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Question 1
Correct
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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: 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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Correct
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A 6-year-old boy is found to have a systolic murmur.
Select from the list the single feature that would be most suggestive of this being an innocent murmur.Your Answer: Heard during a febrile illness
Explanation:Understanding Innocent Heart Murmurs in Children
Innocent heart murmurs are common in children between the ages of 3 and 8 years. They occur when blood flows noisily through a normal heart, usually due to increased blood flow or faster blood movement. Innocent murmurs are typically systolic and vibratory in quality, with an intensity of 2/6 or 1/6. They can change with posture and vary from examination to examination. Harsh murmurs, pansystolic murmurs, late systolic murmurs, and continuous murmurs are usually indicative of pathology. Heart sounds in innocent murmurs are normal, with a split second heart sound in inspiration and a single second heart sound in expiration. It’s important to note that the absence of symptoms doesn’t exclude important pathology, and some murmurs due to congenital heart disease may not be easily audible at birth.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Correct
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A 65-year-old Indian man with recently diagnosed atrial fibrillation is started on warfarin. He visits the GP clinic after 5 days with unexplained bruising. His INR is measured and found to be 4.5. He has a medical history of epilepsy, depression, substance abuse, and homelessness. Which medication is the most probable cause of his bruising from the following options?
Your Answer: Sodium valproate
Explanation:Sodium valproate is known to inhibit enzymes, which can lead to an increase in warfarin levels if taken together. The patient’s medical history could include any of the listed drugs, but the question is specifically testing knowledge of enzyme inhibitors. Rifampicin and St John’s Wort are both enzyme inducers, while heroin (diamorphine) doesn’t have any effect on enzyme activity.
P450 Enzyme System and its Inducers and Inhibitors
The P450 enzyme system is responsible for metabolizing many drugs in the body. Induction of this system occurs when a drug or substance causes an increase in the activity of the P450 enzymes. This process usually requires prolonged exposure to the inducing drug. On the other hand, P450 inhibitors decrease the activity of the enzymes and their effects are often seen rapidly.
Some common inducers of the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking. Smoking affects CYP1A2, which is the reason why smokers require more aminophylline.
In contrast, some common inhibitors of the P450 system include antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, acute alcohol intake, and quinupristin.
It is important to be aware of the potential for drug interactions when taking medications that affect the P450 enzyme system. Patients should always inform their healthcare provider of all medications and supplements they are taking to avoid any adverse effects.
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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 55-year-old man with Tourette's and poorly controlled type 2 diabetes presents to you with concerns about intermittent chest pain on exertion. He drinks 21 units of alcohol per week and smokes 20 cigarettes a day. His father died of a myocardial infarction at the age of 56 years. You refer him for suspected angina, provide advice on what to do if he experiences chest pain, and prescribe a GTN spray for use as needed. While prescribing the GTN spray, you notice a medication on his prescription list that he should avoid taking while being investigated for chest pain or using the GTN spray. What medication is this referring to?
Your Answer: Sildenafil
Explanation:Sildenafil, a type of PDE 5 inhibitor, should not be used together with nitrates and nicorandil due to potential risks of significant hypotension and myocardial infarction. On the other hand, there are no known interactions between nitrates and metformin, gliclazide, sitagliptin, or atorvastatin according to the BNF.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 5
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 6
Correct
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A 45-year-old man is brought to the Emergency Department following a fall. He recalled rushing for the train before feeling dizzy. His father recently died suddenly because of a heart problem. On examination, he has a ‘jerky’ pulse, a thrusting apex beat with double impulse and a late ejection systolic murmur which diminishes on squatting.
What is the most likely diagnosis?Your Answer: Hypertrophic cardiomyopathy
Explanation:Hypertrophic cardiomyopathy is a genetic heart condition that is the leading cause of sudden cardiac death in young people. It is characterized by an enlarged left ventricle, which can cause obstruction of blood flow. A jerky pulse and an intensifying systolic murmur during activities that decrease blood volume in the left ventricle are common examination findings. Aortic stenosis, Brugada syndrome, mitral regurgitation, and mitral valve prolapse are other heart conditions that have different symptoms and examination findings.
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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 32-year-old man complains of palpitations.
Select from the list the single situation in which palpitations will most likely need urgent further investigation.Your Answer: Palpitations accompanied by syncope or near syncope
Explanation:Understanding Palpitations and When to Seek Medical Attention
Palpitations are a common occurrence that can be described as an abnormally perceived heartbeat. While they are usually benign, they can be frightening. A risk stratification system has been developed to determine when urgent referral is necessary. This includes palpitations during exercise, palpitations with syncope or near syncope, a family history of sudden cardiac death or inheritable cardiac conditions, high degree atrioventricular block, and high-risk structural heart disease. However, a history of hypertension is not an indication for urgent referral. Ventricular extrasystoles on an ECG are likely benign unless there is a family history or known structural heart disease. Recurrent episodes of the heart beating fast may indicate a tachyarrhythmia and require routine referral. A normal ECG also warrants routine referral, except for second- and third-degree atrioventricular block, which require urgent referral. It is important to understand when to seek medical attention for palpitations to ensure proper care and treatment.
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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 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 9
Incorrect
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A 32-year-old man presents to the General Practitioner for a consultation. He has been diagnosed with Raynaud's phenomenon and is struggling to manage the symptoms during the colder months. He asks if there are any medications that could help alleviate his condition.
Which of the following drugs has the strongest evidence to support its effectiveness in improving this patient's symptoms?
Your Answer: Aspirin
Correct Answer: Nifedipine
Explanation:Treatment Options for Raynaud’s Phenomenon
Raynaud’s phenomenon is a condition that causes the blood vessels in the fingers and toes to narrow, leading to reduced blood flow and pain. The most commonly used drug for treatment is nifedipine, which causes vasodilatation and reduces the number and severity of attacks. However, patients may experience side-effects such as hypotension, flushing, headache, and tachycardia.
For those who cannot tolerate nifedipine, other agents such as nicardipine, amlodipine, or diltiazem can be tried. Limited evidence suggests that angiotensin receptor-blockers, fluoxetine, and topical nitrates may also provide some benefit. However, there is no evidence to support the use of antiplatelet agents.
In secondary Raynaud’s phenomenon, management of the underlying cause may help alleviate symptoms. Treatment options are similar to primary Raynaud’s phenomenon, with the addition of the prostacyclin analogue iloprost, which has shown to be effective in systemic sclerosis.
Overall, treatment options for Raynaud’s phenomenon aim to improve blood flow and reduce the frequency and severity of attacks. It is important to work with a healthcare provider to find the most effective treatment plan for each individual.
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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 44-year-old man has an irregular tachycardia with a ventricular rate of 130. He played in a football match the previous day and consumed 28 units of alcohol on the evening of the match. On examination his blood pressure is 95/50 mmHg.
Select from the list the single most likely diagnosis.Your Answer: Atrial Flutter
Correct Answer: Atrial fibrillation
Explanation:Common Cardiac Arrhythmias and Their Characteristics
Acute atrial fibrillation is characterized by a sudden onset within the past 48 hours and may be triggered by excessive alcohol or caffeine intake. An ECG is necessary for diagnosis. Atrial flutter is less common than atrial fibrillation and typically presents with a rapid, irregular or regular pulse with a ventricular rate of approximately 150 beats per minute. Extrasystoles are extra heartbeats that disrupt the normal rhythm of the heart and can originate from either the atria or ventricles. Sinus arrhythmia is a common occurrence in children and young adults and involves cyclic changes in heart rate during breathing. Sinus tachycardia is a physiological response to various stimuli such as fever, anxiety, pain, exercise, and hyperthyroidism, and is characterized by a regular heart rate of over 100 beats per minute.
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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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A 35-year-old woman of African origin comes in for a routine health check. She is a non-smoker, drinks 14 units of alcohol per week, is physically fit, active, and enjoys regular moderate exercise and a balanced diet. Her BMI is 26.8 kg/m2. Her average BP measured by home monitoring for 7 days is 160/95.
What is the most suitable initial course of action?Your Answer: Refer for investigation of a secondary cause of hypertension
Correct Answer: Start an ACE inhibitor
Explanation:Treatment Recommendations for Hypertension
Patients diagnosed with hypertension with a blood pressure reading of >150/95 mmHg (stage 2 hypertension) should be offered drug therapy. For patients younger than 55 years, an ACE inhibitor is recommended as the first-line treatment. However, patients over the age of 55 and black patients of any age should initially be treated with a calcium channel blocker or a thiazide diuretic. These recommendations aim to provide effective treatment options for patients with hypertension based on their age and race.
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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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An asymptomatic 63-year-old man is found to have an irregular pulse during a routine check-up. A 12-lead ECG confirms atrial fibrillation. His blood pressure is 130/80 mmHg and his heart rate is 106bpm. He is not taking any regular medications and his blood and urine tests are normal. The physician prescribes bisoprolol to manage his condition.
What is the most appropriate next step in managing this patient's atrial fibrillation?Your Answer: Refer to cardiology for cardioversion
Correct Answer: Do not offer anticoagulation
Explanation:According to NICE guidelines, anticoagulation should be considered for individuals with a CHA2DS2-VASc score of 1 or greater for men and 2 or greater for women to assess stroke risk in atrial fibrillation. As the patient’s score is 1, anticoagulation is not currently indicated. However, this will need to be reassessed if the patient reaches the age of 65 or develops other criteria such as congestive heart failure, hypertension, diabetes mellitus, stroke/TIA, or vascular disease. Direct-acting oral anticoagulants are the first-line choice for anticoagulation in atrial fibrillation, unless contraindicated or not suitable. Low molecular weight heparin is not a suitable choice for anticoagulation in this case. Warfarin may be considered as a second-line option if anticoagulation is required but a direct oral anticoagulant is not suitable or tolerated.
Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.
When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.
For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular Health
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Question 13
Correct
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A 78-year-old gentleman visited his GP last week and was referred for 24 hour ambulatory blood pressure monitoring. The results showed a daytime average of 144/82 mmHg. He is currently taking amlodipine 10 mg once a day and ramipril 10 mg once a day. What would be the best course of action for managing this patient?
Your Answer: Continue current therapy
Explanation:ABPM vs Solitary Clinic Blood Pressure
Note the difference between a solitary clinic blood pressure and ABPM. ABPM stands for ambulatory blood pressure monitoring, which is a method of measuring blood pressure over a 24-hour period. This is different from a solitary clinic blood pressure, which is taken in a medical setting at a single point in time.
For patients over the age of 80, their daytime average ABPM or average HBPM (hospital blood pressure monitoring) blood pressure should be less than 145/85 mmHg. This is according to NICE guidelines, which state that for people under 80 years old, the daytime average ABPM or average HBPM blood pressure should be lower than 135/85 mmHg.
It’s important to note that ABPM targets are different from clinic BP targets. This is because ABPM provides a more accurate and comprehensive picture of a patient’s blood pressure over a 24-hour period, rather than just a single reading in a medical setting. By using ABPM, healthcare professionals can better monitor and manage a patient’s blood pressure, especially for those over the age of 80.
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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 54-year-old man has scheduled a meeting to discuss his struggles with poor concentration and feeling sleepy while working. He works as a truck driver and frequently has to operate heavy machinery. His spouse has noticed that he experiences brief pauses in breathing while sleeping at night and occasionally makes choking sounds.
The patient is currently receiving treatment for hypertension and benign prostatic hyperplasia. His Epworth sleepiness scale score is 16.
Considering his condition, what is the best course of action for the patient to take regarding operating heavy machinery?Your Answer: He is required to inform the DVLA but can continue driving
Correct Answer: He is required to inform the DVLA and stop driving
Explanation:If a person has mild, moderate, or severe obstructive sleep apnoea (OSA) that causes excessive daytime sleepiness, they must inform the Driver Vehicle and Licensing Agency (DVLA). Excessive sleepiness refers to sleepiness that can negatively impact driving. The severity of OSA is determined by the number of apnoea/hypopnoea episodes per hour (apnoea-hypopnoea index [AHI]). Mild OSA is defined as an AHI of 5-14 per hour, moderate OSA is an AHI of 15-30 per hour, and severe OSA is an AHI of more than 30 per hour. If a person is diagnosed with OSA and experiences enough sleepiness to impair driving, they must inform the DVLA and stop driving. In this case, there is no need to retake a driving assessment, and the GP will not inform the DVLA initially. However, if the patient fails to inform the DVLA after multiple reminders and being informed that the GP may break confidentiality, the GP will inform the DVLA. If a person is being investigated for or has a diagnosis of OSA but doesn’t experience daytime sleepiness severe enough to impair driving, they do not need to inform the DVLA or stop driving. If a person is successfully using continuous positive airway pressure (CPAP) or an intra-oral device and their symptoms are controlled to the point where they no longer impair driving, they should inform the DVLA but do not need to stop driving.
Understanding Obstructive Sleep Apnoea/Hypopnoea Syndrome
Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a condition that causes interrupted breathing during sleep due to a blockage in the airway. This can lead to a range of health problems, including daytime somnolence, respiratory acidosis, and hypertension. There are several predisposing factors for OSAHS, including obesity, macroglossia, large tonsils, and Marfan’s syndrome. Partners of those with OSAHS often complain of excessive snoring and periods of apnoea.
To assess sleepiness, patients may complete the Epworth Sleepiness Scale questionnaire, and undergo the Multiple Sleep Latency Test (MSLT) to measure the time it takes to fall asleep in a dark room. Diagnostic tests for OSAHS include sleep studies (polysomnography), which measure a range of physiological factors such as EEG, respiratory airflow, thoraco-abdominal movement, snoring, and pulse oximetry.
Management of OSAHS includes weight loss and the use of continuous positive airway pressure (CPAP) as a first-line treatment for moderate or severe cases. Intra-oral devices, such as mandibular advancement, may be used if CPAP is not tolerated or for patients with mild OSAHS without daytime sleepiness. It is important to inform the DVLA if OSAHS is causing excessive daytime sleepiness. While there is limited evidence to support the use of pharmacological agents, they may be considered in certain cases.
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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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What is the typical target INR for a patient with a mechanical aortic valve?
Your Answer: 2.5
Correct Answer: 3.5
Explanation:The recommended target INR for mechanical valves is 3.0 for aortic valves and 3.5 for mitral valves.
Prosthetic Heart Valves: Options and Considerations
Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.
It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.
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This question is part of the following fields:
- Cardiovascular Health
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Question 16
Correct
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A 60-year-old man presents to his General Practitioner complaining of shortness of breath during physical activity. He has a medical history of hypertension and has experienced a STEMI in the past. Upon examination, his pulse is 68 beats per minute, his blood pressure is 122/72 mmHg, and he displays bilateral pitting ankle edema. Which medication is most likely to decrease mortality in this patient? Choose ONE answer.
Your Answer: Bisoprolol
Explanation:This man is experiencing heart failure due to ischaemic heart disease, which is a leading cause of death among men in the UK. Beta-blockers are the only medication proven to reduce all-cause mortality in patients with heart failure with reduced ejection fraction, and they can also help control hypertension. However, before starting treatment, his blood pressure and pulse should be checked to ensure that he is not at risk of bradycardia or hypotension. Spironolactone is not recommended for improving mortality in heart failure patients, but it can be used to treat hypertension and oedema. U&Es should be monitored regularly to avoid renal function deterioration and hyperkalaemia. Amlodipine and furosemide have not been shown to improve mortality in heart failure patients, but they can be used to control hypertension and oedema, respectively. U&Es should also be monitored regularly when using these medications. Ramipril has been shown to reduce hospital admissions in heart failure patients, but it can impair renal function and cause hyperkalaemia. U&Es should be checked regularly, and the medication should not be initiated if the patient’s potassium level is too high. Patients should also be advised to stop taking ramipril during diarrhoea or vomiting illnesses to avoid dehydration and acute kidney injury.
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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 70-year-old man with a history of hypertension only complains of worsening breathlessness and swollen ankles for the past 3 months. You plan to conduct a BNP test. What could cause a falsely low BNP result in this patient?
Your Answer: A high protein meal 6 hours before the blood test
Correct Answer: Being on ramipril for his blood pressure
Explanation:Serum levels of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) can be measured to assess the likelihood of heart failure in patients. NT-proBNP is the inactive prohormone of BNP and is released from the left ventricle in response to ventricular strain. It acts to increase renal excretion of water and sodium, and relax vascular smooth muscle causing vasodilation.
BNP measurements are recommended for patients with suspected heart failure who have not had a previous myocardial infarction. Elevated BNP levels (>400) indicate a poor prognosis and require an urgent referral for echocardiography and specialist assessment. However, normal BNP levels do not confirm the absence of heart failure, as levels may be elevated due to other conditions such as left ventricular hypertrophy, pulmonary hypertension, or renal impairment.
NICE guidelines suggest that BNP measurements are not necessary for patients with suspected heart failure who have had a previous myocardial infarction, as urgent referral and assessment are required regardless of BNP levels. BNP levels may also be affected by medications such as ACE inhibitors and beta-blockers, as well as obesity.
Overall, BNP measurements can be a useful tool in assessing the likelihood of heart failure, but should be interpreted in conjunction with other clinical findings and patient history.
B-type natriuretic peptide (BNP) is a hormone that is primarily produced by the left ventricular myocardium in response to strain. Although heart failure is the most common cause of elevated BNP levels, any condition that causes left ventricular dysfunction, such as myocardial ischemia or valvular disease, may also raise levels. In patients with chronic kidney disease, reduced excretion may also lead to elevated BNP levels. Conversely, treatment with ACE inhibitors, angiotensin-2 receptor blockers, and diuretics can lower BNP levels.
BNP has several effects, including vasodilation, diuresis, natriuresis, and suppression of both sympathetic tone and the renin-angiotensin-aldosterone system. Clinically, BNP is useful in diagnosing patients with acute dyspnea. A low concentration of BNP (<100 pg/mL) makes a diagnosis of heart failure unlikely, but elevated levels should prompt further investigation to confirm the diagnosis. Currently, NICE recommends BNP as a helpful test to rule out a diagnosis of heart failure. In patients with chronic heart failure, initial evidence suggests that BNP is an extremely useful marker of prognosis and can guide treatment. However, BNP is not currently recommended for population screening for cardiac dysfunction.
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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 65-year-old lady presents with a brief history of sudden onset severe left lower limb pain lasting for three hours. The pain started while she was at rest and there was no history of injury or any previous leg or calf pain.
Upon examination, her pulse rate is irregular and measures 92 bpm. The left lower limb is cold and immobile with decreased sensation. No pulses can be felt from the level of the femoral pulse downwards in the left leg, but all pulses are palpable on the right. There are no abdominal masses or bruits, and chest auscultation is normal.
What is the probable diagnosis?Your Answer: Embolus
Correct Answer: Sciatica
Explanation:Acute Limb Ischaemia: Causes and Symptoms
Acute limb ischaemia is a condition characterized by a painful, paralysed, and pulseless limb that feels perishingly cold with paraesthesia. This condition is usually caused by either an embolus or thrombotic occlusion, which can occur on the background of intermittent claudication (chronic limb ischaemia). In most cases, the likely cause of acute limb ischaemia is an embolism secondary to atrial fibrillation. Other sources of emboli include defective heart valves, cardiac mural thrombi, and thrombus from within an aortic aneurysm.
If a patient presents with a painful, paralysed, and pulseless limb, an echocardiogram, abdominal ultrasound, and duplex of proximal limb vessels are indicated. These tests can help identify the underlying cause of the condition. It is important to note that acute limb ischaemia is a medical emergency that requires immediate attention. Delayed treatment can lead to irreversible tissue damage and even limb loss.
In summary, acute limb ischaemia is a serious condition that requires prompt diagnosis and treatment. Patients with this condition should seek medical attention immediately to prevent irreversible tissue damage and limb loss.
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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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Which of the following statements about the cause of venous thromboembolism (VTE) is accurate?
Your Answer: Female gender is a risk factor recurrent VTE
Correct Answer: Tamoxifen therapy increases the risk of VTE
Explanation:Risk Factors for Venous Thromboembolism
Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While some common predisposing factors include malignancy, pregnancy, and the period following an operation, there are many other factors that can increase the risk of VTE. These include underlying conditions such as heart failure, thrombophilia, and nephrotic syndrome, as well as medication use such as the combined oral contraceptive pill and antipsychotics. It is important to note that around 40% of patients diagnosed with a PE have no major risk factors. Therefore, it is crucial to be aware of all potential risk factors and take appropriate measures to prevent VTE.
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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 65-year-old lady is on warfarin for stroke prevention in atrial fibrillation. She comes in with a significantly elevated INR. Which of the following drugs is the most probable cause?
Your Answer: Carbamazepine
Correct Answer: Ciprofloxacin
Explanation:Drug Interactions with Warfarin
Ciprofloxacin, a cytochrome p450 inhibitor, can prolong the half-life of warfarin and increase the international normalized ratio (INR). However, the reaction is not always predictable, and susceptibility may be influenced by factors such as fever, infection, or malnutrition. While aspirin is known to increase the risk of bleeding due to its antiplatelet activity, it doesn’t have a clear relationship with INR.
Drugs that are metabolized in the liver can induce hepatic microsomal enzymes, which can increase the rate of metabolism of another drug, resulting in lower plasma concentrations and a reduced effect. St. John’s wort is an enzyme inducer and can increase the metabolism of warfarin, making it less effective. It is important to be aware of potential drug interactions with warfarin to ensure its effectiveness and prevent adverse effects.
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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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You see a 50-year-old type one diabetic patient who has come to see you regarding his erectile dysfunction. He reports a gradual decline in his ability to achieve and maintain erections over the past 6 months. After reviewing his medications and discussing treatment options, you suggest he try a phosphodiesterase (PDE-5) inhibitor and prescribe him sildenafil.
What advice should you give this patient regarding taking a PDE-5 inhibitor?Your Answer: Of the available PDE-5 inhibitors, this patient can only get sildenafil on an NHS prescription
Correct Answer: Sexual stimulation is required to facilitate an erection
Explanation:PDE-5 inhibitors do not cause an erection on their own, but rather require sexual stimulation to assist in achieving an erection. They are typically the first choice for treating erectile dysfunction, as long as there are no contraindications.
The primary cause of ED is often vasculogenic, such as cardiovascular disease, which means that the same lifestyle and risk factors that apply to CVD also apply to ED. Treatment for ED typically involves a combination of lifestyle changes and medication. It is important to advise patients to lose weight, quit smoking, reduce alcohol consumption, and increase exercise. Lifestyle changes and risk factor modification should be implemented before or alongside treatment.
Generic sildenafil is available on the NHS without restrictions. Additionally, other PDE-5 inhibitors may be prescribed on the NHS for certain medical conditions, such as diabetes.
For most men, as-needed treatment with a PDE-5 inhibitor is appropriate. The frequency of treatment will depend on the individual.
Sildenafil should be taken one hour before sexual activity and requires sexual stimulation to facilitate an erection.
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.
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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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You have a phone review scheduled with Mrs. Johansson, a 55-year-old woman who has recently been diagnosed with hypertension, which had been detected during a routine check-up. Subsequent ambulatory home blood pressure monitoring showed an average home BP of 148/84 mmHg.
You arranged an ECG, urine albumin-creatinine ratio (ACR), and some blood tests, and scheduled the appointment to discuss the findings. The ACR and blood tests are within normal limits. The ECG shows sinus rhythm with a rate of 70 beats per minute. You entered her cholesterol results into a cardiovascular risk calculator, which estimates a 10-year CV risk of 6.5%.
What is the appropriate management plan for her hypertension?Your Answer: Lifestyle advice and monitor annually
Correct Answer: Lifestyle advice, and discuss commencing a calcium-channel blocker
Explanation:Consider medication for stage 1 hypertension in patients aged 60 or under, but for those aged 55 or over, a calcium channel blocker is the first-line option. Lifestyle advice should also be given. Referral to cardiology is not necessary at this stage.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 23
Correct
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A 29-year-old female patient complains of intermittent episodes of white fingers that turn blue and then red, accompanied by pain. The symptoms are more severe during winter but persist throughout the year, and wearing gloves doesn't alleviate them. Physical examination of her hands, skin, and other joints reveals no abnormalities. Which of the following treatments might be helpful?
Your Answer: Nifedipine
Explanation:Raynaud’s phenomenon is a condition where the arteries in the fingers and toes constrict excessively in response to cold or emotional stress. It can be classified as primary (Raynaud’s disease) or secondary (Raynaud’s phenomenon) depending on the underlying cause. Raynaud’s disease is more common in young women and typically affects both sides of the body. Secondary Raynaud’s phenomenon is often associated with connective tissue disorders such as scleroderma, rheumatoid arthritis, or systemic lupus erythematosus. Other causes include leukaemia, cryoglobulinaemia, use of vibrating tools, and certain medications.
If there is suspicion of secondary Raynaud’s phenomenon, patients should be referred to a specialist for further evaluation. Treatment options include calcium channel blockers such as nifedipine as a first-line therapy. In severe cases, intravenous prostacyclin (epoprostenol) infusions may be used, which can provide relief for several weeks or months. It is important to identify and treat any underlying conditions that may be contributing to the development of Raynaud’s phenomenon. Factors that suggest an underlying connective tissue disease include onset after 40 years, unilateral symptoms, rashes, presence of autoantibodies, and digital ulcers or calcinosis. In rare cases, chilblains may also be present.
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This question is part of the following fields:
- Cardiovascular Health
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Question 24
Correct
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A 65-year-old man presents with symptoms of intermittent claudication and is referred to the local vascular unit. Peripheral arterial disease is diagnosed and his blood pressure is measured at 130/80 mmHg with a fasting cholesterol level of 3.9 mmol/l. According to the latest NICE guidelines, what medication should be prescribed for this patient?
Your Answer: Clopidogrel + statin
Explanation:Managing Peripheral Arterial Disease
Peripheral arterial disease (PAD) is closely associated with smoking, and patients who still smoke should be provided with assistance to quit. Comorbidities such as hypertension, diabetes mellitus, and obesity should also be treated. All patients with established cardiovascular disease, including PAD, should be taking a statin, with atorvastatin 80 mg currently recommended. In 2010, NICE recommended clopidogrel as the first-line treatment for PAD patients over aspirin.
Exercise training has been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions. Severe PAD or critical limb ischaemia may be treated with endovascular or surgical revascularization, with endovascular techniques typically used for short segment stenosis, aortic iliac disease, and high-risk patients. Surgical techniques are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery.
Drugs licensed for use in PAD include naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life, and cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, which is not recommended by NICE.
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This question is part of the following fields:
- Cardiovascular Health
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Question 25
Correct
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A 58-year-old man presents to the rapid access transient ischaemic attack clinic after experiencing three episodes of transient left-sided weakness in the past two weeks. What advice should be given regarding driving?
Your Answer: Cannot drive for 3 months
Explanation:DVLA guidance following multiple TIAs: driving prohibited for a period of 3 months.
The DVLA has guidelines for individuals with neurological disorders who wish to drive cars or motorcycles. However, the rules for drivers of heavy goods vehicles are much stricter. For individuals with epilepsy or seizures, they must not drive and must inform the DVLA. If an individual has had a first unprovoked or isolated seizure, they must take six months off driving if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met, the time off driving is increased to 12 months. Individuals with established epilepsy or those with multiple unprovoked seizures may qualify for a driving license if they have been free from any seizure for 12 months. If there have been no seizures for five years (with medication if necessary), a ’til 70 license is usually restored. Individuals should not drive while anti-epilepsy medication is being withdrawn and for six months after the last dose.
For individuals with syncope, a simple faint has no restriction on driving. A single episode that is explained and treated requires four weeks off driving. A single unexplained episode requires six months off driving, while two or more episodes require 12 months off. For individuals with other conditions such as stroke or TIA, they must take one month off driving. They may not need to inform the DVLA if there is no residual neurological deficit. If an individual has had multiple TIAs over a short period of time, they must take three months off driving and inform the DVLA. For individuals who have had a craniotomy, such as for meningioma, they must take one year off driving. If an individual has had a pituitary tumor, a craniotomy requires six months off driving, while trans-sphenoidal surgery allows driving when there is no debarring residual impairment likely to affect safe driving. Individuals with narcolepsy/cataplexy must cease driving on diagnosis but can restart once there is satisfactory control of symptoms. For individuals with chronic neurological disorders such as multiple sclerosis or motor neuron disease, they should inform the DVLA and complete the PK1 form (application for driving license holders’ state of health). If the tumor is a benign meningioma and there is no seizure history, the license can be reconsidered six months after surgery if the individual remains seizure-free.
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This question is part of the following fields:
- Cardiovascular Health
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Question 26
Correct
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A 60-year-old woman with suspected heart failure undergoes open-access Doppler echocardiography and is diagnosed with heart failure with reduced ejection fraction. She has experienced increased shortness of breath since the diagnosis and now requires four pillows to sleep comfortably. Which medication is most likely to provide the quickest relief of symptoms for this patient?
Your Answer: Furosemide
Explanation:Medications for Heart Failure: Understanding the Recommendations
Heart failure is a serious condition that requires careful management. When it comes to medication, it’s important to understand which drugs are recommended and when they should be prescribed. Here’s a breakdown of some common medications and their appropriate use in heart failure treatment:
Furosemide: This loop diuretic is recommended by the National Institute for Health and Care Excellence (NICE) for patients with symptoms of fluid overload. The dose should be adjusted based on symptoms and reviewed regularly.
Spironolactone: While this aldosterone antagonist can be considered for all patients, NICE advises that it should only be added if symptoms persist despite optimal treatment with an ACE inhibitor and beta-blocker. Referral to a specialist may be necessary.
Carvedilol: This beta-blocker is indicated for heart failure, but it won’t provide rapid symptom relief. It may even worsen symptoms if given while there are still signs of fluid overload.
Digoxin: This drug has a limited role in heart failure management and should not be routinely prescribed. It may be helpful for patients in normal sinus rhythm.
Ramipril: An ACE inhibitor should be prescribed routinely, but it should not be initiated in patients with suspected valve disease until a specialist has assessed the condition. An angiotensin-II receptor antagonist is an alternative if the ACE inhibitor is not tolerated.
Understanding the appropriate use of these medications can help improve outcomes for patients with heart failure.
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This question is part of the following fields:
- Cardiovascular Health
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Question 27
Correct
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A 47-year-old man has recently been prescribed apixaban by his haematologist after experiencing a pulmonary embolism. He is currently taking other medications for his co-existing conditions. Can you identify which of his medications may potentially interact with apixaban?
Your Answer: Carbamazepine
Explanation:If anticoagulation is being used for deep vein thrombosis or pulmonary embolism, the British National Formulary recommends avoiding the simultaneous use of apixaban and carbamazepine. This is because carbamazepine may lower the plasma concentration of apixaban. No interactions have been identified between apixaban and the other options listed.
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.
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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 59-year-old male is referred to you from the practice nurse after an ECG shows he is in atrial fibrillation.
When you take a history from him he complains of palpitations and he has also noticed some weight loss over the last two months. On examination, he has an irregularly irregular pulse and displays a fine tremor.
What is the next most appropriate investigation to perform?Your Answer: Thyroid function tests
Correct Answer: Exercise tolerance test
Explanation:Assessing Patients with Atrial Fibrillation
When assessing patients with atrial fibrillation, it is crucial to identify any underlying causes. While some cases may be classified as lone AF, addressing any precipitating factors is the first step in treatment. Hyperthyroidism is a common cause of atrial fibrillation, and checking thyroid function tests is the next appropriate step in diagnosis. Other common causes include heart failure, myocardial infarction/ischemia, mitral valve disease, pneumonia, and alcoholism. Rarer causes include pericarditis, endocarditis, cardiomyopathy, sarcoidosis, and hemochromatosis.
For paroxysmal arrhythmias, a 24-hour ECG can be useful, but in cases of persistent atrial fibrillation, an ECG is not necessary. Exercise tolerance tests are used to investigate and risk-stratify patients with cardiac chest pain. While an echocardiogram is useful in patients with atrial fibrillation to look for valve disease and other structural abnormalities, it is not the next most appropriate investigation in this case. Overall, identifying the underlying cause of atrial fibrillation is crucial in determining the appropriate treatment plan.
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This question is part of the following fields:
- Cardiovascular Health
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Question 29
Correct
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A 58-year-old man with a history of hypertension experiences sudden onset of severe chest pain, radiating to the back and left shoulder. On examination, he is hemiplegic, with pallor and sweating. His heart rate is 120 bpm and his blood pressure is 174/89 mmHg, but 153/72 mmHg when measured on the opposite arm.
What is the most probable diagnosis?Your Answer: Dissection of the thoracic aorta
Explanation:Differential diagnosis of hemiplegia in a patient with chest pain
Aortic dissection, myocardial infarction, intracranial haemorrhage, ruptured thoracic aneurysm, and ruptured ventricular aneurysm are among the possible causes of chest pain and hemiplegia in a patient with a history of hypertension. Aortic dissection is the most likely diagnosis, given the abrupt onset and maximal severity of chest pain at onset, as well as the potential for carotid involvement and limb blood pressure differences. Myocardial infarction may also cause chest pain but is less likely to present with hemiplegia. Intracranial haemorrhage may cause hemiplegia but is more likely to present with a headache. Ruptured thoracic aneurysm may cause acute chest, back, or neck pain, but is unlikely to cause hemiplegia. Ruptured ventricular aneurysm is a complication of myocardial infarction but typically doesn’t rupture. A careful differential diagnosis is essential for appropriate management and prognosis.
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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 73-year-old man who underwent bioprosthetic aortic valve replacement three years ago is being evaluated. What type of antithrombotic treatment is he expected to be receiving?
Your Answer: Aspirin + clopidogrel
Correct Answer: Aspirin
Explanation:For patients with prosthetic heart valves, antithrombotic therapy varies depending on the type of valve. Bioprosthetic valves typically require aspirin, while mechanical valves require a combination of warfarin and aspirin.
Prosthetic Heart Valves: Options and Considerations
Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.
It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.
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This question is part of the following fields:
- Cardiovascular Health
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Question 31
Incorrect
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A 67-year-old man presents for follow-up. He has a medical history of small cell lung cancer and ischemic heart disease. His cancer was detected five months ago and he recently finished a round of chemotherapy. In terms of his heart health, he experienced a heart attack two years ago and underwent primary angioplasty with stent placement. He has not had any angina since then.
Over the past week, he has been experiencing increasing shortness of breath, particularly at night, and has an occasional non-productive cough. He has also noticed that his wedding ring feels tight. Upon examination, his chest appears normal, but he does have distended neck veins and periorbital edema. What is the most probable diagnosis?Your Answer: Heart failure secondary to chemotherapy
Correct Answer: Superior vena cava obstruction
Explanation:Understanding Superior Vena Cava Obstruction
Superior vena cava obstruction is a medical emergency that occurs when the superior vena cava, a large vein that carries blood from the upper body to the heart, is compressed. This condition is commonly associated with lung cancer, but it can also be caused by other malignancies, aortic aneurysm, mediastinal fibrosis, goitre, and SVC thrombosis. The most common symptom of SVC obstruction is dyspnoea, but patients may also experience swelling of the face, neck, and arms, headache, visual disturbance, and pulseless jugular venous distension.
The management of SVC obstruction depends on the underlying cause and the patient’s individual circumstances. Endovascular stenting is often the preferred treatment to relieve symptoms, but certain malignancies may require radical chemotherapy or chemo-radiotherapy instead. Glucocorticoids may also be given, although the evidence supporting their use is weak. It is important to seek advice from an oncology team to determine the best course of action for each patient.
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This question is part of the following fields:
- Cardiovascular Health
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Question 32
Incorrect
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A man of 65 comes to see you with a suspected fungal nail infection.
You notice he has not had his blood pressure taken for many years. The lowest reading observed is 175/105 mmHg. Fundoscopy is normal and his pulse is of normal rate and rhythm. He is otherwise well.
With reference to the latest NICE guidance on Hypertension (NG136), what is your next action?Your Answer: Refer to hospital to be seen the same day
Correct Answer: Repeat his blood pressure in a month
Explanation:Management of Hypertension in Primary Care
Referring a patient to the hospital for hypertension without suspicion of accelerated hypertension is inappropriate. According to the updated NICE guidelines on Hypertension (NG136) in September 2019, immediate treatment should only be considered if the blood pressure is equal to or greater than 180/120 mmHg. In this case, it is recommended to bring the patient back for ambulatory monitoring or record their home blood pressure readings for at least four days. Repeating blood pressure with the nurse is no longer preferred, as ambulatory or home readings are considered better. The presence of a fungal nail infection is irrelevant, but it may be necessary to check the patient’s fasting blood sugar or HbA1c to rule out diabetes. When answering AKT questions, it is important to consider the bigger picture and remember that the questions test knowledge of national guidance and consensus opinion, not just the latest NICE guidance.
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This question is part of the following fields:
- Cardiovascular Health
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Question 33
Incorrect
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A 65-year-old man visits your GP practice, who is typically healthy. He had come to see you a few weeks ago with a viral infection, during which you recorded his clinic blood pressure as 168/105 mmHg. You have since arranged for ambulatory blood pressure monitoring (ABPM), blood tests, urine dip, an ECG, and are now reviewing the results with him.
The ABPM average shows his blood pressure to be 157/100 mmHg. You have also conducted blood tests to check his plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol, and HDL cholesterol. His renal function and glucose levels are normal, and a urine dip for protein and ECG are also normal. Upon checking the back of his eyes, you find that the fundi are normal. His QRisk is calculated to be 28%.
You discuss potential treatment options with the patient. What should be included in your management plan?Your Answer: Offer ramipril, lifestyle advice, atorvastatin and aim for clinic BP <135/85 mmHg
Correct Answer:
Explanation:As a primary prevention measure for cardiovascular disease, it is recommended to discuss and suggest statin therapy to the patient. The target for clinic blood pressure should be less than 140/90 mmHg and less than 135/85 mmHg for ambulatory blood pressure monitoring. To achieve this, amlodipine and lifestyle advice should be offered along with atorvastatin.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 34
Correct
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An 80-year-old man presents with a three-week history of increasing fatigue and palpitations on exertion. He has a medical history of myocardial infarction and biventricular heart failure and is currently taking ramipril 5mg, bisoprolol 5mg, aspirin 75 mg, and atorvastatin 80 mg. During examination, his heart rate is irregularly irregular at 98/min, and his blood pressure is 172/85 mmHg. An ECG confirms the diagnosis of new atrial fibrillation. What medication should be avoided in this patient?
Your Answer: Verapamil
Explanation:Verapamil is more likely to worsen heart failure compared to dihydropyridines such as amlodipine.
Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.
Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.
Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.
Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.
According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.
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This question is part of the following fields:
- Cardiovascular Health
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Question 35
Incorrect
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A 70-year-old woman is prescribed amlodipine 5mg once daily for hypertension. She has no significant medical history and her routine blood tests (including fasting glucose) and ECG were unremarkable.
What is the recommended target blood pressure for her while on amlodipine treatment?Your Answer: < 130/80 mmHg
Correct Answer:
Explanation:The recommended blood pressure target for individuals under 80 years old during a clinic reading is 140/90 mmHg. However, the Quality and Outcomes Framework (QOF) indicator for GPs practicing in England specifies a slightly higher target of below 150/90 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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 36
Incorrect
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A 60-year-old man who was active all his life develops sudden severe anterior chest pain that radiates to his back. Within minutes, he is unconscious.
He has a history of hypertension, but a recent treadmill test had revealed no evidence for cardiac disease.
What is the most probable diagnosis?Your Answer: Pulmonary embolism
Correct Answer: Tear in the aortic intima
Explanation:Aortic Dissection: A Probable Cause of Sudden Collapse with Acute Chest Pain
The patient’s history is indicative of aortic dissection, which is a probable cause of sudden collapse accompanied by acute chest pain radiating to the back. Although other conditions may also lead to sudden collapse, they do not typically present with these symptoms in the presence of a recent normal exercise test. While acute myocardial infarction (MI) is a possibility, it is not the most likely explanation. For further information on the diagnosis and management of aortic dissection, please refer to the following references: BMJ Best Practice, BMJ Clinical Review, and eMedicine.
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This question is part of the following fields:
- Cardiovascular Health
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Question 37
Correct
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You are a GPST1 working in a general practice. A practice nurse seeks your guidance on a routine ECG performed on a 50-year-old man. Upon examining the ECG, you observe that the patient is in regular sinus rhythm with a rate of 70 beats per minute. However, the patient has a long QT interval and small T waves.
What could be the reason for this distinct ECG pattern?Your Answer: Hypokalaemia
Explanation:Long QT syndrome may result from hypokalaemia.
Long QT syndrome (LQTS) is a genetic condition that causes a delay in the ventricles’ repolarization. This delay can lead to ventricular tachycardia/torsade de pointes, which can cause sudden death or collapse. The most common types of LQTS are LQT1 and LQT2, which are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.
There are various causes of a prolonged QT interval, including congenital factors, drugs, and other conditions. Congenital factors include Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome. Drugs that can cause a prolonged QT interval include amiodarone, sotalol, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Other factors that can cause a prolonged QT interval include electrolyte imbalances, acute myocardial infarction, myocarditis, hypothermia, and subarachnoid hemorrhage.
LQTS may be detected on a routine ECG or through family screening. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress, exercise, or auditory stimuli. Long QT3 events often occur at night or at rest and can lead to sudden cardiac death.
Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers are often used, and implantable cardioverter defibrillators may be necessary in high-risk cases. It is important to note that sotalol may exacerbate LQTS.
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This question is part of the following fields:
- Cardiovascular Health
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Question 38
Incorrect
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A 35-year-old woman visits her doctor for a check-up. She is worried about her risk of developing cardiovascular disease after hearing about a family member's recent diagnosis.
Which of the following factors would most significantly increase her risk of cardiovascular disease?
Your Answer: Father had a myocardial infarction (MI) aged 65-years-old
Correct Answer: Rheumatoid arthritis
Explanation:Patients with rheumatoid arthritis may have an increased risk of developing accelerated atherosclerosis, which is believed to be linked to the inflammatory process. The QRisk2 calculator, used to predict the 10-year risk of developing cardiovascular disease, includes rheumatoid arthritis as a risk factor. However, a blood pressure reading of 130/80 mmHg and a BMI of 24 kg/m2 are within the normal range and not a cause for concern. Additionally, the HbA1c level of 41 mmol/mol is normal and doesn’t indicate an increased risk of diabetes. While a family history of myocardial infarction is significant, it is only considered a risk factor if the relative was diagnosed before the age of 60, not at 65.
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This question is part of the following fields:
- Cardiovascular Health
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Question 39
Correct
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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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 40
Correct
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A 45-year-old man visits his GP clinic seeking sildenafil (Viagra) as he is nervous every time he is intimate with his new partner. He can still achieve his own erections and has morning erections. His recent NHS health screening blood tests were all normal, and he has normal blood pressure. The GP examines his medication history and advises him against using sildenafil. Which of the following medications listed below is not recommended to be used with sildenafil?
Your Answer: Isosorbide mononitrate (ISMN)
Explanation:When considering treatment options for this patient, it is important to note that PDE 5 inhibitors such as sildenafil are contraindicated when used in conjunction with nitrates and nicorandil. This is due to the potential for severe hypotension. Therefore, alternative treatment options should be explored and discussed with the patient.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 41
Incorrect
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An 80-year-old woman is admitted to the hospital for symptomatic first-onset atrial fibrillation. She has a history of two falls in the past year and the doctors are preparing to discharge her home after rate control treatment. One of the doctors has been requested to assess her bleeding risk using an ORBIT score.
Considering the patient's risk factors, what is the best course of action regarding her anticoagulation?Your Answer: Delay anticoagulation for three months
Correct Answer: Start anticoagulation
Explanation:Anticoagulation should be started despite the risk of falls or old age alone, according to NICE guidelines. Previously, doctors would consider factors such as alcohol abuse when deciding whether to start anticoagulation due to the risk of haemorrhage. However, the ORBIT score is now recommended by NICE to determine the risk of haemorrhage. Delaying or withholding anticoagulation could be dangerous for the patient while they are at risk of stroke. Aspirin is no longer used for thromboembolism prophylaxis in atrial fibrillation, so both answers involving aspirin are incorrect.
Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.
When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.
For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular Health
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Question 42
Correct
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A 26-year-old woman has a 2-year history of right-sided throbbing headache that comes and goes, accompanied by nausea and sensitivity to light. She often experiences visual disturbances before the headache starts. Despite trying various over-the-counter pain relievers, she has found little relief. Her doctor has prescribed an oral medication to be taken at the onset of the headache, with the option of taking another tablet after 2 hours if needed. What is a typical adverse effect of this medication?
Your Answer: Tightness of the throat and chest
Explanation:Triptans are prescribed for migraines with aura and should be taken as soon as possible after the onset of the headache. A second dose can be taken if needed, with a minimum interval of 2 hours between doses. However, triptans may cause tightness in the throat and chest.
Understanding Triptans for Migraine Treatment
Triptans are a type of medication used to treat migraines. They work by activating specific receptors in the brain called 5-HT1B and 5-HT1D. Triptans are usually the first choice for acute migraine treatment and are often used in combination with other pain relievers like NSAIDs or paracetamol.
It is important to take triptans as soon as possible after the onset of a migraine headache, rather than waiting for the aura to begin. Triptans are available in different forms, including oral tablets, orodispersible tablets, nasal sprays, and subcutaneous injections.
While triptans are generally safe and effective, they can cause some side effects. Some people may experience what is known as triptan sensations, which can include tingling, heat, tightness in the throat or chest, heaviness, or pressure.
Triptans are not suitable for everyone. People with a history of or significant risk factors for ischaemic heart disease or cerebrovascular disease should not take triptans.
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This question is part of the following fields:
- Cardiovascular Health
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Question 43
Correct
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A 65-year-old man has been diagnosed with hypertension and has a history of chronic heart failure due to alcoholic cardiomyopathy (NYHA class I). Which medication should be avoided due to contraindication?
Your Answer: Verapamil
Explanation:Medications to Avoid in Patients with Heart Failure
Patients with heart failure need to be cautious when taking certain medications as they may exacerbate their condition. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil should also be avoided due to its negative inotropic effect. NSAIDs and glucocorticoids should be used with caution as they can also cause fluid retention. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin outweigh the risks. Class I antiarrhythmics, such as flecainide, should also be avoided as they have a negative inotropic and proarrhythmic effect. It is important for healthcare providers to be aware of these medications and their potential effects on patients with heart failure.
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This question is part of the following fields:
- Cardiovascular Health
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Question 44
Incorrect
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You are asked to do a new baby check on a 4-day-old boy born at home after an uneventful pregnancy. The labour was normal and the baby has been fine until today, when he was noted to be slightly blue around the lips on feeding, recovering quickly. On examination there is a systolic murmur and you are unable to feel pulses in the legs.
Select the single most likely diagnosis.Your Answer: Transient tachypnoea of the newborn
Correct Answer: Coarctation of the aorta
Explanation:Common Congenital Heart Defects in Newborns
Congenital heart defects are abnormalities in the structure of the heart that are present at birth. Here are some common congenital heart defects in newborns:
Coarctation of the aorta: This defect is a narrowing of the aorta, usually just distal to the origin of the left subclavian artery, close to the ductus arteriosus. It usually presents between day 2 and day 6 with symptoms of heart failure as the ductus arteriosus closes. The patient may have weak femoral pulses and a systolic murmur in the left infraclavicular area.
Fallot’s tetralogy: This defect consists of a large ventricular septal defect, overriding aorta, right ventricular outflow obstruction, and right ventricular hypertrophy. It leads to a right to left shunt and low oxygen saturation, which can cause cyanosis. Most cases are diagnosed antenatally or on investigation of a heart murmur.
Ductus arteriosus: The ductus arteriosus connects the pulmonary artery to the proximal descending aorta. It is a normal structure in fetal life but should close after birth. Failure of the ductus arteriosus to close can lead to overloading of the lungs because a left to right shunt occurs. Heart failure may be a consequence. A continuous (“machinery”) murmur is best heard at the left infraclavicular area or upper left sternal border.
Transient tachypnoea of the newborn: This condition is seen shortly after delivery and consists of a period of rapid breathing. It is likely due to retained lung fluid and usually resolves over 24-48 hours. However, it is important to observe for signs of clinical deterioration.
Ventricular septal defects: These defects vary in size and haemodynamic consequences. The presence of a defect may not be obvious at birth. Classically there is a harsh systolic murmur that is best heard at the left sternal edge. With large defects, pulmonary hypertension may develop resulting in a right to left shunt (Eisenmenger’s syndrome). Patients with the latter may have no murmur.
In conclusion, early detection and management of congenital heart defects in newborns are crucial for better outcomes.
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This question is part of the following fields:
- Cardiovascular Health
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Question 45
Correct
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A 58-year-old male with stable angina complains of muscle aches and pains. He has been on simvastatin 40 mg daily, atenolol 50 mg daily, and aspirin 75 mg daily for two years. He was recently hospitalized for acute coronary syndrome and additional therapies were added. His CPK concentration is 820 IU/L (50-200). What is the most probable cause of his statin-related myopathy?
Your Answer: Omega-3 fatty acids
Explanation:Statin-Associated Myopathy and Drug Interactions
Statin-associated myopathy is a potential side effect that affects up to 5% of individuals taking statins. This condition can be exacerbated by the co-prescription of certain drugs, including calcium channel blockers, macrolide antibiotics, fibrates, amiodarone, and grapefruit juice. Even patients who tolerate statins well may experience myopathy or rhabdomyolysis when these agents are added to their treatment regimen.
It is important for healthcare providers to be aware of these potential drug interactions and to monitor patients closely for signs of myopathy. Additionally, NICE guidance on Myocardial infarction: secondary prevention (NG185) advises against the use of omega-3 capsules to prevent another MI. By staying informed and following evidence-based guidelines, healthcare providers can help ensure the safety and well-being of their patients.
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This question is part of the following fields:
- Cardiovascular Health
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Question 46
Incorrect
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A 59-year-old man visits his General Practitioner to discuss his medication for hypertension. He is currently taking ramipril 10 mg daily, amlodipine 10 mg daily, and immediate-release indapamide 1.5 mg daily. Despite tolerating this treatment without any side-effects, his clinic blood pressure remains high at an average of 155/100 mmHg. The patient has no adverse lifestyle factors and a family history of hypertension and stroke. Secondary causes for hypertension have been ruled out, and routine blood tests including renal function, electrolytes, lipids, and glucose are all normal. His serum potassium level is 4.7 mmol/l (normal range 3.5-5.5 mmol/l). What is the most appropriate modification to this patient's treatment?
Your Answer: Add spironolactone 25 mg daily
Correct Answer: Increase indapamide to 2.5 mg daily
Explanation:Treatment options for resistant hypertension
Resistant hypertension can be a challenging condition to manage, and the National Institute for Health and Care Excellence (NICE) has provided guidelines to help healthcare professionals make informed decisions. In step 4 of the guidelines, NICE recommends a combination of ACE inhibitor, calcium channel blocker, and diuretic therapy, with the addition of further diuretic or alpha or beta blocker if necessary.
If further diuretic therapy is required, NICE suggests a higher-dose thiazide-like diuretic or spironolactone, depending on the patient’s serum potassium level. However, if spironolactone is not licensed for use or not tolerated, increasing the dose of indapamide is a suitable alternative. It’s important to note that the maximum dose of modified-release indapamide is 1.5mg daily.
If further diuretic therapy is not tolerated or contraindicated, NICE recommends considering an alpha or beta blocker. In cases of resistant hypertension, seeking expert advice may also be beneficial. By following these guidelines, healthcare professionals can provide effective treatment options for patients with resistant hypertension.
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This question is part of the following fields:
- Cardiovascular Health
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Question 47
Correct
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A 55-year-old man presents after experiencing a panic attack at work. He reports feeling extremely hot and unable to concentrate, with a sensation of the world closing in on him. Although his symptoms have mostly subsided, he seeks medical attention. Upon examination, his pulse is 78 beats per minute, blood pressure is 188/112 mmHg, and respiratory rate is 14 breaths per minute. Fundoscopy reveals small retinal hemorrhages, but cardiovascular examination is otherwise unremarkable. The patient's PHQ-9 score is 15 out of 27. What is the most appropriate course of action?
Your Answer: Admit for a same day assessment of his blood pressure
Explanation:This individual is experiencing severe hypertension, according to NICE guidelines, and is also exhibiting retinal haemorrhages. In such cases, NICE advises immediate referral and assessment. While the reported panic attack may be unrelated, it is important to rule out the possibility of an underlying phaeochromocytoma.
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 48
Incorrect
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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: Their potential risks far outweigh their benefits so they should not be prescribed in patients with cardiovascular disease
Correct 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
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This question is part of the following fields:
- Cardiovascular Health
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Question 49
Correct
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A 64-year-old man visits his primary care physician for a blood pressure check-up. He has a medical history of hypertension, hypercholesterolemia, and ischemic heart disease.
The patient is currently taking the following medications:
- Ramipril 10 mg once daily
- Amlodipine 10 mg once daily
- Bendroflumethiazide 2.5mg once daily
- Atorvastatin 80 mg once daily
- Aspirin 75 mg once daily
The most recent change to his blood pressure medication was the addition of bendroflumethiazide 6 months ago, which has reduced his average home systolic readings by approximately 15 mmHg. The average of home blood pressure monitoring over the past two weeks is now 160/82 mmHg.
A blood test is conducted, and the results show:
- K+ 4.6 mmol/L (3.5 - 5.0)
After ruling out secondary causes of hypertension, what is the next course of action in managing his blood pressure?Your Answer: Add atenolol 25 mg orally once daily
Explanation:The patient has poorly controlled hypertension despite taking an ACE inhibitor, calcium channel blocker, and a standard-dose thiazide diuretic. As their potassium levels are above 4.5mmol/l, it is recommended to add an alpha- or beta-blocker to their medication regimen. According to the 2019 NICE guidelines, this stage is considered treatment resistance hypertension, and the GP should also assess for adherence to medication and postural drop. If blood pressure remains high, referral to a specialist or adding a fourth drug may be necessary. Bendroflumethiazide should not be stopped as it has been effective in lowering blood pressure. Atenolol is a suitable beta-blocker to start with, and a reasonable starting dose is 25 mg, which can be adjusted based on the patient’s response. Spironolactone should only be considered if potassium levels are below 4.5mmol/l.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 50
Incorrect
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A 75-year-old man with a history of angina, well-controlled on a combination of aspirin 75 mg, atenolol 50 mg od, simvastatin 40 mg od, and isosorbide mononitrate 20 mg bd, presents with a pulse rate of 70 bpm and blood pressure of 134/84 mmHg. He also has type II diabetes mellitus, managed with metformin. What is the most effective medication that should be prescribed for optimal secondary prevention?
Your Answer: Nicorandil
Correct Answer: Perindopril
Explanation:Medication Options for Angina and Hypertension
The National Institute for Health and Care Excellence (NICE) recommends considering treatment with an angiotensin-converting enzyme (ACE) inhibitor for secondary prevention in patients with stable angina and diabetes mellitus, as long as there are no contraindications. This should also be prescribed where there is co-existing hypertension, left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction (MI).
Amlodipine is a calcium-channel blocker which could be added to control hypertension; however, this patient’s blood pressure is normal on current therapy.
Diltiazem is a non-dihydropyridine calcium-channel blocker which can be used as an alternative first-line treatment in angina. This patient is already on atenolol and is well controlled.
Doxazosin is an alpha-blocker used in the management of hypertension. This patient’s blood pressure is within normal limits, so it is not currently indicated.
Nicorandil is an anti-anginal medication due to its vasodilatory properties which can be added or used as a monotherapy when symptoms of angina are not controlled with a beta-blocker or calcium-channel blocker or these are not tolerated. This patient’s symptoms are controlled on atenolol, so nicorandil is not indicated.
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This question is part of the following fields:
- Cardiovascular Health
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