Managing Chronic Coronary Disease

Special guest Dave L. Dixon, PharmD, FACC, FAHA, FCCP, FNLA, BCACP, CDCES, CLS, the Nancy L. and Ronald H. McFarlane Professor of Pharmacy and Chair of the Department of Pharmacotherapy & Outcomes Science at the Virginia Commonwealth University School of Pharmacy, joins us to talk about chronic coronary disease.

Listen in as he discusses the management of chronic coronary disease with a focus on the new American College of Cardiology/American Heart Association guidelines.

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Anthony A. Donato, Jr., MD, MHPE, Associate Program Director, Tower Health System Internal Medicine Residency Program and Professor of Medicine at the Drexel University College of Medicine
• Steven E. Nissen, MD, MACC, the Chief Academic Officer at the Heart and Vascular Institute and the Lewis and Patricia Dickey Chair in Cardiovascular Medicine Professor of Medicine at the Cleveland Clinic Lerner School of Medicine at Case Western Reserve University
• Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science University

For the purposes of disclosure, Dr. Dixon reports a relevant financial relationship [GLP-1 agonists, SGLT2 inhibitors] with Boehringer Ingelheim (grants/research support). Dr. Steven Nissen reports relevant financial relationships [cardiology] with AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Esperion, Medtronic, MyoKardia, New Amsterdam Pharma, Novartis, Pfizer, Silence Therapeutics (grants/research support).

The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter or Prescriber’s Letter account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter and Prescriber’s Letter: 

• Toolbox: Optimizing Care of Patients with Coronary Artery Disease
• Chart:  Dual Antiplatelet Therapy for Coronary Artery Disease
• Chart:  Treatment of Hypertension

Email us: ContactUs@trchealthcare.com.

The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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Transcript

Narrator 0:05

Welcome to Medication Talk, the official podcast of TRC Healthcare, Homopharmacist Letter, Prescribers Letter, our next advanced and the most trusted clinical resources. On today's episode, listen in as our expert panel reviews management of chronic coronary disease with a focus on the new American College of Cardiology, American Heart Association Guidelines. Our guest today is Dr. Dave Dixon from the Virginia Commonwealth University School of Pharmacy. You'll also hear practical advice from panelists on TRC's editorial advisory board, Dr. Anthony Donato from the Tower Health System, Dr. Stephen Nissan from the Cleveland Clinic, and Dr. Craig Williams from the Oregon Health and Science University. This podcast is an extract from TRC's Emerging Recommendations panel webinar. Each month, experts and frontline providers discuss current medication therapy topics and practical recommendations to include in TRC's letter articles. The full webinar originally aired on September 18, 2023.

CE Narrator 1:03

And now, CE information.

Narrator 1:08

This podcast offers continuing education credit for pharmacists, physicians, and nurses. Please log into your pharmacist letter or prescribers letter account and look for the title of this podcast in the list of available CE courses. For the purposes of disclosure, Dr. Dixon reports a relevant financial relationship by receiving grants or research support from Boe Ringer Ingelheim. Dr. Stephen Nixon reports a relevant financial relationship by receiving grants or research support from AFI, Amgen, AstraZeneca, Bristol Meyer Squib, Eli Lilly, Esperion, Medtronic, Myocardia, New Amsterdam Pharma, Novartis, Pfizer, and Silence Therapeutics. The other speakers you'll hear have nothing to disclose. All relevant financial relationships have been mitigated. Now, let's join TRC editors, Dr. Jeff Lingford and Dr. Sarah Clockers, to start our discussion.

Jeff Langford 2:00

We're talking about this topic today because you you're going to see questions begin to surface about management of chronic coronary disease based on the new updated American College of Cardiology and American Heart of Association guidelines. And Dave, I want to pull you right into this and ask you to help us get started by answering really a foundational question of what is chronic coronary disease? I think it may be newer terminology for some of us, referring to familiar patients, but using different words.

Dave L. Dixon 2:28

Yes, absolutely. So, you know, I think most folks would think of stable ischemic heart disease, right? As the term that you know we're uh used to using historically. But chronic coronary disease really is intended to simplify the approach and also be consistent with the lingo used across the pond there in Europe as well. So what exactly uh is chronic coronary disease? And it's a bit of a loaded question, uh, but for the sake of the guideline, we focused on patients post-discharge for ACS or with a revascularization, those with left ventricular dysfunction and known coronary artery disease or ischemic cardiomyopathy, patients with stable angina symptoms that are medically managed, those patients with angina that have evidence of vasospasm or microbascular angina, and then lastly those patients with a positive screening study, such as a stress test or a CTA. And certainly there might be other groups, but this is what we agreed upon in terms of that definition to develop recommendations for.

Jeff Langford 3:35

That's really helpful, and I think it helps us visualize that spectrum of patients that we can readily identify with those we see in practice. For simplicity, we're gonna really try to drill this down to five key areas where we can optimize regimens for patients with chronic coronary disease. And we're gonna kind of use the ABCD's acronym to guide us through that conversation. And we're gonna start with A for antiplatelet, and just this topic in and of itself could probably give us plenty of material for a whole hour of discussion. But I want to try to drill down in some specific areas for these antiplatelet regimens because I think this can be intimidating for many clinicians in practice when they uh consider how to optimize and manage these regimens. So we're gonna touch on and get your insight on single antiplatelet therapy, dual antiplatelet therapy regimens, either aspirin plus a P2Y12 inhibitor, clopidogril, pryuril, or ticagrilor. And then we're gonna even tackle the complexity of triple therapy, at least briefly talking about that. Let's jump into single antiplatelet therapy first. And can you help us kind of lay the foundation of which medication is preferred if we're choosing single antiplatelet therapy for a patient?

Dave L. Dixon 4:53

Sure. So single antiplatelet therapy is really primarily referring to aspirin or klepidogril, and these can be used as single antiplatelet therapy. Clepidogril, you know, generally going to be reserved for those who are allergic or intolerant of aspirin. And if patients post-PCI with a drug-eluding stent that are not at high bleeding risk, then we're generally going to follow the use of dual antiplatelet therapy for six months and then followed by single antiplatelet therapy. And as we get into the discussion, I'm sure that you know we'll get into some of the nuance, but that's fundamentally what we're talking about.

Jeff Langford 5:30

Okay, very good. So if we're using one drug, if if a single antiplatelet is appropriate for the patient, we could think of aspirin or clopidogril. And I feel like the discussion around clopitogril as a choice has gotten more buzz lately, driven in part by the host exam study that came out a couple of years ago. And I wondered if you could briefly summarize that trial for us in terms of some of the key findings and outcomes of that study that might be leading to some discussion or consideration of clopitogril.

Dave L. Dixon 5:59

Absolutely. It's a very interesting trial. And so the host exam trial, the harmonizing optimal strategy for treatment of coronary artery disease, extended antiplatelet monotherapy trial, was a trial that enrolled a little over 5,500 participants from East Asia. And that's an important uh caveat here from a generalizability aspect. And if the participants tolerated DAPT for 6 to 18 months without any ischemic or major bleeding complication, they were randomized to receive clopidogrill 75 milligrams daily, or aspirin 100 milligrams daily for 24 months. And top line, the trial showed that the benefit of clopidogrill over aspirin was observed in both the thrombotic and bleeding complication endpoints, suggesting you know, clopidogril uh may be actually uh an option in these patients.

Craig Williams 7:01

It's a great discussion, I think, Dave, for being here. You know, this trial was interesting in that uh I'm not aware of another trial where an alternative antiplatelet won on both thrombotic reduction and bleeding benefits. So I think a lot of us would love to see this replicated, and Dave alluded to the somewhat unique patient population. But do you know of another study that did this, Dave? Or do you I I have not considered that data sufficient to kind of move away from aspirin in our practice?

Dave L. Dixon 7:27

Yeah, not to my knowledge, and and certainly there is absolutely a need for additional study. Yeah.

Jeff Langford 7:34

So, Steve, on that point, I'm gonna pick your brain for a minute and just ask you. Dave alluded to some of the limitations of the data, and certainly Craig's pointing out the fact that it's a single study. Do you have any other context to add around those limitations and how you might interpret this data in in your practice?

Steven E. Nissen 7:50

Yeah, I I have some concerns about the data. Um, first of all, you know, it's not a population like the population that we see in the United States. And as I think uh most people are aware, uh poor metabolizers are more common amongst the Asiatic population. And so we really don't know what fraction of these people were poor metabolizer. Now keep in mind that that can have effect not just on efficacy, but also on safety. Because if you're a poor metabolizer and you get less active clopidogrel, then you may have less bleeding. You know, I think there are so many different kinds of patients that are treated uh with aspirin or clopidogrel that a single study can never answer all of the questions. I do think we need a lot more data. Having said that, it's interesting, it has certainly changed the practice of a lot of people at our institution, but I do do not think it's definitive, and I would be a bit careful about overinterpreting the findings.

Jeff Langford 9:04

Dave, I'd certainly like your opinion about this. We say continue to rely on aspirin for most patients, and justify that with the fact that many patients tolerate it well, plus it's over-the-counter and cost just pennies a day. And then we do give the flip side that clopidogril is an option that may be considered, especially for patients with high bleeding or cardiovascular risk. Factors that could weigh into that discussion would also be the fact that it's generically available with a relatively low cost of about $10 per month. Do you agree with those kind of bottom line recommendations based on our overall data?

Dave L. Dixon 9:38

That's very reasonable. I definitely agree with Craig's comments, you know, regarding that aspirin is tried and true. And, you know, also uh in that trial, there was uh an increased risk for, you know, a slightly increased or higher risk of all-cause mortality in the plopidogrope group. And, you know, I think uh, you know, for all the reasons we've discussed, uh, you know, aspirin is the go-to for most patients.

Jeff Langford 10:05

Very good, very good. Well, let's continue in this antiplatelet space, but broaden out the discussion to the dual antiplatelet regimens. And you mentioned those a bit earlier, Dave, kind of alluded to that. So, can you walk us through when we are going to use or recap for us again when we would use dual antiplatelet therapy?

Dave L. Dixon 10:22

Sure. So dual antiplatelet therapy uh is still critical in patients uh with ACS, with or without PCI in that first year, and generally provides benefit, you know, even beyond the first year in select high-risk patients. We are generally starting to shift a bit towards shorter duration for DAPT in patients who maybe have PCI and have a higher risk of bleeding, maybe they have a slightly lower ischemic risk, or if there is also an indication for oral anticoagulation. And there's a great figure in the chronic coronary disease guideline that that maps out exactly sort of when to consider different durations of therapy. And I think that this continues to be an evolving area. You know, we've already commented on all of the research in this space, yet we still have a lot of unanswered questions.

Jeff Langford 11:16

I would like to dig in a little bit to those shorter durations that you mentioned. I think over the past five years or so, we've seen kind of this steady stream of data examining a lot of different options for shorter durations. And I wondered if you could comment a bit on what that looks like, perhaps in your practice. What kind of shorter duration might you use? And which patients, again, would you focus that selection on?

Dave L. Dixon 11:42

Sure. So certainly the patient that has a PCI that has high bleeding risk and has a drug eluding stent. So that's where you know we might consider somewhere in the first one to three months of keeping them on DAPT, and then possibly switching over, you know, to maybe a PTY12 agent. Uh, and then once we get out past a year, that's where maybe we end up on single antiplatelet therapy, which for most patients, for many patients, would be aspirin.

Steven E. Nissen 12:09

We have to be a little bit careful about a one-size-fits-all approach. And one of the what I hear from our interventional colleagues is, you know, if they have a very difficult case where they, you know, there's a lot of calcium, they had good difficulty getting good stent opposition, you know, they're going to treat for longer. And, you know, there are high-risk subsets of patients where the prudent practitioner will want to go a little bit longer. So we can't have sharp dividing lines about when we stop. The patient is also a variable. And the second point here is that stents continue to evolve. And if you look at trials, you have to know when was the trial done, what was the stent at the time being used, because there has been an improvement. The thickness of the stent and the drugs being eluted. So this is not a simple one size fits all approach. So we ought to make sure people understand that some degree of flexibility is probably warranted.

Anthony A. Donato 13:21

It's very easy for people to say it's not my drug, but that that communication and especially even just putting on a prescription for how long you want it so things don't drop off because there's a lot of errors of automation that happen with this.

Jeff Langford 13:35

Great point, Andy. I think that can often be a chart hunt as you're trying to track down that that intended duration of therapy. So documenting that clearly clearly and even more than once is super helpful. Let's turn out of this antiplateless space and move along to blood pressure management. And Dave, I want to start with just a question about blood pressure targets. And what blood pressure goal in your clinic are you aiming for for most patients with chronic coronary disease? And what outcome or reasoning would you use to support that with your patients?

Dave L. Dixon 14:06

So you know, blood pressure is really critical for reducing risk of not just cardiovascular complications, uh, all-cause mortality, the risk of lymph ventricular dysfunction, development of heart failure. There's even some data now showing uh you know potential benefit from a risk of uh neurocognitive disorders as well. So we definitely treat blood pressure, not aggressively, but intentionally, I'll say, in our clinic. And so our patients, we were generally aiming for less than 130 over 80. And the caveat there is that we're not just relying on the blood pressure that we're getting in the clinic. So whether it's through patient self-home blood pressure monitoring or even uh utilizing 24-hour inventory blood pressure monitoring, we're we're trying to get outside data to ensure that you know we're using more than one measurement and that we're also assessing the patient's blood pressure at home. And that really helps a lot in terms of identifying those who might have either white coat or mass hypertension, but also helping to minimize the risk of overshooting and you know inducing adverse effects uh and hypertension.

Jeff Langford 15:21

That's great. I love the intentionality wording that you folded in there. I think that's such a great word as we talk about that target and selecting it.

Steven E. Nissen 15:32

All other things being equal in the coronary disease patient, the 130 over 80 is a good idea, assuming you don't have these other issues such as frailty and fall risk and so on.

Jeff Langford 15:46

Talk to us about the regimen overall. What drugs should we include, or at least classes of drugs should we include in these regimens as a first effort to manage blood pressure with chronic coronary disease?

Steven E. Nissen 15:59

Well, from my perspective, it depends on what the what the indication exactly. Yeah, in patients with angina, there's no question that dihydropyridines such as m lodipine are quite effective, but so of course are beta blockers. Beta blockers are not great drugs for hypertension, but if you have angina, they probably are reasonable. Certainly, as you point out, recent MI beta blockers or heart failure beta blockers come first. In spite of all hat, there is a reluctance in a lot of circles to use effective doses of thiazydes right up front, mainly because when used alone in full therapeutic doses, the hypochalemia risk can be a problem. So I think your your idea of starting with an ACE or an ARB is reasonable, but it needs to be an effective ACE or ARB. And I see an awful lot of people on ineffective regimens.

Jeff Langford 17:00

Okay, well, that's a great point, and we may unpack ACEs and ARBs in a little more detail in a coming month. So I'm glad very glad we got that discussion started. So we'll keep that on our radar. Let's move along to cholesterol management or the C in our ABCDs. And and Dave, help us think through this statement. Our article advises generally using a high-intensity statin, such as a torvostatin, 80 milligrams, for these patients with CCD, and wondering do you agree with this? And if you agree with the high intensity statin statement, why would you advocate for that?

Dave L. Dixon 17:34

Sure. So so yeah, I think you know high-intensity satin is is generally what we're gonna try to start with in this population. You know, I think we have you know several trials uh dating back over the years comparing you know kind of the higher intensity satin with the more moderate intensity satin. And you know, I I think that there is a reality uh that not all patients will tolerate or or achieve their LDL goals on a high intensity satin. And so you know there is some emerging evidence floating the idea of you know, could we get away with you know a more maybe a moderate intensity combined with the xenomide, you know, right from the start to try to reduce the the dose-related adverse effects associated with statin therapy and maybe have a better chance of getting patients uh to a lower LDL as quickly as possible. Because certainly we're we're talking about a torvostatin and resuva statin from a high intensity standpoint. I generally stick with a torva 40 and resuva 20 for most patients. Okay. Uh again, just trying to get the most LDL reduction I can while at least uh attempting to mitigate the risk of side effects or even perceived risk of side effects. And then it's you know, it's off to the races to the bottom, uh, in my opinion, from an LDL standpoint.

Jeff Langford 18:56

Okay, well, that's a great segue, Steve. I wanted to pull you in for the the comment that Dave set us up very nicely for there. And that's where are we going? Where are we going with this treatment?

Steven E. Nissen 19:05

What's our you know, I I I would maybe tilt a little bit more toward using the full therapeutic doses. Now you have to understand I did several of these trials and published the you know the results, which showed that the top dose of a torvostatin or the top dose of resubastatin did in fact provide some incremental benefits. The data is quite compelling that you know lower levels of LDL are better. And so, you know, using whatever means you can you have to get there, and it may be to add azetomide to a medium intensity statin for tolerability purposes, but it may also be the top dose of a statin, you know, with azetomide. But I think that the European guidelines, which suggest getting LDL below 55 milligrams per deciliter in the very high risk patient, that the Europeans are right and the American guidelines are wrong. And so I tend to follow the European guidelines.

Anthony A. Donato 20:14

Steve, this is Andy. Will you start someone on a top dose statin as their first dose?

Steven E. Nissen 20:20

Post MI, always, you know.

Anthony A. Donato 20:23

Um how about just chronic coronary disease? Uh, you're meeting them, they're off something.

Steven E. Nissen 20:28

Okay, so so chronic CAD, so I'm gonna look at their LDL. These are predictable drugs. We know about how much LDL reduction we get from 40 and 80 of a torva and 20 and 40 of a SUVA. You know, if you're starting out at 160 or 170 milligrams per deciliter, you're not gonna get there with mid with middle doses of even a high-intensity statin. And so I will in those patients go to the top dose. If you're at an LDL of 110 or 120 and you need to be on the statin, then it's perfectly reasonable to give a more middle dose with the idea of getting down to at least 70. And it's certainly if you're any higher risk down to 55. So the starting LDL makes a huge difference here, and people need to understand. You know, I teach our residents, I give them a chart that shows the mean LDL reduction for each of the statins at each of the doses, and that is a useful tool to have available.

Jeff Langford 21:35

We're gonna move along just a bit. Let's stay in cholesterol for a minute, but let's move to the patient that may need a non statin. And Dave, I want to think through that for a minute. And if you could kind of paint out for us the picture of when we might consider a non statin. We alluded to percent LDL reduction, we also alluded to LDL levels. But when are you typically gonna bring that out if that high intensity statin was not enough?

Dave L. Dixon 22:00

So as we were discussing earlier, you know, and again, uh I'm I'm in the camp of I I like having the LDL cutoffs, um, but the guidelines do talk about achieving at least a 50% reduction in LDL cholesterol. As we all know the practice, uh, you know, you don't always know exactly what the baseline is. And so that's where having those LDL cutoffs can be helpful. And you know, if if they're on maximally tolerated statin, and if the LDL is you know 70 or greater, and again, possibly down to 55, I think we could, you know, have a whole hour just on debating that one aspect. Um but you know, those are you know, those are cut points, and maybe in the very high risk ASCBD patient that, you know, again had a recent event, they have diabetes, they have hypertension, you know, there's a lot of other factors there. We might be a bit more aggressive. So, you know, I think we'll continue to see a shift toward lower thresholds to consider non-statin therapy. But you know, 70 or possibly 55 is sort of where those lines are now. And again, getting a patient on some dose of a statin they can tolerate is is a great starting place. But uh we'll still often have to utilize non-statins in cases of intolerance, patients who just simply are under-responders to statin therapy. So, you know, the mean reduction that Steve mentioned earlier is great, and most patients will hit that mean, but there are patients who are under responders to statin therapy, and we won't get that desired reduction. And so, again, that's where we're going to utilize uh select non-statins that have been shown to not just reduce LDL cholesterol, but have also been shown to reduce the risk of events.

Craig Williams 23:45

I kind of like the AC ACCHA add-on guideline of a few years ago that said, you know, for for most of us that aren't working in subspecialty clinics, optimize your statin and then think about azetomide because it's it is so well tolerated, and the extra 15 to 20% lowering in LDL matters if you're not near the LDL number you want. And as Dave alluded to, we could talk 55 and 70 all day, but an easy number, so I think if your secondary prevention, you you actually had an event or you have angina and you're optimized on a statin and the LDL is still above 100, that's an easy case to make for adding something on. And and the first to add something on is a ZMI. And then I think to Steve's point, now if you look at your LDL now, and yeah, you're still 130. Are bad if you're on optimized oral therapy. And we've had the PCS canine agents around long enough. I think they're the first to go to injectable with improving insurance coverage as our costs has come down. But I think you need to optimize those two oral classes first. And in my book, we really need to have a residual LDL above 100 to think about going that direction for a patient. I'm not gonna think about that for someone because their LDL is still 60, and I want them at 55.

Jeff Langford 25:03

Yeah.

Steven E. Nissen 25:04

Agreed.

Jeff Langford 25:06

Okay, well, thank you, Craig. And we're gonna move along now to diabetes. I do want us to have a few minutes to talk about management of diabetes in this patient population. Dave, you set this up at the beginning, telling us you know, we roughly had this decade of data to unpack. And just in this diabetes space, there's been so much in terms of cardiovascular outcomes trials that we've seen uh emerge in this last decade. So I would like to ask you to lay out an overview for us on based on this evolving data, what key medications do you want to consider incorporating for your patients with chronic coronary disease and diabetes?

Dave L. Dixon 25:47

So I think it's safe to say that you know the estro T2 inhibitors and GLP1 receptor agonists are really revolutionizing how we care for patients, especially those with diabetes and chronic coronary disease. I think any patient with diabetes and chronic coronary disease should be receiving at least one of these therapies, possibly both. You know, I think that you know that's not unreasonable. We know SLT2 inhibitors uh certainly have significant effect in improving heart failure-related outcomes. We also have strong data in terms of kidney outcomes and the GLP1 receptor agonists in terms of reducing the risk of major adverse cardiovascular events. Unfortunately, uh, you know, there's been a number of studies showing that the utilization of these two classes is quite poor among clinicians, and it doesn't matter if it's the primary care provider, the endocrinologist, or the cardiologist. Most of that data suggests that we we could all do better in terms of utilizing these medications, uh, even in patients with diabetes, where you would think that there would be a fairly clear indication to use again one or possibly both.

Steven E. Nissen 27:01

So, Dave, you're gonna have to convince the pharmacy benefit managers to let us use more of these drugs.

Dave L. Dixon 27:08

Yes, there is always that battle.

Steven E. Nissen 27:10

That's the obstruction. I mean, that's you know, I can tell you my colleagues are all just clamoring to get their patients on these agents and they can't get them through the PBMs, which are are blocking access. You know, there are some nuances here, and they're they're they're related not so much to heart disease indication, but if the patient is obese, you know, I would tend to tilt toward the GLP1 agonists. And if they obviously have kidney disease, you want to, you know, SGLT2 and everything's first. So some of it is about the comorbidities and how to manage them.

Jeff Langford 27:48

Yeah, just that gives us some good points for how to tailor. We're considering cost, we're considering patient preferences, as Dave mentioned, and certainly identifying comorbidities that may favor one of those agents if possible. Well, let's don't miss out on talking about symptom relief. That's the S in our ABCDs, and I don't want to miss that because I think that, although it comes last in our list, it really is clearly very important for our patients with chronic coronary disease. And Dave, our article uses the wording that we need to individualize med choice for symptom relief. And we say, for example, start with a beta blocker if there's a compelling indication, such as a recent heart attack or hefref, or use a calcium channel blocker, especially if a beta blocker isn't tolerated or enough. And I'd just like your thoughts on those initial choices and how that might match your your clinical practice.

Dave L. Dixon 28:38

Yeah, it matches it pretty well. I mean, generally with the compelling indication, especially heart failure, reduced ejection, fraction, you know, we're gonna go beta blocker absolutely. And you know, in patients, sometimes we we can't get the beta blocker dose to where we need it to help improve symptoms, either due to maybe a heart rate barrier or tolerability. And you know, and lodipine is a is a great you know option to add, especially if you know the blood pressure can tolerate that. And kind of long-acting nitrates kind of come in as usually a third option in a lot of our patients. Uh you know, it's perfectly fine to use you know multiple therapies if needed. And and then, you know, kind of that you know next option, you know, renolazine. Uh no, it can it's it's a medication that seems to either it it works, you know, and it's a lifesaver for some patients in terms of providing that symptom relief, or it just doesn't do absolutely anything. Uh so you can you can try it, you know, and and see if that improves symptoms. And if it doesn't, then it's also an easy medication to stop. But you do have to be alert for drug-drug interactions uh with the rhinolazine.

Jeff Langford 29:47

Well, Craig, I wanted to turn to you in this space to just unpack nitroglycerin for us a little bit. They mentioned that certainly as an option that we can consider for symptom management. But I think on the front lines, it's can be very confusing, both for clinicians selecting the agent to prescribe, or and on the pharmacy side is people try to sort out the choices. So as you drill that down and make it simple in your practice, what's kind of your go-to and what are some caveats that you might keep in mind in prescribing nitroglycerin?

Craig Williams 30:16

Yeah, so you know, for symptom relief, I think you have it positioned well, and the guidelines have it positioned well, that generally behind beta blockers and CCBs. And for the nitrates, I I like the mononitrate more because the problem with these is the nitrate-free period is difficult for people to work in there. And and the fact you need a nitrate-free period means there's some period of every day where you're not giving anginal symptom release. So you kind of have to pick do I cover people who wake up at night with nocturnal anginal pain or do I cover during the day? And that's a hard choice. So I agree their third line. I agree, I like mononitrate because it's a once-a-day drug. You kind of pick, am I gonna take it in the morning and cover my daytime symptoms, or take it at night to avoid waking and cover my nighttime symptoms? And the problem with dinitrates, if you start taking any of these more than once a day, the mononitrate's a metabolite of dinitrate, so you get some long-acting drug in there anyway. And I think tachyphylaxis is a bigger problem with the dinitrate. So I like the mononitrate approach, but it's just a difficult drug class to use well, I think, in practice.

Steven E. Nissen 31:19

Yeah, I would add to Craig that exactly that last comment, which is that the efficacy of nitrates is very limited. I mean, you know, if you look at the treadmill studies that have been done, you know, people are going to go a few seconds longer on a treadmill before they get angina. So they really are third-line drugs, and I don't find them terribly efficacious. I can't tell you I have very many patients on long-acting nitrates anymore.

Sara Klockars 31:47

Today's discussion, we really focused on med management. But as you alluded to earlier, Craig, we don't want to forget about lifestyle management and encouraging changes for all of our patients with um CCD. So just a reminder and a plug there. And then also I wanted to bring up just the bottom line that we heard over and over again today is you know, individualizing therapy and continuing to use a patient-centered team-based approach and share decision making with them. So just kind of the take-home um message from today is that shared decision making with the patient who might need a handful of medications.

Narrator 32:34

We hope you enjoyed and gained practical insights from listening into this discussion. Now that you've listened, pharmacists, physicians, and nurses can receive CE credit. Just log into your pharmacist letter or prescribers letter account and look for the title of this podcast in the list of available CE courses. You'll also be able to access and print out additional materials on this topic, like charts and other quick reference tools from the pharmacist letter and prescribers letter websites. If you're not yet a pharmacist letter or prescribers letter subscriber, find out more about our product offerings at trchealthcare.com. Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. It helps spread the word about our show and is a great way for you to let us know how we're doing. You can also reach out to provide feedback or make suggestions by emailing us at contact us at trchealthcare dot com. Thanks for listening to Medication Talk.