About 6 months later, Mr KK visits your pharmacy again. He tells you his GP has diagnosed him as having angina. What is angina and what symptoms would you expect him to experience?

NICE Bites – Management of stable angina, UKMI, September 2011

BACKGROUND READING

Stable angina – Clinical features and diagnosis. Clinical Pharmacist, January 2012

Stable angina – Management. Clinical Pharmacist, January 2012

WORKSHOP EXERCISE

Fill in the empty boxes in the diagram of the renin-angiotensin system below.

ANSWER ALL THESE QUESTIONS USE THE READING LIST IN PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS IN DETAIL

Mr KK, a 61 year old Caucasian secondary school teacher, has recently been diagnosed with hypertension. His recent blood pressure reading was 165/100mmHg.

He feels generally well but has been under a great deal of stress at work recently. He has no past medical history. His older brother has hypertension and type II

diabetes and his father died aged 52 following a myocardial infarction. He has no other medical problems. He smokes 15 cigarettes a day and weighs about 100kg.

He doesn’t think that he has hypertension as he has had only 2 high readings but he is to have 24 hour blood pressure (BP) monitoring next week. He has also had blood

tests to check his blood sugar, cholesterol, renal function and liver function. He has read about white coat hypertension in the newspaper but was not sure what this

means.

1)    Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment?

Category    Systolic BP mmHg (Clinic)    Diastolic BP mmHg (Clinic)    Systolic BP mmHg (Ambulatory)    Diastolic BP mmHg (Ambulatory)
Normal

High-normal

Stage 1

Stage 2

2)    What lifestyle measures would you advise Mr KK to help lower his blood pressure? Why are lifestyle measures important?

3)    About 1 week later Mr KK comes back into your pharmacy, he has now had 24 hour BP monitoring and his diagnosis of hypertension has been confirmed.

a.    How should an initial antihypertensive treatment be chosen for Mr KK?

b.    What antihypertensive therapy would you choose to start Mr KK on? What target blood pressure would you recommend for Mr KK and how often would you monitor his

blood pressure?

Fill this in on your care plan.
Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Hypertension

PART B: CARDIOVASCULAR RISK

4)    Mr KK has a cholesterol of 6.5mmol/L and his total cholesterol:HDL ratio is 6.5. Calculate his overall cardiovascular risk using the tables in the BNF.

Complete the table below with his modifiable and non-modifiable risk factors for CVD

Modifiable    Non-modifiable

5)    Mr KK’s doctor now wants to start other medicines for primary prevention. What do you understand by primary prevention? Suggest a drug and dosage regime if

appropriate. What counselling would you give Mr KK about any new medicines you recommend?

Fill this in on your care plan.

Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Cardiovascular Risk

PART C: OTHER CO-MORBIDITIES

Although you should refer to the NICE guidance for hypertension when choosing antihypertensive therapy consideration should also be given to co-morbid conditions

6)    In four groups, discuss, giving reasons, which antihypertensive(s)
would be a good choice or poor choice. What target BP would you aim for in these patients?

•    White male accountant, 34 years old, asthma and weighs 82kg

•    White male, 70 years old, diabetes and CKD (Creatinine 250micromol/L). He weighs 70kg and is 5 feet 9 inches tall.

•    28 year old African woman with CKD (Creatinine 290micrmol/L)

•    72 year old African American woman with chronic cardiac failure NYHA Stage 3.

PART D: ISCHAEMIC HEART DISEASE

7)    About 6 months later, Mr KK visits your pharmacy again. He tells you
his GP has diagnosed him as having angina. What is angina and what symptoms would you expect him to experience?

8)    What changes would you recommend to Mr KK’s prescription and why? What counselling and monitoring would he need?

9)    Mr KK comes back to your pharmacy 3 months later with a prescription for a GTN spray. You notice this will be his 4th repeat prescription for this in the last

3 months. What questions do you want to ask him before you dispense this and what changes could you suggest to his therapy?

Question        Response

10)    Mr KK collects a new prescription for his GTN spray and asks you when he should expect to need a new one. Each GTN spray contains 200sprays; Mr KK is now using

2 puffs 4 times a week. The spray you have dispensed for him expires in May 2015.

WORKSHOP THREE

MAJOR THEMES:
CHRONIC HEART FAILURE

LEARNING OBJECTIVES

Following the lecture, workshop, directed and background reading, students should be able to:

1)     Describe the aetiology and presentation of heart failure
2)     List the desired outcomes in care of patients with heart failure and how
pharmacists can help achieve these
3)     Discuss the pharmaceutical management of heart failure
4)     Outline how to initiate and titrate angiotensin converting enzyme inhibitor (ACEI) therapy and beta blocker therapy
5)    List the counselling required by patients commencing therapy on ACEIs and beta blockers for heart failure

DIRECTED READING

Karagkounis D. Heart Failure – clinical features and diagnosis. Clinical Pharmacist. 2014; 6: 119-122 2010

Williams H. Heart Failure – management. Clinical Pharmacist. 2014; 6:123-1282010

BNF sections 2.5.5

NICE Bites – Chronic Heart Failure (NW MI) September 2010

NICE Clinical Guideline No: 108 August 2010: Management of Chronic Heart Failure in adults in Primary and Secondary Care. NICE guideline Pages 15-20 Pharmacological