The Pharmacist's Role in Heart Health

Todd Eury: hey pharmacy podcast nation, welcome to the next rx safe transforming the role and transforming the pharmacy industry.

Todd Eury: This is an exciting opportunity for us to come together and give our Community pharmacy owners some really good content that you can use as.

Todd Eury: programs that help to build your business but, more importantly, what it's doing for your Community what it's doing for your patience, you see your patience.

Todd Eury: So much more than your primary care physician partners see your patients, you know this nine to 10 times more your patients are coming to you.

Todd Eury: With questions about vaccines about vitamins about different experiences skin ailments there's so many things that come across.

Todd Eury: The counter to you the pharmacist who they trust the most and because of that, the pharmacy podcast network has partnered.

Todd Eury: With Ark safe to build components and build program information that you can take from subject matter experts.

Todd Eury: and build programs around this for your Community we're excited today to welcome a four part Panel for person panel, that is going to be talking about.

Todd Eury: heart health specifically pharmacist impact on heart health cardiovascular disease is highly prevalent it we're talking about for of every 10 Americans are suffering something.

Todd Eury: To do with heart health, and this is costing our health care system $1.1 trillion estimated by 2035 this was noted by a published article in the journal of American heart association.

Todd Eury: That is huge and heart health is more important because it has other impacts on people's relationships and being able to take care of themselves and staying at home, instead of having to go to some.

Todd Eury: skilled nursing Center the pharmacist role is so important in this pharmacist can be that key source of support for an individual looking to manage their heart health.

Todd Eury: and also to be able to manage those conditions that could be you could do preventative care so that you don't end up having to be on a medication.

Todd Eury: For the rest of your life, however, if you are there's an aspect of adherence that can keep you healthy and keep you safe keep you alive.

Todd Eury: I want to welcome our panel, I want to start off with Dr Sandra and Dr Sandra away she is here today with us, and I want to welcome you to the Ark safe panel.

Sandra Awaida: I taught in there Thank you so much for having me i'm really excited to be here and I know that we gotta probably introduce ourselves quickly so i'm.

Sandra Awaida: A doctor and pharmacy I graduate i'm a foreign Grad I came to the United States, maybe in 1999 and.

Sandra Awaida: I worked at the mass general hospital for a few years as a clinical pharmacist as an authentic pharmacist in the icu and the medical.

Sandra Awaida: floor and I thought at some universities preceptor few students as well, while I was there and.

Sandra Awaida: After that I worked in big pharma I was at Novartis in the medical information department and now i'm in Florida, and I work in private practice in the cardiology office and I do.

Sandra Awaida: For the past three years i've been implementing progressively new innovative approach to preventative care, and so we have chronic care management I started a remote patient monitoring as well, and now incorporated pharmacogenomics in in our practice.

Todd Eury: that's my favorite word right now in pharmacy is pharmacogenomics it's a whole nother series and we'll have to have you back after today's presentation Thank you so much for.

Sandra Awaida: Being here.

Todd Eury: Dr Nathan, Brian welcome to the pharmacy podcast network and the Ark safe panel thanks for being here.

Dr. Nathan S. Bryan: Thank you Todd i'm stoked for any amount and a pleasure to be amongst this expert panel, here is my name is Nathan, Brian i'm.

Dr. Nathan S. Bryan: An acquisition, for the past 20 years I get a bachelor's degree in biochemistry from the University of Texas at Austin.

Dr. Nathan S. Bryan: And from there, I went to an llc school of medicine wearing a PhD in molecular and cellular physiology and then did my postdoctoral training at Boston medical Center in.

Dr. Nathan S. Bryan: Boston and then don't faculty at the University of Texas Medical School and Houston for a number of years and then from there, I went to baylor college of medicine.

Dr. Nathan S. Bryan: i've been in drug discovery and drug development for the past 20 years in an academic environment made a number of discoveries.

Dr. Nathan S. Bryan: So today i'm retired from full time academia mainly an entrepreneur and run a number of companies, including the clinical stage drug company, where we have a coma drug and I prefer to have a drug and phase three clinical trials and we now have a long pipeline, of being.

Dr. Nathan S. Bryan: routed or clinical drugs that were going for a number of different indications, including ischemic heart disease pulmonary hypertension even basket dimension also.

Todd Eury: Thank you for mentioning that Dr Brian we are going to be doing a whole series on clinical trials and the impact that pharmacists have on the trust it's built with the participants and the patients in that so we'll have to Ping you about that and get you.

Todd Eury: involved Thank you so much for being here.

Todd Eury: I want to introduce to everyone, Dr Brittany, Mr Mr Dr Brittany so excited for you to be here Thank you so much for joining us.

Brittany Messer: Thank you for having me I really appreciate the opportunity.

Brittany Messer: So i'm what you would call a nurse practitioner, and I graduated three years ago and may from Marshall university school of pharmacy in Huntington West Virginia.

Brittany Messer: And I stayed local to do a PG by one pharmacy residency at our local va medical Center and i'm lucky enough to work at Marshall cardiology now and.

Brittany Messer: So i'm the first to my position i've built it from the ground up and I primarily work with the heart failure teams and I run our hypertension clinic so we receive referrals from within Marshall health outside.

Brittany Messer: establishments now, which has been really cool so my primary role is to optimize GMT for heart failure and between clinic visits I do a lot of presenting with the school of pharmacy I precept our pharmacy residence and i'm adjunct faculty at the physician assistant school as well.

Todd Eury: Thank you so much for today and for being here thanks for having me Dr Jennifer marquez how are you so excited that you're here linked with you on linkedin and it's been fun to read up on some of your publications Thank you and welcome to the Ark safe panel.

Jennifer Clark Marquez: Thank you Todd i'm so grateful to be here today and to have this opportunity to speak with these other panelists as well.

Jennifer Clark Marquez: I went to pharmacy school at all burn and got my doctor of pharmacy in 2002 and since then.

Jennifer Clark Marquez: completed her residency and have practiced in a number of progressive practice settings i've worked in ambulatory care environments.

Jennifer Clark Marquez: I have worked in oncology for the last 17 years and i've also managed to anticoagulation clinic so i've had lots of experience with cardiology patients.

Jennifer Clark Marquez: And, most recently I founded a company, where I do pharmacogenomics consulting called farm DNA and I love to see the impact that pharmacogenomics can have on drug therapy so i'm very excited to be here today.

Todd Eury: We are as well, thank you so much for our listeners if you're listening live, you can submit questions along the way during this webinar.

Todd Eury: If you're listening through podcasting don't worry all the show notes will be down below so if you're driving jogging.

Todd Eury: chopping vegetables do whatever you're going to do don't worry, we can get the information and the contact of our panelists to you, their linkedin will definitely be there.

Todd Eury: Alright let's jump in heart attack stroke heart failure arrhythmia heart valve complications.

Todd Eury: The list goes on and it's kind of scary when I started reading into this, I was like oh yeah let's do a heart, health and then I started reading and I started getting.

Todd Eury: One of those like what do they call those pains where you feel for someone else, and I was like a little chest playing I was like in my era and i'm like Okay, maybe i'll take my.

Todd Eury: Maybe i'll take my my nitric oxide till today, but I want to just start off with Dr Sandra I want you to kind of give us an overview why our pharmacist positioned to be some of the best providers to help patients with heart health.

Sandra Awaida: yeah I think truly pharmacists are very well positioned and no matter what area of pharmacy they're practicing, of course, in Community pharmacy and I know, most of our listeners are in Community pharmacy they are.

Sandra Awaida: You know the the closest to the people they are you know the easiest persons to do the outreach to.

Sandra Awaida: to patients, and you know, there was this number once that that was thrown on screen for me and I was like oh my gosh I never thought about it, there are 67,000 pharmacies in the US and 15,000 starbucks, so I think.

Sandra Awaida: Just to put things in perspective, you know how much contact and facetime opportunity pharmacist have in in retail, but in the clinical setting you know in also in practice in private practice or in academia it's really impacts at three levels, I think it impacts.

Sandra Awaida: The economic level, the humanistic level and also the outcome, the clinical level, and we are very speaking of outcome we are very well trained.

Sandra Awaida: To be able to you know assess the guidelines look at the, especially in heart disease, since we're talking about it today, the ha the ACC and applied to our patients.

Sandra Awaida: The humanistic approach is really knowing the patient, knowing that they have is dedicated team Member.

Sandra Awaida: To be able to sit down with share their concerns share their side effects and knowing that they have the time to do it, and knowing that their problem will be addressed is invaluable and at the outcome level really.

Sandra Awaida: mainly economic outcome, then this is the most exciting exciting part for me right now is.

Sandra Awaida: The impact that we have with these new programs that pharmacists are involved in, and I know there are.

Sandra Awaida: A lot of people trying to crunch, the numbers to show how valuable that economic impact can be in decreasing hospitalizations and i'm sure we're going to talk about it later on in the show.

Todd Eury: Thank you, Dr Nathan, I look at the metrics I read up on this to prepare for today's webinar and I see a fine line between the preventative.

Todd Eury: And then the reactive and I kind of want to get your gauge, I know, pharmacists play roles on both sides of that fence, but where do you want to start you want to start with preventative and giving some of our listeners and our pharmacists some some some advice.

Dr. Nathan S. Bryan: of where they can start to care for their patients.

Dr. Nathan S. Bryan: Well, you know the numbers don't lie cardiovascular disease remains the number one killer of men and women worldwide, and for me that's simply unacceptable because.

Dr. Nathan S. Bryan: We know how to diagnose party vast disease we know the symptoms and we know how to treat it in preventing.

Dr. Nathan S. Bryan: So the problem is not the lack of tools it's education and awareness and so that I see is my job i'm not a pharmacist and talking to them about chemist physiologist but i've worked in both academia.

Dr. Nathan S. Bryan: For a number of drug companies and now on my own drug company, but what's clear to me in terms of nitric oxide, in part, hill whether its heart disease or kidney disease brain disease.

Dr. Nathan S. Bryan: it's all reduce blood flow its lack of blood flow to the effective Oregon and that's a result of lack of nitric oxide production.

Dr. Nathan S. Bryan: So if we can train and teach not only pharmacists, but the patients in the general public on the awareness around like report side and how they can test.

Dr. Nathan S. Bryan: and get measures of into the legal function recognized early symptoms of nitric oxide deficiency whether it's a slight elevation and blood pressure or sexual dysfunction.

Dr. Nathan S. Bryan: And then employ lifestyle strategies even stop doing the things that disrupt Microsoft side production and start doing the things that stimulated and promoted.

Dr. Nathan S. Bryan: And then you can prevent disease, and that is the goal, because we know that modern medicine today.

Dr. Nathan S. Bryan: it's not working, you know 50% of the people that are given into hypertensive medications and drugs don't work.

Dr. Nathan S. Bryan: So there's no benefit and not to even address the number of adverse side events from these terms, so we've got to take a different approach and we've got to be proactive instead of reactive.

Dr. Nathan S. Bryan: And I think all that starts with proper education and taking a very complex science like cardiovascular physiology and nitric oxide about chemistry.

Dr. Nathan S. Bryan: and putting it into language that the pharmacist can then communicate to the patients that they understand it, then they can take control of their own home and prevent getting the best the goal.

Todd Eury: Dr master you have experienced that a health system level and so many of your colleagues i'm sure are focused on.

Todd Eury: heart attacks and things that are you know happening within the hospital system, what have you found to be kind of the the sweet spots of where pharmacists can truly make an impact on on better heart health for our patients.

Brittany Messer: i'm truly patient education and the smoking cessation so that's one thing that i've been.

Brittany Messer: lucky to have in our state at wv medicine another hospital system they offer a certified tobacco treatment specialist opportunity, so I participated in that and that's left a huge impact because.

Brittany Messer: A lot of the providers, they don't want to take time to do the smoking secession part which is fine, so that's where pharmacists can come into play, where the experts on that top of stuff after all dietary recommendations.

Brittany Messer: that's a huge make basically lost all modifications and in terms of actual medication i'm consultant a lot on our recommendation on lifted management.

Brittany Messer: that's huge year following the guidelines monitoring labs is huge, because that's something we can easily do and give our recommendations on top.

Brittany Messer: Of that and and if the patient calls having any adverse effects what's our next phase, so I found that that's our biggest impact here in our establishment.

Todd Eury: Thank you so much, Dr mark Hayes I you know you your readings and i've been stalking you because I do that to every pharmacist that comes on one of our shows and.

Todd Eury: i've read up on Piedmont health and in 20 plus years of your experience in this, what does this taught you to be able to disseminate your key findings to pharmacist listening right now with regards to heart, health and just some some pearls that you can share with us.

Jennifer Clark Marquez: Well, my experience in a healthcare setting has just really given me lots of different opportunities in different patient populations starting my career with.

Jennifer Clark Marquez: In an ambulatory clinic where I had opportunity to interact with patients with diabetes patients with metabolic syndrome other conditions that are commonly encountered with cardiovascular disease.

Jennifer Clark Marquez: To be able to round with providers and make recommendations for lipid management and hypertension and.

Jennifer Clark Marquez: You know it's it's very interesting now working in oncology environment and also working with anticoagulation patients to.

Jennifer Clark Marquez: see the impact that a pharmacist can make they can help with monitoring these drugs actually started and managed took over management of.

Jennifer Clark Marquez: anticoagulation patients here in a cancer Center for three years and we actually had better outcomes, we have less bleeding events and tighter control of the INR.

Jennifer Clark Marquez: But we know pharmacists, a lot of times have a little more time to deal with these issues than some of the other health care providers and.

Jennifer Clark Marquez: pharmacists really have an opportunity to shine when they are allowed to participate at a higher degree in drug therapy outcomes and decision making processes so that's been very rewarding.

Todd Eury: So I think of the conditions that I mentioned at the beginning in the opening, I want to concentrate on stroke for just a second, and I want to come back to Dr Sandra and just.

Todd Eury: kind of unpack the fact that we know 8789 as high i've seen metrics.

Todd Eury: Where there's a percentage of all strokes being is a call to a seismic stroke account for that and it's the blockage of blood vessels that deliver blood and oxygen to the brain.

Todd Eury: causing a stroke and, of course, all centered around your heart, so when I think of that and I think of the world of adherence and adherence isn't just a medication.

Todd Eury: it's a lifestyle it's it's being adherent to something adherence to taking a walk adherent to making sure that i'm not you know eating too many cholesterol.

Todd Eury: You know fatty foods or whatever it is, and you can we can guess as consumers i'm the consumer so.

Todd Eury: I could sit here and guests, but that's why we have pharmacist here so around stroke what specifically have you researched or have you found.

Todd Eury: Where there's an opportunity for pharmacists to educate their patients and then stay with their patients to build an adherence strategy to prevent stroke.

Sandra Awaida: yeah I think the first thing that comes to mind when we talk about stroke is blood pressure control, you know blood pressure, control is definitely the leading cause of stroke and.

Sandra Awaida: The patients who are non adherent to medication like you said.

Sandra Awaida: The first thing that I tell them is really you know if you don't feel them because they always tell us you know, but I feel okay I don't think I need anything because i'm Okay, and I thought they had you know you're Okay, and then.

Sandra Awaida: They of course you know don't really have the answer to that, but then, when you put in perspective for them is that you know you could have a stroke, this is a leading cause of stroke.

Sandra Awaida: They do pause and think about it, and I know it's not the subject today but also progression to kidney disease, those are very big deterrence for patients, when we tell them that this is, this is why you need to have your blood pressure medication.

Sandra Awaida: Taken or manager blood pressure and put it under control.

Sandra Awaida: The biggest program that I think is doing a tremendous impact on stroke, prevention and other cardiovascular outcome and negative outcome.

Sandra Awaida: Around blood pressure is remote blood pressure, monitoring, so we used to have this very social.

Sandra Awaida: interaction with patients, you know patients would come into the office.

Sandra Awaida: They either have a blood pressure, reading from home or they don't or they take it in the office we take it for them in the office and now we're really treating it very you know just one number, I mean that's traditionally.

Sandra Awaida: We progressed into our patients to keep a blood pressure log sometimes they don't bring it sometimes they do sometimes it's incomplete sometimes they forget it, they say Oh, I did it, I wrote it, I promise I did.

Sandra Awaida: It and now with the fact that we can see their blood pressure on our portal before they come in, over the course of days and weeks and look at the average blood pressure.

Sandra Awaida: is a tremendous help, first of all to even start with even diagnosing blood pressure, you know, confirming the diagnosis of blood pressure for patients who are studying on new medication sometimes.

Sandra Awaida: You know they it was probably just like a white coat syndrome in the office and at home, they are perfectly.

Sandra Awaida: Control So these are, I think this is one big thing of a stroke, prevention and bringing them sooner so bringing them to go much sooner, because we are able to see their numbers.

Sandra Awaida: We call them we do the Tele health or we bring them for in office visit, so they don't wait for three to four weeks for a follow up because we see that they actually need their medication to be tailored according to what we were we want them to be.

Todd Eury: anything we mentioned nitric oxide and that's something that i'm taking myself just based on talking with several pharmacists, including Dr Lisa fast, who talked to me about.

Todd Eury: Berkeley life and i've been on that for about six months now, I do see a difference, I feel.

Todd Eury: More energy in the morning, I still drink that cup of coffee, so I think that, in combination with that skin me extra pat.

Todd Eury: But um there's the sexual health side of things that I definitely see an impact i'm going to be 50 this summer, but i'm starting to pay attention to my health a lot better than I used to.

Todd Eury: And that's been kind of part of my new regimen based on what i've read as well as the the the the the pulitzer prize or.

Dr. Nathan S. Bryan: Nobel Prize.

Todd Eury: Nobel prize that was done on nitric oxide, exactly, so I was really fascinated by that can you kind of talk about nitric oxide, specifically in why.

Todd Eury: it's a heart health tool that a pharmacist could could recommend and feel feel that they're not just talking about some hey here's another supplement take this it's it's backed by scientific information.

Dr. Nathan S. Bryan: yeah so it's you know every major human chronic disease is a result of lack of blood flow and like of nitric oxide production so on the topic of stroke.

Dr. Nathan S. Bryan: You know, a stroke, because you have disease bug business it's not because you have heart disease, heart disease results from endothelial dysfunction and.

Dr. Nathan S. Bryan: Insufficient perfusion to the heart and it's because the blood vessels, the coronary arteries get inflamed they get five built that the pipe becomes unstable.

Dr. Nathan S. Bryan: And it ruptures it's been represented accordingly, but so it's a heart attack vectors in a cerebral blood vessel it's an ischemic stroke.

Dr. Nathan S. Bryan: So it's systemic disease that's the problem and you cannot separate heart disease from baster dementia and alzheimer's to kidney disease and renal insufficiency it's all the same problem.

Dr. Nathan S. Bryan: you've got a disease blood vessel that can't make nitric oxide and the consequences of that, as you have increased inflammation.

Dr. Nathan S. Bryan: oxidative stress and immune dysfunction is characteristic of every single disease, whether it's diabetes, heart disease, kidney disease, I mean it's all the same problem.

Dr. Nathan S. Bryan: So that's the importance of nitric oxide, if your blood vessels are healthy the endothelial cells and cells, the line the blood vessels.

Dr. Nathan S. Bryan: can make nitric oxide, they maintain their barrier function and that barrier function is much different in the brain than it is in the heart delivered.

Dr. Nathan S. Bryan: So there's local control and that local control is mediated by the ability of those in the female cells in that basket been to make nitric oxide.

Dr. Nathan S. Bryan: To dilate the blood vessels to refuse those regions upon need same thing with the sex organs, if you have sexual dysfunction That means that you have vascular dysfunction.

Dr. Nathan S. Bryan: You cannot violate the blood vessels to getting bored when you're trying to recall memory and you can dilate the blood vessels, the prefrontal cortex you can't recall memory.

Dr. Nathan S. Bryan: You get faster dimension, the mechanism is all the same, and it all revolves around the production of Microsoft side you can make nitric oxide.

Dr. Nathan S. Bryan: You have a Hypo profusion of oregon's your blood pressure, goes up you have more damage to the blood vessels and it's a vicious cycle.

Dr. Nathan S. Bryan: The only way to stop that vicious cycle is to restore the production of nitric oxide, unfortunately, you know, through my 20 years of research, I have dozens of issued patents.

Dr. Nathan S. Bryan: We commercialized a lot of this we have many clinical published randomized placebo controlled clinical trials showing the benefits.

Dr. Nathan S. Bryan: So we started out in the supplement space, because I don't know if a lot of people if your audience knows, but nitric oxide is a gas.

Dr. Nathan S. Bryan: it's a gas that's produced the lining of the blood vessels it's gone in less than a second, so we figured out how to make a solid dose of nitric oxide, that you can put in your mouth and allow the body to metabolize this and generate nitric oxide get.

Dr. Nathan S. Bryan: So that's the trick and that's been really the hurdle for big pharma to develop drugs for the past 30 years everybody's been unsuccessful because they didn't realize, you know the physical chemistry of Microsoft sudden we've cracked we solve that.

Todd Eury: But the key word that he just said Jennifer was materialisation and immediately makes me think of you for your.

Todd Eury: passion and pharmacogenomics and assuring that the medications that we're taking our in fact working as designed should be based on that testing.

Todd Eury: Can you kind of give our listeners how you've incorporated PG X into the world of cardiovascular health and even give us some examples of of what you've learned.

Absolutely.

Jennifer Clark Marquez: pharmacogenomics is the interplay of how your genes and your drugs interact with one another and when the mapping of the human genome project.

Jennifer Clark Marquez: happened they began to identify the genes that were associated with drug metabolism, and they have found out so much information about drugs toxicities efficacy and a large portion of the pharmacogenomics jeans.

Jennifer Clark Marquez: Do interfere with cardiovascular agents so agents, one of the the most well known, is Plavix or clopidogrel.

Jennifer Clark Marquez: And we know that about a third of the population lacks sufficient enzyme activity to activate that pro drug.

Jennifer Clark Marquez: And so, in those patients, it is not likely to be as effective or in some patients not effective at all, so that puts patients who have.

Jennifer Clark Marquez: Am I and need a stent and they they get put on Plavix if they lack that enzyme activity and then can't activate the drug then they're at much higher risk of having a second heart attack developing stroke.

Jennifer Clark Marquez: Because they're basically on an inactive growth and, in that case we would make recommendations for those patients to try and alternative agent that is likely to be effective for them so that's one example.

Jennifer Clark Marquez: You know, patients that do have clots that need to go on warfarin as someone that has dealt with warfarin before and it's a nightmare At times they have identified four genes probably more but for.

Jennifer Clark Marquez: That are involved with or for metabolism and there's actually an online tool, you can use that will take a patient specific genetic Leal results.

Jennifer Clark Marquez: Along with other factors like smoking liver disease concurrent drugs, and you can use their.

Jennifer Clark Marquez: Genetic results, and this calculator will help you decide and initial dose for war friend and for somebody that did this 10 years ago and didn't have this technology that is just mind blowing that.

Jennifer Clark Marquez: You can figure out how to best dose someone with your friend from their genetics that's just amazing.

Jennifer Clark Marquez: Other examples would be Staten therapy, so we know there are genes associated with.

Jennifer Clark Marquez: Staten my apathy and toxicity, so we can predict which patients may have that toxicity and maybe choose alternative agents that are less likely to cause those issues it's just very fascinating and it's really lead to improvements in patient care for patients with cardiovascular disease.

Todd Eury: So I think of this starting point of where the patient is getting a super intense amount of attention, and that is the emergency room they came in there in an ambulance they had a heart attack.

Todd Eury: Maybe they went unconscious the the ambulance crew, Ms brought them back everything's there now they rushed into the emergency room.

Todd Eury: They go through the process of whatever they go through the physician saves their lives now it's time to get them, you know, in a position of recovery.

Todd Eury: And at that point it's a wake up call this individual let's say it's you know it's me it's I wake up i'm like wow what happened.

Todd Eury: And now it's time for me to meet with the discharge and the and the, the pharmacist and in walks in DR Brittany and she's like you know Todd you're a mass.

Todd Eury: You probably wouldn't say it that way let's start you on a regimen of medications to assure that xyz is taken care of.

Todd Eury: Brittany take us through it, because i'm sure that that's an actual situation that you've probably been through numerous of times but take us through.

Todd Eury: How do we go from that bedside situation in coaching to the patient falling off in adherence and then coming back to the emergency room or unfortunately maybe dying because they didn't pay attention.

Brittany Messer: This is where I feel like pharmacists pharmacists can make the biggest impact, I do I do a lot of transitions okay and you're correct I would not probably call them a mess, but.

Brittany Messer: My first thing first I work with the medical team to see okay what's our plan are we all on the same page and a lot of times i'll ask me or my recommendations.

Brittany Messer: And so once I know what i'm walking into in regards to like Okay, this is our plan for discharge in terms of the medications.

Brittany Messer: I like to talk with the patient find out honestly their social situation, because the first thing I look for is barriers to success.

Brittany Messer: And are those a is that something I can eat with do I have any recommendations or resources, I can provide to them, because I do work in a very rural area so that's huge a lot of times, it can be as small as.

Brittany Messer: Well, I can't call him my refills because I can't read or write.

Brittany Messer: And that's a real life situation i've encountered in it's sad but that's the good part of this i'm able to figure out like hey Okay, and I know this is a.

Brittany Messer: I do not do this for every patient but Okay, how can I do this, he doesn't have a caregiver he doesn't have any relatives that helped him.

Brittany Messer: If I can mark on my calendar once a month when his refills do he actually I got him set up with our pharmacy here at Marshall health, we have an outpatient pharmacy we use.

Brittany Messer: And I called them and said hey Mr so and so it's it's due for his refills do it like that's taken care of so utilizing the resources, you have available to i'm lucky to have an outpatient pharmacy we can use.

Brittany Messer: They meld a patient's so say we live two hours away it's hard for us to get out of our hauler it's hard for us to get transportation Okay, what can I do to make sure they're able to get the meds.

Brittany Messer: Say it's just the compliance issue well I just forget easy recommendation, do you got a cell phone yes set an alarm on your phone daily.

Brittany Messer: And we always think of the toolbox, but just by the big thing for me is trying to just narrow down okay what's our barrier here, and how can we overcome that talk to them if they're blessed enough to have a caregiver at home.

Brittany Messer: talk with them, because a lot of times I see, especially in our elderly patients it's the children or the spouse, taking care of them in that situation i'm.

Brittany Messer: Just preach compliance, a lot of times, where I am in a position to the transitions of care i'll do one quick follow up Okay, how are we doing if I think it's going to be more of a situation like hey.

Brittany Messer: They probably need a senior follow up go ahead and get that making sure they keep their appointments nursing and the discharge papers may tell them that, but just making sure like hey, this is the important part.

Brittany Messer: Not just compliance, not just the medications but make sure you're taking the recommendations you've been.

Brittany Messer: taught upon discharge, making sure you're following the lifestyle modifications if you're able, because not everybody can exercise 30 minutes a day, I see a lot of transplant all bad patients that's not practical so just trying to narrow down for them what works for them in their.

Brittany Messer: Home Office essentially and making sure that they have the resources to overcome their barriers is huge.

Todd Eury: And thank you so much for that one of the key terms conditions, chronic conditions that i'm hearing about Sandra is hypertension.

Todd Eury: And how this turns it could be, you know prevented obviously through maintaining healthy weight or eating a diet, full of vegetables or something that's.

Todd Eury: In it, with less trans fats and less sugars cutting back on your salt exercising regularly limiting your alcohol managing stress it sounds.

Todd Eury: You know, we can rattle that off, but sometimes in the real world it's it's hard to do all of those things to prevent hypertension and or.

Todd Eury: bring down the hypertension level that becomes very dangerous for a patient's life.

Todd Eury: What i'm trying to build through the puzzle pieces of today's webinar for our listeners and our Community pharmacy owners are programs that they can put together but break it down into sections that are.

Todd Eury: palatable that we can bite on them as a as a communicator as an educator as a healthcare destination for our Community pharmacies, can you kind of break down the hypertension, specifically and kind of give our listeners, a kind of a.

Todd Eury: Maybe a mini blueprint.

Todd Eury: of how to actually manage that, from a preventative aspect, but then also dealing with the chronic disease state as in itself.

Sandra Awaida: Sure, so maybe like talking about how to start a remote patient monitoring program is that what you.

Todd Eury: Know be.

Todd Eury: that'd be terrific because I want to talk to more about the technology that we can employ to through remote remote patient monitoring.

Sandra Awaida: yeah, so I think with remote patient monitoring and but also in chronic care management, you really need a software system to support that so you need a portal for the monitoring of.

Sandra Awaida: You know the weight or the blood pressure, whichever vital that you choose to monitor and same thing for the chronic care management, you need something to track the patients must be, because this is a monthly service that we provide and just to jump back a little bit on.

Sandra Awaida: The previous discussion about you know the continuation of care that Dr message was talking about is chronic care management provides the service, not all pharmacists are as great a doctor Messer as.

Sandra Awaida: At following up with their patients when they leave the hospital, because once they leave hospital, they are very confused.

Sandra Awaida: As to Okay, I came in with something very different than what I left with, and if there was no medication reconciliation, there is this room, this opportunity for intervention that really impacts patient tremendously.

Sandra Awaida: they're usually older patients, they have dementia, and so they really need the support system to coach them as to what medication to take, and this in between visits, so that the chronic care management provides.

Sandra Awaida: Is the biggest value they know they have someone to call they know someone to have the questions but.

Sandra Awaida: And that's a completely different subject that we can talk to you about for two hours about you know what other benefits that brings not only to the patient, but also to the practice itself to have a chronic care management Program.

Sandra Awaida: Set up but to go back to your question for rpm for remote patient monitoring we do, we chose to do a blood pressure.

Sandra Awaida: And you can do vitals also like wait for heart failure patients as well, because you know we know all everybody knows, the issue of you know, water retention and you know changing something changes in one or two pound weights within 24 hours this all needs to be tracked but to.

Sandra Awaida: For rpm specifically.

Sandra Awaida: We need to vet which vendor we want to use if we are using.

Sandra Awaida: A vendor to send the devices to the patient, because the devices, need to be sent to patients home or they can be set up in the practice this is really a preference that the practice itself, you know chooses to.

Sandra Awaida: To do the portal how accessible the portal is how the alert comes in, how do we pay for the portal so understanding the business as well or remote patient monitoring is a very big.

Sandra Awaida: Factor because you need to justify the expense as well, I mean How much is it going to be paid for by medicare who covers it.

Sandra Awaida: So there's a lot of components involved, besides the clinical aspect, and of course the.

Sandra Awaida: Financial outcome beneficial outcome on the society at large and on healthcare expenditure at large, but also to the practice itself, and this really needs to be way into set it up and i've helped several pharmacists do that.

Sandra Awaida: And they I connected with them through linkedin because they need is tremendous you know they like you just tell me how did you set it up and there's tremendous opportunity for pharmacists, not only in private practice or academia, but also in.

Sandra Awaida: In Community pharmacy I know, Dr amenable Walker and.

Sandra Awaida: JESSICA.

Sandra Awaida: hair yep yes, thank you, thank you, they have published a great study in last year and 20 end of 2020 where they did implement a.

Sandra Awaida: type of chronic care management Oh, thank you, you are very well prepared.

Sandra Awaida: Okay, great and yeah so they do discuss how they did it and the challenges that it involved and.

Sandra Awaida: So it is being implemented in Community pharmacy as well.

Todd Eury: So listeners my favorite people pharmacists providers out there you have an opportunity to package this together it's not packaged for you, because your Community pharmacy is different than everybody's.

Todd Eury: Your resources, the technology that you employ the pharmacy software system that you have.

Todd Eury: it's a little different but there's an opportunity to announce to your community that you have a program a clinic a class something to bring them in to educate your patient first.

Todd Eury: to let them know that you're prepared to invest in their heart health.

Todd Eury: and being able to do a collection of different things to help them understand the importance of heart health whether that's preventative.

Todd Eury: Or if it's after an occurrence of a heart attack or something that was very serious that came from an occurrence that they experienced regardless.

Todd Eury: you're the key you are the healthcare destination so think about this nitric oxide nutrition exercise remote patient monitoring.

Todd Eury: Follow ups, maybe a clinic maybe this clinic has meetings once every two months, or maybe it's part of a Community Center gathering.

Todd Eury: that that is a Community communicating this to your your community, but I absolutely agree with Dr Messer was saying with Dr Brian was saying, Dr marquez and Dr a sorry to say.

Todd Eury: A lot of a lot of said that they're all saying the exact same thing, and that is education, first, so I kind of want to come back to Dr Brian and talk about adherence, and that is.

Todd Eury: So now i'm a Community pharmacists i'm listening to this, I have an Ark safe system that allows me to package medications to make it very easy for my patients to strip off their 8am dose there.

Todd Eury: Should the prescribed medications also a company something else that a patient should be taking, you know aka nitric oxide and who is this for and what's the base case case scenario to kind of introduced this to my patient base.

Dr. Nathan S. Bryan: yeah great question and i'll just take a step back and address the hypertension, because hypertension, is the number one modifiable risk factors for the number one number one killer of men and women worldwide, which is cardiovascular disease.

Dr. Nathan S. Bryan: So remote patient monitoring is important but it's only important if you act on the data.

Dr. Nathan S. Bryan: And, as I mentioned 50% of the people that are put on an antihypertensive medications their blood pressure, some in two out of three Americans have.

Dr. Nathan S. Bryan: elevated blood pressure and two out of three Americans use mouthwash we put on this several years ago.

Dr. Nathan S. Bryan: it's not a coincidence, we clearly defined the mechanism of this bios of the oral microbiome and hypertension.

Dr. Nathan S. Bryan: fact I was part of a National Institute of Health experts working through years ago there's a clear association, we will define.

Dr. Nathan S. Bryan: That, if you have this bios is we focus on the oral microbiome that it's hypertension, is a symptom of world disposed so.

Dr. Nathan S. Bryan: If you have unmanaged blood pressure and this explains resistant hypertension.

Dr. Nathan S. Bryan: So your blood pressure not mom not normalized with ace inhibitors are aarp us, but then you don't have a renewed interest it's a problem, calcium channel antagonists don't normalize your blood pressure, because you don't have a dysregulation of calcium.

Dr. Nathan S. Bryan: You have an oral dis bios because, whether you use an antiseptic mouthwash that kills the good bacteria that generate nitric oxide.

Dr. Nathan S. Bryan: or you're using fluoride based toothpaste, which acts as an antiseptic and fills the good bacteria and disrupt your microbiome.

Dr. Nathan S. Bryan: The result is the same are the consequences, the same you become nitric oxide, efficient, you have high blood pressure, the other problem is an acid specifically proton pump.

Dr. Nathan S. Bryan: It completely shut down nitric oxide, in fact, patients have been on TV is for three to five years have a 40% higher incidence of heart attack and stroke again the mechanism as well defined and published and.

Dr. Nathan S. Bryan: it's it's monitoring but being able to understand the mechanism and etiology and individual patients to understand why do you have high blood pressure.

Dr. Nathan S. Bryan: You have the problem is a magnesium deficiency so from my experience, if you get a reason mouthwash stop using mouthwash allow the microbiome to repopulate and become diversified replete magnesium.

Dr. Nathan S. Bryan: and get off certain drugs that are causing nitric oxide deficiency, the body heals itself that's the magic of the human body, it heals itself provided you give it what it needs.

Dr. Nathan S. Bryan: But going back now to phase to kind of phrase your question I think medication is important if you have to be on it and manage.

Dr. Nathan S. Bryan: But I think it's more important to give your body what it needs most diseases chronic diseases are caused from nutrient deficiency.

Dr. Nathan S. Bryan: So you're going to repeat what the body is missing, so our approach is look if you're on medication or some type of form of therapy to manage your chronic condition or even like you condition.

Dr. Nathan S. Bryan: Then that's fine that's kind of the life balance, but then let's get to the root cause and nitric oxide is kind of the I think the savior model from.

Dr. Nathan S. Bryan: I mean, obviously I have a very strong bias, but I think the clinical and scientific data cooperate them.

Dr. Nathan S. Bryan: That, if you start to restore the body's production of my oxide blood pressure roses markers of inflammation go down.

Dr. Nathan S. Bryan: You profuse oregon's better, including the sex organs, the heart the brain every tissue to the body performs better if you.

Dr. Nathan S. Bryan: have an open highway to get oxygen and nutrients to individual organs, tissues and cells of the body.

Dr. Nathan S. Bryan: So that's our approach, I think, if you send them home with medication, there are certain certain medications will actually lead to a depletion of certain nutrients.

Dr. Nathan S. Bryan: And I think pharmacist understand that better than anybody, so if you're taking stands, you have to take co Q 10.

Dr. Nathan S. Bryan: If you're taking an assets, you have to repeat the vitamins and hired and iodine things that you need stomach and support.

Dr. Nathan S. Bryan: But the body will never hear, without fail, without with without stomachache so best case scenario, you can begin to wean patients off.

Dr. Nathan S. Bryan: I think that's the conversation both physicians and pharmacists need to do that conversations never, never happened.

Dr. Nathan S. Bryan: You put on medication to go back to your doctor no that's not working, a spiritual another medication that's the wrong approach.

Dr. Nathan S. Bryan: We have to change the conversation and say what's going on in your body your body let's address it, where we can eventually get you off of these drugs when we're not dealing with an acute Christ.

Todd Eury: So I want to talk about the sensitivity of that communication between the primary care physician and the pharmacist and in the majority of time from my experience in talking with so many Community pharmacy owners.

Todd Eury: That communication is there and it's it's healthy and there isn't really any issues, but we know we don't live in a perfect world, and the tension between.

Todd Eury: A physician and a pharmacist can can come into play and i'm wondering Jennifer in new understanding PG X, for example, you may find out hey the the medication that your physician has prescribed you.

Todd Eury: isn't working as its intended as it was designed to do, therefore i'm going to make a suggestion to your physician to change that medication.

Todd Eury: talk to me about maybe as an instance that that was an experience that you had and and then communicate with our pharmacy owners listening in right now, some of your advice of how to actually approach that.

Jennifer Clark Marquez: Absolutely, this is something that I actually dealt with yesterday and.

Jennifer Clark Marquez: part of my business model is I market directly to patients so patients actually come directly to me to get a pharmacogenomics consultation and comprehensive medication evaluation done.

Jennifer Clark Marquez: So I work with patients directly, but I also work directly with providers, so if a patient comes to me directly, and we almost always have a finding that is significant for at least one of their medications.

Jennifer Clark Marquez: Then there is definitely an art to communicating with physician, that has not asked for your advice.

Jennifer Clark Marquez: But you're providing it and I just make sure to be very clear, I do prepare soap notes, and so in that note I make it clear that this is a service that the patient has pursued on their own.

Jennifer Clark Marquez: And that i'm providing the communication to them as a part of my console but the patient, that the patient has requested, you know that I.

Jennifer Clark Marquez: share my recommendations for therapy and I just make sure to be clear about the fact.

Jennifer Clark Marquez: That especially for pharmacogenomics we have evidence based guidelines that are.

Jennifer Clark Marquez: regularly updated freely available and I actually quote the guidelines in my notes, so that the physicians are very familiar with clinical guidelines so.

Jennifer Clark Marquez: they're more receptive when they know something is evidence based and they can see it, even if they're not familiar with it or familiar with the terminology so.

Jennifer Clark Marquez: It is, it can be interesting, sometimes when you're like I said, giving advice to people that didn't ask for it, but once they see the the evidence there.

Jennifer Clark Marquez: i've had good success with providers being very receptive and listening to the recommendations and considering those and i've seen some wonderful results with patients it's it's very rewarding.

Jennifer Clark Marquez: And it's very exciting, it can be a little scary though so it's understandable, you want to be very careful with how you approach your communication, but you know, pharmacists are pros at communicating with physicians and standing their ground so.

Jennifer Clark Marquez: it's it's a natural process.

Todd Eury: Brittany, this is your cue because you're surrounded by physicians all day long that you work with and some you probably work with very well and others, maybe not so much, but.

Todd Eury: Recently, the American Medical Association was arguing basically with pharmacist with regards to test to treat initiatives governing coven 19 therapies and therapeutics and pharmacists are.

Todd Eury: Lifting their hands up and they are saying, where the medication experts, we don't want to be the physician.

Todd Eury: We want to be a.

Todd Eury: pharmacist, would you please, let us be pharmacist, what do you say to our listeners that want to understand that communication for better heart health specifically.

Brittany Messer: So.

Brittany Messer: As she mentioned stay underground I always say if you're not 100% sure offer to look it up in this stance, you have to present with confidence respect, of course, but with confidence, because if you don't.

Brittany Messer: they're going to be like yeah okay go on your way and not take you seriously so that's the biggest thing I know I came into this position, and I was like who.

Brittany Messer: You know cardiology cannot the stereotypical like who they're hard to talk to you i'm just showing like okay this, these are my skills.

Brittany Messer: This is why I know i'm here for a reason and just kind of I call it earn in the street cred so show your worth.

Brittany Messer: And that's the biggest things I preach to my pharmacy residents i'm like, if you want to be taken seriously, you need to show that you can do good work you need to answer questions with confidence so yeah going back to that scenario I think just.

Brittany Messer: That with respect but show like this, this is what I have to say, this is why i'm saying it and always go back to guidelines go to your primary literature.

Brittany Messer: updates journals anything you can find a backup your answer, but make sure you go to them with confidence so that way you can under strict credit.

Todd Eury: Excellent.

Todd Eury: Thank you for that Sandra I want to come back to you because i'm thinking you know if i'm a Community pharmacist and I have a program that i've designed that includes pharmacogenomics.

Todd Eury: Adherence packaging coaching education nitric oxide evidence based medicine to kind of wrap all around it and I sent a PDF to.

Todd Eury: A physician and saying you know here's what we'd like to do it, I can't help but think that the physician would applaud that and they'd say you know this is amazing, but what What about that communication of such a program to get the blessing from that primary care physician.

Sandra Awaida: yeah and it's very interesting you mentioned this today because.

Sandra Awaida: Yesterday, there was a very interesting 30 minute presentation on the GT Mr X, Mr X website on the value based proposition of pharmacists doing those interventions.

Sandra Awaida: And the University of South Carolina is working on an amazing program I think it's called the right drug act or collaborative something, and they are in the process of publishing it and they've been.

Sandra Awaida: Actually, either they start slow they don't start you know by saying Okay, we want to take over all your patients and take care of them doing those all those services for them, I think this is a very important way to approach it is to.

Sandra Awaida: You know, like a pilot type of type of type of intervention and then this will show value and will help them proceed further into expanding their program another.

Sandra Awaida: strategy I think is very key is that physicians are burned out, they have so much on their plate they see so many patients and they have such little time to.

Sandra Awaida: spend so if we touch on their pain points which is really you know i'll take care of that you know i'll answer your patient medication questions I will monitor or we you know, depending on how how who you are right through presenting this this program we will be able to look at their.

Sandra Awaida: For instance, diabetes.

Sandra Awaida: blood sugar readings, we will manage that we will look at their.

Sandra Awaida: blood pressure readings, we will look at their weight it takes a lot of their plate, and so it doesn't take much for physician to say you know what, if I have someone.

Sandra Awaida: You know who is doing this, the nitty gritty of chronic care chronic disease management, and I can focus on let's say, depending on the specialty you know, whatever they're actually you know, need to be treating.

Sandra Awaida: It it's not a hard seller, I would say, and especially now, and this is what actually the University of South Carolina is doing they're partnering with payers and.

Sandra Awaida: And the PCP and try to find a way to for pharmacists to be paid for the service and, obviously, you know, trying to buy in on the physicians because it does bring a lot of.

Sandra Awaida: referrals also to the practice because it brings it brings up the patient satisfaction, it brings up the the.

Sandra Awaida: You know, it makes better outcome for the patient and patient come back and ask for it, and I think they've had such an amazing feedback from patients that they have to ask.

Sandra Awaida: physicians the healthcare actually system, ask the physicians, why is it that we have suddenly such amazing ratings that from patients, and it is it really coincided with the service where pharmacists were actually spending, this time with their patients.

Sandra Awaida: So I think this those are really good points, you know that will help physicians on board, and I have to also definitely agree with everything that was said before about the guidelines.

Sandra Awaida: Before PGA expenses, we do pharmacogenomics for clopidogrel in our practice and it was only post ACS and post pci where we had guidelines for that, and recently with the January 2020 to.

Sandra Awaida: update it really expanded to all neuro vascular or I mean a lot of neuro vascular indication, so it was definitely a door opener for newer vascular and neurologist to start accepting and incorporating PG X in their decision making.

Todd Eury: So Nathan, my favorite people are Brittany and Jennifer and sanjay just because they're pharmacist and i'm a i'm a fanboy so.

Todd Eury: You know you're the researcher of the group, but you present an extremely interesting background, and in really leveraging your evidence based studies.

Todd Eury: So if you were a pharmacist and you were in the place of Sandra Jennifer Brittany and you were trying to communicate with a with a physician about evidence based study to kind of back up a program that you were.

Todd Eury: Launching talk to us about how you would communicate that in an x and be specific around nitric oxide as well.

Dr. Nathan S. Bryan: yeah so I come from a little different background with it with a degree in biochemistry and molecular and cellular physiology.

Dr. Nathan S. Bryan: You know I think I have a pretty good understanding of how the body works.

Dr. Nathan S. Bryan: And how drugs are completely different and how the drug body interactions is a much more complex sentence so.

Dr. Nathan S. Bryan: I can see where they your favorite snippet coming, so my favorite to them, and I think pharmacists, are some of the most important health care.

Dr. Nathan S. Bryan: providers out there, because they understand that the interaction with the drug drug interactions from coke kinetics now the pharmacogenomics but for me in terms of nitric oxide my job, and I think everyone's job positions job would be to get people off.

Dr. Nathan S. Bryan: We have the technology now that we understand the extent and mechanism of every single human chronic disease, to the extent we can fix it.

Dr. Nathan S. Bryan: We know what goes wrong and people with heart disease cardiovascular disease and alzheimer's and now we have the technology to diagnose it and give the body what it needs for the body to heal itself.

Dr. Nathan S. Bryan: And in my 20 years of research on nitric oxide it's become very clear to me that the body cannot and will not feel or perform until you restore the production of nitric oxide.

Dr. Nathan S. Bryan: Now it's not a silver bullet it's, not an end all be all pure all their other problems you have to do, but you cannot fix these problems, whether it's hormonal whether it's.

Dr. Nathan S. Bryan: neurological until you restore the blood supply to that particular organ can you do, that the only way you do that is through nitric oxide and you have.

Dr. Nathan S. Bryan: Clear Tropic effects of nitric oxide you suppress the vascular installation you decrease oxidative stress you decrease the immune dysfunction.

Dr. Nathan S. Bryan: that's hallmarks of any major chronic disease So for me from any program whether it's kind of an adjunct for pharmacotherapy nitric oxide is the first shouldn't be the first consideration for anything.

Dr. Nathan S. Bryan: Because you have to get oxygen nutrients to every single organ tissue and cell of the body.

Dr. Nathan S. Bryan: And then, if you want to deliver drugs specifically if they're you know neurotrophic drugs for your logical disease.

Dr. Nathan S. Bryan: those parts of the brain are a scheming because they don't have one So what do you do to deliver those drugs.

Dr. Nathan S. Bryan: You know, we did this 15 years ago where we were you know loading nanoparticles with nitric oxide for directed chemo therapeutic agents directly to the hypoxic to environment.

Dr. Nathan S. Bryan: So the science is there now you don't have to do that, you can we have technology that produces nitric oxide in the human body, you open up the.

Dr. Nathan S. Bryan: resistant vessels lowers blood pressure, you open up the small blood vessels for fuse you know individual tissues and cells of the body.

Dr. Nathan S. Bryan: that's the basis, and I think everybody wins from that because it gives you know the pharmacist, a better indication of how the body is going to work, we can normalize that you get adequate perfusion to organs pharmacogenetics and form of code.

Dr. Nathan S. Bryan: are much more predictable if vascular function structure of patients become normal.

Dr. Nathan S. Bryan: And then you can begin to have the discussion of weaning people off trends specifically status proton pump inhibitors I mean those are the two that.

Dr. Nathan S. Bryan: are, I think the risk benefit analysis is way tilted for the risk, instead of any known benefit.

Dr. Nathan S. Bryan: So I think that's the program you're going to start and look it's the same theme it's education and where does it start you know.

Dr. Nathan S. Bryan: I think, Britain, we had a very good point it's very hard to train physicians it's like teaching an old dog new tricks.

Dr. Nathan S. Bryan: So, to train physicians only importance of nitric oxide that our cardiologists pulmonologist that are used to you know given nitroglycerin nitric oxide delta to Angela patients for pulmonary hypertension.

Dr. Nathan S. Bryan: You know you have to start, so we started with educating the consumers, and I think in this particular venue here, we have to educate all people that have a point of care and interaction.

Dr. Nathan S. Bryan: With both patients and consumers that's the program it's education.

Dr. Nathan S. Bryan: But it's educating the proper science and that's very important, there are a lot of charlatans out there, especially in the supplement world.

Dr. Nathan S. Bryan: And you have to be able to distinguish real science from fraudulent marketing by some companies often, so I think that's that's the game, we got to play and I think the only way we're going to make a huge difference in healthcare is through education and reaching the masses.

Todd Eury: Absolutely an amen and I love the fact that you said you know the the fake meds and the fake.

Todd Eury: You know, information that's out there it's it's that it's that place of trust it's evidence based study it's evidence based practice it's.

Todd Eury: it's following up on your your continuing education and just continuing to fill your your mind with the next innovative way of taking care of patients.

Todd Eury: I am so excited about this if you're listening in this has been an amazing panel, I want to say thank you to Dr a way to I want to say thank you to Dr Brian Thank you so much, Dr master for being here, Dr marquez.

Todd Eury: will be following up with you very soon, but pharmacy podcast listeners are safe, a special thank you to the Ark safe team for doing this for us today and sponsoring this content for us today.

Todd Eury: There is so much to put together, you are not alone if you're listening to this right now you're a pharmacy owner, you can reach out to the rx a team their marketing team is so.

Todd Eury: Educational driven and based that we can get you plugged in with a remote patient monitoring solution or we can get you plugged in with pharmacogenomics or an adherence Program.

Todd Eury: regardless, you are not alone, so this is just the tip of the iceberg, to really dig down into pharmacist important the role of pharmacist in heart health and with that I thank you so much for listening today and I thank you to our panelists.

Dr. Nathan S. Bryan: Thank you.

Jennifer Clark Marquez: Thank you.

Brittany Messer: for having us.