Question 16#

A 52-year-old man is seen in the hypertension clinic. He was diagnosed around three months ago and started on ramipril. This has been titrated up to 10mg od but his blood pressure remains around 156/92 mmHg.

What is the most appopriate next step in management?

A. Add bendroflumethiazide

Correct Answer D: Calcium channel blockers are now preferred to thiazides in the treatment of hypertension.

The 2011 NICE guidelines reflected the changing evidence base supporting the use of calcium channel blockers in preference to thiazide-type diuretics in the management of hypertension.

Hypertension diagnosis and management:

NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include: 

• Classifying hypertension into stages
• Recommending the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)
• Calcium channel blockers are now considered superior to thiazides
• Bendroflumethiazide is no longer the thiazide of choice

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):

• At least 2 measurements per hour during the person's usual waking hours (for example, between 08:00 and 22:00)
• Use the average value of at least 14 measurements If ABPM is not tolerated or declined HBPM should be offered.

Home blood pressure monitoring (HBPM):

• For each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
• BP should be recorded twice daily, ideally in the morning and evening
• BP should be recorded 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

Managing hypertension:

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension):

• Treat if < 80 years of age and any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension):

• Offer drug treatment regardless of age

For patients < 40 years consider specialist referral to exclude secondary causes.

Step 1 treatment:

• Patients < 55-years-old: ACE inhibitor (A)
• Patients > 55-years-old or of Afro-Caribbean origin: calcium channel blocker 

Step 2 treatment:

• ACE inhibitor + calcium channel blocker (A + C)

Step 3 treatment:

• Add a thiazide diuretic (D, i.e. A + C + D)
• NICE now advocate using either chlorthalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide
• 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:

• Consider further diuretic treatment
• If potassium < 4.5 mmol/l add spironolactone 25mg od
• If potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
• If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or betablocker

If BP still not controlled seek specialist advice.

New drugs:

Direct renin inhibitors:

• e.g. Aliskiren (branded as Rasilez)
• By inhibiting renin blocks the conversion of angiotensinogen to angiotensin I
• No trials have looked at mortality data yet. Trials have only investigated fall in blood pressure. Initial trials suggest aliskiren reduces blood pressure to a similar extent as angiotensin converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists
• Adverse effects were uncommon in trials although diarrhoea was occasionally seen
• Only current role would seem to be in patients who are intolerant of more established antihypertensive drugs

 

Question 17#

A 65-year-old man is found to have an ejection systolic murmur and narrow pulse pressure on examination. He has experienced no chest pain, breathlessness or syncope. An echo confirms aortic stenosis and shows an aortic valve gradient of 40 mmHg.

How should this patient be managed?

A. Routine aortic valve replacement

Correct Answer E: Aortic stenosis management: Aortic Valve Replacement (AVR) if symptomatic, otherwise cut-off is gradient of 50 mmHg.

No action should be taken at present as he is currently asymptomatic. If the aortic valve gradient > 50 mmHg or there is evidence of significant left ventricular dysfunction then surgery is sometimes considered in selected asymptomatic patients.

Aortic stenosis:
Features of severe aortic stenosis:

• Narrow pulse pressure
• Slow rising pulse
• Delayed ESM
• Soft/absent S2
• S4
• Thrill
• Duration of murmur
• Left ventricular hypertrophy or failure

Causes of aortic stenosis:

• Degenerative calcification (most common cause in older patients > 65 years)
• Bicuspid aortic valve (most common cause in younger patients < 65 years)
• William's syndrome (supravalvular aortic stenosis)
• Post-rheumatic disease
• Subvalvular: HOCM

Management:

• If asymptomatic then observe the patient is general rule
• If symptomatic then valve replacement
• If asymptomatic but valvular gradient > 50 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
• Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement

Question 18#

A 30-year-old woman presents to the Emergency Department with a one-day history of central chest pain. The pain is described as severe, non-radiating and eases on expiration. Clinical examination of her cardiorespiratory system is unremarkable other than a heart rate of 96 / min. An ECG shows widespread ST elevation in the anterior, inferior and lateral leads. Bloods show the following: Full blood count Normal Urea and electrolystes Normal Troponin I 0.8 ng/mL (< 0.2 ng/mL).

What is the most likely diagnosis?

A. Pulmonary embolism

Correct Answer D: A modest rise in troponin is seen in around one-third of patients with acute pericarditis.

Pericarditis:

Pericarditis is one of the differentials of any patient presenting with chest pain. 

Features:

• Chest pain: may be pleuritic. Is often relieved by sitting forwards
• Other symptoms include non-productive cough, dyspnoea and flu-like symptoms
• Pericardial rub
• Tachypnoea
• Tachycardia

Causes:

• Viral infections (Coxsackie)
• Tuberculosis xuraemia (causes 'fibrinous' pericarditis)
• Trauma
• Post-myocardial infarction, Dressler's syndrome
• Connective tissue disease
• Hypothyroidism

ECG changes:

• Widespread 'saddle-shaped' ST elevation
• PR depression 

Question 19#

A 58-year-old man with no past medical history of note is admitted to hospital with crushing central chest pain. ECG on arrival shows anterior ST elevation and he is subsequently thrombolyzed with a good resolution of symptoms and ECG changes.

Two months following discharge from hospital, which combination of drugs should he be taking?

A. ACE inhibitor + beta-blocker + statin + aspirin

Correct Answer A: The current guidance is to continue clopidogrel for 4 weeks following a ST-elevation myocardial infarction.

Myocardial infarction: secondary prevention:

NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2007. Some key points are listed below.

All patients should be offered the following drugs:

• ACE inhibitor
• Beta-blocker
• Aspirin
• Statin

Clopidogrel:

• ST-segment-elevation MI: patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks
• Non-ST segment elevation myocardial infarction (NSTEMI): following the 2010 NICE unstable angina and NSTEMI guidelines clopidogrel should be given for the first 12 months if the 6 month mortality risk* is > 1.5%

Aldosterone antagonists:

• Patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment (e.g. eplerenone) should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy

*This can be calculated using scoring systems such as GRACE

Question 20#

A 71-year-old man is reviewed in the coronary care unit. He was admitted with an anterior ST elevation myocardial infarction and received thrombolysis with alteplase. Ninety minutes following this an ECG shows a 30-40% resolution in the ST elevation.

What is the most appropriate management?

A. Percutaneous coronary intervention

Correct Answer A: 

Myocardial infarction: management:
A number of studies over the past 10 years have provided an evidence for the management of STelevation myocardial infarction (STEMI) In the absence of contraindications, all patients should be given:

• Aspirin
• Clopidogrel: the two major studies (CLARITY and COMMIT) both confirmed benefit but used different loading doses (300mg and 75mg respectively)
• Low molecular weight heparin

NICE suggest the following in terms of oxygen therapy:

• Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission

Only offer supplemental oxygen to:

• People with oxygen saturation (SpO₂) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
• People with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available

Primary percutaneous coronary intervention (PCI) has emerged as the gold-standard treatment for STEMI but is not available in all centres. Thrombolysis should be performed in patients without access to primary PCI

With regards to thrombolysis:

• Tissue plasminogen activator (tPA) has been shown to offer clear mortality benefits over streptokinase
• Tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase with a similar adverse effect profile

An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation:

• If there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis
• For patients successfully treated with thrombolysis PCI has been shown to be beneficial. The optimal timing of this is still under investigation