Primary Care Guidelines – Details, episodes & analysis

The video version of this podcast can be found here:

·      https://youtu.be/SA7pJQLlmvg

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for August 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-08-01&to=2024-08-31&ndt=Guidance&ndt=Quality+standard

The links to the current guidance can be found here:

Diabetic retinopathy: Management and monitoring:

·      https://www.nice.org.uk/guidance/ng242

Abaloparatide for treating osteoporosis after menopause:

·      https://www.nice.org.uk/guidance/ta991

National Osteoporosis Guideline Group (NOGG) clinical guideline for the prevention and treatment of osteoporosis:

·      https://www.nogg.org.uk/full-guideline

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in August 2024, focusing on what is relevant to Primary Care only.

We are going to cover just two areas, the treatment of osteoporosis and the management of diabetic retinopathy, so it is a brief episode.

Let’s jump into it.

The first area is a technology appraisal on Abaloparatide for treating osteoporosis after the menopause.

And you may be thinking, Abaloparatide, is this really something that we need to know about in Primary Care?

And the answer is yes. And let’s see why.

And we will start by saying that treatments of osteoporosis can be broadly divided into 2 types:

·    antiresorptive treatments (which slow the rate of bone breakdown), such as our usual bisphosphonates and

·    anabolic (or bone-forming) treatments.

Treatment with anabolic skeletal agents result in rapid and greater fracture risk reductions than bisphosphonates. So, if we are used to prescribing bisphosphonates for the majority of our patients, who should be getting anabolic agents instead?

And the guidelines stipulate that people with a very high fracture risk should be referred for the consideration of these agents. According to the National Osteoporosis Guideline Group, 'very high risk' is defined as a FRAX-based fracture probability that exceeds the intervention threshold by 60%.

So, looking at this diagram based on FRAX, we can see how patients can fall into the different risk categories depending on their scores.

Apart from the patients already in the very high risk of fractures, we should also consider additional clinical risk factors for patients in the high-risk category, (e.g., frequent falls, or a very low spine Bone Mass Density) in case that they may move them from high to very high risk of fracture.

So, in summary, we need to be aware that these anabolic drugs exist and that they are recommended for people with a very high risk of fractures so that when we see such patients, we refer them appropriately to get these drugs.

Existing anabolic treatments are Romosozumab and Teriparatide and, following this technology appraisal, NICE recommends Abaloparatide too.

These anabolic agents can only be taken for a limited time between 12 and 24 months depending on the drug, and afterwards patients will continue to receive an antiresorptive treatment (such as an oral bisphosphonate).

Although abaloparatide is licensed for 'treatment of osteoporosis in postmenopausal women', we must also include trans men and non-binary people registered female at birth.

The next area is a brand-new NICE guideline on Diabetic retinopathy, its management and monitoring. It is mostly aimed at the diabetic retinal screening service and ophthalmologists but it also covers some areas of diabetic care that affects us in primary care. Let’s have a look at it.

1.   Firstly, we should always discuss with patients that good long-term diabetic control can have long-term benefits for their vision.

2.   Then the second recommendation refers to the effects on retinopathy of a rapid reduction in HbA1c.This is because there is some, although limited, evidence about the potential risk of worsening retinopathy from treatments that result in a rapid, substantial drop in HbA1c. Early worsening of diabetic retinopathy does not necessarily mean that the treatment is harmful in the long term but, instead, it highlights the need for close monitoring. NICE therefore recommended that an ophthalmologist should assess the patient before intensive glycaemic treatment is started, and then closely monitors for changes afterwards.

3.   We know that both HbA1c and blood pressure levels can be used to predict the likelihood of retinopathy progression. So, the third recommendation is that ophthalmologists should have access to a person's HbA1c and blood pressure records.

4.   Additionally, NICE has highlighted that the presence of renal disease can also influence retinopathy progression. The evidence for this is of low quality, but is supported by clinical experience.

5.   Also, we know that managing blood pressure in hypertensive patients can reduce retinopathy progression, so achieving good blood pressure control is important. However, we must also be aware that reducing blood pressure with antihypertensives in people who do not have hypertension has no such positive effect.

6.   There is some evidence that fenofibrate is beneficial for people with type 2 diabetes in respect of retinopathy progression. However, there is no evidence on other outcomes such as visual acuity or quality of life. NICE therefore recommends that it should be ophthalmologists who initiate fenofibrate for this indication. There is no evidence for people with type 1 diabetes, so they are not included in the recommendation.

7.   NICE has recommended further research about statins preventing retinopathy progression, because there is no strong evidence to this effect.

8.   The rest of the recommendations are entirely for secondary care and cover areas such as cataract surgery as well as recommendations of the treatment and frequency of monitoring for both proliferative and non-proliferative diabetic retinopathy and diabetic macular oedema.

So that is it, a review of the NICE updates relevant to primary care.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/pxOeszuHRsI

This episode makes reference to guidelines produced for NHS Greater Glasgow and Clyde and Liverpool University Hospitals NHS Trust. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the management of hypocalcaemia, in particular, we will look at the guidance on the management of hypocalcaemia in NHS Greater Glasgow and Clyde and in Liverpool University Hospitals NHS Trust, always focusing on what is relevant in Primary Care only.  

I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

●      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

●      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e

●      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P

●      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D

●      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3

There is a YouTube version of this and other videos that you can access here: 

●       The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk 

The resources consulted can be found here:

The guidance on the management of hypocalcaemia by Liverpool University Hospitals NHS Trust can be found here:

·      https://pathlabs.rlbuht.nhs.uk/Guideline%20for%20Treating%20and%20Monitoring%20Hypocalcaemia%20for%20non-critical%20areas%20of%20Trust.pdf

The guidance on the management of hypocalcaemia by the Adult Therapeutics Handbook for the NHS Greater Glasgow and Clyde can be found here:

·      https://handbook.ggcmedicines.org.uk/guidelines/electrolyte-disturbances/management-of-hypocalcaemia/

Calcium – The Lancet - Bushinksy DA, Monk RD. Calcium. Lancet 1998; 352 (9124): 306-311:

·      https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)12331-5/abstract 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

●       Music provided by Audio Library Plus 

●       Watch: https://youtu.be/aBGk6aJM3IU 

●       Free Download / Stream: https://alplus.io/halfway-through 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description. 

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the management of hypocalcaemia, in particular, we will look at the guidance on the management of hypocalcaemia in NHS Greater Glasgow and Clyde, and in Liverpool University Hospitals NHS Trust, always focusing on what is relevant in Primary Care only. The links to their guidelines and the other sources consulted are in the episode description. 

Right, without further ado, let’s jump into it. 

As a quick overview of calcium metabolism, I will simply say that it is tightly regulated by vitamin D and the parathyroid hormone or PTH. Active vitamin D or calcitriol enhances intestinal calcium absorption and PTH both enhances calcium reabsorption in the kidneys, and releases calcium from the bones by increasing osteoclast activity and bone resorption. 

Both phosphate and magnesium can also affect calcium levels. For example, a low magnesium can impair PTH secretion and action, resulting in hypocalcaemia.  

On the other hand, a high phosphate, like seen in CKD, can lead to the precipitation of calcium with phosphate and the consequent reduction in serum calcium and hypocalcaemia.

Right, now that we have done this review, let’s now look at hypocalcaemia itself.

The reference range for adjusted serum calcium is 2.2 - 2.6mmol/L.

Symptoms of hypocalcaemia, typically develop when serum adjusted calcium falls below 1.9mmol/L. However, this threshold varies and symptoms also depend on the rate of fall. 

So, we will talk of hypocalcaemia when we have an adjusted serum calcium less than 2.2 mmol/L, although you should always take into account your local path lab reference range.  

The cause of hypocalcaemia may be varied depending on whether we are talking about acute or chronic hypocalcaemia. And we must remember that hypocalcaemia is far less common than hypercalcaemia because of the role of the bones as a calcium reserve to maintain homeostasis. 

So, let’s look at causes of acute hypocalcaemia first. The most common cause is hyperventilation which induces transient hypocalcaemia with normal serum total calcium levels normal. Let’s quickly see why this is the case. 

• When a person hyperventilates, they breathe out excessive CO₂ which leads to a decrease of carbonic acid, and respiratory alkalosis.
• Alkalosis causes more calcium to bind to albumin, reducing the concentration of free (ionized) calcium. Given that the ionized form is the physiologically active form, this decrease leads to symptoms of hypocalcaemia.
• However, despite the decrease in ionized calcium, the total serum calcium remains normal because this value includes the calcium bound to albumin. 

Other less common causes are:

·      Other forms of alkalosis.

·      Medications, for example post IV bisphosphonate or denusomab treatment

·      A high phosphate. We have to remember that phosphate and calcium often behave like two parts of a seesaw, where changes in one can inversely affect the other. Therefore, hypocalcaemia can be seen in clinical situations where phosphate is high, like in:

• rapid tumour lysis – like e.g. during cytotoxic treatment of leukaemia or
• in excessive phosphate intake – like for example excessive phosphate containing enemas.
• And finally, another less common cause of hypocalcaemia is acute pancreatitis. 

Let’s now look at the causes of chronic hypocalcaemia. And the most common cause is a decrease in levels of active vitamin D. This could be because there is:

• An overall vitamin D deficiency, like in dietary causes, malabsorption, and lack of sunlight or
• A reduction in the active form of vitamin D or calcitriol, due to poor renal conversion as seen in CKD

Less common causes are:

• hypoparathyroidism which can be post-surgical, autoimmune, genetic, idiopathic etc.
• hypomagnesaemia, because low magnesium impair the secretion and function of PTH, giving rise to a functional hypoparathyroidism.
• Pseudohypoparathyroidism, which is a rare, genetic disorder characterized by the body’s resistance to PTH despite normal or elevated PTH levels and finally
• low plasma albumin caused by, for example, malnutrition, or liver disease. However, it is worth mentioning that a low plasma albumin can lead to low total calcium levels but it does not cause true hypocalcaemia (understood as a low ionized or free calcium). Instead, it leads to pseudohypocalcaemia, where only the bound calcium is reduced, so patients typically do not experience symptoms of low calcium unless their ionized calcium is also low.

It is also worth mentioning that dietary lack of calcium intake is a very rare cause of hypocalcaemia. 

What are the symptoms and signs of hypocalcaemia?

Well, the clinical features of hypocalcaemia are connected to its effects on the nerves and muscles. Typical features include: 

·      Effects on the nervous system like:

• Paraesthesia
• convulsions which may occur because hypocalcaemia lowers the seizure threshold, and
• psychiatric effects, from general malaise to overt psychosis in chronic hypocalcaemia
• Effects on the muscles like:
• painful cramps
• tetany, which may result in spontaneous muscular spasms largely precipitated by exercise
• laryngeal spasm causing stridor, and obstructive respiratory symptoms and
• latent tetany, which may be demonstrated by Trousseau's and Chvostek's signs. Let’s quickly have a look at them:

For Trousseau’s sign, a blood pressure cuff is inflated usually about 20 mm Hg above the systolic BP, and it is left inflated for about 3 minutes. A positive sign is indicated by involuntary contraction of the muscles in the hand and fingers, known as carpal spasm or "Trousseau’s phenomenon." 

On the other hand, Chvostek's sign is performed by tapping on the facial nerve just in front of the ear, at the angle of the jaw, which is the area where the facial nerve crosses the masseter muscle. A positive sign is indicated by twitching of the facial muscles on that same side.  

Both Trousseau's and Chvostek's signs are indicative of increased neuromuscular excitability, which is often associated with hypocalcemia, although not exclusively. 

Other features of chronic hypocalcaemia depend on the underlying cause. They can be very varied so I will mention only a few like:

• candidiasis
• nail dystrophy
• alopecia, and
• rickets or osteomalacia - from chronic vitamin D deficiency

What investigations should be carried out in primary care if we find hypocalcaemia? And we are obviously talking about mild asymptomatic hypocalcaemia because patients with severe or symptomatic hypocalcaemia should be referred to hospital. 

Initial investigations should include as a minimum: 

• A repeat serum adjusted calcium and phosphate
• Parathyroid hormone (PTH)
• Urea and electrolytes
• Magnesium
• Vitamin D and
• A 12-lead ECG as there is a significant likelihood of QT prolongation, in which case cardiac monitoring may be required.

We should monitor calcium concentrations regularly to judge response and review treatment. Serum bone profile should be checked regularly according to clinical judgement, perhaps weekly or fortnightly depending on the case until concentrations are stable. 

Let’s now have a look at the treatment of hypocalcaemia. 

The treatment depends on the severity of symptoms and underlying condition: 

• treatment generally invovles administration of calcium. How calcium is administered and the need for additional agents such as vitamin D depends on the acuity and severity of the hypocalcaemia as well as the underlying cause.
• Severe Hypocalcaemia, that it, a serum adjusted calcium <1.9mmol/L and/or symptomatic hypocalcaemia should be treated as a medical emergency because it can be life-threatening. So, these patients should be referred to hospital for the administration of IV calcium.
• Chronic, Asymptomatic Mild Hypocalcaemia, that is, serum adjusted calcium between 1.9 - 2.2mmol/L is treated with oral calcium and often vitamin D supplements.
• Because calcium binds with dietary phosphate and oxalate we should advise patients that calcium is better absorbed when taken between meals.
• oral calcium is given to increase its availability and, often, vitamin D to enhance absorption.
• calcium carbonate is widely available in tablet form and we should aim for a daily dose of 1-2.6 g and then adjust according to response.
• Examples of calcium carbonate supplements are adcal and calcichew.
• NHS Greater Glasgow and Clyde recommend starting Calcichew Forte Chewable, 2 tablets twice a day, which is an unlicensed dose, and adjust the dose according to the patient’s requirements. As soon as it is appropriate, we should prescribe the licensed dose of 1 tablet daily.
• Alternatively, Liverpool Hospitals recommend starting oral calcium and vitamin D supplements such as Adcal D3 (2 to 4 tab daily) with monitoring and adjustment.
• calcium citrate and calcium phosphate should be avoided because they may cause problems, especially in patients with renal failure.
• If the patient is vitamin D deficient, we will start oral vitamin D supplementation with loading doses of colecalciferol as per the NICE guideline on vitamin D deficiency.
• vitamin D2 or ergocalciferol and vitamin D3 or colecalciferol at doses of 400 units a day are adequate to avoid nutritional deficiency, although higher doses may be needed in malabsorption.
• However, they require conversion to the active form calcitriol and therefore they are not suitable if the alpha-hydroxylation process is impaired, like for example in renal failure. In these cases, we should be guided by the renal team.
• Other general principles that apply to the management of hypocalcaemia are:
• magnesium levels should be checked and corrected if low. If patient has hypomagnesaemia, we should stop any precipitating drug and admit the patient to hospital for the administration of IV magnesium.
• patients on digoxin should be monitored carefully because administration of calcium may lead to digoxin toxicity and death
• Patients with hypoparathyroidism have decreased renal calcium reabsorption and oral calcium supplementation, may lead to hypercalciuria with possible nephrocalcinosis or kidney stones. Therefore, in hypoparathyroidism, the treatment should be guided by endocrinology.
• If hypocalcaemia is secondary to post-thyroidectomy, we will also seek specialist advice.
• When calcium is given to patients with hyperphosphataemia, there is a risk of soft-tissue calcium phosphate precipitation, so we should get specialist advice on the use of phosphate binders. Calcium supplements may have to be delayed until phosphate levels come down.

Right, so that is it. We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.  

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/0cD2zityw9I

The interactive flowchart can be accessed here:

https://1drv.ms/b/s!AiVFJ_Uoigq0mRYQ2Yw67rtg00TM?e=2DpSYI

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the recently published NICE guideline on vitamin B12 deficiency in adults, focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

·      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e

·      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P

·      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D

·      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline “Vitamin B12 deficiency in over 16s: diagnosis and management” (NICE guideline NG239 can be found here:

·      https://www.nice.org.uk/guidance/ng239

The links to the resource “Oral vitamin B12 replacement: ongoing care and follow up” can be found here:

·      https://www.nice.org.uk/guidance/ng239/resources/visual-summary-ongoing-care-and-followup-for-vitamin-b12-replacement-pdf-13315996909

The B12 pandemic guidance by the British Society of Haematology can be found here:

·       https://apps.nhslothian.scot/refhelp/guidelines/haematology/b12deficiency/

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE guideline on vitamin B12 deficiency in adults, published as recently as March 2024, focusing on what is relevant in Primary Care only.

Make sure to stay for the entire episode because, at the end, I will tell you how to access an interactive flowchart that I have created and that summarises the guidance.

Right, so let’s jump into it.

Let’s start by looking at common symptoms and signs of vitamin B12 deficiency, which are:

·      anaemia or macrocytosis on a FBC, but we should not rule out a diagnosis of vitamin B12 deficiency based solely on the absence of either anaemia or macrocytosis

·      difficulty concentrating or short-term memory loss, also sometimes described as 'brain fog'

·      glossitis and mouth ulcers

·      unexplained fatigue

·      eyesight problems related to optic nerve dysfunction like

o  blurred vision

o  a visual field loss or scotoma and

o  optic atrophy signs on fundoscopy

·      neurological or mobility problems including

o  balance issues and falls due to impaired proprioception or sensory ataxia

o  impaired gait and

o  paraesthesia, and finally

·      it can also be associated with mental health problems, including symptoms of depression, anxiety or psychosis.

There are also common risk factors for vitamin B12 deficiency. Before looking at them, let’s briefly look at the physiology of vit B12 in the human body.

In food, vitamin B-12 is generally bound to protein, so in the stomach, gastric enzymes such as pepsin separate the vitamin B12 from the protein using. Then, the freed vitamin B12 then combines with a protein produced by parietal cells in the stomach, called intrinsic factor. The vitamin B12-IF complex is taken to the cells in the terminal ileum, where the vitamin B12 is absorbed. So, in summary, for vit B12 to be absorbed effectively, we need a sufficient dietary intake and normal physiological processes in the stomach and terminal ileum.

So, with that in mind, the common risk factors for vitamin B12 deficiency are:

·      diet low in vitamin B12, for example, in people who:

o  follow a vegan diet or low in animal-source foods

o  people who do not consume items fortified with vitamin B12

o  people who have an allergy to some foods such as eggs, milk or fish

o  and people who have difficulties following a well-balanced diet, e.g.:

§ in dementia, frailty, and mental illness

§ in low-income situations and

§ in eating disorders

·      other risk factors include conditions such as:

o  atrophic gastritis

o  coeliac disease or another autoimmune condition and

o  previous gastrointestinal surgery like:

§ bariatric surgery and

§ gastrectomy or terminal ileal resection

·      some medicines like:

o  colchicine

o  H2-receptor antagonists and proton pump inhibitors

o  metformin and

o  some antiepileptics like phenobarbital, pregabalin, primidone and topiramate

·      a family history of vitamin B12 deficiency or an autoimmune condition and finally

·      recreational nitrous oxide use.

We should use our clinical judgement as to when to check for vitamin B12 levels, paying attention as to whether patients have symptoms, signs and risk factors.

In order to diagnose vitamin B12 deficiency, we will use either total B12 (or serum cobalamin) or active B12 (serum holotranscobalamin) unless:

·      the test needs to be done during pregnancy (when we should always use active B12 or serum holotranscobalamin), or if

·      recreational nitrous oxide is the suspected cause, when we will use plasma homocysteine or serum methylmalonic acid (or MMA)

We should not delay vitamin B12 replacement while waiting for the test results in:

·      suspected megaloblastic anaemia,

·      neurological symptoms or

·      suspected vitamin B12 secondary to medication.

We will use caution when interpreting test results if:

·      they are already using an over-the-counter preparation containing vitamin B12 because they may mask a deficiency but may not fully treat it or if

·      they are taking the combined oral contraceptive pill because this can lower total B12 concentrations without causing a true deficiency.

·      We also need to be aware that people of Black ethnicity may have a higher reference range for serum vitamin B12 concentrations.

The NICE guideline gives Vit B12 thresholds to decide whether the vitamin B12 deficiency is unlikely, confirmed or whether the value is indeterminate, but it also recommends using local validated thresholds if they exist. So, in the absence of local guidance we will follow these thresholds:

·      If total B12 is less than 180 nanograms per litre or active B12 is less than 25 pmol per litre, then the vit B12 deficiency is confirmed.

·      If total B12 is more than 350 nanograms per litre or active B12 is more than 70 pmol per litre, then the vit B12 deficiency is unlikely and we will investigate other causes of their symptoms and if they are still experiencing symptoms 3 to 6 months later, we will repeat the vit B12 test.

·      And finally, if total B12 is between 180 and 350 nanograms per litre or active B12 is between 25 and 70 pmol per litre, then the vit B12 levels are considered to be indeterminate, meaning that vit B12 deficiency is possible but not confirmed. In these cases, we will measure serum MMA concentrations if there are symptoms or signs of deficiency. While waiting for the results, we will start vit B12 replacement if

o  they could deteriorate rapidly, for example, neurological or haematological conditions such as ataxia or anaemia

o  if they have a suspected irreversible cause of vitamin B12 deficiency (for example, autoimmune gastritis, a gastrectomy, terminal ileal resection or some types of bariatric surgery or if

o  they are pregnant or breastfeeding.

If the vitamin B12 deficiency is confirmed, we will investigate further and we will:

·      Check for anti-intrinsic factor antibody if autoimmune gastritis is suspected bearing in mind that a negative test result does not rule out the presence of autoimmune gastritis.

·      If autoimmune gastritis is still suspected despite a negative anti-intrinsic factor antibody test, we will consider further investigations such as:

o  an anti-gastric parietal cell antibody test

o  a test to measure gastrin levels

o  a CobaSorb test to measure whether vitamin B12 can be absorbed and

o  gastroscopy with gastric body biopsy and

·      if the cause of the vitamin B12 deficiency is still unknown, we will test for coeliac disease

In terms of the management of the vitamin B12 deficiency, the management will vary depending on the cause.

In malabsorption due to:

·      autoimmune gastritis, 

·      a total gastrectomy, or a complete terminal ileal resection

we will offer lifelong intramuscular vitamin B12 replacement

In malabsorption for other reasons like coeliac disease, or bariatric surgery:

·      we will consider intramuscular instead of oral vitamin B12 replacement.

·      But if we offer an oral preparation, we will prescribe at least 1 mg a day.

In medicine- or nitrous oxide-induced vitamin B12 deficiency we will:

·      give either intramuscular or oral vitamin B12 replacement, based on clinical judgement and

·      we will advise to stop nitrous oxide and consider stopping the medication causing the deficiency if appropriate.

If the vitamin B12 deficiency is due to diet:

·      we will give dietary advice

·      we will consider oral vitamin B12 replacement, and, during pregnancy or breastfeeding, we will give at least 1 mg daily and

·      we will consider intramuscular vitamin B12 injections if the condition deteriorates rapidly or there are concerns about adherence to oral treatment

We will also explain that some over the counter supplements may not contain enough vitamin B12 or the right type to be effective and advise them to pick an oral supplement that contains cyanocobalamin, methylcobalamin or adenosylcobalamin.

In unknown causes of vitamin B12 deficiency we will consider oral instead of intramuscular vitamin B12 replacement and review the response to treatment.

Initial follow-up appointments after starting vitamin B12 replacement should be:

·      at 3 months or earlier depending on severity of symptoms, or

·      at 1 month if they are pregnant or breastfeeding.

In oral supplementation, we will ask about symptoms and if they have not sufficiently improved, got worse or are new we will:

·      increase the oral dosage to the maximum licensed dosage or

·      if they are already taking the maximum, switch to intramuscular injections and

·      consider further testing with serum MMA, or plasma homocysteine.

If the symptoms have resolved, we will continue with oral vitamin B12 replacement if the cause has not been addressed (for example, the person is still taking a medicine that could affect vitamin B12 absorption), or the cause of deficiency is unknown.

But we will consider stopping treatment if:

·      the symptoms have resolved and

·      the cause has been addressed (for example, the person has increased their dietary intake of the vitamin) although

·      we will advise to come back if symptoms develop.

For people receiving intramuscular replacement, we will not repeat the initial diagnostic test. If the symptoms have not improved enough, we will:

·      increase the frequency of injections if needed, in line with the summary of product characteristics and

·      think about alternative diagnoses and

·      agree a date for reassessment of the person's symptoms.

If a person has, or is suspected of having, an irreversible cause of vitamin B12 deficiency:

·      we will continue with lifelong intramuscular injections, even if their symptoms have resolved, and

·      we will advise them to come back if symptoms recur

If the person's symptoms have resolved, and they have either a reversible cause that has not been addressed (for example, continuing medication), or the cause is unknown:

·      we will continue with intramuscular injections and

·      we will continue to follow up.

But if the cause has been resolved and the symptoms have disappeared, we will:

·      think about stopping or reducing the frequency of injections and

·      advise them to come back if symptoms recur.

As we have seen, the guideline covers deficiency caused by autoimmune gastritis. But let’s pause for a minute. Is autoimmune gastritis the same as pernicious anaemia? Well, NICE does not use the term pernicious anaemia in this guideline. So, let’s see why:

Autoimmune gastritis can destroy the parietal cells in the stomach, which can prevent the absorption of vitamin B12, and also impair iron absorption.

Although pernicious anaemia can be a consequence of chronic, severe vitamin B12 deficiency caused by autoimmune gastritis, pernicious anaemia in its true sense (that is, life-threatening anaemia) is now extremely rare and for this reason, this term has not been used in the recommendations.

Also, although autoimmune gastritis is associated with the presence of auto-antibodies against gastric parietal cells and intrinsic factor, which can be detected blood tests, we should also bear in mind that they are not always present and, even when they are present, this is not always indicative of autoimmune gastritis.

We also need to take into account that people who have autoimmune gastritis:

·      are at higher risk of developing gastric neuroendocrine tumours and

·      may also be at higher risk of developing gastric adenocarcinoma.

So, we will refer them promptly for gastrointestinal endoscopy if they develop new, or worsening, upper gastrointestinal symptoms (for example, dyspepsia, nausea or vomiting)

To end the video, NICE has created a 2-page visual summary on ongoing care and follow-up options for oral and intramuscular vitamin B12 replacement. Let’s have a look at it.

So, for people on oral vitamin B12 replacement

At follow up

If the symptoms are not sufficiently improved

We will either increase the oral dose to the maximum licensed dose or, if they are on this already, we will switch to intramuscular administration, taking into account the patient’s preferences.

If there are new or worsening symptoms

We will see if the diagnosis was made using MMA or plasma homocysteine

If the answer is no, we will think about alternative diagnoses and consider testing serum MMA or, if not available, plasma homocysteine, continuing treatment until the results are received.

When the results are received …

if the deficiency is still present, we will either increase the oral dose to the maximum licensed dose or, if they are on this already, we will switch to intramuscular administration, taking into account the patient’s preferences.

However, if the results do not show a deficiency, we will explore alternative diagnoses to explain the symptoms.

If the answer to the question about MMA or plasma homocysteine testing is yes

Then we will consider alternative diagnoses and, taking into account the patient’s preference, we will either increase the oral dose of vit B12 to the maximum or, if the patient is already on the maximum oral dose, we will switch to intramuscular injections

Finally, if the symptoms have improved or resolved

If the cause has not been addressed or is unknown

We will continue with the oral replacement and continue follow up.

On the other hand, if the cause has been addressed,

We will consider stopping treatment, advising the patient to seek medical advice if the symptoms get worse, reappear or new ones emerge.

Now let’s have a look at the summary for patients on intramuscular vit B12 replacement

So, at follow up

If there are new symptoms, they are worsening or have not sufficiently improved

We will increase the frequency of injections, we will think about alternative diagnoses and we will continue reviewing the patient.

Conversely, if the symptoms have improved or resolved

If the cause is irreversible,

We will continue with lifelong injections, advising the patient to seek medical advice if the symptoms reappear, get worse or new ones appear.

However, if the cause is reversible but it has not been addressed or is unknown,

We will continue with the injection and regular reviews.

And finally, if the cause has been resolved,

We will think about stopping or reducing the frequency of the injections, advising the patient to seek medical advice if the symptoms get worse, reappear or new ones emerge.

I have created an interactive flowchart that incorporates these visual summaries as well as other NICE guidance and also advice given by the British Society of Haematology. You can access it in the episode description. I hope that you find it helpful.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/KjALe_M-tIw

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in May 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The YouTube video on the management of headaches can be found here:

·      https://youtu.be/6AZttMzfFr0?si=yxPcoC4legE8zS_p

The Full NICE News bulletin for May 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-05-01&to=2024-05-31&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered can be found here:

Atogepant for preventing migraine - Technology appraisal guidance [TA973] can be found here:

·      https://www.nice.org.uk/guidance/ta973

Headaches in over 12s: diagnosis and management - Clinical guideline [CG150] can be found here:

·      https://www.nice.org.uk/guidance/cg150

The educational poster on the diagnosis of diagnosis of tension-type headache, migraine and cluster headache can be found here:

·      https://www.nice.org.uk/guidance/cg150/resources/diagnosis-poster-pdf-188219341

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in May 2024, focusing on what is relevant in Primary Care only.

And again, in May we have had very little new guidance relevant to primary care, in fact, there was only one guideline containing relevant information for us, the published technology appraisal on atogepant for migraine prophylaxis. You may remember that we covered this to some degree last month, when we reviewed the final draft NICE guidance on the subject. To make up for the shortage of Primary Care updates, we will also go through the clinical signs and symptoms that differentiate between tension-type headache, migraine and cluster headache. We will do so by reviewing the NICE guideline on headaches. If you are interested in the full headache guideline, covering headaches other than migraine, please see the corresponding video on this channel. The link is in the episode description.

Right, we have a migraine heavy episode, so let’s jump into it.

And let’s start with an overview. Although we are covering atogepant, the guidance on Rimegepant is very similar. Both Rimegepant and atogepant, are a new class of drugs, also known as gepants, that have been developed specifically for the treatment of migraines. They are a calcitonin gene-related peptide (or CGRP) receptor antagonist which works by blocking this CGRP receptor. And although the mechanism of action is not fully understood, we know that CGRP is a protein found in the sensory nerves of the head and neck and causes blood vessels to dilate, which can lead to inflammation and migraine pain. 

Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans.

Gepants can be used as an acute treatment of migraine and also as prophylaxis, but only if there have been at least 4 migraine days per month and where at least 3 previous preventive treatments have failed. Rimegepant is only recommended as prophylaxis of episodic migraines, whereas NICE has recommended atogepant as prophylaxis for both chronic and episodic migraines.

What’s the difference between episodic and chronic migraine?

The definition of episodic migraine is when there are fewer than 15 headache days each month. On the other hand, chronic migraine is when for more than 3 months there are at least 15 headache days a month, with at least 8 of those having features of migraine.

And here it is a good time to look at the clinical features of migraine compared to other types of headaches such as tension-type headache and cluster headache.

NICE has produced a poster that classifies the signs and symptoms for all three types of headaches. Let’s have a look at it:

The first thing to look at are the features of the headache in terms of:

·      Location

·      Quality

·      Intensity and

·      Duration

So, the location of the pain is:

·      Bilateral in tension type headache,

·      Unilateral or bilateral in migraine and

·      Unilateral, generally around the eye, above the eye and along the side of the head/face in cluster headache.

The quality of the pain is:

·      Pressing or tightening and non-pulsating in tension headache,

·      Pulsating in migraine although it can be described as throbbing or banging in young people and

·      It can be variable in cluster headache, as it can be sharp, boring, burning, throbbing or tightening.

As for the intensity of the pain, it can be:

·      Mild or moderate in tension-type headache

·      Moderate or severe in migraine and

·      Severe or very severe in cluster headache.

And for the duration, we will say that it generallylasts:

·      From 30 minutes to continuous in tension-type headache,

·      4 to 72 hours in migraine in adults although it can be shorter in young people, from 1 to 72 hours and

·      From 15 minutes to 3 hours in cluster headaches, so usually a shorter headache but much more intense.

Other factors that can help us differentiate between them are the effects that the headaches have on daily activities and whether there are other associated symptoms.

When considering the effects of daily living, we will say that:

·      Tension-type headache is not usually aggravated by routine activities,

·      Migraines are aggravated by, or causes avoidance of, routine activities and

·      Cluster headache causes restlessness or agitation.

And when considering other symptoms, we must be aware that:

·      Tension headaches don’t normally have any 

·      Migraine can be associated to light and sound sensitivity or nausea and vomiting.

·      If there is migraine with aura, we need to remember that typical aura symptoms can occur with or without headache and include:

o  Visual symptoms such as flickering lights, spots or lines and partial loss of vision

o  Sensory symptoms such as numbness and pins and needles and

o  Speech disturbance.

o  But in order to diagnose migraine with aura the symptoms must be fully reversible, develop over at least 5 minutes and last generally between 5 minutes and 1 hour.

Finally, in cluster headache, we will find, usually on the same side as the headache, associated symptoms such as:

·      A red or watery eye

·      Nasal congestion or a runny nose

·      A swollen eyelid

·      Forehead and facial sweating and

·      A constricted pupil or drooping eyelid

This is the summary poster that NICE has produced in the headache guideline. The link to it is in the episode description. Now that we have had a look at the clinical features, let’s go back to the management.

Currently, the most effective prophylactic options for people with chronic migraines who have already tried 3 prophylactic treatments are drugs that need to be injected, such as for example:

·      Erenumab and galcanezumab and

·      botox

So, oral treatments such as atogepant or Rimegepant offer more choice for patients.

When should we stop atogepant? We should stop it after 12 weeks if the frequency of migraines does not reduce by:

·      at least 50% in episodic migraine (that is, fewer than 15 headache days per month)

·      at least 30% in chronic migraine (that is, 15 or more headache days per month, with at least 8 of those having features of migraine).

Clinical trial evidence shows that atogepant reduces monthly migraine days more than placebo, but there is no clinical trial evidence directly comparing it with other preventive medicines. The results from indirect comparisons are uncertain and it is unclear whether atogepant is better or worse than the other treatments. However, it has lower costs than injectables, so it is recommended for preventing episodic and chronic migraine after 3 or more preventive medicines have been tried.

So now, with that in mind, let’s quickly look at the preventative treatment pathway that NICE has produced.

First, for prophylaxis treatment to be considered, the patient needs to have 4 or more migraine days per month.

In that case, we will give 1st, 2nd and 3rd line prophylaxis with propranolol, amitriptyline and topiramate.

If there is inadequate response, then we move to 4th line treatment.

For episodic migraine we can give Rimegepant.

For both episodic and chronic migraines, we have a number of injectable medications and atogepant as the only oral medication.

Finally, if it is chronic migraine, then the recommended treatment will be with botox.

Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid. However, atogepant is a tablet to be taken orally.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/0yQ_Be-xU6o

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the NICE guideline [NG106] on Chronic Heart Failure in adults, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Chronic Heart Failure in adults: diagnosis and management - NICE guideline [NG106]:

·      https://www.nice.org.uk/guidance/ng106

The visual summary for the diagnosis of chronic heart failure can be found here:

·      https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-diagnosis-visual-summary-pdf-6663137726

The visual summary for the management of chronic heart failure can be found here:

·      https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-management-visual-summary-pdf-6663137725

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do a quick up-to-date review of the NICE guidelines on the diagnosis and management of chronic heart failure in adults, including the visual summary flowcharts, always focusing on what is relevant in Primary Care only.

Right, so let’s jump into it.

And we start with the diagnosis. We will take a detailed history and examination and, we will consider the following investigations to exclude other potential conditions:

·      an ECG

·      a chest X-ray

·      blood tests including FBC, renal, liver and thyroid function tests, a lipid profile and HbA1c

·      urinalysis and

·      peak flow or spirometry.

And, if we suspect heart failure, we will measure the N-terminal pro-B-type natriuretic peptide, which from now on we will refer to as NT‑proBNP

High levels of NT‑proBNP carry a poor prognosis. For this reason:

·      If the levels are very high, i.e. above 2,000 ng/litre or 236 pmol/litre, we will refer them urgently to have specialist assessment and a transthoracic echocardiogram within 2 weeks.

·      However, if the levels are only moderately high, that is, between 400 and 2,000 ng/litre or 47 to 236 pmol/litre, we will refer them also urgently but to be seen within 6 weeks.

We also need to be aware that:

·      an NT‑proBNP level less than 400 ng/litre or 47 pmol/litre in an untreated person makes heart failure less likely so we should consider alternative causes and refer if in doubt.

·      the NT‑proBNP level does not differentiate between heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. Let’s remember that heart failure with preserved ejection fraction is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, so it has normal left ventricular ejection fraction and evidence of diastolic dysfunction, whereas the opposite is true for heart failure with reduced ejection fraction, when the ejection fraction is below 40%.

·      the NT‑proBNP level can be reduced in obesity, African or African–Caribbean family background, or drugs such as diuretics, ACE inhibitors, ARBs, beta‑blockers, and mineralocorticoid receptor antagonists or MRAs

·      conversely, the NT‑proBNP level can be high due to other reasons such as, for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia, like in PE and COPD, eGFR less than 60, sepsis, diabetes, and liver cirrhosis.

The purpose of the initial transthoracic echocardiogram is to exclude valve disease, assess left ventricular function, and detect intracardiac shunts. However, alternative cardiac imaging can be considered if the transthoracic images are poor.

Finally, if a patient with a pre-existing diagnosis of heart failure has not been fully investigated in the past, then we should arrange the appropriate investigations in order to confirm the diagnosis.

NICE has produced a useful visual summary covering the diagnosis of chronic heart failure in the form of a flow chart. Let’s have a look at it.

If we suspect chronic heart failure

We will take a full history and examination

And then we will investigate by measuring the NT-proBNP level

And by performing alternative investigations such as an ECG, a CXR, blood tests, urinalysis and peak flow or spirometry.

If the NT-proBNP levels are very high, we will refer to specialist services urgently to be seen within 2 weeks.

If the NT-proBNP levels are only moderately high, we will refer to specialist services, also urgently but to be seen within 6 weeks

And this specialist assessment should also include a transthoracic echocardiogram.

If the NT-proBNP levels are not high

Then, we will consider alternative diagnoses and we will get specialist input if in doubt.

Finally, if heart failure is confirmed on an echocardiogram, then we will assess the severity and possible causes as well as correctable factors.

Let’s now have a look at the treatment.

I will start with the management that is applicable to all forms of heart failure, that is, both HFpEF and HFrEF,

but we need to be aware that there are specific recommendations for HFrEF that I will cover later.

So, for all types of heart failure, diuretics should be used for the relief of congestive symptoms and fluid retention, and titrated (up and down) according to need. A low to medium dose of loop diuretics (for example, no more than 80 mg furosemide per day) should be used in HFpEF.

As general recommendations, we will avoid verapamil, diltiazem and short-acting dihydropyridine agents like nifedipine in people who have heart failure with reduced ejection fraction.

Amiodarone should be initiated by a specialist only

And if a patient is in sinus rhythm, anticoagulation should be considered for those with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus.

In terms of non-pharmacological treatment:

·      Flu and pneumococcal vaccinations are recommended

·      In women of childbearing potential, contraception and pregnancy should be discussed and the patient referred if pregnancy is being considered or it occurs.

·      We will not routinely advise sodium or fluid restriction but we will restrict fluids is there is dilutional hyponatraemia and we will advise reducing salt intake if it is excessive. We should also advise against salt substitutes that contain potassium.

·      Air travel will be possible for most patients.

·      And we should follow the DVLA guidelines in terms of driving.

So, let’s now have a look at the specific treatment for HFrEF, that is, when the left ventricular function is below 40%

As first-line treatment, we will offer an ACE inhibitor and a beta‑blocker licensed for heart failure using clinical judgement when deciding which drug to start first. If an ACE inhibitor is not tolerated, we will substitute it with an ARB licensed for heart failure.

Currently, the betablockers licensed for heart failure in the UK are:

·      Bisoprolol

·      Carvedilol

·      Nebivolol

And currently, the ARBs licensed for heart failure in the UK are:

·      Candesartan

·      Losartan

·      Valsartan

But we will not offer ACE inhibitors if there is a clinical suspicion of haemodynamically significant valve disease, until seen by a specialist.

In terms of betablockers, we will not withhold them solely because of age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease or chronic obstructive pulmonary disease. Also, if a patient develops heart failure, we will switch people who are already taking a beta-blocker for something else, for example, angina or hypertension, to a beta-blocker licensed for heart failure.

After this, we will offer a mineralocorticoid receptor antagonist (or MRA) such as spironolactone, in addition to an ACE inhibitor (or ARB) and beta-blocker, if they continue to have symptoms.

When prescribing ACE inhibitors, ARBs, betablockers and MRAs:  

·      We will start at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached.

·      We will measure sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, ARB or MRA, and after each dose increment.

·      We will measure blood pressure before and after each dose increment and, in addition, we will assess the heart rate when giving betablockers.

·      Once the target or maximum tolerated dose is reached, we will monitor the treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell.

As well as ACE inhibitors, ARBs, betablockers and MRAs, there are a number of other drugs that can be given for heart failure by a heart failure specialist. These are:

·      Dapagliflozin and empagliflozin

·      Ivabradine

·      Sacubitril valsartan

·      Hydralazine in combination with nitrate and

·      Digoxin

We will give the same treatment to people who have heart failure with reduced ejection fraction and chronic kidney disease but:

·      If the eGFR is between 30 and 45, we will consider lower doses and/or slower titration of dose of ACE inhibitors, ARBs, MRAs and digoxin, monitoring closely and taking into account the increased risk of hyperkalaemia.

·      If the eGFR is below 30 we will liaise with a renal physician.

Monitoring treatment for all types of heart failure should include:

·      a clinical assessment

·      a review of medication

·      and an assessment of renal function. Monitoring potassium is particularly important if the patient is on digoxin or an MRA.

The frequency of monitoring depends on the clinical situation and stability of the person. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is needed at least 6-monthly for patients who are stable.

We will consider measuring NT-proBNP for monitoring purposes only in a specialist care setting.

A cardiac rehabilitation programme should be offered, unless their condition is unstable.

And in terms of palliative care, we will not offer long-term home oxygen therapy for heart failure alone.

And just like for the diagnosis, NICE has produced a useful visual summary covering the management of chronic heart failure in the form of a flow chart. Let’s have a look at it.

Once chronic heart failure has been diagnosed,

We can use diuretics for congestive symptoms and fluid retention, and then any further treatment will depend on the type of heart failure.

If it is heart failure with preserved ejection fraction, we will simply manage comorbidities such as hypertension, atrial fibrillation, ischaemic heart disease and diabetes

and we will offer a cardiac rehabilitation programme unless the condition is unstable.

On the other hand, if it is heart failure with reduced ejection fraction, we will offer and ACEI and a betablocker as first line, followed by an MRA if symptoms persist.

And we can give an ARB if the patient cannot tolerate an ACEI because of side effects.

And we will do this, as well as offering cardiac rehabilitation unless the condition is unstable.

If that is not enough, then we move to specialist referral for re-assessment and consideration of other forms of treatment.

So, if symptoms persist despite first-line treatment, specialist services may consider one or more of the following options:

Replacing the ACEI or ARB by sacubitril valsartan or

Adding ivabradine or

Adding hydralazine and a nitrate,

which can also be considered if ACEIs and ARBs are not tolerated at an earlier stage and

adding digoxin

and finally

Although it does not appear on this flowchart, SGLT2 inhibitors such as dapagliflozin and empagliflozin are now recommended for both HFpEF and HFrEF, so they could be another option here.

And that is it, a quick summary of the NICE guideline on chronic heart failure.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/Pi7cBcov2fI

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through a thorough review of the NICE guideline [NG136] on Hypertension in adults, with a series of multiple-choice questions. Each question is paired with quotation, aiming to clarify key concepts and enhance understanding. This informative segment is created to support continuous learning always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]:

·      https://www.nice.org.uk/guidance/ng136

The NICE hypertension flowcharts can be found here:

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

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Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do a revision of the NICE guidelines on hypertension, including the changes introduced in November 2023, always focusing on what is relevant in Primary Care only.

I have created a number of multiple-choice questions, many of them presented as clinical scenarios, which will help you revise, test your knowledge and also assist you in remembering the facts more effectively.

The range of questions varies from fairly easy and straightforward ones to others which are more complex and require more thinking. After each question and their four options, you will get the correct answer paired with a guiding quotation from the NICE guideline.

Please note that the correct answers only reflect the strict use of the guideline, not a flexible clinical judgement.

Finally, I am going to delegate the reading of this section to an automated voice. I hope that you find it useful.

Good luck with your self-test!

Sarah, a 50-year-old woman with type 2 diabetes and hypertension, is starting step 1 antihypertensive treatment. What should be offered to her?

 Calcium-channel blocker

 Thiazide-like diuretic

 ACE inhibitor or ARB

 Beta-blocker

The correct answer is: 

ACE inhibitor or ARB

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

have type 2 diabetes and are of any age or family origin

What is recommended regarding lifestyle advice for people with suspected or diagnosed hypertension?

 Offer magnesium, and potassium supplements.

 Discourage excessive consumption of coffee and other caffeine-rich products.

 Avoid physical activity.

 Offer calcium supplements.

The correct answer is: 

Discourage excessive consumption of coffee and other caffeine-rich products.

NICE quote:

Discourage excessive consumption of coffee and other caffeine-rich products. 

Emma, a 54-year-old woman with hypertension, is taking an ACE inhibitor as step 1 treatment. Despite this, her blood pressure remains uncontrolled. What should be offered to her as step 2 treatment?

 Alpha-blocker

 Calcium-channel blocker

 ARB

 Beta-blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

a Calcium-channel blocker or

a thiazide-like diuretic. 

James, a 40-year-old man, has severe hypertension of 188/123 with no symptoms indicating same-day referral. What should be considered for confirmation of diagnosis?

 Repeat clinic blood pressure measurement within 7 days

 Repeat clinic blood pressure measurement within 14 days

 Start antihypertensive drug treatment immediately

 HBPM after 7 days of lifestyle modifications

The correct answer is: 

Repeat clinic blood pressure measurement within 7 days.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days.

What action is recommended when there is a significant difference in blood pressure readings between both arms?

 Repeat the measurements with the same arm.

 Discard the measurements and measure blood pressure again after 24 hours.

 Repeat the measurements with the arm showing the higher reading.

 Ignore the difference and proceed with the diagnosis.

The correct answer is: 

Repeat the measurements with the arm showing the higher reading.

NICE quote:

If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.

Tom, a 65-year-old man with hypertension on step 1 treatment, develops oedema as a side effect of Calcium-channel blocker therapy. What alternative treatment should be offered to him?

 Thiazide-like diuretic

 ARB

 ACE inhibitor

 Beta-blocker

The correct answer is: 

Thiazide-like diuretic

NICE quote:

If a Calcium-channel blocker is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension.

If a person has severe hypertension with a clinic blood pressure of 180/120 mmHg or higher, but no symptoms indicating same-day referral, what action should be taken?

 Start antihypertensive drug treatment immediately

 Monitor using ABPM

 Repeat clinic blood pressure measurement within 30 days

 Carry out investigations for target organ damage

The correct answer is: 

Carry out investigations for target organ damage

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible.

Emma, a 55-year-old woman with hypertension, is considering combining ACE inhibitor with ARB for better blood pressure control. What should she be advised regarding this combination?

 Combination therapy is recommended for better control.

 Combination therapy should be avoided.

 Combination therapy is suitable only for resistant hypertension.

 Combination therapy is recommended only for people with diabetes.

The correct answer is: 

Combination therapy should be avoided.

NICE quote:

Do not combine an ACE inhibitor with an ARB to treat hypertension. 

For which group of patients is seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment recommended?

 Adults aged over 80.

 Adults aged under 40.

 Adults aged between 40 and 60.

 Adults aged between 60 and 80.

The correct answer is: 

Adults aged under 40.

NICE quote:

For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks.

When would you suspect phaeochromocytoma?

 If they have a history of hypertension.

 If they experience labile blood pressure.

 If they have mild headaches.

 If they have leg pain.

The correct answer is: 

If they experience labile blood pressure.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

What is the definition of stage 1 hypertension?

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema.

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg.

 Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg.

 Clinic systolic blood pressure of 180 mmHg or higher.

The correct answer is: 

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg.

NICE quote:

Stage 1 hypertension

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.

Tom, a 65-year-old man with hypertension, has recently started a new exercise regimen and dietary changes to manage his blood pressure. How should his response to lifestyle changes be monitored?

 Immediately arrange ABPM.

 Monitor blood pressure every 6 months.

 Immediately organise HBPM.

 Use clinic blood pressure measurements.

The correct answer is: 

Use clinic blood pressure measurements.

NICE quote:

Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. 

Emily, a 55-year-old asymptomatic woman, is found to have no target organ damage despite a blood pressure of 173/122 mmHg. What is an acceptable choice to confirm the diagnosis of hypertension?

 Repeat clinic blood pressure measurement within 7 days.

 Start antihypertensive drug treatment immediately.

 Monitor Emily's blood pressure using ABPM for two weeks.

 Check Emily's Blood pressure in the emergency Department.

The correct answer is: 

Repeat clinic blood pressure measurement within 7 days.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days.

John, a 60-year-old man with hypertension, experiences cough as a side effect of ACE inhibitor therapy. What alternative treatment should be offered to him?

 Thiazide diuretic

 Calcium-channel blocker

 Thiazide-like diuretic

 ARB

The correct answer is: 

ARB

NICE quote:

If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension. 

What action should be taken if a person with a blood pressure of 185/110 mmHg has signs of retinal haemorrhage or papilloedema?

 Monitor blood pressure using HBPM

 Start antihypertensive drug treatment immediately

 Refer to ophthalmology

 Refer for specialist assessment on the same day

The correct answer is: 

Refer for specialist assessment on the same day

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

Which term refers to a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements?

 Accelerated hypertension

 Masked hypertension

 White-coat effect

 Persistent hypertension

The correct answer is: 

White-coat effect.

NICE quote:

White-coat effect

A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

Sarah, a 75-year-old woman on antihypertensive medication and type 2 diabetes, experiences dizziness when standing up. How should her blood pressure be managed considering her symptoms?

 No treatment is necessary.

 Review medication and treat to a blood pressure target based on sitting blood pressure.

 Review medication and treat to a blood pressure target based on standing blood pressure.

 Review medication and treat to a blood pressure target based on lying down blood pressure.

The correct answer is: 

Review medication and treat to a blood pressure target based on standing blood pressure.

NICE quote:

In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.

After checking the blood pressure twice, how should clinic blood pressure be recorded?

 Record the higher of the last 2 measurements.

 Record the average of all measurements taken during the consultation.

 Record the lower of the last 2 measurements.

 Record the first measurement only.

The correct answer is: 

Record the lower of the last 2 measurements.

NICE quote:

Record the lower of the last 2 measurements as the clinic blood pressure.

When should investigations for target organ damage be carried out in a person with severe hypertension (180/120 mmHg or higher)?

 Within 30 days

 As soon as possible

 After confirming the diagnosis with ABPM

 After starting antihypertensive drug treatment

The correct answer is: 

As soon as possible

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible.

James, a 60-year-old man with hypertension and type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 Thiazide-like diuretic

 Beta-blocker

 ACE inhibitor

 Calcium-channel blocker

The correct answer is: 

ACE inhibitor

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

have type 2 diabetes and are of any age or family origin 

John, a 50-year-old man, presents with a clinic blood pressure of 185/125 mmHg. He has no symptoms indicating same-day referral. What should be done next?

 Start antihypertensive drug treatment immediately.

 Monitor John's blood pressure using HBPM.

 Repeat clinic blood pressure measurement within 7 days.

 Perform investigations for target organ damage.

The correct answer is: 

Perform investigations for target organ damage.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible

Emma, a 45-year-old woman with hypertension, is of Black African origin and does not have type 2 diabetes. What drug should be offered to her as step 1 antihypertensive treatment?

 ARB

 ACE inhibitor

 Thiazide-like diuretic

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker (Calcium-channel blocker) to adults starting step 1 antihypertensive treatment who:

…

are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 

Lisa, a 70-year-old woman, is experiencing new onset confusion along with a clinic blood pressure of 185/125 mmHg. What is the appropriate step?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Monitor Lisa's blood pressure using ABPM with a review within 7 days.

 Refer Lisa for specialist assessment on the same day.

The correct answer is: 

Refer Lisa for specialist assessment on the same day.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

In what range of clinic blood pressure should ambulatory blood pressure monitoring (ABPM) be offered to confirm the diagnosis of hypertension?

 130/80 mmHg to 150/100 mmHg

 120/80 mmHg to 160/100 mmHg

 140/90 mmHg to 180/120 mmHg

 150/90 mmHg to 190/130 mmHg

The correct answer is: 

140/90 mmHg to 180/120 mmHg.

NICE quote:

If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. 

Which term describes clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher?

 Target organ damage

 Stage 3 or severe hypertension

 White-coat effect

 Persistent hypertension

The correct answer is: 

Stage 3 or severe hypertension.

NICE quote:

Stage 3 or severe hypertension

Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.

How should blood pressure be measured if pulse irregularity is detected?

 Use automated devices

 Measure manually using direct auscultation over the brachial artery

 Ignore the irregularity and proceed with automated measurement

 Measure manually using direct auscultation over the radial artery

The correct answer is: 

Measure manually using direct auscultation over the brachial artery

NICE quote:

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. 

When should antihypertensive drug treatment be offered in addition to lifestyle advice to adults with persistent stage 2 hypertension (clinic BP 160/100 or higher)?

 Only in individuals aged under 60.

 Only in individuals aged over 80.

 Only in individuals aged between 60 and 80.

 To adults of any age.

The correct answer is: 

To adults of any age.

NICE quote:

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity

Mark, a 65-year-old man, presents with a clinic blood pressure of 180/120 mmHg but no symptoms indicating same-day referral. What action should be taken next?

 Start antihypertensive drug treatment immediately.

 Monitor Mark's blood pressure using HBPM.

 Repeat clinic blood pressure measurement within 7 days.

 Perform investigations for target organ damage.

The correct answer is: 

Perform investigations for target organ damage.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …, carry out investigations for target organ damage … as soon as possible

James, a 65-year-old man of Black African origin with hypertension, is already taking a Calcium-channel blocker as step 1 treatment. Despite this, his blood pressure remains uncontrolled. What should be offered to him as step 2 treatment?

 ACE inhibitor

 ARB

 Alpha-blocker

 Beta-blocker

The correct answer is: 

ARB

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of a Calcium-channel blocker, offer the choice of 1 of the following drugs in addition to step 1 treatment:

an ACE inhibitor or

an ARB or

a thiazide-like diuretic.

If hypertension is not controlled in adults of Black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment.

What should be done while waiting for confirmation of a diagnosis of hypertension with ABMP?

 Immediate initiation of antihypertensive medication.

 Investigations for target organ damage followed by formal cardiovascular risk assessment.

 Minimise physical activity.

 Home blood pressure monitoring (HBPM) for at least 10 days.

The correct answer is: 

Investigations for target organ damage followed by formal cardiovascular risk assessment.

NICE quote:

While waiting for confirmation of a diagnosis of hypertension, carry out:

investigations for target organ damage …, followed by

formal assessment of cardiovascular risk using a cardiovascular risk assessment tool 

Emma, a 50-year-old woman with hypertension, has conflicting clinic and non-clinic blood pressure results. What additional method of blood pressure monitoring should be considered for her?

 Use only clinic blood pressure measurements by a doctor.

 Use only clinic blood pressure measurements by a nurse.

 Use only clinic blood pressure measurements in the community, e.g. pharmacy.

 Use ABPM or HBPM in addition to clinic blood pressure measurements.

The correct answer is: 

Use ABPM or HBPM in addition to clinic blood pressure measurements.

NICE quote:

Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements.

What is recommended when measuring the initial blood pressure in people with symptoms of postural hypotension?

 Measure blood pressure with the person standing

 Measure blood pressure after vigorous exercise

 Measure blood pressure in a crowded environment

 Measure blood pressure with the person lying on their back or consider a seated position if it's inconvenient to lie down

The correct answer is: 

Measure blood pressure with the person lying on their back or consider a seated position if it's inconvenient to lie down

NICE quote:

In people with symptoms of postural hypotension, including falls or postural dizziness:

measure blood pressure with the person lying on their back (or consider a seated position, if it is inconvenient to measure blood pressure with the person lying down)

Tom, a 65-year-old man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 ACE inhibitor

 Thiazide-like diuretic

 ARB

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker to adults starting step 1 antihypertensive treatment who:

are aged 55 or over and do not have type 2 diabetes

What is the definition of masked hypertension?

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 High blood pressure at repeated clinical encounters

 Clinic blood pressure measurements are normal, but blood pressure measurements are higher when taken outside the clinic

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

The correct answer is: 

Clinic blood pressure measurements are normal, but blood pressure measurements are higher when taken outside the clinic.

NICE quote:

Masked hypertension

Clinic blood pressure measurements are normal (less than 140/90 mmHg), but blood pressure measurements are higher when taken outside the clinic using average daytime ambulatory blood pressure monitoring (ABPM) or average home blood pressure monitoring (HBPM) blood pressure measurements.

When should people with a clinic blood pressure of 180/120 mmHg and higher be referred for specialist assessment on the same day?

 If they experience hip pain

 If they have a cardiovascular risk >10%

 If they have signs of retinal haemorrhage or papilloedema

 If they have a history of hypertension

The correct answer is: 

If they have signs of retinal haemorrhage or papilloedema

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

Sarah, a 70-year-old woman with hypertension, is already on treatment with a Calcium-channel blocker as step 1 therapy. Despite this, her blood pressure remains uncontrolled. What should be offered to her as step 2 treatment?

 ACE inhibitor

 Spironolactone

 Beta-blocker

 Alpha-blocker

The correct answer is: 

ACE inhibitor

NICE quote:

If hypertension is not controlled in adults taking step 1 treatment of a Calcium-channel blocker, offer the choice of 1 of the following drugs in addition to step 1 treatment:

an ACE inhibitor or

an ARB or

a thiazide-like diuretic. 

David, a 60-year-old man, experiences labile blood pressure along with headaches and palpitations. What should be considered for David?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Monitor David's blood pressure using HBPM.

 Refer David for specialist assessment on the same day.

The correct answer is: 

Refer David for specialist assessment on the same day (suspected phaeochromocytoma).

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

When should subsequent blood pressures be measured in people with confirmed postural hypotension?

 After 5 minutes of standing

 Once, regardless of symptoms

 With the person lying down

 With the person standing for at least 1 minute

The correct answer is: 

With the person standing for at least 1 minute

NICE quote:

measure blood pressure again after the person has been standing for at least 1 minute.

If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:

measure subsequent blood pressures with the person standing

Jack, a 45-year-old Asian man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him?

 ACE inhibitor

 Thiazide-like diuretic

 Beta-blocker

 Calcium-channel blocker

The correct answer is: 

ACE inhibitor

NICE quote:

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

…

are aged under 55 but not of Black African or African–Caribbean family origin.

How often should blood pressure be measured in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease?

 At least monthly

 At least quarterly

 At least six monthly

 At least annually

The correct answer is: 

At least annually

NICE quote:

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice.

Sarah, a 60-year-old woman with hypertension is on amlodipine, ramipril and indapamide and she has been advised to reduce her dietary sodium intake. However, she asks if she can use salt substitutes containing potassium chloride instead. How should the healthcare provider respond to Sarah's inquiry?

 Encourage her to use salt substitutes containing potassium chloride.

 Discourage any changes in dietary sodium intake.

 Advise her to reduce sodium salt and avoid substitutes containing potassium chloride.

 Ignore her dietary sodium intake and manage with antihypertensive medication.

The correct answer is: 

Advise her to reduce sodium salt and avoid substitutes containing potassium chloride.

NICE quote:

Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. Encourage salt reduction in these groups.

Tom is a 55-year-old man with hypertension, chronic kidney disease and type 2 diabetes. What guideline should be consulted for guidance on choice of hypertensive agent?

 NICE guideline on type 2 diabetes.

 NICE guideline on chronic kidney disease.

 NICE guideline on hypertension.

 NICE guideline on type 1 diabetes.

The correct answer is: 

NICE guideline on chronic kidney disease.

NICE quote:

For guidance on choice of hypertensive agent in people with chronic kidney disease, see NICE's guideline on chronic kidney disease.

How many consecutive measurements should be taken for each blood pressure recording when using HBPM to confirm a diagnosis of hypertension?

 One measurement per recording.

 Three consecutive measurements per recording at least one minute apart.

 Two consecutive measurements per recording at least one minute apart.

 Four consecutive measurements per recording at least one minute apart.

The correct answer is: 

Two consecutive measurements per recording at least one minute apart.

NICE quote:

When using HBPM to confirm a diagnosis of hypertension, ensure that:

for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and

blood pressure is recorded twice daily, ideally in the morning and evening and

blood pressure recording continues for at least 4 days, ideally for 7 days.

Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. 

What action should be taken if target organ damage is identified in an asymptomatic person with severe hypertension?

 Repeat clinic blood pressure measurement within 7 days

 Consider monitoring using ABPM

 Start antihypertensive drug treatment immediately

 Refer for specialist assessment

The correct answer is: 

Start antihypertensive drug treatment immediately.

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral …:

If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

James, a 60-year-old man without type 2 diabetes, is starting step 1 antihypertensive treatment. What drug should be offered to him based on the guideline?

 ARB

 Thiazide-like diuretic

 ACE inhibitor

 Calcium-channel blocker

The correct answer is: 

Calcium-channel blocker

NICE quote:

Offer a calcium-channel blocker (Calcium-channel blocker) to adults starting step 1 antihypertensive treatment who:

are aged 55 or over and do not have type 2 diabetes

What should be encouraged regarding dietary sodium intake?

 Keeping a diary of sodium intake.

 Substituting sodium salt with salt substitutes containing potassium chloride.

 Reducing or substituting sodium salt.

 Discouraging any changes in dietary sodium intake.

The correct answer is: 

Reducing or substituting sodium salt.

NICE quote:

Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. 

What is the definition of accelerated hypertension?

 Clinic blood pressure of 160/100 mmHg or higher

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic systolic blood pressure of 180 mmHg or higher

The correct answer is: 

Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema.

NICE quote:

Accelerated hypertension

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

John, a 60-year-old man with hypertension, is already on treatment with bendroflumethiazide and has stable, well-controlled blood pressure. What should be done regarding his treatment?

 Continue with current treatment

 Switch to an ACE inhibitor

 Switch to indapamide immediately

 Switch to Calcium-channel blocker

The correct answer is: 

Continue with current treatment.

NICE quote:

For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment.

What is a recommended choice if no target organ damage is identified in a person with severe hypertension?

 Repeat clinic blood pressure measurement within 30 days

 Start antihypertensive drug treatment immediately

 Monitor using HBPM for two weeks

 Confirm diagnosis by repeating clinic blood pressure measurement within 7 days

The correct answer is: 

Confirm diagnosis by repeating clinic blood pressure measurement within 7 days

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days. 

When should specialist investigations be considered for possible secondary causes of hypertension?

 Only in severe cases of hypertension

 In all cases of hypertension

 When signs and symptoms suggest a secondary cause

 When there is a family history of hypertension

The correct answer is: 

When signs and symptoms suggest a secondary cause

NICE quote:

Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. 

Tom, a 70-year-old man with resistant hypertension, has uncontrolled blood pressure despite optimal tolerated doses of four drugs. What should be considered next?

 Adding a fifth antihypertensive drug

 Seeking specialist advice

 Discontinuing treatment

 Continuing current treatment without changes

The correct answer is: 

Seeking specialist advice

NICE quote:

For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. 

Why is it advised to palpate the radial or brachial pulse before measuring blood pressure?

 To ensure the person is in a relaxed setting.

 To confirm the presence of atrial fibrillation.

 To check for pulse irregularity.

 To standardize the blood pressure measurement environment.

The correct answer is: 

To check for pulse irregularity.

NICE quote:

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. 

Emma is a 50-year-old woman with isolated systolic hypertension. How should she be treated?

 She should have the same blood pressure target but be treated with a calcium channel blocker by default.

 If the diastolic blood pressure is below 80 mmHg, she should be treated with lifestyle changes only.

 She should have the same treatment as people with both raised systolic and diastolic blood pressure.

 No treatment is necessary for isolated systolic hypertension, just close monitoring.

The correct answer is: 

She should have the same treatment as people with both raised systolic and diastolic blood pressure.

NICE quote:

Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure.

What is the definition of persistent hypertension?

 High blood pressure at repeated clinical encounters

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic blood pressure of 160/100 mmHg or higher

 Clinic systolic blood pressure of 180 mmHg or higher

The correct answer is: 

High blood pressure at repeated clinical encounters.

NICE quote:

Persistent hypertension

High blood pressure at repeated clinical encounters.

James, a 75-year-old man with stage 1 hypertension, has a clinic blood pressure of 150/90 mmHg for several months. How should the healthcare provider manage James' hypertension?

 Monitor blood pressure for further 6 months.

 Ignore his hypertension.

 Start antihypertensive drug treatment straightaway.

 Consider treatment if has end organ damage, diabetes of a cardiovascular risk of 10% or higher.

The correct answer is: 

Consider treatment if has end organ damage, diabetes of a cardiovascular risk of 10% or higher.

NICE quote:

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

target organ damage

established cardiovascular disease

renal disease

diabetes

an estimated 10‑year risk of cardiovascular disease of 10% or more.

Use clinical judgement for people with frailty or multimorbidity

James, a 75-year-old man with hypertension, is using ABPM to monitor his blood pressure response to treatment. What should be his target blood pressure based on HBPM?

 Below 130/80 mmHg

 Below 135/85 mmHg

 Below 140/90 mmHg

 Below 145/85 mmHg

The correct answer is: 

Below 135/85 mmHg

NICE quote:

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours ... Reduce blood pressure and ensure that it is maintained:

below 135/85 mmHg for adults aged under 80

below 145/85 mmHg for adults aged 80 and over.

How often should clinic blood pressure be measured subsequently if hypertension is not diagnosed initially?

 Every 2 years.

 Every 3 years.

 Every 5 years.

 Every year.

The correct answer is: 

Every 5 years.

NICE quote:

If hypertension is not diagnosed, measure the person's clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic blood pressure is close to 140/90 mmHg. 

James, a 50-year-old man with hypertension, is considering taking calcium, magnesium, or potassium supplements to help reduce his blood pressure. What should the healthcare provider tell James about the effectiveness of these supplements?

 Inform him that these supplements can decrease blood pressure but do not recommend them.

 Advise him to avoid these supplements as they have no effect on blood pressure.

 Encourage him to start taking these supplements.

 Suggest he consult with a specialist before starting these supplements.

The correct answer is: 

Advise him to avoid these supplements as they have no effect on blood pressure.

NICE quote:

Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. 

John, a 60-year-old man with hypertension, is interested in self-monitoring his blood pressure at home. Which method of blood pressure monitoring should he use?

 ABPM only.

 Clinic blood pressure measurements only.

 Blood pressure monitoring in local pharmacy.

 Use HBPM for self-monitoring.

The correct answer is: 

Use HBPM for self-monitoring.

NICE quote:

Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM.

What is the definition of stage 2 hypertension?

 Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg

 Clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema

 Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg

 Clinic blood pressure of 180/100 mmHg or higher

The correct answer is: 

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg.

NICE quote:

Stage 2 hypertension

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.

Sarah, a 45-year-old woman, visits the clinic with a clinic blood pressure of 190/130 mmHg. Upon examination, signs of retinal haemorrhage are noted. What is the appropriate action?

 Start antihypertensive drug treatment immediately.

 Repeat clinic blood pressure measurement within 7 days.

 Refer Sarah for specialist assessment on the same day.

 Refer Sarah to the Eye Clinic urgently.

The correct answer is: 

Refer Sarah for specialist assessment on the same day.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

Sarah, a 55-year-old woman with hypertension and no other medical history, is aiming to reduce her blood pressure. What should her clinic blood pressure target be?

 Below 130/80 mmHg

 Below 140/90 mmHg

 Below 150/90 mmHg

 Below 160/100 mmHg

The correct answer is: 

Below 140/90 mmHg

NICE quote:

For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level. 

Emma, a 60-year-old woman with a blood pressure persistently just over 160/100 mmHg, has been following lifestyle advice but her blood pressure remains elevated. What treatment option should now be offered to Emma?

 Continue lifestyle advice periodically.

 No treatment, just more regular monitoring.

 Antihypertensive drug treatment.

 Immediate statin therapy.

The correct answer is: 

Antihypertensive drug treatment.

NICE quote:

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity

What action is recommended if hypertension is not diagnosed but there is evidence of target organ damage?

 Initiate antihypertensive medication immediately.

 Repeat clinic blood pressure measurements after 24 hours.

 Consider carrying out investigations for alternative causes of target organ damage.

 Discontinue further blood pressure monitoring.

The correct answer is: 

Consider carrying out investigations for alternative causes of target organ damage.

NICE quote:

If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes of the target organ damage

Which term describes damage to organs such as the heart, brain, kidneys, and eyes?

 Masked hypertension

 White-coat effect

 Target organ damage

 Stage 3 or severe hypertension

The correct answer is: 

Target organ damage.

NICE quote:

Target organ damage

Damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio.

Compared with the lying down blood pressure reading, when can postural hypotension be diagnosed?

 When the standing systolic blood pressure drops by 20mmHg and the standing diastolic blood pressure drops by 10 mmHg

 When both the standing systolic and diastolic blood pressure drops by 20mmHg

 When the standing systolic blood pressure drops by 10mmHg and the standing diastolic blood pressure drops by 20 mmHg

 When both the standing systolic and diastolic blood pressure drops by 10mmHg.

The correct answer is:

When the standing systolic blood pressure drops by 20mmHg and the standing diastolic blood pressure drops by 10 mmHg

NICE quote:

Postural hypotension: If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute

Which symptoms warrant same-day specialist assessment for a person with severe hypertension?

 Mild headache

 Diarrhoea

 Limb pain

 Signs of heart failure

The correct answer is: 

Signs of heart failure

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

What alternative is recommended if ambulatory blood pressure monitoring (ABPM) is unsuitable or the person cannot tolerate it?

 Repeat clinic blood pressure measurements.

 Offer home blood pressure monitoring (HBPM).

 Refer the person to specialist care.

 Disregard the diagnosis of hypertension.

The correct answer is: 

Offer home blood pressure monitoring (HBPM).

NICE quote:

If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension.

Emma, a 75-year-old woman with hypertension, experiences oedema as a side effect of Calcium-channel blocker therapy. What alternative treatment should be offered to her?

 ARB

 Beta-blocker

 ACE inhibitor

 Thiazide-like diuretic

The correct answer is: 

Thiazide-like diuretic

NICE quote:

If a Calcium-channel blocker is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension. 

How should cardiovascular risk be estimated in people with hypertension?

 Use ABPM measurements to calculate cardiovascular risk

 Estimate cardiovascular risk based on family history

 Use clinic blood pressure measurements to calculate cardiovascular risk

 Rely on symptoms reported by the patient to calculate cardiovascular risk

The correct answer is: 

Use clinic blood pressure measurements to calculate cardiovascular risk

NICE quote:

Use clinic blood pressure measurements to calculate cardiovascular risk. 

John, a 70-year-old man with stage 1 hypertension (clinic blood pressure between 140/90 and 160/100 mmHg), has established cardiovascular disease. He is unsure about starting antihypertensive drug treatment. How should the healthcare provider discuss treatment options with John?

 Discuss with him his individual cardiovascular disease risk and treatment preferences, then consider treatment.

 Start antihypertensive drug treatment without discussing options.

 Just offer lifestyle advice.

 Advise him to continue monitoring for now.

The correct answer is: 

Discuss with him his individual cardiovascular disease risk and treatment preferences, then consider treatment.

NICE quote:

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

target organ damage

established cardiovascular disease

renal disease

diabetes

an estimated 10‑year risk of cardiovascular disease of 10% or more.

Use clinical judgement for people with frailty or multimorbidity

John, an active and fit 85-year-old man with a medical history of hypertension and hyperlipidaemia only, is experiencing difficulty maintaining his blood pressure below the recommended target. What should his clinic blood pressure target be?

 Below 130/80 mmHg

 Below 140/90 mmHg

 Below 150/90 mmHg

 Below 160/100 mmHg

The correct answer is: 

Below 150/90 mmHg

NICE quote:

For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity.

What action should be taken if the person's blood pressure falls by specific thresholds after standing for at least 1 minute?

 Review the person's current medication.

 Immediately refer the person to specialist care.

 Measure subsequent blood pressures with the person lying down.

 Disregard the symptoms and continue with regular monitoring.

The correct answer is: 

Review the person's current medication.

NICE quote:

If the person's systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:

consider likely causes, including reviewing their current medication

What is the term for a severe increase in blood pressure to 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema?

 Masked hypertension

 Stage 2 hypertension

 Accelerated hypertension

 Persistent hypertension

The correct answer is: 

Accelerated hypertension.

NICE quote:

Accelerated hypertension

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

Sarah, a 55-year-old woman with stage 1 hypertension (clinic blood pressure between 140/90 and 160/100 mmHg) is considering starting antihypertensive drug treatment. How should the healthcare provider advise Sarah?

 Monitor blood pressure daily for six months

 Recommend against antihypertensive drug treatment at present.

 Consider antihypertensive drug treatment in addition to lifestyle advice regardless cardiovascular risk.

 Consider antihypertensive drug treatment in addition to lifestyle advice if cardiovascular risk is 10% or greater.

The correct answer is: 

Consider antihypertensive drug treatment in addition to lifestyle advice regardless cardiovascular risk.

NICE quote:

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10‑year risk below 10%. Bear in mind that 10‑year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease. 

What should be done if a person has suspected phaeochromocytoma?

 Start antihypertensive drug treatment immediately

 Refer for specialist assessment within 30 days

 Monitor using ABPM

 Refer for same-day specialist assessment

The correct answer is: 

Refer for same-day specialist assessment.

NICE quote:

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

Tom, a 40-year-old man of Black African origin with hypertension and type 2 diabetes, is considering starting antihypertensive drug treatment. What should be considered when choosing his medication?

 Prescribe an ACE inhibitor in preference.

 Prescribe an ARB in preference.

 Avoid ACE inhibitors and ARBs.

 Prescribe a calcium channel blocker in preference.

The correct answer is: 

Prescribe an ARB in preference.

NICE quote:

When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. 

Emma, a 60-year-old woman with hypertension, is using ABPM to monitor her blood pressure response to treatment. What should be her target blood pressure based on ABPM?

 Below 130/80 mmHg

 Below 135/85 mmHg

 Below 140/90 mmHg

 Below 145/85 mmHg

The correct answer is: 

Below 135/85 mmHg

NICE quote:

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours … Reduce blood pressure and ensure that it is maintained:

below 135/85 mmHg for adults aged under 80

below 145/85 mmHg for adults aged 80 and over.

When should hypertension be confirmed in people with a clinic blood pressure of 140/90 mmHg or higher?

 ABPM daytime average or HBPM average of 130/80 mmHg or higher.

 ABPM daytime average or HBPM average of 135/85 mmHg or higher.

 ABPM daytime average or HBPM average of 140/90 mmHg or higher.

 ABPM daytime average or HBPM average of 145/95 mmHg or higher.

The correct answer is: 

ABPM daytime average or HBPM average of 135/85 mmHg or higher.

NICE quote:

Confirm diagnosis of hypertension in people with a:

clinic blood pressure of 140/90 mmHg or higher and

ABPM daytime average or HBPM average of 135/85 mmHg or higher. 

If a person with severe hypertension has no symptoms indicating same-day referral, what is an acceptable option for confirmation of diagnosis?

 ABPM with review within 7 days

 Repeat clinic blood pressure measurement within 30 days

 Start antihypertensive drug treatment immediately

 Lifestyle modifications

The correct answer is: 

ABPM with review within 7 days

NICE quote:

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral:

If no target organ damage is identified, confirm diagnosis by:

repeating clinic blood pressure measurement within 7 days, or

considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), … ensuring a clinical review within 7 days. 

Sarah, a 65-year-old woman with hypertension, type 2 diabetes and chronic heart failure, is prescribed antihypertensive drug treatment. What guideline should be followed for her medication choice?

 NICE guideline on hypertension.

 NICE guideline on type 2 diabetes.

 NICE guideline on acute heart failure.

 NICE guideline on chronic heart failure.

The correct answer is: 

NICE guideline on chronic heart failure.

NICE quote:

For people with cardiovascular disease:

Follow the recommendations for disease-specific indications in the NICE guideline on their condition ... Relevant recommendations include:

… acute coronary syndromes

… acute heart failure

… chronic heart failure

… stable angina

… type 1 diabetes ...

What is an essential initial test for end organ damage that should be offered to all people with hypertension?

 Dipstick for leucocytes in the urine

 Blood test for calcium and vitamin D

 An echocardiogram

 A 12-lead ECG

The correct answer is: 

A 12-lead ECG

NICE quote:

For all people with hypertension offer to:

… a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip

… measure …HbA1C, electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

examine the fundi for the presence of hypertensive retinopathy

arrange for a 12‑lead electrocardiograph to be performed. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/dVpfeUxt8K8

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in April 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for April 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-04-01&to=2024-04-30&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered can be found here:

Endometriosis: diagnosis and management- NICE guideline [NG743] can be found here:

·      https://www.nice.org.uk/guidance/ng73

Final draft guidance on Atogepant for preventing migraine [ID5090] | can be found here:

·      https://www.nice.org.uk/guidance/indevelopment/gid-ta10992/documents

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

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Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in April 2024, focusing on what is relevant in Primary Care only.

And in April we have had very little new guidance relevant to primary care, in fact, there was only one guideline containing relevant information for us, the guideline on endometriosis. But, to make up for it, we also have the NICE final draft guidance on atogepant for migraine prophylaxis, which I will cover briefly after the endometriosis update.

Right, let’s jump into it.

So, let’s start with the guideline on Endometriosis. The management is normally guided by secondary care but this guideline also includes recommendations relevant to primary care such as the clinical presentation, diagnosis and referral recommendations.

And let’s start with the clinical presentation.

NICE says that we should suspect endometriosis in women (including those under 17) if they have at least 1 of the following:

·      chronic pelvic pain

·      dysmenorrhoea

·      deep pain during or after sexual intercourse and

·      either period-related or cyclical gastrointestinal and urinary symptoms, in particular, painful bowel movements, haematuria or dysuria

We will offer an abdominal examination to exclude masses and, if appropriate, a pelvic and vaginal examination too.

What investigations should we organise?

Well, we can do a transvaginal ultrasound, which can identify signs of endometriosis.

If a transvaginal scan is not appropriate, we will do a transabdominal pelvic ultrasound scan.

We will not use serum CA125 to diagnose endometriosis but if it is available we must be aware that:

·      a high level may be consistent with endometriosis but that

·      endometriosis may be present despite normal serum CA125 levels

Equally, pelvic MRI is not recommended as a primary investigation for endometriosis. However, this can be considered in secondary care to assess the extent of deep endometriosis involving the bowel, bladder or ureter.

But, and this is an important but, we must not exclude endometriosis just because the examination, ultrasound or MRI are normal. If there is a high clinical suspicion, we should refer for further assessment.

So, the question is, should we be initiating investigations in Primary Care if we know that we may end up referring to gynaecology anyway?

My view is that if there is a high clinical suspicion of endometriosis, then we are probably better off referring the patient straightaway, as this is likely to lead to an earlier diagnosis and management. However, if we are not certain or we wish to exclude other possible diagnoses, we could do some investigations first.

So, when do we need to refer?

And the answer is simple. We should refer if:

·      they have symptoms or signs of endometriosis or if

·      not responding to the initial management

There are updated management recommendations if fertility is a priority and these are obviously more relevant for secondary care. From a primary care perspective, we should know that, in general, surgical approaches are recommended because they are likely to improve the chance of spontaneous pregnancy.

However, the opposite is true for hormonal treatment, either alone or in combination with surgery, so it is not recommended because of its effect on fertility.

And that is it, this is the only published update for us.

But, as promised, let’s have a look at the NICE final draft on atogepant for migraine prophylaxis.

I will not say very much because we will be covering this fully when the final guidance is published, but I will give you just an overview.

Both Rimegepant and atogepant, are a new class of drugs, also known as gepants, that have been developed specifically for the treatment of migraines. They are a calcitonin gene-related peptide (or CGRP) receptor antagonist which works by blocking this CGRP receptor. And although the mechanism of action is not fully understood, we know that CGRP is a protein found in the sensory nerves of the head and neck and causes blood vessels to dilate, which can lead to inflammation and migraine pain. Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans. Gepants can be used as an acute treatment of migraine and, although rimegepant has a licence for migraine prophylaxis, NICE only recommends as prophylaxis of episodic migraines. However, NICE has recommended atogepant as an option for preventing both chronic and episodic migraines. But this is only if there have been at least 4 migraine days per month and where at least 3 previous preventive treatments have failed.

What’s the difference between episodic and chronic migraine?

The definition of Episodic migraine is when there are fewer than 15 headache days each month. On the other hand, chronic migraine is when there is at least 15 headache days a month, with at least 8 of those having features of migraine.

Currently, the most effective options for people with chronic migraines who have already tried 3 prophylactic treatments are drugs that need to be injected so an oral treatment such as Atogepant offers more choice for patients.

So, with that in mind, let’s quickly look at the preventative treatment pathway that NICE has produced in their new draft guidance.

First, for prophylaxis treatment to be considered, the patient needs to have 4 or more migraine days per month.

In that case, we will give 1st, 2nd and 3rd line prophylaxis with propranolol, amitriptyline and topiramate.

If there is inadequate response, then we move to 4th line treatment.

For episodic migraine we can give Rimegepant.

For both episodic and chronic migraines, we have a number of injectable medications and atogepant as the only oral medication.

Finally, if it is only chronic migraine, then the recommended treatment will be with botox.

Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid. However, atogepant is a tablet to be taken orally.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

https://youtu.be/8dYGalK25os

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the concept of Hypertensive Urgency as opposed to Hypertensive Emergency.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]:

·      https://www.nice.org.uk/guidance/ng136

The NICE hypertension flowcharts can be found here:

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

Worcestershire Acute Hospitals NHS Trust guideline on the Management of Hypertensive crises:

·      https://www.bing.com/ck/a?!&&p=9b5fdeea73ebb791JmltdHM9MTcxMzU3MTIwMCZpZ3VpZD0xODRhNTBkMS0xZGExLTYzZWItMjMyYi00NGMwMWNhNzYyYjMmaW5zaWQ9NTIwOA&ptn=3&ver=2&hsh=3&fclid=184a50d1-1da1-63eb-232b-44c01ca762b3&psq=Worcestershire+Acute+Hospitals+NHS+Trust+guidelines+hypertensive+crises&u=a1aHR0cHM6Ly9hcHBzLndvcmNzYWN1dGUubmhzLnVrL0tleURvY3VtZW50UG9ydGFsL0hvbWUvRG93bmxvYWRGaWxlLzM3NDk&ntb=1

The Worcestershire Acute Hospitals NHS Trust Hypertensive crisis flowchart can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mRX6no6c5m3ddfEC?e=aPVQ67

NICBH PUBMED

·    https://www.ncbi.nlm.nih.gov/books/NBK513351/

Slides MRCP

·      https://www.bing.com/ck/a?!&&p=695818f027015fbaJmltdHM9MTcxMzU3MTIwMCZpZ3VpZD0xODRhNTBkMS0xZGExLTYzZWItMjMyYi00NGMwMWNhNzYyYjMmaW5zaWQ9NTIxMQ&ptn=3&ver=2&hsh=3&fclid=184a50d1-1da1-63eb-232b-44c01ca762b3&psq=adrian+stanley+hypertensive+urgency&u=a1aHR0cHM6Ly93d3cucmNwbG9uZG9uLmFjLnVrL2ZpbGUvMjk2Ny9kb3dubG9hZA&ntb=1

NEJM article: Acute severe hypertension:

·      https://www.nejm.org/doi/full/10.1056/NEJMcp1901117

Approach to HTN urgency in primary care setting

·      https://journals.lww.com/tnpj/Fulltext/2021/10000/Approach_to_a_patient_with_hypertensive_urgency_in.13.aspx

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Music provided by Audio Library Plus 

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Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today I will touch on a subject which is not really covered by NICE, which is the concept of hypertensive urgency, as opposed to hypertensive emergency. It is an interesting subject which we are going to illustrate with a practical case, so make sure that you stick around till then. For this I have consulted a number of medical publications and guidelines and the links are in the episode description.

Right, so let’s jump into it.

So, let’s start with some definitions.

·      Severe hypertension is defined as SBP ≥180mmHg and/or DBP ≥120mmHg

·      Hypertensive emergency is defined as severe hypertension associated with evidence of target organ damage. 

·      Hypertensive urgency is defined as severe hypertension without evidence of ongoing target organ damage.  Studies have shown that Hypertensive urgency is two to three times more common than hypertensive emergencies.

We know from the hypertension NICE guideline that for people with a BP of 180/120 or higher we should investigate for target organ damage, that is, we have to differentiate between hypertensive urgency and emergency.

Starting with the history, we should look at possible causes, and non-compliance with antihypertensive drug treatment is the most common precipitating factor. Other possible factors include excess alcohol, anxiety or panic, drugs, either prescribed, over-the-counter, or illicit like cocaine, amphetamines, sympathomimetic agents, nonsteroidal anti-inflammatory drugs, and high-dose steroids.

We will need to consider the past medical history. Systematic reviews have concluded that hypertensive crises occur more often if there is a history of CKD, coronary heart disease, stroke and congestive heart failure and therefore checking whether the patient have these diagnoses is important because they represent both risk factors and consequences of severe hypertension.

In terms of examination, we will ensure that the BP reading is correct, that is, we will take the measurements in both arms making sure that the cuff is the correct size, and take at least two or three readings in the arm with the highest BP.

A study has shown that in up to a third of patients with severe hypertension, the blood pressure falls to less than 180/120 mm Hg after 30 minutes of quiet rest. So, if feasible, we could also try this.

And, in the history and examination we will look for signs and symptoms of possible end organ damage. So:

·      In the eye we will look for symptoms and signs of retinopathy such as blurring or loss of vision, dizziness, retinal haemorrhage, and papilloedema,

·      In the CNS we will look for symptoms and signs of hypertensive encephalopathy, intracerebral haemorrhage or ischaemic stroke such as headache, nausea, vomiting, confusion, seizures, visual disturbance, focal deficit, dysphagia, abnormal or loss of sensation, changes in mental status (like agitation or lethargy) and ataxia

·      In the aorta we will look for symptoms and signs of aortic dissection such as acute severe back pain or chest pain radiating to the back, unequal peripheral pulse or BP measurements, and diastolic murmur of aortic insufficiency

·      In the chest we will look for symptoms and signs of:

o  Acute coronary syndrome such as chest pain and shortness of breath and of

o  Acute pulmonary oedema such as shortness of breath, elevated JVP, decreased lung sounds, hypoxaemia, tachypnoea and bi-basal crackles and finally

·      In the kidneys will look for symptoms and signs of acute kidney injury such as oliguria, haematuria, and proteinuria

If there are any symptoms or signs of target organ damage, we will refer the patient to hospital as an emergency.

It is worth saying too that according to NICE, we should send the patient to hospital too if the patient has suspected phaeochromocytoma based on symptoms, for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis. 

Otherwise, without concerning symptoms or signs, as we know, we should carry out initial investigations such as:

·      UEs, FBC, HbA1c, Lipid profile, and TFTs

·      Urine dipstick for blood and protein as well as Albumin Creatinine ratio 

·      Fundoscopy – and, if unsure, we could consider an urgent optician retinal photography or an ophthalmological assessment

·      A Chest X-ray

·      An ECG and an

·      ECHO if there is evidence of LVH on ECG

Okay, so this is all very good in theory, but let’s put it into practice with a fictitious case:

A 54-year-old Caucasian woman without known hypertension comes to see you for an unrelated problem and you decide to check her BP. Her BP is 200/130 mm Hg. She is otherwise asymptomatic. On examination, funduscopy and the remainder of the examination is normal, including urinalysis.

What should we do next?

First of all, she has no symptoms of concern and no signs of end organ damage, so, assuming that the BP measurement is correct and that there are no other precipitating or risk factors, the next step will be to carry out investigations for end organ damage.

But, in practice, we do not have immediate access to chest x-rays and in some places, ECGs. Even if we can do blood tests and check ACR straightaway, the results wouldn’t be available immediately. Besides, our fundoscopy skills may not be perfect and getting an adequate fundoscopy assessment can also take time. Does this mean that we should always send the patient to the emergency department for a full assessment?

Most of us would probably find a BP of 200/130 quite scary. Our imagination may start thinking of all the possible things that could go wrong: neurological problems, cardiovascular events, retinal haemorrhages and acute kidney injury amongst many others.

In addition, we want to be good doctors, we want to do the best for our patients, we don’t want to get patients’ complaints and even less to be the subject of GMC investigations. But above all, we want to have peace of mind and sleep well at night.

So, what do we do?

And the first thing to say is that we have to do what feels right, it is our clinical judgement, and if it feels right to send the patient to the emergency department for a full screen, then so be it. This would be particularly relevant if we consider the patient to be at high risk because of, for example, other co-morbidities such as CKD, CHD or a previous stroke.

But there may be times when sending the patient to hospital may not be possible, or, perhaps, we will try but the medical team may refuse to accept the patient. What do we do then?

So, for then, let’s consider a few things.

As far as we know, this patient does not have any symptoms or signs of end organ damage.

NICE specifically says that when a patient does not have symptoms or signs indicating same day referral, we should carry out investigations for target organ damage “as soon as possible”. So NICE is asking us to use symptoms and signs, that is, history and examination as the basis for our assessment as to whether the patient needs to be seen in the emergency department or not. What carrying out investigations “as soon as possible” means exactly will be open to interpretation, but we should not take it as having to be done in hospital as an emergency.

Also, although repeated episodes of hypertensive urgency may have long-term complications, the immediate risk of hypertensive urgency is relatively low, and some studies have shown only 1 cardiovascular event per 1,000 patients in the week following the presentation. Therefore, the vast majority of these patients can be safely treated in Primary Care with oral antihypertensives.

Also, in the absence symptoms and signs of acute organ damage, there is limited evidence on benefits of immediate emergency blood and other diagnostic tests. A trial of patients presenting with hypertensive urgency in Primary Care showed that only 5% of ordered tests were abnormal, many of them being simply indicative of poorly controlled chronic hypertension. Consequently, although recommended, for most patients these tests are not needed as an emergency.

Also, most of these patients are likely to suffer from chronic hypertension. We know that many of these patients will have had very high blood-pressure readings for months or even years and we also know that for them the BP needs to be lowered slowly.

Why slowly? This is because perfusion of cardiac, renal, and brain tissue is tightly autoregulated in the body. And what does autoregulation mean?

Autoregulation of organ blood flow refers to physiological adaptations that allow organ perfusion to remain relatively constant across a wide blood-pressure range. For example, in chronic severe hypertension, cerebral blood flow is maintained at similar levels as in normotensive people, but its autoregulatory mechanism allows patients to tolerate higher blood-pressure levels without developing cerebral oedema. However, precisely because of this autoregulation, if the blood pressure is lowered too quickly, these patients are at risk of cerebral hypoperfusion, and this can happen even at higher-than-normal BP levels.

Therefore, although our wish may be to see a substantial drop in BP quickly, with no end organ damage, the BP should be lowered gradually, over a period of days to avoid hypotension, syncope, myocardial ischaemia and acute kidney injury which are commonly associated with, for example, the administration of sublingual nifedipine which is no longer widely advocated precisely for that reason.

Limited data suggest that hypertensive patients recover normal autoregulatory responses within weeks after treatment initiation.

Right, so, we have decided that this patient does not necessarily need to attend A&E so we will arrange investigations for end organ damage as soon as possible which, in Primary Care could be blood tests and ACR within 24 hours with available results generally within 48 hours. The availability of ECGs and CXRs may vary from practice to practice but, as long as there are no concerning symptoms, doing them within a few days may be acceptable. Equally, if we do not feel confident about our fundoscopy examination, we could arrange retinal photographs via an optometrist or arrange an alternative ophthalmological assessment, also within a number of days.

Now that we have arranged the investigations, and we have reassured ourselves that we do not need to send the patient to hospital, what do we actually do with the patient?

If the patient is known to have hypertension and the severe hypertension is secondary to, for example, non-compliance with medication, then it is easy. We will restart the medication counselling and monitoring the patient accordingly.

However, for those without a previous diagnosis of hypertension, NICE says that, as long as there are no symptoms or signs of end organ damage, we will confirm the diagnosis by either repeating the BP within 7 day or by reviewing the HBPM or ABPM results also within seven days, and then treat them if the diagnosis of hypertension is confirmed.

But I know that some of you will be thinking: really? Are we really going to let a patient go home for up to a week with a BP of 200/130 just like that?

Well, NICE says “review the BP within 7 days”, so this could mean reviewing the patient much more quickly, for example within 1 or 2 days. But I know that whilst this may be an appropriate management strategy for many patients, for others we, as doctors, would feel happier if we could do something sooner.

And this may also be a fair approach. In fact, although not advocated by NICE, there are other guidelines that recommend starting hypertensive medication straightaway in these situations, for example, the current guideline on the management of hypertensive crises by Worcestershire Acute Hospitals NHS Trust.

So, if you are worried enough to want to start medication straightaway, you could be justified doing just that, even if that means deviating from the NICE guideline.

And the next question is, how should this patient be treated?

Medical publications state that there is little evidence addressing directly what specific agent is best to use in the case of hypertensive urgency, that is a BP of 180/120 or higher without evidence of end organ damage.

This patient is Caucasian and she is under 55 years of age, so according to NICE, we should start her on an ACEI or an ARB.

But this is where some of the guidelines also differ. For example, some guidelines recommend starting what they call  “rapid” antihypertensive agents. For example, the Worcestershire guideline advocates starting a 10 to 20 mg daily dose of oral slow release nifedipine if the patient is not on a calcium channel blocker because it can be titrated up as required and it has a faster onset of action compared to amlodipine. When switching to amlodipine, they also recommend an overlap of 1-2 days, during which a patient can receive both Nifedipine and Amlodipine, to allow for the latter to reach adequate therapeutic levels before stopping nifedipine. To minimise the risk of cerebral hypoperfusion, an initial BP target of 160/100 within 6 to 24 hours is generally recommended.

After that, in general, once the hypertensive urgency has been addressed, the treatment options should be guided by NICE recommendations.

Worcestershire Acute Hospitals NHS Trust has created a simple flow chart which you will be able to find in the episode description.

Let’s have a look at it.

So, if the patient has severe hypertension, we will ask ourselves if there is evidence of end organ damage. If the answer is yes, then we will treat this as a hypertensive emergency, we will admit the patient and consider lowering the BP with IV medication.

If on the other hand, there is no evidence of end organ damage, then we will treat it as a hypertensive urgency that may not need admission and may be treated with oral medication. This could be nifedipine slow release orally or simply restarting usual antihypertensive medication in the case of non-compliance.

In summary, we must distinguish hypertensive emergency from hypertensive urgency. Short-term risk for serious cardiovascular events is minimal with hypertensive urgency and most of these patients can be safely treated in the Primary Care. Referral to the Emergency Department, aggressive BP reduction, and immediate diagnostic tests are generally unwarranted unless we have specific concerns. BP control is best achieved with the initiation or adjustment of long-acting oral antihypertensive medications although more rapid agents such as oral slow release nifedipine can be used if a faster onset of action is necessary. We should also consider and address any other possible precipitating factors.

Right, so this is it, a review of hypertensive urgencies.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/wjIbwy9SdAQ?si=hBe18dtUf_rPtRc8 

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE. 

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the NICE guideline [NG136] on Hypertension in adults, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:  

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]: 

·      https://www.nice.org.uk/guidance/ng136

Chronic kidney disease: assessment and management - NICE guideline [NG203]:

·      https://www.nice.org.uk/guidance/ng203

The NICE hypertension flowcharts can be found here:

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Full NICE guideline Hypertension in pregnancy: diagnosis and management [NG133] can be found at:

·      https://www.nice.org.uk/guidance/ng133/chapter/Recommendations

The Clinic BP targets tables can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do an up-to-date review of the NICE guidelines on hypertension, including the changes introduced in November 2023, always focusing on what is relevant in Primary Care only. 

Right, so let’s jump into it.

First, this guideline does not cover specific recommendations in CKD, type 1 diabetes, or pregnancy. However, it does cover type 2 diabetes, given that the management of hypertension in type 2 diabetes is no different than in the general population.

Let’s just remind ourselves that, when checking the BP, we should always palpate the pulse first and, if there is pulse irregularity, we should measure the BP manually, because automated devices are not accurate when the pulse is irregular like in AF.

If there are symptoms of postural hypotension, like falls or dizziness:

·      We will measure their BP while lying on their back (although we can consider a seated position, if inconvenient)

·      And we will measure their BP again after standing for at least 1 minute. 

If the systolic BP falls by 20 or more, or their diastolic BP by 10 or more:

·      we will consider the causes, and review their medication

·      we will manage the risk of falls

·      we will check future BP readings with the patient standing and

·      we will refer if necessary

Also, in order to diagnose hypertension, we will measure the BP in both arms:

·      If the difference is more than 15 mmHg, more than once, we will measure subsequent BPs in the arm with the higher reading. 

If BP measured in the clinic is 140/90 mmHg or higher:

·      We will take a second measurement.

·      If it is substantially different, we will take a third measurement and we will record the lowest of them as the clinic BP. 

If clinic BP is between 140/90 mmHg and 180/120 mmHg, we will confirm hypertension by doing ambulatory BP monitoring (ABPM) or, if necessary, home BP monitoring (HBPM). While waiting, we will:

·      Estimate the cardiovascular risk using the clinic BP and we will

·      Carry out investigations for target organ damage by doing:

o  A urine test for a haematuria dipstick and an albumin-creatinine ratio or ACR

o  A blood test for HbA1C, renal function, total cholesterol and HDL cholesterol

o  A 12‑lead ECG

o  And examination of the fundi for the presence of hypertensive retinopathy

If a person has a clinic BP of 180/120 mmHg or higher, we will check for red flags symptoms or signs that would indicate the need for urgent same day assessment in hospital. These are:

·      signs of retinal haemorrhage or papilloedema or

·      life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury or 

·      Signs or symptoms suggestive of phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis or excessive sweating). 

If there are no symptoms or signs indicating same-day referral, we will carry out investigations for target organ damage as soon as possible and:

·      If target organ damage is identified, we will consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

·      If no target organ damage is identified, we will confirm diagnosis by:

o  Either repeating the BP within 7 days, or

o  using ABPM or HBPM, also reviewing the patient within 7 days. 

When using HBPM, we will ensure that:

·      the BP is checked twice, at least 1 minute apart and

·      the BP is recorded twice daily, ideally in the morning and evening and

·      the BP checked for at least 4 days, ideally for 7 days

·      we will then disregard the BP readings taken on the first day and use the average value of the rest to confirm the diagnosis. 

We will confirm the diagnosis of hypertension if:

·      the clinic BP is 140/90 mmHg or higher and

·      the ABPM daytime average or HBPM average is 135/85 mmHg or higher. As a rule of thumb, the ambulatory or home  readings are 5 mmHg lower than for clinic measurements

Obviously, if hypertension is not diagnosed but there is target organ damage, we will investigate further.

If hypertension is confirmed, we will offer lifestyle advice in respect of diet, exercise, smoking and alcohol and we will encourage low caffeine and salt consumption. Salt substitutes containing potassium should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking ACE inhibitors and ARBs.

When it comes to starting antihypertensive medication, we will always use clinical judgement for people with frailty or multimorbidity, but in general:

·      At any age, we will start antihypertensives if the clinic BP is 160/100 or higher or ABPM or HPBM is 150/95 or higher

·      If the patient is over 80, we will consider antihypertensives if the clinic BP is over 150/90 mmHg

·      If the patient is between 60 and 80, we will consider antihypertensives if the clinic BP is 140/90 or higher or ABPM or HBPM is 135/85 or higher but only if there is:

o  target organ damage

o  established CVD

o  renal disease

o  diabetes or

o  a CV risk of 10% or more

·      If the patient is under 60, we will consider antihypertensives if the clinic BP is 140/90 or higher or ABPM or HBPM is 135/85 regardless of the CV risk

·      And if the patient is under 40, we should consider referral for investigations of secondary causes.

In terms of monitoring, we will check for postural hypotension if:

·      There are symptoms for example falls and dizziness or if

·      There is type 2 diabetes or if

·      The patient is aged 80 and over.

And if there is postural hypotension or symptoms, we should base the BP target on the standing BP reading. 

In straightforward hypertension without any other consideration, the BP targets that we need to remember are:

·      If under 80, the target clinic BP is below 140/90 mmHg (or 135/85 if using ABPM or HBPM)

·      If aged 80 and over, the target clinic BP is below 150/90 mmHg (or 145/85 if using ABPM or HBPM), always using clinical judgement if there is frailty or multimorbidity.

These targets are for everyone, including type 2 diabetes, but not if the patient is pregnant or has CKD or type 1 diabetes.

NICE has created two tables with BP targets including patients with CKD and type 1 diabetes, so, let’s have a look at them:

·      If the person is aged under 80, we have two targets:

o  Below 140/90 for general hypertension, with or without type 2 diabetes, or Type 1 diabetes with ACR <70 or CKD with ACR <70; and the second target is

o  Below 130/80 in Type 1 diabetes with ACR of 70 or more or CKD with ACR of 70 or more

·      If the person is 80 or over, we have three targets:

o  Below 150/90 for people with hypertension, with or without type 2 diabetes and also for those with type 1 diabetes regardless of ACR levels, then

o  Below 140/90 in CKD with an ACR <70 and the third target is

o  Below 130/80 in CKD with an ACR of 70 or more

I have streamlined these two tables into a single flowchart which you will be able to access in the episode description.

Now, to achieve these targets, what antihypertensives should we choose?

And, again, let’s remember that if the patient has certain conditions, we will not follow the hypertension guidelines but the specific guideline for those conditions, such as the guideline on:

·      Type 1 diabetes

·      CKD

·      Cardiovascular disease like heart failure, stable angina and acute coronary syndromes and

·      Pregnancy and in particular we will note the MHRA advice to avoid ACEIs and ARBs during pregnancy or breastfeeding or for women planning pregnancy.

Otherwise, the following recommendations apply to everybody else regardless of whether they have type 2 diabetes or not, and treating isolated systolic hypertension (that is a systolic BP 160 mmHg or more) the same way as in both raised systolic and diastolic BP. 

Also, when treating patients of Black African or African–Caribbean family origin, we will go for an ARB, in preference to ACE inhibitor. This is because they have a low-renin state and therefore ACEIs and ARBs are less effective for them. However, when they are needed in this group of patients, ARBs are clinically more effective than ACEIs.

The treatment of hypertension comes in 4 steps. Step 1 treatment is with one drug, step 2 treatment with two drugs, step 3 with three and so on.

So, in Step 1 treatment, that is, when we initiate medication for the first time, we will offer an ACE inhibitor or an ARB if:

·      They have type 2 diabetes and are of any age or family origin or

·      They are aged under 55 but not of Black African or African–Caribbean family origin. 

Conversely, we will offer a CCB if:

·      They are aged 55 or over and do not have type 2 diabetes or

·      are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 

If a CCB is not tolerated, for example because of oedema, we will offer a thiazide-like diuretic. And we should offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.

Step 2 treatment is treatment with two drugs. That is, if hypertension is not controlled with one drug, then, if the patient is taking an ACE inhibitor or ARB, we will offer either:

·      a CCB or

·      a thiazide-like diuretic

On the other hand, if hypertension is not controlled with a CCB, we will offer either:

·      an ACE inhibitor or an ARB or

·      a thiazide-like diuretic. 

Step 3 treatment is with three drugs so if hypertension is not controlled taking step 2 medication, we will offer a combination of them all, that is:

·      an ACE inhibitor or ARB and

·      a CCB and

·      a thiazide-like diuretic

But if hypertension is not controlled taking these three drugs, we will regard them as having resistant hypertension. 

And before considering further treatment:

·      We will discuss adherence 

·      We will confirm it with ABPM or HBPM

·      And we will assess for postural hypotension.

If resistant hypertension is confirmed, we may consider:

·      either seeking specialist advice

·      or adding a fourth antihypertensive drug as step 4 treatment

So, what is step 4 treatment with four drugs? Well, if we decide to give a fourth drug, we will need to look at the potassium level and:

·      If the potassium level of 4.5 mmol/l or less we will give further diuretic therapy with low-dose spironolactone, with particular caution if the eGFR is very low because of the risk of hyperkalaemia. When prescribing spironolactone, we will monitor electrolytes and eGFR within 1 month and repeat as needed thereafter. 

·      If the potassium level of more than 4.5 mmol/l we will give an alpha-blocker or a beta-blocker instead. 

If the BP remains uncontrolled with 4 drugs, then we will need to seek specialist advice. 

And that is it, a quick summary of the NICE guideline on hypertension.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here: https://youtu.be/41MH-Z-tcf8

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in March 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for March 2024 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2024-03-01&to=2024-03-31&ndt=Guidance&ndt=Quality+standard

The links to the guidance covered can be found here:

Ovarian cancer: identifying and managing familial and genetic risk- NICE guideline [NG241] can be found here:

·      https://www.nice.org.uk/guidance/ng241

Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management- NICE guideline [NG240] can be found here:

·      https://www.nice.org.uk/guidance/ng240

Vitamin B12 deficiency in over 16s: diagnosis and management- NICE guideline [NG239] can be found here:

·      https://www.nice.org.uk/guidance/ng239

My summary of meningitis and meningococcal disease symptoms can be found here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mRE17SGM9XfnH-0n?e=lx7zVg

2-page visual summary on ongoing care and follow up options for oral and intramuscular vitamin B12 replacement:

·      https://www.nice.org.uk/guidance/ng239/resources/visual-summary-ongoing-care-and-followup-for-vitamin-b12-replacement-pdf-13315996909 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

Music provided by Audio Library Plus 

Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in March 2024, focusing on what is relevant in Primary Care only. 

And in March we have had a feast of new guidance. Not because there have been many updates but because of three completely new guidelines that have been published for the very first time. We will be covering managing genetic risk of ovarian cancer, bacterial meningitis and meningococcal disease and the eagerly awaited vitamin B12 deficiency guideline. Right, let’s jump into it. 

So, let’s start with the guideline on identifying and managing genetic risk of ovarian cancer saying that these recommendations are for anyone who has a familial or genetic risk of ovarian cancer. This includes people with both female and male reproductive organs because although people with male reproductive organs cannot develop ovarian cancer, they can pass the risk on to their children, and may be at risk of developing other cancers.

So, the brief summary for us is that, in primary care, we should refer people for genetic testing if they have:

·      A first or second degree relative with a diagnosis of ovarian cancer

·      A diagnosis of ovarian cancer themselves

·      They have already been identified to be at high risk and if

·      they are from an at‑risk population, that is, those with at least 1 grandparent from the following populations:

o  Ashkenazi Jewish

o  Sephardi Jewish and

o  Greenlander

As we know, the combined oral contraceptive reduces the risk of ovarian cancer. However, we will only give it to reduce the risk of ovarian cancer if the reduction in the ovarian cancer risk outweighs the increased risk of breast cancer 

Equally, we can offer HRT until the average age of menopause (usually around 51 years) for people who:

·      have not had breast cancer and

·      have had bilateral salpingo-oophorectomy 

For those who have had breast cancer, HRT should be discussed with their breast cancer team.

Now let’s move to the guideline on bacterial meningitis and meningococcal disease, focusing on the recognition and diagnosis.

This guideline does not cover infection in babies under 28 days of age, or people with immunodeficiency, or any intracranial or spinal anomalies that increase the risk of meningitis.

The difficulty that we have with the diagnosis of meningitis or meningococcal disease, is that symptoms can be rapidly evolving and non-specific and they can be hard to distinguish from other infections and therefore we should always consider giving safety netting advice.

NICE has produced three long tables with signs and symptoms of when to suspect meningitis and meningococcal disease both in children and adults. We will not go through them here but I have created a summary that you can access in the episode description.

But we should strongly consider meningitis when encountering the following red flag combination:

·      fever

·      headache

·      neck stiffness and

·      altered level of consciousness (including confusion or delirium).

Also, we will really strongly suspect meningococcal disease if there is any of these red flag symptoms:

·      haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura)

·      rapidly progressive and/or spreading non-blanching petechial or purpuric rash and

·      any symptoms and signs of bacterial meningitis, when combined with a non-blanching petechial or purpuric rash.

But on the other hand, we will not rule out meningococcal disease just because there is no rash.

When looking for a rash we will check all over the body (including nappy areas), and check for petechiae in the conjunctivae, particularly if the person has brown, black or tanned skin.

There are a number of risk factors for bacterial meningitis and meningococcal disease like, to name but a few:

·      missed relevant immunisations

·      splenectomy

·      being a student in further or higher education, particularly if in large shared accommodation and

·      being in contact with someone with the disease, or having been in an area with an outbreak of meningococcal disease

We will obviously transfer people with suspected bacterial meningitis or meningococcal disease to hospital as an emergency, warning them that the patient is coming.

But, do we need to give antibiotics before sending the patient to hospital? Well, the things to consider in this respect are that:

·      First of all, we should not delay admission to hospital to give antibiotics

·      Second, we will give them in suspected meningitis only if there is likely to be a clinically significant delay in the transfer

·      But we will always give them in suspected meningococcal disease, unless this will cause a delay

·      And finally, if we give them, we will administer intravenous or intramuscular ceftriaxone or benzylpenicillin unless there is a known and severe allergy to these drugs.

Let’s now look at the guideline on vitamin B12 deficiency, which is probably one that is very relevant in our day-to-day practice. Because it’s so improtant, I think that the subject deserves its own dedicated episode, so I will only give a very quick overview here, just to give you a taste of what the guideline says.

And to start we will say that NICE does not use the term pernicious anaemia in this guideline but refers to autoimmune gastritis instead. And we also need to remember that people who have autoimmune gastritis:

·      are at higher risk of developing gastric neuroendocrine tumours and

·      may also be at higher risk of developing gastric adenocarcinoma.

So, we will refer them for gastrointestinal endoscopy if they develop upper gastrointestinal symptoms

The guideline explains that we should not rule out vitamin B12 deficiency just because there is no anaemia or macrocytosis.

We also need to be aware that vitamin B12 deficiency can be associated with mental health problems, including depression, anxiety or psychosis.

We will test vit B12 levels depending on symptoms and risk factors including gastrointestinal surgery, autoimmune medical conditions and medication taken.

To diagnosing vitamin B12 deficiency we can use total B12 levels, that is, serum cobalamin but in certain circumstances we will need to test for active B12 that is, serum holotranscobalamin, plasma homocysteine or serum methylmalonic acid or MMA.

In order to identify the cause of vitamin B12 deficiency, we will consider testing for anti-intrinsic factor antibodies if autoimmune gastritis is suspected, bearing in mind that a negative test result does not rule it out.

If it is still suspected despite a negative anti-intrinsic factor antibody test, we will consider further investigations including anti-gastric parietal cell antibodies or even a gastroscopy with biopsy

And we should consider testing for coeliac disease where the cause of deficiency remains unknown

In terms of managing vitamin B12 deficiency, we will give lifelong vitamin B12 injections if autoimmune gastritis is the cause, or they have had a total gastrectomy, or a complete terminal ileal resection.

For other causes of malabsorption, dietary problems, for medication related deficiencies and nitrous oxide use we can use either intramuscular or oral vitamin B12 replacement, based on clinical judgement

During follow up, we will not check vit B12 levels if we are giving vitamin B12 injections, but we will be guided by symptoms instead. If the symptoms have not improved enough, we will:

·      increase the frequency of injections if needed, and

·      think about alternative diagnoses 

If a person has an irreversible cause we will continue with lifelong injections, even if their symptoms have disappeared.

However, if the symptoms have disappeared and the reversible cause has been resolved we will think about stopping or reducing the vitamin B12 replacement, advising them to come back if symptoms recur.

NICE has produced a 2-page visual summary on ongoing care and follow up options for oral and intramuscular vitamin B12 replacement and the link to it is in the episode description.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.