Outline how to initiate and titrate angiotensin converting enzyme inhibitor (ACEI) therapy and beta blocker therapy

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)


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


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


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.


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.




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


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

Treatment of Heart Failure and Appendix D – Practical Notes


Myocardial infarction; secondary prevention – NICE Guidelines 2007 – quick reference guide. May 2007

Chapter on Congestive Cardiac Failure) in Clinical Pharmacy and Therapeutics or similar textbook

For each of the following group of drugs for heart failure indicate initiation and maximum dose and what stage of heart failure they should be used.

Beta-blockers (Licensed in heart failure)
When are they indicated:…

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