Cardiovascular drug interventions in the cardio-oncology clinic by a cardiology pharmacist: ICOP-Pharm study

Figures

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  FIGURE 1. The Iraqi Cardio-Oncology Program-Pharmacist (ICOP-Pharm) paradigm at the cardio-oncology clinic. The workflow consists of five steps. During Step 2 the cardiologist performs echocardiography on the first patient, at the same time, the cardiology pharmacist meets the second patient for the same action in Step 1, resulting in less patient waiting time. *If a patient presents only for baseline echocardiography and has no cardiovascular risk factors or disease, the cardiology pharmacist performs a face-to-face interview and registration without drug interventions. **When the cardiologist completes echocardiography, he informs the cardiology pharmacist about the cardiac condition, so the cardiology pharmacist adds any additional suggestions for drug interventions while the cardiologist is printing the echocardiography report before moving to Step 3.

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  FIGURE 2. The ICOP-Pharm study flow diagram. At the cardio-oncology clinic, 200 of 333 patients with cancer had CVD/CVRF. Among patients with CVRF/CVD, drug interventions by the heart team were done for 79 patients who were included in the ICOP-Study analysis. *Patients without CVRF/CVD were referred to the clinic either for baseline echocardiography before starting cardiotoxic cancer therapy or for suspected cardiac disease. **Patients without drug interventions because they did not bring their home cardiovascular drugs and they did not know their medication name. Therefore, drug interventions were not applicable. For those patients, appointments were scheduled for drug optimization. CVD, cardiovascular disease; CVRF, cardiovascular risk factor; and FIT, fellow in training.

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  FIGURE 3. Cardiovascular risk factor/cardiovascular disease at baseline and post-initiation of cancer therapy. The majority of DM, HTN, and IHD are documented at the baseline as CVRF and CVD among patients with cancer. AF, atrial fibrillation; CVD, cardiovascular disease; CVRF, cardiovascular risk factor; DM, diabetes mellitus; DVT, deep vein thrombosis; HF, heart failure; HTN, hypertension; IHD, ischemic heart disease; and TIA, transient ischemic attack.

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  FIGURE 4. Complementary drug interventions according to the main types of interventions. The cardiology pharmacist performed most of the drug interventions due to her initial interventional complementary role in the heart team with the cardiologist/FIT. FIT, fellow in training.

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  FIGURE 5. Drug interventions by the cardiology pharmacist. Drug initiation was the most common drug intervention by the cardiology pharmacist; it represented more than one-half of the total interventions followed by cessation of unnecessary cardiovascular drugs or drugs that exacerbate the cardiovascular disease.

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  FIGURE 6. Complementary drug interventions in different CVRF/CVD. Based on the complementary approach, most of the drug intervention by the cardiology pharmacist was in patients with baseline HF followed by CTRCD. Others included transient ischemic attack, hypertriglyceridemia, and right atrial thrombus. CVD, cardiovascular disease; CTRCD, cancer therapy-related cardiac dysfunction; CVRF, cardiovascular risk factor; HF, heart failure; HTN, hypertension; IHD, ischemic heart disease.

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  FIGURE 7. Most common CVRF/CVD treated initially by the cardiology pharmacist. Based on the total drug interventions by the cardiology pharmacist, HTN, followed by CTRCD, were the main CVRF/CVD cases treated initially by the cardiology pharmacist. CVD, cardiovascular disease; CTRCD, cancer therapy-related cardiac dysfunction; CVRF, cardiovascular risk factor; HF, heart failure; HTN, hypertension; IHD, ischemic heart disease.

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  FIGURE 8. Frequency of different CVRF/CVD in different types of drug interventions. The most common drug interventions in different CVRF/CVD cases were dose titration in CTRCD, switching between drugs in HTN, and drug initiation in IHD. CVD, cardiovascular disease; CTRCD, cancer therapy-related cardiac dysfunction; CVRF, cardiovascular risk factor; HF, heart failure; HTN, hypertension; IHD, ischemic heart disease.

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  FIGURE 9. Frequency of drug cessation and initiation at the cardio-oncology clinic. Non-steroidal anti-inflammatory drugs and antiplatelets were the most common drugs to be stopped at the cardio-oncology clinic due to the lack of indication for their use or due to exacerbation of the underlying cardiovascular disease or risk factor. ACEI and beta-blockers were the most common drugs to be initiated at the clinic because of their integral role in the management of CVRF/CVD, in addition to cancer therapy-related cardiac dysfunction. ACEI, angiotensin-converting enzyme inhibitors; BB, beta-blockers; CCB, calcium channel blockers; NSAID, non-steroidal anti-inflammatory drug; MRA, mineralocorticoid receptor antagonist.