Pharmacytechnician.org

Instructor: CoraLynn B. Trewet, MS, PharmD, BCPS, CDE Clinical Professor, University of Iowa College of Pharmacy

Introduction Heart disease is the cause for one of every three deaths in the United States. Every 25 seconds someone experiences a coronary event and every minute someone will die from a coronary event. This translates to the staggering number of people in the United States that have cardiovascular disease, one in every three people. The total cost for cardiovascular disease each year is more than 400 billion dollars. Women, specifically, have different risks and issues to consider in heart disease. Women are more likely to survive a coronary event and have a greater risk for stroke than men. In the most recent statistics from the American Heart Association, more than 50% of white women and approximately 75% of black and Hispanic women are overweight or obese and at high risk for cardiovascular disease. More than 50% of women age 20 and older have elevated cholesterol, another risk factor for cardiovascular disease.1 Recently, a national initiative has started aimed at decreasing heart attacks and strokes. The Million Hearts campaign is an initiative by the Centers of Disease Control and Prevention (CDC), Department of Health and Human Services (HSS) and Centers for Medicare and Medicaid Services (CMS) with the goal to prevent one million heart attacks and strokes by the year 2017. There are five aims of the Million Hearts campaign: 1) improving access to effective care; 2) improving the quality of care for the ABCS; 3) focusing clinical attention on the prevention of heart attack and stroke; 4) motivating the public to lead a heart-healthy lifestyle; and 5) improving the prescription and adherence to appropriate medications for the ABCS.2 Pharmacies and pharmacy personnel are the most visible, available and trusted health professionals caring for patients with cardiovascular disease. Many pharmacies have services that offer blood pressure readings and cholesterol screenings. Other pharmacies provide smoking cessation programs for patients. Pharmacists can play an essential role in the prevention of coronary events and the optimization of drug therapy for cardiovascular disease. Pharmacists have been shown to improve medication use in patients with cardiovascular disease and decrease risk of adverse drug events and medication errors. Pharmacy technicians are part of the team of people who help patients receive the very best care to optimize medication outcomes for cardiovascular disease. A is for Appropriate Aspirin Therapy What is it? Aspirin is a medication in the category of salicylates. Aspirin can be used for pain or headaches, or it can be used as an antiplatelet to help thin the blood to prevent cardiovascular disease, such as a stroke or heart attack. A dose of 325mg or more is used for pain, while a lower dose such as 81mg is used for prevention of cardiovascular events. For the purpose of this article, the use of aspirin in preventing a cardiovascular event, as opposed to using it for pain, will be the main focus. Cardiovascular events such as a heart attack or stroke occur because of a blood clot. A blood clot is formed when there is injury to a blood vessel. Platelets in the blood then become sticky and adhere to each other at the site of injury and, with the help of the body's clotting system, form a blood clot. Aspirin prevents the blood from clotting by inhibiting the platelets from sticking together, therefore reducing the risk of a cardiovascular event by preventing clots. As with any medication, there are risks when taking aspirin. Aspirin is an antiplatelet that will thin the blood and can increase the chance of bleeding anywhere in the body.3 If a patient is taking aspirin, they should be counseled by their pharmacist on the warning signs of a bleed or allergic reaction. Prevention Aspirin has a place in both primary and secondary prevention of cardiovascular disease. Primary prevention is preventing a first cardiovascular event from happening in someone at risk for such an event. Secondary prevention is preventing another cardiovascular event in someone who has already experienced such an event and is at risk for another event. Studies have shown the use of aspirin in primary prevention should be based on the individual's characteristics and risk factors and also on the clinical judgment of the provider. The patient's coronary heart disease risk must first be assessed before they are prescribed aspirin for primary prevention. Risk factors for cardiovascular disease are listed in Table 1. Some of these risk factors can be altered by the patient (modifiable) while some cannot and are non-modifiable).4 Health care providers can assess a patient's cardiovascular disease risk by using calculators such as the Framingham Risk Score. This calculator weighs each of the patient's risk factors and demographics by points and then calculates their total risk in percentage for the next ten years of their life.5 This specific calculator weighs the following risk factors: age, cholesterol, blood pressure, presence of diabetes, and smoking status.5 Table 1: Risk Factors for Cardiovascular Disease4 Current Guidelines The United States Preventive Services Task Force (USPSTF), American Heart Association (AHA), American College of Chest Physicians (ACCP), and the American Society of Health System Pharmacists (ASHP) have developed recommendations for the use of aspirin for primary prevention of cardiovascular disease based on evidence through current studies.6-9 Recommendations are listed in Table 2. These organizations recommend the use of aspirin in these specific patient populations only if the benefit of preventing a cardiovascular event outweighs the risk of bleeding.6-9 The USPSTF recommends the use of low dose, daily aspirin as primary prevention for men to prevent a heart attack and for women to prevent a stroke because evidence shows that men are significantly more likely to experience a heart attack as a result of coronary heart disease and women are more likely to experience a stroke.6 According to AHA, ACCP, and the ASHP, any person with a 10-year Framingham risk for coronary heart disease of over 10% should be on low dose aspirin for primary prevention.7-9 The American Diabetes Association (ADA) also recommends low dose aspirin for primary prevention if the patient had diabetes and a 10-year Framingham risk score for coronary heart disease over 10%.3 The ADA also recommends low dose aspirin use for primary prevention in diabetic men over the age of 50 and women over the age of 60 with at least one major cardiovascular risk factor. These major cardiovascular risk factors include: high blood pressure, high cholesterol, family history of cardiovascular disease, and albumin in the urine.3 Table 2: Recommendations for Use of Asprin6-9 If a person has already experienced a cardiovascular event, such as a heart attack or stroke, they will most likely be prescribed an anticoagulant, or blood thinner, to prevent a second event from happening. Examples of medications used besides aspirin to help prevent a second event are warfarin, clopidogrel, or dipyridamole. The dose of aspirin prescribed for secondary prevention depends on what type of cardiovascular event the patient experienced, but a dose of 75-100 mg is the typical dose prescribed if someone has already experienced a cardiovascular event.3 Some disease states may require higher doses such as 325 mg. Overall, aspirin is used to prevent the blood from sticking together and forming clots that can cause cardiovascular events, and it has a place in therapy for primary and secondary prevention of such events. B is for Blood Pressure Control What is it? Maintaining a healthy blood pressure is important in preventing cardiovascular diseases, including stroke and heart attack. For example, patients with high blood pressure, or hypertension, have a 30.5% chance of having a heart attack or stroke.2 One in three Americans has high blood pressure with half of these people not having their condition controlled.2 The prevalence of high blood pressure increases with age. For example, around half of Americans age 60-69 and around 75% of Americans over the age of 70 have high blood pressure. As their blood pressure increases, so does the chance of developing cardiovascular disease, such as heart attack, stroke, heart failure, and kidney disease.11 Blood pressure is measured as systolic over diastolic (SBP/DBP). Systolic blood pressure measures the force of blood out of the heart as it contracts. Diastolic blood pressure measures the force of blood as the heart rests between contractions. Patients cannot tell if they have high blood pressure because there are usually are no signs or symptoms. Therefore, it is important to have blood pressure measurements taken at least every two years if the patient's blood pressure was found to be normal or once yearly for patients at risk for hypertension.11 Diagnosis of hypertension is made based on a patient's blood pressure measurement from a health care provider. Current Guidelines The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, or the JNC 7, is a resource many health care providers use to help aid in the diagnosis, treatment, and prevention of high blood pressure. The JNC 7 has classified blood pressure into stages, shown in Table 3. The goal blood pressure of a healthy adult is less than or equal to 120/80. If a patient has a history of high blood pressure, the goal blood pressure is 140/90. However, the goal blood pressure of a person with either diabetes or chronic kidney disease is 130/80 because they are at an increased risk of cardiovascular disease.11 Table 3: JNC 7 Classification of High Blood Pressure11 Prevention If a patient does not already have high blood pressure, and is at risk for developing high blood pressure, there are many preventative lifestyle methods one could take to decrease the risk. For example, many factors that contribute to the risk of developing high blood pressure can be changed or modified by a patient's lifestyle. The factors that contribute to the development of high blood pressure are listed in Table 4 along with recommendations on how to prevent those factors from increasing blood pressure according to the JNC 7.11 Table 4: Contributing Factors to High Blood Pressure and Recommended Lifestyle Modifications11 Current Medications for Treatment Many people with high blood pressure that cannot be controlled by lifestyle modifications alone need medication for treatment. Multiple medications exist that can help lower blood pressure. The number of blood pressure medications a patient should be on is determined by the stage of hypertension they are in. Stage 2 hypertension patients start with up to two different medications to help control their blood pressure.11 The choice of medication depends on the patient's other medications, chronic conditions, and allergies. Once a patient is started on a blood pressure medication, they need to follow up with their doctor in four weeks to have a blood pressure measurement taken to see if they need an increased dose or if they need to add another medication to their regimen.11 Table 5 lists the classes of medications that can be used for blood pressure along with an examples from each class that is commonly prescribed for this purpose. Not only are there individual drugs for certain classes of medications, there are also combination blood pressure medications to benefit the patient. With combination medications, patients will have to take less medication and this becomes less of a burden on them. Table 5: Common Medications Used for Hypertension C is for Cholesterol What is it? Cholesterol is a natural part of the human body. Levels of cholesterol are affected by a variety of risk factors such as age, gender and family history (Table 1). Higher levels of cholesterol can run in families. Older individuals tend to have higher cholesterol as well. It has been observed that women tend to have lower levels of cholesterol when they are younger, but usually catch up to men later in life. These risk factors are not under our control. However, patients are in control of other risk factors such as diet, body weight, and the amount of physical exercise. One can reduce the amount of cholesterol in a diet by avoiding foods high in fat, saturated fat specifically, and cholesterol. By increasing the amount of physical activity a person performs, it is possible to lower body weight and bad cholesterol, as well as increase good cholesterol and feelings of well-being.12,13 A body can either make cholesterol from scratch or can obtain cholesterol from the diet. There are multiple types of cholesterol. 'Bad' cholesterol is also known as low-density lipoprotein, or LDL. When the body has too much LDL in the bloodstream, cholesterol slowly builds up on the inner walls of blood vessels. After a long period of time, the build-up of LDL causes the bloodstream to narrow and decreases the amount of oxygen flowing to the heart, which may cause a heart attack.12 'Good' cholesterol is called high-density lipoprotein, or HDL. Higher levels of HDL have been shown to be protective against heart attacks. Lower levels of HDL have also been associated with higher risk of heart attack. Experts think that HDL helps the body remove LDL build-up and take cholesterol back to the liver, where it is eliminated from the body.12 Triglycerides are a type of fat made by the body. Elevated levels of triglycerides are often found in patients with heart disease, diabetes, and commonly are elevated when a patient's total cholesterol level is high. This elevation can be due to a variety of factors like obesity, excessive alcohol intake, smoking, a diet high in carbohydrates, and physical inactivity.12 Ideally, when health care providers and patients try to control cholesterol they aim to lower the amount of bad (LDL) cholesterol in the blood while at the same time increasing the amount of good (HDL) cholesterol. This is achieved by controlling diet, body weight, and by using drugs to help achieve the cholesterol goals. Each person's cholesterol goal depends on a variety of factors. These would include their current cholesterol levels and any other diseases a person has as well. The ATP III Guidelines has offered ideal cholesterol goal values for patients and clinicians to strive for during the course of treatment (Values are listed in Table 6).14 Table 6: Current Classifications for High Cholesterol14 Current Guidelines The National Cholesterol Education Panel (NCEP) recommends a diet of less than seven percent of total daily calories from saturated fat and less than a total of 200 milligrams of dietary cholesterol daily.14 This diet can be further improved with the addition of fiber (10 - 25 grams per day) from either natural or synthetic sources or by the addition of plant stanols and sterols (2 grams per day). Plant stanols and sterols are found in wheat products, beans, and are often added to yogurts and select margarine spreads.15 The 2008 Physical Activity Guidelines for Americans suggests that all patients try to perform at least some physical activity every day, as even the bare minimum activity is better than performing none. In order to truly receive health benefits from exercise, patients should aim to either perform 120 minutes of moderate-level activity or 75 minutes of vigorous-level activity spread out over one week.16 It is also suggested to find an activity that the patient finds enjoyable, as they will be more likely to stick with their exercise regimen. Treatment goals for cholesterol are set based on a patient's risk factors and disease state(s). A summary of the target levels for therapy is presented in Table 7. Patients with more risk factors, who have coronary heart disease, or have a disease equal to coronary heart disease in severity, will have lower cholesterol goals. Once a target goal has been identified, patients can begin using lifestyle changes and drug therapy to work towards reducing cholesterol levels.14 Table 7: Current Recommendations for Cholesterol Goals15 Medications for Treatment There is also a multitude of medication options for patients still needing help in lowering their bad cholesterol and raising their good cholesterol. These drugs often require a prescription from their physician and help from a pharmacist. Patients with questions about their medications should be referred to their pharmacist. The NCEP also offers recommendations on appropriate drugs to use in patients.17 HMG-CoA reductase inhibitors, also known as statins, help prevent the body from making cholesterol (Table 8). Statins remain the most effective medication available to lower the amounts of bad cholesterol. The choice of statin primarily depends on a patient's levels of cholesterol but can also be affected by price, poor kidney or liver function, and whether a patient experiences any adverse effects from one statin over another. Statins are usually well tolerated by patients. Patients may report feelings of muscle weakness or aches, and these patients should be referred to the pharmacist.17 Table 8: Common Statins Used to Lower Cholesterol Niacin is a drug that is effective at helping lower levels of LDL and triglycerides, but is also very effective at raising levels of HDL. Niacin at smaller doses can be purchased over-the-counter. Most patients will require prescription strength niacin. Occasionally, patients will experience flushing with niacin. Because of this common side effect, many formulations of niacin are available. Patients struggling with side effects should talk to their pharmacist to develop strategies to tolerate the medication better.17 Fibrates, like gemfibrozil and fenofibrate, work primarily by lowering triglycerides. These drugs have several drug interactions, but minimal side effects. Omega-3 fatty acids, or fish oils, are commonly seen in the treatment of cholesterol. Fish oil helps by significantly lowering the levels of triglycerides in the blood. Many patients find that fish oil tends to produce a lot of belching and fishy breath. Patients asking about fish oil should be referred to a pharmacist to help determine the correct dose to take.17 S is for Smoking What is it? It has been well documented that smoking leads directly to many health complications and deaths annually. Smoking tobacco has been shown to increase the risk of blood clots leading to strokes, lowers HDL (good cholesterol), and increases risk of peripheral artery disease and heart disease. Smoking has also been linked to causing multiple types of cancer, like lung, throat, and mouth cancer.18,19 People who are breathing the air around others who smoke (termed second-hand smoke) also have higher risks of stroke and heart disease. Studies have predicted that second-hand smokers have approximately a 25-30% increased risk of heart disease over individuals who are not exposed to second-hand smoke. Children of smokers tend to have more respiratory tract infections than children of non-smokers.18,19 Despite knowing risks, people continue to smoke. A study published in the journal, Addictive Behaviors, found that roughly half of individuals ages 14-21 years old who smoke less than once a month display signs of nicotine addiction. About 30% of those individuals also displayed the same addiction characteristic after just one cigarette. The results of this study show the high risk of addiction to nicotine in cigarettes.20 Many individuals find that it is very difficult to quit smoking. Even with social support and the use of smoking cessation aids, the path to quitting is difficult. When somebody uses nicotine, the brain is exposed to more chemicals than normal. These chemicals provide feelings of pleasure and increased energy associated with nicotine use. Eventually though, the brain becomes less responsive to nicotine and requires much more nicotine to feel the same effects. This is called tolerance.21 Unfortunately, tolerance to a drug can lead to dependence on a drug. Dependence is a state where lack of a drug in the body causes unwanted and generally unpleasant effects. For example, when a person who normally smokes tobacco is placed into a situation where smoking is forbidden (i.e. workplace) they may become irritable and agitated. The combination of tolerance and dependence makes it very difficult for people to stop smoking. It is highly suggested that individuals interested in smoking cessation talk to their physician or pharmacist about assistance programs.21 Current Guidelines At the core of the issue, every major guideline for maintaining patients' health and preventing heart disease emphasizes the need to stop smoking. The benefits from smoking cessation are also realized immediately. Within a half hour, a patient's blood pressure will drop to the level it was prior to any tobacco use. Before the month is over, a patient will notice that it is easier to breathe as their lung function improves. Roughly one year later, a patient's risk of heart disease is cut in half. By years five to fifteen, the stroke risk is cut in half. After ten years, a quitter's risk of cancer is greatly decreased.18 Medications for Treatment There is a plethora of pharmacologic options for patients looking for assistance with smoking cessation. Nicotine gums, lozenges and patches provide relief from nicotine withdrawal and are available over-the-counter at most pharmacies. There are also a few prescription drugs, like Zyban (buproprion) and Chantix (varenicline), which help patients deal with the physiological cravings associated with nicotine. Each product has its own advantages and disadvantages for patients. There are many considerations such as patient preference and triggers that need to be taken into account as pharmacists help patients select the best smoking cessation product. Nicotine gum is used with the chew-chew-park method. After chewing a few times, the piece of gum should be placed in between the gum and cheeks and left there for a little under a minute. If done correctly, a person should begin to feel a slight tingling around the site of the gum. The gum should not be swallowed after use. The gum gives a patient nicotine for approximately thirty minutes before the piece is exhausted. The maximum amount of gum a patient should use per day is 24 pieces. Side effects of using nicotine gum include upset stomach, tired mouth, oral irritation, and unpleasant taste. Nicotine lozenges are also another option for patients seeking nicotine replacement. The lozenge works similarly to candied lozenges. One simply needs to swish the lozenge around the mouth and let it dissolve in order to receive the nicotine dose. Patients should not use more than 20 lozenges per day. Side effects associated with the lozenges include a greater amount of stomach upset compared to nicotine gums, oral irritation, headache, heartburn, nausea and flatulence.17,22 Nicotine patches work by delivering a set amount of nicotine across the skin over a long period of time each day. Notable side effects from nicotine patch use include nausea, dizziness, diarrhea, sweating, headache and vivid dreams. Local skin irritation is also a possibility with patients who have sensitive skin. Nicotine inhalers deliver nicotine through a device that resembles a cigarette. It is optimal for patients who also find that the hand to mouth act of smoking itself is pleasurable. Side effects associated with inhaled nicotine include oral irritation, cough and occasional nasal congestion. Nicotine nasal sprays work much like nasal sprays used for seasonal allergies. Patients simply spray the dose into each nostril. The nasal spray provides the fastest relief of withdrawal symptoms of all the nicotine replacement products. Patients may report a peppery nasal irritation, coughing, sneezing, or watery eyes while using the nicotine spray.17,22 Bupropion is a commonly prescribed prescription drug for mood disorders. However, it can also be used to help patients cease smoking because it alters the chemical pathways in the brain. This helps patients slowly reduce their addictive habits, nicotine cravings and withdrawal symptoms. The most common side effects reported include sleeping problems and dry mouth. The FDA has given bupropion a black box warning due to post-marketing surveillance studies. These studies have found that patients taking bupropion may be at an increased risk of agitation, hostility, depression or suicidal ideation.17,22 Varenicline is the newest agent available to assist with smoking cessation. The drug works in the brain in ways similar to nicotine; however, it does not cause the same harmful effects as tobacco products. The most common side effects reported with varenicline include headache, insomnia, nausea, and vivid dreams. Varenicline also has a black box warning from the FDA for agitation, hostility, depression and suicidal ideation.17,22 Role for Technicians There is a significant role for pharmacy in helping reduce cardiovascular disease and prevent one million heart attacks and strokes in the next five years. The team of pharmacists and pharmacy technicians can promote healthy living and risk reduction strategies. As outlined in Table 4, innovative programs at pharmacies can promote weight loss, healthy eating and increased physical activity. Technicians can assist pharmacists in development of drug utilization review mechanisms which identify appropriate patients for aspirin use. Blood pressure machines are commonly located in pharmacies and can be promoted by technicians for patients taking medications for blood pressure. Many pharmacies have cholesterol screening programs to identify patients with high cholesterol. The technician can play a significant role in the development and implementation of these and other screening programs. Smoking cessation products should be placed in prominent locations in the pharmacy. Technicians can assist patients in promotion of these products and referral to pharmacists as patients work to quit smoking. The success of preventing heart attacks and strokes will require a team approach. Pharmacy technicians can play an important role in helping patients to reduce heart disease. References 1. Executive Summary: Heart Disease and Stroke Statistics--2012 Update : A Report From The American Heart Association. Circulation 2012;125:188-197. 2. Million Hearts. Centers for Disease Control and Prevention. 29 May 2012 . 3. Lexi-Comp. Aspirin. 23 May 2012 . 4. Coronary Heart Disease Risk Factors. National Heart Lung and Blood Institute. 24 May 2012 . 5. Framingham Heart Study. 24 May 2012 . 6. Aspirin for the Prevention of Cardiovascular Disease. December 2009. U.S. Preventive Services Task Force. 23 May 2012. http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm>. 7. Mosca L, et al. Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women - 2011 Update. JACC 2011; 57: 1401-1423. 8. Cairns, JA, Therous P, Lewis HD Jr. et al. Antithrombotic agents in coronary artery disease. Chest. 2001; 119 (1 suppl): 228S-52S. 9. Saseen JJ. ASHP therapeutic statement on the daily use of aspirin for preventing cardiovascular events. Am J Health-Syst Pharm. 2005; 62:1398-405. 10. Standards of medical care in diabetes. Diabetes Care 2012;28 (suppl 1: S11-S63. 11. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003;289. 12. Good vs. Bad Cholesterol. Mar 2012 American Heart Association. 30 May 2012. http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/Good-vs-Bad-Cholesterol_UCM_305561_Article.jsp>. 13. Heart Attack: MedlinePlus. May 2012. U.S. National Library of Medicine. 28 May 2012 . 14. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). ATP 3 Cholesterol Guidelines, NHLBI. Circulation 2002;106:3143. 15. Concord Hospital. Plant Stanols and Sterols. Sept 2006. Concord Hospital, University of New Hampshire. 28 May 2012. . 16. Physical Activity Guidelines. 2008. U.S. Department of Health and Human Services. 28 May 2012. . 17. Antilipemic Agents, Smoking Cessation. Lexi-Comp. Lexi-Comp, Inc. Web. 30 May 2012. . 18. How Cigarettes Damage Your Body. Mar 2012. American Heart Association. 29 May 2012 . 19. Quit Smoking. 2012. American Heart Association. 31 May 2012 . 20. Scragg R, Wellman RJ,Laugesen M, DiFranza JR. Diminished Autonomy over Tobacco Can Appear with the First Cigarettes. Addictive Behaviors 2008;33.5:689-98. 21. Drug Facts: Understanding Drug Abuse and Addiction Understanding Drug Abuse and Addiction. Understanding Drug Abuse and Addiction. Mar 2011. National Institute of Drug Abuse. 31 May 2012. . 22. Medicines To Help You Quit Smoking. Mar 2011. American Heart Association. 31 May 2012 . Author Bio: CoraLynn B. Trewet is an Associate Clinical Professor of Family Medicine for The University of Iowa where she coordinates the endocrine therapeutics course and serves as the Director of Continuing Education. Dr. Trewet is a Board Certified Pharmacy Therapy Specialist (BCPS), a Certified Diabetes Educator (CDE) and is certified as a Wellcoach Health Coach. Dr. Trewet currently serves on the NHLBI Coordinating Committee of the National Program to Reduce Cardiovascular Risk (NPRCR), where she is involved with the development and dissemination of the upcoming hypertension, cholesterol and obesity guidelines. Idea In Brief: The Million Hearts campaign is an initiative with the goal to prevent one million heart attacks and strokes by the year 2017. A main focus of the Million Hearts initiative is based around ABCS of cardiovascular disease which stand for aspirin use, blood pressure control, cholesterol management and smoking cessation. This activity will highlight current guidelines and treatments in these four areas of cardiovascular disease. Idea In Practice: More patients come into the pharmacy with cardiovascular disease than any other disease state. A new initiative, The Million Hearts Campaign, is based around ABCS of cardiovascular disease which stand for aspirin use, blood pressure control, cholesterol management and smoking cessation. These four areas are specific areas pharmacy technicians can focus their efforts to help improve patient care and decrease heart disease.