Clinical Study Day 1, Patient A

Question 1

What is the recommended alcohol units intake per week?

Answer 1

14 per week for men and women

Question 2

How many units of alcohol are in a large glass of wine?

Answer 2

3.5

Question 3

NICE recommends that adults with a TC of above what before treatment are assessed for familial hypercholesterolaemia?

Answer 3

Above 7.5mmol/L

Question 4

What is the NICE target TC level?

Answer 4

5mmol/l or less

Question 5

What are the treatment options for familial hypercholesterolaemia?

Answer 5

High-intensity statin and aim for at least a 50% reduction in LDL-C concentration from the baseline measurement.

Ezetimibe monotherapy is recommended as an option for treating primary heterozygous-familial hypercholesterolaemia in adults in whim initial statin therapy is contraindicated.

Ezetimibe and statin co-therapy only in those whose LDL is not controlled.

The decision to offer treatment with a bile acid sequestrant (resin) or a fibrate in addition to initial statin therapy should be taken by a specialist in people with an intolerance to statins and ezetimibe.

Question 6

What mAb are available for the treatment of FH?

Answer 6

Alirocumab and evolocumab.

Question 7

Stage 1 hypertension is defined as?

Answer 7

Clinic blood pressure is 140/90mmHg or higher and subsequent ABPM daytime average or home blood pressure monitoring (HBPM) is 135/85mmHg or higher.

Question 8

What are the mechanisms of action of statins?

Answer 8

HMG-CoA reductase inhibitors, inhibit cholestorel synthesis, increase LDL uptake, decrease specific protein prenylation.

Question 9

To who should atorvastatin 20mg od be offered for the primary prevention of CVD?

Answer 9

To people who have a 10% or greater 10-year risk of developing CVD.

Question 10

Antihypertensive treatment should be offered to people under 80 years of age with stage 1 hypertension who have one or more of what? [5]

Answer 10

1. Target organ damage
2. Established cardiovascular disease.
3. Renal disease
4. Diabetes
5. A 10-year cardiovascular risk equivalent to 20% or greater.

Question 11

What is the target clinic blood pressure in people aged 80 or over with treated hypertension?

Answer 11

80 and over, below 50/90mmHg.

Under 80, below 140/90mmHg

Question 12

People under the age of 55 years should be offered what as stage 1 antihypertensive treatment?

Answer 12

ACE inhibitor or a low cost ARB if ACEi not tolerated.

Question 13

What are the possible side effects of ACE inhibitor?

Answer 13

Dry cough.
Increased blood-potassium level (hyperkalemia).
Fatigue. 
Dizziness due to low blood pressure.
Headache.
Loss of taste.

Question 14

Why do ACE inhibitors cause dry cough at times?

Answer 14

Cause is multifactorial, ACEi prevent the breakdown of bradykinin and substance P, resulting in an accumulation of these protussive mediators in the respiratory tract.

Question 15

What is step 1 antihypertensive treatment for people aged over 55 years of age or black/caribbean people of any age?

Answer 15

CCB, if a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic instead.

Question 16

In people over the age of 55 or black/caribbean people of any age, what is the diuretic of choice if those unable to be treated with CCBs?

Answer 16

Thiazide-like diuretic, such as chlortalidone (12.5 - 25.0mg once daily) or indapamide (1.5mg modified-release once daily or 2.5mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.

Question 17

In who would beta-blockers be initiated for hypertension?

Answer 17

In younger people, particularly:

Those with an intolerance or contraindication to ACEi and ARB or

Women of child-bearing potential or

people with evidence of increased sympathetic drive.

Question 18

What are the main side effects of CCB?

Answer 18

Lightheadedness/low blood pressure. 
Slower heart rate. 
Constipation.
Swelling of the feet ankles and legs. 
GERD. 
Increased appetite. 
Gingival overgrowth.

Question 19

What is step 3 antihypertensive treatment in a white man of 50?

Answer 19

Meds review to ensure adherence to step 2.

Then, the combination of an ACE inhibitor/ angiotensin II receptor blocker, CCB and thiazide-like diuretic should be used.

Question 20

What are the main side effects of ARBs?

Answer 20

Hyperkalaemia
Headaches
Nausea 
Vomiting 
Dizziness

Question 21

What is step 4 treatment of hypertension?

Answer 21

Specialist.
For treatment of resistant hypertension consider further diuretic therapy with low-dose spironolactone (25mg once daily) if the blood potassium level is 4.5mmol/l or lower.

Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5mmol/l.

Question 22

What is the advice regarding the prescribing of simvastatin and potent CYP3A4 inhibitors (Itraconazole, ketoconazole, erythromycin, clarithromycin, telithromycin, and HIV protease inhibitors)?

Answer 22

All are contraindicated with simvastatin.

Question 23

What is the advice regarding the prescribing of atorvastatin and potent CYP3A4 inhibitors (Itraconazole, ketoconazole, erythromycin, clarithromycin, telithromycin, and HIV protease inhibitors)?

Answer 23

Avoid if possible: consider temporary suspension of atorvastatin if interacting drug is taken for short period; itraconazole: do not exceed 40mg atorvastatin daily; Clarithromycin: do not exceed 20mg atorvastatin daily.

Question 24

What is the maximum daily dose of simvastatin when used in combination with diltiazem?

Answer 24

40mg daily.

Question 25

What is the maximum daily dose of simvastatin/atorvastatin with ciclosporin?

Answer 25

10mg for both. Contraindicated in rosuvastatin.