GP 1 Flashcards
What is QIntervention?
Qintervention is a simple on-line tool that works out 10 year risk of developing CVD and diabetes. It is very quick to complete on-line, and importantly it shows patients:
Their 10 year risks in a very simple graphic display
Calculates what the benefits would be of various interventions, such as going on statins, losing weight, stopping smoking and reducing BP
estimates for patients a cardiovascular risk ‘age’ for them (similar to the ‘lung age’ concept when performing spirometry in smokers)
The QRISK data has been validated and should now be used as the ‘predictor of choice’. It predicts risk better than Framingham scores for UK populations.
High BP increases the risk of which conditions?
- stroke
- myocardial infarction
- heart failure
- chronic kidney disease
- cognitive decline
- premature death
How does BP relate to mortality?
Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality:
- 7% from heart disease
- 10% from stroke.
Is hypertension screened for in the UK population and how much of the budget is spent on hypertension care?
Routine periodic screening for high blood pressure is now commonplace in the UK as part of National Service Frameworks for cardiovascular disease prevention. Consequently, the diagnosis, treatment and follow-up of people with hypertension is one of the most common interventions in primary care, accounting for approximately 12% of Primary Care consultation episodes and approximately £1billion in drug costs in 2006.
What proportion of the UK population have hypertension?
At least one quarter of adults (and more than half of those older than 60) have high blood pressure.
What is hypertension?
Interpret mean for ABPM or HBPM of ≥135/85 as Stage 1 Hypertension i.e. equivalent to clinic reading of ≥ 140/90
Interpret mean for ABPM or HBPM ≥ 150/95 Stage 2 Hypertension i.e. equivalent to clinic reading of ≥ 160/100
How do you diagnose hypertension?
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [2011]
When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00).
Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. [2011]
When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that:
- for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and
- blood pressure is recorded twice daily, ideally in the morning and evening and
- blood pressure recording continues for at least 4 days, ideally for 7 days.
Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [2011]
When should you offer antihypertensive treatments?
Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:
- target organ damage
- established cardiovascular disease
- renal disease
- diabetes
- a 10-year cardiovascular risk equivalent to 20% or greater. [2011]
Offer antihypertensive drug treatment to people of any age with stage 2 hypertension. [2011]
For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. [2011]
How should you treat hypertension?
Step 1 treatment:
- Offer people aged under 55years step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB. [new 2011] [1.6.6]
- Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011] [1.6.7]
- Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55years and to black people of African or Caribbean family origin of any age. 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. [new 2011] [1.6.8] [KPI]
- If diuretic treatment is to be initiated or changed, offer a 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. [new 2011] [1.6.9] [KPI]
- For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.10] [KPI]
Related recommendations:
Recommendations 1.6.11 and 1.6.12 have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 34, 2006).
Step 2 treatment
If blood pressure is not controlled by step1 treatment, offer step2 treatment with a CCB in combination with either an ACE inhibitor or an ARB. [new 2011][1.6.13]
If a CCB is not suitable for step2 treatment, 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. [new 2011] [1.6.14]
For black people of African or Caribbean family origin, consider an ARB in preference to an ACE inhibitor, in combination with a CCB. [new 2011] [1.6.15]
*Choose a low-cost ARB
Additional information: the pathway above focuses on stage 1 and 2 hypertension. For the full care pathway see page 35 of the NICE guideline.
Step 3 treatment
Before considering step3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses. [new 2011] [1.6.16]
If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor blocker), calcium-channel blocker and thiazide-like diuretic should be used. [2006] [1.6.17]
Step 4 treatment
Regard clinic blood pressure that remains higher than 140/90mmHg after treatment with the optimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as resistant hypertension, and consider adding a fourth antihypertensive drug and/or seeking expert advice. [new 2011] [1.6.18]
For treatment of resistant hypertension at step 4:
Consider further diuretic therapy with low-dose spironolactone4 (25mg once daily) if the blood potassium level is 4.5mmol/l or lower. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia.
Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5mmol/l. [new 2011] [1.6.19] [KPI]
When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium and potassium and renal function within 1month and repeat as required thereafter. [new 2011] [1.6.20]
If further diuretic therapy for resistant hypertension at step 4 is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker. [new 2011] [1.6.21]
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained.
What are the different stages of hypertension?
Stage 1 hypertension
Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension
Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Severe hypertension
Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.
What is postural hypertension and what should you do?
If the systolic blood pressure falls by 20 mmHg or more when the person is standing:
- review medication
- measure subsequent blood pressures with the person standing
- consider referral to specialist care if symptoms of postural hypotension persist. [2004, amended 2011]
What are the side effects of statins?
A few people may get unintended effects when starting statin treatment.
With the statins, you would have the following risks in the next 10 years:
- 5% risk of acute renal failure (ARF)
- 8% risk of cataract
- 2% risk of having abnormal liver function tests (LFT) severe enough for you to need to stop taking statins
- 6% risk of getting serious myopathy
Where should you measure BP?
Both arms!
An inter-arm difference of >10mmHg suggests peripheral arterial disease,
The increased cardiovascular mortality suggests that such patients should be treated with antiplatelets and statins, but this approach has yet to be tested in RCTs
How do you treat someone with severe hypertension?
If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM
While waiting for confirmation of a diagnosis of hypertension, what investigations should you carry out?
Investigations for target organ damage:
- a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool
- test urine for presence of protein
- take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol
- examine fundi for hypertensive retinopathy
- arrange a 12-lead ECG.
What blood pressures should you aim for?
140/90 mmHg in people aged under 80
150/90 mmHg in people aged 80 and over
How would you treat hypertension in a woman of child bearing age?
CCB
What lifestyle factors would you suggest for hypertension?
- Ask routinely about diet and exercise patterns and offer guidance backed up with written and/or audio-visual material
- Stop smoking!
Reduce
- Total and saturated fat and red meat, sugar and sugary drinks and refined carbohydrate
- Salt
- Alcohol, except modest amounts of red wine
- Discourage ‘excessive caffeine’
Increase
- Fruits and vegetables, whole grains, fish and poultry
- Low fat dairy products, olive oil and garlic
- Aerobic exercise
- Relaxation!
- Relaxation therapies reduce BP. NICE state people may wish to try them, but they would not expect PCTs to fund them!!
Up to what age can QRisk2 be used?
84
What are the pitfalls of QRisk2?
- Do not use QRISK2 in patients with CKD Stage 3 or more (eGFR<60)
- Take into account that risk scores may under-estimate risk in some groups of patients e.g.
with serious mental illness, inflammatory disorders and HIV - Measure total cholesterol and HDL to best estimate risk, and fasting sample is NOT needed
- USE QINTERVENTION TOOL AS PATIENT DECISION AID
What baseline assessments should you do before starting lipid lowering treatment?
Before starting treatment, perform baseline bloods
- Full lipid profile including triglycerides
- HbA1c
- Renal function and eGFR, Transaminase level (ALT or AST) and TSH
- Can use statins if upper limit <3 times upper limit of normal
- Before starting, ask if patients have had unexplained persistent muscle pain and if they have check
- CK levels (do not check CK if asymptomatic)
- If >5 times upper limit of normal, re-measure after 1 week. If still at this level, do not start statin. If CK raised but at <5 times upper limit of normal, start statin at a lower
When should you use a statin?
Primary prevention
- offer high intensity treatment to those with a > 10% 10 year risk
- Atorvastatin 20mg is recommended as the primary prevention drug of choice
- Consider offering to those aged over 85 because ‘statins maybe of benefit in reducing nonfatal MI’ in this group
Secondary prevention
- Patients with established CVD should be offered a high dose of 80mg of atorvastatin
- Use lower dose if patient preference or concern re interactions or adverse effects
- Do not delay statin treatment in secondary prevention to manage risk factors
Diabetes
- Offer atorvastatin 20mg to all patients with type 1 diabetes for primary prevention if they
are older than 40, have had diabetes for >10 years or have other CVD risk factors (C)
- Offer atorvastatin 20mg for the primary prevention to people with type 2 DM if they have >10% 10 year risk on QRISK2
CKD
- Offer atorvastatin 20mg for primary or secondary prevention of CVD to people with CKD
- If eGFR is <30, specialist advice on higher doses is needed
What’s the aim of lipid lowering therapy?
check levels after 3/12, and if a >40% reduction in non-HDL cholesterol (this is total cholesterol minus HDL, which is confusingly not the same as LDL!) has not been achieved to
Discuss adherence and take at night, optimise lifestyle advice and consider a dose increase (upto a maximum of atorvastatin 80mg) based on clinical judgement
What would you not give someone with renal artery stenosis?
ACEi (ramapril)
ARB (losartan)
What initial care and support should I offer an adult with type 2 diabetes?
- Ensure that an individual care plan is set up for all adults with type 2 diabetes, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long-term interventions because of reduced life expectancy.
- Offer a structured group education programme (diabetes together in Oxford), for example the DESMOND (Diabetes Education for Self-Management for Ongoing and Newly Diagnosed) programme, to the person and/or their family/carers.
- Offer this programme at or around the time of diagnosis, with annual reinforcement and review.
- Explain to the person and/or their family/carers that structured education is an integral part of diabetes care.
- Provide an alternative of equal standard for a person unable or unwilling to participate in group education, depending on local availability.
- ## Ensure that the person and/or their family/carers know how to contact the diabetes team during working hours and out of hours, as available.Provide information on government disability benefits, if needed — Benefits calculators are available at www.gov.uk.
- Manage lifestyle issues, such as diet and exercise.
- Screen for complications of type 2 diabetes, such as retinopathy and diabetic foot problems.
- Provide up-to-date information (including written information) on diabetes support groups (local and national), including information on how to contact them and the benefits of membership. e.g diabetes UK
How do you diagnose diabetes?
Diabetes symptoms (e.g. polyuria, polydipsia and unexplained weight loss for Type 1) plus:
- a random venous plasma glucose concentration ≥ 11.1 mmol/l or
- a fasting plasma glucose concentration ≥ 7.0 mmol/l (whole blood ≥ 6.1 mmol/l) or
- two hour plasma glucose concentration ≥ 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT)
- An HbA1c of 48mmol/mol (6.5%) is recommended as the cut off point for diagnosing diabetes
2 positive tests if asymptomatic
What is pre diabetes known as and what are the cut offs?
Non diabetic hyperglycaemia
- HbA1c 6-6.4%
- Fasting 5.5-6.9 mmol/l
- GTT 7.8-11
What are the 9 processes of care?
Monitor:
- HbA1c
- urine albumin:creatine ratio
- eGFR
- BP
- eyes
- foot
- BMI
- cholesterol
- smoking
What are the complications of diabetes?
Short term
- feeling shit
- infection
Long term
Microvascular - retinopathy - neuropathy - nephropathy (complication of poor glycaemic control)
Macrovascular - CV disease - cerebrovascular disease - peripheral vascular disease (mainly determined by BP control, cholesterol, smoking)
How should you treat diabetes?
- diet and exercise
2. diet, exercise and metformin (500mg/day, build to 1g/day)
What are the benefits and SE of metformin?
Benefit: improves glycaemic control and macrovascular complication rate
SE: GI upset
If someone has poorly controlled diabetes with diet/exercise or diet/exercise/metformin what should you do?
- check compliance
- review what they’re doing
- add in a second oral agent
What oral agents are used to control diabetes? What are the benefits/SE?
Gliptin/dipeptidyl peptidase 4 inhibitors
- increase glucose in insulin dependent manner
- increase satiety
- decrease HbA1c by 0.6%
- don’t improve macrovascular events
- Adverse effects, including nasopharyngitis, headache, nausea, heart failure, hypersensitivity and skin reactions, increased risk of developing acute pancreatitis
Pioglitazone
- not used now
- roseglitazone increased rate of CV mortality
- increase risk of bladder cancer
- inc risk of atypical fractures
Sulphonylureas
- risk of hypos/weight gain
- no macrovascular improvement
GLP1/Glucagon-like peptide-1
- injected 1/day or 2/day or 1/week
- increase satiety
- increase weight loss
- doesn’t improve CV outcome
SGLT2 inhibitors
- weight loss
- good CV outcomes
- SE: UTIs, candidia
- normoglycaemic ketoacidosis
How do gliptins work?
Gliptins/DPP-4 inhibitors work by blocking the action of DPP-4, an enzyme which destroys the hormone incretin.
Incretins help the body produce more insulin only when it is needed and reduce the amount of glucose being produced by the liver when it is not needed. These hormones are released throughout the day and levels are increased at meal times.
How do glitazones work?
activating PPARs/reduce insulin resistance
How do sulphonylureas work?
activate pancreatic beta cells to realease insulin
How do SGLT2 inhibitors work?
SGLT2 inhibitors, also called gliflozins, are a class of medications that inhibit reabsorption of glucose in the kidney and therefore lower blood sugar. They act by inhibiting sodium-glucose transport protein 2 (SGLT2).
Who do you give statins to?
- QRisk > 10%
- diabetics with nephropathy
- previous CV event
- diabetics with end organ damage
