Evelyn’s 2nd follow-up appointment with the GP

The GP considers each possible option

Scene 1

GP: BP still up – 152/98 pulse 76 and regular ….

… Start ACE Inhibitor/ARB?
Several trials have shown that adding an ACE inhibitor to a CCB reduces the incidence of ankle oedema. The effects of ARBs are likely to be similar

Scene 2

GP: BP still up – 152/98 pulse 76 and regular ….

… Change to another calcium channel blocker?
Switching to another class of CCB may reduce ankle oedema, although the evidence for this is conflicting. Evelyn is currently taking amlodipine, a dihydropyridine CCB; switching to verapamil or diltiazem may help.

Scene 3

GP: BP still up – 152/98 pulse 76 and regular ….

… Increase amlodipine?
Ankle-oedema is dose related, so increasing the dose is likely to increase the severity of the ankle oedema.

Scene 4

GP: BP still up – 152/98 pulse 76 and regular ….

…. Start diuretic to reduce swelling?
Diuretics have little effect on CCB-induced ankle oedema. This is because the oedema is caused by vasodilatory induced fluid pooling, rather than water retention.

Scene 5

GP: BP still up – 152/98 pulse 76 and regular ….

…. Continue on current treatment and tell Evelyn to elevate her legs when possible?
Elevating the legs is an option for some people with mild oedema, however, there is little evidence to suggest that this is effective.

Scene 6

The GP decides to start Evelyn on ramipril.