The number of patients with cardiovascular and kidney disease in the United States continues to grow as the population ages, increasing the demand on the health care system and its providers. Many patients develop chronic conditions in which optimization of care is labor intensive, specifically hypertension, hyperlipidemia, diabetes, heart failure, and chronic kidney disease. Therefore, innovative and collaborative approaches to health care are warranted. Several team-based health care models have evolved and are gaining popularity, including the Patient-Centered Medical Home (PCMH) and Medication Therapy Management (MTM). Team-based care is widely supported in the literature, demonstrating significant improvement in cardiovascular and renal outcomes. This article will review the premises of PCMH and MTM, review the evidence and roles for team-based care specific to cardiovascular and renal outcomes, and introduce fundamentals to implement collaborative practice focusing on pharmacist-provider teams.

Electronic cigarettes have gained popularity among patients as a smoking cessation aid despite not being approved or supported for this purpose by the United States Food and Drug Administration due to concerns with poor manufacturing practices and the presence of known carcinogens in the limited products that they tested. A few studies have evaluated the effects of electronic cigarettes on plasma nicotine levels and heart rate but found negligible effects. Safety data are mainly limited to surveys in which patients report only minor side effects, such as mouth and throat irritation, headache, vertigo, and nausea. The efficacy of electronic cigarettes has been evaluated in studies in which patients report great success with being able to cut back or stop tobacco cigarette consumption. However, many of these studies introduce bias due to recruiting on e-cigarette Web sites and having tobacco cigarette use self-reported by the participant rather than objectively tested. A few studies have formally evaluated nicotine craving when using electronic cigarettes with mixed results. Although patients support the use of electronic cigarettes in smoking cessation, more formal studies on safety and efficacy should be completed in order to determine whether these products have a role in smoking cessation.

The association of atrial fibrillation and resultant thromboembolic stroke is readily recognized in the published literature. However, the identification and weight of other risk factors that increase stroke risk are varied. To predict which patients are at greatest risk for thromboembolic stroke, numerous risk stratification schemas have been developed to guide thromboprophylactic treatment decisions. The well-known CHADS(2) scoring system incorporates risk factors such as congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, and previous stroke or transient ischemic attack. Recently, a novel risk stratification model, CHA2DS2 -VASc, has entered the literature and international guidelines, prompting further review of newly added risk factors-age 65-74 years, presence of vascular disease, and female sex-and the increased allotment of 2 points (vs 1 point in CHADS2) for age 75 years or older. The rationale for CHA2DS2 -VASc, as put forth by its authors, is that other risk assessment models omit important risk factors, have low predictive ability, and categorize too many patients as intermediate risk, leaving the choice of anticoagulant or antiplatelet therapy to the discretion of the clinician. Although CHA2DS2 -VASc readily identifies those patients truly at low risk, it classifies more patients as high risk who would then receive anticoagulation therapy. Therefore, implementation of this risk schema warrants further evaluation, especially when weighing the risk for bleeding and the risk for stroke. This critical review provides practitioners with an understanding of the literature that prompted the inclusion of these new risk factors and increased point allocations, compares and contrasts the risk schemas, and reviews national and international guidelines, thereby equipping the health care provider with the knowledge to aid clinical decision-making.

Substantial morbidity, mortality, and costs are associated with progressive diabetic kidney disease (DKD). A goal of Healthy People 2020 is to reduce kidney disease attributable to diabetes mellitus and increase the proportion of patients who receive agents that interrupt the renin-angiotensin system (RAS), such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). The mechanisms that contribute to progressive loss of kidney function in patients with diabetes are disrupted by inhibition of the RAS. ACEIs, ARBs and direct renin inhibitors (DRIs) all reduce the effect of angiotensin II, yet each works through a different mechanism and displays properties that may or may not be replicated by the others. As single agents, RAS inhibitors and blockers have been shown to slow the rate of progression of DKD and to reduce new cases of end-stage renal disease in various subsets of patients with diabetes and proteinuria (e.g., albuminuria). However, even with contemporary use of ACEIs, ARBs, and, more recently, DRIs, the burden of kidney disease remains high. Thus investigators sought to explore the utility of combining agents (e.g., dual RAS therapy) in various regimens for cardiovascular and kidney end points. Recent data from the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) and Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE) studies suggest that kidney-related outcomes (composite of dialysis initiation, doubling serum creatinine concentration, or death) were increased with ACEI plus ARB or DRI plus ARB combinations. Consequently, dual therapy should not be routinely prescribed in patients with diabetes until further data become available from other future studies. This review provides an introduction to DKD and a rationale for using RAS inhibition; discusses screening, detection, and monitoring of patients with DKD; and summarizes results from meta-analyses and critical reviews and from recent large randomized controlled studies published since the meta-analyses or reviews. Finally, we suggest a clinical approach for using RAS agents in patients with DKD.