GP Flashcards
(43 cards)
HTN in clinic
none
moderate
severe
> 80
<140/90
140/90 - 179/119
>180/120
<150/90
HTN with Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM)
none
moderate
severe
> 80
<135/85
135/85 - 149/94
>150/95
<145/85
clinic HTN 140/90 - 179/119 managment
OFFER LIFE STYLE ADVICE • Offer ABPM (or HBPM if ABPM is declined or not tolerated) • Investigate for target organ damage • Assess cardiovascular risk
clinic HTN >180/120 management
OFFER LIFE STYLE ADVICE
Assess for target organ damage as soon
as possible:
• Consider starting drug treatment immediately without ABPM/HBPM if target organ damage
• Repeat clinic BP in 7 days if no target organ damage
Refer for same-day specialist review if:
• retinal haemorrhage or papilloedema (accelerated hypertension) or
• life-threatening symptoms or
• suspected pheochromocytoma
HTN abpm/hbpm >135/85 management
OFFER LIFE STYLE ADVICE and discuss starting drug treatment
if <40 consider secondary causes
HTN lifestyle advice
a low salt diet is recommended caffeine intake should be reduced stop smoking drink less alcohol eat a balanced diet rich in fruit and vegetables exercise more lose weight
HTN
without T2DM and
age 55+ or Black African or African–Caribbean family origin (any age)
stage 1 treatment
calcium channel blocker (INE)
amlopidine
nifedipine
SE - flushes, fatigue, ankle odema/swelling
HTN
without T2DM and
age 55+ or Black African or African–Caribbean family origin (any age)
stage 2 treatment
calcium channel blocker (INE) - amlopidine, nifedipine
SE - flushes, fatigue, ankle odema/swelling
AND
ACEi (PRIL) - ramipril
SE - cough, hyperkalaemia (U+E)
or ARB (STARTAN) - candestartan SE - renal impairment (k+), vertigo, postural hypotension
or thiazide-like duiretic -
SE -
HTN
without T2DM and age <55
or with T2DM
stage 1 treatment
ACEi (PRIL) - ramipril
SE - cough, hyperkalaemia (U+E)
or ARB (STARTAN) - candestartan SE - renal impairment (k+), vertigo, postural hypotension
HTN
without T2DM and age <55
or with T2DM
stage 2 treatment
ACEi (PRIL) - ramipril
SE - cough, hyperkalaemia (U+E)
or ARB (STARTAN) - candestartan
SE - renal impairment (k+), vertigo, postural
AND
calcium channel blocker (INE) - amlopidine, nifedipine
SE - flushes, fatigue, ankle odema/swelling
or thiazide-like duiretic -
SE -
stage 3 treatment for all HTN
ACEi (PRIL) - ramipril
SE - cough, hyperkalaemia (U+E)
or ARB (STARTAN) - candestartan
SE - renal impairment (k+), vertigo, postural
AND
calcium channel blocker (INE) - amlopidine, nifedipine
SE - flushes, fatigue, ankle odema/swelling
AND
thiazide-like duiretic -
SE -
stage 4 treatment for HTN
Confirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherence
Consider seeking expert advice or adding a:
• low-dose spironolactone if blood potassium level is ≤4.5 mmol/l
• alpha-blocker or beta-blocker if blood potassium level is >4.5 mmol/l
chronic heart failure investigations
ECG
CXR
transthoracic echocardiography
NT-proBNP
chronic heart failure with preserved ejection fraction
Manage comorbidities such as HTN, AF
Offer a personalised exercise-based cardiac rehabilitation
chronic heart failure with reduced ejection fraction
stage 1
ACEi (PRIL) - ramipril
SE - cough, hyperkalaemia (U+E)
AND
beta adrenoreceptor blockers (LOL) - carvedilol, bisoprolol
SE - ED, sleep problems, fatigue, peripheral vascular disease
Measure serum sodium, potassium and assess renal function before and after starting and after each dose increment
consider ARB if ACEi intolerant
chronic heart failure with reduced ejection fraction
stage 2
replace ACE with sacubitril valsartan if ejection fraction <35% (monitor Na and K as can cause electrolyte imbalance)
Add ivabradine for sinus rhythm with heart rate >75 and
ejection fraction <35%
Add hydralazine and nitrate (especially if of AfricanCaribbean descent) (may cause rapid hypotension)
Digoxin for heart failure with sinus rhythm to improve symptoms (arrhythmias)
HbA1C DM values
normal - <41
pre diabetes - 42-47
diabetes - >48
heart failure signs and symptoms
Breathlessness Cyanosis Reduced exercise tolerance Tachycardia Oedema Elevated jugular venous pressure Faitgue Displaced apex beat S3-heart sound
asthma management
1) newly diagnosed - short-acting beta2 agonist (SABA)
2) low dose of an inhaled corticosteroid
3) offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.
4) offer a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA treatment
5) offer to change the person’s ICS and LABA maintenance therapy to a MART regimen with a low maintenance ICS dose.
6) increase the ICS to a moderate maintenance dose
asthma drugs and SE
SABA - salbutamol
SE - tachyarrthymias, hypokalaemia
ICS - beclometasone
SE - oral candidiasis (brush teeth after use)
LTRA - montelukast
SE - diarrhoea, URTI
LABA - salmeterol
SE - tachyarrthymias, hypokalaemia
spiro ostructive v restrictive
obstructive ratio<70%
retrictive fev1 + fvc <80%
If HbA1c rises to 48 mmol/mol (6.5%) on lifestyle interventions management
metformin - increases sensitivity of insulin
SE - diarrhoea
FIRST INTENSIFICATION
If HbA1c rises to 58 mmol/mol management
Consider dual therapy with:
metformin and a DPP-4i (GLIPTIN) - alogliptin
metformin and pioglitazone (SE - increased weight, fractures)
metformin and a sulfonylurea (GLI) - gliclazide (SE diarrhoea)
metformin and a sodium-glucose co-transporter 2 (SGLT2) (FLOZIN) - canagliflozin
SECOND INTENSIFICATION If HbA1c rises to 58 mmol/mol
Consider: - triple therapy with:
metformin, a DPP-4i and an SU
metformin, pioglitazone and an SU
metformin, pioglitazone or an SU, and an SGLT-2i
