HOT TOPICS

for MRCGP and

General Practitioners
4TH EDITION
Contents

Foreword xi
Acknowledgements xiii
Introduction xv
Why bother with Hot Topics? xvii
Useful reading material for ‘Hot Topics’ revision xix
1. Cardiovascular Disease 1
Hypertension 4
Assessing CVD risk 15
Hyperlipidaemia 17
Antiplatelet treatment 25
Heart failure 29
Atrial fibrillation 36
Coronary heart disease – lifestyle factors 41
Stroke and TIA 47
2. Diabetes Mellitus 53
How is the diagnosis of diabetes confirmed? 55
What are the implications of the National Service Framework 56
(NSF) for diabetes?
What are the Standards of the NSF? 56
Diabetes and the General Medical Services (GMS) contract 57
Is there evidence that improved glycaemic control leads to a
reduction in complications? 58
How often should we measure HbA1c? 59
HbA1c targets (NICE 2002) 60
Self-monitoring 60
Should there be a screening programme for type 2 diabetes? 61
How important is treating hypertension in diabetic patients? 61
Should we give all diabetics ACE inhibitors? 62
How do we treat diabetic nephropathy? 62
What is the evidence for statin use in diabetics? 63
What are the glitazones? 64
What about the meglitinides? 65
Inhaled insulin 65

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HOT TOPICS FOR MRCGP AND GENERAL PRACTITIONERS

What does all this mean for patients? 65

Impaired glucose tolerance (IGT) 66
How can we stop people with IGT from developing diabetes? 66
The metabolic syndrome 67
3. Respiratory Diseases 69
Asthma 71
Chronic obstructive pulmonary disease 80
Smoking cessation 85
Influenza 92
4. Psychiatry 97
Mental health National Service Framework 99
Depression 102
Post-natal depression 109
Post-traumatic stress disorder (PTSD) 109
Schizophrenia 111
Eating disorders 115
Alcohol 117
Drug misuse 122
Counselling 129
5. The Elderly 131
National Service Framework (NSF) for older people 133
Falls 135
Depression 136
Alzheimer’s disease 137
Osteoporosis 142
Parkinson’s disease 149
Osteoarthritis 151
6. Obstetrics and Gynaecology 157
Hormonal contraception 159
Emergency hormonal contraception 164
Teenagers and sexual health 166
Sexual health and chlamydia 169
Hormone replacement therapy 174
7. Paediatrics 183
The NSF for children, young people and maternity services
Standards 185
Every child matters 187

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Prescribing for children 189

Looking after teenagers 189
Childhood vaccinations 190
8. Cancer 195
The NHS Cancer Plan 197
Prostate cancer 202
Screening for bowel cancer 209
Mammography 210
Cervical cancer 213
Screening 214
9. Antibiotics 217
Antibiotic resistance 219
Urinary tract infections 222
Sore throat 224
Otitis media 226
Respiratory tract infections 228
Acute conjunctivitis 230
10. Clinical Governance 231
What are the components of clinical quality? 233
What can we do to improve? 233
Why is it needed? 233
In reality 234
How does it work in Primary Care Trusts (PCTs)? 234
Conclusions 234
National Institute for Clinical Excellence (NICE) 235
11. Revalidation 241
Self-regulation 243
Arguments for self-regulation 243
Organisation of self-regulation 243
Latest arrangements for revalidation 244
Professional regulatory reform in the UK: a brief chronology 248
National Clinical Assessment Authority (NCAA) 253
Practice and personal development plans (PPDPs) 255
12. The Future of General Practice 257
Shaping tomorrow: issues facing general practice in the new
millennium, GPC 2000 260
Primary Care Trusts 264

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HOT TOPICS FOR MRCGP AND GENERAL PRACTITIONERS

The New GMS Contract 264

Rationing 267
Access to healthcare 270
NHS Direct 271
Walk-in Centres 275
Diagnostic and treatment centres 278
Specialist GPs 279
Nurse practitioners 280
Post ‘Shipman’: what are the long-term effects? 284
Practice-based commissioning 287
The National Programme for Information Technology (NPfIT) 290
13. Medicine and the Internet 293
What makes the internet attractive? 295
Is there any regulation of the information available on the internet? 296
What is the Health on the Net Foundation? 296
What problems may the internet pose to healthcare professionals? 296
Are there any problems with writing for medical websites? 297
The e-patient and e-mail consultations 297
14. Complementary Medicine 303
St John’s wort 306
Ginkgo biloba 306
Phytoestogens 307
Saw Palmetto 307
Is there any good evidence available to support homoeopathy? 307
15. Medicolegal Issues and Guidelines 309
General Medical Council 311
Complaints 313
Confidentiality 315
Consent 317
Medical negligence 320
Guidelines 321
16. Advance Directives and End-of-Life Decisions 325
Advance directives 327
BMA guidance regarding advance statements (living wills) 327
End-of-life decisions 329

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17. Miscellaneous Topics 333

Refugees 335
Recent advances in ethics 339
18. The Consultation 343
Non-attendance 357
Telephone consultations 359
Consultation models 360

Glossary 369
Journals referenced in this book 374
Index 376

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 CHAPTER 1:
CARDIOVASCULAR
DISEASE
 CHAPTER 1:
CARDIOVASCULAR
DISEASE
The prevention of cardiovascular disease (CVD) is one of the most important
tasks for general practice. CVD remains the principal cause of death in the UK
– half the population of the UK will be killed or disabled by a myocardial
infarction (MI), cerebrovascular accident (CVA) or other cardiovascular event
and one-fifth of these deaths occur below retirement age. One-third are
considered to be premature – occurring before the age of 75. CVD is also
considered to be the leading cause of disability in Europe. It has been estimated
that 4.2% of men and 3.2% of women in England and Wales are being treated
for coronary heart disease (CHD). The main risk factors are smoking,
hypertension, hyperlipidaemia, diabetes mellitus, obesity and social deprivation.
These will all be discussed within this chapter.
The medical priority is to focus on those who are at highest risk of CVD. The
first priority is secondary prevention for patients with established CVD. The
second priority is primary prevention for people at high risk of developing CVD,
ie those with an absolute CVD risk >20% (equivalent to CHD risk >15%)
over 10 years, as calculated using the Joint British Society’s coronary risk-
prediction charts.

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HOT TOPICS FOR MRCGP AND GENERAL PRACTITIONERS

Hypertension
Hypertension was defined by the World Health Organization in 1993 as the
blood pressure above which intervention reduces risk. Hypertension is a very
common but poorly managed condition. More than one-quarter of the world’s
adult population had hypertension in 2000; this is predicted to increase to 29%
by 2025 (Lancet 2005; 365: 217–223).
The control of hypertension is still very poor – only about 10% of the
hypertensive patients in the UK have adequate control (Hypertension 2004; 43:
10–17). With the increasingly tough treatment targets proposed by the British
Hypertension Society (BHS), it is likely that even fewer patients will be
‘adequately controlled’.
Hypertension treatment decreases the risk of fatal and non-fatal stroke, cardiac
events and death. People at a greater cardiovascular risk when they start
treatment, such as elderly patients, derive the most absolute benefit from drug
treatment. However, the potential for side-effects such as falls resulting from
postural hypotension should not be ignored. The question of whether to start
treatment in the elderly should be decided on a case by case basis, taking into
account co-morbidities.

By how much should blood pressure (BP) be

lowered?
The 2004 BHS guidelines state that:
? In non-diabetic patients, the aim is to reduce the BP to below
140/85 mmHg. The maximum acceptable level (audit standard) is
150/90 mmHg.
? In diabetic patients, patients with established CVD and patients
with renal impairment, BP should be reduced to below 130/80
mmHg. The maximum acceptable level is 140/80 mmHg.
This differs from the General Medical Services (GMS) contract, which awards
quality and outcomes framework (QOF) points for achieving BP targets of
<150/90 mmHg (145/85 mmHg for diabetics).
For most patients over the age of 50 years, systolic BP is more important than
diastolic BP in terms of risk of CVD.

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 CARDIOVASCULAR DISEASE

The BP targets proposed by the BHS are partly based on one large randomised
controlled trial, the Hypertension Optimal Treatment (HOT) trial (Lancet 1998;
351: 1755–1762), which looked at outcomes in terms of major CVD events in
18,790 hypertensive patients aged between 50 and 80 who were randomly
assigned to a target diastolic BP of <90, <85 or <80 mmHg.
This study showed that the lowest incidence of CVD events occurred at a mean
diastolic blood pressure of 82.6 mmHg (and systolic pressure of 138.5 mmHg)
and the lowest overall CVD mortality occurred at a diastolic pressure of 86.5
mmHg. An even lower diastolic blood pressure was found to be beneficial in
diabetics (<80 mmHg). Stroke risk was also lowest at a diastolic BP of <80
mmHg.
The HOT study is unique in that it was designed to evaluate optimum target BP
levels. It also set out to examine the role of aspirin in the primary prevention of
CVD, and half the participants were randomised to receive this. Aspirin was
found to reduce major CVD events by 15% and non-fatal MI by 36%, although
it had no effect on the stroke rate. The benefit of aspirin for primary prevention
had been controversial before this study.

What is the best drug regime to treat hypertension?

It is still unclear whether the benefits of specific antihypertensive drugs come
from their direct effects on raised BP or from various other indirect actions.
However, the overall consensus is that the degree of BP reduction achieved is
probably more important than the class of drug used.
Most patients will need at least two medications to control their BP adequately.
Giving low-dose antihypertensives in combination is more effective and
produces fewer side-effects than a single drug at a high dose (BMJ 2003; 326:
1427).
It is generally accepted that best practice is to choose therapeutic agents likely
to do more good than harm, given each patient’s social circumstances,
preferences, co-existing medical conditions and risk factors. This is also likely to
improve compliance. One study showed that only one-third of patients
prescribed antihypertensives and lipid-lowering therapy were still taking both
medications after six months (Arch Intern Med 2005; 165: 1147–1152).
Some of the most important hypertension studies are highlighted below.

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