LEVO-CTS Trial: Should Cardiac Surgery Patients Use Levosimendan?

Sandy Liu, Mercer University College of Pharmacy

Utilizing a heart-lung machine, cardiopulmonary bypass replaces the heart’s pumping action and adds oxygen to blood, allowing the heart and lungs to be still prior to cardiac surgeries. [1]  Morbidity and mortality have demonstrated to be associated with this surgery, as is low cardiac output syndrome. [2]  Despite being managed with inotropic agents and mechanical cardiac assist devices, it has been suggested that short-term mortality is higher compared to patients without this syndrome. [3]  Some available inotropic agents may still have unknown safety profiles or known adverse effects.  [4]

Levosimendan is a calcium-sensitizing inotrope and an adenosine triphosphate (ATP) sensitive potassium channel opener used to enhance cardiac contractility and vasodilation.  This medication increases the sensitivity of cardiac myofilament to calcium, rather than increasing intracellular concentrations of free calcium.  By binding to cardiac troponin C in a calcium-dependent manner, levosimendan stabilizes troponin C and the kinetics of actin-myosin cross-bridges without increasing myocardial consumption of ATP. [5]

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Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease

Sandy Liu, Mercer University College of Pharmacy

A 2016 guideline from the American College of Cardiology stated that the inability to achieve a 30%-50% low-density lipoprotein cholesterol (LDL-C) reduction with statins and/or dietary interventions may necessitate the initiation of the following medications: ezetimibe, bile acid sequestrants and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.  [1]

Evolocumab is a human monoclonal antibody that inhibits proprotein convertase subtilisin/kexin type 9 by binding to low-density lipoprotein receptors on hepatocyte surfaces to promote LDL-receptor degradation within the liver, thereby lowering LDL-C levels. [2]

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A Comparison of Stroke and Bleeding Risk Scoring Systems in Atrial Fibrillation

Dakota Thaxton Craft, Mercer University College of Pharmacy

Atrial fibrillation (AF) is a type of supraventricular tachycardia that may lead to blood clots and increase the risk of stroke. [1]  Goals of therapy include rate control or correction of rhythm disturbance and prevention of thromboembolism.  The selection of antithrombotic therapy may be based on the risk of thromboembolism due to stroke as assessed by CHADS2, or the more inclusive CHA2DS2VASC. [2]  Due to increased bleeding risks associated with antithrombotic therapy, it is recommended to stratify bleeding risks by using the HAS-BLED score (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly > 65 years, drugs/alcohol concomitantly). [3]  The HAS-BLED score is not applicable to all patients due to lack of available information for “labile INR” in naive patients. [4]

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RE-CIRCUITing Anticoagulants for Catheter Ablation

Sandy Liu, Mercer University College of Pharmacy

Catheter ablation of atrial fibrillation is typically performed with uninterrupted anticoagulation with warfarin or interrupted non-vitamin K antagonist (NVKA) oral anticoagulant therapy.  Due to the lack of controlled data, it is unknown whether uninterrupted anticoagulation with a NVKA agent, such as dabigatran, is a safer option than warfarin. [1]

Warfarin is a vitamin K antagonist that competitively inhibits the subunit 1 of the multi-unit vitamin K epoxide reductase (VKOR) complex, thus depleting functional K reserves and reducing synthesis of active clotting factors. [2]  Conversely, dabigatran is a reversible, direct thrombin inhibitor that inhibits both free and fibrin-bound thrombin, thereby preventing thrombin-mediated effects, including cleavage of fibrinogen to fibrin monomers, inhibition of thrombin-induced platelet aggregation and activation of factors V, VIII, XI and XIII. [3]

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Topical Atorvastatin Emulgel May Reduce Pain Post-hemorrhoidectomy

Jessica Swain, Mercer University College of Pharmacy

Hemorrhoids is defined as the symptomatic enlargement and/or distal displacement of anal cushions.  Risk factors for hemorrhoids include: aging, obesity, abdominal obesity, depressive mood, pregnancy, constipation, and prolonged straining. [1]

The effect of topical atorvastatin on wound healing has not been evaluated.  The American College of Gastroenterology (ACG) recommends excision of thrombosed external hemorrhoids, symptomatic treatment for internal hemorrhoids using topical over-the-counter therapies, and office procedures, such as rubber-band ligation, for internal hemorrhoids that remain symptomatic after lifestyle modifications and over-the-counter medications. [2]

Postoperative care for an excisional hemorrhoidectomy may include nonsteroidal anti-inflammatory drugs supplemented by opioid analgesics.  Stool softeners and bulking agents are recommended to ease the passage of stool post-procedure.  Topical metronidazole 10% and topical diltiazem have been shown to decrease postoperative pain.  [3]

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Cardiovascular Safety of Celecoxib

Tyler Marie Kiles, PharmD, Mercer University College of Pharmacy

The selective cyclooxygenase-2 (COX-2) inhibitor rofecoxib was withdrawn from the market in 2004 due to evidence of adverse cardiovascular outcomes in a placebo-controlled trial.1 In 2005, the U.S. Food and Drug Administration (FDA) concluded that an increased risk of serious adverse cardiovascular events appears to be a class effect of non-steroidal anti-inflammatory drugs (NSAIDs).  Further research was mandated by the FDA in response to observed cardiovascular effects of another marketed COX-2 inhibitor,  Celebrex™ (celecoxib).2

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Risperidone, Haloperidol Not Superior to Placebo in Delirium Patients in Palliative Care

Jessica Swain, Mercer University College of Pharmacy

Delirium is a clinical disorder distinguished by loss of cognitive function, perception, and/or consciousness usually occurring over 1-2 days.  Patients with delirium can be combative or uncooperative, have hallucinations and confusion, and have sleep disturbances.  Risk factors for delirium include: age 65 or older, some degree of cognitive impairment, and severe illness with progression or risk of progression.  Reorientation for the patient, identification of the underlying cause, and comfort measures for the patient are ways to manage delirium. [1]

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