Session 4.3 - Group Work Flashcards
1) A 60 year old man is found to have a persistently raised blood pressure of around 200/115. He also has signs and symptoms of mild congestive cardiac failure.
PMH: Type II diabetes controlled by diet alone. Osteoarthritis of both knees.
Medication: Naproxen 500 mg twice daily.
a) What factors might be contributing to his hypertension?
- Diabetes: Nephropathy and vascular problems
- Congestive cardiac failure
- Naproxen : reduces blood flow to the kidney
1) A 60 year old man is found to have a persistently raised blood pressure of around 200/115. He also has signs and symptoms of mild congestive cardiac failure.
PMH: Type II diabetes controlled by diet alone. Osteoarthritis of both knees.
Medication: Naproxen 500 mg twice daily.
b) Would you consider antihypertensive treatment at this level of blood pressure?
Yes - this patient has severe hypertension (systolic is >180, and diastolic above >100)
There is a high risk of vascular collapse or stroke
1) A 60 year old man is found to have a persistently raised blood pressure of around 200/115. He also has signs and symptoms of mild congestive cardiac failure.
PMH: Type II diabetes controlled by diet alone. Osteoarthritis of both knees.
Medication: Naproxen 500 mg twice daily.
c) What might he gain from effective control of his blood pressure?
Reduced effects of congestive heart failure, prevent progression to more severe HF.
Reduced risk of stroke/MI/vascular collapse
Reduced risk of atherosclerosis, arteriosclerosis
1) A 60 year old man is found to have a persistently raised blood pressure of around 200/115. He also has signs and symptoms of mild congestive cardiac failure.
PMH: Type II diabetes controlled by diet alone. Osteoarthritis of both knees.
Medication: Naproxen 500 mg twice daily.
d) What drug might be most suitable for first line treatment?
Ramipril
1) A 60 year old man is found to have a persistently raised blood pressure of around 200/115. He also has signs and symptoms of mild congestive cardiac failure.
PMH: Type II diabetes controlled by diet alone. Osteoarthritis of both knees.
Medication: Naproxen 500 mg twice daily.
e) What target blood pressure would you aim for on treatment?
Your ideal target is below 130/80 mmHg (because the patient has diabetes),
(Diabetes and renal disease you’d want it even lower: 125/70 mmHg)
However, you want to reduce from severe hypertension to Stage 2 hypertension which is 160/100 mmHg
1) A 60 year old man is found to have a persistently raised blood pressure of around 200/115. He also has signs and symptoms of mild congestive cardiac failure.
PMH: Type II diabetes controlled by diet alone. Osteoarthritis of both knees.
Medication: Naproxen 500 mg twice daily.
f) Your first line treatment achieves a blood pressure of around 160/100. What action would you take?
Either titrate the dose upwards or combine with a calcium channel blocker such as verapimil.
2) A 50-year-old man is admitted to hospital complaining of central, crushing chest pain. An acute anterior myocardial infarction is diagnosed. He receives treatment with aspirin, oxygen and primary PCI etc. He makes an uncomplicated recovery. His only identifiable risk factor for coronary heart disease is smoking (20 cigarette-pack-year history) and his only significant previous medical history is of “asthma” for which he uses a salbutamol inhaler. 48 hours after admission he is asymptomatic, BP 110/78 mmHg, heart rate 102 beats per minute, respiratory and cardiovascular examinations are otherwise normal.
a) What drug treatments would you consider at this stage?
Check local or NICE guidelines
ACE inhibitor e.g. ramipril
Beta-blocker e.g. bisoprolol, atenolol
Dual antiplatelet therapy (aspirin plus a second antiplatelet agent e.g. ticagrelor)
Statin - improves mortality doesn’t matter if you have high cholesterol
(In reality, the reason is because “in clinical trials it improves stuff”)
https://www.nice.org.uk/guidance/CG172/chapter/1-Recommendations#drug-therapy-2
2) A 50-year-old man is admitted to hospital complaining of central, crushing chest pain. An acute anterior myocardial infarction is diagnosed. He receives treatment with aspirin, oxygen and primary PCI etc. He makes an uncomplicated recovery. His only identifiable risk factor for coronary heart disease is smoking (20 cigarette-pack-year history) and his only significant previous medical history is of “asthma” for which he uses a salbutamol inhaler. 48 hours after admission he is asymptomatic, BP 110/78 mmHg, heart rate 102 beats per minute, respiratory and cardiovascular examinations are otherwise normal.
b) An echocardiogram confirms significant left ventricular dysfunction in spite of normal examination. You decide to initiate ACE inhibitor therapy.
What mechanisms underlie the beneficial therapeutic effect of ACE inhibitors in this clinical situation?
Vasodilation through inhibition of ACE reducing afterload on the heart reducing stress on the cardiac tissue
2) A 50-year-old man is admitted to hospital complaining of central, crushing chest pain. An acute anterior myocardial infarction is diagnosed. He receives treatment with aspirin, oxygen and primary PCI etc. He makes an uncomplicated recovery. His only identifiable risk factor for coronary heart disease is smoking (20 cigarette-pack-year history) and his only significant previous medical history is of “asthma” for which he uses a salbutamol inhaler. 48 hours after admission he is asymptomatic, BP 110/78 mmHg, heart rate 102 beats per minute, respiratory and cardiovascular examinations are otherwise normal.
c) What are the possible adverse effects of ACE inhibitors and how would you monitor the patient for these?
Persistent dry cough
Angioedema - Vasodilation changes vascular permeability giving protein exudation
Renal failure - reduced aldosterone reduces GFR
Hyperkalaemia - reduces renal excretion of potassium
Hypotension
2) A 50-year-old man is admitted to hospital complaining of central, crushing chest pain. An acute anterior myocardial infarction is diagnosed. He receives treatment with aspirin, oxygen and primary PCI etc. He makes an uncomplicated recovery. His only identifiable risk factor for coronary heart disease is smoking (20 cigarette-pack-year history) and his only significant previous medical history is of “asthma” for which he uses a salbutamol inhaler. 48 hours after admission he is asymptomatic, BP 110/78 mmHg, heart rate 102 beats per minute, respiratory and cardiovascular examinations are otherwise normal.
d) What other pharmacological & non-pharmacological factors would you consider in the clinical treatment of this man?
Pharmacological
- any other medication he may be on
- dietary advice: avoid grapefruit juice (drug interactions) CYP 3A4
- GTN spray to take home
- Re-assess asthma, give him beta-blocker
- Spironolactone
Non-pharmacological
- smoking cessation advice
- go see a doctor if it gets worse
3) A 35 year old lady presents at an antenatal appointment where her blood pressure is recorded as 155/105 mmHg. This is her first pregnancy and she reports that there is no familial history of pre-eclampsia. Prior to becoming pregnant her blood pressure was 123/84 and she was fit and healthy with a BMI of 26 kg/m2
.
a) What test should be carried out prior to initiating any treatment?
Check for proteinuria, a sign of pre-eclampsia, and to monitor it
3) A 35 year old lady presents at an antenatal appointment where her blood pressure is recorded as 155/105 mmHg. This is her first pregnancy and she reports that there is no familial history of pre-eclampsia. Prior to becoming pregnant her blood pressure was 123/84 and she was fit and healthy with a BMI of 26 kg/m2
b) A diagnosis of gestational hypertension is confirmed. What is the recommended treatment for this patient and what is the mechanism of action?
https://www.nice.org.uk/guidance/cg107/chapter/1-Guidance#management-of-pregnancy-with-gestational-hypertension
- Oral labetalol
- Nifedipine (CCB)
- Methyl-dopa (MOA unknown)
These lower the blood pressure in pre-eclampsia
3) A 35 year old lady presents at an antenatal appointment where her blood pressure is recorded as 155/105 mmHg. This is her first pregnancy and she reports that there is no familial history of pre-eclampsia. Prior to becoming pregnant her blood pressure was 123/84 and she was fit and healthy with a BMI of 26 kg/m2
c) What ongoing investigations should be carried out during the remainder of the pregnancy?
- Regulation of blood pressure and proteinuria
3) A 35 year old lady presents at an antenatal appointment where her blood pressure is recorded as 155/105 mmHg. This is her first pregnancy and she reports that there is no familial history of pre-eclampsia. Prior to becoming pregnant her blood pressure was 123/84 and she was fit and healthy with a BMI of 26 kg/m2
d) Following successful delivery of the baby, the mother’s blood pressure remains elevated and requires antihypertensive treatment. Which class of antihypertensive is there evidence to suggest may cause harm if breastfeeding and should be avoided?
Diuretics
- Cross through the breast milk and you do not want to dehydrate a baby
- Can also affect the amount of lactation)
4) A 46 year black man is having a routine health check for by occupational health at his employer after 6 months in a new job. His BMI is 29 kg/m2 and his total cholesterol is 7.0 mmol/litre. His blood pressure is recorded as 145/125. The new role is particularly sedentary requiring very little physical activity.
a) The GP discusses the elevated blood pressure with the patient who is not keen to initiate pharmacological therapy. What recommendations supported by evidence could the GP make before a follow up appointment in 12 weeks?
- Improve exercise/reduce sedentary lifestyle
- Eat better (change4life campaign)
