Pharmacist-Led Strategies for Cardiovascular Disease Prevention & Management

This issue of the M&D Clinical Corner highlights the pharmacist’s role in preventing and managing cardiovascular disease (CVD).  Topics include key guideline updates, how fatty liver (recently renamed from NASH to MASLD) and oxidized damage from inflammation are a couple of the root causes of CVD, and actionable strategies pharmacists can use to optimize patient outcomes.

Lipid Management: Updated Targets & Pharmacist Strategies

1. 2023 Lipid Panel Targets

Updated guidelines emphasize stricter lipid targets for cardiovascular risk reduction are listed below. Expect for there to be confusion when it comes to ideal levels. Multiple studies have been published showing that non-statin users with an LDL-C less than 70mg/dL had a strong and independent associated increased risk of cancer, CVD, and all cause mortality. Data has shown that reducing LDL-C levels in someone who was >100 mg/dL at baseline showed a benefit, whereas those who were <100 mg/dL at baseline didn’t show the same benefit and had an increased risk.

In another study, investigators set out to determine why and how statins sometimes increase concentrations of liver enzymes and cause rhabdomyolysis. Results showed that raised liver enzymes were significantly related to higher doses of statins. The rate of raised liver enzymes was 271 with high dose statin, 195 with intermediate dose, and 114 with low dose statin per 100 000 person years for each10% reduction in LDL cholesterol (P<0.001 for all pairwise comparisons). Rates of rhabdomyolysis were also higher with higher doses of statins, although not significantly so.

Despite many published studies that have conflicting evidence, the guidelines with treatment goals are still addressing LDL-C and the targets below and focusing on a goal level. If a patient is concerned or cannot tolerate statins, pharmacists can educate them on the availability of other labs that test for fat oxidization and explain how inflammation is the target to aim at decreasing.

2. The Role of Oxidized LDL in Cardiovascular Disease

Cholesterol itself is not inherently harmful—oxidized LDL (oxLDL) is the real threat. When LDL is damaged by oxidative stress, it triggers inflammation and plaque formation in arteries. Specialized lab tests like oxLDL blood tests can assess a patient’s risk beyond standard lipid panels.

How to Reduce LDL Oxidation:

• Antioxidants: Vitamin C, pycnogenol, fisetin, and melatonin help neutralize oxidative stress
• Anti-Inflammatory Diet: Whole foods rich in polyphenols (berries, dark

chocolate, green tea) support arterial health

• Lifestyle: Reducing processed foods, quitting smoking, and stress management lower oxidation risks

Inflammation & Fatty Liver: The Root Causes of Cardiovascular Disease

1. The Link Between Fatty Liver, Inflammation and Heart Disease

Fatty liver disease is a silent driver of CVD, as it promotes systemic inflammation and dyslipidemia. Patients with non-alcoholic fatty liver disease (NAFLD) often have elevated triglycerides, insulin resistance, and metabolic syndrome—key contributors to heart disease. The term Non-Alcoholic Fatty Liver Disease (NAFLD) has been renamed to Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), and Non-Alcoholic Steatohepatitis (NASH) has been renamed to Metabolic Dysfunction-Associated Steatohepatitis (MASH). The change in name shows the metabolic dysfunction that drives the disease rather than implying that alcohol is the primary factor.

Signs of High Inflammation:

• Elevated hs-CRP (high-sensitivity C-reactive protein)
• Increased homocysteine and fibrinogen
• High oxidized LDL and lipoprotein(a) [Lp(a)]

2. Strategies to Lower Inflammation & Improve Lipid Health

Anti-Inflammatory Supplements:

• Vitamin D (Optimized to 50-80 ng/mL) – Low vitamin D levels correlate with increased cardiovascular risk. A level of less than 30 is associated with increased risk of CAD

• Antioxidants (Vitamin C, pycnogenol, fisetin, melatonin) – Reduce oxidative stress

• CoQ10 (100 mg/day) – Supports mitochondrial function and offsets statin side effects

• Omega-3s (EPA/DHA 2-4g/day) – Reduce triglycerides and inflammation

Diet & Lifestyle:

• Mediterranean Diet: Emphasizes whole foods, healthy fats, and lean proteins
• Exercise (detailed below): Enhances lipid metabolism and reduces inflammation

Hypertension & Heart Failure Updates

1. Hypertension: 2023 Management Guidelines Hypertension remains a leading contributor to CVD. Updated recommendations emphasize:

• BP Targets: <130/80 mmHg for most patients, <120/80 mmHg for high-risk individuals
• First-Line Therapy: ACE inhibitors, ARBs, thiazide diuretics, and calcium channel blockers
• Resistant Hypertension: Consider adding aldosterone antagonists (spironolactone, eplerenone) or SGLT2 inhibitors in patients with diabetes or heart failure
• Lifestyle Interventions:
  • Sodium Restriction (<2,300 mg/day) & Potassium-Rich Diets (fruits, vegetables, nuts)
  • Weight Loss & Regular Exercise

2. Heart Failure: Pharmacist Interventions

Heart failure (HF) guidelines continue to emphasize a quadruple therapy approach:

• SGLT2 inhibitors (dapagliflozin, empagliflozin) improve outcomes in HF with reduced ejection fraction (HFrEF)
  ARNI (sacubitril/valsartan) replaces ACE inhibitors in select patients
• Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) remain foundational
• Mineralocorticoid Receptor Antagonists (spironolactone, eplerenone) further reduce hospitalizations
• Counsel patients on the importance of medication adherence, particularly for heart failure management. Emphasize the need to take medications consistently to reduce hospital readmissions and improve quality of life.
• Educate patients about recognizing the symptoms of heart failure (e.g., shortness of breath, swelling, weight gain) and the importance of regular weight monitoring (a sudden weight increase may indicate fluid retention).
• Provide counseling on diet and sodium restriction to help manage fluid balance and reduce heart failure symptoms. Recommend the DASH diet (Dietary Approaches to Stop Hypertension) or a low-sodium diet, depending on the patient’s specific condition.
• Encourage physical activity, with tailored recommendations based on the patient’s condition and ability (e.g., light walking or resistance training). Exercise has been shown to improve cardiovascular function and reduce symptoms in stable heart failure patients.

Anticoagulation Therapy Updates

1. Direct Oral Anticoagulants (DOACs) vs. Warfarin

• DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) are now preferred over warfarin for most indications due to lower bleeding risk and no need for frequent INR monitoring.

• Warfarin remains first-line in patients with mechanical heart valves or valvular atrial fibrillation.

2. Pharmacist-Led Strategies

Medication Management and Monitoring:

• DOAC dosing adjustments should be made based on renal function to prevent over or under-dosing.
• INR monitoring for warfarin users is crucial to maintain a therapeutic range (typically 2.0-3.0).
• Monitor for drug interactions, including NSAIDs, herbal supplements (e.g., John’s Wort, garlic, ginger), and other medications that may increase bleeding risk or reduce drug efficacy.

Patient Education:

• Emphasize adherence to prescribed anticoagulants, particularly with warfarin, which requires consistent vitamin K intake (e.g., leafy greens and certain oils) to maintain stable INR levels.
• For DOACs, dietary restrictions are minimal, but herbal supplements (e.g., John’s Wort, ginger, garlic) can still interact and affect drug efficacy.
• Counsel on recognizing signs of bleeding (e.g., easy bruising, blood in urine or stools, coughing up blood, nausea that doesn’t get better with treatment) and stress the importance of seeking medical attention if these occur.
• Advise lifestyle modifications to minimize bleeding risks, such as avoiding high-injury activities (e.g., contact sports) and caution with alcohol, food, and supplements that may interfere with anticoagulant therapy.

Supplements and Coagulation Modifiers:

• CoQ10 supplementation can help minimize the impact of warfarin by counteracting vitamin K antagonists.People on warfarin do not need to avoid CoQ10 entirely, but they should use it in moderate doses (e.g., 100 mg/day) and monitor their INR levels regularly to ensure that warfarin remains effective. CoQ10 doesn’t give more flexibility in vitamin K consumption, and patients should still maintain a consistent intake of vitamin K-rich foods.
• Omega-3s offer anti-inflammatory benefits and may support cardiovascular health, but they should be used cautiously alongside anticoagulants due to potential bleeding risk.

Who Should Get a Coronary Artery Calcium (CAC) Score?

Coronary Artery Calcium (CAC) Scoring is a non-invasive CT scan that detects calcified plaque in coronary arteries, helping stratify cardiovascular risk.

Recommended for:

• Men ≥40 and women ≥50 with intermediate CVD risk.
• Patients with diabetes, hypertension, or family history of early heart disease.
• Individuals with borderline lipid profiles and who need further risk assessment.

More Information: Mayo Clinic: Coronary Artery Calcium Scoring

Exercise Recommendations for Cardiovascular Health

Exercise is as crucial as medication in preventing heart disease.

Strength Training:

• 2-3 days per week
• Compound movements (squats, deadlifts, push-ups) improve metabolic health

Cardio (Aerobic Exercise):

• 150-300 minutes per week of moderate intensity (brisk walking, cycling).
• OR 75-150 minutes of vigorous activity (running, HIIT workouts)

Flexibility & Stress Reduction:

• Yoga & Breathwork: Reduce stress and inflammation.

Key Takeaways for Pharmacists

• Lipid Management: LDL-C <55 mg/dL for high-risk patients. Consider oxidized LDL testing.

• Hypertension & Heart Failure: Updated medication guidelines, with SGLT2 inhibitors playing a key role.
• Anticoagulation Therapy: DOACs are preferred for most patients over warfarin.
• Inflammation & Fatty Liver: Address through diet, antioxidants, and lifestyle changes.
• Exercise: Resistance training + cardio is critical for lipid and inflammation control.
• Statin Therapy: Identify candidates and mitigate side effects with CoQ10. Consider red yeast rice as an alternative.
• Don’t forget that statin use will affect the hormone levels for patients, namely testosterone. The effects will vary in each person, and some statins (atorvastatin) lowers testosterone more than others (simvastatin). Mention the need to have hormone labs drawn for statin patients if they are experiencing symptoms of low testosterone.

• Sexual dysfunction/erectile dysfunction is often an early sign in men that they have heart disease. Consider using your pharmacy software to alert for male patients taking erectile dysfunction meds that are not taking a statin or cholesterol medication, and counsel them on the need to have their PCP check their risk of cardiac disease.

Pharmacists are essential in cardiovascular risk reduction. By implementing guideline updates, counseling on inflammation and lifestyle changes, and personalizing lipid management, we can significantly impact patient outcomes.

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The Clinical Corner is a monthly feature from Morris & Dickson that highlights a variety of important pharmacist topics that is written by Dr. Jesica Mills, PharmD, ND, MBA, RPh, BCES, BCLS, BCNP.