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Question 1
Correct
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You are reviewing a 75-year-old woman.
You saw her several weeks ago with a clinical diagnosis of heart failure and a high brain natriuretic peptide level. You referred her for echocardiography and cardiology assessment. Following the referral she now has a diagnosis of 'Heart failure with reduced ejection fraction'.
Providing there are no contraindications, which of the following combinations of medication should be used as first line treatment in this patient?Your Answer: ACE inhibitor and beta blocker
Explanation:Treatment for Heart Failure with Left Ventricular Systolic Dysfunction
Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers are recommended for patients with heart failure due to left ventricular systolic dysfunction, regardless of their NYHA functional class. The 2003 NICE guidance suggests starting with ACE inhibitors and then adding beta-blockers, but the 2010 update recommends using clinical judgement to determine which drug to start first. For example, a beta-blocker may be more appropriate for a patient with angina or tachycardia. However, combination treatment with an ACE inhibitor and beta-blocker is the preferred first-line treatment for patients with heart failure due to left ventricular dysfunction. It is important to start drug treatment in a stepwise manner and to ensure the patient’s condition is stable before initiating therapy.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Incorrect
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A 50-year-old man presents with complaints of dizziness and syncope. Upon examination, he has a slow-rising pulse and normal blood pressure, with a narrow pulse pressure. An ejection systolic murmur is heard in the aortic area, and an echocardiogram confirms a valvular abnormality. What is the most probable cause of this abnormality in a man of this age?
Your Answer: Rheumatic fever
Correct Answer: Bicuspid aortic valve
Explanation:Understanding the Causes of Aortic Stenosis: A Comparison of Possible Factors
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms and complications. One of the most common causes of aortic stenosis is a bicuspid aortic valve, which affects 1-2% of the population and is more prevalent in males. However, other factors can also contribute to the development of aortic stenosis, including hypertension and hypercholesterolemia. While hypertension is a risk factor for calcific aortic stenosis in both bicuspid and tricuspid valves, it is not the most common cause. On the other hand, hypercholesterolemia doesn’t directly cause aortic stenosis. Another condition that can present similarly to aortic stenosis is obstructive hypertrophic cardiomyopathy, which results from mid-systolic obstruction of flow through the left-ventricular outflow tract. Finally, valvular heart disease due to rheumatic fever is currently uncommon in the UK and is unlikely to be the cause of aortic stenosis in most cases. By understanding the different factors that can contribute to aortic stenosis, healthcare professionals can better diagnose and manage this condition.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Incorrect
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A 60-year-old patient of yours has a persistently high diastolic blood pressure above 90 mmHg.
Ambulatory blood pressure monitoring is not currently available so you decide to check his home blood pressures.
According to NICE what is the minimum number of blood pressure readings a patient should record at home?Your Answer: Three times a day for 4 days
Correct Answer: Twice a day for 4 days
Explanation:NICE Guidelines for Hypertension Monitoring
The management of hypertension is a crucial aspect of general practice, and knowledge of the NICE guidelines is essential for GPs. According to the 2019 NICE guidance on Hypertension (NG136), updated in March 2022, blood pressure should be recorded twice daily for at least four days, ideally for seven days. Two consecutive measurements should be taken for each recording, at least one minute apart, with the person seated. The first day’s measurements should be discarded, and the average value of the remaining measurements used to confirm the diagnosis. Although home readings are acceptable if ambulatory equipment is unavailable, they should not be considered equal to ambulatory monitoring. This question tests your knowledge of the NICE guidelines for hypertension monitoring, which have remained consistent since the earlier guidance (CG127) issued in 2011.
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This question is part of the following fields:
- Cardiovascular Health
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Question 4
Correct
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A 65-year-old man with a history of depression and lumbar spinal stenosis presents with a swollen and painful left calf. He is seen in the DVT clinic and found to have a raised D-dimer. As a result, he undergoes a Doppler scan which reveals a proximal deep vein thrombosis. Despite being active and otherwise healthy, the patient has not had any recent surgeries or prolonged periods of immobility. He is initiated on a direct oral anticoagulant.
What is the appropriate duration of treatment for this patient?Your Answer: 6 months
Explanation:For provoked cases of venous thromboembolism, such as those following recent surgery, warfarin treatment is typically recommended for a duration of three months. However, for unprovoked cases, where the cause is unknown, a longer duration of six months is typically recommended.
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
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This question is part of the following fields:
- Cardiovascular Health
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Question 5
Incorrect
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A 67-year-old man who had a stroke 2 years ago is being evaluated. He was prescribed simvastatin 40 mg for secondary prevention of further cardiovascular disease after his diagnosis. A fasting lipid profile was conducted last week and the results are as follows:
Total cholesterol 5.2 mmol/l
HDL cholesterol 1.1 mmol/l
LDL cholesterol 4.0 mmol/l
Triglyceride 1.6 mmol/l
Based on the latest NICE guidelines, what is the most appropriate course of action?Your Answer: No change in medication, repeat lipid profile in 6 months
Correct Answer: Switch to atorvastatin 80 mg on
Explanation:In 2014, the NICE guidelines were updated regarding the use of statins for primary and secondary prevention. Patients with established cardiovascular disease are now recommended to be treated with Atorvastatin 80 mg. If the LDL cholesterol levels remain high, it is suitable to consider switching the patient’s medication.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 6
Correct
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A 65-year-old man with a history of type 2 diabetes, moderate aortic stenosis, and stage 3b chronic kidney disease presents for hypertension management. His blood pressure in the clinic is 150/90 mmHg, and he has been recording an average of 155/84 mmHg for the past month. He has previously refused antihypertensive medication due to concerns about dizziness and falls. What is the appropriate initial antihypertensive to consider in this case?
Your Answer: Calcium channel blocker
Explanation:Due to the patient’s moderate-severe aortic stenosis, ACE inhibitors are contraindicated and a calcium channel blocker should be prescribed as the first-line treatment for hypertension. Alpha-blockers may be considered later in the treatment algorithm if necessary, typically at step 4 of the guidelines when potassium levels are high. While ACE inhibitors are typically recommended for patients with type 2 diabetes to protect the kidneys, they should not be used in this patient due to their aortic stenosis. Beta-blockers are not the first-line treatment for hypertension and are better suited for heart failure and post-myocardial infarction. They may be considered later in the treatment algorithm if needed, typically at step 4 when potassium levels are high.
Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.
While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.
Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.
The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.
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This question is part of the following fields:
- Cardiovascular Health
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Question 7
Correct
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A 68-year-old man visits his General Practitioner for a check-up. He is taking warfarin for a mechanical aortic valve and has a history of trigeminal neuralgia, depression, and COPD. During an INR check, his INR is found to be subtherapeutic at 1.5. Which drug is most likely to cause a decrease in his INR if co-prescribed with warfarin therapy? Choose ONE answer.
Your Answer: Carbamazepine
Explanation:Interactions with Warfarin: Understanding the Effects of Carbamazepine, Alcohol, Clarithromycin, Prednisolone, and Sertraline
Warfarin is a commonly prescribed anticoagulant medication that requires careful monitoring to ensure its effectiveness and safety. However, several factors can interact with warfarin and affect its metabolism and anticoagulant effect. Here are some examples:
Carbamazepine is a medication used to manage trigeminal neuralgia, but it is also a hepatic enzyme inducer. This means that it can accelerate the metabolism of warfarin, leading to a reduced effect and a decreased international normalized ratio (INR).
Alcohol consumption can enhance the effects of warfarin, which can increase the risk of bleeding. Therefore, patients on warfarin should avoid heavy drinking or binge drinking.
Clarithromycin is an antibiotic that may be prescribed for a COPD exacerbation. However, it is associated with reduced warfarin metabolism and enhanced anticoagulant effect, which can lead to a raised INR.
Prednisolone is a steroid medication that may also be prescribed for a COPD exacerbation. It is associated with an enhanced anticoagulant effect, which can increase the risk of bleeding when taken with warfarin.
Sertraline is an antidepressant medication that belongs to the selective serotonin reuptake inhibitor (SSRI) class. SSRIs have an antiplatelet effect, which can also increase the risk of bleeding when taken with warfarin.
In summary, understanding the interactions between warfarin and other medications or substances is crucial for managing its anticoagulant effect and preventing adverse events. Patients on warfarin should always inform their healthcare providers of any new medications or supplements they are taking to avoid potential interactions.
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This question is part of the following fields:
- Cardiovascular Health
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Question 8
Correct
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A 65-year-old woman presents to the General Practitioner with intermittent cramp-like pain in the buttock, thigh and calf. The symptoms are worse on walking and relieved by rest. She had a stent placed in her coronary artery three years ago. On examination, both legs are of normal colour, but the pedal pulses are difficult to palpate. Sensation is mildly reduced in the right foot.
What is the most suitable course of action?Your Answer: Measure ankle : brachial systolic pressure index
Explanation:Understanding Intermittent Claudication: Diagnosis and Management
Intermittent claudication is a common symptom of peripheral arterial disease. Patients typically experience pain or cramping in their legs during physical activity, which subsides with rest. An ankle-brachial pressure index (ABPI) of less than 0.9 supports the diagnosis, indicating reduced blood flow to the affected limb.
The severity of arterial disease can be assessed using the ABPI, with values under 0.5 indicating severe disease. Exercise can improve walking distance, and patients should be encouraged to continue walking beyond the point of pain. Addressing any risk factors for cardiovascular disease is also important.
Referral to a vascular surgeon may be necessary if symptoms are lifestyle limiting. Magnetic resonance angiography can be used to assess the extent of arterial disease prior to any revascularization procedure. Ultrasonography can help determine the site of disease in peripheral arterial disease.
Bilateral symptoms may indicate neurogenic claudication due to spinal stenosis, which can be confirmed with an MRI scan. Sciatica is also a possible differential diagnosis, particularly if there are sensory changes in the foot. An MRI scan may be useful in such cases.
Overall, understanding the diagnosis and management of intermittent claudication is crucial for effective treatment and improved quality of life for patients.
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This question is part of the following fields:
- Cardiovascular Health
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Question 9
Incorrect
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A 72-year-old man who rarely visits the clinic presents with several weeks of orthopnoea, paroxysmal nocturnal dyspnoea, and swollen ankles. His wife brings him in for examination. On assessment, he has bilateral basal crepitations and a resting heart rate of 110 beats per minute. An ECG shows sinus rhythm. Echocardiography confirms a diagnosis of heart failure. Despite receiving optimal doses of an ACE inhibitor and furosemide, he remains symptomatic and tachycardic.
Which of the following statements is the most accurate regarding his further management?Your Answer:
Correct Answer: He should be started on a beta-blocker
Explanation:The Importance of Beta-Blockers in Heart Failure Management
Heart failure is a serious condition that affects millions of people worldwide. Current guidance recommends the use of beta-blockers in all patients with symptomatic heart failure and an LVEF ≤40%, where tolerated and not contra-indicated. Beta-blockers have been shown to increase ejection fraction, improve exercise tolerance, and reduce morbidity, mortality, and hospital admissions.
It is important to note that beta-blockers should be initiated even if a patient is already stabilized on other drugs. While diuretics can be used to control initial oedema, the mainstay of treatment for heart failure is ACE inhibitors and beta-blockade. Digoxin and spironolactone have a place in heart failure management, but they are not first or second line treatments.
For severe heart failure, biventricular pacing with an implantable defibrillator can be useful. Overall, the use of beta-blockers is crucial in the management of heart failure and should be considered in all eligible patients.
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This question is part of the following fields:
- Cardiovascular Health
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Question 10
Incorrect
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A 68-year-old man presents for follow-up of his atrial fibrillation. He recently underwent catheter ablation for atrial fibrillation and it was successful.
The patient has a medical history of hypertension and type 2 diabetes. His most recent blood pressure reading was 150/92 mmHg.
What is the optimal approach for managing his anticoagulation?Your Answer:
Correct Answer: Continue anticoagulation long-term
Explanation:Patients who have undergone catheter ablation for atrial fibrillation must continue with long-term anticoagulation based on their CHA2DS2-VASc score. According to the guidelines of the American College of Cardiology, the decision to discontinue anticoagulation after two months of catheter ablation should be based on the patient’s stroke risk profile, not on the outcome of the procedure. There is no published evidence that it is safe to stop anticoagulation after ablation if the CHA2DS2-Vasc score is equal to or greater than 1. Therefore, in the given scenario, since the CHA2DS2-VASc score indicates moderate to high risk (3 points), anticoagulation should be continued.
Although monitoring heart rhythm is crucial due to the risk of recurrence, anticoagulation should still be continued even if the patient remains in sinus rhythm. Blood pressure readings do not provide any indication to stop anticoagulation.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 11
Incorrect
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You are assessing a 67-year-old woman with longstanding varicose veins. A couple of weeks ago, she experienced pain and redness around one of them, which resolved after using ibuprofen gel for a few weeks. Upon examination, her legs appear normal except for the varicose veins, and she has normal distal pulses. Based on current NICE guidelines, what is the most suitable next step in management?
Your Answer:
Correct Answer: Routine referral to vascular services
Explanation:Patients with varicose veins and a history of superficial thrombophlebitis should be referred for routine referral to vascular services according to NICE guidance. This condition is usually self-limiting but has a high likelihood of recurrence without treatment. Dermatology is not involved in this condition, and ABPI is usually used in the context of peripheral arterial disease or compression bandaging. Class 2 compression stockings are used in the treatment of varicose veins without complications in primary care.
Understanding Varicose Veins
Varicose veins are enlarged and twisted veins that occur when the valves in the veins become weak or damaged, causing blood to flow backward and pool in the veins. They are most commonly found in the legs and can be caused by various factors such as age, gender, pregnancy, obesity, and genetics. While many people seek treatment for cosmetic reasons, others may experience symptoms such as aching, throbbing, and itching. In severe cases, varicose veins can lead to skin changes, bleeding, superficial thrombophlebitis, and venous ulceration.
To diagnose varicose veins, a venous duplex ultrasound is typically performed to detect retrograde venous flow. Treatment options vary depending on the severity of the condition. Conservative treatments such as leg elevation, weight loss, regular exercise, and compression stockings may be recommended for mild cases. However, patients with significant or troublesome symptoms, skin changes, or a history of bleeding or ulcers may require referral to a specialist for further evaluation and treatment. Possible treatments include endothermal ablation, foam sclerotherapy, or surgery.
In summary, varicose veins are a common condition that can cause discomfort and cosmetic concerns. While many cases do not require intervention, it is important to seek medical attention if symptoms or complications arise. With proper diagnosis and treatment, patients can manage their condition and improve their quality of life.
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This question is part of the following fields:
- Cardiovascular Health
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Question 12
Incorrect
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A 50-year-old woman has a mid-systolic ejection murmur in the third left intercostals space. It radiates into the left arm and shoulder.
Select from the list the single associated symptom that this woman is most likely to have.Your Answer:
Correct Answer: Angina
Explanation:Understanding Symptoms of Aortic Stenosis
Aortic stenosis is a condition where the aortic valve becomes narrowed, leading to restricted blood flow from the heart. One of the most common symptoms of aortic stenosis is a murmur heard in the aortic area. This is often due to calcification of the valve. However, symptoms usually only appear when the stenosis becomes severe.
Patients with aortic stenosis may experience dyspnea on exertion, which is difficulty breathing during physical activity. More concerning symptoms include angina, syncope, or symptoms of heart failure. Angina is caused by left ventricular hypertrophy, while syncope is thought to be due to a failure to increase cardiac output during times of peripheral vasodilation and subsequent hypotension. It’s important to note that drugs that cause peripheral vasodilation, such as nitrates or ACE inhibitors, can increase the risk of syncope.
Dysphagia is a rare complication of left atrial hypertrophy due to mitral valve disease. Palpitations and transient ischemic attacks are not symptoms that are typically associated with aortic stenosis. The most common source of emboli with transient ischemic attacks is the carotids. Vertigo is not caused by aortic stenosis.
In summary, understanding the symptoms of aortic stenosis is crucial for early detection and treatment. If you experience any concerning symptoms, it’s important to speak with your healthcare provider.
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This question is part of the following fields:
- Cardiovascular Health
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Question 13
Incorrect
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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:
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 14
Incorrect
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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:
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 15
Incorrect
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A 63-year-old man is taking warfarin for atrial fibrillation.
Select the single ideal target INR from the options.Your Answer:
Correct Answer: 2.5
Explanation:Recommended INR Levels for Anticoagulation Therapy
Anticoagulation therapy is used to prevent blood clots in individuals with certain medical conditions. The target level for the majority of indications is an INR (international normalized ratio) of 2.5. However, for individuals who are already receiving warfarin and have recurrent deep vein thrombosis or pulmonary embolism, a higher INR of 3.5 is recommended. Additionally, for patients with mechanical prosthetic heart valves, the recommended INR level ranges from 3.0 to 3.5 depending on the type of valve. It is important to closely monitor INR levels and adjust the dosage of anticoagulation therapy as needed to prevent complications.
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This question is part of the following fields:
- Cardiovascular Health
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Question 16
Incorrect
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A 55-year-old man presents to his General Practitioner to discuss the uptitration of his medication as advised by cardiology. He suffered an anterior myocardial infarction (MI) four weeks ago. His history reveals that he is a smoker (20 per day for 30 years) and works in a sedentary office job, where he often works long days and eats ready meals to save time with food preparation.
On examination, his heart rate is 62 bpm and his blood pressure is 126/74 mmHg, body mass index (BMI) is 31. His bisoprolol is increased to 5 mg and ramipril to 7.5 mg.
Which of the following is the single non-pharmacological intervention that will be most helpful in reducing his risk of a future ischaemic event?
Your Answer:
Correct Answer: Stopping smoking
Explanation:Reducing Cardiovascular Risk: Lifestyle Changes to Consider
Cardiovascular disease (CVD) is a leading cause of death worldwide, but many of the risk factors are modifiable through lifestyle changes. The three most important modifiable and causal risk factors are smoking, hypertension, and abnormal lipids. While hypertension and abnormal lipids may require medication to make significant changes, smoking cessation is the single most important non-pharmacological, modifiable risk factor in reducing cardiovascular risk.
In addition to quitting smoking, there are other lifestyle changes that can help reduce cardiovascular risk. A cardioprotective diet should limit total fat intake to 30% or less of total energy intake, with saturated fat intake below 7%. Low-carbohydrate dietary intake is also thought to be important in cardiovascular disease prevention.
Regular exercise is also important, with 150 minutes or more per week of moderate-intensity aerobic activity and muscle-strengthening activities on at least two days a week recommended. While exercise is beneficial, stopping smoking remains the most effective lifestyle change for reducing cardiovascular risk.
Salt restriction can also help reduce risk, with a recommended intake of less than 6 g per day. Patients should be advised to avoid adding salt to their meals and minimize processed foods.
Finally, weight reduction should be advised to decrease future cardiovascular risk, with a goal of achieving a normal BMI. Obese patients should also be assessed for sleep apnea. By making these lifestyle changes, individuals can significantly reduce their risk of developing cardiovascular disease.
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This question is part of the following fields:
- Cardiovascular Health
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Question 17
Incorrect
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A 65-year old man has had syncopal attacks and exertional chest pain which settles spontaneously with rest. He presents to his General Practitioner, not wanting to bother the Emergency Department. On auscultation, there is a loud ejection systolic murmur. Following an electrocardiogram (ECG) he is urgently referred to cardiology and aortic stenosis is diagnosed.
Given the likely diagnosis, which of the following comorbid conditions is most associated with a poor prognosis?
Your Answer:
Correct Answer: Left ventricular failure
Explanation:Understanding Prognostic Factors in Aortic Stenosis
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to limited blood flow and various symptoms such as dyspnea, angina, and syncope. While patients may be asymptomatic for years, the prognosis for symptomatic aortic stenosis is poor, with a 2-year survival rate of only 50%. Sudden deaths can occur due to heart failure or other complications.
Valvular calcification and fibrosis are the primary causes of aortic stenosis, and the presence of calcification doesn’t have a direct impact on prognosis. However, mixed aortic valve disease, which includes aortic regurgitation, can increase mortality rates, particularly in severe cases.
Left ventricular failure is a significant prognostic factor in aortic stenosis, indicating late-stage hypertrophy and fibrosis. Patients with left ventricular failure have a poor prognosis both before and after surgery. Hypertension can also impact left ventricular remodelling and accelerate the progression of aortic stenosis, but it is not as significant a prognostic factor as left ventricular failure.
Electrocardiogram (ECG) changes, such as left ventricular hypertrophy, are common in patients with aortic stenosis but are not directly correlated with mortality risk. Understanding these prognostic factors can help healthcare providers better manage and treat patients with aortic stenosis.
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This question is part of the following fields:
- Cardiovascular Health
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Question 18
Incorrect
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A 30-year-old healthy woman visits her General Practitioner to obtain a health insurance policy. She has no significant medical history, is a non-smoker, and drinks 3 units of alcohol weekly. During examination, a faint systolic murmur is detected. Her ECG shows a heart rate of 68 bpm and is normal. An echocardiogram reveals a bicuspid aortic valve.
What is the most appropriate management option for this patient?Your Answer:
Correct Answer: Referral for heart surgery at a later date
Explanation:Bicuspid Aortic Valve: Risks and Recommendations
Bicuspid aortic valve is a common congenital heart disease in adults, occurring in 1-2% of the population with a familial incidence of around 10%. While some patients may be asymptomatic, about 30% develop complications such as aortic stenosis or insufficiency, which may require surgery. Additionally, the aorta of patients with bicuspid aortic valve has reduced tensile strength, putting them at higher risk for aortic dissection and aneurysm formation in the ascending aorta.
To manage the cardiovascular risk associated with this condition, low-dose aspirin and cholesterol-lowering drugs may be prescribed as appropriate. While there is evidence supporting a familial predisposition, screening for family members is not yet universally recommended. Finally, while infective endocarditis is a potential complication, antibiotic prophylaxis during dental procedures is no longer recommended.
In summary, bicuspid aortic valve requires careful monitoring and management to prevent complications and ensure optimal cardiovascular health.
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This question is part of the following fields:
- Cardiovascular Health
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Question 19
Incorrect
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A 65-year-old Afro-Caribbean woman has a blood pressure of 150/96 mmHg on ambulatory blood pressure testing.
She has no heart murmurs and her chest is clear. Past medical history includes asthma and chronic lymphoedema of the legs.
As per the latest NICE guidance on hypertension (NG136), what would be the most suitable approach to manage her blood pressure in this situation?Your Answer:
Correct Answer: Advise lifestyle changes and repeat in one year
Explanation:NICE Guidance on Antihypertensive Treatment for People Over 55 and Black People of African or Caribbean Family Origin
According to the latest NICE guidance, people aged over 55 years and black people of African or Caribbean family origin of any age should be offered step 1 antihypertensive treatment with a CCB. If a CCB is not suitable due to oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, a thiazide-like diuretic should be offered instead.
This guidance aims to provide effective treatment options for hypertension in these specific populations, taking into account individual circumstances and potential side effects. It is important for healthcare professionals to follow these recommendations to ensure the best possible outcomes for their patients.
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This question is part of the following fields:
- Cardiovascular Health
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Question 20
Incorrect
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A 60-year-old man has been diagnosed with heart failure and his cardiologist recommends starting a beta-blocker along with other medications. He is currently stable hemodynamically. What is the most suitable beta-blocker to use in this case?
Your Answer:
Correct Answer: Bisoprolol
Explanation:Beta-Blockers for Heart Failure: Medications and Contraindications
Heart failure is a serious condition that requires proper management to reduce mortality. Beta-blockers are a class of medications that have been shown to be effective in treating heart failure. Despite some relative contraindications, beta-blockers can be safely initiated in general practice. However, there are still absolute contraindications that should be considered before prescribing beta-blockers, such as asthma, second or third-degree heart block, sick sinus syndrome (without pacemaker), and sinus bradycardia (<50 bpm). Bisoprolol, carvedilol, and nebivolol are all licensed for the treatment of heart failure in the United Kingdom. Among these medications, bisoprolol is the recommended choice and should be started at a low dose of 1.25 mg daily and gradually increased to the maximum tolerated dose (up to 10 mg). Other beta-blockers such as labetalol, atenolol, propranolol, and sotalol have different indications and are not licensed for the treatment of heart failure. Labetalol is mainly used for hypertension in pregnancy, while atenolol is used for arrhythmias, angina, and hypertension. Propranolol is indicated for tachycardia linked to thyrotoxicosis, anxiety, migraine prophylaxis, and benign essential tremor. Sotalol is commonly used to treat atrial and ventricular arrhythmias, particularly atrial fibrillation. In summary, beta-blockers are an important class of medications for the treatment of heart failure. However, careful consideration of contraindications and appropriate medication selection is crucial for optimal patient outcomes.
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This question is part of the following fields:
- Cardiovascular Health
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Question 21
Incorrect
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A patient who started taking simvastatin half a year ago is experiencing muscle aches all over. What is not considered a risk factor for myopathy caused by statins?
Your Answer:
Correct Answer: Large fall in LDL-cholesterol
Explanation: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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 22
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 23
Incorrect
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A 35-year-old woman presents to her General Practitioner with a 3-year history of increasing dyspnoea with strenuous exercise. She has also had occasional chest pain on exertion.
On examination, she has an ejection systolic murmur. Following an examination and electrocardiogram (ECG) in primary care, she is referred for a cardiology review and hypertrophic cardiomyopathy is diagnosed.
Which of the following is the most appropriate screening method for her sister?Your Answer:
Correct Answer: Echocardiography
Explanation:Diagnosing Hypertrophic Cardiomyopathy: Methods and Limitations
Hypertrophic cardiomyopathy (HCM) is a genetic heart condition that can lead to sudden death, especially in young athletes. Diagnosis of HCM is based on the demonstration of unexplained myocardial hypertrophy, which can be detected using two-dimensional echocardiography. However, the criteria for diagnosis vary depending on the patient’s size and family history. Genetic screening is not always reliable, as mutations are only found in 60% of patients. An abnormal electrocardiogram (ECG) is common but nonspecific, while exercise testing and ventilation-perfusion scans have limited diagnostic value. It is important to consider the limitations of these methods when evaluating patients with suspected HCM.
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This question is part of the following fields:
- Cardiovascular Health
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Question 24
Incorrect
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Samantha is a 64-year-old woman who presents to you with a new-onset headache that started 3 weeks ago. Samantha's medical history includes type 2 diabetes and hypercholesterolaemia, and she has a body mass index of 29 kg/m².
During your examination, you measure Samantha's blood pressure which is 190/118 mmHg. A repeat reading shows 186/116 mmHg. Upon conducting fundoscopy, you observe evidence of retinal haemorrhage.
What would be the most appropriate initial management?Your Answer:
Correct Answer: Refer for same-day specialist assessment
Explanation: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
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This question is part of the following fields:
- Cardiovascular Health
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Question 25
Incorrect
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A man attends the surgery for an 'MOT' having just had his 55th birthday. He is keen to reduce his risk of cardiovascular disease and asks about being started on a 'statin'.
He has no significant past medical history and takes no medication. His father had a 'heart attack' aged seventy, but his father was obese and a heavy smoker. There is no other family history of note. There is no suggestion of a familial lipid condition.
What is the most appropriate management approach at this point?Your Answer:
Correct Answer: Optimise adherence to diet and lifestyle measures
Explanation:Primary Prevention of Cardiovascular Disease
This patient has no history of cardiovascular disease (CVD), and therefore, the primary prevention approach is necessary. The first step is to use a CVD risk assessment tool such as QRISK2 to evaluate the patient’s cardiovascular risk. If the patient has a 10% or greater 10-year risk of developing CVD, measuring their lipid profile and offering atorvastatin 20 mg daily would be appropriate. Additionally, providing advice to optimize diet and lifestyle measures is necessary. However, if the patient’s risk is less than 10%, then diet and lifestyle advice/optimization in isolation would be appropriate. At this point, there is no specific indication for lipid clinic input. The use of QRISK2 in this scenario is the best approach as it guides the management, including whether pharmacological treatment with a statin is necessary.
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This question is part of the following fields:
- Cardiovascular Health
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Question 26
Incorrect
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An 80-year-old man who is currently taking warfarin inquires about the feasibility of switching to dabigatran to eliminate the requirement for regular INR testing.
What would be a contraindication to prescribing dabigatran in this scenario?Your Answer:
Correct Answer: Mechanical heart valve
Explanation:Patients with mechanical heart valves should avoid using dabigatran due to its increased risk of bleeding and thrombotic events compared to warfarin. The MHRA has deemed it contraindicated for this population.
Dabigatran: An Oral Anticoagulant with Two Main Indications
Dabigatran is an oral anticoagulant that directly inhibits thrombin, making it an alternative to warfarin. Unlike warfarin, dabigatran doesn’t require regular monitoring. It is currently used for two main indications. Firstly, it is an option for prophylaxis of venous thromboembolism following hip or knee replacement surgery. Secondly, it is licensed for prevention of stroke in patients with non-valvular atrial fibrillation who have one or more risk factors present. The major adverse effect of dabigatran is haemorrhage, and doses should be reduced in chronic kidney disease. Dabigatran should not be prescribed if the creatinine clearance is less than 30 ml/min. In cases where rapid reversal of the anticoagulant effects of dabigatran is necessary, idarucizumab can be used. However, the RE-ALIGN study showed significantly higher bleeding and thrombotic events in patients with recent mechanical heart valve replacement using dabigatran compared with warfarin. As a result, dabigatran is now contraindicated in patients with prosthetic heart valves.
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This question is part of the following fields:
- Cardiovascular Health
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Question 27
Incorrect
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A 42-year-old woman, who is a frequent IV drug user, presents with a 2-week history of intermittent fever and fatigue. During examination, her temperature is 38.5 °C, heart rate 84 bpm and blood pressure 126/72 mmHg. A soft pansystolic murmur is detected along the right sternal margin and there is an area of tenderness and cellulitis in the left groin.
What is the most suitable first step in managing this patient?Your Answer:
Correct Answer: Emergency admission to the hospital
Explanation:Emergency Management of Suspected Infective Endocarditis
Suspected infective endocarditis is a life-threatening condition that requires urgent hospital admission. IV drug use is a major risk factor for this condition, which presents with fever and a new cardiac murmur. Oral therapy is not recommended due to concerns about efficacy, and IV therapy is preferred to ensure adequate dosing and administration. It is important to obtain blood cultures before starting antibiotics to isolate the causative organism. Ultrasound scan for a groin abscess is not necessary as it would not explain the pansystolic murmur on examination. Echocardiography is indicated but should not delay urgent treatment. Early diagnosis and management are crucial to prevent permanent cardiac damage.
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This question is part of the following fields:
- Cardiovascular Health
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Question 28
Incorrect
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A 68-year-old man with lung cancer is diagnosed with deep vein thrombosis. He is seen in the hospital clinic and prescribed a direct oral anticoagulant (DOAC). What would be the best course of treatment?
Your Answer:
Correct Answer: Continue on the DOAC for 3-6 months
Explanation:In 2020, NICE revised their guidance to suggest the use of DOACs for individuals with active cancer who have VTE. Prior to this, low molecular weight heparin was the recommended treatment.
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
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This question is part of the following fields:
- Cardiovascular Health
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Question 29
Incorrect
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A 60-year-old man meets the criteria for initiating statin therapy for CVD prevention. He reports a history of persistent unexplained generalised muscle pains and so a creatine kinase (CK) level is checked on a blood test prior to starting treatment.
The CK result comes back and it is four times the upper limit of normal.
What is the most appropriate management approach in this instance?Your Answer:
Correct Answer: Statin therapy should not be started and a fibrate should be prescribed instead
Explanation:Statin Therapy and Creatine Kinase Levels
Prior to offering a statin, it is recommended to check creatine kinase (CK) levels in individuals with persistent generalised unexplained muscle pain, according to NICE guidelines. If CK levels are more than 5 times the upper limit of normal, statin therapy should not be started. The CK level should be rechecked after 7 days, and if it remains elevated to more than 5 times the upper limit of normal, a statin should not be initiated. However, if CK levels are elevated but less than 5 times the upper limit of normal, statin treatment can be initiated, but a lower dose is recommended. It is important to monitor CK levels in patients receiving statin therapy to ensure that muscle damage is not occurring.
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This question is part of the following fields:
- Cardiovascular Health
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Question 30
Incorrect
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A 65-year-old man comes in for a blood pressure check. His at-home readings have consistently been high at 155/94 mmHg. He reports feeling fine. He is currently on the maximum dose of amlodipine. An echocardiogram done recently showed moderate to severe aortic stenosis.
What is the most suitable course of action for management?Your Answer:
Correct Answer: Add indapamide and review urea and electrolytes and blood pressure in 2 weeks
Explanation:It is not recommended to prescribe ACE inhibitors to patients with moderate-severe aortic stenosis, making ramipril an inappropriate choice. Similarly, angiotensin-II receptor blockers like losartan are also contraindicated. Furosemide is not indicated for hypertension treatment. According to NICE CKS guidance, a combination of thiazide-like diuretics and calcium channel blockers is recommended, making indapamide a suitable alternative to ramipril and losartan. Digoxin has no role in hypertension treatment in this case.
Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.
While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.
Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.
The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.
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This question is part of the following fields:
- Cardiovascular Health
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