Pharmacist intervention in Canada reduces risk of cardiovascular events

An intervention at 56 community pharmacies in Alberta, Canada led to a 21 percent decrease in the risk of cardiovascular events among a cohort of adults at high risk for cardiovascular disease.

During the study, patients randomized to the intervention group received a medication therapy management review from their pharmacist as well as cardiovascular disease risk assessment and education. Meanwhile, the other patients received no intervention from their pharmacist.

Adults in the intervention group also had better improvements in low-density lipoprotein cholesterol, systolic blood pressure, glycosylated hemoglobin and smoking cessation.

Lead researcher Ross T. Tsuyuki, PharmD, MSc, of the University of Alberta in Edmonton, and colleagues published their results online in the Journal of the American College of Cardiology on June 20.

In this study, known as RxEACH (Alberta Vascular Risk Reduction Community Pharmacy Project), the researchers enrolled 723 patients at high risk for cardiovascular events between Jan. 27, 2014, and June 3, 2015. They defined high risk as patients with diabetes, chronic kidney disease, atherosclerotic vascular disease or primary prevention patients with multiple risk factors and Framingham risk score of higher than 20 percent.

The patients were also required to have at least one of the following uncontrolled risk factors: blood pressure higher than 140/90 mm Hg or higher than 130/80 mm Hg if diabetic, low-density lipoprotein cholesterol greater than 2.0 mmol/l, HbA1c level greater than 7.0 percent or current smoker.

Patients were then randomized in a 1:1 ratio to an intervention group or a usual care group. The intervention group underwent a medication therapy management consultation with their pharmacist that included blood pressure measurement, waist circumference measurement, weight and height measurements, laboratory assessment and cardiovascular disease risk assessment and education. The pharmacists also were in regular contact with the patients’ families and met with the patients every three to four weeks for three months.

Patients in the usual care group did not have any specific interventions for three months. After the three months, all patients could participate in the intervention.

At baseline, the groups were well balanced. The mean age was 62 years old, the mean body mass index was 34 kg/m2 and 58 percent of patients were males. In addition, 84 percent had hypertension, 83 percent had dyslipidemia, 79 percent had diabetes, 64 percent had a sedentary lifestyle, 40 percent had chronic kidney disease and 27 percent were smokers.

After three months, the estimated mean cardiovascular risk decreased from 26.6 percent to 25.9 percent in the usual care group and from 25.6 percent to 20.5 percent in the intervention group.

After adjusting for baseline characteristics and the center effect, the researchers estimated that patients in the intervention group had a 21 percent relative decrease in cardiovascular risk compared with the usual care group.

After three months, patients in the intervention group also had 9.37 mm Hg greater reduction in systolic blood pressure, a 0.92 percent greater improvement in glycemic control, a 20 percent greater relative reduction in smoking and 0.2 mmol/L greater reduction in LDL cholesterol.

The researchers cited a few limitations of the study, including its three-month duration. They also mentioned that the results might not be generalizable to community pharmacies outside of Alberta. In addition, they used risk estimation equations that were not designed to measure change. Further, patients self-reported their smoking status, while pharmacists also assessed whether patients smoked. However, they did not use more reliable methods such as carbon monoxide detection.

“Our study demonstrating the impact of an advanced scope of pharmacist practice might have important public health implications,” the researchers wrote. “Indeed, engaging pharmacists could bring to bear another 450,000 helping hands in the United States and Canada to help reduce the burden of [cardiovascular disease]. It is important to note that the reductions in cardiovascular risk were achieved on top of (not instead of) usual physician care. Interprofessional communication and collaboration remain key. We would encourage policymakers to consider broadening the scope of practice of pharmacists (as in Alberta) and for pharmacists and professional pharmacy organizations to seize these opportunities for the betterment of patient care.”