Pharmacotherapeutic Management of Cardiovascular Disease Complications: A Textbook for Medical Students

The cardiac system represents the heart and blood vessels. The blood is distributed to multiple organs present in the body. Capillaries are minute blood vessels, allow the gas exchange processes. Veins send blood to the heart from the capillaries. The heart is situated in the thorax, posterior to the sternum and superior surface of the diaphragm. The heart has four chambers, and two atria above and two ventricles below. The oxygenated blood moves to left portion of the heart and enters into the left atria and ventricle. The deoxygenated blood pumped into the right side of the heart and moves into the right ventricle and flows towards the lungs. The heart is covered with three protective layers which include an epicardium, myocardium, and endocardium. The cardiac physiological functions are controlled by a group of electrical impulses. The electrical impulse origin from the sinoatrial node and located on the top side of the right atrium. It causes atria muscle contractions and thereby sends blood into the ventricles. A cardiac cell demonstrated the electrical activity and transmits the cardiac impulses to the heart to maintain the normal heart beating and initiation of the cardiac cycle. The cardiac event causes the opening and closing of valves results in contraction and relaxation of cardiac chambers. The cardiac cycle consists of systole and diastole events, during the systole, ventricles contract and send blood to arteries and during diastole, the ventricle relaxes and collects blood from atria. The electrical activity of the heart originates from SA node and causes atria to initiate contraction of cardiac muscles and supply of blood into the ventricles.

Cardiovascular diseases cause more deaths in the world. Atherosclerotic plaques cause thrombus formation in the blood vessels leads to impediment in the vascular lumen can create a complete blockage of the blood vessels which increases the risk of developing coronary artery disease. The biomarker is used to assess the biological process and pharmacological responses of the drugs to a targeted intervention. It is used to identify the disease progression burden among the affected population. The cardiovascular biomarkers include B-type natriuretic peptide, urinary NGAL, troponin, C-reactive protein, N-terminal prohormone BNP, myeloperoxidase, lipoprotein-associated phospholipase A2, cytokine IL-37, troponin, fibrinogen, metalloproteinase-1, and cystatin C is used to predict the risk of progression of cardiovascular diseases.

Cardiovascular diseases are a group of disorders of the cardiovascular system which include coronary heart disease, hypertension, myocardial infarction, angina pectoris, rheumatic heart disease, and stroke etc. Currently, cardiovascular diseases are causing 21.9 percent of total deaths globally and that will rise to 26.3 percent by 2030. The risk factors for cardiovascular disease include hypertension, stress, alcohol, diabetes mellitus, smoking, and obesity which highly impact the development of cardiovascular disease. The cardiovascular disease diagnostic test includes electrocardiogram, echocardiography, MRI scan, CT scan, treadmill test, Doppler studies and coronary angiography tests which are vital for determining the severity of cardiovascular disease among diagnosed patients. Early detection of cardiovascular disease risk factors and regular cardiovascular disease risk screening modalities can lower the alarming incidences of cardiovascular diseases in health care settings.

Valvular heart disease occurs by the defects in tricuspid, aortic, mitral, pulmonary artery leads to develop heart valve abnormalities. Gender, age, hypertension, diabetes mellitus, alcohol, smoking and hypercholesterolemia can contribute to the progression of valvular heart disease. Previous research studies stated that one-third of elderly patients echocardiographic examination showed that the evidence of calcific aortic valve sclerosis. Patients with age more than 60 years suffer from the calcific aortic stenosis. It is more prevalent in western countries as compared with other cardiovascular diseases such as coronary artery disease, angina pectoris, myocardial infarction, and hypertension. Previous research studies demonstrated that 40 million people are affected by the age group of 65 years in the 2010 year and expected to rise 55 million in 2020 and 72 million in 2030. Patients with clinical signs of aortic stenosis during the physical examination should undergo various other examinations like chest x-ray, electrocardiogram, and echocardiogram useful for the detection of valvular heart disease risk at the early stages. Aortic valve replacement is used to lower the progression of aortic stenosis among high-risk patients.

Hyperlipidemia is one of the major risk factors for developing cardiovascular complications. The cardiovascular diseases connected with complex risk factors include diabetes, smoking, alcohol, physical inactivity, dyslipidemia, hypertension, and obesity. Cardiovascular disease is causing more deaths in developed and developing countries. Hyperlipidemia associated with high levels of fatty materials deposition in systemic circulation. Cholesterol is a waxy fat protein produced naturally in the liver, present in bloodstream as proteins called lipoproteins. Cholesterol is a fatty substance found in several fatty foods such as eggs, red meat, and cheese. The large amounts of low-density lipoprotein cholesterol deposits in the arterial walls cause narrowing of blood vessels that can increase the risk of serious cardiovascular complications. Dyslipidemia is categorized into primary and secondary types. It includes primary and secondary dyslipidemia. The primary dyslipidemia is noted to be inherited. Secondary dyslipidemia is an acquired condition and develops from obesity and diabetes. Patients diagnosed with dyslipidemia may have xanthomas which are deposits of cholesterol under the skin and also under the eyes. The commonly prescribed medications for the management of dyslipidemia include fibric acid derivatives, bile acid drugs, statins, nicotinic acid, and reduce the progression of dyslipidemia complications in health practice. Early identification of risk factors, diagnosis and cholesterol screening programmes can prevent the progression of the dyslipidemic burden among high cholesterol risk patients.

Hypertension is a major health problem and its incidence was rapidly growing from urban and rural communities. The narrowed arteries can reduce the blood flow in the arteries due to this condition the development of pressure can increase the blood flowing capacity in the arteries is called arterial blood pressure. Patients who are diagnosed with more than 140/90 mmHg reading is known as hypertension. Uncontrolled blood pressure can damage the various vital organs which include cardiac, retinal, renal, neurological diseases. The reduction of systolic and diastolic blood pressure can lower the occurrence of cardiovascular disease. Various pharmacological classes of drugs are available for the treatment of high blood pressure includes beta blockers, diuretics, angiotensin receptor blockers, calcium channel blockers, central sympatholytics, alpha blockers, angiotensin converting enzyme inhibitors, vasodilator drugs can lower the progression of hypertensive complications in the health care.

Atherosclerosis is a long-lasting inflammatory disease that is caused by the more accumulation of fatty materials in the arteries leads to create plaques in blood vessels. The risk factors for atherosclerosis include diabetes mellitus, alcohol, smoking, hypertension, dyslipidemia, and genetic abnormalities can increase the risk of atherosclerotic cardiovascular complications. The incidence of atherosclerotic cardiovascular disease per 1,000 patients was 98.25 in 2014 and 101.11 in 2015. Atherosclerosis major clinical manifestations include ischemic stroke, ischemic heart disease, and peripheral arterial disease. The consumption of cholesterol free diet, regular health care visit, weight control, medication adherence, physical exercises, stress management and maintaining the controlled levels of the lipid, blood pressure, and glycemic levels could reduce the progression of cardiovascular events in the health care.

Deep vein thrombosis is a serious health problem due to thrombosis in the systemic circulation. Ineffective treatment of deep vein thrombosis increases the risk of pulmonary embolism. Venous thrombosis condition decreases the blood flow to the veins in the legs. Valves help to promote the blood flow to the veins, during the hypoxia condition the low level of the blood flow to the veins can manifest the symptoms of venous thrombosis. The incidence of deep vein thrombosis is estimated to one patient per 1000 cases annually. The clinical manifestations of venous thromboembolism include swelling; redness can increase the progression of venous thromboembolism. The blood test, doppler ultra sound, venogram and magnetic resonance imaging test are helpful for the detection of deep vein thrombosis. The pharmacological and non-pharmacological treatment modalities are encouraged in the inpatient and outpatient wards could useful for reducing the progression of disease complications.

The weakening of the artery causes abnormal bulging and rupture of the artery with bleeding results in the development of an aneurysm. An aneurysm occurs in the various vital organs in the body which include the brain, aorta, legs, and spleen. Patients with age more than 60 years, hypertension, smoking, can drastically increase the risk of the aortic aneurysm. The development of aneurysm rupture is influenced by the aneurysm size, expansion rate, and uncontrolled hypertension increases the risk of more bleeding in the arteries. The arteries of brain cells and heart are the most common sites of developing serious aneurysm complications. The incidence of abdominal aortic aneurysms has been increasing from the past few decades. The aortic aneurysm has an incidence of 5-10 cases per 100,000 was seen in more than the age of 60 years. An aneurysm is detected with a computed tomography scan, magnetic resonance image scan, ultrasonography, angiography examinations helpful for detecting the abnormalities in the arteries. The prevention and management of aneurysm through lifestyle modification practices, eating a healthy diet, stress management, regular medication adherence and maintaining controlled levels of risk factors could minimize the future complications of an aneurysm in primary care settings.

Stroke is a clinical condition that is progressed due to the obstruction of blood flow to the brain. The high incidences of stroke can double the burden of disease complications among the affected patients from developed and developing countries. Stroke is a major public health care issue that is associated with multiple risk factors that include physical inactivity, hypertension, smoking, alcohol, diabetes mellitus, stress, and obesity causes occurrence of stroke. Stroke diagnosed through regular physical examination, blood test, CT scan, MRI scan, CSF fluid examination, and cerebral angiogram studies can help to detect and prevent the progression of stroke complications. The management of stroke through prescribing of blood pressure medications, statins, anti platelets, anti coagulants drugs could reduce the future episodes of the occurrence of the stroke.

Heart failure is a multifaceted disease in which the heart is unable to reach the metabolic demands of the body. The heart failure associated with complex risk factors which include Hypertension, increased salt intake, obesity, diabetes, coronary artery disease alcohol, smoking are the strong risk factors for the development of heart failure. The poor blood circulation lowers the blood pumping to the ventricles and reduces the contraction of the myocardial cells leads to increase the risk of heart failure. The clinical manifestations of heart failure include cough, pedal edema, palpitations, shortness of breath, fatigue, weakness, which can increase the risk of heart failure. The electrocardiogram, chest x-ray, echocardiogram, treadmill test, coronary angiogram test can determine the severity of the cardiovascular disease. The medical management of heart failure includes prescribing diuretics, angiotensin receptor blockers, beta blockers, vasodilators, ACE inhibitors, and digoxin improve the health status of the disease patients and also lowers the future occurrence of heart diseases.

The heart conduction and contraction provide the driving force for the pumping of blood to the heart. The abnormalities in the conduction properties of the heart can lead to arrhythmias. The action potential helps the opening and closing of the ion channels that cause conduction of the cardiac muscles. Atrial fibrillation is most commonly occurs in the cardiac arrhythmia. The arrhythmia prevalence has an incidence of 1%, it is an aging dependent factor and the incidence was raise to ≥2.5- fold by the year 2050. Elderly patients the progression of the atrial flutter is related to cardiac disorders. The clinical symptoms of atrial flutter include anxiety, palpitations, dizziness, headache, irregular heartbeat that can impair the quality of life of the patients. The defects in cardiac rhythm are associated with a significant rise in health care cost and also mortality among the affected population. Ventricular arrhythmias are causing about 75% to 80% of the cardiac deaths annually in the world. The ECG devices, echocardiogram, doppler studies, stress test, holter monitoring test are used to identify the risk of developing cardiac arrhythmias among arrhythmias patients. Currently, one third of the patient’s exhibit an absence of arrhythmia symptoms and patients were not aware of abnormal heart rhythm. Therefore timely detection of clinical symptoms and prescribing better therapeutic approaches may improve the quality of the patients.

Myocardial infarction occurred due to severe myocardial ischemia that leads to myocardial necrosis and cardiac remodeling results in the progression of heart failure. The clinical manifestations of the myocardial infarction include sweating, shortness of breath, abnormal heart beating, vomiting, weakness, nausea, fatigue, stress contribute to the development of myocardial infarction. Cardiovascular diseases are the cause of mortality and morbidity from worldwide countries. Cardiovascular disease incidence is expected to increase by 25 million by the year 2020. The progression of myocardial infarction is associated with various risk factors which include smoking, alcohol, high lipid levels; hypertension can likely increase the risk of myocardial infarction. Every year worldwide more than 3 million people are affected with myocardial infarction. The increasing incidence of myocardial infarction was high in males as compared with females. Previous research studies stated that patients with more than 45 years of age can develop the disease. Atherosclerosis is one of the major risk factors for the development of myocardial infarction. It is a chronic inflammatory condition of the endothelial cells, in which the T lymphocytes, monocytes, macrophages cells can thicken the endothelial cell layers which leads to the progression of atherosclerotic events. Chest x-ray, electrocardiogram, echocardiogram, holter monitoring, coronary angiogram, and stress test is used to detect the severity of disease complications. The pharmacological management of myocardial infarction includes anticoagulants, thrombolytics and percutaneous coronary intervention that can lower the progression of disease complications.

Angina pectoris is a symptomatic clinical manifestation of myocardial ischemia which is caused by emotional stress. The patients having the age of 65 years and females age 70 years for women are at higher risk of developing angina pectoris. Currently, 4.1 million people are affected by coronary artery disease. The annual death rates of stable angina patients were 1.2% to 2.4. The major risk factors for angina pectoris include hyperlipidemia, hypertension, diabetes mellitus, stress, physical inactivity, smoking; and alcohol contributes to the development of angina pectoris. The clinical manifestations of angina pectoris include chest tightness, chest pain, chest discomfort, burning chest, fatigue, shortness of breath, sweating, dizziness, nausea, vomiting, aching, chest fullness, and more weight on chest. Chest x-ray, electrocardiogram, echocardiogram, holter monitoring, coronary angiogram, and stress test is used to detect the severity of disease complications. The proper understanding of pathophysiological approaches is essential for better management of angina pectoris. The continuous prescribing practice of statins, beta blockers, calcium channel blockers, heparin, anti-platelets, nitrates, ACE inhibitors, thrombolytic medications could improve the heart rate and improve the blood flow in the vascular stream and also lower the cardiovascular complications in primary care settings.

Congenital heart disease is congenital anomalies that having heart defects origin form the birth. The structural abnormality of the heart, great vessels is diagnosed at the time of birth. It affects childbirth during pregnancy. Congenital heart defects change the blood flow to the heart. The defect ranges from mild to severe clinical symptoms that can lead to developing life-threatening conditions. The progression of congenital heart disease associated with genetic and non-genetic factors. The risk factors for include diabetes mellitus, viral infections, medications like ACE inhibitors, drinking alcohol and smoking during pregnancy, genetics may increase the more health care burden to diagnosed patients. The improper treatment of congenital heart defects can lead to the development of heart failure, cyanosis, stroke, and arrhythmia. The clinical symptoms of congenital heart defects include shortness of breath, chest pain, cyanosis, rapid heartbeat, cardiac murmur, edema can elevate the risk of heart defects. Physical examination of the patient, echocardiographic investigations are useful for the detection of heart defects. Effective prescribing pattern of ace inhibitors, arrhythmias, beta blockers, antiplatelet, and diuretics is used to enhance health condition of the patients.

The inflammation of the heart muscles is caused by the virus, fungi, bacteria, food, smoke, air, and parasites that increase the inflammatory conditions in the heart muscles known as inflammatory heart disease. Endocarditis is an infection that occurs in the inner lining of the heart valves. Endocarditis commonly occurs by the bacteria, fungi or other microbial species present in the body, reaches the blood stream and leads to damaging the heart. Myocarditis is an inflammation of the myocardium which is present in the middle layer of the heart. It is caused by a viral species infection. The clinical manifestations of the myocarditis include chest pain, fatigue, edema, breathlessness, joint pain, fever, weakness, palpitations and abnormal heart rhythms. Pericarditis is a clinical condition in which the cell membrane around the heart is inflamed. The more amount of fluid deposit around the heart may increase the risk of inflammation and causes pericarditis. The electrocardiogram, chest x-ray, echocardiogram, treadmill test; coronary angiogram test can determine the severity of cardiovascular disease. The management of inflammatory heart disease includes antibiotics, corticosteroids, antiplatelets, diuretics, angiotensin converting enzyme inhibitors, and beta blockers control the progression of inflammatory situations associated with the heart.

Dilated cardiomyopathy is a heart muscle disease that occurs due to dilation and dysfunction of ventricles. The proper understanding of etiology, pathogenesis can help with determining better therapeutic options for the management of disease complications. The various types of cardiomyopathy include restrictive cardiomyopathy, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy. Diabetes mellitus, genetic conditions, high blood pressure, heart attack, palpitations, heart valve defects, and pregnancy, smoking, alcohol, and connective tissue disorders are well known risk factors for the development of cardiomyopathy. The clinical manifestations of cardiomyopathy include palpitations, dizziness, headache, chest pain, shortness of breath and edema. The electrocardiogram, chest x-ray, echocardiogram, treadmill test, coronary angiogram test can determine the cardiovascular risk. The clinical management of cardiomyopathy with the prescribing pattern of beta blockers, angiotensin-converting enzyme inhibitors, diuretics, digoxin, angiotensin II receptor blockers, anti-platelet medications can minimize the development of cardiomyopathy complications.

The cardiovascular disease affects the heart, blood vessels and blood circulation cause death in adult patients. The cardiovascular diseases include ischemic heart disease, congestive heart failure, hypertension, angina pectoris, stroke, peripheral vascular disease can develop due to a low level of blood flow to the heart can increase the risk of cardiovascular complications. Rheumatic fever is an autoimmune inflammatory disease which can develop with infectious species like bacteria, fungi, virus creates inflammatory conditions and results in the origin of inflammatory mechanisms in the body. It occurs, when the immune system responds abnormally to the inflammation with slow deposition of the calcium crystals in the heart valves increase the risk of developing rheumatic heart disease. Currently, the high prevalence of rheumatic heart disease occurred from low and middle-income countries. Ineffective control of rheumatic fever damages several vital organs such as the heart, brain, kidney, and lungs. The blood test, electrocardiogram, chest x-ray, echocardiogram, cardiac MRI scan, treadmill test, coronary angiogram test can determine the cardiovascular risk. The clinical management of rheumatic heart disease with prescribing antibiotics, anti-inflammatory drugs, and corticosteroids are used to reduce the inflammation and also minimizes the progression of cardiovascular damage.

Diabetes mellitus is a complex metabolic disorder affecting more than 330 million people around the globe. Diabetes mellitus is identified as the fifth leading cause of death worldwide and causes various complications. The prevalence of diabetes mellitus is rising substantially from worldwide. Over the past few years, the global burden of diabetes mellitus has enlarged 382 million and this count may increase in the future. Cardiovascular disease is a group of numerous diseases such as heart failure, cardiomyopathy, congenital heart disease, coronary heart disease etc. causes severe health complications to the affected patients. The deposition of lipid particles inside the arteries can cause clot and favor for the progression of cardiovascular diseases which led to damage to the function of vital organs. Several risk factors are shared with the development of cardiovascular diseases include smoking, alcohol, stress, insufficient physical activity, poor diet, high blood pressure, high lipid profile, diabetes mellitus can greatly advance the risk of cardiovascular disease. Chest x ray, electrocardiogram, stress test, echocardiogram, holter monitoring, coronary angiogram, blood sugar test, lipid profile, investigations are used to detect the progression of cardiovascular disease in diabetic patients. Cardiovascular disease in diabetes mellitus can be prevented through lifestyle modification counseling and regular medication adherence and advance diagnostic and therapeutic management could reduce the progression of cardiovascular disease among diabetic patients.

Diabetes mellitus is a complex metabolic disorder that is represented with a defect in insulin secretion and insulin action. Diabetic nephropathy is a well-known complication of diabetes that occurs in 20% to 40% of the diabetic population. Kidney failure is categorized into acute and chronic renal disease. Acute renal disease may origin rapidly which is reversible. Chronic kidney disease develops in a slow manner at least three months of duration which leads to cause kidney failure. The permanent damage to the kidney cells by the multiple risk factors that result in loss of renal function which leads to cause renal failure. Chronic renal failure is a well-established risk factor for developing cardiovascular disease complications. Renal failure patients may develop ten to twenty folds risk of developing cardiovascular disease. Dialysis is performed to normalize the health condition of chronic renal failure patients. The progression of kidney failure with cardiovascular disease has been associated with various risk factors such as obesity, hypertension, diabetes, smoking, and alcohol enhances the risk of cardiovascular disease with renal failure. The chest x-ray, electrocardiogram, echocardiogram, coronary angiogram, urine culture test, MRI scan, CT scan, blood test, renal biopsy, fasting blood sugar, random blood sugar, serum creatinine, creatine clearance, uric acid, total proteins, glomerular filtration rate was used to detect the severity of cardiovascular disease in diabetic nephropathy. Early identification of causative factors detection and effective prescribing practice of blood lowering medications, statins, hyperlipidemic drugs, diuretics, and erythropoietin drugs can improve the health outcomes of cardiovascular disease in diabetic nephropathy patients.

Cardiovascular diseases cause mortality and morbidity worldwide. The progression of cardiovascular disease is associated with several risk factors which include hypertension, diabetes mellitus, obesity, stress, kidney disease, smoking and alcohol increase the risk of developing cardiovascular complications. The newer health care technologies in the cardiovascular disease prevention include sensor devices, webbased strategies, smart phone applications, telemedicine; text message based mobile applications, stem cell therapy, robotic sleeve, artificial intelligence algorithms, big data technology, voice technologies, block chain technology, bioresorbable stents, leadless pacemaker, chatbots technology are used to prevent the progression of cardiovascular disease. The cardiovascular diseases are imposing huge health care expenditure burden on patients and their families. Health care innovations deal with the application of ideas, procedures, and novel concepts designed to promotes benefits to society. Advance health care information technologies are useful for the detection of cardiovascular disease risk at the earlier stages to provide better health care interventions to improve their quality of life. The innovative technologies are boosting the advances in cardiovascular health care. The novel health care technologies should focus on developing new innovations for improving the quality of patient care services in hospitals.

Cardiovascular diseases are the disorders of the cardiovascular system which include coronary heart disease, hypertension, myocardial infarction, angina pectoris, rheumatic heart disease, cerebrovascular disease. The development of cardiovascular diseases is associated with complex risk factors such as smoking, alcohol, obesity, unhealthy diet, physical inactivity, stress, family history of cardiovascular disease; hypertension and diabetes mellitus can increase the risk of cardiovascular disease complications. Recent health care statistics revealed that cardiovascular diseases are causing 17.3 million deaths every year and this count will extends 23.6 million by the end of 2030. Clinical pharmacy practice is one of the greatest professions among other health care disciplines in the hospital practice. The clinical pharmacist has a vital role in enhancing the care of patients through providing primary care services such as diet counseling, disease counseling, lifestyle modification counseling, medication counseling which includes uses, indications, warnings, precautions, side effects, dose, time of intake of medications, risk factors identification, risk screening, drug related problems reporting, awareness on pharmacovigilance, conducting awareness programmes on cardiovascular disease prevention, control of lipid, glycemic levels, blood pressure, stress management, weight control, physical exercise, low salt intake, cessation of smoking, alcohol and early implementation of clinical pharmacist services in the hospitals could lower the progression of cardiovascular disease risk incidences.