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  • Question 1 - You receive a call from a nursing home about a 90-year-old male resident....

    Incorrect

    • You receive a call from a nursing home about a 90-year-old male resident. The staff are worried about his increasing unsteadiness on his feet in the past few months, which has led to several near-falls. They are also concerned that his DOAC medication puts him at risk of a bleed if he falls and hits his head.

      His current medications include amlodipine, ramipril, edoxaban, and alendronic acid.

      What steps should be taken in this situation?

      Your Answer: Advise the nursing home that she should only mobilise with help from staff

      Correct Answer: Calculate her ORBIT score

      Explanation:

      It is not enough to withhold anticoagulation solely based on the risk of falls or old age. To determine the risk of stroke or bleeding in atrial fibrillation, objective measures such as the CHA2DS2-VASc and ORBIT scores should be used. The ORBIT score, rather than HAS-BLED, is now recommended by NICE for assessing bleeding risk. A history of falls doesn’t factor into the ORBIT score, but age does. Limiting the patient’s mobility by suggesting she only mobilizes with staff is impractical. There is no rationale for switching the edoxaban to an antiplatelet agent, as antiplatelets are not typically used in atrial fibrillation management unless there is a specific indication. Stopping edoxaban without calculating the appropriate scores could leave the patient at a high risk of stroke.

      Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.

      When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.

      For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

    • This question is part of the following fields:

      • Cardiovascular Health
      344.9
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  • Question 2 - A 56-year-old man collapses after complaining of palpitations and is admitted to the...

    Correct

    • A 56-year-old man collapses after complaining of palpitations and is admitted to the Emergency Department (ED). He is found to be in ventricular tachycardia and is successfully cardioverted. Further investigations reveal an underlying long QT syndrome, and an implantable cardioverter-defibrillator (ICD) is inserted. The man works as an HGV driver. What advice should be given regarding his ability to drive HGV vehicles?

      Your Answer: Permanent bar

      Explanation:

      Regardless of the circumstances, the loss of HGV licence is indicated by ICD.

      DVLA Guidelines for Cardiovascular Disorders and Driving

      The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

      Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

      Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 3 - A 45-year-old woman with no significant medical history presents with a persistent cough...

    Correct

    • A 45-year-old woman with no significant medical history presents with a persistent cough and difficulty breathing for the past few weeks after returning from a trip to Italy. Initially, she thought it was just a cold, but now she has noticed swelling in her feet. Upon examination, she has crackling sounds in both lungs, a third heart sound, and a displaced point of maximum impulse.
      What is the most probable diagnosis?

      Your Answer: Cardiomyopathy

      Explanation:

      Differential Diagnosis for a Young Patient with Cardiomyopathy and Recent Travel History

      Cardiomyopathy is a myocardial disorder that can range from asymptomatic to life-threatening. It is important to consider this diagnosis in young patients presenting with heart failure, arrhythmias, or thromboembolism. While recent travel history may be relevant to other potential diagnoses, such as atypical pneumonia or thromboembolism, neither of these fully fit the patient’s history and examination. Rheumatic heart disease, pericarditis, and pulmonary embolus can also be ruled out based on the patient’s symptoms. The underlying cause and type of cardiomyopathy in this case are unknown but could be multiple.

    • This question is part of the following fields:

      • Cardiovascular Health
      94.7
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  • Question 4 - A 56-year-old patient has recently been diagnosed with heart failure. Choose from the...

    Correct

    • A 56-year-old patient has recently been diagnosed with heart failure. Choose from the options the medical condition that would most likely prevent the use of ß-blockers in this patient.

      Your Answer: Asthma

      Explanation:

      The Benefits and Considerations of β-Blockers in Heart Failure Patients

      β-blockers have been proven to provide significant benefits for patients with heart failure and should be offered to all eligible patients. It is recommended to start with the lowest possible dose and gradually increase it. While β-blockers can generally be safely administered to patients with COPD, caution should be exercised in patients with a history of asthma due to the risk of bronchospasm. However, cardioselective β-blockers such as atenolol, bisoprolol, metoprolol, nebivolol, and acebutolol may be used under specialist supervision. These medications are not cardiac specific and may still have an effect on airway resistance.

      In addition to heart failure, β-blockers can also be used for rate control in patients with atrial fibrillation and as a first-line treatment for angina. While they may worsen symptoms of peripheral vascular disease, this is not a complete contraindication to their use.

      Overall, β-blockers have proven to be a valuable treatment option for heart failure patients, but careful consideration should be given to individual patient factors before prescribing.

    • This question is part of the following fields:

      • Cardiovascular Health
      44.7
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  • Question 5 - A previously healthy 38-year-old woman is 20 weeks pregnant with her first child....

    Correct

    • A previously healthy 38-year-old woman is 20 weeks pregnant with her first child. She has been experiencing increasing shortness of breath in recent weeks and has started coughing up pink frothy sputum, particularly when lying down. She reports no chest pain. Blood tests reveal no anemia, but upon listening to her chest, you detect a mid-diastolic heart murmur at the apex. Her chest exam is otherwise normal, and her resting pulse is 90 bpm SR with O2 sats at 96%. What is the most probable diagnosis?

      Your Answer: Mitral stenosis

      Explanation:

      Mitral Stenosis: Symptoms and Findings

      Mitral stenosis is a condition where patients experience dyspnoea and pulmonary oedema due to increased left atrial pressure. This is more common in younger patients and can be exacerbated by situations of increased blood volume, such as during pregnancy. As a result, a previously asymptomatic patient may present to their GP during pregnancy.

      Typical findings in mitral stenosis include a small pulse that may be irregularly irregular. Jugular venous pressure is only raised if there is heart failure, right ventricular hypertrophy, tapping apex beat, loud S1, loud P2 if pulmonary hypertension, opening snap, mid-diastolic murmur heard at the apex only, or presystolic accentuation murmur if no atrial fibrillation.

      In summary, patients with mitral stenosis may experience dyspnoea and pulmonary oedema, and typical findings include a small pulse and irregularly irregular heartbeat. Jugular venous pressure may only be raised in certain situations.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 6 - You are asked to do a new baby check on a 4-day-old boy...

    Incorrect

    • You are asked to do a new baby check on a 4-day-old boy born at home after an uneventful pregnancy. The labour was normal and the baby has been fine until today, when he was noted to be slightly blue around the lips on feeding, recovering quickly. On examination there is a systolic murmur and you are unable to feel pulses in the legs.
      Select the single most likely diagnosis.

      Your Answer: Transient tachypnoea of the newborn

      Correct Answer: Coarctation of the aorta

      Explanation:

      Common Congenital Heart Defects in Newborns

      Congenital heart defects are abnormalities in the structure of the heart that are present at birth. Here are some common congenital heart defects in newborns:

      Coarctation of the aorta: This defect is a narrowing of the aorta, usually just distal to the origin of the left subclavian artery, close to the ductus arteriosus. It usually presents between day 2 and day 6 with symptoms of heart failure as the ductus arteriosus closes. The patient may have weak femoral pulses and a systolic murmur in the left infraclavicular area.

      Fallot’s tetralogy: This defect consists of a large ventricular septal defect, overriding aorta, right ventricular outflow obstruction, and right ventricular hypertrophy. It leads to a right to left shunt and low oxygen saturation, which can cause cyanosis. Most cases are diagnosed antenatally or on investigation of a heart murmur.

      Ductus arteriosus: The ductus arteriosus connects the pulmonary artery to the proximal descending aorta. It is a normal structure in fetal life but should close after birth. Failure of the ductus arteriosus to close can lead to overloading of the lungs because a left to right shunt occurs. Heart failure may be a consequence. A continuous (“machinery”) murmur is best heard at the left infraclavicular area or upper left sternal border.

      Transient tachypnoea of the newborn: This condition is seen shortly after delivery and consists of a period of rapid breathing. It is likely due to retained lung fluid and usually resolves over 24-48 hours. However, it is important to observe for signs of clinical deterioration.

      Ventricular septal defects: These defects vary in size and haemodynamic consequences. The presence of a defect may not be obvious at birth. Classically there is a harsh systolic murmur that is best heard at the left sternal edge. With large defects, pulmonary hypertension may develop resulting in a right to left shunt (Eisenmenger’s syndrome). Patients with the latter may have no murmur.

      In conclusion, early detection and management of congenital heart defects in newborns are crucial for better outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 7 - You start a patient on atorvastatin after their cholesterol was found to be...

    Correct

    • You start a patient on atorvastatin after their cholesterol was found to be raised in the context of a QRISK of 15%. You repeat the blood tests 6 months after starting treatment.

      Which of the following blood results does NICE recommend using to determine the next course of action?

      Your Answer: Non-HDL cholesterol

      Explanation:

      Monitoring Statin Treatment for Primary Prevention

      Following the initiation of statin treatment for primary prevention, it is recommended to have a repeat blood test after 3 months. The non-HDL cholesterol level should be interpreted to guide the next steps in management. The goal of treatment is to reduce non-HDL levels by 40% of the patient’s baseline. If adherence, timing of the dose, and lifestyle measures are in place, an increase in dose may be necessary.

      It is not routine to investigate creatine kinase in this context, but it would be helpful to investigate unexplained muscle symptoms. Liver function tests are not an option, but NICE advises testing these 3 months and 12 months following statin initiation. If stable, no further monitoring for LFTs is required after this.

    • This question is part of the following fields:

      • Cardiovascular Health
      28.5
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  • Question 8 - A 56-year-old man collapses in the hospital during a nurse-led hypertension clinic. He...

    Correct

    • A 56-year-old man collapses in the hospital during a nurse-led hypertension clinic. He is unresponsive and has no pulse in his carotid artery. What is the appropriate ratio of chest compressions to ventilation?

      Your Answer: 30:02:00

      Explanation:

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken in the event of a cardiac arrest. Patients are divided into those with ‘shockable’ rhythms (ventricular fibrillation/pulseless ventricular tachycardia) and ‘non-shockable’ rhythms (asystole/pulseless-electrical activity). Key points include the ratio of chest compressions to ventilation (30:2), continuing chest compressions while a defibrillator is charged, and delivering drugs via IV access or the intraosseous route. Adrenaline and amiodarone are recommended for non-shockable rhythms and VF/pulseless VT, respectively. Thrombolytic drugs should be considered if a pulmonary embolism is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Following successful resuscitation, oxygen should be titrated to achieve saturations of 94-98%. The ‘Hs’ and ‘Ts’ outline reversible causes of cardiac arrest, including hypoxia, hypovolaemia, and thrombosis.

    • This question is part of the following fields:

      • Cardiovascular Health
      26.5
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  • Question 9 - A 65-year-old man comes to the clinic with a diastolic murmur that is...

    Correct

    • A 65-year-old man comes to the clinic with a diastolic murmur that is most audible at the left sternal edge. The apex beat is also displaced outwards. What condition is commonly associated with these symptoms?

      Your Answer: Aortic regurgitation

      Explanation:

      Characteristics of Aortic Regurgitation

      Aortic regurgitation is a heart condition characterized by the backflow of blood from the aorta into the left ventricle during diastole. One of the key features of this condition is a blowing high pitched early diastolic murmur that can be heard immediately after A2. This murmur is loudest at the left third and fourth intercostal spaces.

      In addition to the murmur, aortic regurgitation can also cause displacement of the apex beat. This is due to the dilatation of the left ventricle, which occurs as a result of the increased volume of blood that flows back into the ventricle during diastole. Despite this dilatation, there is relatively little hypertrophy of the left ventricle.

      Overall, the combination of a high pitched early diastolic murmur and displacement of the apex beat can be strong indicators of aortic regurgitation.

    • This question is part of the following fields:

      • Cardiovascular Health
      51.4
      Seconds
  • Question 10 - A 57-year-old caucasian woman is diagnosed with stage 2 hypertension. Baseline investigations do...

    Correct

    • A 57-year-old caucasian woman is diagnosed with stage 2 hypertension. Baseline investigations do not reveal evidence of end-organ damage. She has a history of atrial fibrillation and takes apixaban. Her ECG is normal. Her QRISK3 score is calculated as 12.4%. She has no known drug allergies. Lifestyle advice is given and appropriate follow-up is scheduled. What is the most effective supplementary treatment choice?

      Your Answer: Atorvastatin and amlodipine

      Explanation:

      According to NICE guidelines, patients who are aged 55 years or over and do not have type 2 diabetes or are of black African or African-Caribbean family origin and do not have type 2 diabetes (of any age) should be prescribed calcium-channel blockers as the first-line treatment for hypertension. In addition, this patient requires a statin for primary cardiovascular disease prevention.

      Amlodipine alone is not sufficient as she requires both an antihypertensive agent and lipid-lowering therapy.

      Atorvastatin and indapamide (a thiazide-like diuretic) is not the best option as indapamide is only recommended as a second-line antihypertensive agent if a calcium-channel blocker is contraindicated, not suitable or not tolerated.

      Atorvastatin and ramipril is also not the best option as ACE inhibitors (or angiotensin-II receptor antagonists) are first-line for patients under the age of 55 and not of black African or African-Caribbean family origin, or those with type 2 diabetes (irrespective of age or family origin).

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

    • This question is part of the following fields:

      • Cardiovascular Health
      62.3
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular Health (8/10) 80%
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