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  • Question 1 - A 72-year-old man who rarely visits the clinic is brought in by his...

    Incorrect

    • A 72-year-old man who rarely visits the clinic is brought in by his daughter with complaints of orthopnoea, paroxysmal nocturnal dyspnoea and swollen ankles that have been present for a few weeks. On examination, he has bilateral basal crepitations and a resting heart rate of 110 beats per minute. An ECG shows sinus rhythm and an echocardiogram reveals a reduced ejection fraction. He responds well to treatment with optimal doses of an ACE inhibitor and furosemide. What is the most accurate statement regarding his future management?

      Your Answer: He should start digoxin for rate control

      Correct Answer: He should be started on a ĂŸ-blocker

      Explanation:

      Treatment Options for Chronic Heart Failure

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. One of the recommended treatment options is the prescription of a cardioselective β-blocker such as carvedilol. However, it should not be taken at the same time as an ACE inhibitor. While diuretics can help control oedema, the mainstay of treatment for chronic heart failure is ACE inhibitors and β-blockade. Although digoxin and spironolactone may have a place in treatment, they are not first or second line options. For severe cases of heart failure, biventricular pacing with an implantable defibrillator can be useful. Overall, a combination of these treatment options can help manage chronic heart failure and improve patient outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
      87.6
      Seconds
  • Question 2 - A 38-year-old man suffers a myocardial infarction (MI) and is prescribed aspirin, atorvastatin,...

    Incorrect

    • A 38-year-old man suffers a myocardial infarction (MI) and is prescribed aspirin, atorvastatin, ramipril and bisoprolol upon discharge. After a month, he experiences some muscle aches and undergoes routine blood tests at the clinic. His serum creatine kinase (CK) activity is found to be 650 u/l (normal range 30–300 u/l). What is the probable reason for the elevated CK levels in this individual?

      Your Answer: Normal-level post-MI

      Correct Answer: Effect of statin therapy

      Explanation:

      Interpreting Elevated CK Levels in a Post-MI Patient on Statin Therapy

      When a patient complains of symptoms while on statin therapy, it is reasonable to check their CK levels. An elevated level suggests statin-induced myopathy, and the statin should be discontinued. However, if the patient doesn’t complain of further chest pain suggestive of another MI, CK is no longer routinely measured as a cardiac marker. Heavy exercise should also be avoided, and CK levels usually return to baseline within 72 hours post-MI. While undiagnosed hypothyroidism can cause a rise in CK, it is less likely than statin-induced myopathy, and other clinical features of hypothyroidism are not mentioned in the scenario.

    • This question is part of the following fields:

      • Cardiovascular Health
      71.8
      Seconds
  • Question 3 - A 62-year-old male smoker comes to see you. His BMI is 35 and...

    Incorrect

    • A 62-year-old male smoker comes to see you. His BMI is 35 and has a 60-pack/year smoking history. His uncle and father both died in their 50s of a myocardial infarction.

      He is found to have a blood pressure of 146/92 mmHg in the clinic. He has no signs of end organ damage on examination and bloods, ACR, urine dip and ECG are normal. His 10-year cardiovascular risk is >10%. He has ambulatory monitoring which shows a blood pressure average of 138/86 mmHg.

      As per the latest NICE guidance, what is the most appropriate action?

      Your Answer: Discuss treatment with an ACE inhibitor

      Correct Answer: Discuss treatment with a calcium antagonist

      Explanation:

      Understanding NICE Guidelines on Hypertension for the AKT Exam

      The NICE guidelines on Hypertension (NG136) published in September 2019 provide important information for general practitioners on the management of hypertension. However, it is important to remember that these guidelines have attracted criticism from some clinicians for being over complicated and insufficiently evidence-based. While it is essential to have an awareness of NICE guidance, it is also important to have a balanced view and consider other guidelines and consensus opinions.

      One example of a question that may be asked in the AKT exam relates to the cut-offs for high blood pressure on ambulatory monitoring. According to the NICE guidelines, stage 1 hypertension is defined as a blood pressure of 135-149/85-94 mmHg and should be treated if there is end organ damage, diabetes, or a 10-year CVD risk of 10% or more. Stage 2 hypertension is defined as blood pressure equal to or greater than 150/95 mmHg and should be treated.

      In the exam, you may be asked to determine the appropriate treatment for a patient with stage 1 hypertension. The NICE guidance suggests a calcium channel blocker in patients above 55 or Afro-Caribbean. However, it is important to note that lifestyle factors are also crucial in risk reduction.

      While it is unlikely that you will be asked to select answers that contradict NICE guidance, it is essential to remember that the AKT exam tests your knowledge of national guidance and consensus opinion, not just the latest NICE guidance. Therefore, it is important to have a broader understanding of the subject matter and consider other guidelines and opinions.

    • This question is part of the following fields:

      • Cardiovascular Health
      59.6
      Seconds
  • Question 4 - Samantha is a 55-year-old female with hypertension which has been relatively well controlled...

    Correct

    • Samantha is a 55-year-old female with hypertension which has been relatively well controlled with lisinopril for 5 years. Her past medical history includes hypercholesterolaemia and osteoporosis.

      During a routine check with the nurse, Samantha's blood pressure was 160/100 mmHg. As a result, she has scheduled an appointment to see you and has brought her home blood pressure readings recorded over 7 days.

      The readings show an average blood pressure of 152/96 mmHg. What would be the most appropriate next step in managing Samantha's condition?

      Your Answer: Continue ramipril and commence amlodipine

      Explanation:

      If a patient with hypertension is already taking an ACE inhibitor and has a history of gout, it would be more appropriate to prescribe a calcium channel blocker as the next step instead of a thiazide. This is because thiazide-type diuretics should be used with caution in individuals with gout as it may worsen the condition. Therefore, a calcium channel blocker should be considered as a second-line Antihypertensive medication.

      It would be incorrect to make no changes to the patient’s medication, especially if their blood pressure readings are consistently high. In this case, a second-line Antihypertensive medication is necessary.

      Stopping the patient’s current medication, ramipril, is also not recommended as it is providing some Antihypertensive effects. Instead, a second medication should be added to further manage the patient’s hypertension.

      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
      77.9
      Seconds
  • Question 5 - A 54-year-old man has scheduled a meeting to discuss his struggles with poor...

    Correct

    • A 54-year-old man has scheduled a meeting to discuss his struggles with poor concentration and feeling sleepy while working. He works as a truck driver and frequently has to operate heavy machinery. His spouse has noticed that he experiences brief pauses in breathing while sleeping at night and occasionally makes choking sounds.

      The patient is currently receiving treatment for hypertension and benign prostatic hyperplasia. His Epworth sleepiness scale score is 16.

      Considering his condition, what is the best course of action for the patient to take regarding operating heavy machinery?

      Your Answer: He is required to inform the DVLA and stop driving

      Explanation:

      If a person has mild, moderate, or severe obstructive sleep apnoea (OSA) that causes excessive daytime sleepiness, they must inform the Driver Vehicle and Licensing Agency (DVLA). Excessive sleepiness refers to sleepiness that can negatively impact driving. The severity of OSA is determined by the number of apnoea/hypopnoea episodes per hour (apnoea-hypopnoea index [AHI]). Mild OSA is defined as an AHI of 5-14 per hour, moderate OSA is an AHI of 15-30 per hour, and severe OSA is an AHI of more than 30 per hour. If a person is diagnosed with OSA and experiences enough sleepiness to impair driving, they must inform the DVLA and stop driving. In this case, there is no need to retake a driving assessment, and the GP will not inform the DVLA initially. However, if the patient fails to inform the DVLA after multiple reminders and being informed that the GP may break confidentiality, the GP will inform the DVLA. If a person is being investigated for or has a diagnosis of OSA but doesn’t experience daytime sleepiness severe enough to impair driving, they do not need to inform the DVLA or stop driving. If a person is successfully using continuous positive airway pressure (CPAP) or an intra-oral device and their symptoms are controlled to the point where they no longer impair driving, they should inform the DVLA but do not need to stop driving.

      Understanding Obstructive Sleep Apnoea/Hypopnoea Syndrome

      Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a condition that causes interrupted breathing during sleep due to a blockage in the airway. This can lead to a range of health problems, including daytime somnolence, respiratory acidosis, and hypertension. There are several predisposing factors for OSAHS, including obesity, macroglossia, large tonsils, and Marfan’s syndrome. Partners of those with OSAHS often complain of excessive snoring and periods of apnoea.

      To assess sleepiness, patients may complete the Epworth Sleepiness Scale questionnaire, and undergo the Multiple Sleep Latency Test (MSLT) to measure the time it takes to fall asleep in a dark room. Diagnostic tests for OSAHS include sleep studies (polysomnography), which measure a range of physiological factors such as EEG, respiratory airflow, thoraco-abdominal movement, snoring, and pulse oximetry.

      Management of OSAHS includes weight loss and the use of continuous positive airway pressure (CPAP) as a first-line treatment for moderate or severe cases. Intra-oral devices, such as mandibular advancement, may be used if CPAP is not tolerated or for patients with mild OSAHS without daytime sleepiness. It is important to inform the DVLA if OSAHS is causing excessive daytime sleepiness. While there is limited evidence to support the use of pharmacological agents, they may be considered in certain cases.

    • This question is part of the following fields:

      • Cardiovascular Health
      52.8
      Seconds
  • Question 6 - Your patient, who has been discharged after a non-ST elevation myocardial infarction, is...

    Correct

    • Your patient, who has been discharged after a non-ST elevation myocardial infarction, is unsure if he has experienced a heart attack. Which statement from the list accurately describes non-ST elevation myocardial infarction?

      Your Answer: There is a risk of recurrent infarction in up to 10% in the first month

      Explanation:

      Understanding Non-ST Elevation Myocardial Infarction (NSTEMI) and Unstable Angina

      Non-ST elevation myocardial infarction (NSTEMI) is a condition that is diagnosed in patients with chest pain who have elevated troponin T levels without the typical ECG changes of acute MI, such as Q-waves and ST elevation. Instead, there may be persistent or transient ST-segment depression or T-wave inversion, flat T waves, pseudo-normalisation of T waves, or no ECG changes at all. On the other hand, unstable angina is diagnosed when there is chest pain but no rise in troponin levels.

      Despite their differences, both NSTEMI and unstable angina are grouped together as acute coronary syndromes. In the acute phase, 5-10% of patients may experience death or re-infarction. Additionally, another 5-10% of patients may experience death due to recurrent myocardial infarction in the month after an acute episode.

      To manage these patients, many units take an aggressive approach with early angiography and angioplasty. By understanding the differences between NSTEMI and unstable angina, healthcare professionals can provide appropriate and timely treatment to improve patient outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
      136.4
      Seconds
  • Question 7 - A 67-year-old man with type 2 diabetes has recently been initiated on insulin...

    Correct

    • A 67-year-old man with type 2 diabetes has recently been initiated on insulin therapy. He has a history of a heart attack 3 years ago and is currently taking a beta-blocker, calcium channel blocker, ace-inhibitor, statin, and GTN-spray. Which of his medications may cause a decreased recognition of hypoglycemic symptoms after starting insulin treatment?

      Your Answer: Beta-blocker

      Explanation:

      Beta-blockers are a class of drugs that are primarily used to manage cardiovascular disorders. They have a wide range of indications, including angina, post-myocardial infarction, heart failure, arrhythmias, hypertension, thyrotoxicosis, migraine prophylaxis, and anxiety. Beta-blockers were previously avoided in heart failure, but recent evidence suggests that certain beta-blockers can improve both symptoms and mortality. They have also replaced digoxin as the rate-control drug of choice in atrial fibrillation. However, their role in reducing stroke and myocardial infarction has diminished in recent years due to a lack of evidence.

      Examples of beta-blockers include atenolol and propranolol, which was one of the first beta-blockers to be developed. Propranolol is lipid-soluble, which means it can cross the blood-brain barrier.

      Like all drugs, beta-blockers have side-effects. These can include bronchospasm, cold peripheries, fatigue, sleep disturbances (including nightmares), and erectile dysfunction. There are also some contraindications to using beta-blockers, such as uncontrolled heart failure, asthma, sick sinus syndrome, and concurrent use with verapamil, which can precipitate severe bradycardia.

    • This question is part of the following fields:

      • Cardiovascular Health
      61.1
      Seconds
  • Question 8 - A 50-year-old man requests you to check his blood pressure after his colleague...

    Incorrect

    • A 50-year-old man requests you to check his blood pressure after his colleague had a heart attack. Upon measurement, his blood pressure is 142/82 mmHg, and five minutes later, it is 134/74 mmHg in the same arm. According to NICE guidelines, what is the best next step to take?

      Your Answer: Arrange ambulatory blood pressure monitoring

      Correct Answer: Reassure him that the second reading is normal and suggest he has it checked in 12 months

      Explanation:

      If the clinic reading is equal to or greater than 140/90 mmHg, it is recommended to offer ABPM/HBPM. However, if the lower reading in the consultation is below 140/90 mmHg, no immediate action is necessary according to NICE guidelines.

      NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

      To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

      If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

      ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

      Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

    • This question is part of the following fields:

      • Cardiovascular Health
      106.4
      Seconds
  • Question 9 - An 80 year old male underwent an ECG due to palpitations and was...

    Incorrect

    • An 80 year old male underwent an ECG due to palpitations and was found to have AF with a heart rate of 76 bpm. Upon further evaluation, you determine that he has permanent AF and a history of hypertension. If there are no contraindications, what would be the most suitable initial step to take at this point?

      Your Answer: Warfarin

      Correct Answer: Direct oral anticoagulant

      Explanation:

      According to the patient’s CHADSVASC2 score, which is 4, they have a high risk of stroke due to factors such as congestive cardiac failure, hypertension, age over 75, and being female. As per NICE guidelines, all patients with a CHADSVASC score of 2 or more should be offered anticoagulation, while taking into account their bleeding risk using the ORBIT score. Direct oral anticoagulants are now preferred over warfarin as the first-line treatment. For men with a score of 1, anticoagulation should be considered. Beta-blockers or a rate-limiting calcium channel blocker should be offered first-line for rate control, while digoxin should only be used for sedentary patients.

      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
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  • Question 10 - A 62-year-old woman has been visiting the practice nurse for a few weeks...

    Incorrect

    • A 62-year-old woman has been visiting the practice nurse for a few weeks for blood pressure (BP) checks. Her results have shown significant variability. She presents you with a diary of home readings that the nurse has instructed her to take twice daily over the past two weeks. Her average BP based on these readings is 135/80 mmHg. Her BP today in the clinic is 162/102 mmHg, and the nurse has recorded similar levels on the last two visits. She doesn't want to take medication for her BP. She has no other medical conditions.
      What is the most suitable course of action? Choose ONE option only.

      Your Answer: Arrange monthly BP reviews with the practice nurse

      Correct Answer: Accept the home blood pressure (BP) readings and diagnose white-coat hypertension

      Explanation:

      Managing White-Coat Hypertension with Home Blood Pressure Monitoring

      According to current NICE guidance, hypertension should be diagnosed in patients with a clinic BP of 140/90 mmHg or greater and either average daily ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) readings of greater than 135/85. However, if a patient’s home readings are within normal range, their elevated clinic BP is likely due to white-coat hypertension. In such cases, further assessment with ABPM is unnecessary. Monthly BP reviews with the practice nurse are also unnecessary if HBPM readings are normal. Treatment is not recommended based on clinic readings alone, and specialist referral is not needed if HBPM readings are within normal range. Home blood pressure monitoring can effectively manage white-coat hypertension.

    • This question is part of the following fields:

      • Cardiovascular Health
      81.1
      Seconds
  • Question 11 - A 65-year-old man presented, having had an episode of right-sided weakness that lasted...

    Incorrect

    • A 65-year-old man presented, having had an episode of right-sided weakness that lasted 10 minutes a fortnight earlier and fully resolved.

      Examination reveals that he is in atrial fibrillation.

      Assuming he remains in atrial fibrillation which of the following is the most appropriate management regime?

      Your Answer:

      Correct Answer: No antithrombotic treatment indicated

      Explanation:

      Thromboprophylaxis for High Risk Stroke Patients

      This patient is at high risk for future stroke and requires anticoagulation with warfarin. To assess the risk of bleeding and stroke, it is important to calculate the HASBLED and CHADS-VASc scores. The CHADS-VASc score takes into account factors such as congestive heart failure, hypertension, age, diabetes, stroke history, vascular disease, and sex. If the score is 1 or higher, oral anticoagulation should be considered. If the score is 0, no anticoagulation is needed. If the score is 1 but the only point is for female gender, it is treated as a score of 0. In this case, the patient’s CHADS-VASc score is 2, indicating a need for anticoagulation. The target range for INR is 2-3, with a target INR of 2.5.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 12 - Which of the following is the least acknowledged in individuals who are prescribed...

    Incorrect

    • Which of the following is the least acknowledged in individuals who are prescribed amiodarone medication?

      Your Answer:

      Correct Answer: Gynaecomastia

      Explanation:

      Gynaecomastia can be caused by drugs such as spironolactone, which is the most frequent cause, as well as cimetidine and digoxin.

      Adverse Effects and Drug Interactions of Amiodarone

      Amiodarone is a medication used to treat irregular heartbeats. However, its use can lead to several adverse effects. One of the most common adverse effects is thyroid dysfunction, which can manifest as either hypothyroidism or hyperthyroidism. Other adverse effects include corneal deposits, pulmonary fibrosis or pneumonitis, liver fibrosis or hepatitis, peripheral neuropathy, myopathy, photosensitivity, a slate-grey appearance, thrombophlebitis, injection site reactions, bradycardia, and lengthening of the QT interval.

      It is also important to note that amiodarone can interact with other medications. For example, it can decrease the metabolism of warfarin, leading to an increased INR. Additionally, it can increase digoxin levels. Therefore, it is crucial to monitor patients closely for adverse effects and drug interactions when using amiodarone. Proper management and monitoring can help minimize the risks associated with this medication.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 13 - A 72-year-old woman is being seen for a routine medical check-up at her...

    Incorrect

    • A 72-year-old woman is being seen for a routine medical check-up at her new GP practice. During the examination, her blood pressure is found to be 146/94 mmHg, which is confirmed on a second reading. According to the latest NICE recommendations, what would be the most suitable course of action?

      Your Answer:

      Correct Answer: Arrange ambulatory blood pressure monitoring

      Explanation:

      NICE guidelines from 2011 acknowledge the issue of overtreatment of ‘white coat’ hypertension and recommend the use of ambulatory blood pressure monitoring (ABPM) to address this problem. ABPM is also considered a more reliable predictor of cardiovascular risk compared to clinic blood pressure readings, based on strong evidence.

      NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

      To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

      If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

      ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

      Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 14 - You start a patient on atorvastatin after their cholesterol was found to be...

    Incorrect

    • 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:

      Correct 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
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  • Question 15 - A 64-year-old man who underwent mechanical mitral valve replacement four years ago is...

    Incorrect

    • A 64-year-old man who underwent mechanical mitral valve replacement four years ago is being evaluated. What is the probable long-term antithrombotic treatment he is receiving?

      Your Answer:

      Correct Answer: Warfarin

      Explanation:

      Antithrombotic therapy for prosthetic heart valves differs depending on the type of valve. Bioprosthetic valves typically only require aspirin, while mechanical valves require both warfarin and aspirin. However, according to the 2017 European Society of Cardiology guidelines, aspirin is only given in addition if there is another indication, such as ischaemic heart disease. Direct acting oral anticoagulants are not used for patients with a mechanical heart valve.

      Prosthetic Heart Valves: Options and Considerations

      Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.

      It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 16 - A 60-year-old man presents to his General Practitioner to discuss whether he requires...

    Incorrect

    • A 60-year-old man presents to his General Practitioner to discuss whether he requires a statin. His brother has encouraged him to book the appointment because ‘everyone in the family takes a statin’, due to familial hypercholesterolaemia. He has no significant medical history and rarely consults with a doctor. His total cholesterol is 8.2 mmol/l.
      What is the most appropriate management option?

      Your Answer:

      Correct Answer: Carry out blood tests for liver, renal and thyroid function, HbA1c and lipid panel

      Explanation:

      Management of Suspected Familial Hypercholesterolaemia

      Suspected familial hypercholesterolaemia requires a thorough diagnostic and management approach. The first step is to carry out blood tests for liver, renal, and thyroid function, HbA1c, and lipid panel. Additionally, a full cardiovascular assessment and exclusion of secondary causes of hypercholesterolaemia should be conducted before referral.

      QRisk2 scoring is not appropriate in suspected familial hypercholesterolaemia due to the high risk of premature heart disease associated with the condition. Atorvastatin 20 mg is a good choice for primary prevention, but further tests are necessary to establish its suitability for the patient. Atorvastatin 80 mg is often given as secondary prevention, but there is no evidence that this is necessary for the patient from the information provided.

      Referral to a lipid clinic in secondary care is imperative for patients with suspected familial hypercholesterolaemia. This condition should be suspected in adults with a total cholesterol >7.5mmol/l and/or a personal or family history of a cardiovascular event before the age of 60 years old. Basic blood tests will provide important diagnostic and management information, ruling out secondary causes of hypercholesterolaemia and assessing the patient’s suitability for treatment with lipid-lowering drugs.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 17 - You are requested to finalize a medical report for a patient who has...

    Incorrect

    • You are requested to finalize a medical report for a patient who has applied for life insurance. Two years ago, he began treatment for hypertension but stopped taking medication eight months later due to adverse reactions. His latest blood pressure reading is 154/92 mmHg. During the patient's visit to your clinic, he requests that you omit any reference to hypertension as everything appears to be fine now. What is the best course of action?

      Your Answer:

      Correct Answer: Contact the insurance company stating that you cannot write a report and give no reason

      Explanation:

      Guidelines for Insurance Reports

      When writing insurance reports, it is important for doctors to be familiar with the GMC Good Medical Practice and supplementary guidance documents. The Association of British Insurers (ABI) website provides helpful information on best practices for insurance reports. One key point to remember is that NHS referrals to clarify a patient’s condition are not appropriate for insurance reports. Instead, the ABI and BMA have developed a standard GP report (GPR) form that doctors can use. It is acceptable for GPs to charge the insurance company a fee for this work, and reports should be sent within 20 working days of receiving the request.

      When writing the report, it is important to only include relevant information and not send a full print-out of the patient’s medical records. Written consent is required before releasing any information, and patients have the right to see the report before it is sent. However, doctors cannot comply with requests to leave out relevant information from the report. If an applicant or insured person refuses to give permission for certain relevant information to be included, the doctor should indicate to the insurance company that they cannot write a report. It is also important to note that insurance companies may have access to a patient’s medical records after they have died. By following these guidelines, doctors can ensure that their insurance reports are accurate and ethical.

      Guidelines for Insurance Reports:
      – Use the standard GP report (GPR) form developed by the ABI and BMA
      – Only include relevant information and do not send a full print-out of medical records
      – Obtain written consent before releasing any information
      – Patients have the right to see the report before it is sent
      – Insurance companies may have access to medical records after a patient has died

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 48-year-old man presents to an out-of-hours community hospital walk-in centre feeling light-headed...

    Incorrect

    • A 48-year-old man presents to an out-of-hours community hospital walk-in centre feeling light-headed and short of breath. Shortly after he arrives, he loses consciousness. He continues to breathe spontaneously, and a nurse is able to maintain his airway and administer oxygen. Observations show a heart rate of 38 bpm and blood pressure of 88/44 mmHg. An electrocardiogram shows complete heart block.
      What is the most appropriate initial step in management?

      Your Answer:

      Correct Answer: Administer atropine 1 mg IV

      Explanation:

      Treatment Options for Bradycardia: Understanding the Correct Administration of Medications

      Bradycardia is a condition characterized by a slow heart rate, which can lead to serious complications if left untreated. There are several treatment options available for bradycardia, but it is important to understand the correct administration of medications to ensure the best possible outcome.

      Administering atropine 1 mg IV is the first-line treatment for bradycardia caused by third-degree heart block. Atropine blocks parasympathetic activity and may improve node conduction. If necessary, it can be repeated every 3-5 minutes to a total of 3 mg.

      Cardiopulmonary resuscitation is not appropriate for patients with a pulse and breathing.

      Adenosine 3 mg IV is contraindicated in heart block and is used in the treatment and diagnosis of atrioventricular node-dependent supraventricular tachycardias.

      Aminophylline 100 mg IV may be indicated as the first line to treat life-threatening bradycardia in certain patients, but it is not the first-line treatment for all cases.

      Adrenaline 1 mg IV is an alternative treatment option if atropine is ineffective, but it is not the first-line treatment.

      Understanding the correct administration of medications is crucial in the treatment of bradycardia. It is important to consult with a healthcare professional to determine the appropriate treatment plan for each individual case.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 19 - A 76-year-old woman presents for review. She underwent ambulatory blood pressure monitoring which...

    Incorrect

    • A 76-year-old woman presents for review. She underwent ambulatory blood pressure monitoring which revealed an average reading of 142/90 mmHg. Apart from hypothyroidism, there is no significant medical history. Her 10-year cardiovascular risk score is 23%. What is the best course of action for management?

      Your Answer:

      Correct Answer: Start amlodipine

      Explanation:

      For patients under 80 years old, the target blood pressure during clinic readings is 140/90 mmHg. However, the average reading is currently above this threshold, indicating the need for treatment with a calcium channel blocker.

      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
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  • Question 20 - A 75-year-old man visits his GP for a follow-up appointment 6 weeks after...

    Incorrect

    • A 75-year-old man visits his GP for a follow-up appointment 6 weeks after undergoing catheter ablation due to unresponsive atrial fibrillation despite antiarrhythmic treatment. He has a medical history of asthma, which he manages with a salbutamol reliever and beclomethasone preventer inhaler, and type II diabetes, which he controls through his diet. The patient is currently receiving anticoagulation therapy in accordance with guidelines. There are no other significant medical histories.

      What should be the next course of action in his management?

      Your Answer:

      Correct Answer: Continue anticoagulation long-term

      Explanation:

      Patients who have undergone catheter ablation for atrial fibrillation still need to continue long-term anticoagulation based on their CHA2DS2-VASc score. In the case of this patient, who has a CHA2DS2-VASc score of 2 due to age and past medical history of diabetes, it is appropriate to continue anticoagulation.

      Amiodarone is typically used for rhythm control of atrial fibrillation, but it is not indicated in this patient who has undergone catheter ablation and has no obvious recurrence of AF.

      Beta-blockers and diltiazem are used for rate control of atrial fibrillation, but medication for AF is not indicated in this patient.

      Anticoagulation can be stopped after 4 weeks post catheter ablation only if the CHA2DS2-VASc score is 0.

      Atrial fibrillation (AF) is a heart condition that requires prompt management. The management of AF depends on the patient’s haemodynamic stability and the duration of the AF. For haemodynamically unstable patients, electrical cardioversion is recommended. For haemodynamically stable patients, rate control is the first-line treatment strategy, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin are commonly used to control the heart rate. Rhythm control is another treatment option that involves the use of medications such as beta-blockers, dronedarone, and amiodarone. Catheter ablation is recommended for patients who have not responded to or wish to avoid antiarrhythmic medication. The procedure involves the use of radiofrequency or cryotherapy to ablate the faulty electrical pathways that cause AF. Anticoagulation is necessary before and during the procedure to reduce the risk of stroke. The success rate of catheter ablation varies, with around 50% of patients experiencing an early recurrence of AF within three months. However, after three years, around 55% of patients who have undergone a single procedure remain in sinus rhythm.

    • This question is part of the following fields:

      • Cardiovascular Health
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular Health (4/10) 40%
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