A 74-year-old woman is reviewed. She recently had ambulatory blood pressure monitoring that showed an average reading of 142/90 mmHg. There is no significant past medical history of note other than hypothyroidism. Her 10-year cardiovascular risk score is 23%.
What is the most appropriate management?
Correct Answer A: The average reading is above the treatment threshold for patients below the age of 80 years. Treatment with a calcium channel blocker should therefore be started.
Hypertension diagnosis and management:
NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
Blood pressure classification:
This becomes relevant later in some of the management decisions that NICE advocate.
Diagnosing hypertension: If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis. Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment. Ambulatory blood pressure monitoring (ABPM)
Managing hypertension ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension):
For patients < 40 years consider specialist referral to exclude secondary causes.
Step 1 treatment:
Step 2 treatment:
Step 3 treatment:
NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice.
Step 4 treatment:
If BP still not controlled seek specialist advice.
New drugs Direct renin inhibitors:
You review a 62-year-old man who has recently been discharged from hospital in Hungary following a myocardial infarction. He brings a copy of an echocardiogram report which shows his left ventricular ejection fraction is 48%. On examination his pulse is 78 / min and regular, blood pressure is 124 / 72 mmHg and his chest is clear. His current medications include aspirin, simvastatin and lisinopril.
What is the most appropriate next step in terms of his medication?
Correct Answer C: Both carvedilol and bisoprolol have been shown to reduce mortality in stable heart failure. The other beta-blockers have no evidence base to support their use.
NICE recommend that all heart failure patients should take both an ACE-inhibitor and a beta-blocker.
Heart failure drug management:
A number of drugs have been shown to improve mortality in patients with chronic heart failure:
No long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.
NICE issued updated guidelines on management in 2010, key points include:
*Digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties. Digoxin is strongly indicated if there is coexistent atrial fibrillation
**Adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
A 55-year-old man is admitted to the Emergency Department with 'tearing' chest pain radiating through to his back. Examination reveals a pulse of 96 / min regular, blood pressure of 130/85 mmHg and oxygen saturations of 97% on room air. A chest x-ray shows mediastinal widening. A CT shows dissection of the ascending aorta.
What is the most suitable initial management?
Correct Answer D:
Aortic dissection:
The question tests ability to apply textbook knowledge to real world situations. Whilst surgical referral should be made as soon as possible definite surgery will inevitably take time and the blood pressure should be controlled in the meantime.
Aortic dissection management:
Stanford classification:
DeBakey classification:
Type A:
Type B*:
*Endovascular repair of type B aortic dissection may have a role in the future
A 72-year-old man presents with lethargy and palpitations for the past four or five days. On examination his pulse is 123 bpm irregularly irregular, blood pressure is 118/70 mmHg and his chest is clear. An ECG confirms atrial fibrillation.
What is the appropriate drug to control his heart rate?
Correct Answer B: Atrial fibrillation: rate control - beta blockers preferable to digoxin.
A number of factors including age and symptoms would favour a rate control strategy. The NICE guidelines suggest either a beta-blocker or a rate limiting calcium channel blocker (i.e. Not amlodipine) in this situation.
Some clinicians would prefer to use a more cardio-selective beta-blocker such as bisoprolol, although this is not stipulated in current guidelines.
Atrial fibrillation: rate control and maintenance of sinus rhythm: The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006. The following is also based on the joint American Heart Association (AHA), American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines.
Agents used to control rate in patients with atrial fibrillation:
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation:
The table below indicates some of the factors which may be considered when considering either a rate control or rhythm control strategy:
A 17-year-old female presents with recurrent attacks of collapse. These episodes typically occur without warning and have occurred whilst she was running for a bus. There is no significant past medical history and the only family history of note is that her father died suddenly when he was 38- years-old.
What is the likely cause?
Correct Answer D: Sudden death, unusual collapse in young person - ?Hypertrophic Obstructive Cardiomyopathy (HOCM).
HOCM features:
Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. The estimated prevalence is 1 in 500.
Associations:
Echo - mnemonic - MR SAM ASH:
ECG:
Click to expand