Given the patient’s age of over 80 years, a clinic reading of less than 150/90 mmHg is deemed acceptable, and thus, no modifications to his current antihypertensive medications are necessary.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

For a patient with poorly controlled hypertension who is already taking an ACE inhibitor, the recommended medication to add would be either a calcium channel blocker or a thiazide-like diuretic. In this case, since the patient has a history of gout, a calcium channel blocker like amlodipine would be the most appropriate choice. Losartan, an A2RB drug, should not be used in combination with ACE inhibitors. The maximum daily dose of ramipril is 10 mg. The target home readings for this patient would be less than 135/85 mmHg.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Thyrotoxicosis as a Cause of Heart Failure

This patient presents with symptoms of heart failure, including fast atrial fibrillation, weight loss, and proximal myopathy. Although hyperthyroidism is typically associated with an increased appetite, apathy and loss of appetite can occur, especially in older patients. The presence of these symptoms suggests thyrotoxicosis, which would be confirmed by a suppressed thyroid-stimulating hormone (TSH) level.

The absence of a thyroid goitre doesn’t rule out Graves’ disease or a toxic nodule as the underlying cause. Echocardiography can confirm the diagnosis of heart failure but cannot determine the underlying cause. Therefore, it is important to consider thyrotoxicosis as a potential cause of heart failure in this patient.

Drug Interactions with Fruit Juices and Supplements

Grapefruit juice can significantly increase the serum concentrations of certain statins by reducing their first-pass metabolism in the small intestine through the inhibition of CYP3A4. Therefore, it is recommended to avoid consuming large amounts of grapefruit juice while taking atorvastatin or to adjust the dosage accordingly. CYP3A4 is a member of the cytochrome P450 system.

On the other hand, while an interaction between cranberry juice and warfarin has been recognized, there have been no reported interactions with other drugs metabolized via the P450 system. Additionally, there have been no known interactions between statins, carrot juice, garlic, or omega-3 fish oils. However, it is important to note that according to NICE CG172, patients should no longer be advised to take omega-3 supplements to prevent another MI.

Patients with heart failure should exercise caution when using NSAIDs as they may lead to fluid retention, making oral NSAIDs like ibuprofen unsuitable.

Medications to Avoid in Patients with Heart Failure

Patients with heart failure need to be cautious when taking certain medications as they may exacerbate their condition. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil should also be avoided due to its negative inotropic effect. NSAIDs and glucocorticoids should be used with caution as they can also cause fluid retention. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin outweigh the risks. Class I antiarrhythmics, such as flecainide, should also be avoided as they have a negative inotropic and proarrhythmic effect. It is important for healthcare providers to be aware of these medications and their potential effects on patients with heart failure.

National Screening Programme for Aortic Aneurysm in Men at 65

The National Screening Programme aims to reduce the rate of premature death from ruptured aortic aneurysm by 50% by screening all men in their 65th year. The prevalence of significant aneurysm in this age group is 4%. Screening will be done through ultrasound, and those without significant aneurysms will be discharged. For those with aneurysms greater than 5.5 cm in diameter, surgery will be offered to 0.5% of men. Those with small aneurysms will enter a follow-up programme. However, the mortality from elective surgery is 5-7%.

If you have had a pacemaker inserted or the box has been changed, it is important to inform the DVLA. It is also necessary to refrain from driving for a minimum of one week.

DVLA Guidelines for Cardiovascular Disorders and Driving

The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

Tips for a Heart-Healthy Diet after a Heart Attack

Following a heart attack, it is important to adopt a healthier overall diet to reduce the risk of future heart problems. Unhealthy diets have been attributed to up to 30% of all deaths from coronary heart disease (CHD). While reducing fat intake is important, exercise also plays a crucial role in maintaining heart health.

Including canned and frozen fruits and vegetables in your diet is just as beneficial as fresh produce. A Mediterranean diet, which includes many protective elements for CHD, is recommended. Replacing butter with olive oil and mono-unsaturated margarine, such as those made from rape-seed or olive oil, is a healthier option. Organic butter is not any better for heart health than non-organic butter.

To reduce cholesterol intake, it is recommended to eat less red meat and replace it with poultry. Margarine containing sitostanol ester may also help reduce cholesterol intake. Adding plant sterol to margarine has been shown to reduce serum low-density lipoprotein cholesterol. Eating more fish, including oily fish, at least once a week is also recommended.

Switching to whole-grain bread instead of white bread and eating more root vegetables and green vegetables is also beneficial. Lastly, it is important to eat fruit every day. By following these tips, you can maintain a heart-healthy diet and reduce the risk of future heart problems.

According to NICE guidelines, the initial test for patients with suspected chronic heart failure should be an NT-proBNP test. This should be done in conjunction with obtaining an ECG, and is recommended for patients who have not previously experienced a myocardial infarction.

Diagnosis of Chronic Heart Failure

Chronic heart failure is a serious condition that requires prompt diagnosis and management. In 2018, the National Institute for Health and Care Excellence (NICE) updated its guidelines on the diagnosis and management of chronic heart failure. According to the new guidelines, all patients should undergo an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation, regardless of whether they have previously had a myocardial infarction or not.

Interpreting the NT-proBNP test is crucial in determining the severity of the condition. If the levels are high, specialist assessment, including transthoracic echocardiography, should be arranged within two weeks. If the levels are raised, specialist assessment, including echocardiogram, should be arranged within six weeks.

BNP is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels of BNP are associated with a poor prognosis. The table above shows the different levels of BNP and NTproBNP and their corresponding interpretations.

It is important to note that certain factors can alter the BNP level. For instance, left ventricular hypertrophy, ischaemia, tachycardia, and right ventricular overload can increase BNP levels, while diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists can decrease BNP levels. Therefore, it is crucial to consider these factors when interpreting the NT-proBNP test.

Common Cardiac Arrhythmias and Their Characteristics

Acute atrial fibrillation is characterized by a sudden onset within the past 48 hours and may be triggered by excessive alcohol or caffeine intake. An ECG is necessary for diagnosis. Atrial flutter is less common than atrial fibrillation and typically presents with a rapid, irregular or regular pulse with a ventricular rate of approximately 150 beats per minute. Extrasystoles are extra heartbeats that disrupt the normal rhythm of the heart and can originate from either the atria or ventricles. Sinus arrhythmia is a common occurrence in children and young adults and involves cyclic changes in heart rate during breathing. Sinus tachycardia is a physiological response to various stimuli such as fever, anxiety, pain, exercise, and hyperthyroidism, and is characterized by a regular heart rate of over 100 beats per minute.

Verapamil is more likely to worsen heart failure compared to dihydropyridines such as amlodipine.

Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

Characteristics of Primary Raynaud’s Phenomenon

Primary Raynaud’s phenomenon is a condition characterized by recurrent vasospasm of the fingers and toes, typically triggered by stress or cold exposure. Here are some key characteristics that can help distinguish primary Raynaud’s phenomenon from secondary disease:

Age of onset: Symptoms that develop before age 30 are more likely to be primary Raynaud’s phenomenon, while later onset may suggest an underlying autoimmune disorder.

Gender: Primary Raynaud’s phenomenon is more common in females than males.

Digital ulceration: Absence of digital ulceration is more likely to indicate primary Raynaud’s phenomenon, while secondary disease is associated with more severe symptoms.

Antinuclear antibody: The presence of an antinuclear antibody may suggest an underlying condition, while its absence is more associated with primary Raynaud’s phenomenon.

Symmetry: Symmetrical involvement of digits is more indicative of primary Raynaud’s phenomenon and the absence of an underlying disorder.

By considering these characteristics, healthcare providers can better diagnose and manage patients with primary Raynaud’s phenomenon.

If a patient experiences palpitations, the first step in investigating the issue should be to conduct a Holter monitor test after conducting initial blood tests and an ECG. Palpitations are often indicative of an arrhythmia, such as atrial fibrillation, and it is important to conduct further investigations to rule out this possibility.

Holter monitoring is the recommended first-line investigation to capture any episodes of arrhythmia. Since the patient experiences these episodes daily, a 24-hour monitoring period is appropriate. However, a troponin test is not necessary as there is no chest pain, and an echocardiogram is not warranted as there are no indications of heart failure.

If the Holter monitoring results are normal and the patient continues to experience symptoms, an external loop recorder may be considered.

Investigating Palpitations: Identifying Possible Causes and Capturing Episodic Arrhythmias

Palpitations are a common symptom that can be caused by various factors such as arrhythmias, stress, and increased awareness of normal heartbeats. To investigate the underlying cause of palpitations, first-line investigations include a 12-lead ECG, thyroid function tests, urea and electrolytes, and a full blood count. However, these investigations may not capture episodic arrhythmias, which are often missed during a short ECG recording.

To capture episodic arrhythmias, the most common investigation is Holter monitoring. This portable battery-operated device continuously records ECG from 2-3 leads for 24 hours or longer if symptoms are less than daily. Patients are asked to keep a diary to record any symptomatic palpitations, which can later be compared to the rhythm strip at the time of the symptoms. At the end of the monitoring, a report is generated summarizing heart rate, arrhythmias, and changes in ECG waveform.

If no abnormality is found on the Holter monitor and symptoms persist, other options include an external loop recorder or an implantable loop recorder. These investigations can help identify the underlying cause of palpitations and guide appropriate management.

In 2014, the NICE guidelines were updated regarding the use of statins for primary and secondary prevention. Patients with established cardiovascular disease are now recommended to be treated with Atorvastatin 80 mg. If the LDL cholesterol levels remain high, it is suitable to consider switching the patient’s medication.

Management of Hyperlipidaemia: NICE Guidelines

Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

For patients of black African or African–Caribbean origin who are taking a calcium channel blocker for hypertension and require a second medication, it is recommended to consider an angiotensin receptor blocker instead of an ACE inhibitor. An alpha-blocker is typically not a first-line option, while spironolactone may be considered as a fourth-line option. However, the 2019 update to the NICE guidelines on hypertension recommends an ARB as the preferred choice for this patient population.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Heart Failure Treatment Options

According to the 2010 update by the National Institute for Health and Care Excellence (NICE), there are several medications that are indicated for the treatment of heart failure. These medications include bisoprolol, metoprolol succinate, carvedilol, and nebivolol. These drugs are commonly used to manage heart failure symptoms and improve overall heart function. It is important to consult with a healthcare provider to determine the best treatment plan for each individual case of heart failure. With proper medication management, individuals with heart failure can experience improved quality of life and better outcomes.

Urgent Admission Criteria for Patients with Atrial Fibrillation

The National Institute for Health and Care Excellence has provided guidelines for urgent admission of patients with atrial fibrillation. These guidelines recommend urgent admission for patients who exhibit a rapid pulse greater than 150 bpm and/or low blood pressure with systolic blood pressure less than 90 mmHg. Additionally, urgent admission is recommended for patients who experience loss of consciousness, severe dizziness, ongoing chest pain, or increasing breathlessness. Patients who have experienced a complication of atrial fibrillation, such as stroke, transient ischaemic attack, or acute heart failure, should also be urgently admitted. While other symptoms may warrant a referral, these criteria indicate the need for immediate medical attention.

Hypertrophic Cardiomyopathy and its ECG Findings

The sudden onset of arrhythmia in a young and previously healthy individual is often indicative of hypertrophic cardiomyopathy (HCM). It is important to screen relatives for this condition. The majority of patients with HCM have an abnormal resting ECG, which may show nonspecific changes such as left ventricular hypertrophy, ST changes, and T-wave inversion. Other possible ECG findings include right or left axis deviation, conduction abnormalities, sinus bradycardia with ectopic atrial rhythm, and atrial enlargement.

Ambulatory ECG monitoring can reveal atrial and ventricular ectopics, sinus pauses, intermittent or variable atrioventricular block, and non-sustained arrhythmias. However, the ECG findings do not necessarily correlate with prognosis. Arrhythmias associated with HCM can include premature ventricular complexes, non-sustained ventricular tachycardia, and supraventricular tachyarrhythmias. Atrial fibrillation is also a common complication, occurring in approximately 20% of cases and increasing the risk of fatal cardiac failure.

It is important to note that there is no history to suggest drug abuse, and aortic stenosis is rare in the absence of congenital or rheumatic heart disease. A myocardial infarction or massive pulmonary embolism would have distinct ECG changes that are not typically seen in HCM.

Treatment Options for Bradycardia: Understanding the Correct Administration of Medications

Bradycardia is a condition characterized by a slow heart rate, which can lead to serious complications if left untreated. There are several treatment options available for bradycardia, but it is important to understand the correct administration of medications to ensure the best possible outcome.

Administering atropine 1 mg IV is the first-line treatment for bradycardia caused by third-degree heart block. Atropine blocks parasympathetic activity and may improve node conduction. If necessary, it can be repeated every 3-5 minutes to a total of 3 mg.

Cardiopulmonary resuscitation is not appropriate for patients with a pulse and breathing.

Adenosine 3 mg IV is contraindicated in heart block and is used in the treatment and diagnosis of atrioventricular node-dependent supraventricular tachycardias.

Aminophylline 100 mg IV may be indicated as the first line to treat life-threatening bradycardia in certain patients, but it is not the first-line treatment for all cases.

Adrenaline 1 mg IV is an alternative treatment option if atropine is ineffective, but it is not the first-line treatment.

Understanding the correct administration of medications is crucial in the treatment of bradycardia. It is important to consult with a healthcare professional to determine the appropriate treatment plan for each individual case.

Here are the recommended doses of adrenaline for Adult Life Support (ALS):
– Anaphylaxis: Administer 0.5mg or 0.5ml of 1:1,000 adrenaline via intramuscular injection.
– Cardiac arrest: Administer 1 mg of adrenaline.

Understanding Adrenaline and Its Effects on the Body

Adrenaline is a hormone that is responsible for the body’s fight or flight response. It is released by the adrenal glands and acts on both alpha and beta adrenergic receptors. Adrenaline has various effects on the body, including increasing cardiac output and total peripheral resistance, causing vasoconstriction in the skin and kidneys, and stimulating glycogenolysis and glycolysis in the liver and muscle.

Adrenaline also has different actions on alpha and beta adrenergic receptors. It inhibits insulin secretion by the pancreas and stimulates glycogenolysis in the liver and muscle through alpha receptors. On the other hand, it stimulates glucagon secretion in the pancreas, ACTH, and lipolysis by adipose tissue through beta receptors. Adrenaline also acts on beta 2 receptors in skeletal muscle vessels, causing vasodilation.

Adrenaline is used in emergency situations such as anaphylaxis and cardiac arrest. The recommended adult life support adrenaline doses for anaphylaxis are 0.5ml 1:1,000 IM, while for cardiac arrest, it is 10ml 1:10,000 IV or 1 ml of 1:1000 IV. However, accidental injection of adrenaline can occur, and in such cases, local infiltration of phentolamine is recommended.

In conclusion, adrenaline is a hormone that plays a crucial role in the body’s response to stress. It has various effects on the body, including increasing cardiac output and total peripheral resistance, causing vasoconstriction in the skin and kidneys, and stimulating glycogenolysis and glycolysis in the liver and muscle. Adrenaline is used in emergency situations such as anaphylaxis and cardiac arrest, and accidental injection can be managed through local infiltration of phentolamine.

The definition of a TIA has been updated to focus on the affected tissue rather than the duration of symptoms. It is now defined as a temporary episode of neurological dysfunction resulting from restricted blood flow to the brain, spinal cord, or retina, without causing acute tissue damage. An ischaemic stroke, on the other hand, is characterized by neurological dysfunction caused by cerebral infarction, while multiple sclerosis is defined by neurological dysfunction caused by demyelination. Finally, a functional neurological disorder is characterized by transient symptoms of psychological origin.

A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

Characteristics of Aortic Regurgitation

Aortic regurgitation is a heart condition characterized by the backflow of blood from the aorta into the left ventricle during diastole. One of the key features of this condition is a blowing high pitched early diastolic murmur that can be heard immediately after A2. This murmur is loudest at the left third and fourth intercostal spaces.

In addition to the murmur, aortic regurgitation can also cause displacement of the apex beat. This is due to the dilatation of the left ventricle, which occurs as a result of the increased volume of blood that flows back into the ventricle during diastole. Despite this dilatation, there is relatively little hypertrophy of the left ventricle.

Overall, the combination of a high pitched early diastolic murmur and displacement of the apex beat can be strong indicators of aortic regurgitation.

The normal corrected QT interval for males is below 430 ms and for females it is below 450 ms. Long QT syndrome (LQTS) is a rare condition that can be inherited or acquired, causing delayed repolarisation of the ventricles and increasing the risk of ventricular tachyarrhythmias. This can result in syncope, cardiac arrest, or sudden death. LQTS can be detected incidentally on an ECG, after a cardiac event such as syncope or cardiac arrest, or following the sudden death of a family member.

Long QT syndrome (LQTS) is a genetic condition that causes a delay in the ventricles’ repolarization. This delay can lead to ventricular tachycardia/torsade de pointes, which can cause sudden death or collapse. The most common types of LQTS are LQT1 and LQT2, which are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.

There are various causes of a prolonged QT interval, including congenital factors, drugs, and other conditions. Congenital factors include Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome. Drugs that can cause a prolonged QT interval include amiodarone, sotalol, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Other factors that can cause a prolonged QT interval include electrolyte imbalances, acute myocardial infarction, myocarditis, hypothermia, and subarachnoid hemorrhage.

LQTS may be detected on a routine ECG or through family screening. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress, exercise, or auditory stimuli. Long QT3 events often occur at night or at rest and can lead to sudden cardiac death.

Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers are often used, and implantable cardioverter defibrillators may be necessary in high-risk cases. It is important to note that sotalol may exacerbate LQTS.

A significant proportion of individuals with resistant hypertension have an underlying secondary cause, such as Conn’s syndrome.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Rate Control vs Rhythm Control in Atrial Fibrillation: Recent Trials and Treatment Guidelines

Recent trials have confirmed that for most patients with atrial fibrillation, rate control is superior to rhythm control in terms of survival benefit. However, DC cardioversion may be considered for new onset and younger patients. The National Institute for Health and Care Excellence (NICE) guidelines recommend first-line therapy with ß-blockers or rate-limiting calcium antagonists, or digoxin if these are not tolerated. Verapamil should not be used in combination with a ß-blocker. These guidelines provide a framework for the management of atrial fibrillation and can help clinicians make informed treatment decisions.

The negative predictive value of BNP for ventricular dysfunction is good, but its positive predictive value is poor.

B-type natriuretic peptide (BNP) is a hormone that is primarily produced by the left ventricular myocardium in response to strain. Although heart failure is the most common cause of elevated BNP levels, any condition that causes left ventricular dysfunction, such as myocardial ischemia or valvular disease, may also raise levels. In patients with chronic kidney disease, reduced excretion may also lead to elevated BNP levels. Conversely, treatment with ACE inhibitors, angiotensin-2 receptor blockers, and diuretics can lower BNP levels.

BNP has several effects, including vasodilation, diuresis, natriuresis, and suppression of both sympathetic tone and the renin-angiotensin-aldosterone system. Clinically, BNP is useful in diagnosing patients with acute dyspnea. A low concentration of BNP (<100 pg/mL) makes a diagnosis of heart failure unlikely, but elevated levels should prompt further investigation to confirm the diagnosis. Currently, NICE recommends BNP as a helpful test to rule out a diagnosis of heart failure. In patients with chronic heart failure, initial evidence suggests that BNP is an extremely useful marker of prognosis and can guide treatment. However, BNP is not currently recommended for population screening for cardiac dysfunction.

Seeking Expert Advice for Resistant Blood Pressure

As per NICE guidelines, if a patient is already taking four antihypertensive medications and their blood pressure remains resistant, it is recommended to seek expert advice. This is because if the blood pressure remains uncontrolled even after taking the optimal or maximum tolerated doses of four drugs, it may indicate a need for further evaluation and management. Seeking expert advice can help in identifying any underlying causes of resistant hypertension and developing an effective treatment plan. Therefore, it is important to consult with a specialist if the blood pressure remains uncontrolled despite taking four antihypertensive medications.

NICE Guidance on Antibiotic Prophylaxis for High-Risk Patients

NICE has released new guidance regarding the use of antibiotic prophylaxis for high-risk patients. The guidance acknowledges that patients with pre-existing cardiac lesions are at risk of developing bacterial endocarditis (IE). However, NICE has concluded that clinical and cost-effectiveness evidence supports the recommendation that at-risk patients undergoing interventional procedures should no longer be given antibiotic prophylaxis against IE.

It is important to note that antibiotic therapy is still necessary to treat active or potential infections. The current antibiotic prophylaxis regimens may even result in a net loss of life. Therefore, it is crucial to identify patient groups who may be most at risk of developing bacterial endocarditis so that prompt investigation and treatment can be undertaken. However, offering antibiotic prophylaxis for these patients during dental procedures is not considered effective. This new guidance marks a paradigm shift from current accepted practice.

Understanding the Causes of Aortic Stenosis: A Comparison of Possible Factors

Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms and complications. One of the most common causes of aortic stenosis is a bicuspid aortic valve, which affects 1-2% of the population and is more prevalent in males. However, other factors can also contribute to the development of aortic stenosis, including hypertension and hypercholesterolemia. While hypertension is a risk factor for calcific aortic stenosis in both bicuspid and tricuspid valves, it is not the most common cause. On the other hand, hypercholesterolemia doesn’t directly cause aortic stenosis. Another condition that can present similarly to aortic stenosis is obstructive hypertrophic cardiomyopathy, which results from mid-systolic obstruction of flow through the left-ventricular outflow tract. Finally, valvular heart disease due to rheumatic fever is currently uncommon in the UK and is unlikely to be the cause of aortic stenosis in most cases. By understanding the different factors that can contribute to aortic stenosis, healthcare professionals can better diagnose and manage this condition.

Travel Restrictions After Myocardial Infarction

After experiencing a myocardial infarction (MI), also known as a heart attack, patients may wonder when it is safe to travel by air. The minimum time for flying after an uncomplicated MI is generally accepted to be seven days, although some authorities suggest waiting up to three weeks. It is important to note that this question specifically asks for the minimum time after an uncomplicated MI that would be safe for air travel.

Consensus national guidance in the UK, including advice from the Civil Aviation Authority and British Airways, supports the seven-day minimum for uncomplicated MI. Patients who have had a complicated MI should wait four to six weeks before flying. Patients with severe angina may require oxygen during the flight and should pre-book a supply with the airline. Patients who have undergone coronary artery bypass graft (CABG) or suffered a stroke should not travel for ten days. Decompensated heart failure or uncontrolled hypertension are contraindications to flying.

In summary, patients who have experienced an uncomplicated MI may fly after seven days without requiring an exercise test. It is important to follow national guidance and consult with a healthcare provider before making any travel plans after a heart attack.

Lipid Management in Primary Care

Lipid management is a common scenario in primary care, and NICE has produced guidance on Lipid modification (CG181) in the primary and secondary prevention of cardiovascular disease. The use of statins in primary prevention is supported by clinical trial data, with WOSCOPS (The West of Scotland Coronary Prevention Study) being a landmark trial. This study looked at statin versus placebo in men aged 45-65 with no coronary disease and a cholesterol >4 mmol/L, showing a reduction in all-cause mortality by 22% in the statin arm for a 20% total cholesterol reduction.

Other study data also supports the use of statins as primary prevention of coronary artery disease. The NICE Clinical Knowledge Summary on lipid modification – CVD prevention recommends Atorvastatin at 20 mg for primary prevention and 80 mg for secondary prevention. Risk is assessed using the QRISK2 calculator. Overall, lipid management is an important aspect of primary care, and healthcare professionals should be familiar with the latest guidance and clinical trial data to provide optimal care for their patients.

Understanding NICE Guidelines on Hypertension for the AKT Exam

The NICE guidelines on Hypertension (NG136) published in September 2019 provide important information for general practitioners on the management of hypertension. However, it is important to remember that these guidelines have attracted criticism from some clinicians for being over complicated and insufficiently evidence-based. While it is essential to have an awareness of NICE guidance, it is also important to have a balanced view and consider other guidelines and consensus opinions.

One example of a question that may be asked in the AKT exam relates to the cut-offs for high blood pressure on ambulatory monitoring. According to the NICE guidelines, stage 1 hypertension is defined as a blood pressure of 135-149/85-94 mmHg and should be treated if there is end organ damage, diabetes, or a 10-year CVD risk of 10% or more. Stage 2 hypertension is defined as blood pressure equal to or greater than 150/95 mmHg and should be treated.

In the exam, you may be asked to determine the appropriate treatment for a patient with stage 1 hypertension. The NICE guidance suggests a calcium channel blocker in patients above 55 or Afro-Caribbean. However, it is important to note that lifestyle factors are also crucial in risk reduction.

While it is unlikely that you will be asked to select answers that contradict NICE guidance, it is essential to remember that the AKT exam tests your knowledge of national guidance and consensus opinion, not just the latest NICE guidance. Therefore, it is important to have a broader understanding of the subject matter and consider other guidelines and opinions.

Diagnostic Tests for Stable Angina: CT Coronary Angiography, Non-Invasive Functional Imaging, ECG, Endoscopy, and Exercise ECG

Stable angina is suspected when a patient experiences constricting discomfort in the chest, neck, shoulders, jaw, or arms during physical exertion, which is relieved by rest or glyceryl trinitrate within five minutes. A typical angina diagnosis can be confirmed through a computed tomography (CT) coronary angiography, which should be offered if the patient exhibits typical or atypical angina or if the ECG shows ST-T changes or Q waves. Non-invasive functional imaging is recommended if the CT coronary angiography is not diagnostic or if the coronary artery disease is of uncertain functional significance. While ECG changes may suggest coronary artery disease, a normal ECG doesn’t confirm or exclude a diagnosis of stable angina. Endoscopy is used to investigate gastro-oesophageal causes of chest pain, but exercise-induced chest pain is more likely to be cardiac in nature. Exercise electrocardiograms are no longer recommended to diagnose or exclude stable angina in patients without known coronary artery disease.

Risks Associated with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) have the potential to increase the risk of thrombotic cardiovascular disease, even with short-term use. This risk applies to all NSAID users, regardless of their baseline risk, and is particularly high in patients with risk factors for cardiovascular events. Observational data suggests that high doses of diclofenac and ibuprofen pose the greatest risk, while naproxen and lower doses of ibuprofen do not have significant cardiovascular risk.

It is recommended to avoid NSAIDs in patients with cardiovascular disease, and if necessary, to use the lowest effective dose for the shortest possible time. NSAIDs may also counteract the antiplatelet effects of aspirin and increase the risk of gastrointestinal bleeds. Therefore, it is advised to avoid concomitant use and consider prescribing gastroprotection with a proton pump inhibitor if necessary.

For more information on the risks associated with NSAIDs, please refer to the following link: http://cks.nice.org.uk/nsaids-prescribing-issues#!scenario

NICE Guidance on Antihypertensive Treatment for People Over 55 and Black People of African or Caribbean Family Origin

According to the latest NICE guidance, people aged over 55 years and black people of African or Caribbean family origin of any age should be offered step 1 antihypertensive treatment with a CCB. If a CCB is not suitable due to oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, a thiazide-like diuretic should be offered instead.

This guidance aims to provide effective treatment options for hypertension in these specific populations, taking into account individual circumstances and potential side effects. It is important for healthcare professionals to follow these recommendations to ensure the best possible outcomes for their patients.

Due to the significantly elevated blood pressure of this relatively young patient, despite being on four antihypertensive medications, it is necessary to consider the possibility of a secondary cause. Therefore, referral to secondary care is recommended for further investigation. As per NICE guidelines, if the blood pressure remains uncontrolled even after using the optimal or maximum tolerated doses of four medications, it is advisable to seek expert advice if it has not already been obtained.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

If a beta-blocker is not effective in controlling angina, the recommended course of action is to add a longer-acting dihydropyridine calcium channel blocker to the treatment plan. Among the options listed, amlodipine is the only dihydropyridine available.

It is not advisable to add diltiazem due to the risk of complete heart block when used with atenolol. Although the risk is lower compared to verapamil, the potential harm outweighs the benefits.

Verapamil should also not be added as it can cause complete heart block due to the combined blockade of the atrioventricular node with beta-blockers.

While switching to diltiazem or verapamil is possible, it is not the best option. Dual therapy is recommended when monotherapy fails to control angina.

Angina pectoris can be managed through lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. NICE recommends using either a beta-blocker or a calcium channel blocker as first-line treatment, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker like amlodipine or modified-release nifedipine should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If initial treatment is ineffective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, long-acting nitrate, ivabradine, nicorandil, or ranolazine can be considered. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

Nitrate tolerance is a common issue for patients who take nitrates, leading to reduced efficacy. NICE advises patients who take standard-release isosorbide mononitrate to use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. However, this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate.

Antithrombotic therapy for prosthetic heart valves differs depending on the type of valve. Bioprosthetic valves typically only require aspirin, while mechanical valves require both warfarin and aspirin. However, according to the 2017 European Society of Cardiology guidelines, aspirin is only given in addition if there is another indication, such as ischaemic heart disease. Direct acting oral anticoagulants are not used for patients with a mechanical heart valve.

Prosthetic Heart Valves: Options and Considerations

Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.

It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.

If a black African or African-Caribbean patient with hypertension is already taking a calcium channel blocker and requires a second medication, it is recommended to add an angiotensin receptor blocker instead of an ACE inhibitor. This is because studies have shown that this class of medication is more effective in patients of this heritage. In this case, the patient would benefit from the addition of candesartan to lower their blood pressure. An alpha-blocker is not necessary at this stage, and a beta-blocker is not recommended as it is better suited for heart failure and post-myocardial infarction. Increasing the dose of amlodipine is also unlikely to be helpful as the patient is already on the maximum dose.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.