Cardiovascular Clinic Visit

Our Advance Practice Management Lab has physical assessment modules, each dealing with common disease states that pharmacists have a key role in managing. Last semester we had a Pulmonary Clinic Visit. We reviewed all of the major types of inhalers and their proper use, peak flow meter technique and EpiPen administration. These modules focus on the key counseling points that patients need when dealing with complex disease states such as: which inhaler is maintenance versus which inhaler is for acute symptoms, what are the proper techniques and uses and what are some non-pharmalogical things that I can do to help my symptoms? I love doing these modules because they are all real life problems patients struggle with that we as pharmacists can help with.

This semester we have a Cardiovascular Clinic Visit and a Endocrine Clinic Visit. I just had my Cardiovascular Clinic Visit yesterday in lab so I thought this was the perfect time to review some of the pearls to dealing with hypertension, what a pharmacist’s role is and how to properly take a blood pressure reading. As I am sure many of you are aware the new hypertension guidelines just came out in November of 2017 by the ACC/AHA (American College of Cardiology/American Heart Association). The biggest change with this guideline is that hypertension is now defined as a blood pressure higher than 130/80 mmHg rather than above 140/90 mmHg. This lowered the threshold for stage II hypertension as well, it is now defined at >140/90 mmHg instead of >160/100 mmHg. I am currently taking an ambulatory care elective and we just did a review of the new guidelines a few weeks ago which was super helpful. I don’t want to go into a total review of the guidelines in this post (if you want me to do a full review comment below) but it is important to emphasize this major change in the guidelines, because this means many more Americans will be diagnosed with hypertension.

With my cardiovascular clinic visit just wrapping up, I want to review hypertension and why it is so important to treat. Untreated hypertension can lead to damage of every major organ in the body:

Heart: coronary artery disease, angina, myocardial infarction, heart failure, etc
Kidneys: proteinuria, renal insufficiency, atherosclerosis of renal arteries, etc
Brain: transient ischemic attacks, stroke
Eyes: retinopathy (can lead to blindness)
Vasculature: decreased pulses in extremities, atherosclerosis, claudication (angina of the legs), etc

Hypertension is known as the “silent killer” because patients don’t feel like there is anything wrong, meanwhile they have end organ damage. This is an important counseling point for patients. Stressing medication adherence is always important, but most the time if a patient can feel the benefit of the medication they are more likely to take it, so with a disease state like this medication adherence counseling is vital. When we started this module our professors kept emphasizing the importance of having the skill of taking accurate blood pressure readings as a pharmacist. If you aren’t in the medical field or for some of you med students, PA students, nursing students and even P1-P2 pharmacy students, you may not have experience with this role of a pharmacist. It may seem strange that we would even need to carry a stethoscope, but I promise you we do use them! As medication experts pharmacists have a major role in managing common disease states including hypertension, diabetes, asthma/COPD, Warfarin therapy, etc. Patients who attend outpatient or ambulatory clinics meet with a pharmacist one on one to manage these disease states. In some instances pharmacists also have prescribing ability and can freely adjust the patients maintenance therapies as needed. Even if a patient is being managed for a disease state other than hypertension, it is best practice to take a blood pressure at each visit and a pharmacist preforms this task.

A huge benefit to have a pharmacist manage a patients disease state, especially a complicated patient with multiple diseases and medications is that a pharmacist has more time to focus on talking to the patient and can most likely see the patient again sooner than a primary care provider. Talking to patients in depth really lets a pharmacist get a better idea of what is going on. Is the patient truly adherent? If not, what is holding the patient back from being adherent? How are their lifestyle changes going? This also allows the pharmacist to truly counsel the patient in depth about their medications and disease state management, which leads to better adherence and better patient outcomes.

Some important lifestyle counseling points for hypertension are:

AHA’s ideal sodium intake no more than 1,500mg for most adults, AHA recommends no more than 2,300mg but says even diets less than 2,400mg will simnifically improve blood pressure and heart health
most of the sodium we each actually is NOT from the salt shaker, be cautious of processed food, sauces, restaurant food, etc.
DASH diet: high in veggies, fruit and whole grains, eat lean meats like chicken and fish, low fat dairy, eat healthy fats like nuts and olive oil.
AVOID: processed food, limit red meat, limit food high in fat, limit sweets
decrease alcohol consumption
increase physical activity, examples: moderate intensity (fast walk) >30 mins 5x a week or vigorous exercise (jogging) >20 mins 3x a week
importance of weight loss for cardiovascular healthSteps to taking an accurate blood pressure:

Make sure the patient is rested, sitting with their legs uncrossed
Rest the patients arm on a surface at heart level or hold the patients arm at their heart level (patient should not have to hold up their arm or strain at all)
Find the brachial artery (inside of the bicep crease down to about an inch above the patients elbow)
Wrap the blood pressure cuff around the patients arm, lining up the artery mark with their brachial artery (the cuff size is correct if the patients arm falls between the two lines indicated on the inside of the cuff, some small women may need the pediatric cuff and men with large muscles or obese patients may need the XL adult cuff)
Make sure the cuff is on correctly, should be able to fit two fingers in-between the cuff and the patients arm
Place the head of the stethoscope on the patients brachial artery (should not shove the stethoscope up the cuff, hold it in place with your fingers on either side)
Inflate the cuff about 30 mmHg more than the patients normal blood pressure (if you get a reading higher than expected deflate the cuff and inflate it above that number)
Slowly deflate the cuff while listening closely
The first sound you hear is the systolic blood pressure (note: it is not when you SEE the hand on the dial first move, it is when you HEAR the first sound)
The very last sound you hear is the diastolic blood pressure (note: the sound may be very faint at the end, after you hear the last sound continue to slowly deflate for another 10 mmHg incase there is another beat, then fully deflate)
Record and counsel patient based on the result

I am so excited to go on my APPE rotations starting in May and get some hands on experience with real patients. Ambulatory care is a specialty I am very interested in l, so making sure I know how to take an accurate blood pressure reading has been very important to me. To learn more about a pharmacist’s role with taking blood pressure from someone currently on rotations check out Gianna’s post: http://phlpharmstudent.blogspot.com/2017/09/youre-pharmacist-why-do-you-have.html She is a P4 pharmacy student in Philadelphia and her blog is amazing!