Clinical Case Studies Week 1 (HTN,AF,HF)

Question 1

Reference range for potassium?

Answer 1

Reference Range: 3.5 – 5.0 mmol/L

Question 2

Reference range for sodium

Answer 2

Reference range: 135 – 145 mmol/L

Question 3

What mmol/L indicates a diabetic patient for 2 hour postprandial glucose challenge?

Answer 3

< 7.8 mmol/L indicate normal glucose

>7.8 and < 11.0 mmol/L indicate impaired glucose tolerance

> 11.1 mmol/L indicate diabetes is likely

Question 4

What is the glycosylated hemoglobin (HbA1c) test? What is the target?

Answer 4

Reflect average of your blood glucose level over the past 10–12 weeks (average life cycle for RBC)

Target: ≤53 mmol/mol or ≤7%

Question 5

Total cholesterol, LDL cholesterol, HDL cholesterol, Triglycerides level target?

Answer 5

Total cholesterol < 5.5 mmol/L

LDL cholesterol< 2 – 3.4 mmol/L

HDL cholesterol> 1.0 mmol/L

Triglycerides <1.7 mmol/L

Hypercholesterolaemia is defined as total cholesterol > 5.5 mmol/L

Hypertriglyceridaemia is defined as triglyceride level of > 1.7 mmol/L

Question 6

What is the blood pressure readings for hypertension?

Answer 6

Systolic BP (pressure during ventricular contraction –> pumping) > 140 mmHg

Diastolic BP (pressure during ventricular filling / relaxation –>filling) > 90 mmHg

Question 7

Adverse effects of ace inhibitors?

Answer 7

Hypotension (especially first dose effect)

Angioedema

Dry Cough (5-20% of patients)

Hyperkalaemia (especially in Type I Diabetes, and in patients with renal impairment).

Headache, facial flushing –> renal impairment, skin rashes, l

Question 8

Dose of the following ace inhibitors for hypertension:

A) Ramipril

B) Perindopril

C) Lisinopril

D) Quinapril

E) Captopril

Answer 8

A)

Adult, oral 2.5 mg once daily, increase after 2–3 weeks to 5 mg if necessary. Maximum 10 mg daily in 1 or 2 doses.

B)

Perindopril arginine, adult, oral, start at 5 mg once daily. Maximum 10 mg once daily.

Perindopril erbumine: 4 to 8 mg orally, daily

C)

Adult, oral, initially 5–10 mg once daily; if necessary, increase at intervals of 2–4 weeks up to 20 mg once daily. Maximum 40 mg daily.

D)

Adult, oral, initially 5–10 mg once daily; increase at 4‑week intervals to 10–40 mg daily in 1 or 2 doses.

E)

Oral, initially 12.5 mg twice daily, increased at intervals of 2–4 weeks to 25–50 mg twice daily.

Question 9

ARB and ACE inhibitors have the same drug interactions except for?

Answer 9

Lithium –> decreased excretion of Lithium and increased risk of lithium toxicity in Angiotensin Receptor Blockers (ARB)

Question 10

Common and infrequent AE of ARB?

Answer 10

Common adverse effects

Dizziness, hyperkalaemia, headache.

dont use in pregnancy

Infrequent adverse effects

First dose orthostatic hypotension

Rash, diarrhoea, dyspepsia, muscle cramps

Insomnia, nasal congestion.

Question 11

Doses of the following ARB (sartans) for hypertension:

A) Candersartan

B) Irbesartan

C) Olmesartan

D) Telmisartan

E) Valsartan

Answer 11

A)

Adult, oral, initially 8 mg once daily; usually 8–16 mg once daily; increase if necessary to 32 mg once daily.

B)

Adult, oral, usually 150 mg once daily; increase if necessary to 300 mg once daily.

C)

Oral, initially 20 mg once daily; after 8 weeks, increase if necessary to 40 mg once daily.

D)

Hypertension, oral, usually 40 mg once daily; increase if necessary to 80 mg once daily.

E)

Adult, oral, usually 80 mg once daily; increase if necessary to 160 mg once daily. Maximum 320 mg once daily

Question 12

Common and infrequent/rare AE of CCB?

Answer 12

common AE

headache, flushing, peripheral oedema & palpitations (DHPs especially)

> gingival hyperplasia

> bradycardia (diltiazem, verapamil)

> constipation (verapamil)

infrequent/rare AE

Dyspepsia (DHPs especially)

AV block, hepatitis, development or worsening of heart failure (diltiazem, verapamil)

Question 13

Diltiazem/verapamil with digoxin?

Answer 13

Increased digoxin concentration

Question 14

Dihydropyridines/verapamil with hepatic enzyme inducers such as carbamazepine, phenobarbitone, phenytoin, rifampicin

Answer 14

Increase metabolism of dihyropyridines and verapamil –> reduce efficacy of dihydropyridines

Question 15

Diltiazem with lithium

Answer 15

Increased risk of lithium neurotoxicity

Question 16

What are the doses for the following CCB for hypertension:

A) Amlodipine

B) Nifedipine

C) Felodipine

D) Nimodipine

E) Diltiazem

F) Verapamil

Answer 16

A)

Adult, child >6 years: initially 2.5–5 mg once daily, increasing if necessary after at least 1–2 weeks to a maximum of 10 mg once daily.

B)

Controlled release tablet: initially 30 mg once daily, increase to a maximum of 90 mg once daily (angina) or 120 mg once daily (hypertension)

Conventional tablet: initially 10–20 mg twice daily, increase to 20–40 mg twice daily.

C)

Adult, oral, initially 5 mg once daily; maintenance dose 5–10 mg once daily; maximum dose 20 mg once daily

D)

Adult, oral 60 mg every 4 hours.

E)

Controlled release products, oral, initially 180–240 mg once daily; increase as required up to 360 mg once daily.

F)

Conventional tablet, adult, initially 80 mg 2 or 3 times daily; maintenance dose, 160 mg 2 or 3 times daily.

Controlled release tablet, adult, initially 120–180 mg once daily; usual maintenance dose 240 mg once daily; increase if necessary to a maximum of 240 mg twice daily. Give daily doses >240 mg in 2 doses.

Question 17

What beta blockers to use in hypertension? When are they used? What is the dose used?

Answer 17

Not first line –> less effective than first line drugs in reducing risk of stroke. Useful in patients with both elevated BP and stable angina, and after myocardial infarction

• atenolol 25 to 100 mg orally, daily
• metoprolol tartrate 25 to 100 mg orally, twice daily.

Question 18

Thiazide diuretic to reduce blood pressure? What dose? When to use?

Answer 18

Thiazide and thiazide-like diuretics are not recommended as first-line therapy in younger patients because they are associated with new-onset diabetes

> used as first-line therapy for uncomplicated elevated BP in patients over 65 years

> avoid in those with gout

• chlortalidone 12.5 to 25 mg orally, daily
• hydrochlorothiazide 12.5 to 50 mg orally, daily
• indapamide 1.25 to 2.5 mg orally, daily
• indapamide modified-release 1.5 mg orally, daily.

Question 19

What to monitor patients taking ACE inhibitor/ARB therapy for?

Answer 19

Hypotension, kidney impairment and hyperkalaemia.

• A small rise in serum creatinine (up to 25%) or serum potassium (within the normal range) should not necessarily prompt dose reduction or cessation of the ACEI.

Question 20

What can DHP CCB cause?

Answer 20

Their vasodilatory action can cause peripheral oedema, if the peripheral oedema does not subside, it may be necessary to reduce the dose or stop therapy.

Question 21

What is the aim to reduce BP to?

Answer 21

BP to below 140/90 mmHg

Question 22

Non-pharmacological management of elevated blood pressure?

Answer 22

regular aerobic exercise (can reduce daytime BP by 3.2/2.7 mmHg)

reduction of alcohol intake

moderate sodium restriction

healthy eating

weight reduction in overweight patients (5 kg weight loss can reduce BP by 7/3 mmHg).

• Nonpharmacological strategies should continue even if drug therapy is started; they have a complementary effect on BP and improve cardiovascular outcomes beyond their effect on BP.

Question 23

What is first line drugs used foor blood pressure?

Answer 23

Angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptors blockers (ARB), dihydropyridine calcium channel blockers, and thiazide and thiazide-like diuretics are suitable first-line drugs for uncomplicated elevated BP

• Overall, these drug classes have similar efficacy in reducing BP.

Question 24

Beta blockers are no longer recommended as first-line therapy in patients with uncomplicated elevated BP, why? When are they used?

Answer 24

They are less effective than the first-line drugs in reducing the risk of stroke. However, they have a clear place in the management of patients with heart failure with reduced ejection fraction (HFrEF) and patients with coronary heart disease.

Question 25

Stepwise appproach to reducing blood pressure?

Patients commonly require two or more drugs to reach BP target

Answer 25

Start BP-lowering treatment with a single drug, usually at a low to moderate dose.

If the BP target has not been reached after 3 months of treatment, add a low dose of a second drug from a different class. This is usually more effective than increasing the dose of the initial drug.

If BP remains above the target and both drugs are well tolerated, increase the dose of one of the drugs incrementally to the maximum dose, then increase the dose of the second drug, if required.

• a thiazide or thiazide-like diuretic with an ACEI, ARB or beta blocker
• an ACEI or ARB with a calcium channel blocker
• a beta blocker with a dihydropyridine calcium channel blocker
• an ACEI or ARB with a dihydropyridine calcium channel blocker and a thiazide or thiazide-like diuretic.