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Quick Reference
to
Cardiovascular
Pharmacotherapy
Edited by
Judy W. M. Cheng, Pharm.D., BCPS

CRC PR E S S
Boca Raton London New York Washington, D.C.
Quick Reference
to
Cardiovascular
Pharmacotherapy
Edited by
Judy W. M. Cheng, Pharm.D., BCPS

CRC PR E S S
Boca Raton London New York Washington, D.C.
TX447_book Page 2 Friday, August 9, 2002 11:17 AM

Library of Congress Cataloging-in-Publication Data

Quick reference to cardiovascular pharmacotherapy / edited by Judy W.M. Cheng.

p. ; cm.
Includes bibliographical references and index.
ISBN 1-58716-044-7 (alk. paper)
1. Cardiovascular agents--Handbooks, manuals, etc. I. Cheng, Judy W. M.
[DNLM: 1. Cardiovascular Diseases--drug therapy--Handbooks. 2. Cardiovascular
Agents--administration & dosage--Handbooks. WG 39 Q67 2002]
RM345 .Q53 2002
615′.71--dc21 2002067403

This book contains information obtained from authentic and highly regarded sources. Reprinted material
is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable
efforts have been made to publish reliable data and information, but the author and the publisher cannot
assume responsibility for the validity of all materials or for the consequences of their use.
Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, microfilming, and recording, or by any information storage or
retrieval system, without prior permission in writing from the publisher.
All rights reserved. Authorization to photocopy items for internal or personal use, or the personal or
internal use of specific clients, may be granted by CRC Press LLC, provided that $.50 per page
photocopied is paid directly to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923
USA. The fee code for users of the Transactional Reporting Service is ISBN 1-58716-044-
7/03/$0.00+$1.50. The fee is subject to change without notice. For organizations that have been granted
a photocopy license by the CCC, a separate system of payment has been arranged.
The consent of CRC Press LLC does not extend to copying for general distribution, for promotion,
for creating new works, or for resale. Specific permission must be obtained in writing from CRC Press
LLC for such copying.
Direct all inquiries to CRC Press LLC, 2000 N.W. Corporate Blvd., Boca Raton, Florida 33431.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation, without intent to infringe.

Visit the CRC Press Web site at www.crcpress.com

© 2003 by CRC Press LLC

No claim to original U.S. Government works

International Standard Book Number 1-58716-044-7
Library of Congress Card Number 2002067403
Printed in the United States of America 1 2 3 4 5 6 7 8 9 0
Printed on acid-fee paper
TX447_book Page 3 Friday, August 9, 2002 11:17 AM

Dedications
This handbook is dedicated to all the greatest mentors
who have believed in me and inspired me in my
professional career, and most importantly, to my family,
who has provided me the best of what life can offer,
and endless support to pursue my desire.

Judy Cheng
Special thanks to my husband, David Lai, for his
unwavering support, and to my friends, mentors, and students,
without whose inspiration I would not have
been able to accomplish this work.

Angela Cheng-Lai
This work is dedicated to the many pharmacists,
physicians, nurses, and patients who have taught and inspired me
during my professional life. Above all, this is for
Joseph and Ian, who teach me daily to appreciate
what is truly important.

Sherry K. Milfred-LaForest
TX447_book Page 4 Friday, August 9, 2002 11:17 AM

Dedicated to my aunt, Ita Faingerts, whose life,

although abruptly halted by cancer, is a pulsating
reflection of what an extraordinary woman she will
always be remembered as. Her spirit, dreams, purpose
continue to shape the lives of her loved ones and
those touched by her kindness.

Vitalina Rozenfeld
To my mother, Geraldine, for being a continual source
of support throughout this endeavor.

Cynthia Sanoski
TX447_book Page 5 Friday, August 9, 2002 11:17 AM

Preface
This quick pocket reference serves as a guide for pharmacists and other health-
care professionals who provide care to patients with cardiovascular diseases, and
will also be useful for pharmacy trainees (fellows, residents, and students) as a
collection of important evidence-based guidelines and standard of care in phar-
macological management of cardiovascular diseases.
Cardiovascular diseases have always been the number one killer of Amer-
icans. Treatment of cardiovascular disorders is one of the most highly evidence-
based area of medicine and pharmacy practice. This book is written based on
the most updated treatment guidelines and standard of practice of different
cardiovascular disorders, as well as experience of our contributors, who are
clinical pharmacy specialists in cardiology or practice in environments dealing
mostly with patients with cardiac disorders.
This book is not intended to be a complete text. It is a collection of important
treatment algorithms and other clinical pearls that are helpful to practitioners in
their day-to-day practice. The quick reference begins with management of impor-
tant cardiovascular risk factors: hypertension and hyperlipidemia. Following are
important pharmacotherapeutics-oriented cardiovascular disorders: stable
angina, acute coronary syndrome, acute and chronic heart failure, cardiogenic
shock and heart transplantation, endocarditis, and arrhythmias. In addition, we
have also added two chapters tackling other important pharmacotherapeutics
problems related to managing patients with cardiovascular diseases: drug-
induced cardiovascular diseases and alternative pharmacotherapy used in man-
aging cardiovascular diseases.
Perhaps the most efficient way to utilize this pocket guide is by either looking
through the table of contents or by going through the index for the topic of interest.
The contributors, based on their clinical experience, have incorporated information
on most of the commonly encountered clinical problems in our practice. It is,
however, important to realize that cardiovascular disease management is an area
of constant change. Continuous research brings us new results and strategies for
disease management. It is always important to keep up-to-date with the latest
clinical trial results and incorporate those results into our practice appropriately.
Judy Cheng
TX447_book Page 6 Friday, August 9, 2002 11:17 AM
TX447_book Page 7 Friday, August 9, 2002 11:17 AM

Acknowledgment
We would like to thank the following people for providing their valuable opinions
to this reference: Dr. Horatio Fung, Pharm.D., BCPS, Veterans Affairs Medical
Center, Bronx, NY; Ms. Kimberly Huck, RN, ND, University Hospitals of Cleve-
land, Cleveland, OH; and Dr. Robert W. Stewart, M.D., University Hospitals of
Cleveland, Cleveland, OH.
TX447_book Page 8 Friday, August 9, 2002 11:17 AM
TX447_book Page 9 Friday, August 9, 2002 11:17 AM

The Editor
Judy W.M. Cheng, Pharm.D, BCPS, is associate professor of Arnold and Marie
Schwartz College of Pharmacy, Long Island University, clinical pharmacy special-
ist in cardiology at Mount Sinai Medical Center in New York. She is also an
adjunct clinical instructor for the School of Nursing at Columbia University. Dr.
Cheng received her bachelor of science degree from the University of Toronto.
She then completed a clinical pharmacy residency at St. Michael’s Hospital in
Toronto. She received her doctor of pharmacy degree from Philadelphia College
of Pharmacy and further completed a fellowship in cardiovascular pharmacother-
apy at the same institution. Dr. Cheng is also a board-certified pharmacotherapy
specialist with added qualification in cardiovascular pharmacotherapy.
Dr. Cheng is a member of the editorial advisory board of the Annals of
Pharmacotherapy. She is also a member of the cardiology item writing panel
for the Board Certification of Pharmaceutical Specialties Examination. Dr.
Cheng is an active member of the American College of Clinical Pharmacy, the
American Society of Health System Pharmacists, and the American Association
of College of Pharmacy. She has also served as chair of the Cardiology Practice
Relation Network of the American College of Clinical Pharmacy. Dr. Cheng’s
research areas of interest include cardiovascular pharmacotherapy, treatment
guidelines adherence, and patient outcomes. She has published extensively in
these areas.
TX447_book Page 10 Friday, August 9, 2002 11:17 AM
TX447_book Page 11 Friday, August 9, 2002 11:17 AM

Contributors
Judy W.M. Cheng, Pharm.D., BCPS
Associate Professor of Pharmacy Practice and Health Sciences
Long Island University
Brooklyn, New York
and
Clinical Pharmacy Specialist in Cardiology
Mount Sinai Medical Center
New York, New York

Angela Cheng-Lai, Pharm.D.

Clinical Pharmacy Manager/Adult Medicine
Montefiore Medical Center
Bronx, New York
and
Assistant Professor of Medicine
Albert Einstein College of Medicine
Bronx, New York

Sherry K. Milfred-LaForest, Pharm.D., BCPS

Clinical Pharmacist, Heart Failure and Heart Transplantion
Heart Failure Center
University Hospitals of Cleveland
Cleveland, Ohio

James Nawarskas, Pharm.D., BCPS

Assistant Professor of Clinical Pharmacy
College of Pharmacy
University of New Mexico
Albuquerque, New Mexico
TX447_book Page 12 Friday, August 9, 2002 11:17 AM

Vitalina Rozenfeld, Pharm.D., BCPS

Assistant Professor of Pharmacy Practice
Long Island University
Brooklyn, New York
and
Clinical Pharmacy Specialist
Lenox Hill Hospital
New York, New York

Cynthia A. Sanoski, Pharm.D.

Assistant Professor of Clinical Pharmacy
Philadelphia College of Pharmacy
Philadelphia, Pennsylvania
TX447_book Page 13 Friday, August 9, 2002 11:17 AM

Table of Contents
Chapter 1
Pharmacological Management of Hypertension .................................................1
Angela Cheng-Lai

Table 1.1 Classification of Blood Pressure for Adults................................2

Table 1.2 Risk Stratification and Treatment................................................3
Table 1.3 Blood Pressure Goals for Patients with Hypertension
and Other Coexisting Diseases....................................................4
Figure 1.1 Algorithm for the Treatment of Hypertension ............................5
Table 1.4 Lifestyle Modifications for Prevention and Management
of Hypertension ...........................................................................6
Table 1.5 Use of Antihypertensive Drug Therapy in Patients with
Comorbid Conditions ..................................................................7
Table 1.6 Dosage and Therapeutic Considerations for Oral
Antihypertensive Medications .....................................................9
Table 1.7 Pharmacologic Properties of Oral Antihypertensive
Medications................................................................................18
Table 1.8 Follow-Up Plans ........................................................................24
Figure 1.2 Evaluation and Management of Resistant Hypertension..........27
Table 1.9 Hypertensive Urgency and Emergency .....................................28
Table 1.10 Parenteral Drugs for the Management of Hypertensive
Emergencies ...............................................................................29
Table 1.11 Therapeutic Considerations for End-Organ Complications
of Hypertensive Emergencies ....................................................32
References..........................................................................................................34
TX447_book Page 14 Friday, August 9, 2002 11:17 AM

Chapter 2
Hyperlipidemia ..................................................................................................37
Judy W.M. Cheng

Figure 2.1 Evaluation of Patients with Hyperlipidemia .............................38

Table 2.1 Framingham Point Scores (estimate of 10-year risk) ...............39
Table 2.2 LDL Goals and Cutpoints for TLC and Drug Therapy
in Different Risk Categories......................................................41
Table 2.3 Initiation of TLC........................................................................42
Table 2.4 Clinical Identification of the Metabolic Syndrome after
3 Months of TLC.......................................................................43
Table 2.5 Antihyperlipidemic Therapy......................................................44
Figure 2.2 Treating Elevated Triglycerides and Decreased HDL ..............46
References..........................................................................................................47

Chapter 3
Pharmacologic Management of Chronic Stable Angina...................................49
James Nawarskas

Figure 3.1 Pharmacologic Management of Chronic Stable Angina...........50

Table 3.1 Select Pharmacologic and Pharmacokinetic Characteristics
of Beta-Adrenergic Antagonists Used for the Treatment
of Angina Pectoris .....................................................................51
Table 3.2 Dosing Characteristics of Beta-Adrenergic
Antagonists Used in the Treatment of Angina Pectoris ...........52
Table 3.3 Select Pharmacologic and Pharmacokinetic
Characteristics of Calcium Channel Antagonists......................53
Table 3.4 Dosing Characteristics of Calcium Channel Antagonists.........54
Table 3.5 Monitoring Parameters, Adverse Effects, and
Contraindications for Antianginal Drugs ..................................56
Table 3.6 Dosing Characteristics of Available Nitrate Products...............58
References..........................................................................................................59
TX447_book Page 15 Friday, August 9, 2002 11:17 AM

Chapter 4
Pharmacologic Management of Acute Coronary Syndromes...........................61
James Nawarskas

Table 4.1 American College of Cardiology/American Heart

Association Classification System.............................................62
Table 4.2 ACC/AHA Guidelines for the Treatment of USA
or NSTEMI ................................................................................63
Table 4.3 Dosage, Contraindications, and Monitoring of
Medications Used in the Treatment of ACS .............................68
Table 4.4 Initial Management of Acute Myocardial Infarction
(AMI) .........................................................................................74
Table 4.5 Chronic Management of Myocardial Infarction .......................81
Table 4.6 Comparison of Unfractionated Heparin, Low-
Molecular-Weight Heparin, and Bivalirudin .............................84
Table 4.7 Comparison of Thrombolytic Drugs .........................................85
Table 4.8 Absolute and Relative Contraindications to Thrombolytic
Therapy for Acute Myocardial Infarction .................................86
Table 4.9 Comparison of Glycoprotein IIb/IIIa Receptor
Antagonists ................................................................................87
Table 4.10 Antithrombotic Therapy in Patients Undergoing
Percutaneous Coronary Intervention .........................................88
References..........................................................................................................89

Chapter 5
Acute and Chronic Systolic Heart Failure ........................................................91
Judy W.M. Cheng

Figure 5.1 Algorithm in Chronic Heart Failure Management....................92

Table 5.1 Stepwise Approach in Diuresing Patients with

Decompensated Heart Failure ...................................................93
Table 5.2 Medications Used in Heart Failure ...........................................94
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