00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A 75-year-old man visits his GP for a follow-up appointment 6 weeks after...

    Correct

    • 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: 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
      77
      Seconds
  • Question 2 - A 55-year-old woman suffers from angina and fibromyalgia. She finds ibuprofen more effective...

    Correct

    • A 55-year-old woman suffers from angina and fibromyalgia. She finds ibuprofen more effective than simple analgesics for her fibromyalgia pain.
      Select from the list the single true statement regarding the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with cardiovascular disease.

      Your Answer: Low-dose ibuprofen and naproxen appear to be associated with a lower cardiovascular risk compared with diclofenac

      Explanation:

      Risks Associated with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

      Non-steroidal anti-inflammatory drugs (NSAIDs) have the potential to increase the risk of thrombotic cardiovascular disease, even with short-term use. This risk applies to all NSAID users, regardless of their baseline risk, and is particularly high in patients with risk factors for cardiovascular events. Observational data suggests that high doses of diclofenac and ibuprofen pose the greatest risk, while naproxen and lower doses of ibuprofen do not have significant cardiovascular risk.

      It is recommended to avoid NSAIDs in patients with cardiovascular disease, and if necessary, to use the lowest effective dose for the shortest possible time. NSAIDs may also counteract the antiplatelet effects of aspirin and increase the risk of gastrointestinal bleeds. Therefore, it is advised to avoid concomitant use and consider prescribing gastroprotection with a proton pump inhibitor if necessary.

      For more information on the risks associated with NSAIDs, please refer to the following link: http://cks.nice.org.uk/nsaids-prescribing-issues#!scenario

    • This question is part of the following fields:

      • Cardiovascular Health
      58.1
      Seconds
  • Question 3 - A 76-year-old female, recently diagnosed with hypertension, presents to the emergency department after...

    Correct

    • A 76-year-old female, recently diagnosed with hypertension, presents to the emergency department after collapsing. She reports feeling dizzy just before the incident and had recently begun a new medication prescribed by her GP. Her medical history includes type II diabetes mellitus, glaucoma, and diverticular disease.

      Which medication is most likely responsible for her symptoms?

      Your Answer: Ramipril

      Explanation:

      First-dose hypotension is a potential side effect of ACE inhibitors like ramipril, which is commonly used as a first-line treatment for hypertension in diabetic patients. If a patient experiences dizziness or lightheadedness, it may be a warning sign of impending syncope.

      Prochlorperazine is not indicated for any of the patient’s medical conditions and is unlikely to cause syncope. Fludrocortisone, on the other hand, can increase blood pressure and is therefore not a likely cause of syncope.

      Metformin is not known to cause hypoglycemia frequently, so it is unlikely to be the cause of the patient’s collapse. While beta-blockers can cause syncope, it is unlikely to occur after the application of eye drops.

      ACE inhibitors are a type of medication that can have side-effects. One common side-effect is a cough, which can occur in around 15% of patients and may happen up to a year after starting treatment. This is thought to be due to increased levels of bradykinin. Another potential side-effect is angioedema, which may also occur up to a year after starting treatment. Hyperkalaemia and first-dose hypotension are also possible side-effects, especially in patients taking diuretics.

      There are certain cautions and contraindications to be aware of when taking ACE inhibitors. Pregnant or breastfeeding women should avoid these medications. Patients with renovascular disease may experience significant renal impairment if they have undiagnosed bilateral renal artery stenosis. Aortic stenosis may result in hypotension, and patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) are at increased risk of hypotension. Individuals with hereditary or idiopathic angioedema should also avoid ACE inhibitors.

      Monitoring is important when taking ACE inhibitors. Urea and electrolytes should be checked before treatment is initiated and after increasing the dose. A rise in creatinine and potassium levels may be expected after starting treatment, but acceptable changes are an increase in serum creatinine up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. It is important to note that different guidelines may have slightly different acceptable ranges for these changes.

    • This question is part of the following fields:

      • Cardiovascular Health
      45.7
      Seconds
  • Question 4 - A 65-year-old male is being evaluated for hypertension associated with type 2 diabetes.

    Currently,...

    Correct

    • A 65-year-old male is being evaluated for hypertension associated with type 2 diabetes.

      Currently, he is taking aspirin 75 mg daily, amlodipine 10 mg daily, and atorvastatin 20 mg daily. However, his blood pressure remains consistently around 160/92 mmHg.

      What antihypertensive medication would you recommend adding to improve this patient's hypertension?

      Your Answer: Ramipril

      Explanation:

      Hypertension Management in Type 2 Diabetes

      This patient with type 2 diabetes has poorly controlled hypertension, but is currently tolerating his medication well. The recommended antihypertensive for diabetes is an ACE inhibitor, which can be combined with a calcium channel blocker like amlodipine. Beta-blockers should be avoided for routine hypertension treatment in diabetic patients. Methyldopa is used for hypertension during pregnancy, while moxonidine is used when other medications have failed. If blood pressure control is still inadequate, a thiazide diuretic can be added to the current regimen of ramipril and amlodipine. Proper management of hypertension is crucial in diabetic patients to prevent complications and improve overall health.

    • This question is part of the following fields:

      • Cardiovascular Health
      45.1
      Seconds
  • Question 5 - What is the only true statement about high blood pressure from the given...

    Correct

    • What is the only true statement about high blood pressure from the given list?

      Your Answer: Treatment of hypertension reduces the risk of coronary heart disease by approximately 20%.

      Explanation:

      Understanding Hypertension: Prevalence, Types, and Treatment

      Hypertension, or high blood pressure, is a common condition that affects both men and women, with its prevalence increasing with age. Essential hypertension, which has no identifiable cause, is the most common type of hypertension, affecting 95% of hypertensive patients. However, indications for further evaluation include resistant hypertension and early, late, or rapid onset of high blood pressure.

      Reducing blood pressure by an average of 12/6 mm Hg can significantly reduce the risk of stroke and coronary heart disease. Salt restriction, alcohol reduction, smoking cessation, aerobic exercise, and weight loss can also help reduce blood pressure by 3-5 mmHg, comparable to some drug treatments.

      In severe cases, hypertension can lead to target organ damage, resulting in a hypertensive emergency. Malignant hypertension, which is diagnosed when papilloedema is present, can cause symptoms such as severe headache, visual disturbance, dyspnoea, chest pain, nausea, and neurological deficit.

      Understanding hypertension and its types is crucial in managing and treating this condition. By implementing lifestyle changes and seeking medical attention when necessary, individuals can reduce their risk of hypertension-related complications.

    • This question is part of the following fields:

      • Cardiovascular Health
      34.7
      Seconds
  • Question 6 - A 67-year-old man with a history of type 2 diabetes mellitus and ischaemic...

    Correct

    • A 67-year-old man with a history of type 2 diabetes mellitus and ischaemic heart disease is experiencing erectile dysfunction. The decision is made to try sildenafil therapy. Is there any existing medication that can be continued without requiring adjustments?

      Your Answer: Nateglinide

      Explanation:

      The BNF advises against using alpha-blockers within 4 hours of taking sildenafil.

      Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.

    • This question is part of the following fields:

      • Cardiovascular Health
      352.5
      Seconds
  • Question 7 - A 50-year-old woman has been diagnosed with an unprovoked proximal deep vein thrombosis....

    Correct

    • A 50-year-old woman has been diagnosed with an unprovoked proximal deep vein thrombosis. What are the available treatment options for this condition?

      Your Answer: Warfarin or Rivaroxaban or Dabigatran or Apixaban

      Explanation:

      Direct oral anticoagulants (DOACs) are medications used to prevent stroke in non-valvular atrial fibrillation (AF), as well as for the prevention and treatment of venous thromboembolism (VTE). To be prescribed DOACs for stroke prevention, patients must have certain risk factors, such as a prior stroke or transient ischaemic attack, age 75 or older, hypertension, diabetes mellitus, or heart failure. There are four DOACs available, each with a different mechanism of action and method of excretion. Dabigatran is a direct thrombin inhibitor, while rivaroxaban, apixaban, and edoxaban are direct factor Xa inhibitors. The majority of DOACs are excreted either through the kidneys or the liver, with the exception of apixaban and edoxaban, which are excreted through the feces. Reversal agents are available for dabigatran and rivaroxaban, but not for apixaban or edoxaban.

    • This question is part of the following fields:

      • Cardiovascular Health
      27.2
      Seconds
  • Question 8 - You are evaluating a 75-year-old patient who has just been diagnosed with heart...

    Correct

    • You are evaluating a 75-year-old patient who has just been diagnosed with heart failure after an echocardiogram revealed a left ventricular ejection fraction of 35%. He has been experiencing mild shortness of breath during physical activity and has no other known medical conditions. He is not currently taking any medications.

      What is the most suitable recommendation to provide?

      Your Answer: Yearly influenza and one off pneumococcal vaccines

      Explanation:

      It is recommended that patients diagnosed with heart failure receive an annual influenza vaccine and a single pneumococcal vaccine.

      The Department of Health recommends that people over the age of 65 and those with certain medical conditions receive an annual influenza vaccination. These medical conditions include chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, chronic neurological disease, diabetes mellitus, immunosuppression, asplenia or splenic dysfunction, and pregnancy. Additionally, health and social care staff, those living in long-stay residential care homes, and carers of the elderly or disabled may also be considered for vaccination at the discretion of their GP.

      The pneumococcal polysaccharide vaccine is recommended for all adults over the age of 65 and those with certain medical conditions. These medical conditions include asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. Asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant. Controlled hypertension is not an indication for vaccination.

    • This question is part of the following fields:

      • Cardiovascular Health
      73.3
      Seconds
  • Question 9 - A 72-year-old woman with a history of ischaemic heart disease visits her General...

    Correct

    • A 72-year-old woman with a history of ischaemic heart disease visits her General Practitioner, reporting light-headedness and difficulty breathing. The doctor observes a slow heart rate and orders an electrocardiogram (ECG) to investigate further. The ECG reveals no correlation between P waves and the QRS complex, with QRS complexes appearing at a rate of 40 bpm.
      What is the most probable underlying diagnosis?

      Your Answer: Complete heart block

      Explanation:

      Different Types of Heart Blocks: A Comparison

      Heart block is a condition where the electrical signals that control the heartbeat are disrupted, leading to an abnormal heart rhythm. There are different types of heart blocks, each with its own characteristic features. Here is a comparison of four types of heart blocks:

      Complete Heart Block:
      In this type of heart block, there is a complete absence of atrioventricular conduction, resulting in no supraventricular impulses being conducted to the ventricles. The perfusing rhythm is maintained by a junctional or ventricular escape rhythm. On the ECG, this appears as a rhythm with regular P waves that are completely unconnected to the rhythm of the QRS complexes. The rate of the QRS complex may be < 45 bpm, and the patient may be overtly symptomatic or haemodynamically unstable. Second-Degree Mobitz Type II Block:
      In this type of heart block, there are intermittent non-conducted P waves without progressive prolongation of the PR interval. A significant proportion of atrial activations will still lead to ventricular activation.

      Atrial Fibrillation:
      In this type of heart block, the ECG will show the absence of P waves and irregularly irregular QRS complexes. The heart rate will usually be normal or high, rather than low, as seen on this ECG.

      First-Degree Heart Block:
      In this type of heart block, the PR interval is prolonged at > 0.2 seconds. However, each atrial activation will still lead to a ventricular activation, with a 1:1 correspondence. On this ECG, there is no correspondence between the P waves and the QRS complex.

      Second-Degree Mobitz Type I Block:
      In this type of heart block, the ECG shows progressive prolongation of the PR interval, culminating in a non-conducted P wave. However, the majority of atrial activations will still lead to ventricular activation.

    • This question is part of the following fields:

      • Cardiovascular Health
      95.5
      Seconds
  • Question 10 - A 65-year-old male on long-term warfarin for atrial fibrillation visits the anticoagulation clinic....

    Correct

    • A 65-year-old male on long-term warfarin for atrial fibrillation visits the anticoagulation clinic. Despite maintaining a stable INR for the past 3 years on the same dose of warfarin, his INR is found to be 5.4. What is the most probable cause of this sudden change?

      Your Answer: Cranberry juice

      Explanation:

      St John’s Wort induces the P450 enzyme system, which results in a decrease in the INR instead of an increase.

      Understanding Warfarin: Mechanism of Action, Indications, Monitoring, Factors, and Side-Effects

      Warfarin is an oral anticoagulant that has been widely used for many years to manage venous thromboembolism and reduce stroke risk in patients with atrial fibrillation. However, it has been largely replaced by direct oral anticoagulants (DOACs) due to their ease of use and lack of need for monitoring. Warfarin works by inhibiting epoxide reductase, which prevents the reduction of vitamin K to its active hydroquinone form. This, in turn, affects the carboxylation of clotting factor II, VII, IX, and X, as well as protein C.

      Warfarin is indicated for patients with mechanical heart valves, with the target INR depending on the valve type and location. Mitral valves generally require a higher INR than aortic valves. It is also used as a second-line treatment after DOACs for venous thromboembolism and atrial fibrillation, with target INRs of 2.5 and 3.5 for recurrent cases. Patients taking warfarin are monitored using the INR, which may take several days to achieve a stable level. Loading regimens and computer software are often used to adjust the dose.

      Factors that may potentiate warfarin include liver disease, P450 enzyme inhibitors, cranberry juice, drugs that displace warfarin from plasma albumin, and NSAIDs that inhibit platelet function. Warfarin may cause side-effects such as haemorrhage, teratogenic effects, skin necrosis, temporary procoagulant state, thrombosis, and purple toes.

      In summary, understanding the mechanism of action, indications, monitoring, factors, and side-effects of warfarin is crucial for its safe and effective use in patients. While it has been largely replaced by DOACs, warfarin remains an important treatment option for certain patients.

    • This question is part of the following fields:

      • Cardiovascular Health
      40.8
      Seconds
  • Question 11 - You assess a 70-year-old man who has been diagnosed with hypertension during his...

    Correct

    • You assess a 70-year-old man who has been diagnosed with hypertension during his annual review for chronic obstructive pulmonary disease (COPD). In the clinic, his blood pressure measures 170/100 mmHg, and you initiate treatment with amlodipine 5mg once daily. What guidance should you provide regarding driving?

      Your Answer: No need to notify DVLA unless side-effects from medication

      Explanation:

      If you have hypertension and belong to Group 1, there is no requirement to inform the DVLA. However, if you belong to Group 2, your blood pressure must consistently remain below 180/100 mmHg.

      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
      45.8
      Seconds
  • Question 12 - A 44-year-old woman has been released from the nearby stroke unit following a...

    Incorrect

    • A 44-year-old woman has been released from the nearby stroke unit following a lacunar ischaemic stroke. She has a history of hypertension and is a smoker who is currently taking lisinopril. However, her discharge medications do not include a statin. What would be the most suitable prescription for initiating statin therapy?

      Your Answer: Simvastatin 40 mg

      Correct Answer: Atorvastatin 80 mg

      Explanation:

      For primary prevention of cardiovascular disease, atorvastatin 20 mg is recommended, while for secondary prevention, the dose is increased to 80 mg. The patient was previously not on statin therapy for primary prevention despite being hypertensive. However, after experiencing a confirmed vascular event, the patient now requires the higher dose of atorvastatin for secondary prevention as per current guidelines. Simvastatin is not the preferred choice for secondary prevention and neither the 40 mg nor the 20 mg dose would be appropriate. Atorvastatin 10 mg is not recommended for secondary prevention, and the 20 mg dose is only licensed for primary prevention. High-intensity statin treatment is recommended for both primary and secondary prevention.

      Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

    • This question is part of the following fields:

      • Cardiovascular Health
      30.2
      Seconds
  • Question 13 - A 67-year-old woman presents to the emergency department with a 3-day history of...

    Incorrect

    • A 67-year-old woman presents to the emergency department with a 3-day history of pain and swelling in her left lower leg. She denies any recent injury.

      Upon examination, you observe that her left calf is swollen and red, measuring 3 cm larger in diameter than the right side. She experiences localised tenderness along the deep venous system.

      Based on your clinical assessment, you suspect a deep vein thrombosis (DVT) and order blood tests, which reveal a D-Dimer level of 900 ng/mL (< 400).

      You initiate treatment with therapeutic doses of apixaban and schedule a proximal leg ultrasound for the next day.

      However, the ultrasound doesn't detect any evidence of a proximal leg DVT.

      What is the most appropriate course of action?

      Your Answer: Continue apixaban and repeat ultrasound in 48 hours

      Correct Answer: Stop apixaban and repeat ultrasound in 7 days

      Explanation:

      Most isolated calf DVTs do not require treatment and resolve on their own, but in some cases, the clot may extend into the proximal veins and require medical intervention.

      Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.

      If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).

      The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.

      All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was

    • This question is part of the following fields:

      • Cardiovascular Health
      120
      Seconds
  • Question 14 - A 61-year-old woman is prescribed statin therapy (rosuvastatin 10 mg daily) for primary...

    Incorrect

    • A 61-year-old woman is prescribed statin therapy (rosuvastatin 10 mg daily) for primary prevention of cardiovascular disease (CVD) due to a QRISK2 assessment indicating a 10-year risk of CVD greater than 10%. Her liver function profile, renal function, thyroid function, and HbA1c were all normal at the start of treatment. According to NICE guidelines, what is the most appropriate initial monitoring plan after starting statin therapy?

      Your Answer: Her liver function and lipid profile should be measured 3 months after statin initiation

      Correct Answer: Her liver function, renal function and HbA1c should be measured 12 months after statin initiation

      Explanation:

      Monitoring Requirements for Statin Treatment

      It is important to monitor patients who are undergoing statin treatment. Even if their liver function tests are normal at the beginning, they should be repeated after three months. At this point, a lipid profile should also be checked to see if the treatment targets have been achieved in terms of non-HDL cholesterol reduction. After 12 months, liver function should be checked again. If it remains normal throughout, there is no need for routine rechecking unless clinically indicated or if the statin dosage is increased. In such cases, liver function should be checked again after three months and after 12 months of the dose change.

    • This question is part of the following fields:

      • Cardiovascular Health
      118.5
      Seconds
  • Question 15 - A 50-year-old man presents for a routine check-up and inquires about the benefits...

    Incorrect

    • A 50-year-old man presents for a routine check-up and inquires about the benefits and drawbacks of taking daily aspirin. He has normal blood pressure and his cholesterol and glucose levels are within normal limits.
      What is the one accurate statement regarding the advantages and disadvantages of aspirin in primary prevention?

      Your Answer: The risk of gastrointestinal bleeding remains constant regardless of duration of aspirin use

      Correct Answer: Aspirin use in primary prevention reduces risk of non-fatal myocardial infarction

      Explanation:

      The Pros and Cons of Aspirin in Primary Prevention

      Aspirin has been found to reduce the risk of myocardial infarction in primary prevention studies. However, this benefit is counterbalanced by an increased risk of gastrointestinal bleeding, which is highest in the first 1-2 years of use but decreases with continued use. Despite this, there is a significant body of evidence indicating that aspirin can reduce the risk of cancer, particularly colorectal cancer, and also lower the risk of metastases. Additionally, stopping aspirin use can lead to a temporary increase in the risk of myocardial infarction. Currently, there is no consensus on whether aspirin or other antiplatelets should be recommended for primary prevention in otherwise healthy patients due to insufficient evidence.

    • This question is part of the following fields:

      • Cardiovascular Health
      101.6
      Seconds
  • Question 16 - A 55-year-old man visits your clinic to request a refill of his sildenafil...

    Incorrect

    • A 55-year-old man visits your clinic to request a refill of his sildenafil prescription, which he has been taking for several years. Upon reviewing his medical history, you discover that he suffered a heart attack four months ago. What course of action should you take?

      Your Answer: Prescribe this as the patient is established on this

      Correct Answer: Do not prescribe as contraindicated

      Explanation:

      Sildenafil use is not recommended for patients who have had a recent myocardial infarction or unstable angina, as stated in both the BNF and NICE guidelines. As the patient in this question had a myocardial infarction just 4 months ago, prescribing sildenafil is contraindicated. Therefore, the answer to this question is do not prescribe.

      Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.

    • This question is part of the following fields:

      • Cardiovascular Health
      43.4
      Seconds
  • Question 17 - An 80-year-old woman presents with a leg ulcer above the right medial malleolus....

    Incorrect

    • An 80-year-old woman presents with a leg ulcer above the right medial malleolus. Compression bandaging is being considered as a treatment option. Without diabetes, what is the minimum ankle-brachial pressure index (ABPI) recommended by SIGN guidelines to ensure the safety of compression bandaging?

      Your Answer: 0.9

      Correct Answer: 0.8

      Explanation:

      It is safe to use compression therapy for patients with leg ulcers who have an ABPI of 0.8 or higher.

      Ankle-Brachial Pressure Index for Evaluating Peripheral Arterial Disease

      The ankle-brachial pressure index (ABPI) is a diagnostic tool used to evaluate peripheral arterial disease (PAD). It measures the ratio of systolic blood pressure in the lower leg to that in the arms. A lower blood pressure in the legs, resulting in an ABPI of less than 1, is an indicator of PAD. This test is particularly useful in evaluating patients with suspected PAD, such as a male smoker who presents with intermittent claudication.

      In addition, it is important to determine the ABPI in patients with leg ulcers. Compression bandaging is often used to treat venous ulcers, but it can be harmful in patients with PAD as it further restricts blood supply to the foot. Therefore, ABPIs should always be measured in patients with leg ulcers to determine if compression bandaging is appropriate.

      The interpretation of ABPI values is as follows: a value greater than 1.2 may indicate calcified, stiff arteries, which can be seen in advanced age or PAD. A value between 1.0 and 1.2 is considered normal, while a value between 0.9 and 1.0 is acceptable. A value less than 0.9 is likely indicative of PAD, and values less than 0.5 indicate severe disease that requires urgent referral. The ABPI is a reliable test, with values less than 0.90 having a sensitivity of 90% and a specificity of 98% for PAD. Compression bandaging is generally considered acceptable if the ABPI is greater than or equal to 0.8.

    • This question is part of the following fields:

      • Cardiovascular Health
      24.5
      Seconds
  • Question 18 - A 72-year-old man presents to the General Practitioner with complaints of leg pain...

    Correct

    • A 72-year-old man presents to the General Practitioner with complaints of leg pain while walking. Upon examination, his feet appear cool and dusky, with the right foot being more affected than the left. An ankle brachial pressure index is measured at 0.8 on the right and 0.9 on the left. Both femoral pulses are present, but posterior tibial and dorsalis pedis pulses are absent in both legs. His blood pressure is 140/85 mmHg.
      Which of the following medications is LEAST likely to provide relief for his symptoms?

      Your Answer: Amlodipine

      Explanation:

      Treatment options for Peripheral Arterial Disease (PAD)

      Peripheral Arterial Disease (PAD) is a condition that causes intermittent claudication. Antiplatelet therapy is recommended for those with symptomatic disease to reduce major cardiovascular events. Clopidogrel is suggested as the drug of first choice by the National Institute for Health and Care Excellence (NICE). Angiotensin converting enzyme inhibitors have been shown to reduce cardiovascular morbidity and mortality in patients with PAD. However, they should be carefully monitored as more than 25% of patients have co-existent renal artery stenosis. Statins are also recommended as they reduce the risk of mortality, cardiovascular events and stroke in patients with PAD. Naftidrofuryl oxalate is an option for the treatment of intermittent claudication in people with PAD for whom vasodilator therapy is considered appropriate. Amlodipine, a calcium channel blocker, is not indicated for this case.

    • This question is part of the following fields:

      • Cardiovascular Health
      133.8
      Seconds
  • Question 19 - A 67-year-old woman presents with exertional breathlessness and heart failure is suspected. She...

    Correct

    • A 67-year-old woman presents with exertional breathlessness and heart failure is suspected. She is not acutely unwell. She has a history of chronic hypertension and takes amlodipine but no other medication.
      An NT-proBNP level is ordered and the result is 962 pg/mL.
      What is the next best course of action in managing her condition?

      Your Answer: Refer urgently for specialist assessment and echocardiography to be seen within 2 weeks

      Explanation:

      Measuring NT-proBNP Levels for Heart Failure Assessment

      Measuring NT-proBNP levels is a useful tool in assessing the likelihood of heart failure and determining the appropriate referral pathway. If the NT-proBNP level is greater than 2000 pg/mL, urgent specialist referral and echocardiography should be conducted within 2 weeks. For NT-proBNP levels between 400 and 2000 pg/mL, referral for specialist assessment and echocardiography should occur within 6 weeks. If the NT-proBNP level is less than 400 pg/mL, heart failure is less likely, but it is still important to consider discussing with a specialist if clinical suspicion persists. By utilizing NT-proBNP levels, healthcare professionals can effectively manage and treat patients with suspected heart failure.

    • This question is part of the following fields:

      • Cardiovascular Health
      87.2
      Seconds
  • Question 20 - A 65-year-old man presents for follow-up at the hypertension clinic. He is currently...

    Incorrect

    • A 65-year-old man presents for follow-up at the hypertension clinic. He is currently on a regimen of amlodipine and ramipril and has no significant medical history. He regularly checks his blood pressure at home and brings in a printed spreadsheet of his readings. What is the recommended target blood pressure for these home measurements?

      Your Answer: <= 130/80 mmHg

      Correct Answer:

      Explanation:

      The threshold for stage 1 hypertension, as measured by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), is a reading of 135/85 mmHg.

      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
      112.7
      Seconds
  • Question 21 - A 52-year-old man is currently on lisinopril, nifedipine and chlorthalidone for his high...

    Correct

    • A 52-year-old man is currently on lisinopril, nifedipine and chlorthalidone for his high blood pressure. During his clinic visit, his blood pressure is measured at 142/88 mmHg and you believe that he requires a higher level of treatment. The patient's blood test results are as follows: Serum Sodium 135 mmol/L (137-144), Serum Potassium 3.6 mmol/L (3.5-4.9), Urea 8 mmol/L (2.5-7.5), and Creatinine 75 µmol/L (60-110). Based on the most recent NICE guidelines on hypertension (NG136), what would be your next course of action?

      Your Answer: Add spironolactone

      Explanation:

      Understanding NICE Guidelines on Hypertension

      Managing hypertension is a crucial aspect of a general practitioner’s role, and it is essential to have a good understanding of the latest NICE guidelines on hypertension (NG136). Step 4 of the guidelines recommends seeking expert advice or adding low-dose spironolactone if the blood potassium level is ≤4.5 mmol/l, and an alpha-blocker or beta-blocker if the blood potassium level is >4.5 mmol/l. If blood pressure remains uncontrolled on optimal tolerated doses of four drugs, expert advice should be sought.

      It is important to note that hypertension management is a topic that may be tested in various areas of the MRCGP exam, including the AKT. Therefore, it is crucial to have a good understanding of the NICE guidelines on hypertension to perform well in the exam. By following the guidelines, general practitioners can provide optimal care to their patients with hypertension.

    • This question is part of the following fields:

      • Cardiovascular Health
      50.4
      Seconds
  • Question 22 - Which beta blocker has been approved for treating heart failure? ...

    Incorrect

    • Which beta blocker has been approved for treating heart failure?

      Your Answer: Bisoprolol

      Correct Answer: Acebutolol

      Explanation:

      Heart Failure Treatment Options

      According to the 2010 update by the National Institute for Health and Care Excellence (NICE), there are several medications that are indicated for the treatment of heart failure. These medications include bisoprolol, metoprolol succinate, carvedilol, and nebivolol. These drugs are commonly used to manage heart failure symptoms and improve overall heart function. It is important to consult with a healthcare provider to determine the best treatment plan for each individual case of heart failure. With proper medication management, individuals with heart failure can experience improved quality of life and better outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
      14.5
      Seconds
  • Question 23 - A 72-year-old woman presents to her GP with breathlessness and leg swelling. She...

    Incorrect

    • A 72-year-old woman presents to her GP with breathlessness and leg swelling. She has heart failure (ejection fraction 33%), rheumatoid arthritis and type 2 diabetes mellitus. Her medications are 7.5mg bisoprolol once daily, 10 mg lisinopril once daily, 20 mg furosemide twice daily, 500mg metformin three times daily and 1g paracetamol four times daily.

      During examination, she has mild bibasal crackles, heart sounds are normal and there is bilateral pedal pitting oedema. Heart rate is 72 beats per minute and regular, respiratory rate is 18 breaths per minute, oxygen saturations are 94% on room air, blood pressure is 124/68 mmHg and her temperature is 36.2oC.

      Bloods from an appointment two weeks previously:

      Na+ 140 mmol/L (135 - 145)
      K+ 4.2 mmol/L (3.5 - 5.0)
      Bicarbonate 23 mmol/L (22 - 29)
      Urea 6.2 mmol/L (2.0 - 7.0)
      Creatinine 114 µmol/L (55 - 120)

      What medication would be most appropriate to initiate?

      Your Answer: Ivabradine

      Correct Answer: Spironolactone

      Explanation:

      For individuals with heart failure with reduced ejection fraction who continue to experience symptoms, it is recommended to add a mineralocorticoid receptor antagonist, such as spironolactone, to their current treatment plan of an ACE inhibitor (or ARB) and beta-blocker. Prior to starting or increasing the dosage of a mineralocorticoid receptor antagonist, it is important to monitor serum sodium, potassium, renal function, and blood pressure. Amiodarone is not typically used as a first line treatment for heart failure and should only be prescribed in consultation with a cardiology specialist. Digoxin may be recommended if heart failure worsens or becomes severe despite initial treatment, but it is important to note that a mineralocorticoid receptor antagonist should be prescribed first. Ivabradine may also be used in heart failure, but it should not be prescribed if the patient’s heart rate is below 75 and is not typically used as a first line treatment.

      Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.

    • This question is part of the following fields:

      • Cardiovascular Health
      140.3
      Seconds
  • Question 24 - A 75-year-old gentleman with type 2 diabetes and angina is seen for review.

    He...

    Incorrect

    • A 75-year-old gentleman with type 2 diabetes and angina is seen for review.

      He has been known to have ischaemic heart disease for many years and has recently seen the cardiologists for outpatient review. Following this assessment he opted for medical management and they have optimised his bisoprolol dose. His current medications consist of:

      Aspirin 75 mg daily

      Ramipril 10 mg daily

      Bisoprolol 10 mg daily

      Simvastatin 40 mg daily, and

      Tadalafil 5 mg daily.

      He reports ongoing angina at least twice a week when out walking which dissipates quickly when he stops exerting himself. You discuss adding in further treatment to try and reduce his anginal symptoms.

      Assuming that his current medication remains unchanged, which of the following is contraindicated in this gentleman as an add-on regular medication?

      Your Answer: Ranolazine

      Correct Answer: Isosorbide mononitrate

      Explanation:

      Contraindication of Co-Prescribing Phosphodiesterase Type 5 Inhibitors and Nitrates

      Phosphodiesterase type 5 inhibitors and nitrates should not be co-prescribed due to the potential risk of life-threatening hypotension caused by excessive vasodilation. It is important to consider whether nitrates are administered regularly or as needed (PRN) when prescribing phosphodiesterase type 5 inhibitors. Patients who take regular daily nitrates, such as oral isosorbide mononitrate twice daily, should avoid phosphodiesterase type 5 inhibitors altogether.

      For patients who use sublingual GTN spray as a PRN nitrate medication, it is recommended to wait at least 24 hours after taking sildenafil or vardenafil and at least 48 hours after taking tadalafil before using GTN spray. This precaution helps to prevent the risk of hypotension and ensures patient safety. Overall, it is crucial to carefully consider the potential risks and benefits of co-prescribing these medications and to follow appropriate guidelines to ensure patient safety.

    • This question is part of the following fields:

      • Cardiovascular Health
      287.1
      Seconds
  • Question 25 - You see a 65-year-old gentleman who you have recently diagnosed with heart failure...

    Incorrect

    • You see a 65-year-old gentleman who you have recently diagnosed with heart failure and an ejection fraction of 35%. You have titrated him up to the maximum dose of ACE-I and his renal function, sodium and potassium have all remained within normal limits for the past three months.

      According to NICE, how often should he now have his treatment monitored?

      Your Answer: Every 3 months

      Correct Answer: No further monitoring required

      Explanation:

      Monitoring ACE-I Treatment

      According to NICE guidelines, it is recommended to monitor ACE-I treatment every 6 months once the maximum tolerated dose has been reached. This ensures that the treatment is still effective and that any potential side effects are identified and managed promptly. Additionally, it is important to review the treatment if the person becomes acutely unwell. This allows for adjustments to be made to the treatment plan as needed. Regular monitoring and review of ACE-I treatment can help improve patient outcomes and prevent complications.

    • This question is part of the following fields:

      • Cardiovascular Health
      99.2
      Seconds
  • Question 26 - A 55-year-old man with type 2 diabetes presents with widespread myalgia and limb...

    Incorrect

    • A 55-year-old man with type 2 diabetes presents with widespread myalgia and limb weakness that has developed over the past few weeks. His simvastatin dose was recently increased from 40 mg to 80 mg per day. A colleague advised him to stop taking the statin and have blood tests taken due to the severity of his symptoms. Upon review, the patient reports some improvement in his symptoms but they have not completely resolved. Blood tests show normal renal, liver, and thyroid function but a creatine kinase level eight times the upper limit of normal. What is the most appropriate course of action in this case?

      Your Answer: As his symptoms have improved he should restart the simvastatin at the previously tolerated dose of 40 mg nocte

      Correct Answer: He should stay off the statin for now, have creatine kinase levels measured fortnightly, and be advised to monitor his symptoms closely until the creatine kinase levels return to normal and the symptoms resolve

      Explanation:

      Management of Statin-Induced Elevated Creatine Kinase Levels

      When a patient taking statins presents with elevated creatine kinase levels, it is important to consider other potential causes such as underlying muscle disorders or hypothyroidism. If the creatine kinase level is more than five times the upper limit of normal, the statin should be stopped immediately and renal function should be checked. Creatine kinase levels should be monitored every two weeks.

      If symptoms resolve and creatine kinase levels return to normal, the statin can be reintroduced at the lowest dose with close monitoring. If creatine kinase levels are less than five times the upper limit of normal and the patient experiences muscular symptoms, the statin can be continued but closely monitored. If symptoms are severe or creatine kinase levels increase, the statin should be stopped.

      If the patient is asymptomatic despite elevated creatine kinase levels, the statin can be continued with the patient advised to report any muscular symptoms immediately. Creatine kinase levels should be monitored to ensure they do not increase. By following these guidelines, healthcare providers can effectively manage statin-induced elevated creatine kinase levels.

    • This question is part of the following fields:

      • Cardiovascular Health
      133.2
      Seconds
  • Question 27 - A 67-year-old man presents for follow-up. Despite being on ramipril 10 mg od,...

    Incorrect

    • A 67-year-old man presents for follow-up. Despite being on ramipril 10 mg od, amlodipine 10 mg od, and indapamide 2.5mg od, his latest blood pressure reading is 168/98 mmHg. He also takes aspirin 75 mg od and metformin 1g bd for type 2 diabetes mellitus. He has a BMI of 34 kg/m², smokes 10 cigarettes/day, and drinks approximately 20 units of alcohol per week. His most recent HbA1c level is 66 mmol/mol (DCCT - 8.2%). What is the most probable cause of his persistent hypertension?

      Your Answer: His alcohol intake

      Correct Answer: His raised body mass index

      Explanation:

      A significant proportion of individuals with resistant hypertension have an underlying secondary cause, such as Conn’s syndrome.

      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
      111.8
      Seconds
  • Question 28 - You have a scheduled telephone consultation with Mrs. O'Brien, a 55-year-old woman who...

    Incorrect

    • You have a scheduled telephone consultation with Mrs. O'Brien, a 55-year-old woman who has been undergoing BP monitoring with the health-care assistant. The health care assistant has arranged the appointment as her readings have been consistently around 150/90 mmHg. Upon reviewing her records, you see that she was prescribed amlodipine due to her Irish ethnicity, and she is taking 10 mg once a day. Her only other medication is atorvastatin 20 mg. The health care assistant has noted in the record that the patient confirms she takes her medications as directed.

      As per NICE guidelines, what is the next step in managing hypertension in Mrs. O'Brien, taking into account her ethnic background?

      Your Answer: Angiotensin-converting enzyme inhibitor

      Correct Answer: Angiotensin II receptor blocker

      Explanation:

      For patients of black African or African–Caribbean origin who are taking a calcium channel blocker for hypertension and require a second medication, it is recommended to consider an angiotensin receptor blocker instead of an ACE inhibitor. An alpha-blocker is typically not a first-line option, while spironolactone may be considered as a fourth-line option. However, the 2019 update to the NICE guidelines on hypertension recommends an ARB as the preferred choice for this patient population.

      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
      77.4
      Seconds
  • Question 29 - A 67-year-old man presents with shortness of breath.
    An ECG shows atrial fibrillation (AF).
    He...

    Correct

    • A 67-year-old man presents with shortness of breath.
      An ECG shows atrial fibrillation (AF).
      He takes digoxin, furosemide, and lisinopril.
      What further drug would improve this patient's outcome?

      Your Answer: Abciximab

      Explanation:

      Prophylactic Therapy for AF Patients with Heart Failure

      The risk of embolic events in patients with heart failure and AF is high, with the risk of stroke increasing up to five-fold in non-rheumatic AF. The most appropriate prophylactic therapy for these patients is with an anticoagulant, such as warfarin.

      According to studies, for every 1,000 patients with AF who are treated with warfarin for one year, 30 strokes are prevented at the expense of six major bleeds. On the other hand, for every 1,000 patients with AF who are treated with aspirin for one year, only 12.5 strokes are prevented at the expense of six major bleeds.

      It is important to note that NICE guidelines on Atrial fibrillation (CG180) recommend warfarin, not aspirin, as the preferred prophylactic therapy for AF patients with heart failure.

    • This question is part of the following fields:

      • Cardiovascular Health
      40.6
      Seconds
  • Question 30 - A 38-year-old man presents to clinic for a routine check-up. He is concerned...

    Incorrect

    • A 38-year-old man presents to clinic for a routine check-up. He is concerned about his risk for heart disease as his father had a heart attack at the age of 50. He reports a non-smoking history, a blood pressure of 128/82 mmHg, and a body mass index of 25 kg/m.

      His recent blood work reveals the following results:

      - Sodium: 142 mmol/L
      - Potassium: 3.8 mmol/L
      - Urea: 5.2 mmol/L
      - Creatinine: 78 mol/L
      - Total cholesterol: 6.8 mmol/L
      - HDL cholesterol: 1.3 mmol/L
      - LDL cholesterol: 4.5 mmol/L
      - Triglycerides: 1.2 mmol/L
      - Fasting glucose: 5.1 mmol/L

      Based on these results, his QRISK2 score is calculated to be 3.5%. What is the most appropriate plan of action for this patient?

      Your Answer: Reassure him that his risk of cardiovascular disease is low

      Correct Answer: Refer him to a specialist lipids clinic

      Explanation:

      The 2014 NICE lipid modification guidelines provide recommendations for familial hyperlipidaemia. Individuals with a total cholesterol concentration above 7.5 mmol/litre and a family history of premature coronary heart disease should be investigated for familial hypercholesterolaemia as described in NICE clinical guideline 71. Those with a total cholesterol concentration exceeding 9.0 mmol/litre or a nonHDL cholesterol concentration above 7.5 mmol/litre should receive specialist assessment, even if they do not have a first-degree family history of premature coronary heart disease.

      Management of Hyperlipidaemia: NICE Guidelines

      Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

    • This question is part of the following fields:

      • Cardiovascular Health
      149
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular Health (15/30) 50%
Passmed