiple risk factors and Framingham
risk score > 20%. Patients also had at
least 1 uncontrolled risk factor: blood
pressure >140/90 or >130/80 mm Hg
if diabetic, low-density lipoprotein cholesterol (LDL-C) > 2.0 mg/dL, HbA1c
>7.0%, or current smoker. Patients
were randomized to intervention or
usual care groups. Patients randomized to the intervention group received
a Medication Therapy Management
consultation from their pharmacist
including:
• Patient assessment (blood pressure management, waist circumference, and weight and height
measurements)
• Laboratory assessment (HbA1c,
fasting cholesterol profile, estimated glomerular filtration rate,
and albuminto-creatinine ratio)
• Individualized risk assessment of
CVD risk and education about this
risk (targets for intervention and
healthy life-style options)
• Providing guideline-based treatment recommendations
care and 370 to intervention. Estimated baseline cardiovascular risk was
26.6 ± 19.3% in the usual care group
and 25.6 ± 17.8% in the intervention
group. Estimated cardiovascular risk
changed over the 3-month follow-up
period from 26.6 ± 19.3% to 25.9 ±
19.6% in the usual care group, compared with 25.6 ± 17.8% at baseline
to 20.5 ± 15.9% in the intervention
group. After adjustments, this corresponded to a relative decrease in
estimated cardiovascular risk of 21%.
Significant reductions were seen in the
intervention group in LDL-C, blood
pressure, HbA1c, and smoking. Body
mass index changed from 34.08 ±
15.3 kg/m2 to 32.9 ± 8.0 kg/m2 in the
usual care group and from 33.27 ±
10.8 kg/m2 to 32.6 ± 8.8 kg/m2 in the
intervention group.
“Pharmacists
[can] have major
public health
implications in
reducing the
burden of CVD.”
—Ross T. Tsuyuki, PharmD, MSC
• Prescription adaptations and/or de
novo prescriptions when necessary
• Regular communication with the
patient’s family physician after
each contact with the patient
• Regular follow-up with all patients
a minimum of every 3–4 weeks
for 3 months
Patients randomized to the usual
care group received usual pharmacist
and physician care with no specific
interventions for 3 months. Thereafter,
they were offered the interventions.
Researchers randomized 723
patients, with 353 assigned to usual
14
CardioSource WorldNews
“We found that engaging community pharmacists in identifying
at-risk candidates […] and managing their cardiovascular risk factors
using an advanced scope of practice that included prescribing and
ordering laboratory tests, resulted
in a 21% reduction in [patient] risk
for cardiovascular events in only 3
months,” the authors wrote. “Because
pharmacists are highly accessible
primary health care providers, this
could have major public health implications in reducing the burden of
CVD if these practices were widely
adopted.”
In an editorial published along with
the study, Larry A. Weinrauch, MD,
Alissa R. Segal, PharmD, and John A.
D’Elia write, “That better management
could be achieved with appropriate case
finding and rigorous attention to goals
should be a wake-up call. Whether
such management must be delivered by
physicians, pharmacists, nurse practitioners, or other facilitators […] is less
important than the observation that we
are able to recruit or case find patients
who might benefit from additional
management and that better results are
rapidly achievable.”
They add that “observations from
this study should trigger analysis of
potential public health benefits from
additional studies of larger size and longer duration, if for no other reason than
financial benefits to the community.”
Tsuyuki RT, Al Hamarneh YN, Jones
CA, Hemmelgarn BR. J Am Coll Cardiol.
2016;67(24):2846-54.
Good News for
CPVT Patient
Athletes
Patients with catecholaminergic
polymorphic ventricular tachycardia
(CPVT), who are usually disqualified
from participating in most sports due
to a risk of sudden cardiac death, may
be able to safely participate in athletics
as long as they are well treated and
well informed, according to a study
published June 20 in JACC: Clinical
Electrophysiology.
Michael J. Ackerman, MD, PhD,
retrospectively analyzed records of 63
patients age 6 and older with CPVT
treated at Mayo Clinic’s Genetic Heart
Rhythm Clinic to determine the impact of continued sports participation.
Patients in the study were diagnosed at
an average age of 16, and 31 participants sai d they were athletes at some
point before diagnosis.
Of the 24 patients in the study
who identified as athletes at the time
of diagnosis, 21 continued to compete
in sports. They also found that 76% of
the athletes had cardiac events prior to
diagnosis compared to 43% in the nonathlete group. Of the 63 patients, nine
patients experienced a CPVT-related
event during follow-up despite ongoing treatment. However, there was
no difference in events or event rates
between the athletes and non-athletes—three athletes experienced one
event each, while seven events total
were reported among six non-athletes.
There were no deaths in either group.
According to the researchers, the decision for these patients to compete in
sports is complex and must involve all
relevant family members and coaches,
especially if the patient is a minor.
There must be a discussion of the risks
and benefits of associated with sports,
the diagnosis, as well as the impact of
any side-effects associated with treatment before a decision is made. The
authors add that larger studies will be
needed to fully understand the impact
and outcomes of sports participation
for patients with CPVT. The results also
may not be generalizable to patients
evaluated and treated elsewhere, especially centers with a lack of experience
in treating this specific genetic heart
rhythm disorder.
“While breakthrough events can
and do occur even among CPVT
patients receiving the best care at
dedicated CPVT centers of excellence,
there are also the known risks of a sedentary lifestyle as well as a decreased
quality of life that may come with quitting physical activity and/or athletics,”
said Ackerman.
In an accompanying editorial,
Andrew D. Krahn, MD, and Shubhayan Sanatani, MD, said the study
is good news for patients with CPVT.
The authors noted limitations of the
retrospective study and emphasized
the need for care in highly specialized
multidisciplinary clinics and an automated external defibrillator as part of
the athlete’s equipment.
“Shared decision-making supported
by evidence-guided medical therapy
and incremental interventions lays
the foundation for a more permissive
approach to not only allowing, but potentially encouraging participation in
physical activity, including competitive
sports,” they said. “Although highly
publicized, sudden death in the young,
particularly during athletic competition, is rare, even in CPVT. None of the
events in this series would be prevented by activity restriction and our bias
should be towards health promotion
and athletic participation.” ■
Ostby ST, Bos M, Owen, HJ, et al.
JACCCEP. 2016;2(3):253-62.
July 2016