You review an 82-year-old woman in clinic. Last month she had a one-off blood pressure reading of 150/92 mmHg and was offered ambulatory blood pressure monitoring. This shows an average reading of 146/94 mmHg. She has no significant past medical history of note other than hypothyroidism. Her 10-year cardiovascular risk is calculated to be 16%.
What is the most appropriate management?
Correct Answer C:
NICE now only recommend diagnosing people over the age of 80 years as hypertensive if they have stage 2 hypertension (ABPM daytime average or HBPM average BP >= 150/95 mmHg). Remember that the diagnostic criteria are different from the blood pressure targets once treatment has started, which for people over the age of 80 years are:
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:
What is the target INR for a patient with a mechanical mitral valve?
Correct Answer D:
Mechanical valves - target INR:
Prosthetic heart valves:
The most common valves which need replacing are the aortic and mitral valve. There are two main options for replacement: biological (bioprosthetic) or mechanical.
Following the 2008 NICE guidelines for prophylaxis of endocarditis antibiotics are no longer recommended for common procedures such as dental work.
What is the main reason for checking the urea and electrolytes prior to commencing a patient on amiodarone?
Correct Answer E:
All antiarrhythmic drugs have the potential to cause arrhythmias. Coexistent hypokalaemia significantly increases this risk.
Amiodarone:
Amiodarone is a class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias.
The main mechanism of action is by blocking potassium channels which inhibits repolarisation and hence prolongs the action potential. Amiodarone also has other actions such as blocking sodium channels (a class I effect).
The use of amiodarone is limited by a number of factors:
Monitoring of patients taking amiodarone:
Adverse effects of amiodarone use:
Which one of the following statements regarding Brugada syndrome is correct?
Brugada syndrome:
Brugada syndrome is a form of inherited cardiovascular disease with may present with sudden cardiac death. It is inherited in an autosomal dominant fashion and has an estimated prevalence of 1:5,000-10,000.
Brugada syndrome is more common in Asians.
Pathophysiology:
ECG changes:
Management:
A 62-year-old female with no past medical history is admitted to hospital with a left-sided hemiparesis. Examination reveals that she is in atrial fibrillation. CT scan of her brain shows a cerebral infarction.
What is the most appropriate anticoagulation strategy for this patient?
Correct Answer B:
Atrial fibrillation: post-stroke:
NICE issued guidelines on atrial fibrillation (AF) in 2006. They included advice on the management of patients with AF who develop a stroke or transient-ischaemic attack (TIA). Recommendations include:
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