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Question 1
Incorrect
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A 68-year-old man presents with severe epigastric pain and nausea. He reports not having a bowel movement in 3 days, despite normal bowel habits prior to this. The patient has a history of coronary stents placed after a heart attack 10 years ago. He has been asymptomatic since then and takes aspirin for his cardiac condition and NSAIDs for knee arthritis. He has not consumed alcohol in the past 5 years due to a previous episode of acute gastritis.
On examination, there is mild tenderness over the epigastrium but no guarding. Bowel sounds are normal. An erect CXR and abdominal X-ray are unremarkable. Blood gases and routine blood tests (FBC, U&E, LFTs) are normal, with a normal amylase. Upper GI endoscopy reveals gastric erosions.
What is the most important differential diagnosis to consider for this patient?Your Answer: Duodenal ulcer
Correct Answer: Myocardial infarction
Explanation:Possible Diagnoses for a Patient with Epigastric Pain and History of Cardiac Stents
Introduction:
A patient with a history of cardiac stents presents with epigastric pain. The following are possible diagnoses that should be considered.Myocardial Infarction:
Due to the patient’s history of cardiac stents, ruling out a myocardial infarction (MI) is crucial. An electrocardiogram (ECG) should be performed early to treat any existing cardiac condition without delay.Duodenal Ulcer:
A duodenal ulcer would have likely been visualized on an oesophagogastroduodenoscopy (OGD). However, a normal erect CXR and absence of peritonitis exclude a perforated duodenal ulcer.Acute Gastritis:
Given the patient’s history of aspirin and NSAID use, as well as the gastric erosions visualized on endoscopy, acute gastritis is the most likely diagnosis. However, it is important to first exclude MI as a cause of the patient’s symptoms due to their history of MI and presentation of epigastric pain.Pancreatitis:
Pancreatitis is unlikely, given the normal amylase. However, on occasion, this can be normal in cases depending on the timing of the blood test or whether the pancreas has had previous chronic inflammation.Ischaemic Bowel:
Ischaemic bowel would present with more generalized abdominal pain and metabolic lactic acidosis on blood gas. Therefore, it is less likely to be the cause of the patient’s symptoms. -
This question is part of the following fields:
- Cardiology
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Question 2
Correct
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A 42-year-old man is admitted with a 30-min history of severe central ‘crushing’ chest pain radiating down the left arm. He is profusely sweating and looks ‘grey’. The electrocardiogram (ECG) shows sinus tachycardia and 3-mm ST elevation in V3–V6.
Which of the following is the most appropriate treatment?Your Answer: Give the patient aspirin, ticagrelor and low-molecular-weight heparin, followed by a primary percutaneous coronary intervention (PCI)
Explanation:Treatment Options for ST Elevation Myocardial Infarction (STEMI)
When a patient presents with a ST elevation myocardial infarction (STEMI), prompt and appropriate treatment is crucial. The gold standard treatment for a STEMI is a primary percutaneous coronary intervention (PCI), which should be performed as soon as possible. In the absence of contraindications, all patients should receive aspirin, ticagrelor, and low-molecular-weight heparin before undergoing PCI.
Delaying PCI by treating the pain with sublingual glyceryl trinitrate (GTN), aspirin, and oxygen, and reviewing the patient in 15 minutes is not recommended. Similarly, giving the patient aspirin, ticagrelor, and low molecular weight heparin without performing PCI is incomplete management.
Thrombolysis therapy can be performed on patients without access to primary PCI. However, if primary PCI is available, it is the preferred treatment option.
It is important to note that waiting for cardiac enzymes is not recommended as it would only result in a delay in definitive management. Early and appropriate treatment is crucial in improving outcomes for patients with STEMI.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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Examine the cardiac catheter data provided below for a patient. Which of the following clinical scenarios is most consistent with the given information?
Anatomical site Oxygen saturation (%) Pressure (mmHg) End systolic/End diastolic
Superior vena cava 74 -
Inferior vena cava 72 -
Right atrium 73 5
Right ventricle 74 20/4
Pulmonary artery 74 20/5
Pulmonary capillary wedge pressure - 15
Left ventricle 98 210/15
Aorta 99 125/75Your Answer: A 65-year-old woman with a two year history of increasing exertional dyspnoea who presents following a single episode of haemoptysis
Correct Answer: A 17-year-old boy who presents after an episode of exercise-induced syncope
Explanation:Left Ventricular Pressure and Cardiac Conditions
Left ventricular pressures that exhibit a sharp decline between the LV and aortic systolic pressures are indicative of hypertrophic cardiomyopathy. This condition is consistent with the catheter data obtained from the patient. However, the data are not consistent with other cardiac conditions such as cyanotic congenital heart disease, post-MI VSD or mitral regurgitation, mitral stenosis, or mitral regurgitation. Although aortic stenosis may also present with a left ventricular outflow obstruction, it is not typically associated with exercise-induced syncope. These findings suggest that the patient’s symptoms are likely due to hypertrophic cardiomyopathy.
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This question is part of the following fields:
- Cardiology
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Question 4
Correct
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A 38-year-old man presents to his GP for a routine health check. Upon physical examination, no abnormalities are found. However, laboratory test results reveal the following:
- Serum glucose: 4.5 mmol/L
- Haemoglobin A1c: 4.2% (22 mmol/mol)
- Total cholesterol: 5.8 mmol/L
- LDL cholesterol: 4.2 mmol/L
- HDL cholesterol: 0.6 mmol/L
Based on these results, what is the most likely mechanism for injury to the vascular endothelium in this patient?Your Answer: Collection of lipid in foam cells
Explanation:Atherosclerosis and Related Conditions
Atherosclerosis is a condition characterized by the accumulation of lipids in arterial walls, leading to the formation of atheromas. This process is often associated with hypercholesterolemia, where there is an increase in LDL cholesterol that can become oxidized and taken up by arterial wall LDL receptors. The oxidized LDL is then collected in macrophages, forming foam cells, which are precursors to atheromas. This process is exacerbated by hypertension, smoking, and diabetes, which can lead to the degradation of LDL to oxidized LDL and its uptake into arterial walls via scavenger receptors in macrophages.
Diabetes mellitus with hyperglycemia is also associated with the accumulation of sorbitol in tissues that do not require insulin for glucose uptake. This accumulation can contribute to the development of atherosclerosis. However, neutrophilic inflammation, which is often the result of infection, is not related to atherosclerosis and is unusual in arteries. Additionally, atherosclerosis is not a neoplastic process, although mutations can result in neoplastic transformation.
Overall, the process of atherogenesis is slow and does not involve significant inflammation or activation of complement. the underlying mechanisms of atherosclerosis and related conditions can help in the development of effective prevention and treatment strategies.
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This question is part of the following fields:
- Cardiology
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Question 5
Correct
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A 70-year-old man with a history of chronic cardiac failure with reduced ventricular systolic function presents with recent onset of increasing breathlessness, and worsening peripheral oedema and lethargy. He is currently taking ramipril and bisoprolol alongside occasional paracetamol.
What is the most appropriate long-term management?Your Answer: Addition of spironolactone
Explanation:For the management of heart failure, first line options include ACE inhibitors, beta-blockers, and aldosterone antagonists. In this case, the patient was already on a beta-blocker and an ACE inhibitor which had been effective. The addition of an aldosterone antagonist such as spironolactone would be the best option as it prevents fluid retention and reduces pressure on the heart. Ivabradine is a specialist intervention that should only be considered after trying all other recommended options. Addition of furosemide would only provide symptomatic relief. Insertion of an implantable cardiac defibrillator device is a late-stage intervention. Encouraging regular exercise and a healthy diet is important but does not directly address the patient’s clinical deterioration.
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This question is part of the following fields:
- Cardiology
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Question 6
Correct
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A 56-year-old, 80 kg woman arrives at the Emergency Department complaining of chest pain that began 5 hours ago. She has no known allergies and is not taking any regular medications. Her electrocardiogram shows T-wave inversion in lateral leads but no ST changes, and her serum troponin level is significantly elevated. What is the appropriate combination of drugs to administer immediately?
Your Answer: Aspirin 300 mg, prasugrel 60 mg, fondaparinux 2.5 mg
Explanation:For patients with different combinations of medications, the appropriate treatment plan may vary. In general, aspirin should be given as soon as possible and other medications may be added depending on the patient’s condition and the likelihood of undergoing certain procedures. For example, if angiography is not planned within 24 hours of admission, a loading dose of aspirin and prasugrel with fondaparinux may be given. If PCI is planned, unfractionated heparin may be considered. The specific dosages and medications may differ based on the patient’s individual needs and risk factors.
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This question is part of the following fields:
- Cardiology
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Question 7
Correct
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A 55-year-old woman arrives at the emergency department with a two hour history of central crushing chest pain. She has a history of ischaemic heart disease and poorly controlled diabetes. The ECG shows ST-elevation in V1, V2 and V3, and her serum troponin levels are elevated. What is the most suitable definitive management approach?
Your Answer: Primary percutaneous coronary intervention (PCI)
Explanation:Treatment Options for ST-Elevation Myocardial Infarction (STEMI)
ST-Elevation Myocardial Infarction (STEMI) is a medical emergency that requires immediate intervention. The diagnosis of STEMI is confirmed through cardiac sounding chest pain and evidence of ST-elevation on the ECG. The primary treatment option for STEMI is immediate revascularization through primary percutaneous coronary intervention (PCI) and placement of a cardiac stent.
Therapeutic alteplase, a thrombolytic agent, used to be a common treatment option for STEMI, but it has been largely replaced by primary PCI due to its superior therapeutic outcomes. Aspirin is routinely given in myocardial infarction, and clopidogrel may also be given, although many centers are now using ticagrelor instead.
High-flow oxygen and intravenous morphine may be used for adequate analgesia and resuscitation, but the primary treatment remains primary PCI and revascularization. Routine use of high flow oxygen in non-hypoxic patients with an acute coronary syndrome is no longer advocated.
It is crucial to avoid delaying treatment for STEMI, as it can lead to further deterioration of the patient and increase the risk of cardiac arrhythmia or arrest. Therefore, waiting for troponin results before further management is not an appropriate option. The diagnosis of STEMI can be made through history and ECG findings, and immediate intervention is necessary for optimal outcomes.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 57-year-old man arrives at the Emergency Department with sudden onset central crushing chest pain. The patient reports feeling pain in his neck and jaw as well. He has no significant medical history, but he does smoke socially and consumes up to 60 units of alcohol per week. An ECG is performed, revealing widespread ST elevation indicative of an acute coronary syndrome.
What is the earliest point at which the microscopic changes of acute MI become apparent?Your Answer: 3-10 days
Correct Answer: 12-24 hours after the infarct
Explanation:The Pathological Progression of Myocardial Infarction: A Timeline of Changes
Myocardial infarction, commonly known as a heart attack, is a serious medical condition that occurs when blood flow to the heart is blocked, leading to tissue damage and potentially life-threatening complications. The pathological progression of myocardial infarction follows a predictable sequence of events, with macroscopic and microscopic changes occurring over time.
Immediately after the infarct occurs, there are usually no visible changes to the myocardium. However, within 3-6 hours, maximal inflammatory changes occur, with the most prominent changes occurring between 24-72 hours. During this time, coagulative necrosis and acute inflammatory responses are visible, with marked infiltration by neutrophils.
Between 3-10 days, the infarcted area begins to develop a hyperaemic border, and the process of organisation and repair begins. Granulation tissue replaces dead muscle, and dying neutrophils are replaced by macrophages. Disintegration and phagocytosis of dead myofibres occur during this time.
If a patient survives an acute infarction, the infarct heals through the formation of scar tissue. However, scar tissue does not possess the usual contractile properties of normal cardiac muscle, leading to contractile dysfunction or congestive cardiac failure. The entire process from coagulative necrosis to the formation of well-formed scar tissue takes 6-8 weeks.
In summary, understanding the timeline of changes that occur during myocardial infarction is crucial for early diagnosis and effective treatment. By recognising the macroscopic and microscopic changes that occur over time, healthcare professionals can provide appropriate interventions to improve patient outcomes.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 62-year-old woman is being evaluated on the medical ward due to increasing episodes of dyspnoea, mainly on exertion. She has been experiencing fatigue more frequently over the past few months. Upon examination, she exhibits slight wheezing and bilateral pitting ankle oedema. Her medical history includes type I diabetes, rheumatoid arthritis, hypertension, recurrent UTIs, and hypothyroidism. Her current medications consist of insulin, methotrexate, nitrofurantoin, and amlodipine. She has never smoked, drinks two units of alcohol per week, and does not use recreational drugs. Blood tests reveal a haemoglobin level of 152 g/l, a white cell count of 4.7 × 109/l, a sodium level of 142 mmol/l, a potassium level of 4.6 mmol/l, a urea level of 5.4 mmol/l, and a creatinine level of 69 µmol/l. Additionally, her N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is 350 pg/ml, which is higher than the normal value of < 100 pg/ml. What is the most probable diagnosis?
Your Answer: Left ventricular failure
Correct Answer: Cor pulmonale
Explanation:Differential Diagnosis: Cor Pulmonale vs. Other Conditions
Cor pulmonale, or right ventricular failure due to pulmonary heart disease, is the most likely diagnosis for a patient presenting with symptoms such as wheeze, increasing fatigue, and pitting edema. The patient’s history of taking drugs known to cause pulmonary fibrosis, such as methotrexate and nitrofurantoin, supports this diagnosis. Aortic stenosis, asthma, COPD, and left ventricular failure are all possible differential diagnoses, but each has distinguishing factors that make them less likely. Aortic stenosis would not typically present with peripheral edema, while asthma and COPD do not fit with the patient’s lack of risk factors and absence of certain symptoms. Left ventricular failure is also less likely due to the absence of signs such as decreased breath sounds and S3 gallop on heart auscultation. Overall, cor pulmonale is the most likely diagnosis for this patient.
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This question is part of the following fields:
- Cardiology
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Question 10
Incorrect
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A 65-year-old woman presents to the Emergency Department with chest pain that has worsened over the past 2 days. She also reported feeling ‘a little run down’ with a sore throat a week ago. She has history of hypertension and hyperlipidaemia. She reports diffuse chest pain that feels better when she leans forward. On examination, she has a temperature of 37.94 °C and a blood pressure of 140/84 mmHg. Her heart rate is 76 bpm. A friction rub is heard on cardiac auscultation, and an electrocardiogram (ECG) demonstrates ST segment elevation in nearly every lead. Her physical examination and blood tests are otherwise within normal limits.
Which of the following is the most likely aetiology of her chest pain?Your Answer: Chest radiation
Correct Answer: Post-viral complication
Explanation:Pericarditis as a Post-Viral Complication: Symptoms and Differential Diagnosis
Pericarditis, inflammation of the pericardium, can occur as a post-viral complication. Patients typically experience diffuse chest pain that improves when leaning forward, and a friction rub may be heard on cardiac auscultation. Diffuse ST segment elevations on ECG can be mistaken for myocardial infarction. In this case, the patient reported recent viral symptoms and then developed acute pericardial symptoms.
While systemic lupus erythematosus (SLE) can cause pericarditis, other symptoms such as rash, myalgia, or joint pain would be expected, along with a positive anti-nuclear antibodies test. Uraemia can also cause pericarditis, but elevated blood urea nitrogen would be present, and this patient has no history of kidney disease. Dressler syndrome, or post-myocardial infarction pericarditis, can cause diffuse ST elevations, but does not represent transmural infarction. Chest radiation can also cause pericarditis, but this patient has no history of radiation exposure.
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This question is part of the following fields:
- Cardiology
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Question 11
Incorrect
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A 65-year-old moderately obese man is brought to the Emergency Department with complaints of severe chest pain and shortness of breath. Upon physical examination, a pericardial tamponade is suspected and confirmed by an electrocardiogram (ECG) showing total electrical alternans and an echocardiogram revealing pericardial effusion. Which jugular vein is typically the most reliable indicator of central venous pressure (CVP)?
Your Answer: Right anterior
Correct Answer: Right internal
Explanation:The Best Vein for Measuring Central Venous Pressure
Pericardial tamponade can lead to compression of the heart by the pericardium, resulting in decreased intracardiac diastolic pressure and reduced blood flow to the right atrium. This can cause distension of the jugular veins, making the right internal jugular vein the best vein for measuring central venous pressure (CVP). Unlike the right external vein, which joins the right internal vein at an oblique angle, the right internal vein has a straight continuation with the right brachiocephalic vein and the superior vena cava, making CVP measurement more accurate. On the other hand, the left internal jugular vein makes an oblique union with the left brachiocephalic vein and the external jugular veins, making it a less reliable indicator of CVP. Similarly, the left external vein also joins the left internal vein at an oblique angle, making CVP reading less reliable.
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This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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A 50-year-old man with a long-standing history of hypertension visits his primary care physician for a routine check-up. He mentions experiencing a painful, burning sensation in his legs when he walks long distances and feeling cold in his lower extremities. He has no history of dyslipidaemia. During the examination, his temperature is recorded as 37.1 °C, and his blood pressure in the left arm is 174/96 mmHg, with a heart rate of 78 bpm, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% on room air. Bilateral 1+ dorsalis pedis pulses are noted, and his lower extremities feel cool to the touch. Cardiac auscultation does not reveal any murmurs, rubs, or gallops. His abdominal examination is unremarkable, and no bruits are heard on auscultation. His renal function tests show a creatinine level of 71 μmol/l (50–120 μmol/l), which is his baseline. What is the most likely defect present in this patient?
Your Answer: Atrial septal defect
Correct Answer: Coarctation of the aorta
Explanation:The patient’s symptoms suggest coarctation of the aorta, a condition where the aortic lumen narrows just after the branches of the aortic arch. This causes hypertension in the upper extremities and hypotension in the lower extremities, leading to lower extremity claudication. Chest X-rays may show notching of the ribs. Treatment involves surgical resection of the narrowed lumen. Bilateral lower extremity deep vein thrombosis, patent ductus arteriosus, renal artery stenosis, and atrial septal defects are other conditions that can cause different symptoms and require different treatments.
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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A 75-year-old man comes to the clinic with a complaint of experiencing severe dizziness upon standing quickly. He is currently taking atenolol 100 mg OD for hypertension. Upon measuring his blood pressure while lying down and standing up, the readings are 146/88 mmHg and 108/72 mmHg, respectively. What is the main cause of his postural hypotension?
Your Answer: Increased adrenaline release on standing
Correct Answer: Impaired baroreceptor reflex
Explanation:Postural Hypotension
Postural hypotension is a common condition that affects many people, especially the elderly and those with refractory hypertension. When standing up, blood tends to pool in the lower limbs, causing a temporary drop in blood pressure. Baroreceptors in the aortic arch and carotid sinus detect this change and trigger a sympathetic response, which includes venoconstriction, an increase in heart rate, and an increase in stroke volume. This response helps to restore cardiac output and blood pressure, usually before any awareness of hypotension. However, a delay in this response can cause dizziness and presyncope.
In some cases, the reflex response is partially impaired by medications such as beta blockers. This means that increased adrenaline release, decreased pH (via chemoreceptors), or pain (via a sympathetic response) can lead to an increase in blood pressure rather than a decrease. postural hypotension and its underlying mechanisms can help individuals manage their symptoms and prevent complications.
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This question is part of the following fields:
- Cardiology
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Question 14
Incorrect
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A 68-year-old man presents to his general practitioner (GP) with shortness of breath. He describes shortness of breath on exertion and feeling short of breath when he lies flat. He now uses four pillows when sleeping. His past medical history is remarkable for hypertension, hypercholesterolaemia and type II diabetes.
On examination, he has bilateral crepitation, a jugular venous pressure (JVP) of 5 cm and pitting oedema up to his shins. Despite these symptoms, his oxygen saturation is 99% and he is functioning normally at home. He says the symptoms started gradually about 6 months ago and have progressed slowly since.
Which of the following should the GP do first to confirm the provisional diagnosis?Your Answer: Myocardial perfusion scan
Correct Answer: Serum brain natriuretic peptide (BNP)
Explanation:The first-line investigation for heart failure in primary care is checking the levels of brain natriuretic peptide (BNP), according to the National Institute for Health and Care Excellence (NICE) guidelines. BNP levels are widely available, non-invasive, quick, and cost-efficient. A normal BNP level can rule out heart failure, but if it is abnormal, an echocardiogram should be done within 6 weeks if it is raised and within 2 weeks if it is very high. Patients with a history of myocardial infarction should have an echocardiogram straightaway. An echocardiogram is the most definitive test diagnostically, as it can accurately assess various parameters. Troponin T level is used to assess myocardial injury resulting from a myocardial infarction, but it is not relevant in chronic heart failure. Myocardial perfusion scans are useful in the diagnosis of coronary artery disease, but they are not the first-line investigation for heart failure. An ECG may be helpful, but it is not sensitive or specific enough to be used as a conclusive diagnostic tool. A chest X-ray can show features of heart failure, but they are usually found in progressed chronic congestive heart failure, which are unlikely to be present at the very first presentation.
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This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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A 28-year-old woman presents to the Emergency department with sudden onset of palpitations. Upon examination, her pulse rate is found to be 180 bpm and she appears warm and well perfused. Her blood pressure is 135/80 mmHg, respiratory rate is 20/min, and oxygen saturation is 100% on air. Chest auscultation reveals no signs of cardiac failure, but an ECG shows a narrow complex tachycardia. Despite attempts at carotid massage and Valsalva manoeuvre, the rhythm disturbance persists. What is the appropriate initial management?
Your Answer: IV magnesium
Correct Answer: IV adenosine
Explanation:Management of Narrow Complex Supraventricular Tachycardia
When a patient presents with narrow complex supraventricular tachycardia, the initial management would be to administer IV adenosine, provided there are no contraindications such as asthma. This medication creates a transient conduction delay, which may terminate the tachycardia or slow down the heart rate enough to identify the underlying rhythm. This information is crucial in determining the optimal antiarrhythmic therapy for the patient.
However, if the patient experiences chest pain, hypotension, SBP <90 mmHg, or evidence of cardiac failure, then DC cardioversion would be necessary. It is important to note that if the patient is not haemodynamically compromised, IV adenosine is the preferred initial management for narrow complex supraventricular tachycardia. By following these guidelines, healthcare professionals can effectively manage this condition and provide the best possible care for their patients.
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This question is part of the following fields:
- Cardiology
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Question 16
Correct
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A patient presents to the Emergency Department following a fracture dislocation of his ankle after a night out drinking vodka red-bulls. His blood pressure is low at 90/50 mmHg. He insists that it is never normally that low.
Which one of these is a possible cause for this reading?Your Answer: Incorrect cuff size (cuff too large)
Explanation:Common Factors Affecting Blood Pressure Readings
Blood pressure readings can be affected by various factors, including cuff size, alcohol and caffeine consumption, white coat hypertension, pain, and more. It is important to be aware of these factors to ensure accurate readings.
Incorrect Cuff Size:
Using a cuff that is too large can result in an underestimation of blood pressure, while a cuff that is too small can cause a falsely elevated reading.Alcohol and Caffeine:
Both alcohol and caffeine can cause a temporary increase in blood pressure.White Coat Hypertension:
Many patients experience elevated blood pressure in medical settings due to anxiety. To obtain an accurate reading, blood pressure should be measured repeatedly on separate occasions.Pain:
Pain is a common cause of blood pressure increase and should be taken into consideration during medical procedures. A significant rise in blood pressure during a procedure may indicate inadequate anesthesia.Factors Affecting Blood Pressure Readings
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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A 61-year-old man experiences persistent, intense chest pain that spreads to his left arm. Despite taking multiple antacid tablets, he finds no relief. He eventually seeks medical attention at the Emergency Department and is diagnosed with a heart attack. He is admitted to the hospital and stabilized before being discharged five days later.
About three weeks later, the man begins to experience a constant, burning sensation in his chest. He returns to the hospital, where a friction rub is detected during auscultation. Additionally, his heart sounds are muffled.
What is the most likely cause of this complication, given the man's medical history?Your Answer: Viral infection
Correct Answer: Autoimmune phenomenon
Explanation:Understanding Dressler Syndrome
Dressler syndrome is a condition that occurs several weeks after a myocardial infarction (MI) and results in fibrinous pericarditis with fever and pleuropericardial chest pain. It is believed to be an autoimmune phenomenon, rather than a result of viral, bacterial, or fungal infections. While these types of infections can cause pericarditis, they are less likely in the context of a recent MI. Chlamydial infection, in particular, does not cause pericarditis. Understanding the underlying cause of pericarditis is important for proper diagnosis and treatment of Dressler syndrome.
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This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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An 82-year-old woman is brought to the Emergency Department after experiencing a sudden loss of consciousness while grocery shopping. Upon examination, she is fully alert and appears to be in good health.
Her vital signs are normal, with a CBG of 5.8 mmol/l. However, her cardiovascular system shows an irregular, low volume heart rate of 90-110 beats per minute, and her blood pressure is 145/120 mmHg while lying down and standing up. Her JVP is raised by 5 cm, and her apex beat is displaced to the mid-axillary line, with diffuse heart sounds. A loud pansystolic murmur is heard at the apex, radiating to the axilla and at the lower left sternal edge, along with a mid-diastolic rumble best heard at the apex. There are occasional bibasal crackles in her chest, which clear up with coughing. Additionally, she has mild peripheral edema up to the mid-calf.
Based on these clinical findings, what is the most likely cause of her collapse?Your Answer: Mixed aortic valve disease
Correct Answer: Mixed mitral valve disease
Explanation:This patient exhibits features of mixed mitral valve disease, which can be challenging to diagnose due to contradictory signs. She has a mid-diastolic rumble, low-volume pulse, and atrial fibrillation, indicating mitral stenosis. However, she also has a displaced apex beat and a pan-systolic murmur, indicating mitral regurgitation. Mixed aortic valve disease is also common in these patients. Aortic stenosis and mixed aortic valve disease are unlikely diagnoses based on the clinical findings, while mitral stenosis and mitral regurgitation alone do not fully explain the examination results.
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This question is part of the following fields:
- Cardiology
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Question 19
Correct
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A 48-year-old woman comes to you for a follow-up appointment after a recent fall. She has a medical history of type 2 diabetes mellitus, bilateral knee replacements, chronic hypotension, and heart failure, which limits her mobility. Her weight is 118 kg. During her last visit, her ECG showed atrial fibrillation (AF) with a heart rate of 180 bpm, and she was started on bisoprolol. She underwent a 48-hour ECG monitoring, which revealed non-paroxysmal AF. What is the most appropriate course of action for her management?
Your Answer: Start her on digoxin
Explanation:Treatment Options for Atrial Fibrillation in a Patient with Heart Failure
When treating a patient with atrial fibrillation (AF) and heart failure, the aim should be rate control. While bisoprolol is a good choice for medication, it may not be suitable for a patient with chronic low blood pressure. In this case, digoxin would be the treatment of choice. Anticoagulation with either a novel oral anticoagulant or warfarin is also necessary. Electrical cardioversion is not appropriate for this patient. Increasing the dose of bisoprolol may be reasonable, but considering the patient’s clinical presentation and past medical history, it may not be the best option. Amlodipine will not have an effect on rate control in AF, and calcium-channel blockers should not be used in heart failure. Amiodarone should not be first-line treatment in this patient due to her heart failure. Overall, the best treatment option for AF in a patient with heart failure should be carefully considered based on the individual’s medical history and current condition.
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This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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What is the most accurate statement regarding the electrocardiograph?
Your Answer: S1Q3T3 is a common finding in patients diagnosed with a pulmonary embolism
Correct Answer: ST depression and tall R waves in leads V1 and V2 are consistent with a diagnosis of a posterior myocardial infarction
Explanation:Common ECG Findings and Their Significance
Electrocardiogram (ECG) is a valuable tool in diagnosing various cardiac conditions. Here are some common ECG findings and their significance:
1. ST depression and tall R waves in leads V1 and V2 are consistent with a diagnosis of a posterior myocardial infarction.
2. Pneumonia causes low-voltage QRS complexes. This can be caused by the dampening effect of extra layers of fat, fluid, or air between the heart and thoracic wall.
3. The corrected QT interval (QTc) is calculated by Bazett’s formula: QTc = QT interval ÷ square root of the RR interval (in seconds).
4. A 2-mm ST elevation in leads II, III, aVF, V4, and V5 is consistent with an anterior myocardial infarction. This suggests an inferior lateral infarction, as opposed to just an inferior myocardial infarction.
5. The S1Q3T3 pattern is seen in up to 20% of patients with a pulmonary embolism. Sinus tachycardia is the most common ECG abnormality seen in patients presenting with pulmonary emboli. Other potential findings include a right ventricular strain pattern, complete and incomplete right bundle branch block (RBBB), and P pulmonale indicating right atrial enlargement.
Understanding these common ECG findings can aid in the diagnosis and management of various cardiac conditions.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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A 50-year-old man with atrial fibrillation visited the Cardiology Clinic for electrophysiological ablation. What is the least frequent pathological alteration observed in atrial fibrillation?
Your Answer: Apical–radial pulse deficit
Correct Answer: Fourth heart sound
Explanation:Effects of Atrial Fibrillation on the Heart
Atrial fibrillation is a condition characterized by irregular and rapid heartbeats. This condition can have several effects on the heart, including the following:
Fourth Heart Sound: In conditions such as hypertensive heart disease, active atrial contraction can cause active filling of a stiff left ventricle, leading to the fourth heart sound. However, this sound cannot be heard in atrial fibrillation.
Apical-Radial Pulse Deficit: Ineffective left ventricular filling can lead to cardiac ejections that cannot be detected by radial pulse palpation, resulting in the apical-radial pulse deficit.
Left Atrial Thrombus: Stasis of blood in the left atrial appendage due to ineffective contraction in atrial fibrillation is the main cause of systemic embolisation.
Reduction of Cardiac Output by 20%: Ineffective atrial contraction reduces left ventricular filling volumes, leading to a reduction in stroke volume and cardiac output by up to 20%.
Symptomatic Palpitations: Palpitations are the most common symptom reported by patients in atrial fibrillation.
Overall, atrial fibrillation can have significant effects on the heart and may require medical intervention to manage symptoms and prevent complications.
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This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A 65-year-old male with a nine year history of type 2 diabetes is currently taking metformin 1 g twice daily and gliclazide 160 mg twice daily. He has gained weight over the past year and his HbA1c has worsened from 59 to 64 mmol/mol (20-42). The doctor is considering treating him with either insulin or pioglitazone. The patient is curious about the potential side effects of pioglitazone.
What is a common side effect of pioglitazone therapy?Your Answer: Photosensitivity rash
Correct Answer: Fluid retention
Explanation:Common Side Effects of Diabetes Medications
Pioglitazone, a medication used to treat diabetes, can lead to fluid retention in approximately 10% of patients. This side effect can be worsened when taken with other drugs that also cause fluid retention, such as NSAIDs and calcium antagonists. Additionally, weight gain associated with pioglitazone is due to both fat accumulation and fluid retention. It is important to note that pioglitazone is not recommended for patients with cardiac failure.
Metformin, another commonly prescribed diabetes medication, can cause lactic acidosis as a side effect. This is a known risk and should be monitored closely by healthcare providers.
Sulphonylureas, a class of medications used to stimulate insulin production, may cause a rash that is sensitive to sunlight.
Finally, statins and fibrates, medications used to lower cholesterol levels, have been associated with myositis, a condition that causes muscle inflammation and weakness. It is important for patients to be aware of these potential side effects and to discuss any concerns with their healthcare provider.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A patient comes to your general practice with deteriorating shortness of breath and ankle swelling. You have been treating them for a few years for their congestive cardiac failure, which has been gradually worsening. Currently, the patient is at ease when resting, but standing up and walking a few steps cause their symptoms to appear. According to the New York Heart Association (NYHA) classification, what stage of heart failure are they in?
Your Answer: II
Correct Answer: III
Explanation:Understanding NYHA Classification for Heart Failure Patients
The NYHA classification system is used to assess the severity of heart failure symptoms in patients. Class I indicates no limitation of physical activity, while class IV indicates severe limitations and symptoms even at rest. This patient falls under class III, with marked limitation of physical activity but no symptoms at rest. It is important for healthcare professionals to understand and use this classification system to properly manage and treat heart failure patients.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 16-year-old girl is referred to cardiology outpatients with intermittent palpitations. She describes occasional spontaneous episodes of being abnormally aware of her heart. She says her heart rate is markedly increased during episodes. She has no significant medical or family history. She is on the oral contraceptive pill. ECG is performed. She is in sinus rhythm at 80 beats per min. PR interval is 108 ms. A slurring slow rise of the initial portion of the QRS complex is noted; QRS duration is 125 ms.
What is the correct diagnosis?Your Answer: Hyperthyroidism
Correct Answer: Wolff–Parkinson–White syndrome
Explanation:Understanding Wolff-Parkinson-White Syndrome: An Abnormal Congenital Accessory Pathway with Tachyarrhythmia Episodes
Wolff-Parkinson-White (WPW) syndrome is a rare condition with an incidence of about 1.5 per 1000. It is characterized by the presence of an abnormal congenital accessory pathway that bypasses the atrioventricular node, known as the Bundle of Kent, and episodes of tachyarrhythmia. While the condition may be asymptomatic or subtle, it can increase the risk of sudden cardiac death.
The presence of a pre-excitation pathway in WPW results in specific ECG changes, including shortening of the PR interval, a Delta wave, and QRS prolongation. The ST segment and T wave may also be discordant to the major component of the QRS complex. These features may be more pronounced with increased vagal tone.
Upon diagnosis of WPW, risk stratification is performed based on a combination of history, ECG, and invasive cardiac electrophysiology studies. Treatment is only offered to those who are considered to have significant risk of sudden cardiac death. Definitive treatment involves the destruction of the abnormal electrical pathway by radiofrequency catheter ablation, which has a high success rate but is not without complication. Patients who experience regular tachyarrhythmias may be offered pharmacological treatment based on the specific arrhythmia.
Other conditions, such as first-degree heart block, pulmonary embolism, hyperthyroidism, and Wenckebach syndrome, have different ECG findings and are not associated with WPW. Understanding the specific features of WPW can aid in accurate diagnosis and appropriate management.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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During a routine GP check-up, a 33-year-old woman is found to have a mid-diastolic rumbling murmur accompanied by a loud first heart sound. What valvular abnormality is likely causing this?
Your Answer: Mitral regurgitation
Correct Answer: Mitral stenosis
Explanation:Valvular Murmurs
Valvular murmurs are a common topic in medical exams, and it is crucial to have a good of them. The easiest way to approach them is by classifying them into systolic and diastolic murmurs. If the arterial valves, such as the aortic or pulmonary valves, are narrowed, ventricular contraction will cause turbulent flow, resulting in a systolic murmur. On the other hand, if these valves are incompetent, blood will leak back through the valve during diastole, causing a diastolic murmur.
Similarly, the atrioventricular valves, such as the mitral and tricuspid valves, can be thought of in the same way. If these valves are leaky, blood will be forced back into the atria during systole, causing a systolic murmur. If they are narrowed, blood will not flow freely from the atria to the ventricles during diastole, causing a diastolic murmur.
Therefore, a diastolic murmur indicates either aortic/pulmonary regurgitation or mitral/tricuspid stenosis. The loud first heart sound is due to increased force in closing the mitral or tricuspid valve, which suggests stenosis. the different types of valvular murmurs and their causes is essential for medical professionals to diagnose and treat patients accurately.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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What do T waves represent on an ECG?
Your Answer: Atrial repolarisation
Correct Answer: Ventricular repolarisation
Explanation:The Electrical Activity of the Heart and the ECG
The ECG (electrocardiogram) is a medical test that records the electrical activity of the heart. This activity is responsible for different parts of the ECG. The first part is the atrial depolarisation, which is represented by the P wave. This wave conducts down the bundle of His to the ventricles, causing the ventricular depolarisation. This is shown on the ECG as the QRS complex. Finally, the ventricular repolarisation is represented by the T wave.
It is important to note that atrial repolarisation is not visible on the ECG. This is because it is of lower amplitude compared to the QRS complex. the different parts of the ECG and their corresponding electrical activity can help medical professionals diagnose and treat various heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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A 65-year-old retiree visits his GP as he is becoming increasingly breathless and tired whilst walking. He has always enjoyed walking and usually walks 3 times a week. Over the past year he has noted that he can no longer manage the same distance that he used to be able to without getting breathless and needing to stop. He wonders if this is a normal part of ageing or if there could be an underlying medical problem.
Which of the following are consistent with normal ageing with respect to the cardiovascular system?Your Answer: Blood pressure = 76/54 mmHg
Correct Answer: Reduced VO2 max
Explanation:Ageing and Cardiovascular Health: Understanding the Normal and Abnormal Changes
As we age, our organs may still function normally at rest, but they may struggle to respond adequately to stressors such as exercise or illness. One of the key indicators of cardiovascular health is VO2 max, which measures the maximum rate of oxygen consumption during exercise. In normal ageing, VO2 max may decrease along with muscle strength, making intense exertion more difficult. However, significantly reduced VO2 max, left ventricular ejection fraction (LVEF), or stroke volume are not consistent with normal ageing. Additionally, hypotension or hypertension are not typical changes associated with ageing. Understanding these normal and abnormal changes can help us better monitor and manage our cardiovascular health as we age.
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This question is part of the following fields:
- Cardiology
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Question 28
Correct
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An 80-year-old man is hospitalized with acute coronary syndrome and is diagnosed with a heart attack. After four days, he experiences another episode of chest pain with non-specific ST-T wave changes on the ECG. Which cardiac enzyme would be the most suitable for determining if this second episode was another heart attack?
Your Answer: CK-MB
Explanation:Evaluating Chest Pain after an MI
When a patient experiences chest pain within ten days of a previous myocardial infarction (MI), it is important to evaluate the situation carefully. Troponin T levels remain elevated for ten days following an MI, which can make it difficult to determine if a second episode of chest pain is related to the previous event. To make a diagnosis, doctors will need to evaluate the patient’s creatine kinase (CK)-myoglobin (MB) levels. These markers rise over three days and can help form a diagnostic profile that can help determine if the chest pain is related to a new MI or another condition. By carefully evaluating these markers, doctors can provide the best possible care for patients who are experiencing chest pain after an MI.
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This question is part of the following fields:
- Cardiology
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Question 29
Incorrect
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A 42-year-old man presents to the Emergency Department with severe central chest pain that worsens when lying down, is relieved by sitting forward, and radiates to his left shoulder. He has a history of prostate cancer and has recently completed two cycles of radiotherapy. On examination, his blood pressure is 96/52 mmHg (normal <120/80 mmHg), his JVP is elevated, and his pulse is 98 bpm with a decrease in amplitude during inspiration. Heart sounds are faint. The ECG shows low-voltage QRS complexes. What is the most appropriate initial management for this patient?
Your Answer: Fluid challenge with 1 litre of sodium chloride STAT
Correct Answer: Urgent pericardiocentesis
Explanation:The patient is experiencing cardiac tamponade, which is caused by fluid in the pericardial sac compressing the heart and reducing ventricular filling. This is likely due to pericarditis caused by recent radiotherapy. Beck’s triad of low blood pressure, raised JVP, and muffled heart sounds are indicative of tamponade. Urgent pericardiocentesis is necessary to aspirate the pericardial fluid, preferably under echocardiographic guidance. A fluid challenge with sodium chloride is not recommended as it may worsen the pericardial fluid. Ibuprofen is not effective in severe cases of pericardial effusion. GTN spray, morphine, clopidogrel, and aspirin are useful in managing myocardial infarction, which is a differential diagnosis to rule out. LMWH is not appropriate for tamponade and may worsen the condition if caused by haemopericardium.
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This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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A 54-year-old man, with a family history of ischaemic heart disease, has been diagnosed with angina. His total cholesterol level is 6.5 mmol/l. He has been prescribed a statin and given dietary advice. What dietary modification is most likely to lower his cholesterol level?
Your Answer:
Correct Answer: Replace saturated fats with polyunsaturated fats
Explanation:Lowering Cholesterol Levels: Dietary Changes to Consider
To lower cholesterol levels, it is important to make dietary changes. One effective change is to replace saturated fats with polyunsaturated fats. Saturated fats increase cholesterol levels, while unsaturated fats lower them. It is recommended to reduce the percentage of daily energy intake from fat, with a focus on reducing saturated fats. Increasing intake of foods such as pulses, legumes, root vegetables, and unprocessed cereals can also help lower cholesterol. Using a margarine containing an added stanol ester can increase plant stanol intake, which can also reduce cholesterol. However, reducing intake of dairy products and meat alone may not be as effective as replacing them with beneficial unsaturated fats. It is important to avoid replacing polyunsaturated fats with saturated fats, as this can raise cholesterol levels.
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This question is part of the following fields:
- Cardiology
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