case studies

Question 1

Patient is a 50 year old male with a blood pressure reading of 150/95mmHg. Started to notice an increase in tiredness and occasional headaches. FHx father MI. No regular meds or allergies. British asain background.

Patient has CV risk> 10%, what pharmacological intervention could be made to help lower his BP?

Answer 1

ACEi - ramipril 2.5mg-5mg OD
or ARB - Losartan 50mg everyday

Question 2

what counselling advice must be given when taking these drugs and what must be monitored?

Answer 2

Take first dose sitting down or before bed. Renal function, electrolytes and BP must be monitored.

Question 3

what other treatment could be offered to lower his CVD risk factor?

Answer 3

Statin treatment e.g. Atorvastatin 20mg OD

Question 4

He comes back later with a higher blood pressure and is not willing to optimise his health by lifestyle changes, what other medication could be prescribed in order to help control BP and avoid target organ damage?

Answer 4

CCB - Amlodipine 5mg OD (first-line)
Thiazide - like diuretic is second line e.g. hydrochlorothiazide

Question 5

what is the physiological reason for ankle oedema with amlodipine?

Answer 5

causes vasodilation in arterioles, causing increased capillary hydrostatic pressure. So a build up of fluids leak out causing oedema.

Question 6

what enzyme is responsible for the metabolism of amlodipine to convert it to its major inactive metabolite?

Answer 6

CYP3A4 - oxidises the dihydropyridine ring.

Question 7

why is it advised against taking grapefruit juice with dihydropyridine CCBs?

Answer 7

because grapefruit juice inhibits intestinal CYP450, leading to an increased concentration of the active drug as oxidation of 1,4-DHP ring doesn’t occur as frequently.

Question 8

Patient A has chest pain when walking the dog and playing golf. He is 110kg, 5ft 8, British Asian, 60yo.
PC:
S - pain in centre of chest
O - comes during exercise
C- feels like someone is sitting on chest
R- can spread to shoulder
A- no other symptoms
T- on exertion
E - when he stops, shortly after
S - 5/10

PMHx - Hypertension + Hyperlipideamia
FHx- Father passed away from heart attack aged 58
SHx- Smoker, but trying to cut down and aiming to stop. Alcohol 2 large glasses of wine most evenings.

What is the most likely diagnosis and why?

Answer 8

Stable angina
symptoms come on exertion, but are relieved shortly after rest.
Risk factors:
- hyperlipidaemia + hypertension
- obesity
-age
-male
-FHx ACS

why not unstable: relieved at rest, predictable and first time presenting

Question 9

what would you prescribe him to relieve symptoms of angina?

Answer 9

GTN 400mcg/dose spray used when required under the tongue

Question 10

why is GTN spray administered sublingually?

Answer 10

rich source of blood vessels
thin epithelium wall
avoid first pass metabolism
sublingual mucosa is lipophilic and so is nitroglycerin