Pharmacists Managing Treatment Improves BP and Lipids in Stroke Patients 

April 14, 2014

EDMONTON, AB – A program that allows pharmacists to initiate and manage treatment for high blood pressure and cholesterol levels in patients who recently suffered a stroke results in better control of these cardiovascular risk factors than nurse-led case management, according to the results of a new study[1].

Whereas the nurses simply recorded blood pressure and cholesterol levels and reported the information back to the primary-care physician, active management by pharmacists involved starting therapy, titrating doses, adding drugs as needed, and optimizing care. This resulted in improved blood pressure and cholesterol levels at six months compared with the nurse-led management, report investigators.

"We saw that the current system isn't really working optimally," lead investigator Dr Finlay McAlister (University of Alberta, Edmonton) told heartwire . "It's difficult for primary-care physicians to be able to squeeze extra patients into the day. The neurologist and the stroke-prevention clinic might see a patient once or maybe twice. This is a way to have it highlighted for the patient that they are at increased risk and have somebody specifically manage their risk factors without taking over the job of the neurologist or the primary-care physician."

The study, which is published online April 14, 2014 in CMAJ, included 279 study participants from three stroke-prevention centers in Alberta. Patients all had an ischemic stroke or transient ischemic attack (TIA) confirmed by the stroke specialist and were eligible for the study if they had blood pressure or LDL-cholesterol levels above the Canadian stroke guideline-recommended targets.

For the nurse-led management, which served as the control arm, the attending neurologist provided treatment targets for vascular risk factors to the primary-care physician. A nurse met with the patient monthly and provided lifestyle advice and checked the patient's blood pressure and cholesterol levels. If the risk factors exceeded guideline targets, the nurses advised the patient to see the primary-care physician. They did not schedule the appointment for the physician.

"On the other hand, if the patient was over the targets for either blood pressure or cholesterol, the [pharmacists] actually gave them a prescription," said McAlister. "We had treatment algorithms for both risk factors. If cholesterol was high, there was an algorithm to start a statin, and if it was high a month later, they would increase the dose. Same thing with blood pressure—if it was high, and they weren't already on an ACE inhibitor or an ARB, those were started. The pharmacist actually did all medication modifications and would let the primary-care physician know about it."

At baseline, none of the patients met both treatment goals for blood pressure and LDL cholesterol set out by the clinical guidelines. By six months, there were significant improvements in both arms, but larger improvements in the pharmacist-led intervention. At six months, 43.4% met the dual systolic blood pressure and LDL-cholesterol targets in the pharmacist-led arm vs 30.9% in the nurse-led control arm, a difference that was statistically significant (p=0.03).

Regarding systolic blood pressure alone, 80% of patients in the pharmacist-led arm achieved the guideline target at six months vs 90% in the nurse-led arm, a difference that was not statistically significant. The researchers point out the benefit was largely driven by greater improvements in LDL cholesterol. At six months, 51% in the pharmacist arm achieved the LDL target of 2.0 mmol/L (77 mg/dL) vs 34% in the nurse-led management arm (p=0.003).

To heartwire , McAlister said available data suggest that more than 75% of patients who have had a stroke/TIA have inadequately controlled vascular risk factors six months following their clinical event. Although the present study highlights improvements in risk-factor control, it was too small and too short to detect whether such improvements would translate into reduced clinical events.

In Alberta, community pharmacists can now be licensed to prescribe medications to certain patients, including stroke and cardiac patients, as part of team-based care. The present study suggests that case management by nonphysician healthcare providers can improve vascular risk factor management for at-risk patients and that "case management is more effective if the case manager can actively modify medications rather than just feedback risk-factor levels to patients and/or their primary-care physicians," said McAlister.

Funding for the study was provided by the Heart and Stroke Foundation, Alberta Heritage Foundation for Medical Research, and Knowledge Translation Canada. McAlister has no conflicts of interest. Disclosures for the coauthors are listed in the article.

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