From a pre-med student: do pharmacists round w/ physicians?

DarkProtoman

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Do pharmacists go on rounds w/ physicians? You PharmDs are *far* too valuable to be shoved behind a counter. When I'm an IM resident, I *really* don't want to have to *guess* about how much valsartan and enalpril I need to give my patient w/ CHF who's about to be discharged; I'd much rather want to write "valsartan and enalpril PO, per pharmacy for CHF", and have you guys figure out the dosing. (Although, if I do become a cardiologist, I'd *better* know my cardiac drugs and how to dose them.) But I probably wouldn't want to try this w/ the Walgreens pharmacy. What would *they* do? Yell at me ("Doctor, this is *not* a hospital!!!! I am *not* your fancy-schmancy 'board-certified clinical pharmacotherapy specialist' *boyfriend*!!!!") for not giving the dosage info, send it back, try to calculate it, what?

Is there any one here who's a BCPS w/ AQs in cardiology?

Does the rounding team on the cardiology wards consist of an attending cardiologist, a cardiovascular clinical pharmacist, a cardiology fellow, a PGY-2 cardiovascular pharmacy resident, a couple IM residents, a couple PGY-1 clinical pharmacy residents, and a couple medical and pharmacy students?

Thanks!!!
 

firefighter9015

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As far as who rounds it depends on the institution. Your larger teaching hospitals will have pharmacists rounding with them. However, smaller community hospitals may not.

By the way, the * in your post tends to make it read sarcastic at first glance.
 

firefighter9015

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Also, I think that your Walgreens pharmacist will help you figure out doses if you need to. I know at the pharmacy that I work for we get calls from docs all of the time helping with doses and such. That is the job of the pharmacist no matter the practice setting.
 
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Yes, pharmacists do round with physicians, and they almost always are PGY1s or PGY2s. They provide lost of info like drug appropriateness, dosing, etc. I definitely agree you wouldn't want some pharmacists I know to dose, but they are older and have been practicing for like 30 years. Oh, and thanks for appreciating the value of Pharm.D.s! I find that more young MDs are willing to work with PharmDs while a lot of older MDs are really hesitant to collaborate with the PharmD.
 

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depends on the hospital and their staffing. But there should always be a pharmacist available to answer dosing questions for you.

I'm glad to see you appreciate our presence on rounds.

Again, it's going to vary from hospital to hospital. But there is usually only 1 or 2 pharmacy representatives on the rounding team - a resident or clinical pharmacist and their student. Last summer I had a few non-pharmacist preceptors and if I had any radical suggestions I ran it by a pharmacist but they were very willing to take my recommendations.
 

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As has been stated it really depends on the institution. I've seen that many of the teaching hospitals include pharmacists on rounds. Where I am doing my residency (starting in July) they have Pharmacy Specialists (mostly BCPS PharmD's) and PGY-1/2 Pharmacy residents on certain teams. It's most common on the critical care teams and certain internal med rounding teams. The DOP said that in the last year or so there has been more and more requests by physicians to include pharmacists on different rounding teams. In fact the physicians are such great proponents that it's resulted in funding for a few extra full-time pharmacists. I think it's great and can't wait to be in an environment where I'm appreciated and wanted. I also have a friend who just graduated med school and the new Doc's definately love and appreciate pharmacists. I think it's great that we're all working as a team, especially since we all bring something different to the table (I would have no idea how to diagnose or read rhythm strips).
 

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The hospital I work at has residents round with the teams. The clinical pharmacists don't round but follow the patients on their own schedule. You have to keep in mind, though, this is a hospital in a smaller area. It is, however, considered a teaching hospital since we do have med students.
 

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I think it depends on region.

Here in the Northeast, the only pharmacists that round, in order of decreasing frequency of rounding:
Teaching RPh's with P4s on rotation
Residents or former residents when they have time
ICU and ED RPhs...and that's if they're not busy covering other floors or fixing stuff
Staff RPhs...but they're usually busy with order verification that 90% of the time they can't spend hours on a ward pontificating medicine and dosing

Then again, a lot of hospitals around here have staffing issues, so that definitely is a contributor to RPh availability for rounds.
 

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I think it depends on region.

Here in the Northeast, the only pharmacists that round, in order of decreasing frequency of rounding:
Teaching RPh's with P4s on rotation
Residents or former residents when they have time
ICU and ED RPhs...and that's if they're not busy covering other floors or fixing stuff
Staff RPhs...but they're usually busy with order verification that 90% of the time they can't spend hours on a ward pontificating medicine and dosing

Then again, a lot of hospitals around here have staffing issues, so that definitely is a contributor to RPh availability for rounds.
yep
 

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Thanks for appreciating our presence. In NYC, pretty much all of the hospitals have pharmacy students/residents round with a medical team. In my opinion, it is nice because not only do I get to learn from the medical team, but we also get to understand each discipline's way of thinking and thus reduce medication errors on both sides.
 

rxlynn

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Do pharmacists go on rounds w/ physicians? You PharmDs are *far* too valuable to be shoved behind a counter. When I'm an IM resident, I *really* don't want to have to *guess* about how much valsartan and enalpril I need to give my patient w/ CHF who's about to be discharged; I'd much rather want to write "valsartan and enalpril PO, per pharmacy for CHF", and have you guys figure out the dosing. (Although, if I do become a cardiologist, I'd *better* know my cardiac drugs and how to dose them.) But I probably wouldn't want to try this w/ the Walgreens pharmacy. What would *they* do? Yell at me ("Doctor, this is *not* a hospital!!!! I am *not* your fancy-schmancy 'board-certified clinical pharmacotherapy specialist' *boyfriend*!!!!") for not giving the dosage info, send it back, try to calculate it, what?

...
Thanks!!!
I think the real problem with sending something like that to Walgreens or whoever is that the pharmacist is not going to want to accept the liability of dosing when they don't have access to the patient's chart. If you don't know weight, you don't know what meds the patients was taking before, you don't know what they were dosed with in the hospital, you don't know creatinine clearance, etc. then it's difficult to know what would be the most appropriate dose. As the earlier poster mentioned, a good pharmacist is going to have a good idea of appropriate dosage, but they won't fill and dispense without confirming dosage with the prescribing physician.
 
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DarkProtoman

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I think the real problem with sending something like that to Walgreens or whoever is that the pharmacist is not going to want to accept the liability of dosing when they don't have access to the patient's chart. If you don't know weight, you don't know what meds the patients was taking before, you don't know what they were dosed with in the hospital, you don't know creatinine clearance, etc. then it's difficult to know what would be the most appropriate dose. As the earlier poster mentioned, a good pharmacist is going to have a good idea of appropriate dosage, but they won't fill and dispense without confirming dosage with the prescribing physician.
Of course, I'd staple a note to the script w/ all pertinent patient chart info...like Dx, weight, age, prev meds and their routes of admin, etc. Probably just fax their entire chart in. Then, a couple months later, I get a letter from Walgreens saying that I'm jamming their fax lines, and making freshly graduated PharmDs that they've hired quit. "Doctor Douglas, you've made us use up all of our printer paper!!! Our fax line is perpetually busy, thanks to you!!!" The PGY-1 MD internal medicine resident vs. the PGY-1 PharmD working at Walgreens.

Anyway, about me prescribing valsartan and enalpril for CHF...is that the drug combo of choice for treating CHF, or are there better medications and/or combos out there?
 

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Of course, I'd staple a note to the script w/ all pertinent patient chart info...like Dx, weight, age, prev meds and their routes of admin, etc. Probably just fax their entire chart in. Then, a couple months later, I get a letter from Walgreens saying that I'm jamming their fax lines, and making freshly graduated PharmDs that they've hired quit. "Doctor Douglas, you've made us use up all of our printer paper!!! Our fax line is perpetually busy, thanks to you!!!" The PGY-1 MD internal medicine resident vs. the PGY-1 PharmD working at Walgreens.

Anyway, about me prescribing valsartan and enalpril for CHF...is that the drug combo of choice for treating CHF, or are there better medications and/or combos out there?
If it becomes that much regular, I would charge you a fee for each consultation and not worry about giving you my time and fax machine papers. The PGY-1 pharmacy residents at hospitals are on hospital payroll.

Drug treatment for CHF varies what stage the pt is in... you just follow the guideline published by ACC/AHA (plus clinical judgment).
 
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DarkProtoman

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If it becomes that much regular, I would charge you a fee for each consultation and not worry about giving you my time and fax machine papers. The PGY-1 pharmacy residents at hospitals are on hospital payroll.

Drug treatment for CHF varies what stage the pt is in... you just follow the guideline published by ACC/AHA (plus clinical judgment).
Which I suppose I could pass on to the patient once I'm in private practice...

And let's say he's in moderate-to-severe CHF...his ejection fraction is 33.333%, and his stroke volume is 46.667ml, his cardiac output is 5600.04ml, and his pulse pressure is 27mmHg. Or would it be time to consult a cardiothoracic surgeon to see about adding an LVAD? What about adding or replacing the valsartan+enalapril w/ digoxin?

And for treatment of an MI causing v-fib, would dronedarone be effective? Let's say I go into status asthmaticus, and my heart becomes so stressed I have a heart attack, and I go into v-fib. Would epiniphrine+dronedarone+100% O2 be effective?

Thanks!!!
 

Chiyo

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Which I suppose I could pass on to the patient once I'm in private practice...

And let's say he's in moderate-to-severe CHF...his ejection fraction is 33.333%, and his stroke volume is 46.667ml, his cardiac output is 5600.04ml, and his pulse pressure is 27mmHg. Or would it be time to consult a cardiothoracic surgeon to see about adding an LVAD? What about adding or replacing the valsartan+enalapril w/ digoxin?

And for treatment of an MI causing v-fib, would dronedarone be effective? Let's say I go into status asthmaticus, and my heart becomes so stressed I have a heart attack, and I go into v-fib. Would epiniphrine+dronedarone+100% O2 be effective?

Thanks!!!
You don't seem to have enough patho background to talk about treatment.
(moderate to severe? NYHD classification? what ACC/AHA stage? symptoms? hosp frequency? how many flights of stairs? LVH?)

Vfib -> shock + CPR + epi +/- amiodarone or lidocaine (ACLS) -> resuscitated Vfib, you go from there.
 
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DarkProtoman

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You don't seem to have enough patho background to talk about treatment.
(moderate to severe? NYHD classification? what ACC/AHA stage? symptoms? hosp frequency? how many flights of stairs? LVH?)

Vfib -> shock + CPR + epi +/- amiodarone or lidocaine (ACLS) -> resuscitated Vfib, you go from there.
OK, here's Mx. Heart Failure's symptoms: severe dyspnea on exertion --as in s/he couldn't climb the front door steps w/o gasping for air and taking his/her bronchodilator --s/he also has (formerly) well controlled asthma; s/he's been thinking her symptoms were related to that-- --, 5 pillow orthopnea, rapid resting heart rate on average of 120bpm, O2 saturation of 75%, BNP of 750pg/mL, left ventricular hypertrophy of 150%, periphial edema, cold sweats, severe vertigo, the list is endless. S/he's been hospitalized several times w/i the last six months w/ severe breathlessness and angina. His/her latest hospitalization is where my scenario comes in. --His/her GP must not be the sharpest drawer in the knife; he still thinks it's exercised-induced asthma--. S/he either has CHF or PPH, but a cardiac catherization I --in my scenario-- ordered ruled out the latter.

And let's scratch the second one.
 

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I definitely agree you wouldn't want some pharmacists I know to dose, but they are older and have been practicing for like 30 years.
This.

Yes, newly minted PharmD graduates know their clinical stuff, but the BSPharm pharmacists almost always do not. Pharmacy is in a transition state right now, so outside of a hospital setting where you know everyone's credentials, I wouldn't bother calling a community pharmacy unless you know the pharmacist personally. Half the time you'd get a young PharmD who knows what's going on, the other half you get a BSPharm who would not only not know how to dose valsartan and enalapril, but probably wouldn't know how to dose ASA (at least they wouldn't tell you anything due to liability).

That's how it is at my pharmacy at least. I have two BSPharm pharmacists who call the MD on everything and claim to know nothing, and one PharmD who is called regularly to consult doctors on therapies. It's sort of a crap shoot.
 
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This.

Yes, newly minted PharmD graduates know their clinical stuff, but the BSPharm pharmacists almost always do not. Pharmacy is in a transition state right now, so outside of a hospital setting where you know everyone's credentials, I wouldn't bother calling a community pharmacy unless you know the pharmacist personally. Half the time you'd get a young PharmD who knows what's going on, the other half you get a BSPharm who would not only not know how to dose valsartan and enalapril, but probably wouldn't know how to dose ASA (at least they wouldn't tell you anything due to liability).

That's how it is at my pharmacy at least. I have two BSPharm pharmacists who call the MD on everything and claim to know nothing, and one PharmD who is called regularly to consult doctors on therapies. It's sort of a crap shoot.
That's...that's...that's...ABSOLUTELY DISGUSTING!!!! The BSPharms should have enough practical experience to at least match a PharmD's knowledge!!!!

And how could a pharmacist *not* know how to dose 2-acetoxybenzoic acid?!!!? When I'm an IM PGY-1, I'll make sure to seek out only those w/ "PharmD, FCCP, BCPS" behind their names for my pharmaceutical and pharmacology needs.

And what were some of the BSPharm-to-MD "consultations" like?

Thanks!
 

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Now I'm not saying that all older pharmacists don't know their stuff, don't get me wrong, but I pretty much agree with you meister
 

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I think some huge, ugly generalizations are being made here.

I absolutely would not judge someone by their degree alone. There are BS Pharmacists in my hospital pharmacy who have more knowledge in their right hand than I'll have after my residency. Now with a PharmD and a residency I may reach that same level of knowledge after fewer years of experience than they did, but no amount of schooling will touch experience.
 

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I think some huge, ugly generalizations are being made here.

I absolutely would not judge someone by their degree alone. There are BS Pharmacists in my hospital pharmacy who have more knowledge in their right hand than I'll have after my residency. Now with a PharmD and a residency I may reach that same level of knowledge after fewer years of experience than they did, but no amount of schooling will touch experience.
Couldn't agree more!! And I think the same goes with only seeking the advice of those with extra letters behind their name. Props to anyone who gets board certified...but it's not always a tell-all. With experience, you'll find out who you can turn to for recs at your specific institution. But you might be surprised one day to see that the only three letters at the end of their names are "RPh". ;)
 

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There are BS Pharmacists in my hospital pharmacy who have more knowledge in their right hand than I'll have after my residency.
That's in the hospital, and I would certainly agree. For the typical Walgreens pharmacist, they are more than likely not PharmD's and won't have that kind of knowledge. Heck, they might even be PharmD's who graduated 10 years ago and have been doing nothing but retail and forgotten all of that knowledge. I would hope whatever the letters are after their name, if they don't know the answer to the question they'll refer to someone who does.
 
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That's in the hospital, and I would certainly agree. For the typical Walgreens pharmacist, they are more than likely not PharmD's and won't have that kind of knowledge. Heck, they might even be PharmD's who graduated 10 years ago and have been doing nothing but retail and forgotten all of that knowledge. I would hope whatever the letters are after their name, if they don't know the answer to the question they'll refer to someone who does.
Yeah, at my local Sams Club pharmacy, there's two pharmacists, Vicky and Hilda; Vicky's sounds like she's worked at a hospital --but she says she hasn't, so she must've went to a very good pharm school--; Hilda was a hospital pharmacist --and is older--, but doesn't know half the stuff --or simply can't articulate her knowledge-- Vicky does. Vicky's the pharm manager, btw. Needless to say, I enjoy chatting w/ Vicky. Plus, she's very witty, funny, and our personalities mesh --we're both spazzes--.

And please answer my CHF question. Thanks.
 
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That's in the hospital, and I would certainly agree. For the typical Walgreens pharmacist, they are more than likely not PharmD's and won't have that kind of knowledge. Heck, they might even be PharmD's who graduated 10 years ago and have been doing nothing but retail and forgotten all of that knowledge. I would hope whatever the letters are after their name, if they don't know the answer to the question they'll refer to someone who does.
I love technicians that think they know it all and run their mouths but really have no idea what in the hell they are talking about.
 

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Anyway, about me prescribing valsartan and enalpril for CHF...is that the drug combo of choice for treating CHF, or are there better medications and/or combos out there?
oh yeah, and here you go smart guy. The answer is in the ACC guidelines. Since you know everything, you should be able to decipher this for yourself, right? So here's a link to the answer of your question

http://www.missouricare.com/pdf/CHFGuidelines.pdf

It's sort of funny that you posted the same question in the cardio forum and they are drawing the same conclusion we are about you....troll

http://forums.studentdoctor.net/showthread.php?t=516286
 

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oh yeah, and here you go smart guy. The answer is in the ACC guidelines. Since you know everything, you should be able to decipher this for yourself, right? So here's a link to the answer of your question

http://www.missouricare.com/pdf/CHFGuidelines.pdf

It's sort of funny that you posted the same question in the cardio forum and they are drawing the same conclusion we are about you....troll

http://forums.studentdoctor.net/showthread.php?t=516286
I <3 Caverject :love:
 

Caverject

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I love mouth breathers who comment about people they know ****all about.
All one has to do is read your post history to figure you out. It's clearly obvious you are/were a technician of some sort, and have way too much time & information on your hands; so you automatically think you're an expert in something you know extremely little about. Sorry, but you've never been to pharmacy school nor have you ever been a pharmacist to really gauge what another pharmacist knows. Many pharmacists can step from a retail setting into a hospital setting with little to no transition at all; regardless of the degree they hold or where it came from.

Simple fact of the matter is, you have little to no respect for pharmacists period and for some odd reason, you want to be one. Why don't you get your facts straight before you do something stupid again like posting something in the big boy pharmacy forum acting like you actually know something. Thanks
 

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That's in the hospital, and I would certainly agree. For the typical Walgreens pharmacist, they are more than likely not PharmD's and won't have that kind of knowledge. Heck, they might even be PharmD's who graduated 10 years ago and have been doing nothing but retail and forgotten all of that knowledge. I would hope whatever the letters are after their name, if they don't know the answer to the question they'll refer to someone who does.
again, with the sweeping generalizations.

some of my best and brightest classmates are looking forward to careers with Walgreens.

Heck, most of my hospital's residents pick up a shift or two per month at walgreen's for the extra cash. Several of my clinical professors do the same just to keep a foot in the retail door. For all you know, the pharmacist ringing up your prescription is PharmD, PhC, BCPS, etc.

(PhC is Pharmacist Clinician - it's a license we have here in New Mexico; gives prescriptive authority under collaborative practice agreements. Retail pharmacists here can also prescribe smoking cessation and immunizations)
 

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Do pharmacists go on rounds w/ physicians?
yes (depends on the hospital and the service)


When I'm an IM resident, I *really* don't want to have to *guess* about how much valsartan and enalpril I need to give my patient w/ CHF who's about to be discharged;
If you're an IM resident, I hope you won't have to guess either. CHF is a common enough disease that you will be used to the dosing of ACEI/ARBs (and what to watch out for with those medications).


Does the rounding team on the cardiology wards consist of an attending cardiologist, a cardiovascular clinical pharmacist, a cardiology fellow, a PGY-2 cardiovascular pharmacy resident, a couple IM residents, a couple PGY-1 clinical pharmacy residents, and a couple medical and pharmacy students?

Thanks!!!
When I was on cardiology, it was the attending cardiologist, a cardiology fellow, a senior medicine resident, 2 medicine interns, occasionally some medical students, a clinical pharmacist (occasionally a pharmacy student), and social worker and clinical coordinator.


And let's say he's in moderate-to-severe CHF...his ejection fraction is 33.333%, and his stroke volume is 46.667ml, his cardiac output is 5600.04ml, and his pulse pressure is 27mmHg. Or would it be time to consult a cardiothoracic surgeon to see about adding an LVAD? What about adding or replacing the valsartan+enalapril w/ digoxin?
HUH? If you only realize how non-sequitur this paragraph is. The topic of management of congestive heart failure takes up many pages in textbooks and occupy many hours of lectures and is beyond the scope of SDN.

I will say that if you make the suggestion of replacing valsartan/enalapril with digoxin, the clinical pharmacist (along with the rest of the medical team) will certainly look at you funny. (perhaps it might be a better move to raise the clinical utility of a combination ace/arb in the settings of CHF since there are some interesting studies out there)



And for treatment of an MI causing v-fib, would dronedarone be effective? Let's say I go into status asthmaticus, and my heart becomes so stressed I have a heart attack, and I go into v-fib. Would epiniphrine+dronedarone+100% O2 be effective?

Thanks!!!
I think some electricity might be better. But if you insist on dronedarone during a code, good luck finding it in stock at the pharmacy (let alone code cart)
 

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Yikes, what's with all the aggression in this thread? While I was a bit too cavalier with my sweeping generalizations, I stand by the general idea. A pharmacist who's been working retail for 30 years simply was not forced to retain a majority of their clinical knowledge and thus has forgotten a lot. That's just the way life is, if you don't use it, you lose it.

I make no claim about hospital pharmacists or those who like to use their education. However, in my experience, retail pharmacists generally just aren't required to know a lot of the stuff they learned.
 
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yes (depends on the hospital and the service)




If you're an IM resident, I hope you won't have to guess either. CHF is a common enough disease that you will be used to the dosing of ACEI/ARBs (and what to watch out for with those medications).




When I was on cardiology, it was the attending cardiologist, a cardiology fellow, a senior medicine resident, 2 medicine interns, occasionally some medical students, a clinical pharmacist (occasionally a pharmacy student), and social worker and clinical coordinator.




HUH? If you only realize how non-sequitur this paragraph is. The topic of management of congestive heart failure takes up many pages in textbooks and occupy many hours of lectures and is beyond the scope of SDN.

I will say that if you make the suggestion of replacing valsartan/enalapril with digoxin, the clinical pharmacist (along with the rest of the medical team) will certainly look at you funny. (perhaps it might be a better move to raise the clinical utility of a combination ace/arb in the settings of CHF since there are some interesting studies out there)





I think some electricity might be better. But if you insist on dronedarone during a code, good luck finding it in stock at the pharmacy (let alone code cart)
I now realize that replacing valsartan+enalapril w/ digoxin would be stupid, if not downright dangerous...digoxin is a positive inotrope, which would overwork my poor patient's heart, and cause death to come ever faster. My new regimen, after researching heart failure management more, would be valsartan, enalapril, verapamil, furosemide, chlorthalidone, and carvedilol, plus a no-sodium diet, and strict bedrest. And consult a cardiothoracic surgeon to see about an LVAD.

And what about combining dronedarone --or amiodarone-- w/ defibrillation? That should be superior to either alone. And shouldn't *major* teaching hospitals, like MGH, UCLA, UCSF, JHU, have amiodarone or dronedarone in their hospital pharmacy, or better yet, their code cart?

Thanks.
 
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You're still breaking one of the major rules of cardiovascular medicine. Thou shalt not combine an ACE-I and ARB because combining them results in more risk than benefit.
 

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This guy won't give up until he get his tx for HF...:rolleyes: Just to end this thread.... there ya go.

Pathophys

Systolic dysfunction: EF <40%
Diastolic dysfunction: EF >40% + symptoms

Clinical Presentation

Right sided failure: peripheral edema, (+) JVD, etc
Left sided failure: DOE, dyspnea, tachypnea, rales, pulmonary edema
Nonspecific findings: fatigue, weakness, tachycardia, cardiomegaly

Staging

ACC/AHA staging

Class A: Pts with no signs/symptoms of HF but who has risk
Class B: pts with structural defect but has no signs/symptoms (pts with LVH)
Class C: symptomatic HF pts
Class D: HF pts who are symptomatic at rest

Management

Class A: ACEI
Class B: ACEI + beta blocker
Class C: ACEI + beta blocker + loop diuretic + prn (spironolactone, ARB, digoxin, nitrates, hydralazine)
Class D: Stage C therapy + hospice

Based on your imaginary pt she would get (assume class C).

ACE I + beta blocker + furosemide + spironolactone (due to LVH).

Then you would add dig if pt wasn't controlled on above regimen and have frequent hospitalization.

Dig is weak inotrope.. so it wouldn't really overwork heart that much and cause faster death. Dig improves HF symptoms & decrease hospitalizations. It does not decrease mortality.

You only use ARB when pt can't tolerate ACEI therapy. So you would only use it to replace ACEI.

Problem #2 It is already answered... what more do you need>>>>>>>>

Vfib -> shock + CPR + epi +/- amiodarone or lidocaine (ACLS) -> resuscitated Vfib

Its in the ACLS algorithm.



Now let this thread die!
 
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This guy won't give up until he get his tx for HF...:rolleyes: Just to end this thread.... there ya go.

Pathophys

Systolic dysfunction: EF <40%
Diastolic dysfunction: EF >40% + symptoms

Clinical Presentation

Right sided failure: peripheral edema, (+) JVD, etc
Left sided failure: DOE, dyspnea, tachypnea, rales, pulmonary edema
Nonspecific findings: fatigue, weakness, tachycardia, cardiomegaly

Staging

ACC/AHA staging

Class A: Pts with no signs/symptoms of HF but who has risk
Class B: pts with structural defect but has no signs/symptoms (pts with LVH)
Class C: symptomatic HF pts
Class D: HF pts who are symptomatic at rest

Management

Class A: ACEI
Class B: ACEI + beta blocker
Class C: ACEI + beta blocker + loop diuretic + prn (spironolactone, ARB, digoxin, nitrates, hydralazine)
Class D: Stage C therapy + hospice

Based on your imaginary pt she would get (assume class C).

ACE I + beta blocker + furosemide + spironolactone (due to LVH).

Then you would add dig if pt wasn't controlled on above regimen and have frequent hospitalization.

Dig is weak inotrope.. so it wouldn't really overwork heart that much and cause faster death. Dig improves HF symptoms & decrease hospitalizations. It does not decrease mortality.

You only use ARB when pt can't tolerate ACEI therapy. So you would only use it to replace ACEI.

Problem #2 It is already answered... what more do you need>>>>>>>>

Vfib -> shock + CPR + epi +/- amiodarone or lidocaine (ACLS) -> resuscitated Vfib

Its in the ACLS algorithm.



Now let this thread die!
Thank you!!!!!!!!!!!!!!!!!! But doesn't some research like http://www.ncbi.nlm.nih.gov/pubmed/16105846 show that combining ACEs w/ ARBs benefits certain pts then either alone? Does my imaginary pt fall into that category?
 

Farmercyst

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group_theory

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I now realize that replacing valsartan+enalapril w/ digoxin would be stupid, if not downright dangerous...digoxin is a positive inotrope, which would overwork my poor patient's heart, and cause death to come ever faster. My new regimen, after researching heart failure management more, would be valsartan, enalapril, verapamil, furosemide, chlorthalidone, and carvedilol, plus a no-sodium diet, and strict bedrest. And consult a cardiothoracic surgeon to see about an LVAD.
so your patient went from valsartan/enalapril to an ace/arb, CCB, loop diuretic, thiazide diuretic, and a beta-blocker. wow. I guess you're trying to set up your patient for your scenerio #2 where you talk about your patient coding.

btw, your patient now hates you for ordering a no-sodium diet

and why are you so anxious to consult CT surgery for a LVAD anyway?

And what about combining dronedarone --or amiodarone-- w/ defibrillation? That should be superior to either alone. And shouldn't *major* teaching hospitals, like MGH, UCLA, UCSF, JHU, have amiodarone or dronedarone in their hospital pharmacy, or better yet, their code cart?

Thanks.
you never mentioned amiodarone in your original piece, only dronedarone. Keep in mind amiodarone is in the ACLS algorithm, dronedarone isn't. Dronedarone is still an investigational drug and you better have a good reason for using it in lieu of amiodarone in an acute setting.

BTW, in this mock scenerio that you have described with your patient, given the history and physical findings that you have described, hopefully you are also working to exclude something else that should be high in your differential diagnosis. You already criticized this patient's GP for not being the "sharpest drawer in the knife", let's see if you're a dull knife yourself.

OK, here's Mx. Heart Failure's symptoms: severe dyspnea on exertion --as in s/he couldn't climb the front door steps w/o gasping for air and taking his/her bronchodilator --s/he also has (formerly) well controlled asthma; s/he's been thinking her symptoms were related to that-- --, 5 pillow orthopnea, rapid resting heart rate on average of 120bpm, O2 saturation of 75%, BNP of 750pg/mL, left ventricular hypertrophy of 150%, periphial edema, cold sweats, severe vertigo, the list is endless. S/he's been hospitalized several times w/i the last six months w/ severe breathlessness and angina. His/her latest hospitalization is where my scenario comes in. --His/her GP must not be the sharpest drawer in the knife; he still thinks it's exercised-induced asthma--. S/he either has CHF or PPH, but a cardiac catherization I --in my scenario-- ordered ruled out the latter.
 

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The more the OP goes on about this case, the more it seems like hes trying to piece knowledge together out of a textbook and doesn't really have a clue. Can we drop this thread already?
 

speednutsII

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I'm somewhat confused...if you're a premed student, why aren't you more concerned about organic chemistry or physics?
 

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You're still breaking one of the major rules of cardiovascular medicine. Thou shalt not combine an ACE-I and ARB because combining them results in more risk than benefit.
you can combine the two to prevent "ACE Escape" once you've got your beta blocker optimized, but you cannot throw spironolactone/aldosterone antag of your choice on that.


and to the OP - Amiodarone better be on every crash cart in the country.
 
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so your patient went from valsartan/enalapril to an ace/arb, CCB, loop diuretic, thiazide diuretic, and a beta-blocker. wow. I guess you're trying to set up your patient for your scenerio #2 where you talk about your patient coding.

btw, your patient now hates you for ordering a no-sodium diet

and why are you so anxious to consult CT surgery for a LVAD anyway?



you never mentioned amiodarone in your original piece, only dronedarone. Keep in mind amiodarone is in the ACLS algorithm, dronedarone isn't. Dronedarone is still an investigational drug and you better have a good reason for using it in lieu of amiodarone in an acute setting.

BTW, in this mock scenerio that you have described with your patient, given the history and physical findings that you have described, hopefully you are also working to exclude something else that should be high in your differential diagnosis. You already criticized this patient's GP for not being the "sharpest drawer in the knife", let's see if you're a dull knife yourself.
OK, the reason I'd consult the CT is "well, the meds seem to be working, but just in case s/he decompensates, I'd like to know whether or not a LVAD is a *possibility* in that event". And a cardiac catheterization ruled out pulmonary hypertension.
 
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I'm somewhat confused...if you're a premed student, why aren't you more concerned about organic chemistry or physics?
I've got my orgchem and physics classes, thank you very much...I post b/w studying for exams.
 

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you can combine the two to prevent "ACE Escape" once you've got your beta blocker optimized, but you cannot throw spironolactone/aldosterone antag of your choice on that.


and to the OP - Amiodarone better be on every crash cart in the country.

to all the hospital folks out there, amio by bedford labs has been recalled. i don't remember the lot, but it's exp date 12/09.

have fun chasing down all the amio around the house. it's moved up in the ACLS pecking order over the past few years....so it's gotta be everywhere!!
 

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Thank you!!!!!!!!!!!!!!!!!! But doesn't some research like http://www.ncbi.nlm.nih.gov/pubmed/16105846 show that combining ACEs w/ ARBs benefits certain pts then either alone? Does my imaginary pt fall into that category?
No. Your link is not a research but more of an editorial or comment from biased investigators. Yes, ACEI and ARB does work more efficient by a few points compared to ACEI alone, but surprisngly the few points do not translate into better results. For example, reducing blood pressure by 3-4 /1 mmhg extra does not translate to a better morbidity and mortality rate due to cardiovascular events. However what it did have is extra side effects such as hyperkalemia, hypotension and syncope, etc.

Two landmark studies involving thousands of patients that are multi insitutional based through 4-5 years is the ONTARGET study and VALLIANT study. They both are great studies (with a little bit of bias) and something maybe you can read up on.

http://content.nejm.org/cgi/content/full/358/15/1547 =ONTARGET study
 

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I don't think he even took statistics/EBM course yet. I feel that it's pointless trying to answer this guy any further.
 

rxforlife2004

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Of course, I'd staple a note to the script w/ all pertinent patient chart info...like Dx, weight, age, prev meds and their routes of admin, etc. Probably just fax their entire chart in. Then, a couple months later, I get a letter from Walgreens saying that I'm jamming their fax lines, and making freshly graduated PharmDs that they've hired quit. "Doctor Douglas, you've made us use up all of our printer paper!!! Our fax line is perpetually busy, thanks to you!!!" The PGY-1 MD internal medicine resident vs. the PGY-1 PharmD working at Walgreens.

Anyway, about me prescribing valsartan and enalpril for CHF...is that the drug combo of choice for treating CHF, or are there better medications and/or combos out there?
CHF? Give Coreg CR 20mg daily. If the patient is obese, give COregCR 40mg daily. Done. Who cares about the guidelines....they're a bunch of BS anyway. No need combo. The only combo that makes sense is when i am at CostCo waiting for my "combo" pizza order! Yummy, it tastes good.
 

rxforlife2004

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I don't think he even took statistics/EBM course yet. I feel that it's pointless trying to answer this guy any further.
I agree...how about answering my question: are you single and available?
 
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