Primary Care Guidelines

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I review the NICE Clinical Knowledge Summaries (CKS) “Osteoporosis - prevention of fragility fractures” looking at both scenarios assessment and management, last updated in April 2023. I have summarised the guidance from a Primary Care perspective.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

The summary on Osteoporosis - prevention of fragility fractures can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/

The CKS “Osteoporosis - prevention of fragility fractures: Scenario: Assessment” can be found here:

·     https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/management/assessment/

The CKS “Osteoporosis - prevention of fragility fractures: Scenario: Management” can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/management/management/

The “Osteoporosis - prevention of fragility fractures: Prescribing information” can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/calcium-colecalciferol-vitamin-d3-preparations/

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/bisphosphonates/

To calculate dietary calcium intake, see the National Osteoporosis Foundation chart:

·      https://www.nof.org/patients/treatment/calciumvitamin-d/steps-to-estimate-your-calcium-intake/

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Transcript 

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Today, we'll be reviewing the NICE Clinical Knowledge Summaries (CKS) on “Osteoporosis - prevention of fragility fractures” looking at two scenarios, assessment and management, both updated in April 2023. I have summarised the guidance from a Primary Care perspective and I have put links in the episode description.

Please note that this is my interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

Please stay until the end, as I'll be sharing fictitious clinical cases created by chat GPT that will illustrate how the guideline is applied in real-life situations.

So, with that said, let's dive in!"

The video has three parts, assessment, management and prescribing information.

• Osteoporosis is characterised by low bone mass and increased bone fragility and it is asymptomatic until a fracture occurs.
• A fragility fracture is a fracture following a fall from standing height or less, typically in the wrist, spine, and hip. Vertebral fractures may occur spontaneously
• Risk factors for osteoporosis include:
• Female sex.
• Increasing age.
• Menopause.
• Oral corticosteroids.
• Smoking and excess alcohol.
• Previous fragility fracture and Parental history of hip fracture
• Inflammatory arthropathies, such as rheumatoid arthritis and
• Body mass index of less than 18.5 kg/m2.

How should we assess a person for fragility fracture risk?

• First, we need to exclude other causes like:
• Metastatic bone disease
• Multiple myeloma
• Osteomalacia and
• Paget's disease and
• Also exclude secondary causes of osteoporosis like:
• Endocrine conditions such menopause, hypogonadism, diabetes mellitus, and hyperthyroidism.
• Inflammatory arthropathies such as rheumatoid arthritis.
• Gastrointestinal malabsorption like in Crohn's disease, ulcerative colitis, coeliac disease, and chronic pancreatitis. 
• Chronic conditions like chronic liver disease and COPD and
• We will then assess for vitamin D deficiency and inadequate calcium intake, especially if they are over 65 years, not exposed to much sun and with a dietary calcium intake of less than 700 mg/day. There are online calculators to estimate dietary calcium and the link is in the episode description.
• We will also assess risks of falls. 
• We will offer a DXA scan without calculating the fragility fracture risk to those:
• Over 50 years of age with a history of fragility fracture.
• Younger than 40 years of age who have a major risk factor for fragility fracture.
• And we will consider starting drug treatment without a DXA scan in vertebral fractures
• We will normally assess the fracture risk first, then depending on the result, we will do a DEXA scan and then depending on the scores, we will consider treatment. So,

·      For all other people with risk factors, we will calculate the 10-year fragility fracture risk prior to a DXA scan, using online assessment calculators such as QFracture® (the preferred one) or FRAX®.

·      If using FRAX®, we must know that it underestimates the risk of:

• Oral steroids
• A history of fragility fractures. 
• And smoking and alcohol excess.

Now that we have completed the assessment, how should we interpret a fragility fracture risk score?

• People at high risk have a QFracture score of 10% or greater or are in the red zone of FRAX.
• People at intermediate risk have a QFracture score close to but below 10% or are in the orange zone of FRAX.
• People at low risk have a QFracture score below 10% or are in the green zone of FRAX.

And how should we manage fragility fracture risk scores?

• If at high risk, we will arrange a DXA scan and:
• offer drug treatment if the T-score is -2.5 or lower. 
• If the T-score is greater than -2.5, we will modify risk factors, treat any underlying conditions, and repeat the DXA, usually within 2 years.
• If at intermediate risk with risk factors we will arrange a DXA scan and offer drug treatment if the T-score is -2.5 or lower.
• If at low risk of fragility fracture, we will not arrange a DXA scan and we will offer lifestyle advice and follow up within 5 years.

What drug treatments are recommended?

• We will prescribe a bisphosphonate (first line in primary care are alendronate 10 mg once daily or 70 mg once weekly, or risedronate 5 mg once daily or 35 mg once weekly) if the T-score is -2.5 or less.
• We will consider biphosphonates if taking oral steroids equivalent to prednisolone 7.5 mg daily or more for 3 months or longer.
• All the bisphosphonates are licensed for use in postmenopausal women. However, only daily alendronate and weekly risedronate are licensed for use in men.
• If an oral bisphosphonate is not possible, we will refer to secondary care for consideration of other options such as zoledronic acid, strontium ranelate, raloxifene, denosumab, and teriparatide. 
• If the dietary calcium intake is adequate (700 mg/day), we will prescribe 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.
• If calcium intake is inadequate:
• We will prescribe the same dose of vitamin D with at least 1000 mg of calcium daily. 
• Or for elderly people who are housebound or living in a nursing home, we will prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily. 
• We will consider HRT for younger postmenopausal women 

What lifestyle information and advice should we give?

• We will advise exercise, a balanced diet, stop smoking and drink alcohol within recommended limits.
• We will also give appropriate patient education. 

How should we follow up a person at risk of fragility fracture?

• After bone-sparing treatment we will ask about adverse effects, in particular:
• Upper GI, such as dyspepsia or reflux. These are common initially and often improve with time.
• Symptoms of atypical fracture, including new onset hip, groin, or thigh pain. If this occurs, stop treatment, and arrange an X-ray of the femur.
• For those taking steroids we will continue bisphosphonates and/or calcium and vitamin D until corticosteroids have stopped, then we will reassess the osteoporotic risk.
• For all other people, we will review the need for bisphosphonates after 3–5 years.
• If they remain at high risk, we will continue alendronic acid for up to 10 years, and risedronate for up to 7 years for those:
• over 75
• or with a previous hip or vertebral fracture.
• In other people, we will arrange a DXA scan and we will consider:
• continuing treatment if the T-score is less than -2.5. We will then reassess every 3–5 years.
• Stopping treatment if the T-score is greater than -2.5 and reassess after 2 years.

We are now going to look at the prescribing information on calcium and Vit D supplements and biphosphonates

Although for further information we will check the British national Formulary or BNF.

Some of the contraindications for calcium and vitamin D preparations are:

• Hypercalcaemia
• Hyperparathyroidism.
• Current renal stone disease.
• CKD stage 4 or 5.
• An allergy to peanuts or soya — soya oil-free products are available

Some of the interactions of calcium and vitamin D preparations include:

• digoxin, thiazides and steroids, as well as
• impaired absorption with a number of drugs, including bisphosphonates, so a period of time needs to be left before taking them.

Some of the contraindications bisphosphonates include:

• Low calcium, vitamin D or parathyroid dysfunction — these should be treated before starting it.
• Severe CKD
• Being unable to be upright for at least 30 minutes, or if there us delay in oesophageal emptying (such as stricture or achalasia) — to reduce the risk of oesophageal reactions. 

Adverse effects of bisphosphonates include:

• Musculoskeletal pain and gastrointestinal symptoms including oesophageal reactions.
• Osteonecrosis of the jaw and of the external auditory canal and atypical stress fractures

Interactions with bisphosphonates include:

• An increased risk of gastrointestinal irritation with nonsteroidal anti-inflammatory drugs.
• Decreased absorption of the bisphosphonate with calcium supplements and antacids, as well as with food and drinks. A minimum of 30 minutes should be left between them.

Routine bisphosphonate advice is as follows:

• They should be taken on an empty stomach.
• They should be swallowed whole with at least 200 mL of water while in an upright position and must not lie down for at least 30 minutes.
• If a dose is missed:
• For daily preparations, they should skip that day and continue the next day as usual. They should not take a double dose.
• For weekly preparations, they should take it on the day that it is remembered and continue on the usual weekly day but two tablets should not be taken on the same day.
• We should inform about possible side effects, including symptoms of atypical fracture (such as hip, groin, or thigh pain) and of osteonecrosis of the jaw (such as jaw pain, swelling, and redness).
• We should advise them to have any necessary dental work done before starting bisphosphonates and to have regular dental check-ups and good oral hygiene thereafter.

 Now that we have reviewed the guideline, let’s look at three clinical cases that illustrate some of the concepts that we have discussed. I have used Chat GPT to generate these random patients.

Clinical case 1

The first patient is

John Smith is a 60-year-old man who develops a Colle’s fracture after tripping over and falling while walking his dog.

How should he be assessed?

Firstly, given that the fracture happened after falling from standing height we can state that John has sustained a fragility fracture.

Considering that he is over 50 with a history of fragility fracture, we should arrange a DXA scan without calculating the fragility fracture risk.

We should also consider alternative diagnoses and screening. We will arrange general blood tests which, according to our clinical judgement, could include the following: male hormones to screen for hypogonadism, vitamin D levels to check for osteomalacia, ESR, CRP and RF to check for inflammatory arthropathies, HbA1c to screen for diabetes, TFTs to check for hyperthyroidism, PTH levels to check for hyperparathyroidism, and LFT’s to screen for chronic liver disease. We will also consider looking for evidence of malignancy including, for example, immunoglobulin electrophoresis, calcium and urinary Bence Jones protein to screen for multiple myeloma. We could also look at X-rays and the alkaline phosphatase, to screen for Paget’s disease of the bone. Finally, depending on the clinical situation, we could screen for conditions causing malabsorption such as checking faecal calprotectin for Crohn’s disease and antigliadin antibodies or tissue transglutaminase antibodies (tTGA) for coeliac disease.

We will also assess risks of falls and calcium intake.

We will consider treatment depending on the DXA scan result. However, if he had been found to have a vertebral fracture instead of a Colle’s fracture, drug treatment would be considered even without a DXA scan.

Clinical case 2

The second patient is

Patient Name: Jane Thompson Age: 62

Medical History: Hypertension, Type 2 diabetes, asthma, and a TIA 5 years ago.

Risk Factors: Family history of osteoporosis, sedentary lifestyle, and history of smoking (quit 5 years ago) following her TIA

Routine blood tests are normal, including vitamin D and calcium. Her eGFR is 65 and she is otherwise asymptomatic.

She comes to see you because she is concerned because her mother had a hip fracture and was diagnosed as having osteoporosis when she was 60.

What further steps should we take?

Before considering a DXA scan to make a diagnosis, we should calculate Jane’s Fragility Fracture Risk and based on her risk factors, the QFracture score is 11.7%. This puts her in the high-risk category.

Since Jane is at high risk, we should arrange a DXA scan to assess her bone mineral density. If the T-score is -2.5 or lower, drug treatment should be offered. If the T-score is greater than -2.5, risk factors and any underlying conditions should be managed, and a repeat DXA scan should be scheduled within 2 years.

Jane's T-score is -2.8 and osteoporosis is diagnosed.

How should we manage her?

1.    Because the T score is less than -2.5 she should have a bisphosphonate: For example Alendronate 70 mg once weekly can be prescribed as the first-line treatment for osteoporosis.

2.    We will assess Jane's dietary calcium using online calculators and we conclude that her intake is adequate.

3.    Jane is not exposed to much sun and she should be given vitamin D Supplementation: so, she will be prescribed 10 micrograms (400 international units) of vitamin D without calcium.

What other advice should we give her?

Jane should be given advice on:

1.    Exercise: engage in weight-bearing exercises, ideally for at least 30 minutes per day.

2.    Balanced Diet: Jane will be encouraged to follow a well-balanced diet rich in calcium and vitamin D sources, including dairy products, leafy greens, and fortified foods.

3.    Smoking Cessation: As Jane has a history of smoking, she will be advised to continue to refrain from smoking.

4.    Alcohol Intake: Jane will be advised to limit her alcohol consumption within recommended guidelines.

5.    Patient Education: Jane will be provided with appropriate patient education materials and resources to enhance her understanding of osteoporosis.

Clinical Case 3

Name: Sarah Johnson

Age: 68

Medical History: Hypertension, GORD (gastroesophageal reflux disease) and osteoporosis, diagnosed after a vertebral fracture seen on an x-ray.

Risk Factors:

1.    Sedentary lifestyle

2.    History of smoking (quit 10 years ago)

3.    Family history of osteoporosis (mother had a hip fracture)

Medication:

1.    Alendronic acid (bisphosphonate) - 70 mg once weekly for the past 5 years

2.    Calcium and vitamin D supplements - 1000 mg calcium and 800 IU vitamin D daily after having found that her dietary calcium and sun exposure are insufficient.

eGFR (estimated glomerular filtration rate): 60 mL/min/1.73m²

How should she be followed up?

1.    We should review side effects: Sarah experienced dyspepsia and occasional reflux during the initial months of starting alendronic acid. However, these symptoms improved over time with continued treatment.

2.    We should always beware of atypical fracture symptoms: And we note that after 3 years of being on alendronic acid, Sarah started experiencing new onset pain in her right thigh and hip. Suspecting an atypical fracture, she was advised discontinuing the medication and arranged an X-ray of her femur to evaluate the possibility. A diagnosis of hip osteoarthritis was made and bisphosphonate treatment was restarted.

3.    Because she has had alendronic acid for 5 years, we should review the need to continue with Bisphosphonate treatment. She could have a DXA scan to assess bone density and response to treatment. However, because Sarah had a previous vertebral fracture, she should be advised to continue alendronic acid for up to 10 years regardless.

4.    Sarah underwent a DXA scan at 5 years, which revealed a T-score of -2.8, indicating a continued need for treatment.

In conclusion, the management of osteoporosis and fragility fractures requires a comprehensive approach that addresses both the underlying causes and the patient's individual risk factors. We have discussed the importance of detection and diagnosis, the assessment of fracture risks, management strategies, and regular reviews.

Please keep in mind that this is only a summary and my interpretation of the guideline.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye  

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. Welcome to the latest instalment in our monthly series, "NICE News," where we discuss new and updated guidelines published by the National Institute for Health and Care Excellence (NICE), specifically as it relates to primary care.

In this episode, I'll be focusing on the NICE guidance and advice published in May 2023. We'll be reviewing the latest recommendations that are relevant to primary care practitioners, with the goal of keeping you informed and up-to-date on the latest developments. This month we are focusing on cardiovascular risk assessment and digital technologies for anxiety and depression 

By way of disclaimer, I am not giving medical advice; this episode is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

The Full NICE News bulletin for May 2023 can be found at:  

·      https://www.nice.org.uk/guidance/published?from=2023-05-01&to=2023-05-31 

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• Music provided by Audio Library Plus   
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Transcript

Hello and welcome to another episode of NICE News. My name is Fernando Florido, a GP in the United Kingdom. Today, we'll be discussing the NICE Guidance and advice published in May 2023, specifically for Primary Care.

This month we are focusing on cardiovascular risk assessment and digital technologies for anxiety and depression

Before we begin, I want to remind you that this episode is not medical advice. It is only my interpretation, and you must use your clinical judgement.

Finally, I'd like to remind you that there is a YouTube version of this episode which can be found in the episode description.

Now, with that said, let’s get straight into it.

The first clinical area refers to cardiovascular risk assessment and lipid modification where new/updated recommendations have been made.

And the first one is to offer those 25 to 84 years of age a CVD risk assessment using the QRISK3 tool. This is because evidence suggested that the additional fields included in QRISK3 (such as severe mental illness, regular corticosteroid use and atypical antipsychotic use) enabled the tool to perform better than QRISK2 at predicting CVD events.

If the 10‑year risk of CVD is 10% or more, we will check for secondary causes, give lifestyle advice and consider atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention. If a statin is given, we will check lipids and LFTs at 3 months.

NICE also reinforces their advice against aspirin in primary prevention.

The definition of high intensity statins was also updated to remove simvastatin 80 mg which is rarely used because of the risk of myopathy.

Finally, evidence showed that statins are cost effective for people with 10‑year CVD risk less than 10% so we can use our clinical judgement to give a statin even if the QRISK3 score is less than 10%.

The second clinical area refers to digitally enabled therapies for anxiety and depression. The following can be used as treatment options:

·      Beating the Blues for anxiety and depression and

·      Space, also for Anxiety or Depression

·      iCT‑either PTSD or SAD for post-traumatic stress disorder or social anxiety disorder

·      Deprexis for depression

They have risk management systems in place, so it has been concluded that using these digital therapies could increase access to treatment and support, while ensuring patient safety.

And finally NICE also reviewed newer point-of-care tests for UTIs that give faster and more accurate results, sometimes showing which antibiotics the infection will respond to.

The tests are still in the early stages and it is difficult to assess the risks and benefits, so, these rapid point-of-care tests (such as Astrego, and Uriscreen), cannot be recommended for early routine use because further research is recommended.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at the NICE guidelines: “Atrial fibrillation: diagnosis and management” (NG196), as well as the Clinical Knowledge Summaries (CKS) on diagnosis of AF and management of AF, both last updated in March 2023. I have summarised the guidance from a Primary Care perspective.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 
• 
  

The full NICE Guideline on “Atrial fibrillation: diagnosis and management” [NG196] can be found here:

·      Overview | Atrial fibrillation: diagnosis and management | Guidance | NICE

Also

The Clinical Knowledge Summary on “When should I suspect atrial fibrillation and how do I confirm the diagnosis? (Last revised in March 2023) can be found here:

·      Diagnosis of atrial fibrillation | Diagnosis | Atrial fibrillation | CKS | NICE

Also

The Clinical Knowledge Summary on “Management of AF” (Last revised in March 2023) can be found here:

·      Scenario: Management of AF | Management | Atrial fibrillation | CKS | NICE

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• Music provided by Audio Library Plus  

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Transcript  

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Some of you have asked me to do more cardiovascular topics so, today, we'll be looking at the NICE guidelines on atrial fibrillation, also known as AF, specifically from a primary care perspective. Proper management of AF is very important, which is why I'm enthusiastic about sharing the most recent evidence-based recommendations from NICE, which were updated as recently as March 2023. However, please note that I'm here to provide information and interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

By the way, please make sure to stay for the entire episode, as I'll be sharing fictitious clinical cases created by chat GPT that will illustrate how the guideline is applied in real-life situations.

By the way, I will be sharing fictitious clinical cases created by chat GPT in the next video, that will illustrate how the guideline is applied in real-life situations. I have not included them in this video to avoid making it too long. However, the next video will not take long so subscribe in order not to miss it!

Remember that my summary is a very simplified version of the guideline. I have put links to the full guidance in the episode description.

So, with that said, let's dive in!"

Let’s start by saying that we are going to address three clinical areas today: the diagnosis, management and annual review of a patient with AF.

One of the first steps in detecting AF is performing a manual pulse palpation. We should do this if a patient presents with symptoms such as breathlessness, palpitations, syncope or dizziness, chest discomfort, or a history of stroke or TIA.

If an irregular pulse is detected, the next step is to perform an ECG, which will help confirm the presence of AF. However, in cases where paroxysmal AF is suspected but is undetected by an ECG, it may be necessary to offer additional testing with ambulatory ECG monitors, event recorders, or other ECG technologies for an appropriate period of time to capture episodes of AF.

Assessing stroke and bleeding risks is crucial in managing AF. To assess stroke risk, we should use the CHA2DS2-VASc stroke risk score. Evaluating bleeding risk is equally important and we should use the ORBIT bleeding risk score. These two tools guide decisions regarding anticoagulation therapy.

The CHA2DS2VASc score tool gives the following points:

• Congestive heart failure/left ventricular dysfunction = 1
• Hypertension (BP>140/90 or on treatment) = 1
• Age 75 years or older = 2
• Diabetes mellitus = 1
• Stroke/TIA = 2
• Vascular disease (prior MI, PVD, or aortic plaque) = 1
• Age 65–74 years = 1
• Sex category (female) = 1

The ORBIT scoring tool gives

• 2 points for:
• Low Hb or HCT (Males Hb <130 g/L or HCT <40% and females <120 g/L or <36%)
• History of bleeding (e.g., GI bleeding, or haemorrhagic stroke) 
• 1 point for:
• Age 74 or more
• eGFR of less than 60
• On antiplatelet treatment
• A score of 2 or less is considered low, 3 medium and 4 or more high.
• 
  

We should see if modifying risk factors for bleeding is possible. This can include addressing uncontrolled hypertension, avoiding concurrent use of aspirin or nonsteroidal anti-inflammatory drugs, minimizing alcohol consumption, and treating reversible causes of anaemia. 

Now, let's talk about the management of AF.  

For all people with AF (including paroxysmal AF):

• We will admit urgently if:
• There are signs and symptoms of haemodynamic instability such as a rapid pulse (greater than 150 beats per minute) and/or low blood pressure (e.g. a systolic blood pressure less than 90 mmHg), as well as symptoms like severe dizziness or syncope, chest pain, or breathlessness. Also be aware that electrical cardioversion may be recommended if the onset of AF is within 48 hours.
• Or we should also consider admission if they are unwell due to another serious associated or underlying condition.
• In new onset AF (of less than 48 hours), we will seek urgent secondary care advice to manage both arrhythmia and anticoagulation (because the latter may involve heparin) and this may also involve sending the patient to the emergency department

It's also important to assess for underlying causes of AF.

These can include:

• Cardiac causes, such as hypertension, valvular heart disease, heart failure, and ischaemic heart disease —for this we will arrange an ECG and consider transthoracic echocardiogram if there is a high risk or suspicion of underlying structural heart disease (such as a heart murmur) or functional heart disease (such as heart failure).
• Respiratory causes, such as chest infection or lung cancer — we will arrange a chest X-ray if lung pathology is suspected.
• Systemic causes, such as excessive alcohol intake, hyperthyroidism, electrolyte depletion, infection, or diabetes mellitus — we will use our clinical judgement to determine the need for blood tests such as a full blood count, liver, renal and thyroid function tests, calcium, magnesium, and glucose
• In summary: We will normally do an ECG, a CXR, blood tests and possibly an echocardiogram depending on the circumstances.

Once an underlying cause is identified, it is essential to manage it whenever possible. Referral to a cardiologist may be necessary, especially in cases of valvular heart disease or suspected heart failure.

However, we will need to refer to a cardiologist for rhythm control (that is, either pharmacological or electrical cardioversion), if:

• The AF has a reversible cause (for example a chest infection).
• There is Heart failure that is caused, or worsened, by AF.
• There is atrial flutter suitable for ablation
• or any other patient for whom rhythm‑control would be more suitable using our clinical judgement. 

Looking at the management in Primary care, the first thing that we need to do is to assess their stroke and bleeding risks using the CHA2DS2VASc and the ORBIT bleeding risk tools, reviewing and managing any modifiable risk factors for bleeding

We will offer anticoagulation with a direct-acting oral anticoagulant (also known as a DOAC) if a CHA2DS2VASc score of 2 or above, and consider a DOAC for men with AF and a CHA2DS2VASc score of 1. 

• Apixaban, dabigatran, edoxaban and rivaroxaban are suitable options.
• We will not offer anticoagulation for lower scores, that is a CHA2DS2VASc score of 0 for men or 1 for women.
• And we will not withhold anticoagulation solely because of a person's age or their risk of falls.

In people with new‑onset AF, if there is uncertainty over the precise time since onset, we will offer oral anticoagulation.

• If DOACs cannot be given, we will offer a vitamin K antagonist, like warfarin.
• However, for those already taking warfarin we will discuss the option of switching treatment.

And we will definitely not offer aspirin solely for stroke prevention in atrial fibrillation. For guidance on antiplatelet therapy for people who have had a myocardial infarction and are having anticoagulation, there are separate guidelines. We will not cover it here because the decision should rest with their cardiologist in secondary care. 

In Primary care, we will also need to look at the arrhythmia management. For most individuals with AF, a rate-control treatment is offered as the first-line approach. This can involve using a standard beta-blocker (but not sotalol) or a rate-limiting calcium-channel blocker, such as diltiazem or verapamil. The choice of medication depends on the person's symptoms, heart rate, comorbidities, and personal preferences.

In some cases, digoxin may be considered as an alternative for those with non-paroxysmal AF who do little or no exercise or when other rate-limiting drug options are not suitable. However, we will not offer amiodarone for long-term rate control.

If there is concomitant heart failure, we will follow the guidelines for chronic heart failure in managing their condition.

We will need to arrange follow-up within 1 week of starting treatment to review symptoms, heart rate, and blood pressure. 

In terms of patient education, we will need to provide information to the patient on:

• AF and Stroke awareness 
• Flying — advising that there are no flying restrictions provided AF is stable.
• Driving — advising that they must inform the driving Licensing Agency and to check their driving insurance still covers them.

After having looked at the diagnosis and initiating treatment, we are now going to look at the regular follow-ups or reviews that are needed. It is recommended to review patients at least annually if the symptoms are controlled or more frequently if necessary, using our clinical judgement to determine the appropriate intervals.

During the reviews, we will do the following:

We will check for symptoms of AF at rest and during exercise, and assess the heart rate.

• Criteria for rate control vary with age, and it is suggested that ventricular rate should be controlled between 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise
• Review the person's rate control drugs and if the person cannot tolerate it, we will prescribe an alternative.

For people taking a rate-control treatment who have persistent symptoms of AF or a fast heart rate, we will consider one of the following options:

• If they are not taking the maximum drug dose, we will consider increasing the dose
• If they are taking the maximum drug dose, we will consider combination treatment with any two of the following drugs: a beta-blocker, digoxin, or diltiazem. We will seek specialist advice before prescribing diltiazem with a beta-blocker because bradycardia, atrioventricular block, asystole, or sudden death can occur with concurrent use.
• If symptoms are not controlled by combination treatment, we will refer to a cardiologist promptly, that is, to be seen within 4 weeks.

For people who have received a rhythm-control treatment in secondary care who have recurrent or persistent symptoms, we will refer back to a cardiologist for further assessment. 

We will also reassess the person's stroke risk using the CHA2DS2VASc assessment tool and bleeding risk (using the ORBIT score tool) at least annually. Stroke risk should also be routinely reviewed when a person reaches 65 or years of age, or if at any age they develop diabetes, heart failure, peripheral arterial disease, coronary heart disease, stroke, transient ischaemic attack, or systemic thromboembolism.

• For people not already taking an anticoagulant, we will offer treatment if they have a CHA2DS2VASc score of 2 or more, and we will consider offering anticoagulation treatment to men with a CHA2DS2VASc score of 1.
• For people already taking an anticoagulant:
• we will not stop anticoagulation solely because atrial fibrillation is no longer detectable — we will base the decision on a reassessment of CHA2DS2-VASc and ORBIT.
• we will review and manage any modifiable risk factors for bleeding.
• we will review anticoagulant therapy, including possible new drug interactions and we will do a FBC, liver and renal function tests at least annually or more frequently if clinically indicated.
• For people with persistent poor anticoagulation control on warfarin, we will consider switching to a DOAC such as apixaban, edoxaban, dabigatran, or rivaroxaban).
•  

For people taking rhythm control drugs that were initiated in secondary care, we will carry out any required monitoring. For amiodarone for example, this includes 6 monthly blood tests and an annual ECG and eye examination. 

And we will assess and manage their CVD risk and any possible complications of AF, including stroke and thromboembolism, heart failure and reduced quality of life.

Right, this is the summary of the guideline. (pause)

 Now, let’s have a look at some fictitious clinical cases created by chat GPT:

Case 1

The first patient is Emily Thompson who is 62 years old.

And has a BP of 130/80 mmHg

Emily has a history of hypertension and hypercholesterolemia. Additionally, Emily was diagnosed with type 2 diabetes five years ago and is currently on the following medication:

·      Amlodipine 5mg once daily

·      Atorvastatin 20mg once daily

·      Metformin 1000mg twice daily

Emily consults you because she experiences occasional episodes of palpitations and breathlessness. She has also reported intermittent dizziness over the past few months. She has not experienced any stroke or TIA symptoms.

What should we do? 

We should suspect AF and therefore we should perform a manual pulse palpation. This detects an irregular pulse.

What diagnostic steps should we take?

1.    We should do an ECG to confirm the presence of AF. However,

2.    If paroxysmal AF is suspected but undetected by the initial ECG, an ambulatory ECG monitor, event recorder, or other ECG technology should be used. This will allow continuous monitoring over a specific period to capture intermittent or infrequent episodes of AF. We should also consider this if the manual pulse palpation was normal but we remain suspicious. 

Case 2

The second patient is John Anderson who is 65. His BP is 140/90 and his pulse rate is 96.

He has a Medical History of Hypertension, hypercholesterolaemia and Valvular Heart Disease

John is currently taking an ACE inhibitor (lisinopril 20 mg OD), a calcium channel-blocker (amlodipine 10 mg BD) and a statin (atorvastatin 20 mg OD).

John presents with symptoms of AF that have only just started in the last day or two and AF has been confirmed with an ECG.

How should we manage him?

1.    We should firstly assess for signs and symptoms of hemodynamic instability: for example, a rapid pulse of 150 beats per minute or more and low blood pressure, e.g. a systolic blood pressure 90 or less. If he exhibits these symptoms, he should be admitted urgently. Luckily, John’s pulse rate is 96 and his BP is 140/90.

2.    However, we should get urgent secondary care advice, given that John's AF seems to have been present for less than 48 hours. This is recommended to address the management of both the arrhythmia and anticoagulation. John may or not be suitable for electrical or pharmacological cardioversion and the initial anticoagulation may involve the use of heparin. This may still require sending him to the emergency department to be fully assessed.

3.    In addition, we should expect the cardiologist to carry out further assessment of possible underlying causes of AF. Since John has a history of valvular heart disease, it is likely that this is contributing to his AF. A transthoracic echocardiogram can be considered to assess any valvular heart disease progression in addition to a CXR and basic blood tests, including a full blood count, liver and renal function tests, thyroid function tests, calcium, magnesium, and glucose levels. 

In summary, the recommended management approach includes evaluating signs of hemodynamic instability, assessing for underlying causes (cardiac, respiratory, and systemic), conducting necessary tests (ECG, CXR, blood tests, and echocardiogram), and seeking urgent secondary care advice given that the onset of AF is within 48 hours.

Case 3

The third patient is Peter Richardson who is 76

His Blood Pressure is 135/85 mmHg and his pulse rate is 78

Peter has a Medical History of hypertension, hyperlipidaemia and an MI ten years ago.

Peter takes lisinopril (10 mg once daily), atorvastatin (80 mg once daily) and clopidogrel (75 mg once daily) as part of his post-MI regimen.

He has been found to have AF on incidental screening, confirmed by an ECG. He has no symptoms and initial assessment includes a normal CXR and blood tests. A non-urgent echocardiogram has been requested as a precaution but he does not have a heart murmur or symptoms of cardiac failure so there is a low suspicion of structural heart disease.

Because of his age and being asymptomatic, after discussion and agreement with the patient and, perhaps after discussion with secondary care, it was decided that he would be managed in primary care and that referral for rhythm control / cardioversion was not appropriate for him. 

How should we assess and manage him further?

• We should assess his Stroke Risk. Using CHA2DS2VASc, the score is 4 (because of age over 75, HTA on treatment and previous vascular disease), indicating a high risk of stroke.
• Using the ORBIT bleeding risk tool, his score is 2 (because of age >74 and taking antiplatelet therapy) so his risk of bleeding is low.
• Considering his CHA2DS2VASc score of 4 and low bleeding risk, Peter is a suitable candidate for anticoagulation. We should always consider modifiable risk factors for bleeding but given that clopidogrel was given for his previous MI, we would need to seek advice from his cardiologist about this.
• As Peter’s exact time of onset of AF is uncertain, oral anticoagulation is recommended.
• We have the options of apixaban, dabigatran, edoxaban, and rivaroxaban, and we decide to prescribe apixaban (5 mg twice daily). If there was a problem with a DOAC, a vitamin K antagonist such as warfarin could be an alternative.
• We should also start him on rate-control treatment, such as a beta-blocker or a rate-limiting calcium-channel blocker. Given his previous history of MI, he is started on a betablocker. Because he has no symptoms and his BP is normal, we could give him a small dose of bisoprolol 1.25 mg daily which can be increased as necessary.
• We should arrange a follow-up appointment within 1 week of starting treatment to assess his symptoms, heart rate, and blood pressure.
• We should also offer Patient Education, including information about AF and Stroke awareness, flying (saying that there are no restrictions if AF is stable), driving (advising him to inform the driving licensing agency and to check his insurance cover), and the need for annual review.

Case 4 

The fourth and final patient is Sarah Johnson, aged 62

Her Blood Pressure is 130/80 mmHg

And her Medical History includes known atrial fibrillation. Although the AF was diagnosed five years ago, recently she has been experiencing some AF symptoms in the form of intermittent palpitations, and occasional shortness of breath. She also has a history of hypertension and well-controlled type 2 diabetes. Sarah had a transient ischemic attack (TIA) two years ago but has not experienced any recurrent episodes since then.

Her medication includes a beta-blocker, atenolol 100 mg daily, to control her heart rate, which is the maximum recommended dose. She also takes an anticoagulant, rivaroxaban 20mg OD, to reduce her risk of stroke. In addition, Sarah takes metformin 500 mg BD for her diabetes management and amlodipine 5 mg OD for blood pressure control.

She comes to see you for her annual review.

What should we do during this review?  

1.    During the annual review, Sarah's symptoms of AF should be assessed, both at rest and during exercise. Her heart rate should be monitored to ensure rate control. It is recommended to maintain her ventricular rate between 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise.

2.    The review should include an assessment of Sarah's current medications. Since she is experiencing persistent symptoms of AF, despite taking the maximum dose of atenolol, we should consider combination treatment with an additional rate-control drug, such as digoxin or diltiazem. Sarah is still active and does regular exercise and therefore digoxin is not felt to be appropriate. Therefore, before prescribing diltiazem with a beta-blocker, specialist advice should be sought due to potential complications.

3.    Sarah's stroke and bleeding risks should also be reassessed using CHA2DS2VASc and ORBIT. These assessments should be conducted annually, but particularly when she reaches the age of 65 or if she develops any new conditions related to cardiovascular health.

4.    As Sarah already has a high stroke risk with a CHA2DS2VASc score of 4 (because of a previous TIA, hypertension and being female), she should continue her anticoagulation treatment with rivaroxaban. We should monitor it, checking for possible new drug interactions and conducting blood tests including a FBC, liver and renal function tests. These assessments should occur at least annually or more frequently if clinically indicated.

5.    Sarah's modifiable risk factors for bleeding should also be reviewed and managed. Her BP is well controlled, she is not abusing alcohol and there are no other concerns in terms of anaemia or drug interactions.

6.    If Sarah were taking rhythm control drugs initiated in secondary care, for example amiodarone, we should arrange the required monitoring.  

In conclusion, the management of AF requires a comprehensive approach that addresses both the underlying causes and the patient's individual risk factors. We have discussed the importance of detection and diagnosis, the assessment of stroke and bleeding risks, management strategies, and regular reviews.

Please keep in mind that this is only a summary and my interpretation of the guideline.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye  

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. Welcome to the latest instalment in our monthly video series, "NICE News," where we discuss new and updated guidelines published by the National Institute for Health and Care Excellence (NICE), specifically as it relates to primary care.

In this episode, I'll be focusing on the NICE guidance and advice published in April 2023. We'll be reviewing the latest recommendations that are relevant to primary care practitioners, with the goal of keeping you informed and up-to-date on the latest developments. This month we are focusing on hypertension disorders in pregnancy 

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

The Full NICE News bulleting for April 2023 can be found at: 

·      Published guidance, NICE advice and quality standards | Guidance | NICE

The full NICE guideline on “Hypertension in pregnancy: diagnosis and management” can be found here:

·      Overview | Hypertension in pregnancy: diagnosis and management | Guidance | NICE 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello and welcome to another episode of NICE News. My name is Fernando Florido, a GP in the United Kingdom. Today, we'll be discussing the NICE Guidance and advice published in April 2023, specifically for Primary Care.

Now, in April there was only one guideline relevant to primary care, which was Hypertension disorders in pregnancy.

However, I must admit that the updated information was not easily accessible, as it was buried in the middle of the guideline. So, to save time and effort, I have gone through and summarised the whole guideline. But please keep in mind that my summary is an extremely simplified version, and it may not contain all the nuances and details that NICE often includes. If you'd like to dive deeper into the guideline, I have included a link to it in the episode description.

Before we begin, I want to remind you that this episode is not medical advice. It is only my interpretation of the guideline, and you must use your clinical judgement.

Finally, I'd like to remind you that there is a YouTube version of this episode which can be found in the episode description.

And to help you remember the key points, I'll be sharing some fictitious clinical cases at the end so make sure that you listen to the whole episode.

Now, onto the guideline itself. Hypertension disorders in pregnancy are generally managed in secondary care by the obstetricians, but in Primary Care, we must still be familiar with the recommendations so let’s get straight into it.

Firstly, for the assessment of Proteinuria we will use an automated reagent-strip

·     If dipstick screening is positive (1+ or more), we will use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria.

·     But we will not use an early morning or a 24‑hour urine sample

·     If using protein:creatinine ratio, 30 mg/mmol is the threshold for pre-eclampsia.

·     Wheras if using albumin:creatinine ratio, it is 8 mg/mmol.

In terms of Management of Chronic Hypertension in Pregnancy, that is, hypertensive women that get pregnant, we must make sure that

·     We refer them appropriately

·     We stop and prescribe an alternative to ACE inhibitors, ARBs and thiazide or thiazide-like diuretics as soon as we know that they are pregnant or planning a pregnancy. This is because of the teratogenic potential

·     We will discontinue treatment if BP< 110/70 mmHg, or if there is symptomatic hypotension.

·     We will offer treatment if BP> 140/90 mmHg

·     We will use a target BP of 135/85 mmHg.

·     In terms of drug treatment, we will give labetalol first line, then nifedipine if labetalol is not suitable, and then methyldopa if both labetalol and nifedipine are not suitable.

·     And we will also offer aspirin 75–150 mg once daily from 12 weeks’ gestation.

In terms of Management of Gestational Hypertension, that is, a woman that becomes hypertensive during pregnancy we will say the following:

·     A full assessment should be carried out in secondary care, including BP monitoring, urine tests, foetal monitoring, medication, and delivery planning.

·     We will admit to hospital if the BP is 160/110 mmHg or higher

·     And the treatment is also labetalol first line, then nifedipine if labetalol is not suitable, and then methyldopa if both labetalol and nifedipine are not suitable.

In terms of antihypertensive Treatment during the Postnatal Period if the woman is breastfeeding, we will say that:

·     amounts in breastmilk are unlikely to have any clinical effect.

·     However, we will need to monitor babies’ BP and symptoms in case of hypotension, although this should be done in secondary care.

·     Enalapril can be offered during the postnatal period

·     But Nifedipine or amlodipine should be offered for women of black African or Caribbean family origin

·     If the BP is not controlled on one drug, a combination of enalapril with nifedipine or amlodipine can be considered.

·     And if this combination is not tolerated or is ineffective, atenolol or labetalol can be added

·     But we will avoid diuretics and ARBs if the woman breastfeeding or expressing milk.

However, if not breastfeeding, there are no special considerations and we will follow the normal guidelines on hypertension.

And finally, in terms of advice and follow-up:

·     We will advise that the overall risk of recurrence in future pregnancies is approximately 1 in 5

·     We will also advise that HTA in pregnancy is associated with an increased risk of hypertension and cardiovascular disease in later life and we will give lifestyle advice

·     If there has been prematurity before 34 weeks, we will consider pre-pregnancy counselling. 

Now let’s use Chat GPT to give us some practical cases in the form of 5 fictitious patients:

·     The first patient is Sarah, a 30-year-old woman who is in her second trimester of pregnancy and has no previous history of hypertension. Although she is asymptomatic, her blood pressure reading during a routine check-up reveals 145/92, and a urine dipstick test shows 1+ protein. What is the next step? According to guidelines, the next step is to request an ACR or PCR to quantify the proteinuria. However, given the potential for Sarah to have pre-eclampsia, it is advisable to refer her urgently to the obstetricians for a full assessment, including foetal monitoring.

·     Our second patient, Jane, is a 35-year-old woman with a history of chronic hypertension. She is on ramipril 5 mg daily and she comes to see you because she is pregnant. What should we do? Our first step is to refer her to the obstetricians. Additionally, we need to stop the ACEI due to their teratogenic effects and switch to an alternative medication. Labetalol, starting at 100 mg twice daily, is the first-line option. We will need to titrate the dosage to achieve a target BP of below 135/85 mmHg, though this will likely be done in secondary care.

Aside from the medication switch, Jane should also be prescribed aspirin 75 -150 mg once daily from 12 weeks' gestation to decrease the risk of preeclampsia.

·     Helen, a 37-year-old pregnant woman with a family history of hypertension but no prior hypertension herself, is the third patient. At 36 weeks of gestation, she sees you with no symptoms but a BP reading of 160/110 mmHg. What should our advice be? Considering the high BP level, hospital admission for close monitoring and management is recommended. Induction of labour may also be necessary due to the severity of her hypertension and gestational age.

·     Maria, a 32-year-old woman of black African descent who has recently given birth to her first child, is our fourth patient. She is currently taking labetalol 400mg BD for gestational hypertension and wishes to breastfeed her baby. However, she has been experiencing tiredness and cold extremities which she attributes to the beta blockers. What should we recommend? As per the NICE guidance for women of black African or Caribbean family origin, we should switch her labetalol to nifedipine or amlodipine, which are known to be more effective in this population and safe for use during breastfeeding. Although the medication in her breastmilk is unlikely to affect her baby, we will arrange for the baby's blood pressure to be monitored in secondary care. Ongoing medication monitoring should also be done in secondary care.

·     Let's consider the case of Stephanie, our fifth and final patient. Stephanie is a 39-year-old woman who has a medical history of chronic hypertension and has recently given birth to her third child. She is currently taking labetalol 200 mg BD and has decided not to breastfeed. How should we manage her? In such a scenario, it is simply recommended to refer to the NICE guideline on hypertension. If you require a refresher, you can refer to the relevant episode on this channel.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at the NICE guidelines: “Stable angina: management” (CG126), and summarise it from a Primary Care perspective.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

The full NICE Guideline on “Stable angina: management” (CG126), can be found here: 

• Website: Overview | Stable angina: management | Guidance | NICE

 Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript  

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Today, we'll be looking at the NICE guidelines on the management of stable angina, specifically from a primary care perspective. Proper management of angina can have a huge impact on patients' lives and that's why I'm excited to share the latest evidence-based recommendations from NICE. However, it's important to note that I'm here to provide information and interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

By the way, I'll be sharing a fictitious clinical case created by chat GPT, together with their treatment management. This will give you the opportunity to see practical guidelines in action and understand how they can be applied in real-life situations

So, with that said, let's dive in!"

We will start by addressing the following:

1.    To diagnose stable angina, we follow different guidelines set out by NICE on recent-onset chest pain of suspected cardiac origin. There are also different guidelines for unstable angina and NSTEMI and acute coronary syndromes.

2.    We’ll explain to patients the factors that can provoke angina such as exertion, emotional stress, exposure to cold, and eating a heavy meal.

3.    We should also explore any misconceptions and implications for activities, cardiovascular risk, and life expectancy.

4.    We will need to advise the patient to seek medical help if there is a sudden worsening in the frequency or severity of their angina.

5.    We should give lifestyle advice and psychological support and address self-management skills such as pacing their activities and goal setting, concerns about the impact of stress, anxiety, or depression, and advice about physical exertion including sexual activity.

In terms of General principles of treatment, we will say that: 

·     Age alone should not exclude patients from treatment.

·     In terms of Preventing and Treating Episodes of Angina:

o  We will offer a short-acting nitrate to prevent and treat episodes of angina.

o  We will advise people that they should use it immediately before any planned exercise or exertion.

o  We will explain the possible side effects, such as flushing, headache and light-headedness and to sit down or find something to hold on to if feeling lightheaded and

o  We will advise them to repeat the dose after 5 minutes if necessary and call an emergency ambulance if the pain has not gone.

·     In respect of Drugs for Secondary Prevention of Cardiovascular Disease:

o  We will consider aspirin 75 mg daily, taking into account the risk of bleeding and comorbidities.

o  We will consider ACE inhibitors for people with stable angina and diabetes.

o  We will offer both antihypertensive treatment and statin therapy in line with the respective NICE guideline on the subject.

·     Regarding Dietary Supplements:

o  We will not offer vitamin or fish oil supplements and we will inform patients that there is no evidence that they help stable angina.

When it comes to general treatment recommendations:

·     Optimal drug treatment for the initial management of stable angina should consist of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease.

·     The aim of anti-anginal drug treatment is to prevent episodes of angina, while the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attacks and strokes.

·     We will review the response to treatment, including any side effects, 2 to 4 weeks after starting or changing drug treatment and

·     We will titrate the dose up to the maximum tolerated dose.

So let’s have a look at the Drugs for treating stable angina:

·     We should offer either a beta blocker or a calcium channel blocker as first-line treatment. The decision on which drug to use should be based on comorbidities, contraindications, and the person's preference.

·     If the patient cannot tolerate the beta blocker or calcium channel blocker, we will consider switching to the other option.

·     If the person's symptoms are not satisfactorily controlled on a single drug, we will consider either switching to the other option or using a combination of the two.

·     When combining a calcium channel blocker with a beta blocker, we will use a dihydropyridine calcium channel blocker, for example, slow release nifedipine, amlodipine, or felodipine.

·     It's essential to remember not to offer anti-anginal drugs other than beta blockers or calcium channel blockers as first-line treatment.

·     If the person cannot tolerate beta blockers and calcium channel blockers, or both are contraindicated, we will consider monotherapy with one of the following drugs:

o  a long-acting nitrate,

o  ivabradine,

o  nicorandil, or

o  ranolazine.

o  Deciding which drug to use should be based on comorbidities, contraindications, the person's preference, and drug costs.

·     Adding a third anti-anginal drug those whose angina is controlled with two anti-anginal drugs is not recommended.

·     However, it's worth considering adding a third anti-anginal drug only when the symptoms are not controlled with two anti-anginal drugs. Deciding which drug to use should be based on comorbidities, contraindications, the person's preference, and drug costs.

Now let’s discuss the recommendations on revascularisation procedures when symptoms are not satisfactorily controlled with optimal medical treatment. And these procedures would be either a coronary artery bypass graft [CABG] or a percutaneous coronary intervention [PCI])

In addition, we can offer coronary angiography to guide our treatment strategy.

The main purpose of revascularisation is to improve the symptoms of stable angina. However, it is important to explain to the patient that repeat revascularisation may be necessary after either CABG or PCI, and the rate is lower after CABG. Stroke is uncommon after either CABG or PCI, and the incidence is similar between the two procedures.

We will offer CABG in suitable patients if symptoms are not controlled with medical treatment, and PCI is not appropriate.

We will offer PCI to suitable patients if symptoms are not controlled with medical treatment, and CABG is not appropriate.

We will take into account that PCI may be more cost-effective than CABG.

However, in Multivessel Disease, we need to be aware of the potential survival advantage of CABG over PCI for those who have diabetes or are over 65 years or have anatomically complex three-vessel disease.

If symptoms are controlled with medical treatment, prognosis without further intervention should be discussed with their cardiologist.

In terms of Pain interventions, we should not offer transcutaneous electrical nerve stimulation (TENS), enhanced external counterpulsation (EECP), and acupuncture.

Now, let’s address Stable angina that has not responded to treatment:

In these cases, it's important to provide comprehensive re-evaluation and advice. This may include:

·     exploring the impact of symptoms on their quality of life, and reviewing the diagnosis while considering non-ischaemic causes of pain.

·     Additionally, it's essential to review drug treatment and consider future drug treatment and revascularisation options.

·     It's also important to acknowledge the limitations of treatment and explain the self-management of the pain. Specific attention should be given to the role of psychological factors in pain, and skills to modify cognitions and behaviours associated with pain.

Cardiac syndrome X

In people with angiographically normal coronary arteries and continuing anginal symptoms, we need to consider a diagnosis of cardiac syndrome X. This condition can be challenging to diagnose, and additional testing may be necessary.

If a patient is diagnosed with suspected cardiac syndrome X, we will continue drug treatment for stable angina only if it improves their symptoms.

We will not routinely offer secondary prevention drugs in suspected cardiac syndrome X. This is because the effectiveness of these drugs in this population is uncertain, and they may cause unnecessary side effects.

Right, so now, let’s have a look at our fictitious clinical case created by chat GPT:

The Patient is John Smith, a 55-year-old man who has just been diagnosed with stable angina.

John has a history of hypertension, high cholesterol, and type 2 diabetes, which is well-controlled with metformin 1000mg twice daily. He has been experiencing chest pain and shortness of breath during exertion for the past 6 months. He is a non-smoker and leads an active lifestyle, but his symptoms are affecting her ability to exercise.

Recent test results: John's most recent blood pressure reading was 148/86 mmHg. His cholesterol levels were 5.8 mmol/L (224 mg/dL), with LDL cholesterol of 3.9 mmol/L (151 mg/dL) and HDL cholesterol of 1.4 mmol/L (54 mg/dL). His HbA1c level was 6.5% (48 mmol/mol).

How should he be treated?

In terms of preventing and treating episodes of angina, we offered John short-acting nitrates to be used immediately before any planned exercise or exertion in the form of a sublingual GTN spray. We advised him to repeat the dose after 5 minutes if necessary and call an emergency ambulance if the pain had not gone. We explained the possible side effects of the medication, such as flushing, headache, and light-headedness, and advised him to sit down or find something to hold on to if feeling lightheaded.

In respect of drugs for secondary prevention of cardiovascular disease, we started John on aspirin 75mg daily, taking into account his risk of bleeding. We also considered ACE inhibitors for John, as he has stable angina and diabetes and he was started on a small dose of lisinopril 2.5 mg daily. In terms of statin therapy, he was started on atorvastatin 80 mg daily for secondary prevention in line with NICE guidance on the subject.

We advised him that there is no evidence to support the use of dietary supplements such as vitamin or fish oil supplements in treating stable angina, and therefore did not prescribe them. The patient was also lifestyle advice.

For treating John's stable angina, both a beta blocker and a calcium channel blocker were considered as first-line treatment. Because of the patient’s concerns on erectile dysfunction, we decided to use a small dose of a CCB, felodipine 2.5mg daily as he had no contraindications to using this medication. We will titrate it against his symptoms up to the maximum tolerated dose.

John's case will be reviewed 2 to 4 weeks after starting his new medication to assess his response to treatment, including any side effects. We will also monitor his blood pressure, cholesterol, and HbA1c levels to ensure they are within the recommended targets.

In conclusion, the management of stable angina requires a comprehensive approach that addresses both the underlying cardiovascular disease and the patient's individual risk factors. By following the general principles of treatment and tailoring the treatment plan to the patient's specific needs, we can help to reduce the risk of cardiovascular events and improve their quality of life.

Please keep in mind that this is only a summary and my interpretation of the guideline. 

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye  

"Chat GPT Patient Meets NICE - Here's What Happened!"

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a complex random clinical case of a patient created by Chat GPT to see how the NICE guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this podcast is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

ChatGPT prompt to create a patient:  

A)   Provide a fictitious patient. Details that you should include are:

1)   patient's medical information including:

·      name

·      age

·      sex

·      ethnicity

·      BMI

·      blood pressure

2)   medical history- you must include:

·      either one, two or three of the following poorly controlled conditions:

·      type 2 diabetes

·      hypertension

·      dyslipidaemia,

·      Any number of other medical conditions of your choice, along with whether they are well controlled or not – the medication for these conditions should appear in the next section “medications”

1. Medications given:

·      indicate whether the patient is currently taking medication for each medical condition or not.

·      If medication is prescribed for a condition, indicate the specific drug(s) and their dosages. You may choose to prescribe one, two, or three drugs for each condition as appropriate.

3)   State whether the patient tolerates the medication well or not, and if not, describe the side effect(s) and their severity.

4)   blood test results (give a bulleted list but do not number them):

·      HbA1c expressed in % and mmol/mol

·      renal function tests to include creatinine (expressed first in µmol/L and then in mg/dL), eGFR, urea, sodium, and potassium (expressed in UK units first and then USA units)

·      lipid profile expressed both in mmol/L first and then in mg/dL.

·      include any other relevant test results for the patient, expressing them in both UK and USA units. If the patient has hypothyroidism or takes levothyroxine medication, provide the results of their thyroid function tests, including both T4 and TSH levels, in both UK and USA units. Also, include the normal range for these investigations.

B)  Provide the patient's cardiovascular risk using the QRISK2 tool, calculated as a percentage of the likelihood of experiencing a cardiovascular event over the next 10 years.

C)   At the end of the patient information, ask: 'What treatment recommendations would you make?' – do not make recommendations yourself

D)  Do not include a disclaimer that the patient is fictitious.

The NICE hypertension flowcharts can be found here: 

• Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517 
• Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn 

The full NICE Guideline on hypertension (NG136) can be found here:  

• Website: https://www.nice.org.uk/guidance/NG136 
• Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus 

The full NICE Guideline on Type 2 diabetes (NG28) can be found here:  

·      Overview | Type 2 diabetes in adults: management | Guidance | NICE 

The full NICE guidance on osteoarthritis (NG226) can be found here: 

·      Overview | Osteoarthritis in over 16s: diagnosis and management | Guidance | NICE 

The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: 

·      Overview | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE

The full NICE guidance on asthma (NG80) can be found here: 

·      Overview | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICE 

The full NICE guidance on depression in adults (NG222) can be found here: 

·      Overview | Depression in adults: treatment and management | Guidance | NICE 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

Transcript  

Today we'll be exploring the world of NICE guidelines and how they apply to a complex patient. But this isn't just any patient - this one was randomly created by the latest buzz in town, ChatGPT. Our focus will be on the pharmacological treatment.

Hello and welcome, I'm Fernando Florido, a GP in the United Kingdom.

Before we dive in, I'd like to make it clear that I'm not here to provide medical advice. Rather, I'll be sharing my interpretation of the guidelines with fellow healthcare professionals. Please always use your clinical judgement when treating your patients.

If you prefer a video format, we've also got a YouTube version of these episodes. The link is in the episode description.

Alright, let's generate our patient using ChatGPT. It was created using a specific prompt, which is available in the episode description. Let's get started!

Right, so our fictitious patient is Sarah Johnson, a 52-year-old African American woman. Sarah is currently obese with a BMI of 31, and her Blood Pressure is above the target at 142/88 mmHg. 

She has a Medical History of 

• Type 2 diabetes and Hypertension, which are both poorly controlled as well as
• Osteoarthritis (which is well-controlled with ibuprofen)
• Asthma (which is well-controlled with salbutamol inhaler) and
• Depression (which is well-controlled with fluoxetine)

Her regular Medications are:

• Metformin 1000 mg twice a day for diabetes
• Lisinopril 20 mg once a day for hypertension
• Atorvastatin 40 mg once a day for dyslipidaemia
• Ibuprofen 400 mg twice a day for osteoarthritis
• Salbutamol inhaler 2 puffs as needed for asthma
• Fluoxetine 20 mg once a day for depression

Fortunately, she tolerates all medications well without any side effects.

We also have her blood test results, which show the following:

• An HbA1c: 8.5% (69 mmol/mol) 
• A Creatinine: 94 µmol/L (1.06 mg/dL)

·      An eGFR: 72 mL/min/1.73m2

(Urea: 5.2 mmol/L (14.67 mg/dL)

Sodium: 139 mmol/L (139 mEq/L)

Potassium: 4.2 mmol/L (4.2 mEq/L))

·      A Total Cholesterol: 6.1 mmol/L (236.39 mg/dL)

(HDL Cholesterol: 1.3 mmol/L (50.1 mg/dL))

·      And an LDL Cholesterol: 4.1 mmol/L (158.57 mg/dL)

(Triglycerides: 1.8 mmol/L (159.27 mg/dL)

TSH: 2.5 mIU/L , 2.5 µIU/mL

Free T4: 15 pmol/L, 1.2 ng/dL

Normal TSH range: 0.4-4.0 mIU/L , 0.4-4.0 µIU/mL

Normal Free T4 range: 9-25 pmol/L , 0.8-2.0 ng/dL ) 

Finally, Sarah's QRISK2 score is 20%, indicating a high risk of developing cardiovascular disease over the next 10 years.

Based on Sarah's medical history, blood test results, and QRISK2 score, I would recommend the following treatment options.

Upon initial examination, this 52-year-old woman presents with a significant amount of multimorbidity, including diabetes, hypertension, dyslipidaemia, osteoarthritis, asthma, and depression. Her obesity is likely exacerbating her conditions, particularly her diabetes, hypertension, and osteoarthritis, and may also be contributing to her depression. Given this, tackling her obesity could potentially have a positive impact on her overall health. However, for the purpose of this case, we will focus on the pharmacological treatment rather than lifestyle interventions.

It is worth noting that the patient's eGFR of 72 indicates stage 2 CKD, which will factor into our treatment decisions. We will assume that there is no significant microalbuminuria since ACR results are not available. Additionally, the patient has a high risk of CVD, so managing her conditions aggressively will also help mitigate this risk.

Moving on to her poorly controlled diabetes, which is currently being treated with metformin 1gr BD and has an HbA1c of 8.5% or 69 mmol/mol, NICE guidelines recommend an SGLT2 inhibitor as step 2 treatment after metformin for patients at high risk of CVD. SGLT2 inhibitors are also beneficial for those with CKD and can promote weight loss, so a good option for this patient. In this case, starting the patient on dapagliflozin 5mg OD initially, and potentially increasing to 10mg daily within four weeks if well-tolerated, would be a suitable option.

It is important to note that SGLT2 inhibitors have been associated with an increased risk of DKA, toe and lower limb amputations, and Fournier's gangrene.

Fournier’s gangrene is a rare but life-threatening type of necrotizing fasciitis, which specifically affects the genital and perineal area. The condition develops rapidly, and symptoms may include fever, severe pain, redness, swelling, and foul-smelling discharge in the affected area. The infection can spread quickly and cause significant tissue damage, leading to sepsis, shock, and organ failure if not treated promptly.

Therefore, it is crucial to educate the patient on DKA symptoms, advise against starting a ketogenic diet while taking an SGLT2 inhibitor, as this increases the risk of DKA, and promote excellent foot care. Additionally, we should advise the patient to seek urgent medical advice if they experience severe pain, erythema, or swelling in the genital or perineal area, especially if there is fever or malaise, as urogenital infection or perineal abscess may precede necrotising fasciitis.

While GLP-1 receptor agonists would be recommended for patients with high CVD risk following the European and American guidelines, the NICE guidelines are more restrictive in this respect. However, an SGLT2 inhibitor is still an effective and straightforward option for this patient.

Now that we have addressed her diabetes, let's move on to her hypertension.

We'll be treating our patient's clinic BP as accurate, in accordance with NICE guidelines. If a patient has hypertension, we don't need to use ABPM or HBPM unless there are concerns, but for patients with diabetes, both sitting and standing BP should be checked due to the risk of postural hypotension, especially if affected by autonomic neuropathy.

Our patient is being treated with an ACEI, lisinopril 20 mg OD, which aligns with NICE guidance. For people with diabetes of any age and ethnicity background, an ACEI or ARB is recommended as first-line treatment, given their protective effect on the kidneys. This is especially important for patients with early stages of CKD like our patient.

I'd like to mention that our patient takes ibuprofen regularly for osteoarthritis. However, this is concerning for two reasons: it can increase blood pressure, and it's a nephrotoxic drug that can worsen CKD. We'll discuss this more when reviewing her osteoarthritis treatment.

Our patient’s BP is 142/88. NICE says that the target BP for people under the age of 80 is below 140/90, making her reading borderline. OK, what would I do?

Our patient's BP is 142/88, with a target BP below 140/90 for people under 80, making her borderline. We are starting her on dapagliflozin for her diabetes so we could see what happens to her BP. SGLT2 inhibitors, due to their diuretic effect, can sometimes have a BP lowering effect, especially when given in combination with antihypertensive agents such as ACEIs. We are probably going to advise this patient to stop or drastically reduce the use of ibuprofen, so that may also have a positive effect on her BP. Because her current BP is not desperately high, we could afford to wait for a few weeks to see if her BP drops spontaneously.

What would I do if the BP remained above target? We know that the dose of lisinopril can be increased to 40 mg and up to a maximum to 80 mg daily. However, we also know that ACEIs and ARBs are generally less effective as monotherapy in patients of African or African-Caribbean family background because these patients have a tendency towards a low renin state and a lower cardiac output, together with increased peripheral resistance.     

So, should we increase her dose of lisinopril or should we start her on a combination with, for example, a CCB? We know that CCBs are the preferred choice for patients of African and African-Caribbean family background if they do not have diabetes.

You can obviously assess her individual circumstances but, in general terms, it would be better to optimise the dose of lisinopril to the maximum tolerated dose and increase it further if possible. ACEIs and ARBs are important in the treatment of chronic kidney disease, and, avoiding these drugs in African-Caribbean patients may inadvertently contribute to worse outcomes for chronic kidney disease in these patients. 

Moving on to her osteoarthritis, we don't know which joints are affected, but we do know her symptoms are well controlled on regular ibuprofen 400mg BD. 

It's important to keep in mind that NICE recommends the following:

A non-pharmacological approach should be attempted first. This involves ensuring that the patient has engaged with physiotherapy and weight loss strategies. If the patient has not received support for this, they should be referred accordingly.

If non-pharmacological management has not been effective, a topical non-steroidal anti-inflammatory drug should be offered for knee osteoarthritis, and it should be considered for other osteoarthritis-affected joints as well. If this treatment has not been tried before, we should recommend it.

If topical treatment is not effective, NICE suggests using oral NSAIDs only at the lowest effective dose and for the shortest possible time. We should review whether to continue treatment regularly. For instance, if the patient is taking ibuprofen regularly, we should assess whether they could cope with intermittent use or a lower dose of, say, 200mg twice daily.

Finally, if the patient requires regular NSAIDs, it should be given with gastroprotection to minimise the risk of upper gastrointestinal bleeding. Therefore, we should be prescribing a proton pump inhibitor, such as omeprazole 20 mg daily, as long as they are taking ibuprofen.

Additionally, NICE advises against the use of paracetamol or weak opioids in osteoarthritis unless they are used infrequently for short-term pain relief and all other treatments have been ineffective or unsuitable.

Now, let’s look at her hyperlipidaemia and her QRISK2 score of 20%. We know that she has no history of cardiovascular disease so we are assessing her for primary prevention. 

We should normally assess patients’ QRISK2 score before starting a statin. After starting a statin, we should focus on the decrease of non-HDL cholesterol with statin therapy instead of the actual QRISK2 score since, by starting a statin, we already know that the patient is at high risk.

Let's take a closer look at the NICE guidelines on this subject:

NICE recommends using the QRISK2 tool to assess cardiovascular risk for primary prevention in individuals up to age 84, including those with type 2 diabetes. However, it's not suitable for people already at high risk due to other medical conditions such as pre-existing CVD, type 1 diabetes, CKD with an eGFR less than 60 and / or  albuminuria, familial hypercholesterolemia, or other genetic causes.

For patients like this one with a QRISK2 score of 10% or higher, NICE recommends offering atorvastatin 20 mg for primary prevention of CVD in addition to lifestyle advice.

After starting atorvastatin 20 mg, we'll recheck the patient's lipids after three months and assess non-HDL cholesterol reduction. If non-HDL cholesterol hasn't decreased by more than 40%, we'll reinforce lifestyle advice and adherence and consider increasing the atorvastatin dose to 40 mg, and later on up to 80 mg, if the patient is at higher risk due to comorbidities.

Regarding this particular patient, we assume that the score is pre-treatment, and even though she is taking 40 mg of atorvastatin, her lipids are still high. We'll need to check her pre-treatment non-HDL cholesterol to see if the 40% drop has been achieved. If not, we may consider increasing the dose to 80 mg daily.

Before we move on, let's quickly summarize what NICE recommends for patients already on statins:

We'll measure liver transaminase enzymes before starting a statin, within three months of starting or increasing the dose, and again at 12 months, unless clinically indicated.

Consider annual non-fasting blood tests for non-HDL cholesterol to inform discussions or annual reviews with the patient.

Do not offer a statin in combination with fibrate, nicotinic acid, or a bile acid sequestrant. However, combining with ezetimibe may be appropriate for patients with primary hypercholesterolemia.

Now, let's turn our attention to the patient's asthma. The history says that her asthma is well controlled with on-demand reliever therapy as needed, in this case, Salbutamol inhaler 2 puffs when required. 

According to NICE guidelines, patients with infrequent, short-lived wheezing and normal lung function can be treated with SABA reliever therapy alone. However, if symptoms indicate the need for maintenance therapy, for example, asthma-related symptoms occurring three or more times a week or symptoms causing waking at night, a low dose of an ICS such as standard beclomethasone 100mcg, one or two inhalations twice daily should be offered.

Moving on to depression, NICE recommends SSRIs such as fluoxetine as the first choice for most people, due to their good safety profile and tolerability. Tricyclic antidepressants, on the other hand, have a higher risk of danger in overdose. Lofepramine is indicated as the TCA with the best safety profile. Antidepressants are usually taken for at least 6 months, and for some time after symptoms remit.

We would need to investigate whether the patient is ready to reduce or stop the medication. NICE advises that withdrawal symptoms can occur with a wide range of antidepressant medication, including tricyclics, SSRIs, and SNRIs. It's also important to note that some commonly used antidepressants, such as paroxetine and venlafaxine, are more likely to be associated with withdrawal symptoms, so particular care is needed with them. However, fluoxetine's prolonged duration of action means that it can sometimes be safely stopped by taking 20mg alternate days for a period of time. For people taking higher doses, such as 40mg to 60mg fluoxetine a day, a more gradual withdrawal schedule should be used.

If a person experiences withdrawal symptoms when they stop taking antidepressant medication or reduce their dose, NICE recommends reassuring them that they are not having a relapse of their depression. It's important to explain that these symptoms are common, and that relapse does not usually happen as soon as medication is stopped or the dose is lowered. Additionally, it's important to note that even if the medication is restarted or the dose is increased, withdrawal symptoms may take a few days to disappear. 

In summary, here are the steps we will be taking:

We will start with dapagliflozin at 5mg and increase to 10mg daily if the patient tolerates it.

We will monitor the patient's blood pressure while on dapagliflozin and consider increasing the dose of lisinopril to 40mg once daily if necessary.

We will encourage the patient to attend physiotherapy and weight management support sessions, while also starting topical NSAIDs and reducing oral ibuprofen as much as possible. Any future doses of ibuprofen will come with gastroprotection, such as omeprazole, and the patient will be warned about the nephrotoxic effects of ibuprofen.

We will check the patient's non-HDL cholesterol levels and consider increasing atorvastatin to 80mg once daily if the current statin therapy has not resulted in a 40% reduction in non-HDL cholesterol.

We will evaluate the patient's asthma control and, if needed, offer low-dose inhaled corticosteroids, such as beclomethasone 100mcg, one or two inhalations twice daily, if the patient experiences asthma-related symptoms three or more times a week or wakes up at night due to asthma symptoms.

Finally, we will discuss the patient's depression and assess whether she is ready to gradually discontinue fluoxetine.

It is important to note that these steps will likely require multiple appointments to complete.

Please keep in mind that this is only my interpretation of the patient's case, and there may be alternative treatment options available.

 We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye  

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at another random case of hypertension to see how the NICE guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement. 

 There is a YouTube version of this and other videos that you can access here:

 ·      The NICE GP YouTube Channel: NICE GP - YouTube

 The NICE hypertension flowcharts can be found here:

 ·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn

 The full NICE Guideline NG136 can be found here:

 ·      Website: https://www.nice.org.uk/guidance/NG136

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]

Music provided by Audio Library Plus

Watch: https://youtu.be/aBGk6aJM3IU

Free Download / Stream: https://alplus.io/halfway-through

Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom. 

 In today’s episode I look at another random case of hypertension to see how the NICE guidelines could apply to it, focusing on the pharmacological treatment. By way of disclaimer, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement.

Remember that there is also a Youtube version of these episodes so have a look in the episode description. 

 Right, so let’s generate our random patient.

 OK, so we have a 45-year-old Caucasian man presenting in clinic with a BP of 180/65, so quite significant isolated systolic hypertension. He has two other co-morbidities, PVD and CKD and he is on treatment and therefore we will assume that he has already been diagnosed with hypertension. He is on 3 different antihypertensives, an alpha blocker, terazosin 10 mg daily, a calcium channel blocker, felodipine 2.5mg daily and spironolactone 25mg daily.

 So, what are my initial thoughts? Well, two really. The first one is that he is fairly young and he has significant hypertension despite being on 3 different medications. The second is that, on first impressions, his treatment looks rather strange and we will need to look into this in more detail.

 We will treat his clinic BP as accurate. NICE says that for people that have been diagnosed with hypertension, we can use clinic blood pressure measurements to monitor drug treatment so there is no need for ABPM or HBPM unless you suspect issues. For the purpose of this case, we will also that he is not under any form of stress and that his high clinic BP reading is like other readings that he has been getting on his home monitor. So, there is no concern about white coat hypertension.

 It is also worrying that, at 45, he already, has PVD and CKD and that makes me wonder whether there is something else going on here that we are missing. Could this patient have renovascular hypertension? He has PVD so we know that there is significant atherosclerosis. Could this be affecting his renal arteries? Also, he has CKD. Whilst one of the possible reasons for the drop in eGFR could simply be hypertensive nephropathy, could it also be due to a fall in renal perfusion secondary to bilateral renal artery stenosis? I think that this patient may very well warrant further investigations and referral.

 NICE says that we should consider further investigations and / or referral in people with signs and symptoms suggesting a secondary cause of hypertension. So, in this case, good ways to start would be auscultating the renal areas for the detection of bruits, checking for proteinuria or microalbuminuria and organising a doppler ultrasound of the kidneys.

 I would also look at his records and see when his hypertension was firstly diagnosed. NICE says that we need to consider referral for patients under 40 with hypertension, for the evaluation of secondary causes of hypertension. So if this patient’s hypertension started more than 5 years ago and he was never fully investigated, a referral would be really recommended.

 I will now look at his medication. Whilst his drug combination seems a little odd, let’s try and think of reasons why this could be the case.

 If we have a look at the NICE guidelines, we will see that the first drug of choice for a person under the age of 55 and not of Black African or Afro Caribbean family background is an ACE inhibitor or ARB. We also know that in the small print, NICE also tells us that for people with hypertension and CKD, we need to follow the NICE guideline on CKD, which also emphasises the need to prescribe an ACEI or ARB if there is microalbuminuria of 30 or more. And yet, this patient is not on an ACEI or ARB. Why could this be?

 Perhaps, if there is indeed renal artery stenosis, the previous initiation of an ACEI or ARB caused a significant and progressive deterioration of his renal function and this is why it was stopped. Remember that for the deterioration in renal function to be significant after an ACEI or ARB, the eGFR has to drop persistently by more than 25% or the creatinine has to increase persistently by more than 30%

 Another reason may be that the drugs were not tolerated, for example, because of a cough. A cough is a common side effect of ACEIs and it is normally managed by switching to an ARB. But, although much rarer, a cough can also be a side effect of ARBs so this could be a reason for not being on these drugs. If this was the reason, I would check if the side effect happened at lower or higher doses and I would see if a lower dose of an ACEI or ARB could be tolerated on the basis that a small dose of an ACEI/ARB is better than no ACEI/ ARB at all.

 Or was it because of hyperkalaemia? If so, did the hyperkalaemia happened when the patient was already on spironolactone? Perhaps it was the combination of these two drugs rather than the ACEI / ARB medication in isolation?

 Another reason could be the development of angioedema, which is not that uncommon with ACEIs. Normally, if this happens, you would switch the patient to an ARB but, although much rarer, angioedema can also be a side effect of ARBs.

 This patient is also on two other drugs, spironolactone and an alpha blocker that are usually reserved for step 4 treatment, when and the combination of an ACEI/ARB, a CCB and a thiazide like diuretic have failed to control the blood pressure.

 The patient is on a CCB but not a thiazide like diuretic. Why? I would check if it has been tried before and whether it could not be tolerated, for example because of gout. Although Bendroflumethiazide is the one typically associated with a rise in uric acid and worsening gout, it can also happen with other thiazide like diuretics such as indapamide and hydrochlorothiazide. Perhaps this is the reason why spironolactone was prescribed instead of the thiazide diuretic?

 And perhaps it is the issue of spironolactone that I am most uncomfortable with. Being a drug at step 4, I feel that it should not have been be initiated before the rest of his treatment has been optimised, especially in view that the history doesn’t give any other indications for it, such as chronic heart failure.

 And the issue or the alpha blocker needs looking into too. I would look to see if perhaps it was prescribed because the patient suffers from urinary outflow obstruction and it was thought that we could, so to speak, “kill two birds with one stone”. Remember that terazosin is licensed for both hypertension and benign prostatic hyperplasia.

 And finally, the dose of his CCB is low. Felodipine can go up to 10 mg daily and he is only on 2.5 mg OD. As long as he has not developed leg / ankle oedema as a side effect on higher doses in the past, increasing the dose could be an option.

 Right, having said all this, in order to progress with the case, we will say the following:

 ·      There are no signs of renal artery stenosis and that he has been fully investigated for secondary causes of hypertension and it has been concluded that he has essential or primary hypertension.

 ·      The reason for not being on an ACEI or ARB is because a cough developed with lisinopril 2.5mg OD and also when the dose of losartan went from 50mg to 100mg OD.

 ·      Felodipine has never been given at a higher dose than 2.5mg OD and currently there is no ankle oedema

 ·      A thiazide diuretic was not tolerated because of gout but since then the patient has been started on allopurinol so gout no longer seems to be a problem.

 ·      Terazosin was given in place of tamsulosin, which was recommended by his urologist for benign prostatic hyperplasia.

 ·      There is no other indication for spironolactone.

 So, what would I do?

 My interpretation is that, given that small doses of an ARB were tolerated before, I would try to restart losartan at 25mg OD increasing to 50mg OD to see if it is tolerated at lower doses without causing a cough. On doing this, I would stop spironolactone to minimise the risk of hyperkalaemia and also because there is no real indication for spironolactone at this stage.

 I would also, at the same time, increase felodipine to 5mg OD and possibly to 10 mg OD soon after depending on the response.

 And I would keep him on terazosin 10 mg OD for the benefit on his BPH.

 Remember that we want to treat him aggressively because of his age. According to NICE, the target BP for people under the age of 80 is <150/90 but <140/90 if the patient has CKD and <130/80 if the patient has CKD and an ACR >70. In his case we know that the target needs to be at least <140/90.

 If the BP is not controlled on the optimal tolerated doses of these 3 drugs, then we would say that he has resistant hypertension.

 And NICE says that before considering further treatment for a person with resistant hypertension:

·      We should confirm it using ambulatory or home blood pressure recordings.

·      We should assess for postural hypotension.

·      We should discuss adherence

And NICE also says that for people with confirmed resistant hypertension, we could consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. 

If it came to that, what would I do?

I may be tempted to refer him because of his young age. But you could also argue in favour of adding a fourth drug. Which one would I choose in this case?

I might start by trying a thiazide diuretic, now that his gout is under control, as he may tolerate it now. Unfortunately, both indapamide and hydrochlorothiazide can potentially interact with allopurinol, increasing the risk of hypersensitivity reactions and, although the manufacturer makes no recommendations in this respect, it is a severe theoretical risk. In this situation I would consider changing the gout treatment from allopurinol to an alternative agent, something like Febuxostat and then add, for example, indapamide MR 1.5mg OD for his hypertension.

If the patient or you did not want to change his gout medication for a reason, the other two options would spironolactone and a betablocker. You could start spironolactone if the potassium levels are below 4.5 but watching the levels carefully as the combination of an ACEI or ARB and spironolactone can increase the risk of hyperkalaemia. If the potassium levels are above 4.5 the choice would be restricted to a betablocker. However, remember that betablockers are contraindicated in severe PVD so this may be a problem in this patient. However, when there is no alternative, sometimes a cardio selective betablocker may be used cautiously under specialist supervision if the PVD is not severe.

 But remember that this is only my interpretation so it is not necessarily the best option. 

 We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye 

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at the NICE guidance on same day referral for hypertension. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement. 

 There is a YouTube version of this and other videos that you can access here:

 ·      The NICE GP YouTube Channel: NICE GP - YouTube

 The NICE hypertension flowcharts can be found here:

 ·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn

 The full NICE Guideline NG136 can be found here:

 ·      Website: https://www.nice.org.uk/guidance/NG136

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]

Music provided by Audio Library Plus

Watch: https://youtu.be/aBGk6aJM3IU

Free Download / Stream: https://alplus.io/halfway-through

Transcript

Hello everyone and welcome. My name is Fernando Florido, a GP in the United Kingdom. 

 In today’s episode we will discuss hypertensive emergencies, and the NICE guidance on same day referral for hypertension. Please note, this is my interpretation and not medical advice; it’s intended for health care professionals, and you must use your clinical judgement. 

Remember that there is also a YouTube version of these episodes so have a look in the episode description. 

 Dealing with hypertension can be challenging, but the good thing is that we often have time to decide on the right treatment. However, in some situations, we do not have the luxury of time due to hypertensive emergencies. Today, we will focus on how to identify and manage these emergencies.

 Before we start, I would like to share some tips I've learned from my 25 years of experience as a GP.

 Remember that we are treating the patient, not the blood pressure. The patient that we are going to be talking about today is not your typical happy antihypertensive patient. We are talking about patients who are not well; they are not happy. They will tell us and we will see it. They may have a headache, or chest pains, extreme fatigue, abdominal pain, shortness of breath, visual disturbances etc. And then, their BP is also very high. This situation is when we need to worry.

 So, if someone comes into our consulting room with a spring on their step, happy and smiling and saying: hello! how are you today? we are not going to be instantly very worried, even if their BP is very high. On the other hand, we may really worry about someone who looks unwell, even if their BP is lower.

 Also, when we finish the consultation, we like the patient leave happy but we should also feel happy about our management. So, following our instinct, our gut feeling is very important. We shouldn’t let a patient go if we are not entirely happy with their management.

 It would be better to tell them: I am sorry, I am a little concerned about your BP today and I would like to recheck it in a few minutes. Please sit quietly in the waiting room for 15-20 minutes and then we will recheck it. And then, we can use that time to seek advice. We will normally be working alongside someone else, so maybe we could ask a colleague, or an experienced doctor in the practice. If we happen to be alone or no one is available, then, and I know that this is not going to be popular with hospital doctors, we could just pick up the phone and ask to speak to the medical duty doctor. We will explain why we are worried and we will get their advice and guidance. And in the worst-case scenario, if there is no one around and nobody picks up the phone, it’s probably best just to send the patient to A&E or the emergency department. Feeling a little silly when the patient tells us: why did you send me there? It was a waste of time! Is better than having the patient, or even worse, a relative tell us: why didn’t you? Because something horrible has happened.

But don’t worry, all of that comes with experience and our clinical judgement improves all the time. Until then, it is also a good idea to rely on clear NICE guidance, which is what we are now going to look at.

 So, what do the guidelines actually say:

 In summary, that we should arrange an urgent or same-day referral in hypertension when we are worried about either the patient’s:

·      BP levels or

·      Symptoms

Let’s start with when are concerned about BP levels, that is, when the patient’s BP is very high and there are red flags. And this situation would be when the

·      BP is 180/120 mmHg or higher and they have either:

o  signs of retinal haemorrhage or papilloedema or

o  new onset of life-threatening symptoms

 Let’s look at the retinal haemorrhage and papilloedema first. They are often a sign of accelerated or malignant hypertension which is often when the BP is >220/120

And you are probably screaming at me now saying: I can’t do fundoscopy!

 And that is fine. Fundoscopy is quite a skill to master and many, if not most doctors will not be trained at a level that makes their examinations reliable. So, what would we do?

We should then be guided by the possible symptoms of retinal haemorrhage or papilloedema, which are all of these:

·      Blurred or distorted vision

·      Vision loss, (partial or complete)

·      Seeing spots or floaters

·      Reduced peripheral vision

·      Difficulty seeing in the dark

·      Eye pain or discomfort

·      Headaches

·      Nausea and vomiting

·      Flashing lights and

·      Double vision

But we also need to be aware that a retinal haemorrhage can have no symptoms at all!

 This would be the case, for example, when the bleeding is small or occurs in the periphery of the retina

But normally that would be spotted because we would:

·      Always do investigations for target organ damage on initial diagnosis and

·      These investigations always include fundoscopy, so there will always be opportunities to spot this problem.

But you will probably want to shout at me again saying: I told you I can’t do fundoscopy!

 And basically, what we need to do is refer the patient for fundoscopy to either:

·      A doctor skilled in fundoscopy or

·      An optician

If we are worried because the BP is 180/120 or higher and the patient has visual symptoms, we could play it safe and send the patient to A&E or the emergency department.

 However, if they have a BP of 180/120 or higher and they do not have any symptoms, a more sensible approach would be to arrange an

o  Urgent referral to an optician or a doctor skilled in fundoscopy

o  Which should ideally be the same or next day

 One top tip.

Even though you say that you can’t do fundoscopy, I would advise you to love your ophthalmoscope and to use it. Look at the fundi every time that an opportunity comes along. We will probably not see anything half of the times and the other half we will not know what we are seeing. It will not change our management and we will still refer the patient for a proper assessment. However, over many years of practice and experience, we may learn to spot something. And even small victories can be satisfying and good for our professional development

Right, now, if we go to the previous slide, we see that we have dealt with the issue of a high BP and retinal concerns. The next point is to address a high BP of 180/120 or higher with new onset life threatening symptoms.

And what are these life-threatening symptoms? They would be new onset:

§ confusion

§ chest pain

§ signs of heart failure, or

§ acute kidney injury or AKI

OK, new onset confusion and chest pain are very clear but, heart failure and AKI?

You may be saying now, how can we diagnose new onset heart failure the same day?

Organising Blood tests and echocardiograms take time!

So, we do what we always do, which is to be guided by the symptoms, which we can also confirm with the physical examination:

And we need to remember that we are talking about new onset heart failure, which is basically acute heart failure. So, we are not talking about those patients who have chronic heart failure and have a little bit of shortness of breath or a bit of leg oedema, etc. We are talking about acute (or acute on chronic) heart failure which is when:

o  The patient is unwell!

So, we are talking about sending to A&E or the emergency department any unwell patient with a BP of 180/120 or higher and with any of the following new symptoms:

·      Shortness of breath, coughing or wheezing, especially at night or when lying down

·      Tachycardia, arrhythmia

·      Leg/ankle/foot oedema

·      Fatigue and weakness

·      Nausea and loss of appetite

·      Confusion or disorientation and

·      Chest pain or pressure

And now you may also be saying, how can we diagnose new onset AKI the same day?

Renal function test results take time!

So, again, we do what we always do, which is to be guided by the symptoms:

And we need to remember that we are talking about acute kidney injury, which is an acute problem. So, we are not talking about those patients who have CKD and have a few symptoms here and there. We are talking about an acute injury to the kidneys, which is when:

o  The patient is unwell!

So, we are talking about sending to A&E or the emergency department any unwell patient with a BP of 180/120 or higher and with any of the following new symptoms:

·      Decreased urine output or no urine output

·      Leg/ankle/foot oedema

·      Fatigue and weakness

·      Shortness of breath

·      Nausea and vomiting

·      Confusion or disorientation and

·      Chest pain or pressure

 So, we now go back to our very first slide and we can see that we have dealt with concerns about patients’ BP levels. But there is still the question of symptoms, so…

 Do you ever refer the same day if BP<180/120?

 And the answer is Yes!

Because we would refer patients if they have phaeochromocytoma symptoms

Now we need to remember that a phaeochromocytoma is a rare tumour of the adrenal glands. The adrenal glands produce adrenaline and noradrenaline, which control heart rate, blood pressure and metabolism. A phaeochromocytoma can produce too much adrenaline and noradrenaline, which often results in problems such as palpitations and high blood pressure.

 So what are those symptoms?

The symptoms of a phaeochromocytoma tend to be unpredictable, often occurring in sudden attacks lasting from a few minutes to an hour, sometimes longer, and the patient will therefore be intermittently unwell

So, we are talking about sending to A&E or the emergency department any patient who has hypertension (without a specific BP threshold) and who is intermittently unwell with any of the following symptoms:

·      headache

·      palpitations

·      pallor

·      abdominal pain and

·      diaphoresis or excessive sweating

Right, will that be difficult to remember?

 Nah!

Because in real life we will have common sense, we will follow our instinct and we will do what we would normally do for any seriously unwell patient

For example:

Regardless of their BP!

Would we refer a patient to A&E or the emergency department if they are unwell with any of these symptoms?

·      Acute confusion:

·      Acute chest pain: 

·      Acute shortness of breath:

·      Acutely unwell with decreased urine output or no urine output:

·      So the answer is yes, and we would do this regardless of the BP. In fact, we would probably call the ambulance first and then check the BP later!

Then, would we refer a patient to A&E or the emergency department if they had a BP of 180/120 or higher and either

·      visual disturbances or

·      the patient is Unwell? : And the answer is Yes! Especially if:

o  Rapid or irregular heartbeat

o  Leg/ankle oedema

o  Fatigue and weakness

o  Coughing or wheezing, especially at night or when lying down and

o  Nausea and vomiting

And, after what we have learned today about pheochromocytoma, would we refer a hypertensive patient to A&E or the emergency department if they were intermittently unwell with any of these symptoms?

o  Palpitations:

o  Pallor

o  abdominal pain or

o  diaphoresis

o  And the answer is Yes! we would do that because we would be worried about pheochromocytoma and we would do it regardless of their BP at the time.

But remember that this is only my interpretation of the guideline, so it is not necessarily correct.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye 

My name is Fernando Florido and I am a GP in the United Kingdom. With this video I continue with the series on the monthly “NICE News” bulletin, which includes new guidance published in that month as well as any updates, also in that particular month, to already published guidelines. However, I will only address guidance which is relevant to Primary Care.

In today’s video, I go through the NICE Guidance and advice published in March 2023.

 There is a YouTube version of this and other epipsodes that you can access here:

 NICEGP YouTube channel:  

·      NICE GP - YouTube 

The Full NICE News bulleting for March 2023 can be found at:  

·      https://www.nice.org.uk/guidance/published?from=2023-03-01&to=2023-03-31

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Music provided by Audio Library Plus

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 Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.

With today’s episode I go through the summary of NICE Guidance and advice published in March 2023 and relevant to Primary Care. 

Remember that there is also a Youtube version of these episodes so have a look in the episode description.

The first guideline that we are looking at refers to a brand-new technology appraisal of: Semaglutide for managing overweight and obesity

And it says that Semaglutide can now be used by weight management specialists for weight loss. Although it will be prescribed by specialists, in primary care we need to know when to refer these patients. Semaglutide for weight loss can be given only if:

·      it is used for a maximum of 2 years within a specialist service and

·      the patient has at least 1 weight-related comorbidity and:

• a BMI of at least 35.0, or
• a BMI of 30-34.9 and meets specialist referral criteria
• BMI thresholds will be usually reduced by 2.5 for people from non-White ethnic family background. This is because people from some minority ethnic family backgrounds have an equivalent risk from obesity at a lower BMI levels.

Semaglutide should be stopped if less than 5% of the initial weight has been lost after 6 months of treatment.

These recommendations are made because clinical trials show that:

·      semaglutide promotes weight loss

·      more weight is lost with semaglutide than with liraglutide

·      semaglutide helps normalise blood glucose in prediabetes

·      semaglutide may decrease the risk of cardiovascular disease.

The next guideline update is in Type 1 diabetes in adults

The main three quality statements are:

·     Patients with type 1 diabetes are offered choice between real-time and intermittently scanned continuous glucose monitoring.

·     Adults with type 1 diabetes aged 40 and over are offered statins for the primary prevention of CVD and

·     Every 12 months patients should have 9 processes recorded: urine ACR, HbA1c, blood pressure, creatinine, cholesterol, BMI, a foot check, eye screening and smoking status

·     The other statements refer to patient education, eating disorders and foot risk assessment in hospital

The next and final guideline update is in Type 2 diabetes in adults

And the main quality statements are four:

·     Adults at high risk of type 2 diabetes are offered a referral to the NHS Diabetes Prevention Programme

·     Adults with insulin-treated type 2 diabetes who cannot self-monitor because of a disability or that have their blood glucose monitored by a care professional are offered continuous glucose monitoring

·     Adults with type 2 diabetes are offered an SGLT2 inhibitor if they have co-existing chronic heart failure, CVD or CKD.

·     Every 12 months patients should have 9 processes recorded: urine ACR, HbA1c, blood pressure, creatinine, cholesterol, BMI, a foot check, eye screening and smoking status

·     The other statements refer to patient education and foot risk assessment in hospital.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a random case of hypertension to see how the NICE guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this podcast is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement. 

There is a YouTube version of this and other videos that you can access here: 

·      The NICE GP YouTube Channel: NICE GP - YouTube 

The NICE hypertension flowcharts can be found here: 

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn

The full NICE Guideline NG136 can be found here:

·      Website: https://www.nice.org.uk/guidance/NG136

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]

Music provided by Audio Library Plus

Watch: https://youtu.be/aBGk6aJM3IU

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.  

In today’s episode I look at a random case of hypertension to see how the NICE guidelines could apply to it, focusing on the pharmacological treatment. By way of disclaimer, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement.

Remember that there is also a YouTube version of these episodes so have a look in the episode description. 

Right, so let’s generate our random patient.

OK, so we have 85-year-old Caucasian woman presenting in clinic with a BP of 168/83. She is not on treatment and therefore we will assume that she has not been diagnosed with hypertension before. 

So, let’s have a look at the NICE guidelines. 

Firstly, NICE says that if the clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, we need to offer ABPM to confirm the diagnosis and if ABPM is unsuitable or the person is unable to tolerate it, then we will offer HBPM instead.

So, we assess this patient and, because of her vascular dementia, we find that she will not be able to tolerate ABPM so we arrange HBPM instead.  

NICE also say that while waiting for the confirmation we should carry out

1-investigations for target organ damage and

2-a formal assessment of cardiovascular risk 

And we can see that she has been investigated previously and we know that she has several comorbidities such as:

1- Vascular dementia

2- Heart failure, which we will say here that it is HF with reduced ejection fraction and

3- Microalbuminuria, which, for the purpose of this case we will say that there is no evidence of structural renal tract issues so we are going to presume that the working diagnosis is hypertensive nephropathy

And all of these three comorbidities indicate end organ damage. Also, there is no need to assess formally her cardiovascular risk because she already has established CVD. 

Right, so we organise the HBPM and let’s say that we have a HBPM result of also 168/83. Isolated systolic hypertension according to NICE is when the systolic BP is >160 but the diastolic BP is not raised. So, in this patient’s case, we will say that she has ISH.

Does she need treatment? Well, NICE says that we should offer people with isolated systolic hypertension the same treatment as people with both raised systolic and diastolic blood pressure. Stage 2 hypertension is when the BP is 160/100 or higher but less than 180/120. This effectively means that this patient needs to be treated exactly the same as if she had stage 2 hypertension.

And NICE says that we need to offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension but of course, using our clinical judgement for anyone with frailty or multimorbidity. 

We assess this patient and consider that despite of, or even because of her multimorbidities, she needs to be started on treatment to lower her BP. According to NICE, the target clinic BP for those aged 80 and over, is below 150/90 mmHg or below 145/85 if using ambulatory or home BP readings, again using our clinical judgement for people with frailty or multimorbidity.

 Right, so we have decided to start medication. How do we treat her?

 If we look at the visual aid resource from NICE, it says that for people without diabetes and over the age of 55, step 1 treatment should be with a calcium channel blocker, right? Well, yes and no, because it will depend on the case. There is always the small print to worry about, and we find it here:

 NICE says that for people with chronic kidney disease, we should follow the NICE’s guideline on chronic kidney disease and for people with heart failure, we should follow the NICE’s guideline on chronic heart failure.

 To be fair, although we know that she has microalbuminuria, presumed to be due to hypertensive nephropathy, the history does not really say that this patient has CKD. But it does say that she has heart failure with reduced ejection fraction. The chronic heart failure NICE guidelines say that in order to reduce morbidity and mortality, we should prescribe both an ACE inhibitor and a beta-blocker escalating to adding Spironolactone and more if necessary. One drug should be introduced at a time, adding the second drug once the person is stable on the first drug and we will use our clinical judgement as to which drug we will start first.

 So, my interpretation in this case is that I would start an ACEI, for example lisinopril 2.5 mg daily, for both her heart failure and hypertension, titrating it up to the target or maximal tolerated dose and, as soon as possible after that, I would also start a betablocker licensed for the treatment of HF, for example bisoprolol 1.25mg OD, also titrating it up also to the target or maximal tolerated dose. And I would do that for her CHF only. However, although betablockers do not appear as an option in the management of hypertension but we do know that they can also have a BP lowering effect so it is likely to be beneficial for her HTA too.

 Remember that she already has vascular dementia so it is likely that she has a degree of widespread atherosclerosis and we should start the ACEI cautiously and watching her renal function closely in case that she has already developed renal artery stenosis.

 And of course, remember that, because she is over 80, we should regularly measure both her sitting and standing BP. And, if there is a significant postural drop or symptoms of postural hypotension, we will base the blood pressure target on the standing blood pressure value. 

 But remember that this is only my interpretation so it is not necessarily the best option. 

 We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye