The cardiovascular merry go round Beverley Bostock RGN
The cardiovascular merry go round Beverley Bostock RGN MSc MA QN
George’s blood pressure • George, age 72, has a BP in surgery of 163/93 mm/Hg. • e. GFR 78 ml/min; ACR 0. 9 • What next?
NICE Guidelines 2011 Step 2 Step 3 Step 4 < 55 yrs >55 yrs or black A C A+C+D Persistent Hypertension A+C+D Consider further diuretic Or Alpha or Beta blocker Consider seeking further advice
Treating hypertension • Age based and co-morbidity based decision • ACE inhibitors: pros and cons • CCBs – possible side effects • Diuretics – indapamide usually • Most people need 2 -3 drugs to reach target • Step 4: think before you treat and ? refer • Beta blockers, alpha blockers, spironolactone etc.
Kidneys
Filtration
Reabsorption
CKD: confirming the diagnosis NICE 2014 • e. GFR <? ? /min for the first time? • Review the history and retest within ? ? weeks in case of ? ? • Abnormalities should be present for at least ? ? for CKD to be diagnosed and staged accurately. • Urinalysis should also be carried out.
Safety first…STOPP the DAMN drugs • D • A • M • N
George’s blood pressure • George, age 72, has a confirmed diagnosis of hypertension • e. GFR 58 ml/min; ACR 0. 9 • What next?
Kathy age 62 • Kathy age 59 has hypertension and OA. She had an MI 2 years ago. • BMI 31. 4 kg/m 2; smokes 2 -3/day. • She works in the restaurant of the local pub. • BP is 153/81 mm/Hg, e. GFR is 62 ml/min and ACR is 1. 7. • TC 4. 4 mmol/mol HDL 1. 1 mmol/mol • On ramipril 5 mg and doxazosin 2 mg for her BP, and she buys Solpadeine and Nurofen OTC for her OA. She stopped her statin post MI due to side effects. • She uses a GTN spray every few weeks.
Time for a change?
Kathy attends again • She DNA’d her next 2 appointments and was lost to follow up • She attends the ‘minor illness’ clinic with dyspnoea and productive cough • Examination reveals bilateral crackles in both lungs, raised JVP • Temp 36. 4, BP 167/99 mm. Hg, HR 98 bpm regular
Now what?
HFr. EF HFp. EF and the ABD of management
Patient centred care • NMC code of conduct 2015: the 4 Ps • Section 1 – Prioritise people • Section 2 – Practice effectively • Section 3 – Preserve safety and • Section 4 – Promote professionalism and trust
Further information • www. educationforhealth. org • b. bostock@educationforhealth. org • NICE (2011) Hypertension guidelines https: //www. nice. org. uk/guidance/cg 127 • NICE (2014) CKD guidelines https: //www. nice. org. uk/guidance/cg 182 • NICE (2014) CVD guidelines including lipid management https: //www. nice. org. uk/guidance/cg 181 • NICE (2010) Chronic heart failure guidelines https: //www. nice. org. uk/guidance/cg 108
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