Pendyffryn Medical Group

CARDIOVASCULAR DISEASE CLINIC PROTOCOL

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The aim of this protocol is to empower the nursing team to become lead practitioners in the care of patients, with evidence of;

1 Past or previous cardiovascular disease.

2 Significant modifiable disease factors, which make it likely they may develop CVD prematurely.

This protocol will deal with risk factors associated with hypertension and hyperlipidaemia.

The clinic consultation is over a 20 minute period covering the following areas.

Lifestyle modification is an important part of dealing with hypertension and hyperlipidaemia.

Give health education and promotion in the following areas, where appropriate

Smoking / give smoking cessation advice.
Diet / give healthy option, and advised on salt reduction if necessary.
Exercise / encourage patient to be more active.

Record the same, via the correct Read code.
Previous medical history should also be taken into account.
Give appropriate drug therapy, as instructed by the GP.

WHITE COAT HYPERTENSION

This category of patient should be monitored annually by 24 hr ABPM. Checking the BP on a frequent basis will not bring it down, therefore this is the best type of monitoring for this group of patients. An average diurnal BP can be set just the same as for the Essential hypertensive patients.

HYPERTENSION

Diagnosis

Diagnosis is made by the GP and added to the appropriate disease register, recorded as, Essential hypertension or White coat hypertension, using a validated and calibrated blood pressure monitor.
All patients who have either of the following:-

• Blood pressure > 140/90 on 3 separate occasions, 2 weeks apart are considered to have hypertension.
  
• Ambulatory blood pressure > 135/85 (daytime average) should be considered to have true hypertension and not white coat hypertension.
  
• A patient who’s BP is recorded > 210/120 is to see a GP as soon as possible.
  
• Any patient who’s BP is recorded > 185/110 is to see a GP within 48hrs.

NB If patients in the last two groups have symptoms, that might be attributable to their hypertension, i.e. headache (recent onset), then they should see a GP as soon as possible.

TO TREAT OR NOT TO TREAT

This is a multi-factorial decision made by a GP, taking into account all other risks and disease patterns into account. Patients not needing an urgent GP opinion the 24hr BP monitor should be ordered prior to the GP appointment, therefore helping the decision on the best treatment.

Prior to the initial consultation with a GP the following investigations are to be arranged, as they will assist the decision on the appropriate course of action.

Investigations: Blood - LFT, U&E , TFT, GGT, RBS, Lipids, FBC.

Urine dipstick test: sugar, blood, protein.
ECG recording

In the initial consultation by the GP, fundoscopy is performed, and the correct Read code is entered on the computer e.g. Essential hypertension, or White coat hypertension.

Target BP and the treatment regime thought best to suit the patient’s requirements must also be stated – e.g.: A-C-D or C-D-A any combination as per the algorithm below can be used.

Once treatment has been commenced these patients are to be reviewed 2 monthly, for blood pressure monitoring, before any treatment change is given

HYPERTENSION THERAPY:

Use the A,B,C,D strategy as recently outlined in the BMJ on 13/3/2004 currently this seems to be the standard therapy regime for therapy of hypertension however many authors have slightly improvised the therapeutic regime as below – ( taken from internet search – GP notes, May 2004).

A suggested treatment algorithm is summarised below:

*Combination therapy involving B and D may induce more new onset
Type 2 diabetes compared with other combinations of drug therapy.

Note that B has been re-included in step three.

This is to avoid people who were moving on to third-line combination therapy, having their beta-blockers dropped from their treatment (even if it was effective).

A= ACE inhibitors.

Standard therapy should be Ramipril titration pack.

U&E blood tests should be taken prior to commencement of this medication and at 2 weeks and 5 weeks, to ensure that renal function has not been compromised.

Serum creatinine levels should not exceed 120; if so discuss with a GP.

N.B Beware interactions with furosemide or NSAIDS

B= Beta Blockers.

Standard therapy should be Atenolol starting at a dose of25 mg increasing at a monthly interval to a maximum of 50 mg for uncomplicated hypertension.

C= Calcium channel blockers.

Standard therapy should be Felodipine 5mg increasing at a monthly interval to a maximum of 10mg for uncomplicated hypertension.

D= Diuretics.

Standard therapy should be Bendroflumethazide 2.5mg a day.

N.B
If a patient is intolerant of Ramipril, their medication should be changed to Telmisartan; an ACE receptor antagonist, which does not induce a cough.

Starting at a dose of 40mg a day and increasing at a monthly interval, to a maximum of 80mg a day.

DRUG SIDE EFFECTS

Bendroflumethazide
Gout, hyperglycaemia, impotence

Atenolol
Cold extremities, impotence, lethargy worsening asthma, tight chest, slow pulse rate.

Ramipril
Cough, renal failure, 1st dose hypotension (advise patient to take the very 1st dose at night-time).

Telmisartan
Renal failure is the only reported side effect of importance.

Felodipine
Ankle swelling, (can be severe) flushing, headaches.

NB. Any medication could cause any side effect albeit rarely, if in any doubt, seek a GP opinion.

Once target BP is reached, STOP going down the treatment ladder.

Monitoring

Once target BP has been achieved the patient is recalled 3/12 for monitoring, at this time compliance /drug side effects and lifestyle can be discussed, subsequently at 9months and then annually.

Emphasis must also be given that the treatment is for life.

A call and recall system is important so as these patients can be seen annually, in the CVD clinic.

Exception recording: To be performed by a GP

In the event of patients over 75 years being on 3 medications at maximum tolerated doses and still not reaching target BP – 150/90 on 3 occasions, they should be excluded from new contract targets – as long as there is no evidence of end organ damage.

In patients under 75 yrs medication is usually better tolerated, and in these patients a fourth agent might be added in the event of these patients being on maximum tolerated doses of four agents and still not reaching target BP – 150/90 on 3 occasions, they should be excluded from new contract targets – as long as there is no evidence of end organ damage.

HYPERLIPIDAEMIA

Group A

Patients in whom total cholesterol and low density lipoprotein level is irrelevant to commencing lipid lowering therapy.

• All patients with significant known cardiovascular disease should be taking Simvastatin 40 mgs at night, unless there has been a previous significant intolerance / allergy reaction.
  Atorvastatin 20mgs is then prescribed.
  
• All patients under 75years of age with CHD risk factor > 20% over a 10 year period should be taking Simvastatin 40mgs at night.
  
• All diabetic patients should be prescribed Simvastatin 40 mgs at night.

If over 50 years of age, this 3 groups of patients should also be taking either of the following;

Discuss with a GP

Aspirin 75mgs daily,
Clopidogrel 75mg daily,
Anti-coagulant therapy.

Group B

This relates to those patients who are considered at high risk of developing cardiovascular disease.

Risk should be assessed using the Sheffield tables or the In Practice computer system tables. If there is a strong family history of premature disease, 6 years should be added to the age.

A decision on whether there is a need to treat with lifestyle advice + / lipid lowering drugs should be the decision of the GP.

If the need for lipid lowering therapy is unclear, and after a period of 3 months of lifestyle changes, blood is taken to recheck TC and LDL, if still not at target level treatment should be commenced – Simvastatin 40mgs at night.

The aim of treatment for this group of patients should be to achieve;

Total cholesterol of 5 or less / and preferably an LDL of 3 or less.

A fasting venous blood sample is taken for the following investigation,
In patients in whom TC/LDL is relevant to commencing lipid lowering therapy:

TC,LDL,HDL lipid profile, TFT,S LFT,GGT,U&E, FBC and blood glucose levels.

Patients are informed that they are to fast for 14hrs, with only water to drink allowed.

Statin dosage is titrated to a dosage to reach the target level of cholesterol.

It is important, that all patients are seen by the dietician, where a careful dietary history is taken, whether or not they are started on treatment.

Monitoring and follow up

Following the decision to treat made by the GP, further follow up should be carried out by the nursing team.

• All patients should be given a prescription for 56 days of medication

A non-fasting blood test form for the following; Lipid profile, LFT, GGT, and creatinine kinase is to be taken 6 weeks after introduction of the medication.

• Read code entry should read STATIN PROPHYLAXIS
  
• If all other blood test are normal, and the TC is < 5, a letter is sent to the patient explaining therapy is for life. Enclosed also, is another prescription for 28-56 days, the medication is available on repeat prescription and that annual review is indicated.
  
• If the TC is > 5, Simvastatin is doubled to 80mgs, and a letter sent to the patient stating therapy is for life, another prescription and informing them the medication is on repeat prescription and the need to be review annually.

ANNUAL FOLLOW UP for HYPERTENSION and HYPERLIPIDAEMIA

This is performed within the CVD clinic on an annual basis.
Prior to their appointment, all patients are requested to bring a specimen of urine to clinic, and have the following non fasting blood sample taken; Total cholesterol lipid profile, LFT, GGT, CK U&E, FBC and blood glucose.

The clinic consultation should last a least 20 minutes, and cover the following areas;

Medical history; record any recent medical condition that may have occurred.

Lifestyle, diet, exercise smoking alcohol, and record any changes.

Question re, any side effects to medication.

Examination / minimum required;

BMI
Weight measurement
Blood pressure
Urinalysis
Discussion;

To address patients concerns regarding CVD risk.

Ensuring total cholesterol remains below 5
.
Monitoring their blood pressure has remained at target level, if not proceed down the regime ladder; the patient was started by the GP.

Assess the need for 24hr ABPM.

Ensure they understand the need for annual follow up
.
At the appropriate time, all at risk patients should be offered a flu vaccine or pneumococal vaccination.

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