1)    Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment? Category    Systolic BP mmHg (Clinic)    Diastolic BP mmHg (Clinic)    Systolic BP mmHg (Ambulatory)    Diastolic BP mmHg (Ambulatory) Normal High-normal Stage 1 Stage 2

1)    Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment?

Category    Systolic BP mmHg (Clinic)    Diastolic BP mmHg (Clinic)    Systolic BP mmHg (Ambulatory)    Diastolic BP mmHg (Ambulatory)


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Stage 1

Stage 2

2)    What lifestyle measures would you advise Mr KK to help lower his blood pressure? Why are lifestyle measures important?

3)    About 1 week later Mr KK comes back into your pharmacy, he has now had 24 hour BP monitoring and his diagnosis of hypertension has been confirmed.

a.    How should an initial antihypertensive treatment be chosen for Mr KK?

b.    What antihypertensive therapy would you choose to start Mr KK on? What target blood pressure would you recommend for Mr KK and how often would you monitor his

blood pressure?

Fill this in on your care plan.
Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling


4)    Mr KK has a cholesterol of 6.5mmol/L and his total cholesterol:HDL ratio is 6.5. Calculate his overall cardiovascular risk using the tables in the BNF.

Complete the table below with his modifiable and non-modifiable risk factors for CVD

Modifiable    Non-modifiable

5)    Mr KK’s doctor now wants to start other medicines for primary prevention. What do you understand by primary prevention? Suggest a drug and dosage regime if

appropriate. What counselling would you give Mr KK about any new medicines you recommend?

Fill this in on your care plan.

Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Cardiovascular Risk


Although you should refer to the NICE guidance for hypertension when choosing antihypertensive therapy consideration should also be given to co-morbid conditions

6)    In four groups, discuss, giving reasons, which antihypertensive(s)
would be a good choice or poor choice. What target BP would you aim for in these patients?

•    White male accountant, 34 years old, asthma and weighs 82kg

•    White male, 70 years old, diabetes and CKD (Creatinine 250micromol/L). He weighs 70kg and is 5 feet 9 inches tall.

•    28 year old African woman with CKD (Creatinine 290micrmol/L)

•    72 year old African American woman with chronic cardiac failure NYHA Stage 3.


7)    About 6 months later, Mr KK visits your pharmacy again. He tells you
his GP has diagnosed him as having angina. What is angina and what symptoms would you expect him to experience?

8)    What changes would you recommend to Mr KK’s prescription and why? What counselling and monitoring would he need?

9)    Mr KK comes back to your pharmacy 3 months later with a prescription for a GTN spray. You notice this will be his 4th repeat prescription for this in the last

3 months. What questions do you want to ask him before you dispense this and what changes could you suggest to his therapy?

Question        Response

10)    Mr KK collects a new prescription for his GTN spray and asks you when he should expect to need a new one. Each GTN spray contains 200sprays; Mr KK is now using

2 puffs 4 times a week. The spray you have dispensed for him expires in May 2015.




Following the lecture, workshop, directed and background reading, students should be able to:

1)     Describe the aetiology and presentation of heart failure
2)     List the desired outcomes in care of patients with heart failure and how
pharmacists can help achieve these
3)     Discuss the pharmaceutical management of heart failure
4)     Outline how to initiate and titrate angiotensin converting enzyme inhibitor (ACEI) therapy and beta blocker therapy
5)    List the counselling required by patients commencing therapy on ACEIs and beta blockers for heart failure


Karagkounis D. Heart Failure – clinical features and diagnosis. Clinical Pharmacist. 2014; 6: 119-122 2010

Williams H. Heart Failure – management. Clinical Pharmacist. 2014; 6:123-1282010

BNF sections 2.5.5

NICE Bites – Chronic Heart Failure (NW MI) September 2010

NICE Clinical Guideline No: 108 August 2010: Management of Chronic Heart Failure in adults in Primary and Secondary Care. NICE guideline Pages 15-20 Pharmacological

Treatment of Heart Failure and Appendix D – Practical Notes


Myocardial infarction; secondary prevention – NICE Guidelines 2007 – quick reference guide. May 2007

Chapter on Congestive Cardiac Failure) in Clinical Pharmacy and Therapeutics or similar textbook

For each of the following group of drugs for heart failure indicate initiation and maximum dose and what stage of heart failure they should be used.

Beta-blockers (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Angiotensin Converting Enzyme Inhibitors
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Angiotensin II Receptor Antagonist (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Aldosterone Antagonists
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Loop diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose

Thiazide diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose


Mrs LL a 70 year old lady attended her GP practice as she had noticed that she had become increasingly tired and short of breath on carrying out her usual activities.

PC     Increased tiredness, SOB and swollen ankles

HPC   She noticed she needed to stop for breath when walking up the stairs.
Feeling tired and lethargic as not sleeping well at night for the last 2/52. Legs are feeling heavy and her shoes feel tight.

PMH    IHD, OA, MI 4 yrs ago
SHx    Lives alone in a house, usually independent, doesn’t drink any alcohol, ex-smoker, quit after her MI
RS    Basal creps in both lower bases, cough for past week producing watery sputum
CVS    BP 150/95mmHg    Pulse 90bpm reg
CNS     Grossly intact

O/E    Pitting oedema on both feet

Weight today = 67kg
Last recorded weight (4 months ago) in practice records = 60kg

Working diagnosis:    Heart failure/COPD/General deterioration

Current Rx:    Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Atenolol 50mg Mane
Ramipril 1.25mg Mane
GTN spray 400mcg 1-2 sprays when required for chest pain

1.    What do you understand by the term heart failure?

2. What medical conditions can lead to the development of heart failure?

3. What signs and symptoms does Mrs LL have that may be suggestive of
heart failure? How do these arise?

4. How would the diagnosis of heart failure in Mrs LL be confirmed?

5. What treatment option would you add to Mrs LL whilst she is awaiting her ECHO and specialist review? Include a suggested dose, preferred route of administration,

any monitoring required, and counselling you should offer Mrs LL.

Mrs LL is seen by a Cardiologist and her ECHO confirms that she has Left Ventricular Systolic Dysfunction (LVSD) with an Ejection Fraction of 30%. The aetiology of her

heart failure is due to ischaemia. The Cardiologist felt no further interventions or stents would be beneficial and optimisation of medical management was the plan.

Mrs LL was referred to the local Community heart failure nurses for optimisation.

On her first appointment the recommendation is to titrate ramipril to 2.5mg daily and switch atenolol to bisoprolol 2.5mg once daily.

6.   Why are angiotensin converting enzyme (ACE) inhibitors and beta-blockers recommended first line in the management of heart failure?

7.    a) How should ACE therapy be titrated and what monitoring is required?

b) What are the main side effects of ACE inhibitors? How should they be managed?

8.    a) How should beta-blockers be initiated in heart failure and what monitoring is required?

b) Why was Mrs LL switched from atenolol to bisoprolol?

c) In which situations are beta –blockers contra-indicated?

d) What are the main side effects of beta –blockers and how can they be managed?

9.    Mrs LL wants to know how many pints of water she can drink in a day? Calculate and advise Mrs LL. (1 pint = 568ml)

Mrs LL attends for a follow up appointment at the heart failure clinic she has noticed an increase in breathlessness since her last appointment and simple things like

brushing her teeth and getting dressed can make her extremely tired. Her osteoarthritis pain has worsened and her GP has given her a new prescription for her pain.

Current Treatment:
Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Bisoprolol 10mg Mane
Ramipril 10 mg Mane
Furosemide 40mg Mane
GTN spray 400mcg PRN
Naproxen 500mg TDS

Bloods: Creatinine 120micromol/L (60-120), urea 9mmol/L (2.5-7.5), potassium 4.5mmol/L (3.5-5)

BP 130/80mmHg, HR 65bpm. mild ankle swelling and lungs clear.

10.    Using the New York Heart Association (NYHA) functional classification,
how would you grade the severity of Mrs LL’s heart failure? Give reasons for your answer.

11.    Could any of Mrs LL’s drug treatments exacerbate her heart failure? If so,
how? Can you suggest alternative treatments that would not exacerbate her heart failure? Fill this in on your care plan.

12. Which other classes of drugs can precipitate or exacerbate heart failure?

13.    If Mrs LL’s heart failure were not controlled on her first-line agents, what second-line agents are available to add in?

14.    Two weeks later Mrs LL’s potassium is reported as 6.6 mmol/L. What is
likely to have caused this and what would you recommend?

Pharmaceutical care plan for Mrs LL (on review clinic at question 11)

Problem    Desired Outcome     Assessment    Actions
Options    Follow up / monitoring    Counselling

Worsening Heart Failure symptoms following titration of ACEi and BB.




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