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Podcast-Hypertension Guidelines in Practice - Clinical case 2
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My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at another random case of hypertension to see how the NICE guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.
There is a YouTube version of this and other videos that you can access here:
The NICE hypertension flowcharts can be found here:
The full NICE Guideline NG136 can be found here:
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
Music provided by Audio Library Plus
Transcript
Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.
In today’s episode I look at another random case of hypertension to see how the NICE guidelines could apply to it, focusing on the pharmacological treatment. By way of disclaimer, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement.
Remember that there is also a Youtube version of these episodes so have a look in the episode description.
Right, so let’s generate our random patient.
OK, so we have a 45-year-old Caucasian man presenting in clinic with a BP of 180/65, so quite significant isolated systolic hypertension. He has two other co-morbidities, PVD and CKD and he is on treatment and therefore we will assume that he has already been diagnosed with hypertension. He is on 3 different antihypertensives, an alpha blocker, terazosin 10 mg daily, a calcium channel blocker, felodipine 2.5mg daily and spironolactone 25mg daily.
So, what are my initial thoughts? Well, two really. The first one is that he is fairly young and he has significant hypertension despite being on 3 different medications. The second is that, on first impressions, his treatment looks rather strange and we will need to look into this in more detail.
We will treat his clinic BP as accurate. NICE says that for people that have been diagnosed with hypertension, we can use clinic blood pressure measurements to monitor drug treatment so there is no need for ABPM or HBPM unless you suspect issues. For the purpose of this case, we will also that he is not under any form of stress and that his high clinic BP reading is like other readings that he has been getting on his home monitor. So, there is no concern about white coat hypertension.
It is also worrying that, at 45, he already, has PVD and CKD and that makes me wonder whether there is something else going on here that we are missing. Could this patient have renovascular hypertension? He has PVD so we know that there is significant atherosclerosis. Could this be affecting his renal arteries? Also, he has CKD. Whilst one of the possible reasons for the drop in eGFR could simply be hypertensive nephropathy, could it also be due to a fall in renal perfusion secondary to bilateral renal artery stenosis? I think that this patient may very well warrant further investigations and referral.
NICE says that we should consider further investigations and / or referral in people with signs and symptoms suggesting a secondary cause of hypertension. So, in this case, good ways to start would be auscultating the renal areas for the detection of bruits, checking for proteinuria or microalbuminuria and organising a doppler ultrasound of the kidneys.
I would also look at his records and see when his hypertension was firstly diagnosed. NICE says that we need to consider referral for patients under 40 with hypertension, for the evaluation of secondary causes of hypertension. So if this patient’s hypertension started more than 5 years ago and he was never fully investigated, a referral would be really recommended.
I will now look at his medication. Whilst his drug combination seems a little odd, let’s try and think of reasons why this could be the case.
If we have a look ...
There is a YouTube version of this and other videos that you can access here:
The NICE hypertension flowcharts can be found here:
The full NICE Guideline NG136 can be found here:
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
Music provided by Audio Library Plus
Transcript
Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.
In today’s episode I look at another random case of hypertension to see how the NICE guidelines could apply to it, focusing on the pharmacological treatment. By way of disclaimer, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement.
Remember that there is also a Youtube version of these episodes so have a look in the episode description.
Right, so let’s generate our random patient.
OK, so we have a 45-year-old Caucasian man presenting in clinic with a BP of 180/65, so quite significant isolated systolic hypertension. He has two other co-morbidities, PVD and CKD and he is on treatment and therefore we will assume that he has already been diagnosed with hypertension. He is on 3 different antihypertensives, an alpha blocker, terazosin 10 mg daily, a calcium channel blocker, felodipine 2.5mg daily and spironolactone 25mg daily.
So, what are my initial thoughts? Well, two really. The first one is that he is fairly young and he has significant hypertension despite being on 3 different medications. The second is that, on first impressions, his treatment looks rather strange and we will need to look into this in more detail.
We will treat his clinic BP as accurate. NICE says that for people that have been diagnosed with hypertension, we can use clinic blood pressure measurements to monitor drug treatment so there is no need for ABPM or HBPM unless you suspect issues. For the purpose of this case, we will also that he is not under any form of stress and that his high clinic BP reading is like other readings that he has been getting on his home monitor. So, there is no concern about white coat hypertension.
It is also worrying that, at 45, he already, has PVD and CKD and that makes me wonder whether there is something else going on here that we are missing. Could this patient have renovascular hypertension? He has PVD so we know that there is significant atherosclerosis. Could this be affecting his renal arteries? Also, he has CKD. Whilst one of the possible reasons for the drop in eGFR could simply be hypertensive nephropathy, could it also be due to a fall in renal perfusion secondary to bilateral renal artery stenosis? I think that this patient may very well warrant further investigations and referral.
NICE says that we should consider further investigations and / or referral in people with signs and symptoms suggesting a secondary cause of hypertension. So, in this case, good ways to start would be auscultating the renal areas for the detection of bruits, checking for proteinuria or microalbuminuria and organising a doppler ultrasound of the kidneys.
I would also look at his records and see when his hypertension was firstly diagnosed. NICE says that we need to consider referral for patients under 40 with hypertension, for the evaluation of secondary causes of hypertension. So if this patient’s hypertension started more than 5 years ago and he was never fully investigated, a referral would be really recommended.
I will now look at his medication. Whilst his drug combination seems a little odd, let’s try and think of reasons why this could be the case.
If we have a look ...
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