BioEd Online

Teacher Background

Modern healthcare often provides more than one option for treating disease or reducing the risk of future health problems. Increasingly, government agencies and private organizations are producing tools to help patients and their doctors collaborate on healthcare decisions, based on the latest scientific information available and patient preferences. Sometimes, the best decision is not clear-cut. Potential benefits and side effects, cost, interactions among medications, and patient behaviors and beliefs all influence the decision-making process.

Comparative effectiveness research helps physicians and patients make better decisions by presenting evidence on the effectiveness, benefits and harms of different treatment options. The evidence is generated by research studies that compare different drugs, medical devices, tests or surgeries.

In this activity, students will learn about two medications shown to help some patients with stable ischemic heart disease (coronary artery disease), high blood pressure or a weakened left ventricle. Then, students will decide if the drugs might be suitable for Arturo, Brian and/or Angela.

Different hypertension and CAD medications work on different aspects of the cardiovascular system. Two common classes of medications work on the renin angiotensin system, which regulates blood volume and arterial pressure. The kidneys are the primary site of renin release.

One main product of the renin angiotensin system is angiotensin II, a hormone that causes blood vessels to constrict, which subsequently increases blood pressure. Angiotensin II also stimulates secretion of the hormone, aldosterone, from the adrenal cortex. Aldosterone causes tubules of the kidneys to increase the levels at which sodium and water are reabsorbed into the blood. This leads to a higher volume of fluid in the body, which, in turn, elevates blood pressure.

Various medications lower blood pressure by blocking different parts of the renin angiotensin system. One class of medications prevents the enzyme, angiotensin converting enzyme (ACE), from converting the molecule, angiotensin I, into angiotensin II (see diagram in step 3 of the lesson PDF). Not surprisingly, these drugs are referred to as ACE inhibitors. Another class of medications, called angiotensin receptor blockers (ARBs), blocks the effects of the hormone, angiotensin, thereby preventing increases in blood pressure (occurs after step 4 in diagram, see lesson PDF).

Objectives and Standards

Materials and Setup

Teacher Materials

• Interactive white board or video projector and computer

• Internet access

• Copies of Part Three of the personal stories of Arturo, Brian and Angela (One set per team. Do not add to binder sections or folders until the activity is concluded.)

• Copies of the consumer guides, ACE Inhibitors and ARBS to Protect Your Heart? and Choosing Medicines for High Blood Pressure (one copy of each per student team, or a classroom set if teaching multiple classes)

Materials per Team of Students

• Binder or folder set with the personal stories of Arturo, Brian and Angela

• Copies of Part Three of the personal stories of Arturo, Brian and Angela (distribute at end of activity)

• Copies (print or digital) of the two decision-making consumer guides, ACE Inhibitors and ARBS to Protect Your Heart? and Choosing Medicines for High Blood Pressure

• Copy of “Decision-making Guiding Questions” student sheet

• Three pieces of notebook paper on which to record decisions and reasons called for on the “Decision-making Guiding Questions” sheet (one page each for Arturo, Brian and Angela)

Setup

• Make copies in advance. The two consumer guides, ACE Inhibitors and ARBS to Protect Your Heart? and Choosing Medicines for High Blood Pressure, may be printed, or students may use  digital versions of the PDF documents on a computer or mobile device. The PDF versions can be found on the Effective Health Care Program website (http://effectivehealthcare.ahrq.gov). Search by title once you have accessed the site.

1. Links to the PDF documents also can be found on the Scientific Decision-making resource page on BioEd Online (http://www.bioedonline.org/lessons-and-more/resource-collections/scientific-decision-making/).

2. Have students work in teams of four. Place all reference materials in a central location prior to class.

Procedure and Extensions

Time: One or two 45-minute class periods

1. Prior to class, assign students the homework of reading the two consumer guides, ACE Inhibitors and ARBS to Protect Your Heart? and Choosing Medicines for High Blood Pressure. Alternately, have copies available in class for students to read as part of the lesson. See Setup for information on locating and downloading the guides.

2. Ask students if they have any questions about the information in the patient guides. Discuss the questions or post them on the board for follow-up later. Then ask, Have any of you used materials like these guides, or helped a family member make a medical decision?

3. Remind students about Arturo, Brian and Angela. Have volunteers present a brief overview and diagnosis of each case, from memory. [Arturo had appendicitis; Brian had a heart attack and two blocked arteries; Angela was pregnant and has high blood pressure.] Ask, Do you think Arturo, Brian and Angela all have coronary heart disease, in addition to their immediate medical problems?

4. Tell the class that all three characters will have medical follow-ups, during which they may receive prescriptions for one or more medication. Inform the class, Now you will act as the personal physician for Arturo, Brian and Angela, and help them make a decision about one kind of medication. Explain that physicians often take aggressive measures to reduce the risk for an initial or repeat heart attack in patients who have coronary artery disease or have had a heart attack. These measures may include drug treatments, lifestyle changes or even surgical procedures.

5. Tell students that they will be reviewing the medications described in the two patient guides. These medications, ACE Inhibitors and ARBs, are used to treat high blood pressure. They act on the hormone system that causes blood vessels to constrict and regulates fluid balance in the body. If you have advanced students, you may wish to explore regulation of blood pressure in greater depth [see "Medications for High Blood Pressure and Coronary Artery Disease (CAD)," lesson PDF].

6. Instruct teams to use the consumer guides, ACE Inhibitors and ARBs to Protect Your Heart? and Choosing Medicines for High Blood Pressure, to answer the questions on the “Decision-making Guiding Questions” student sheet for each patient.

7. Have student teams present their ideas for treatment options, and help the class come to consensus on the most appropriate medications for Arturo, Brian and Angela. Students should consider the following important points in their answers.
   
   Arturo has high blood pressure, but no evidence of coronary artery disease, and no family history of coronary artery disease. He does not have congestive heart failure, diabetes or kidney disease, and did not have a heart attack. Thus, students should reach the conclusion that an ACE Inhibitor or ARB is not appropriate for Arturo at this time. Other blood pressure medications would be more suitable (have students refer to page 2 of both guides for further information).
   
   Brian does have coronary artery disease and has had a heart attack. Even though his heart function does not appear to be damaged, students should conclude that an ACE Inhibitor or ARB might be advisable for Brian (in addition to other medications). Most physicians will prescribe an ACEI first, because it is less expensive and works as well as ARBs to reduce the risk of future heart attacks. However, ACEI drugs do cause a persistent cough in some patients, which warrants changing to an ARB.
   
   Angela is pregnant and has high blood pressure, which might be a result of her pregnancy. She does not have coronary artery disease, congestive heart failure, diabetes or kidney disease, and did not have a heart attack. Thus, students should conclude that ACE Inhibitors and ARBs are not appropriate for her treatment. In addition, many drugs are not prescribed for women who are pregnant.

8. Provide Part Three of each character’s personal story to student groups, or project the stories for the class. If you have Internet access, show the video, Scientific Decision-making, Part Three (http://www.bioedonline.org/lessons-and-more/resource-collections/scientific-decision-making/). If your school limits access to YouTube or Vimeo, download the video directly from BioEd Online.

9. Have students discuss the final outcomes for Arturo, Brian and Angela. and ask students the following.
   
   Did anything about these cases impress or surprise you?
   
   How will the information you learned affect your own lifestyle decisions? 
   
   Have you learned anything that could help your family and friends? 
   
   Do you think you will share this information with them?

Extensions or Homework

Show the online video, It’s Time to Redesign Medical Data by Ted Goetz (http://www.ted.com/talks/thomas_goetz_it_s_time_to_redesign_medical_data.html). Discuss the role of information in modern medicine, particularly the suggestions made in the video to reorganize medical data for consumers. Alternately, have students create their own colorful charts to make patient information, such as blood pressure readings, easier to understand and interpret.

Handouts and Downloads