Community Pharmacists Identification of Gaps in Care - Statin Utilization for Primary Prevention.

Background: Statins are a highly effective lipid-lowering therapy associated with significant reductions in atherosclerotic cardiovascular disease (ASCVD) events and death. Despite these benefits, statins are underutilized. Pharmacist-led interventions to increase statin prescribing are effective. To our knowledge, no prior studies implemented a comprehensive cardiovascular risk assessment utilizing point-of-care (POC) testing in community pharmacies. Objectives: The primary objective was to determine if community pharmacists can be utilized to identify gaps in care regarding appropriate use of statin therapy for prevention of ASCVD events in HPSAs. Secondary objectives were to assess public interest in ASCVD risk assessment and statin prescribing by the pharmacist, and to identify factors associated with statin gaps in care. Methods: A cross-sectional study was conducted at three independent community pharmacies. Participants were identified based on age and medication history and were scheduled at their pharmacy to receive a comprehensive ASCVD risk screening consisting of POC measurement of a complete lipid panel, blood glucose or A1C, and blood pressure. Participants were informed of their statin candidacy at the screening. Participants completed a survey regarding perceptions of the services provided and opinions of statin prescribing by pharmacists. Results: Of the 57 participants, 43 (75.4%) were possible statin candidates. Most indicated trusting their pharmacist to prescribe a cholesterol-lowering medication and felt insurance should pay for these screenings. Conclusion: ASCVD risk assessment conducted within the community pharmacy setting for can be utilized to identify treatment gaps in status use. Participants indicated trusting pharmacists to provide this service and found the service valuable.

Retooling the Remediation Process: An Overview of One School's Process Overhaul.

OBJECTIVE: This article describes the process of review and modification of a Doctor of Pharmacy didactic course remediation process. A highlight of the new process includes early intervention with a Learning Specialist, creating the opportunity for students to address learning issues earlier in the courses. METHODS: Review of past remediation processes, student success, and pertinent literature related to remediation processes to allow for a new remediation process that supports students' learning and success. RESULTS: Creation of a new 2-phase process, including an early intervention and remediation process. The process includes a Learning Specialist position to focus on learning and barriers to academics. Remediation opportunities focus on proficiency in specific areas for each course. CONCLUSION: The new remediation policy provides greater support to students through the Learning Specialist. The new policy helps students connect with resources earlier in the program and provides multiple opportunities for assisting students during the semester. Over the past 4 years, the Learning Specialist has met with an average of 73 individual students per semester, while only an average of 25 students in the didactic portion of the curriculum (year 1-3) require remediation each semester.

Utilization rates and predictors of sodium glucose cotransporter 2 inhibitor use in patients with heart failure with or without type 2 diabetes.

PURPOSE: Sodium glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce cardiovascular deaths and heart failure (HF) hospitalizations in patients with HF. Despite this, utilization remains low. The purpose of this study was to characterize SGLT2 inhibitor utilization rates and predictors of use in a population of patients with or without type 2 diabetes (T2D). METHODS: This was a retrospective, single-center, descriptive chart review study. Individuals 18 years of age or older with HF were eligible for inclusion. Charts were reviewed between August 2021 and February 2022. The primary objective was to identify rates of SGLT2 inhibitor prescribing for patients with HF within a large academic medical center. Logistic regression analyses were conducted to identify potential SGLT2 inhibitor utilization predictors (demographic characteristics, medical history, laboratory results, specialty provider visits, medication use, and medication coverage). RESULTS: A total of 800 patients with HF were included: 377 with HF with reduced ejection fraction (HFrEF), 88 with mildly reduced EF, and 335 with preserved EF. Key baseline characteristics were as follows: 43% female; 47% Hispanic; 42% with T2D; 49% with established atherosclerotic cardiovascular disease; and mean age, 65 years. SGLT2 inhibitor utilization was 6.5% overall. Key predictors of utilization were as follows: T2D (odds ratio [OR], 33.4; 95% CI, 8.01-139.55), HFrEF (OR, 2.8; 95% CI, 1.45-5.51), HF clinic visit (OR, 2.5; 95% CI, 1.40-4.60), visit with pharmacist with prescriptive authority (OR, 5.8; 95% CI, 3.14-10.88), and enrollment in the hospital patient assistance program (OR, 2.3; 95% CI, 1.08-4.97). CONCLUSION: Despite guideline recommendations, SGLT2 inhibitors are underutilized in patients with HF with or without T2D.

Awareness, perceptions, and attitudes toward community pharmacist clinical services: An analysis of data from 2004 and 2018.

OBJECTIVE: This study aimed to describe and compare the public's change in awareness and perceptions of, willingness to use, willingness to pay, and interest in insurance coverage for community pharmacist prescriptive authority services and point of care testing over a time span of 14 years. METHODS: This was a retrospective review of anonymous questionnaires administered by student pharmacists in 2004 and in 2018. Questionnaires were administered to individuals who presented to University of New Mexico College of Pharmacy sponsored health fair screenings and at various community pharmacies throughout the state of New Mexico (NM). RESULTS: In total, 545 (2004) and 659 (2017-2018) participants completed the questionnaire. Awareness of community pharmacist clinical services increased from 2004 to 2018. In 2018, awareness of newer prescriptive authority services provided by pharmacists in NM was low relative to the services assessed in previous years. Most respondents indicated a willingness to use and pay for pharmacist-provided clinical services and felt that pharmacists should receive compensation by their insurance for these services. Trust in pharmacist advice grew from 2004 to 2018. CONCLUSION: Overall rates of awareness of community pharmacist clinical services were low with the exception of immunizations; however, most participants indicated interest in and willingness to use these services. Most participants believed pharmacists should receive reimbursement from insurance companies for clinical services and were also willing to pay a copay or out-of-pocket cost for these services.

Curricular-driven screening for atrial fibrillation at community pharmacies.

BACKGROUND: Atrial fibrillation (AF) increases the risk of stroke. It can be asymptomatic and patients may be unaware they have AF. Therefore, there is a need to develop a sustainable community model to screen for unrecognized AF. OBJECTIVE: The objective is to assess a curriculum driven model developed by the University of New Mexico College of Pharmacy (UNM-CoP) to evaluate AF screening at 3 community pharmacy sites. METHODS: Screenings and education for AF were performed by fourth year pharmacy students during their advanced pharmacy practice experience (APPE) community rotation at pre-selected independent pharmacies. Patients were screened using the KardiaMobile device (AliveCor®, Mountain View, CA), an FDA-cleared device that interprets a medical-grade ECG in 30 seconds. All screening materials and devices were provided by UNM-CoP. Semi-structured interviews with each targeted pharmacy were conducted to assess the logistics, value, and sustainability of the program (N=5 pharmacists). RESULTS: AF assessment was performed over a 7-month period by 8 students at three pharmacies. Students screened a total of 63 patients (62% female, 56 ± 14 years of age) with 92% of the encounters taking less than 10 minutes to complete. Three patients (4.7%) were found to have possible AF. Positive scores were noted when assessing value to the pharmacy (8.8 ± 0.8, scale 1-10 with 10 being high value) and professionally (9.7 ± 0.6). DISCUSSION: Student-pharmacists provides a likely pathway for sustainability for this clinical initiative and provides for a novel and measurable APPE patient interaction. CONCLUSION: Curricular driven AF assessment in community pharmacies was shown to be a feasible model. Additional studies are needed to assess whether population-based real-time assessment and detection of AF can reduce the risk of stroke in previously undetected AF. If stroke reduction is realized, reimbursement for service is likely and can contribute to further sustainability.

Interactive Effects of Omega-3 Polyunsaturated Fatty Acids and Secondhand Smoke in Mice and Human Subjects.

Active smoking and secondhand smoke (SHS) exposure increase the risk of cardiovascular morbidity and mortality. Active smoking is associated with reduced levels of omega-3 polyunsaturated fatty acids (n-3 PUFA) and studies show that n-3 PUFA supplementation can improve smoking-induced vascular dysfunction. However, the relationship between n-3 PUFA and SHS exposure has not been studied. Fat-1 transgenic mice, which convert n-6 to n-3 PUFA, were fed diets with n-3 PUFA or without (n-6 PUFA diet), exposed to air or SHS for 4 weeks, and vasoreactivity, antioxidant indices, and omega-3 index (percent eicosapentaenoic + docosahexaenoic acids in RBC) measured. Compared to air-exposed mice, SHS-enhanced aortic constriction in mice fed the n-6 PUFA diet (omega-3 index, 5.9 ± 0.2%; mean ± SE), but not in mice fed the n-3 PUFA diet (omega-3 index, 7.8 ± 0.6%). SHS also significantly induced mRNA expression of cytochrome P4501A1, NADPH:quinone oxidoreductase, heme oxygenase-1, and angiotensinogen in adipose tissue, and increased antioxidant capacity only in mice on the n-6 PUFA diet. Notably, SHS reduced the omega-3 index by 1.0 percentage point (p = 0.003), compared to air-exposed mice irrespective of diet. Additionally, we recruited human nonsmokers (NS) with and without SHS exposure (n = 40) 19-40 years old and measured the omega-3 index and antioxidant capacity. In human subjects SHS exposure was associated with a significantly lower omega-3 index (NS, 4.4 ± 1.1%; NS + SHS, 3.2 ± 1.0%; mean ± SD, p = 0.002) and higher antioxidant capacity (p < 0.001) than unexposed NS. Thus, SHS exposure is associated with lower levels of n-3 PUFA in mice and humans; however, an omega-3 index of ~ 8% in mice has vasoprotective and antioxidant properties.

Awareness and perceptions of advanced practice pharmacists among health care providers in New Mexico.

OBJECTIVE: The purpose of this study was to evaluate health care provider awareness and perceptions of the 2 types of advanced practice pharmacists (APPhs) in New Mexico: pharmacist clinicians (PhCs) and community pharmacists with independent prescriptive authority (iRPhs). METHODS: A cross-sectional electronic survey was administered to health care providers in New Mexico to describe awareness and perceptions of APPhs and benefits and barriers to collaborative practice with APPhs. RESULTS: A total of 5905 providers received the emailed survey, and 634 (11%) completed the survey, with 68% of the respondents indicating that they were not aware of the 2 types of APPhs in New Mexico. The top benefits of working with a PhC identified by the respondents were access to medication knowledge, enhanced clinical outcomes, and increased access to patient care. The barriers to employing a PhC at their practice included cost, difficulty in billing for services, and limited reimbursement. Importantly, 80% of the respondents felt that PhCs should be recognized as providers for insurance reimbursement. Awareness of iRPhs varied by prescriptive authority service, ranging from 34% for tuberculin skin testing to 84% for adult vaccinations. Overall, 80%-92% indicated that iRPhs should be reimbursed, depending on the prescriptive authority service. CONCLUSION: Provider awareness of APPhs in New Mexico was low; however, the willingness to refer patients to APPhs for clinical services was high. Cost, difficulty in billing for services, and reimbursement for PhC services were the primary identified barriers to adding a PhC into practice. Most of the respondents indicated that both types of APPhs should be granted provider status and reimbursed by third-party payers for their services.

Population screening for atrial fibrillation by student pharmacists at health fairs.

BACKGROUND: Individuals with unrecognized atrial fibrillation (AF) may be at an increased risk of stroke. There is a need to develop a sustainable and reproducible population-based screening model to identify unrecognized AF. OBJECTIVE: The objective of this study is to evaluate AF screening and education at student pharmacist-driven health fairs. METHODS: Screening for AF was performed by student members of the American Pharmacist Association Academy of Student Pharmacists with preceptor oversight. Participants were screened using the KardiaMobile device (AliveCor, Mountain View, CA), a Food and Drug Administration-cleared device that interprets a medical-grade electrocardiogram in 30 seconds. Student pharmacists also calculated a CHA2DS2-VASc score. Participant education was provided using an American Heart Association AF patient information sheet. Learning assessment was evaluated with 3 multiple choice questions. RESULTS: Students screened a total of 697 participants over a 6-month period at 13 health fairs. Overall, 71% of the participants were women aged 56 ± 15 years (mean ± SD). Sixteen of the participants (2.3%) who were screened received results indicating possible AF. None of the participants with a possible positive finding had symptoms suggestive of AF. Of these 16 participants, 11 (69%) had a CHA2DS2-VASc score greater than or equal to 2 (2.7 ± 0.7). Most participants answered each learning assessment question correctly. More than 95% of participants believed that screening for AF at health fairs was important or very important. CONCLUSION: Student pharmacist-driven health fairs were shown to be feasible models to screen for AF and were effective in providing AF education to the public. Student pharmacists also cultivated a clinical skill that is transferable to their future practice setting, including the community pharmacy setting. Additional studies are needed to assess whether population-based real-time assessment and detection of AF can reduce the risk of stroke in individuals with previously undetected AF.

Associations of medium and long chain omega-3 polyunsaturated fatty acids with blood pressure in Hispanic and non-Hispanic smokers and nonsmokers.

Epidemiology studies and clinical trials have shown that omega-3 polyunsaturated fatty acids (n-3 PUFAs) are inversely associated with blood pressure. We sought to determine the influence of cigarette smoking and Hispanic ethnicity on this association. Age- and sex-matched smokers and nonsmokers (n = 98) 19-50 years old lacking cardiovascular disease were recruited. Systolic and diastolic blood pressure (SBP, DBP), heart rate, HbA1c, lipids, BMI, and RBC fatty acids were measured. The omega-3 index (percent eicosapentaenoic and docosahexaenoic acid, EPA+DHA, in RBCs) was significantly lower in smokers (Smokers: 3.19 ± 0.86%; Nonsmokers, 3.88 ± 1.05%, p = 0.001) and Hispanics (Hispanic 3.32 ± 0.93%; Non-Hispanic, 3.82 ± 1.03%, p = 0.006). DHA exhibited a significant inverse association with BP in both smokers and nonsmokers, while alpha-linolenic acid (ALA) exhibited a significant positive association with BP only in smokers. Multiple regression analyses showed that BMI, DHA, smoking status, and smoking status*ALA interaction significantly predicted SBP (p < 0.0001, R2 = 0.44) and DBP (p < 0.0001, R2 = 0.33), while ethnicity had no effect. The observed lower BP when DHA levels are high suggests a possible protective role of DHA on BP in normotensive smokers and nonsmokers. Additionally, the observed higher BP when ALA levels are high only in smokers suggests that ALA may influence the BP-lowering effects of chronic smoking.

Treating Diuretic Resistance: An Overview.

Loop diuretics are central to the management of fluid overload in acute decompensated heart failure. However, a variance in the response to loop diuretics can alter a patient's clinical course and has an adverse effect on clinical outcomes. Thus, a diminished response to loop diuretics is an important clinical issue. Factors thought to contribute to diuretic resistance include erratic oral absorption in congested states and postdiuretic sodium retention. Further contributing to diuretic resistance in patients with advanced heart failure are decreases in renal perfusion and alterations in sodium handling that occur in an attempt to maintain circulatory homeostasis. Several pharmacologic interventions have been used to improve diuretic response. Intravenous diuretic administration, increasing diuretic doses, or changing diuretic agents can potentially overcome pharmacokinetic obstacles which contribute to drug resistance. Combination diuretic therapy may be useful to overcome increased sodium retention, dopamine may improve renal perfusion, and hypertonic saline may transiently increase intravascular volume and improve sodium delivery to the tubules of the nephron. Despite the prevalence of diuretic resistance, there remains a paucity of clinical trial evidence to help guide therapy in these patients.

PCSK9 Inhibitors: An Innovative Approach to Treating Hyperlipidemia.

Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors are novel agents indicated for the treatment of hyperlipidemia. Inhibition of PCSK9 produces an increase in surface low-density lipoprotein (LDL) receptors and increases removal of LDL from the circulation. Alirocumab (Praluent; Sanofi/Regeneron, Bridgewater, NJ) and evolocumab (Repatha; Amgen, Thousand Oaks, CA) are currently available and approved for use in patients with heterozygous familial hypercholesterolemia, homozygous familial hypercholesterolemia, and clinical atherosclerotic cardiovascular disease. Bococizumab (RN316; Pfizer, New York, NY) is currently being studied in similar indications, with an estimated approval date in late 2016. The pharmacodynamic effects of PCSK9 inhibitors have been extensively studied in various patient populations. They have been shown to produce significant reductions in LDL and are well tolerated in clinical studies, but they are very costly when compared with statins, the current mainstay of hyperlipidemia treatment. Clinical outcome studies are underway, but not yet available; however, meta-analyses have pointed to a reduction in cardiovascular death and cardiovascular events with the use of PCSK9 inhibitors. This review will discuss the novel mechanism of action of PCSK9 inhibitors, the results of clinical studies, and the clinical considerations of these agents in current therapy.

Complementary and Alternative Medicine and Therapy Use in a Diverse New Mexican Population.

OBJECTIVE: To describe differences, attitudes, and experiences in use of complementary and alternative medicines and therapy (CAMT) in people living in New Mexico (NM). DESIGN: Cross-sectional survey study. SETTING: Clinics staffed by the University of New Mexico College of Pharmacy faculty between September 2009 and August 2011 in Albuquerque, NM. PARTICIPANTS: Patients 18 years of age or older or parents of patients younger than age 18 years. OUTCOME MEASURES: Descriptive statistics for survey results and mean scores for attitudinal items. Chi-square, t-test, and analysis of variance were used to compare differences between groups across demographic variables. RESULTS: A convenience sample yielded 263 completed surveys. Of the respondents, 62% were male, 39% were single, and 50% were Hispanic. Nearly 56% of respondents used CAMT in the previous 6 months; 38% used CAMT in addition to and 11% used CAMT instead of prescription medications. Average number of CAMT used per respondent was 2.3 ± 1.6. A majority of respondents indicated that their CAMT use in the previous 6 months was useful, a good idea, easy to use, and likely to continue. CAMT use was significantly higher in female respondents (p = 0.03), those with a higher education level (p < 0.01), and those with a higher household income level (p = 0.03). CONCLUSION: Prevalence of CAMT is high in a diverse population of patients. Older respondents were more likely to use CAMT in addition to prescription medications, and younger respondents were more likely to use CAMT instead of prescription medications. Providers need to consider CAMT use when discussing treatment options with patients.

Sacubitril/Valsartan: A Novel Cardiovascular Combination Agent.

Sacubitril/valsartan [LCZ696 (Entresto), Novartis Pharmaceuticals Corp.] is the first in a new class of drugs that combines neprilysin inhibition with angiotensin II receptor antagonism, the combination of which acts to increase endogenous natriuretic peptides while inhibiting the renin-angiotensin-aldosterone system. Sacubitril/valsartan has been studied in the treatment of hypertension, heart failure with reduced ejection fraction (HFrEF), and heart failure with preserved ejection fraction (HFpEF) and has demonstrated clinical efficacy in blood pressure reduction in hypertensive patients with and without HFpEF and a reduction in hospitalizations and mortality for patients with HFrEF. Research to evaluate clinical outcomes in HFpEF is ongoing. Sacubitril/valsartan is approved to reduce hospitalization and risk of cardiovascular death for patients with HFrEF in New York Heart Association (NYHA) functional class II-IV. The product is as well tolerated as an angiotensin-converting enzyme inhibitor, with the most common side effect being hypotension. Expectedly, it is much more costly than generic angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, which will be a factor in determining how widespread the use of this agent will be. In summary, although the number of published studies evaluating its use is limited, sacubitril/valsartan represents a promising new treatment option for patients with HFrEF. Ongoing studies will continue to refine the role of this agent in clinical practice.

Clinical utility of tadalafil in the treatment of pulmonary arterial hypertension: an evidence-based review.

Pulmonary arterial hypertension (PAH) is a chronic and disabling condition characterized by an elevated pulmonary vascular resistance and an elevated mean pulmonary arterial pressure. Despite recent improvements in treatment availability, PAH remains challenging to treat, burdensome for patients, and ultimately incurable. Tadalafil is a phos-phodiesterase-5 inhibitor that is administered once daily by mouth for the treatment of PAH. Current treatment guidelines recommend tadalafil as an option for patients with World Health Organization functional class II or III PAH. In a placebo-controlled clinical trial, patients taking tadalafil demonstrated significantly improved exercise capacity as measured by the 6-minute walk distance. Patients also experienced decreased incidence of clinical worsening, increased quality of life, and improved cardiopulmonary hemodynamics. Uncontrolled studies and smaller trials have indicated a possible role for tadalafil as a suitable alternative to sildenafil and as a beneficial add-on option when used in combination with other treatments for PAH. Tadalafil is generally safe and well tolerated. Adverse events are typically mild-to-moderate in intensity, and discontinuation rates are usually low. The purpose of this review is to provide an evidence-based evaluation of the clinical utility of tadalafil in the treatment of PAH.

Characterization of a novel endothelial biosensor assay reveals increased cumulative serum inflammatory potential in stabilized coronary artery disease patients.

BACKGROUND: Vascular disease is promoted by systemic inflammation that can arise from sites distal to the affected vessels. We sought to characterize the net inflammatory potential of serum from patients with coronary artery disease (CAD) using cultured endothelial cells as a cumulative biosensor. METHODS AND RESULTS: Serum samples from CAD patients (N = 45) and healthy control subjects (N = 48) were incubated with primary human coronary artery endothelial cells at a 1:10 dilution for 4 h, followed by isolation of the cellular RNA. Alteration of inflammation-responsive elements (adhesion molecules and cytokines) was assessed by gene expression. Specific indicators included intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and interleukin-8 (IL-8). Additionally, the cytokine levels in serum samples from all subjects were quantified. Serum from CAD subjects induced greater endothelial ICAM-1, VCAM-1, and IL-8 expression compared to healthy control serum (p < 0.001 for each analysis). The three indicators of inflammatory potential (ICAM-1, VCAM-1, and IL-8 mRNA) trended independently of each other and also of serum inflammatory biomarkers. IL-8 expression correlated negatively with serum HDL levels but positively correlated with VLDL, plasminogen activator inhibitor-1 and C-reactive protein. Interestingly, serum levels of cytokines in CAD patients were not statistically different from healthy control subjects. A year of follow-up in a sub-group of CAD subjects revealed relatively stable measures. CONCLUSIONS: As yet unidentified circulating factors in the serum of CAD patients appear to activate endothelial cells, leading to upregulation of adhesion molecules and chemokines. This cumulative assay performed well in terms of discriminating patients with CAD compared to healthy subjects, with greater range and specificity than specific inflammatory markers.

Ivabradine: A Unique and Intriguing Medication for Treating Cardiovascular Disease.

There has been much research linking elevated resting heart rate to cardiovascular morbidity and mortality. Based on these findings, a lower resting heart rate would be of theoretical benefit in patients with cardiovascular disease. From a pathophysiologic perspective, a lower resting heart rate would be of particular benefit in patients with ischemic heart disease and/or heart failure. Although ß-blockers and nondihydropyridine calcium channel blockers are effective at lowering heart rate, they have many other pharmacologic effects that may not be desirable in some patients, such as negative inotropy. Ivabradine is a drug designed to lower heart rate without any other demonstrable pharmacologic effects; in other words, a pure heart rate-lowering drug. It functions by blocking the hyperpolarization-activated cyclic nucleotide gated channels (f-channels) specific for the sinoatrial node and disrupting If ion current flow. This effectively prolongs diastolic depolarization and slows firing in the sinoatrial node, which lowers heart rate. The effects of ivabradine are most pronounced at higher heart rates (use-dependence), which is important in minimizing the development of symptomatic bradycardia. Clinical trials have demonstrated ivabradine to be an effective antianginal drug both alone and in combination with ß-blocker therapy, although it has not been shown to produce a demonstrable effect on reducing major adverse cardiovascular events. In patients with heart failure, ivabradine has demonstrated many hemodynamic benefits, but its effect on clinical outcomes have been mixed and dependent on baseline heart rate, ie, the drug may be of benefit with higher baseline heart rates, but detrimental with low baseline heart rates. The adverse effects of ivabradine are not uncommon, but are rarely severe and include visual disturbances, bradycardia, and atrial fibrillation. Although ivabradine is a very interesting new agent, its variable benefits in large-scale clinical trials leave its exact place in therapy still somewhat nebulous. Unanswered questions include which patient populations would benefit most from this drug, and which concomitant medications would produce the best clinical outcomes when used with ivabradine.

Improving the effectiveness of pharmacist-assisted tobacco cessation: a study of participant- and pharmacy-specific differences in quit rates.

BACKGROUND: The New Mexico Pharmaceutical Care Foundation provided a pharmacist-assisted tobacco cessation program from 2004 to 2010. In evaluating the program, discrepant 6-month quit rates were observed between pharmacies. OBJECTIVE: To identify participant- and pharmacy-specific factors associated with improved quit rates. METHODS: To supplement data regarding participant characteristics and quit rates, semistructured interviews of 7 participating pharmacists were conducted. Multivariate logistic regression quantified associations between successful abstinence at 6 months and participant characteristics and pharmacy-specific factors. RESULTS: Quit rates by pharmacy ranged from 1.1% to 59.4% (mean = 19.1%). There were 1235 participants enrolled at 7 pharmacies, and because of missing participant data, 883 were included in the quantitative analysis. Three pharmacy-specific characteristics distinguished 6-month success rates: number and duration of follow-ups and format of counseling sessions. Participants followed up at least 3 times were more likely to quit at 6 months than those contacted once or twice (odds ratio [OR] =4.9; 95% CI = 1.6-15.0). Compared with follow-ups of <15 minutes, longer durations of follow-ups were associated with higher success rates: 15 to 30 minutes, OR = 7.2, 95% CI = 3.7-14.3); >30 minutes, OR = 10.0, 95% CI = 3.5-28.9. Participants who attended group sessions were more likely to quit at 6 months than those who attended individual sessions: OR = 8.2; 95% CI = 2.8-23.9. Most pharmacists (88%) noted that participants' high or low commitment to quit was associated with success or failure, respectively. Several pharmacists (43%) noted difficulties with follow-up associated with participants' relapse. Time constraints were an obstacle noted by 70% of pharmacists. CONCLUSIONS: Pharmacy-specific factors, including counseling format and program intensity, affected success.

Quitting patterns and predictors of success among participants in a tobacco cessation program provided by pharmacists in New Mexico.

BACKGROUND: Tobacco use causes hundreds of thousands of deaths in the United States each year. Pharmacists are available in the community to provide tobacco cessation interventions. Between 2004 and 2010, the New Mexico Pharmaceutical Care Foundation (NMPCF) provided a pharmacist-led tobacco cessation program to residents in New Mexico. OBJECTIVES: To (a) obtain point prevalence quit rates at 1 month, 3 months, and 6 months follow-up for participants enrolled in the NMPCF program; (b) differentiate between the quitting patterns of enrolled participants; and (c) identify predictors associated with the quitting patterns. METHODS: Seven-year data were combined for the pattern analysis. Four quitting patterns were defined, including immediate quitters, delayed quitters, once quitters, and never quitters. Multinomial logistic regression was used to identify characteristics of participants with different quitting patterns. RESULTS: The analysis included 1,437 participants. The average point prevalence quit rate at 1 month, 3 months, and 6 months was 29.3%, 23.3%, and 18.0%, respectively. Based on our definition for quitting patterns, the study sample consisted of 145 (10.1%) immediate quitters, 113 (7.9%) delayed quitters, 298 (20.7%) once quitters, and 881 (61.3%) never quitters. Multinomial logistic regression identified associations between quitting patterns and demographics, tobacco use and restrictions, baseline confidence in successful quitting, and pharmacotherapy aids used to quit. Relationships varied between quitting patterns. CONCLUSIONS: The study findings showed that having community pharmacists provide smoking cessation interventions resulted in quitting success rates similar to other health care professionals, which ranged from 9.9% to 26.0%. Since pharmacists are a widely available resource for their patients, managed care organizations may be able to improve the health, and avoid subsequent tobacco-related adverse health outcomes, of their members by implementing a program similar to the NMPCF Tobacco Cessation Program.

Ambrisentan for the treatment of pulmonary arterial hypertension: improving outcomes.

Pulmonary arterial hypertension (PAH) is a progressive disease of the pulmonary vasculature that is associated with severe functional impairment and a poor prognosis. Ambrisentan is a selective endothelin type A receptor antagonist approved for the treatment of patients with PAH World Health Organization group 1. The efficacy and safety of ambrisentan has been evaluated in the ARIES series (Ambrisentan for the Treatment of Pulmonary Arterial Hypertension, Randomized, Double-Blind, Placebo-Controlled, Multicenter, Efficacy Studies), which has established its use as both monotherapy or in conjunction with other PAH therapies. Specifically, ambrisentan is effective at increasing exercise tolerance, decreasing the risk of functional class deterioration, and prolonging time to clinical worsening. Further, ambrisentan has a favorable effect on mortality, with an 88% patient survival rate after two years of therapy compared with a 61% survival rate as estimated by the National Institute of Health Registry. Ambrisentan is generally well tolerated in all patient groups, with the main side effects of peripheral edema, sinusitis, flushing, and nasal congestion considered to be mild to moderate in nature. Ambrisentan has several favorable qualities that potentially make it more acceptable to patients, including once-daily administration, limited adverse drug reactions and drug-drug interactions, and minimal risk of liver enzyme elevation. Because of the potential risk of teratogenicity associated with ambrisentan, it is only available through a limited distribution program, ie, LEAP (the Letairis Education and Access Program). Ongoing clinical trials will help to clarify the role of ambrisentan in the treatment of PAH.

Statin loading before percutaneous coronary intervention to reduce periprocedural myocardial infarction.

Periprocedural myocardial infarction (PMI) is a common complication associated with percutaneous coronary intervention (PCI), occurring in approximately 15% to 20% of patients undergoing the procedure. The established diagnostic criteria for PMI is an increase in cardiac biomarkers, specifically creatine kinase-MB levels > 3 times the upper limit of normal. As PMI has been associated with an increased risk of mortality after PCI, investigative efforts have been directed at therapies that can potentially decrease PMI. One such therapy is the use of hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) administered as a loading dose before PCI. Multiple small, randomized, controlled trials have demonstrated significant reductions in the incidence of PMI with statin loading before PCI. The risk reduction was seen in patients with stable and unstable coronary artery disease, as well in statin-naive patients or those on chronic statin therapy. Potential mechanisms for the rapid benefits of statin loading include: anti-inflammatory effects, reversal of endothelial dysfunction, decrease in oxidative stress, and inhibition of the thrombotic system. None of the current studies were of sufficient power or duration to detect benefits on mortality, though a recent meta-analysis did demonstrate a reduction in major adverse cardiovascular events. In addition to long-term effects, several additional questions remain with regard to statin loading, such as statin type, dose, and optimal timing of administration. However, given the current evidence of benefit and the low risk of adverse events, it can be recommended that all patients undergoing PCI be considered for statin loading before the procedure.