HOT TOPICS for MRCGP and General Practitioners

4TH EDITION

Contents
Foreword Acknowledgements Introduction Why bother with Hot Topics? Useful reading material for Hot Topics revision 1. Cardiovascular Disease Hypertension Assessing CVD risk Hyperlipidaemia Antiplatelet treatment Heart failure Atrial fibrillation Coronary heart disease lifestyle factors Stroke and TIA 2. Diabetes Mellitus How is the diagnosis of diabetes confirmed? What are the implications of the National Service Framework (NSF) for diabetes? What are the Standards of the NSF? Diabetes and the General Medical Services (GMS) contract Is there evidence that improved glycaemic control leads to a reduction in complications? How often should we measure HbA1c? HbA1c targets (NICE 2002) Self-monitoring Should there be a screening programme for type 2 diabetes? How important is treating hypertension in diabetic patients? Should we give all diabetics ACE inhibitors? How do we treat diabetic nephropathy? What is the evidence for statin use in diabetics? What are the glitazones? What about the meglitinides? Inhaled insulin xi xiii xv xvii xix 1 4 15 17 25 29 36 41 47 53 55 56 56 57 58 59 60 60 61 61 62 62 63 64 65 65

HOT TOPICS FOR MRCGP AND GENERAL PRACTITIONERS

What does all this mean for patients? Impaired glucose tolerance (IGT) How can we stop people with IGT from developing diabetes? The metabolic syndrome 3. Respiratory Diseases Asthma Chronic obstructive pulmonary disease Smoking cessation Influenza 4. Psychiatry Mental health National Service Framework Depression Post-natal depression Post-traumatic stress disorder (PTSD) Schizophrenia Eating disorders Alcohol Drug misuse Counselling 5. The Elderly National Service Framework (NSF) for older people Falls Depression Alzheimers disease Osteoporosis Parkinsons disease Osteoarthritis 6. Obstetrics and Gynaecology Hormonal contraception Emergency hormonal contraception Teenagers and sexual health Sexual health and chlamydia Hormone replacement therapy 7. Paediatrics The NSF for children, young people and maternity services Standards Every child matters

65 66 66 67 69 71 80 85 92 97 99 102 109 109 111 115 117 122 129 131 133 135 136 137 142 149 151 157 159 164 166 169 174 183 185 187

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Prescribing for children Looking after teenagers Childhood vaccinations 8. Cancer The NHS Cancer Plan Prostate cancer Screening for bowel cancer Mammography Cervical cancer Screening 9. Antibiotics Antibiotic resistance Urinary tract infections Sore throat Otitis media Respiratory tract infections Acute conjunctivitis 10. Clinical Governance What are the components of clinical quality? What can we do to improve? Why is it needed? In reality How does it work in Primary Care Trusts (PCTs)? Conclusions National Institute for Clinical Excellence (NICE) 11. Revalidation Self-regulation Arguments for self-regulation Organisation of self-regulation Latest arrangements for revalidation Professional regulatory reform in the UK: a brief chronology National Clinical Assessment Authority (NCAA) Practice and personal development plans (PPDPs) 12. The Future of General Practice Shaping tomorrow: issues facing general practice in the new millennium, GPC 2000 Primary Care Trusts

189 189 190 195 197 202 209 210 213 214 217 219 222 224 226 228 230 231 233 233 233 234 234 234 235 241 243 243 243 244 248 253 255 257 260 264

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HOT TOPICS FOR MRCGP AND GENERAL PRACTITIONERS

The New GMS Contract Rationing Access to healthcare NHS Direct Walk-in Centres Diagnostic and treatment centres Specialist GPs Nurse practitioners Post Shipman: what are the long-term effects? Practice-based commissioning The National Programme for Information Technology (NPfIT) 13. Medicine and the Internet What makes the internet attractive? Is there any regulation of the information available on the internet? What is the Health on the Net Foundation? What problems may the internet pose to healthcare professionals? Are there any problems with writing for medical websites? The e-patient and e-mail consultations 14. Complementary Medicine St Johns wort Ginkgo biloba Phytoestogens Saw Palmetto Is there any good evidence available to support homoeopathy? 15. Medicolegal Issues and Guidelines General Medical Council Complaints Confidentiality Consent Medical negligence Guidelines 16. Advance Directives and End-of-Life Decisions Advance directives BMA guidance regarding advance statements (living wills) End-of-life decisions

264 267 270 271 275 278 279 280 284 287 290 293 295 296 296 296 297 297 303 306 306 307 307 307 309 311 313 315 317 320 321 325 327 327 329

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17. Miscellaneous Topics Refugees Recent advances in ethics 18. The Consultation Non-attendance Telephone consultations Consultation models Glossary Journals referenced in this book Index

333 335 339 343 357 359 360 369 374 376

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CHAPTER 1: CARDIOVASCULAR DISEASE

CHAPTER 1: CARDIOVASCULAR DISEASE

The prevention of cardiovascular disease (CVD) is one of the most important tasks for general practice. CVD remains the principal cause of death in the UK half the population of the UK will be killed or disabled by a myocardial infarction (MI), cerebrovascular accident (CVA) or other cardiovascular event and one-fifth of these deaths occur below retirement age. One-third are considered to be premature occurring before the age of 75. CVD is also considered to be the leading cause of disability in Europe. It has been estimated that 4.2% of men and 3.2% of women in England and Wales are being treated for coronary heart disease (CHD). The main risk factors are smoking, hypertension, hyperlipidaemia, diabetes mellitus, obesity and social deprivation. These will all be discussed within this chapter. The medical priority is to focus on those who are at highest risk of CVD. The first priority is secondary prevention for patients with established CVD. The second priority is primary prevention for people at high risk of developing CVD, ie those with an absolute CVD risk >20% (equivalent to CHD risk >15%) over 10 years, as calculated using the Joint British Societys coronary riskprediction charts.

HOT TOPICS FOR MRCGP AND GENERAL PRACTITIONERS

Hypertension
Hypertension was defined by the World Health Organization in 1993 as the blood pressure above which intervention reduces risk. Hypertension is a very common but poorly managed condition. More than one-quarter of the worlds adult population had hypertension in 2000; this is predicted to increase to 29% by 2025 (Lancet 2005; 365: 217223). The control of hypertension is still very poor only about 10% of the hypertensive patients in the UK have adequate control (Hypertension 2004; 43: 1017). With the increasingly tough treatment targets proposed by the British Hypertension Society (BHS), it is likely that even fewer patients will be adequately controlled. Hypertension treatment decreases the risk of fatal and non-fatal stroke, cardiac events and death. People at a greater cardiovascular risk when they start treatment, such as elderly patients, derive the most absolute benefit from drug treatment. However, the potential for side-effects such as falls resulting from postural hypotension should not be ignored. The question of whether to start treatment in the elderly should be decided on a case by case basis, taking into account co-morbidities.

By how much should blood pressure (BP) be lowered?

The 2004 BHS guidelines state that:

? In non-diabetic patients, the aim is to reduce the BP to below

140/85 mmHg. The maximum acceptable level (audit standard) is 150/90 mmHg.

? In diabetic patients, patients with established CVD and patients

with renal impairment, BP should be reduced to below 130/80 mmHg. The maximum acceptable level is 140/80 mmHg. This differs from the General Medical Services (GMS) contract, which awards quality and outcomes framework (QOF) points for achieving BP targets of <150/90 mmHg (145/85 mmHg for diabetics). For most patients over the age of 50 years, systolic BP is more important than diastolic BP in terms of risk of CVD.

CARDIOVASCULAR DISEASE

The BP targets proposed by the BHS are partly based on one large randomised controlled trial, the Hypertension Optimal Treatment (HOT) trial (Lancet 1998; 351: 17551762), which looked at outcomes in terms of major CVD events in 18,790 hypertensive patients aged between 50 and 80 who were randomly assigned to a target diastolic BP of <90, <85 or <80 mmHg. This study showed that the lowest incidence of CVD events occurred at a mean diastolic blood pressure of 82.6 mmHg (and systolic pressure of 138.5 mmHg) and the lowest overall CVD mortality occurred at a diastolic pressure of 86.5 mmHg. An even lower diastolic blood pressure was found to be beneficial in diabetics (<80 mmHg). Stroke risk was also lowest at a diastolic BP of <80 mmHg. The HOT study is unique in that it was designed to evaluate optimum target BP levels. It also set out to examine the role of aspirin in the primary prevention of CVD, and half the participants were randomised to receive this. Aspirin was found to reduce major CVD events by 15% and non-fatal MI by 36%, although it had no effect on the stroke rate. The benefit of aspirin for primary prevention had been controversial before this study.

What is the best drug regime to treat hypertension?

It is still unclear whether the benefits of specific antihypertensive drugs come from their direct effects on raised BP or from various other indirect actions. However, the overall consensus is that the degree of BP reduction achieved is probably more important than the class of drug used. Most patients will need at least two medications to control their BP adequately. Giving low-dose antihypertensives in combination is more effective and produces fewer side-effects than a single drug at a high dose (BMJ 2003; 326: 1427). It is generally accepted that best practice is to choose therapeutic agents likely to do more good than harm, given each patients social circumstances, preferences, co-existing medical conditions and risk factors. This is also likely to improve compliance. One study showed that only one-third of patients prescribed antihypertensives and lipid-lowering therapy were still taking both medications after six months (Arch Intern Med 2005; 165: 11471152). Some of the most important hypertension studies are highlighted below.