CCCP Certification Review

CCCP Certification Review

A Review Guide for the Certified Cardiometabolic Care Pharmacist (CCCP) Exam

ACC/AHA: American College of Cardiology/American Heart Association

ACEi: Angiotensin-Converting Enzyme Inhibitor

ADA: American Diabetes Association

ARB: Angiotensin II Receptor Blocker

ARNI: Angiotensin Receptor-Neprilysin Inhibitor

ASCVD: Atherosclerotic Cardiovascular Disease

BMI: Body Mass Index

BP: Blood Pressure

CAC: Coronary Artery Calcium (Score)

CKD: Chronic Kidney Disease

CVD: Cardiovascular Disease

DAPT: Dual Antiplatelet Therapy

DASH: Dietary Approaches to Stop Hypertension

DPP-4i: Dipeptidyl Peptidase-4 Inhibitor

eGFR: Estimated Glomerular Filtration Rate

GLP-1 RA: Glucagon-Like Peptide-1 Receptor Agonist

HDL-C: High-Density Lipoprotein Cholesterol

HFpEF: Heart Failure with Preserved Ejection Fraction

HFrEF: Heart Failure with Reduced Ejection Fraction

LDL-C: Low-Density Lipoprotein Cholesterol

Lp(a): Lipoprotein (a)

MRA: Mineralocorticoid Receptor Antagonist

NAFLD: Non-Alcoholic Fatty Liver Disease

PCSK9i: Proprotein Convertase Subtilisin/Kexin type 9 Inhibitor

SGLT2i: Sodium-Glucose Cotransporter-2 Inhibitor

T2DM: Type 2 Diabetes Mellitus

TG: Triglycerides

  • The Cardiometabolic Syndrome: A cluster of interrelated conditions (including insulin resistance, hypertension, dyslipidemia, and central obesity) that significantly increase the risk for developing cardiovascular disease and type 2 diabetes.
  • Insulin Resistance: The core pathophysiologic driver. A state where cells in the body do not respond effectively to insulin, leading to elevated blood glucose and compensatory hyperinsulinemia.
  • The Role of Inflammation: Chronic, low-grade inflammation is a key mechanism linking obesity, insulin resistance, and atherosclerosis.
  • Atherosclerosis: The process of plaque buildup in the arteries, which is the underlying cause of heart attacks and most strokes.
  • The Kidney-Heart Connection: Understanding the bidirectional relationship where chronic kidney disease (CKD) is both a cause and a consequence of cardiovascular disease.
  • Lifestyle as Medicine: The foundational principle that nutrition, physical activity, sleep, and stress management are the most powerful interventions for preventing and treating cardiometabolic disease.
  • ACC/AHA Blood Pressure Guidelines: Knowing the current BP categories (Normal, Elevated, Stage 1, Stage 2) and the thresholds for initiating pharmacotherapy.
  • First-Line Agents: The four main classes are thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers.
  • Compelling Indications: Selecting specific antihypertensive agents based on a patient's comorbidities (e.g., ACEi/ARB for patients with CKD or diabetes with albuminuria).
  • Resistant Hypertension: Defined as uncontrolled BP despite the use of three antihypertensive agents of different classes, including a diuretic. Management involves adding a mineralocorticoid receptor antagonist (MRA) like spironolactone.
  • Proper BP Measurement Technique: A critical skill for accurate diagnosis and management, including proper cuff size, patient positioning, and taking multiple readings.
  • Lifestyle Interventions: The importance of the DASH diet, sodium restriction, regular aerobic exercise, and limiting alcohol intake as first-line and adjunctive therapy.
  • Statin Therapy: The cornerstone of ASCVD prevention. Understanding the four statin benefit groups and the different statin intensity levels (high, moderate, low).
  • ASCVD Risk Assessment: Using the Pooled Cohort Equations to estimate a patient's 10-year risk of a first ASCVD event to guide the decision to initiate statin therapy for primary prevention.
  • Non-Statin Therapies: The role of ezetimibe and PCSK9 inhibitors as add-on therapy for very high-risk patients who do not achieve LDL-C goals on maximally tolerated statin therapy.
  • Statin-Associated Muscle Symptoms (SAMS): A common patient concern. Management involves ruling out other causes, potentially holding and re-challenging with a different statin, and considering CoQ10 supplementation.
  • Hypertriglyceridemia: Management focuses on lifestyle changes and addressing secondary causes. Pharmacotherapy (e.g., fibrates, icosapent ethyl) is considered for severe hypertriglyceridemia (>500 mg/dL) to reduce the risk of pancreatitis.
  • Risk-Enhancing Factors: Factors beyond the standard risk calculator that may favor statin initiation in borderline-risk patients, such as a family history of premature ASCVD or a high coronary artery calcium (CAC) score.
  • Comprehensive Care (A, B, C's): Management goes beyond glucose control and includes A1c, Blood pressure, Cholesterol, Diabetes kidney disease, and Cardiovascular risk reduction.
  • First-Line Therapy: Metformin and comprehensive lifestyle modification are the foundation of T2DM management.
  • Cardiorenal Risk Reduction: For patients with established ASCVD, heart failure, or CKD, SGLT2 inhibitors and/or GLP-1 receptor agonists with proven benefit should be used independently of A1c.
  • SGLT2 Inhibitors: A class of drugs that not only lower glucose but also have proven benefits for reducing heart failure hospitalizations and progression of CKD.
  • GLP-1 Receptor Agonists: A class of injectable (and some oral) agents that are highly effective for glucose lowering, promote weight loss, and have proven benefits for reducing MACE in patients with ASCVD.
  • Hypoglycemia Management: Identifying and managing hypoglycemia is a critical safety concern, especially with insulin and sulfonylureas.
  • Technology in Diabetes: Understanding the role of continuous glucose monitors (CGMs) and insulin pumps in modern diabetes management.
  • Obesity as a Chronic Disease: Understanding the complex pathophysiology of obesity, which involves hormonal, genetic, and environmental factors, not just a lack of willpower.
  • Indications for Pharmacotherapy: Anti-obesity medications are indicated as an adjunct to lifestyle changes for patients with a BMI ≥30 kg/m² or a BMI ≥27 kg/m² with at least one weight-related comorbidity.
  • GLP-1 Receptor Agonists for Weight Loss: High-dose GLP-1 RAs (e.g., semaglutide, liraglutide) and dual agonists (e.g., tirzepatide) are the most effective pharmacologic options for weight management.
  • Other Pharmacologic Options: Knowledge of other agents like phentermine/topiramate, naltrexone/bupropion, and orlistat.
  • Metabolic Surgery: Understanding that bariatric surgery is the most effective and durable treatment for severe obesity.
  • Guideline-Directed Medical Therapy (GDMT) for HFrEF: The four pillars of therapy that have been shown to reduce mortality are 1) ARNI/ACEi/ARB, 2) Evidence-based beta-blocker, 3) MRA, and 4) SGLT2 inhibitor.
  • Heart Failure with Preserved Ejection Fraction (HFpEF): Management focuses on controlling blood pressure, managing volume overload with diuretics, and the emerging role of SGLT2 inhibitors.
  • Secondary Prevention of ASCVD: For patients with known ASCVD (e.g., post-MI, stroke), management includes high-intensity statin, antiplatelet therapy (aspirin and/or P2Y12 inhibitor), and aggressive risk factor control.
  • Dual Antiplatelet Therapy (DAPT): Understanding the indications and appropriate duration of DAPT (e.g., aspirin + clopidogrel) after a myocardial infarction or coronary stent placement.

ASCVD Pooled Cohort Equations

A risk calculator that estimates the 10-year risk of a first hard ASCVD event. Used to guide primary prevention statin therapy.

Friedewald Equation (for LDL-C)

LDL-C = Total Cholesterol - HDL-C - (Triglycerides / 5)

Note: This equation is inaccurate when triglycerides are >400 mg/dL.

Blood Pressure Classification (ACC/AHA)

Normal: <120/80 mmHg
Elevated: 120-129/<80 mmHg
Stage 1 HTN: 130-139 or 80-89 mmHg
Stage 2 HTN: ≥140 or ≥90 mmHg

Ankle-Brachial Index (ABI)

A non-invasive test to screen for peripheral artery disease (PAD). Calculated by dividing the ankle systolic pressure by the brachial systolic pressure. An ABI <0.9 is diagnostic of PAD.

  • Treat the Patient, Not the Number: While treatment targets are important, the ultimate goal is to reduce the patient's long-term risk of cardiovascular events and improve their quality of life.
  • The Power of Combination Therapy: Recognizing that cardiometabolic diseases are complex and often require multiple medications with complementary mechanisms of action to achieve treatment goals.
  • Early and Aggressive Intervention: The understanding that preventing or delaying the onset of cardiovascular complications requires early and aggressive management of all modifiable risk factors.
  • Lifestyle is Non-Negotiable: The core belief that pharmacotherapy is an adjunct to, not a replacement for, a foundation of healthy nutrition, regular physical activity, and other lifestyle modifications.
  • Team-Based, Collaborative Care: The most effective cardiometabolic care is delivered by an interprofessional team (pharmacist, physician, dietitian, CDE) working in collaboration with an empowered patient.
  • The Pharmacist as a Clinical Intensivist: The role of the pharmacist is not just to dispense, but to actively manage and intensify therapy in a timely manner to help patients reach their goals faster and more safely.
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