Hipertensión Arterial, Diapositivas de Cardiología

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Hypertension

Clinical case scenarios for primary care

Implementing NICE guidance

nd

Edition October 2013

NICE clinical guideline 127

What this presentation covers

Five clinical case scenarios, including:

presentation

medical history

• examination

The clinical decisions surrounding diagnosis and

management will then be examined

Presentation

38 year old, attending for routine appointment about her contraception, for

which she uses a diaphragm.

Medical history

From her records you notice that Mary’s blood pressure has increased since

her last check twelve months ago. She does not smoke, drinks 10-12 units of

alcohol a week and has no notable medical history.

On examination

Mary’s first clinic blood pressure measurement is 158/94 mmHg. Her heart rate

is 72 beats per minute and regular

You are considering a diagnosis of hypertension and therefore take another

reading in Mary’s other arm. There is no notable difference between readings.

Next steps for diagnosis

Question 1.

What would you do next?

Answer 1.

You would take Mary’s blood pressure a third time during the consultation.

Question 1.

The third reading is 149/93 mmHg. You suspect hypertension – what would you do

next?

Answer 1.2 (continued)

test for the presence of protein in the urine by sending a urine sample for

estimation of the albumin:creatinine ratio and test for haematuria using a

reagent strip

take a blood sample to measure plasma glucose, electrolytes, creatinine,

estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol

examine the fundi for the presence of hypertensive retinopathy

arrange for a 12-lead electrocardiograph to be performed.

Answer 1.2 (continued)

You would also carry out a formal assessment of cardiovascular risk

(Mary’s clinic blood pressure must be used in the calculation of

cardiovascular risk) using a cardiovascular risk assessment tool, in line with

Identification and assessment of CVD risk in ‘Lipid modification’

(NICE clinical guideline 67).

Additionally, you would also ascertain information about lifestyle in areas

such as diet, exercise, alcohol, smoking and caffeine consumption and

dietary sodium intake and offer appropriate lifestyle

advice.

Record the results of all investigations and assessment in

Mary’s notes.

Answer 1.

You would advise that healthy diet and regular exercise can reduce blood

pressure. You would also encourage her to keep her dietary sodium intake

low as this can reduce blood pressure. You should also inform her about

local initiatives

Question 1.

The result of Mary’s ABPM shows daytime average blood pressure of

145/92 mmHg.

What would your diagnosis and your next steps be?

Question 1.

The results of the investigations for target organ damage and formal

assessment of cardiovascular risk are:

no evidence of target organ damage

10-year cardiovascular risk less than 20%.

Nothing abnormal was detected in the other investigations you organised.

What is your next step and what treatment and follow up would you offer?

Answer 1.

Further assessment

You would consider seeking specialist evaluation of secondary causes of

hypertension and a more detailed assessment of potential target organ

damage. This is because 10-year cardiovascular risk assessments can

underestimate the lifetime risk of cardiovascular events in these people.

Additionally, people under 40 years with stage 1 hypertension are less likely to

have overt evidence of target organ damage or vascular disease.

Question 1.

If Mary had been eligible to receive antihypertensive drug treatment, what

should you consider when prescribing antihypertensive drugs for a woman of

child-bearing potential?

Answer 1.

There is an increased risk of congenital abnormalities if women take angiotensin-

converting enzyme (ACE) inhibitors or angiotensin III receptor blockers (ARBs)

during pregnancy, and it is important that women of child-bearing age know this. If

the woman is planning a pregnancy she should discuss this with you. If a woman

taking ACE inhibitors or ARBs becomes pregnant, these antihypertensive drugs

should be stopped and alternatives offered.

Link to related recommendations from the ‘Hypertension in Pregnancy’ (NICE

clinical guideline 107):

• Management of pregnancy with chronic hypertension
• Breastfeeding

Question 1.

What are the key points to remember when measuring blood

pressure to ensure that the reading is as accurate

as possible?

Case scenario 2 : Danny

Presentation

Danny is a 39-year-old black male of Caribbean family origin. He presents to you

with a sore ankle after ‘going over’ on it.

Medical history

Danny has no significant past medical history. Previous presentations have been

related to coughs and colds.

He smokes 25 cigarettes a day, alcohol consumption around 20 units/week and has

done for 18 years. He works shifts and says that he considers his diet to be

unhealthy as a result.

On examination

You conclude that Danny’s ankle is sprained. As part of your routine examination

you measure his blood pressure. The first measurement in

his left arm is 150/92 mmHg, the second measurement in his right

arm is 149/91 mmHg and the third measurement in his left

arm is 151/92 mmHg.

Question 2.

What would you do next?

Case scenario 2 : Danny

Answer 2.

You would record Danny’s clinic blood pressure as 149/91 mmHg. In order to

diagnose hypertension, you organise ambulatory blood pressure monitoring

(ABPM) to confirm a diagnosis of hypertension. When organising this you

ensure that at least two measurements per hour are taken during Danny’s

usual waking hours. You would use the average value of at least

14 measurements taken during Danny’s usual waking hours to confirm a

diagnosis of hypertension.

At the same time you would also carry out investigations for target organ

damage (such as left ventricular hypertrophy, chronic kidney disease and

hypertensive retinopathy).