Heart of the matter

Cardiovascular disease is the second-leading cause of death in Ireland, but prevention and early intervention can save many lives, writes Damien O’Brien MPSI

Introduction

Heart health is fundamental to the overall wellbeing of an individual due to the heart’s crucial role in sustaining life through the circulation of oxygenated blood. The heart is a muscular organ located slightly to the left of the centre of the chest. It pumps blood through the blood vessels to all parts of the body, delivering oxygen and nutrients while carrying away waste products.

The cardiovascular system is made up of the heart and blood vessels. Cardiovascular disease is a significant public health challenge in Ireland. It is the second-leading cause of death in Ireland after cancer, causing approximately 9,000 deaths annually. Cardiovascular disease is also one of the leading causes of disability in Ireland, and many of these conditions may be preventable through health measures and early interventions.

Cardiovascular health involves the efficient functioning of the heart, blood vessels and circulatory system. Pharmacists are accessible healthcare professionals and are ideally positioned to support heart health through patient education, medication management, and promoting lifestyle modifications. This article outlines the pharmacist’s role in promoting heart health, the background of cardiovascular health, strategies for lifestyle modification and risk reduction, and pharmacological treatments.¹

There is a wide range of conditions that may arise within the cardiovascular system, and these are categorised into the following four subtypes:

• Coronary artery disease (CAD) – Results from decreased myocardial perfusion, leading to angina, myocardial infarction (MI) or heart failure.
• Cerebrovascular disease (CVD) – A group of conditions that affect blood flow to the brain, including stroke and transient ischemic attack (TIA).
• Peripheral artery disease (PAD) – Occurs when blood flow is impaired to parts of the body other than the brain and heart.
• Aortic disease – A group of disorders that affect the aorta. The aorta is the largest blood vessel in the body and carries blood from the heart to the rest of the body. One of the most common aortic diseases is an aortic aneurysm.²

Cardiovascular risk factors

Several risk factors contribute to poor heart health. Risk factors are either non-modifiable, meaning they can’t be changed, or modifiable, meaning that an individual can take steps to change them.

Non-modifiable risk factors for cardiovascular disease include age, gender and family history. Age increases the risk of developing heart disease, with approximately 80 per cent of patients who die from cardiovascular disease being 65 or older.

Family history is also a significant risk factor for cardiovascular disease. Individuals with a family history of premature cardiac disease before the age of 50 have an increased cardiovascular mortality risk. Men are also at an increased risk of heart disease, but it is a significant issue for both males and females. Although non-modifiable risk factors cannot be changed, it is still prudent to be aware of them.^2,3

Modifiable risk factors also play a significant role in cardiovascular disease. These include hypertension, high cholesterol levels, diabetes, smoking, obesity, diet, and a sedentary lifestyle. Optimal pharmacological interventions and lifestyle modifications can help reduce these modifiable risk factors, thereby lowering morbidity and mortality.¹

Lifestyle modifications for heart health

Lifestyle modifications are vital in the prevention and management of cardiovascular disease. Lifestyle factors profoundly affect the likelihood of developing cardiovascular disease. Evidence shows that regular physical activity, a healthy diet, maintaining a healthy weight, avoiding smoking and moderating alcohol intake significantly reduce the risk of heart disease. The strength of the evidence supporting these daily health-promoting activities is reflected in their inclusion in evidence-based guidelines for the prevention and treatment of cardiovascular diseases.⁴

A sedentary lifestyle is associated with an increase in cardiovascular disease incidence and mortality. The World Health Organisation (WHO) recommends that all adults from 18-to-64 engage in a minimum of 150 minutes of moderate-intensity aerobic exercise per week. This can be achieved through activities such as running, walking, swimming or cycling. However, it is estimated that less than half of Irish adults achieve this objective.

Even a small increase in physical activity is thought to greatly reduce the risk of cardiovascular disease. Furthermore, physical activity can improve lipid profiles, reduce blood pressure and aid in weight management.^1,4

A poor diet is one of the main risk factors for the development of cardiovascular disease. Evidence suggests that a diet rich in fruits and vegetables is associated with a lower risk of cardiovascular disease. Furthermore, a diet containing oily fish, seafood, whole grains, fibre, legumes and nuts is associated with a lower risk of heart disease. Patients should be encouraged to follow a diet lower in processed meats, refined grains, cholesterol, sodium, saturated fats and trans fats. A caloric balance should be maintained, with an emphasis on portion control. Guidelines also recommend that adults who consume alcohol do so in moderation.^1,4

Maintaining a healthy weight is important to reduce the risk of heart disease and improve heart health. Both being overweight and obesity are significant risk factors for cardiovascular disease.

Obesity is associated with other risk factors such as diabetes, dyslipidaemia and hypertension, but it is also an independent risk factor for cardiovascular disease. Ireland has one of the highest obesity levels in Europe, with the number of people meeting the criteria for being overweight and obesity more than doubling in the last 20 years. Lifestyle changes can produce significant weight loss and have important health benefits, with portion control, healthy eating and regular exercise being vital for this.^1,4

Smoking is a major risk factor for cardiovascular disease, contributing to stroke and heart disease. Second-hand smoke also increases the risk of heart disease. Patient education about the risks of smoking is important for both children and adults. Smoking cessation is vital for patients who smoke, with pharmacological options including nicotine replacement therapy, varenicline and bupropion playing an important role in reducing cravings and withdrawal symptoms. 

Behavioural strategies, including cognitive behavioural therapy, can also be effective in achieving and maintaining cessation. Significant reductions in cardiovascular risk can be observed in individuals who quit smoking, even after a brief period of time.^1,4

Pharmacological treatment

Management of heart disease can vary widely depending on the clinical situation. However, effective pharmacological management is integral to preventing and managing cardiovascular disease and improving heart health, with some commonly used pharmacological options outlined below.²

Antihypertensive drugs

Hypertension is one of the principal causes of increased cardiovascular disease. Lowering blood pressure reduces the risk of cardiovascular disease and prevents complications in patients with heart failure, coronary artery disease, stroke and diabetes.

Normal blood pressure is considered a systolic blood pressure of less than 120mmHg and a diastolic blood pressure of less than 80mmHg. The target blood pressure for someone with hypertension can vary slightly depending on the clinical indication, but most targets are lower than 130/80mmHg. There are multiple classes of medications used to treat hypertension, which should be used in combination with lifestyle modifications.⁵

Calcium channel blockers are a first-line treatment for hypertension. They work by blocking calcium influx in the heart and vascular smooth muscle. This reduces cardiac contractility and causes vasodilation, thereby reducing blood pressure. They reduce all cardiovascular events except heart failure, with amlodipine and lercanidipine being commonly used calcium channel blockers to treat hypertension.⁴

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are first-line treatment option for hypertension. They are particularly useful in patients with chronic kidney disease and heart failure. Both classes of drugs work by inhibiting the renin?angiotensin system (RAS), with ACE inhibitors inhibiting the conversion of angiotensin I to angiotensin II and ARBs blocking the receptor binding of angiotensin II to its target receptors. Both classes share similar efficacy and indications for treatment.

Examples of ACE inhibitors include ramipril, perindopril, lisinopril and enalapril, while examples of ARBs include valsartan, losartan, telmisartan, olmesartan and candesartan.⁴

Thiazide and thiazide-like diuretics are also a first-line therapeutic option for hypertension. They inhibit the reabsorption of sodium in the distal convoluted tubule of the nephron, promoting diuresis and sodium loss. They may also be useful in reducing oedema associated with heart failure. Hydrochlorothiazide, chlorthalidone and indapamide are often used to treat hypertension.⁴

Lipid-lowering therapy

Lipid-lowering therapies are beneficial for patients at an increased risk of cardiovascular events. Abnormally high levels of low-density lipoprotein (LDL) can contribute to atherosclerosis, which is characterised by the development of lesions in the walls of arteries. Atherosclerosis is a major cause of coronary artery disease, stroke and myocardial infarction.

High-density lipoprotein (HDL), also known as ‘good cholesterol,’ is involved in preventing the build-up of plaques in the arteries and reducing cardiovascular events. Therefore, the main objectives of lipid-lowering therapies are to reduce LDL and increase HDL. Statins are the first-line lipid-lowering agents. Other agents may be used to enhance the efficacy of statins, in cases of statin intolerance or in cases of severe hypertriglyceridemia. Similar to hypertensive agents, lipid-lowering therapy should be used in combination with lifestyle modifications.⁶

Statins are the first-line lipid-lowering agents, as they can lower LDL and triglyceride levels and increase HDL levels. Statins reduce the risk of cardiovascular events in high-risk patients. They are competitive inhibitors of hydroxymethylglutaryl (HMG) CoA reductase, an enzyme involved in a crucial step of cholesterol biosynthesis. Atorvastatin, rosuvastatin, pravastatin and simvastatin are commonly used statins. Ezetimibe is not a statin, but it is a drug used to treat high cholesterol and other lipid abnormalities. It works by impairing dietary and biliary cholesterol absorption in the intestine, thereby lowering LDL.⁶

Role of the pharmacist

Heart health is a major public health concern in Ireland that requires a comprehensive and collaborative approach to prevention and management. Pharmacists are well-positioned to positively impact cardiovascular health through patient education, monitoring, medication optimisation and counselling on lifestyle modifications.

Pharmacists address modifiable risk factors by providing advice on the importance of diet and weight management, while also encouraging participation in smoking cessation programmes. They can optimise medication regimens by conducting medication reviews to identify drug interactions and by stressing the importance of adherence to prescribed therapies. Pharmacists can also monitor patients by performing blood pressure, cholesterol and blood glucose checks.

In conclusion, pharmacists make a significant contribution to preventing cardiovascular disease, improving patient outcomes and reducing the burden of heart disease on the healthcare system.