HTN

•Day 1 , a 48-year-old van driver, was identified by his general practitioner

•(GP) as having a resting blood pressure of 162/92 mmHg. He was
•in reasonably good health and purchased over-the-counter (OTC) ibuprofen
•400 mg, which he took up to three times daily for arthritis-type
•pain when necessary. He weighed 95 kg, was 5’7” tall, and had a resting
•pulse rate of 82 beats per minute (bpm). He smoked 15 cigarettes per day
•and drank at least 6 units on 4 nights each week. His total cholesterol
•(TC) had been measured as 5.9mmol/L and his high-density lipoprotein
•(HDL) as 1.5 mmol/L (TC:HDL ratio 4.5).
•Q1 Why is it important to control blood pressure?
•Q2According to current guidelines, should patient be treated for
•hypertension?
•Q3 What non-drug approaches can patient adopt to reduce his blood pressure
•and/or his cardiovascular (CV) risks, and why are these important?
•Q4 What first-line treatments would be suitable for hypertension?
• 1.Why is it important to control blood pressure?
• A1 There is a statistical association between elevated blood pressure
• values (hypertension) and the development of cardiovascular
• disease (CVD) and other organ damage, in particular to the eyes
• and kidneys.
• 2.According to current guidelines, should patient be treated for
• hypertension?
• A3 Not immediately. He is otherwise in good health, has several
• modifiable risk factors, and is only marginally over one of the two
• values normally considered as thresholds for drug treatment
• (160/100 mmHg in most guidelines). The decision to start an
• otherwise healthy patient on potentially lifelong drug therapy
• should not be taken lightly, and for patients with a lower CVD risk
• it might be possible to attempt lifestyle modifications before
• drug treatment is initiated, and to thus delay the initiation of
• therapy.
• 3.What non-drug approaches can patient adopt to reduce his blood
• pressure and/or his cardiovascular (CV) risks, and why are these
• important?
• A4 Non-drug approaches that could be used to reduce Mr FH’s blood
• pressure include losing weight, stopping smoking, reducing his
• alcohol intake, taking more exercise, amending his intake of salt
• and caffeine, and avoiding certain over-the-counter (OTC) drugs
• 4.What first-line treatments would be suitable for his hypertension?
• A5 The choice of first-line treatment for should be influenced
• by his age, ethnicity and comorbidities. Obviously, some patients
• will have compelling reasons owing to their comorbidities to use
• or not use certain therapies, but otherwise the ‘ACD’ rule can be
• used as outlined below. This evidence-based guidance looks at
• the place of three groups of antihypertensives: A(CEIs), C(alciumchannel
• blockers) and D(iuretics), and guides drug choice based
• on ethnicity and age.
• Month 3 he had had his blood pressure recorded twice more and the
• values had been recorded as 160/91 mmHg and 164/92 mmHg.
• Q5Suggest a suitable drug, initial dose, titration regimen, and any monitoring
• required. What counselling would he require?
• Q6 What other investigations, if any, might be appropriate for patient as a
• patient newly diagnosed with hypertension?
• Q7 What target blood pressure is appropriate for him?
• Q8 Should he be started on aspirin and a statin?
• 5.Suggest a suitable initial dose, titration regimen, and any monitoring
• required. What counselling would he require?
• A6 The licensed initial dose of ramipril in hypertension is 1.25 mg,
• increasing every 1–2 weeks to a maximum of 10 mg. renal
• function and potassium levels should be monitored as well as his
• blood pressure. Counselling should cover the reasons why his
• blood pressure is being controlled and what lifestyle issues should
• be addressed, as well as specific information about ramipril
• 6.What other investigations, if any, might be appropriate for him as a
• patient newly diagnosed with hypertension?
• A7 A number of additional routine biochemical tests are appropriate
• for newly diagnosed hypertensive patients to aid the accurate profiling
• of CVD risk, to help detect diabetes or damage to the heart
• and kidneys caused by raised blood pressure, and to look for possible
• causes of secondary hypertension such as kidney damage
• 7.What target blood pressure is appropriate for him?
• A8 NICE advises a target blood pressure of <140/90 mmHg
• 8.Should he be prescribed aspirin and a statin?
• A10 Probably not, unless other risk factors are identified.
• he continued to visit his medical centre at 2-monthly intervals, but
• his blood pressure remained raised, despite the prescribed ramipril. Nine
• months later, he was admitted to the Acute Medical Assessment Unit
• of the local hospital, having collapsed at work with chest pains, which
• resolved rapidly after sublingual glyceryl trinitrate. He admitted that he
• had been getting chest pains on exertion for ‘a couple of months’. His
• blood pressure was measured as 165/99 mmHg. His haematology and biochemistry
• results were as follows:
• Sodium 140 mmol/L (135–145) TC 7.1 mmol/L
• Potassium 4.9 mmol/L (3.5–5) Blood glucose 4.1 mmol/L
• Creatinine 130 micro mol/L (<110) Glycated haemoglobin (HbA1c)6.7%
• Haemoglobin 11.2 g/dL (12–18) 6.7
• His current therapy was:
• Ramipril 5 mg daily Paracetamol 1 g four times daily
• Simvastatin 10 mg daily when required
• Aspirin 75 mg daily
• He admitted to continuing to buy OTC ibuprofen and not being terribly
• compliant with his statin therapy.
• Q9 What additional medication can be added to further control patient
• blood pressure?
• Q10 patient wishes to monitor his own blood pressure at home. What would be
• your recommendation?
• Q11 Outline a pharmaceutical care plan for him
• 9.What additional medication can be added to further control his
• blood pressure?
• A12 A stepped approach to antihypertensive treatment is recommended
• to achieve target blood pressure values, with the addition
• of other drugs as necessary. Second-line therapy for him
• would be a CCB or diuretic (following the ACD rule); however, as
• he now has a diagnosis of IHD, his second-line therapy needs to
• be reconsidered.
• 10.patient wishes to monitor his own blood pressure at home. What would
• be your recommendation?
• A13 Home monitoring or self-measurement of blood pressure is popular
• with patients. There are a number of automated, small and
• lightweight home blood pressure monitors available. All are
• oscillometric and measure the blood pressure on the upper arm,
• wrist or finger. However, due to possible peripheral vasoconstriction,
• sensitivity to posture and the distal location of finger
• devices, home monitoring may lead to inaccurate measurements
• 11.Outline a pharmaceutical care plan for Mr FH.
• A14 The pharmaceutical care plan should consider each of the problems
• identified on his admission with chest pain: hypertension;
• IHD; anaemia; raised creatinine and cholesterol levels. His
• continued smoking also needs to be addressed.