Self-Care in People with Pre-existing Cardiovascular and/or Respiratory Conditions

Overall AIM

Identify

• minor ailments

• worsening of existing medical conditions

• ADR’s

Decide to

• test and/or refer

• give self care advice, treat with OTC?

• how urgent is the referral?

Pharmacists role in self - care

•Help patients and the public by assessing their conditions and making decisions about which medicines they should or shouldn’t take.

•Offer advice and practical help on keeping healthy and managing their conditions

•Medicines reviews

Pharmacists are always available and members of the public will often see pharmacists first as they are more accessible

Any existing medical conditions?
Any existing medication?

• Their new symptom may be related to their existing medical condition

• their new symptom may be an ADR of medication - new doses, change in medication

• their medical condition could interact with GSL and P medicines

What are the CV conditions

• HT

• Heart failure

• Arrhythmia

• Peripheral vascular disease

• coronary heart disease or ischaemic heart disease e.g. angina

• previous myocardial infarction

• previous stroke or transient ischaemic attack

• previous deep vein thrombosis or pulmonary thrombosis

• congenital heart or heart valve defects

Be familiar with patients using different simple terminology to describe their medical condition

Hypertension - high Blood pressure

Often discovered during routine health checks as its asymptomatic

Symptoms are usually rare

Headache or blurred vision 

Referrals often made by opticians

Increases risk of other, often more serious cardiovascular conditions such as HF, MI, CKD, increased risk of vascular dementia

Pharmacists can:

• Measure blood pressure

• Advise on lifestyle changes to decrease risk

• Advise on medication side effects

• requires referral to GP

• If patient is already diagnosed with HT, and has headache, need to find out of its other things causing the headache

• patients may have severe HT - consistently have systolic of greater than 160 and diastolic more than 100 then GP referral within 2 days

• patients with chronic HT - systolic greater than 180 and diastolic ore than 110 then needs A and E or G.P straight away

Heart Failure

The heart not pumping blood as effectively. Caused by other CV conditions   

Symptoms are caused by accumulation of fluid in the lungs or legs and ankles: accumulation in the abdomen in more serious cases

• Breathlessness and fatigue causing decreased exercise tolerance

• Cough or shortness of breath at night

• Unable to lie flat

• Swollen ankles legs

• Weight increase - more than 2kg over a short period of time

• is it a respiratory related symptoms? cough associated with sputum

• give practical advice such as prepping themselves up and using two pillows to help with breathlessness

• Attend A&E if there are sudden and worsening changes in the patient’s usual symptoms

Arrhythmias

Irregular heart rate or rhythm e.g. atrial fibrillation/flutter, or ventricular tachycardia

Normal resting heart rate for adults is 60 to 100 bpm

• Sensation of “fluttering” in chest

• Racing heart (tachycardia) - HR over 100, can be post exertion which is normal or when patients are unwell

• Light-headed or fainting episodes … “funny turn” - ask patient to expand if you don’t understand, refer to A and E, if occasionally then refer to GP

Patients who are treated for arrythmias may also be prescribed anticoagulant therapy to prevent stroke

• Be aware of the common side effects for anticoagulants e.g. unusual bleeding

• Attend A & E if:

  • Involved in an accident

  • Experience a blow to the head or fall

  • Are unable to stop the bleeding

Coronary artery disease

Angina

Tight and pressing pain in the chest, neck or jaw. 

• If exercise induced likely stable angina

• If not exercise induced or happens at rest suspect unstable angina 

• If not previously diagnosed, suspect MI

Myocardial infarction (MI)

Pain (tight, pressing) chest

Also, can spread to jaw, neck, arm (tingling)

Sweating, nausea, breathless and can come on suddenly 

300mg aspirin and GTN spray - can administer this and let ambulance know so they don’t administer again.

If GTN spray doesn’t work then likely high levels of occlusion - call a and e

Peripheral vascular disease

Narrowing or occlusion of the peripheral arteries, reducing the blood supply to the lower limbs

• Intermittent claudication - pain in lower limbs which is relieved by rest

• Shiny skin, hair loss on calves, discolouration

• Temperature differences between legs 

• Numbness or tingling (may be intermittent)

• Poor wound healing or ulceration due to decreased blood supply - common in diabetic patients

• Leg or hip cramps

Ischaemia in the limbs can lead to the need for amputation 

The main risk factors are smoking and diabetes 

Stroke or TIA

Face – the face may drop on 1 side, the person may not be able to smile, or their mouth or eye may have drooped.

Arms – the person may not be able to lift both arms and keep them there due to weakness or numbness in 1 arm.

Speech – speech may be slurred or garbled, or the person may not be able to talk at all despite appearing awake; they may have problems understanding what you say.

Time – to dial 999 immediately if you notice any of these signs or symptoms, AS TREATMENT IS TIME DEPENDENT

Venous thromboembolism (VTE)

Deep vein thrombosis (DVT)

• Pain, swelling and tenderness in one leg (usually calf) 

• A heavy ache in the affected area 

• Warm skin around the area of the clot 

• Red skin, particularly at the back of a leg below the knee

• Sometimes there are no symptoms

Pulmonary embolism (PE)

• Breathlessness which may come on gradually or suddenly 

• Chest pain which may become worse when breathing in 

• Sudden collapse  

• Signs of DVT

Call 999 if patients are experiencing symptoms of…

MI, sudden chest pain that

• Spreads to the arms, back, neck or jaw

• Makes their chest feel tight or heavy

• Accompanied with shortness of breath, sweating and nausea and/or vomiting

• Last more than 15 minutes

• Overwhelming feeling of anxiety

Cardia arrest, collapse or unconsciousness

Stroke symptoms - F.A.S.T

Common adverse effects to CVS medication...

Drug Group	Common adverse effects
Beta blockers [e.g. atenolol, bisoprolol]	Fatigue, cold hands, slow heart beat,  insomnia, impotence
ACE inhibitors [e.g. ramipril, lisinopril]	Dry cough, light-headedness, angioedema
Calcium channel blockers [e.g. amlodipine, nercidipine]	Headache, swollen ankles, flushing-
Diuretics  [e.g. indapamide, bendroflumethiazide]	Dehydration (?), thirst,  Gout, impotence, hypoglycaemia
Statins [e.g. simvastatin, atorvastatin]	Muscle pain and weakness,  raised blood sugar (diabetes)
Anticoagulants  [e.g. warfarin apixaban, rivaroxaban]	Easy to bruise, short nose bleeds Blood in urine, unexplained bruises, severe headaches, bleeding that doesn’t stop

• THIS LIST IS NOT EXHAUSTIVE

• MAKE NOTES ON COMMON SIDE EFFECTS ON ALL CLASSES OF DRUGS YOU LEARN

Current medications

• Many people experience adverse drug reactions (ADRs)

• Always consider the possibility of a symptom being related to prescribed or OTC medication … so always ask the question

• The reaction/s may be mild or severe

• reaction may be individual

•  It may occur immediately or after some time of taking

• Find out how long a medicine/s has been taken for

• Any recent changes to medication - e.g. dose, frequency etc

• If you don’t know the common side-effects for a drug/drug group a person is taking – look it up (especially if the symptom coincides with starting the new drug)

• If person stops amiodarone - still stays in system for months - check when they last stopped taking it so can still interact with other medications

What P/GSL medicines should be avoided in cardiovascular disease?

• Decongestants e.g. pseudoephedrine - constricts blood vessels

• Anti-inflammatories e.g. aspirin, ibuprofen

• Products containing excess sodium – antacids, effervescent/soluble tablets, cystitis sachets

• Oral antifungals – fluconazole can interact and cause arrythmias

• 5-HT agonists - Sumatriptan causes vasoconstriction

*Don’t sell OTC, as not licensed for it

Decongestants

Ephedrine and pseudoephedrine has direct or indirect sympathomimetic activity

Pseudoephedrine is less potent but can still produce elevation in systolic blood pressure by causing vasoconstriction, and can also cause tachycardia.

Aspirin and NSAID’S

Anti-inflammatories inhibit COX enzyme so lower synthesis of prostaglandins which act on kidney as a vasodilator, so reduced blood flow to kidneys, indirect effect on CV system - can lead to heart failure and high blood pressure

High sodium

Recommended sodium intake:

Not more than 2.4g/day

check for sodium content in tablets - paracetamol and Solpadine

Oral antifungal

Has many interactions so better to double check

Sumatriptan

Vasoconstriction to relieve symptoms of migraines caused by vasodilation.

What can be used instead

• Aspirin &  NSAIDs
    For pain & fever recommend paracetamol instead

• Decongestants - ephedrine and pseudoephedrine, including nasal sprays – for blocked nose, recommend eucalyptus vapour rub, steam inhalation

• Regular use of high sodium products
    e.g. effervescent/soluble preparations, certain antacids, cystitis relief sachets

• Fluconazole – antifungal cream for thrush. Or refer to GP for further investigation if cream already tried. Check for diabetes

• Sumatriptan – paracetamol, codeine & antiemetic (where necessary) preparations, licensed to treat migraines

Warfarin interactions

• take care when recommending medicines to anyone taking warfarin and other anticoagulants such as rivaroxaban

• Read SmPC or PIL

• Significance consequence of getting this wrong

• common interactions - St John’s Wort, PPI’s, glucosamine, fluconazole, NSAID's, ASPRIN

• paracetamol can cause bleeding if patients INR is not stable

• Also think about medications increasing bleeding

Natural products

St John’s Wort

Ginseng

Gingko biloba

Echinacea

Liquorice - a lot of products contain this for flavour

Consider:

Blood pressure effects

Effect on bleeding (warfarin)

People with RT conditions

• What are the RT conditions?

• asthma

• COPD

• C.F

a RT symptoms may be new or related to an existing condition

Common adverse effects

Drug Group	Common adverse effects
Beta₂ agonists e.g. salbutamol, formoterol, salmeterol	Palpitations, arrhythmias, headache, tremor, hypokalaemia
Antimuscarinics e.g. ipratropium bromide	Dry mouth, arrhythmias, headache
Corticosteroids  e.g. beclometasone, budesonide, fluticasone,	Oral candidiasis, throat irritation, hoarseness, visual disturbance
Leukotriene antagonists (oral) e.g. montelukast,	Gastrointestinal, headache, upper RTI
Cromoglycate  e.g. sodium cromoglycate, nedocromil sodium	Cough, bronchospasm, headache, throat irritation

Asthma - Aspirin and NSAID’s

• Aspirin and NSAID’S may precipitate bronchospasm in 8 to 20 percent of patients with asthma

• can we ever sell aspirin and NSADI’s to people with asthma

  • if taken before without detriment then yes, otherwise no

• However paracetomal as a wiser option even if they have taken befoe. Some people might not have noticed worsening symptoms with use of NSAID’s

People with respiratory conditions

OPIOIDs:
Codeine, pholcodine, dihydrocodeine, dextromethorphan

• Codeine (co-codamol) & dihydrocodeine (codydramol) in compound pain relief preparations OTC

•  Pholcodine & dextromethorphan (and codeine) in cough suppressants
    and compound cough/cold products 

   Opiates cause respiratory depression (and sputum retention) and so should be avoided in people with respiratory conditions such as 

• Asthma

• COPD

• Cystic fibrosis

Summary

•Aspirin and NSAIDs, e.g. ibuprofen
- avoid these drugs in people with asthma
- they can cause or worsen bronchospasm
- look out for them in compound pain, & cold/flu products

•Codeine, pholcodeine, dihydrocodeine, dextromethorphan
- avoid in asthma, COPD, cystic fibrosis
- they are respiratory suppressants
- they can cause sputum retention
- look out for them in compound pain & cold/flu/cough products

•Alcohol containing products for nit treatment