Dietary approaches to hypertension: a call to pharmacists to promote lifestyle changes.

OBJECTIVES: To describe guideline updates regarding a dietary approach to preventing or treating hypertension and to encourage pharmacists to provide education to patients on the Dietary Approaches to Stop Hypertension (DASH) diet and reducing dietary sodium intake. DATA SOURCES: Abstracts and published articles identified by searching Medline (January 2001 to July 2011) and International Pharmaceutical Abstracts (January 2001 to July 2011) using the terms hypertension, cardiovascular risk, risk reduction behavior, health behavior, community pharmacy services, counseling, diet, and sodium-restricted diet, as well as reports from the Institute of Medicine and Dietary Guidelines for Americans 2010. DATA SYNTHESIS: In the Dietary Guidelines for Americans 2010, the recommended daily dietary sodium intakes for individuals with hypertension, chronic kidney disease, and diabetes was reduced to less than 1,500 mg per day. All other healthy individuals are recommended to achieve dietary sodium intakes of less than 2,300 mg per day. Americans are consuming excessive amounts of dietary sodium in the form of processed foods, which poses a barrier to blood pressure control. Pharmacists should recommend the DASH diet as a way to reduce intake of dietary sodium and use available nutrition resources found on the ChooseMyPlate.gov and Food and Drug Administration websites. Pharmacists should integrate approaches using behavioral and motivational strategies to provide education that is culturally sensitive and appeals to individuals with marginal health literacy. CONCLUSION: Community and ambulatory practice pharmacists, as well as collaborative practice models between pharmacists and physicians, should optimize medication management and incorporate lifestyle interventions that reduce dietary sodium intake as part of a comprehensive approach to improve hypertension outcomes.

Implementing a health literacy module fostering patient-centered written communication in a cardiovascular prevention elective course.

BACKGROUND: A universal approach to health literacy employs clear communication and emphasizes patient action in support of understanding cardiovascular risks and making healthy lifestyle changes. The aim of this project was to evaluate the impact of a health literacy module on enhancing students' written patient education material using standardized readability assessment tools. EDUCATIONAL ACTIVITY: A professional elective course employed team-based learning and a community health fair activity. The course was enhanced with four hours of health literacy content. Pharmacy student learners were assigned a cardiovascular condition and designed an informational pamphlet. Two faculty members evaluated the student pamphlets in the pre-health literacy module (n = 15) and post-module (n = 23) groups using the Flesch grade level, Flesch reading ease score, and 15 health literacy criteria identified from previous literature. CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY: There was a modest integration of health literacy concepts based on the Flesch grade level and the mean total health literacy criteria achieved. Student learners improved in areas of readability, message content, numeracy/statistics, and patient actionability concepts. Simplifying technical jargon remains to be a barrier. The results will be used to improve our health literacy pamphlet rubric and classroom instruction. The health literacy module was valuable in fostering understanding and application of health literacy concepts, and preparing student learners for providing patient-centered communication.

Tolerability of beta-blockers in outpatients with refractory heart failure who were receiving continuous milrinone.

STUDY OBJECTIVE: To investigate the dosing, tolerability, and outcomes associated with the use of concomitant beta-blockers and inotropic therapy in patients with refractory heart failure during the first 6 months of their therapy. DESIGN: Retrospective review. SETTING: University-based, tertiary care heart failure and transplant center. PATIENTS: Sixteen inotrope-dependent outpatients with end-stage refractory heart failure who were receiving continuous intravenous milrinone. Of these patients, 12 also received an oral beta-blocker; the remaining four patients who did not receive beta-blockers served as the comparator group. MEASUREMENTS AND MAIN RESULTS: For each patient, the initial and final study drug doses of continuous intravenous milrinone and oral beta-blocker treatment, when applicable, were recorded over the 6-month period. Mean heart rate, blood pressure, ejection fraction, and oxygen consumption were measured, and 95% confidence intervals were calculated. Serum sodium and creatinine concentrations, as well as the creatinine clearance, were measured. In the 12 patients who received concomitant milrinone and beta-blockers, the mean baseline ejection fraction was approximately 18%, and they received milrinone for 18.6 weeks. Seven patients received carvedilol for 16.1 weeks, and five received metoprolol tartrate for 17.6 weeks. Dosages of the beta-blockers were titrated. Final daily doses were carvedilol 42.8 mg (95% confidence interval 20.3-65.4) and metoprolol 42.5 mg (95% confidence interval 28.0-57.2). Patients continued to receive other standard oral drug therapy for heart failure. One patient discontinued metoprolol and one discontinued carvedilol because of hypotension and/or worsening heart failure. Cardiac adverse events in the concomitant milrinone plus beta-blocker group were heart failure requiring hospitalization in 10 patients and ventricular arrhythmias in one. CONCLUSION: Inotrope-dependent patients with refractory end-stage heart failure tolerated continuous intravenous milrinone plus beta-blockers in addition to diuretics and vasodilators for the 6-month observation period. Beta-blocker dosages were titrated, and three patients achieved the target beta-blocker dosage established for stage A-C heart failure. Additional studies are needed to determine the optimal selection and dosing of drug combinations in this population.

Using cooperative learning for a drug information assignment.

OBJECTIVES: To implement a cooperative learning activity to engage students in analyzing tertiary drug information resources in a literature evaluation course. DESIGN: The class was divided into 4 sections to form expert groups and each group researched a different set of references using the jigsaw technique. Each member of each expert group was reassigned to a jigsaw group so that each new group was composed of 4 students from 4 different expert groups. The jigsaw groups met to discuss search strategies and rate the usefulness of the references. In addition to group-based learning, teaching methods included students' writing an independent research paper to enhance their abilities to search and analyze drug information resources. ASSESSMENT: The assignment and final course grades improved after implementation of the activity. Students agreed that class discussions were a useful learning experience and 75% (77/102) said they would use the drug information references for other courses. CONCLUSION: The jigsaw technique was successful in engaging students in cooperative learning to improve critical thinking skills regarding drug information.

Levosimendan: a novel inotropic agent for treatment of acute, decompensated heart failure.

OBJECTIVE: To review the literature on a novel calcium sensitizer, levosimendan. DATA SOURCES: Articles were identified through searches of MEDLINE (1966-June 2005), International Pharmaceutical Abstracts (1970-June 2005), and EMBASE (1992-June 2005) using the key words levosimendan, simendan, calcium sensitizer, calcium sensitiser, and congestive heart failure. STUDY SELECTION AND DATA EXTRACTION: Clinical trials and pharmacokinetic studies evaluating the safety and efficacy of levosimendan were selected. DATA SYNTHESIS: Levosimendan 6-24 mug/kg intravenous bolus followed by a 24-hour continuous infusion of 0.05-0.2 microg/kg/min improved cardiac output and reduced pulmonary capillary wedge pressure in a dose-dependent manner. Dose-ranging and randomized clinical trials have demonstrated improvement in symptoms and hemodynamics and short-term survival outcomes in the treatment of acute, decompensated heart failure. Clinical trials evaluating retrospective mortality data and combined endpoints (mortality, rehospitalization) have demonstrated better outcomes with levosimendan compared with dobutamine. The incidence of hypotension with levosimendan is not significantly different than with dobutamine, but there is a dose-related increase in heart rate. CONCLUSIONS: Levosimendan is useful in moderate to severe low-output heart failure in patients who have failed to respond to diuretics and vasodilators. Based on current studies, levosimendan appears to be a safe alternative to dobutamine for treatment of acute, decompensated heart failure. Prospective clinical trials are needed to confirm the effect of levosimendan on long-term survival and its role in heart failure in the setting of myocardial infarction.