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  • Question 1 - A 65-year-old woman with a recent diagnosis of heart failure with reduced ejection...

    Correct

    • A 65-year-old woman with a recent diagnosis of heart failure with reduced ejection fraction (on echo) has a blood pressure (BP) of 160/95 mmHg. She is currently on lisinopril (maximum doses).
      Which of the following new agents would you add in?

      Your Answer: Bisoprolol

      Explanation:

      Medications for Heart Failure: Benefits and Guidelines

      Heart failure is a serious condition that requires proper management through medications. Among the drugs commonly used are bisoprolol, bendroflumethiazide, clopidogrel, spironolactone, and diltiazem.

      Bisoprolol and an angiotensin-converting enzyme (ACE) inhibitor are recommended for all heart failure patients as they have been shown to reduce mortality. Bendroflumethiazide and loop diuretics like furosemide can help alleviate symptoms but do not have a mortality benefit. Clopidogrel, on the other hand, is not indicated for heart failure but is used for vascular diseases like NSTEMI and stroke.

      Spironolactone is recommended for patients who remain symptomatic despite treatment with an ACE inhibitor and a b blocker. It is also beneficial for those with left ventricular systolic dysfunction (LVSD) after a myocardial infarction (MI). However, diltiazem should be avoided in heart failure patients.

      According to NICE guidelines, b blockers and ACE inhibitors should be given to all LVSD patients unless contraindicated. Spironolactone can be added if symptoms persist. Proper medication management is crucial in improving outcomes for heart failure patients.

    • This question is part of the following fields:

      • Cardiovascular
      148.3
      Seconds
  • Question 2 - A senior patient presents with congestive heart failure.
    Which of the following drugs may...

    Correct

    • A senior patient presents with congestive heart failure.
      Which of the following drugs may be effective in reducing mortality?

      Your Answer: Enalapril

      Explanation:

      Medications for Heart Failure Management

      Heart failure is a serious condition that requires proper management to improve outcomes. Two drugs that have been shown to reduce mortality in heart failure are angiotensin-converting enzyme (ACE) inhibitors and beta blockers. Aspirin, on the other hand, is used to reduce the risk of mortality and further cardiovascular events following myocardial infarction and stroke, but it has no role in heart failure alone.

      Digoxin can be used for short-term rate control for atrial fibrillation, but long-term use should be approached with caution as it may lead to increased mortality. Furosemide is useful in managing symptoms and edema in heart failure, but it has not been shown to have a mortality benefit.

      Lidocaine and other antiarrhythmic agents are only useful when there is arrhythmia associated with heart failure and should only be used with specialist support for ventricular arrhythmias in an unstable patient. Standard drugs such as digitalis and diuretics have not been shown to improve survival rates.

      Studies have shown that reducing left ventricular afterload prolongs survival rates in congestive heart failure. Vasodilators such as ACE inhibitors are effective in inhibiting the formation of angiotensin II, affecting coronary artery tone and arterial wall hyperplasia. There is also evidence for the use of beta blockers in heart failure management.

      In conclusion, proper medication management is crucial in improving outcomes for patients with heart failure. ACE inhibitors, beta blockers, and vasodilators have been shown to reduce mortality rates, while other drugs such as aspirin, digoxin, and furosemide have specific roles in managing symptoms and associated conditions.

    • This question is part of the following fields:

      • Cardiovascular
      13
      Seconds
  • Question 3 - A 26-year-old woman comes in for her routine medical check-up before starting her...

    Incorrect

    • A 26-year-old woman comes in for her routine medical check-up before starting her new job as a soccer player. She reports feeling healthy and has no notable medical history in her family.

      During the physical examination, her lungs sound clear and her heart has a normal rhythm. Her pulse rate is 62 beats per minute. However, her ECG reveals sinus rhythm with a prolonged PR interval of 215ms.

      What is the appropriate course of action for managing her ECG results?

      Your Answer: Urgent referral to cardiology

      Correct Answer: No intervention needed

      Explanation:

      First-degree heart block is a common occurrence in athletes and does not require any intervention. This patient’s ECG shows a prolonged PR interval, which is the defining characteristic of first-degree heart block. As it is a normal variant, there is no need for any referral or further investigations. The patient can continue to play football without any concerns.

      Normal Variants in Athlete ECGs

      Athletes may exhibit certain ECG changes that are considered normal variants. These include sinus bradycardia, junctional rhythm, first degree heart block, and Mobitz type 1 (Wenckebach phenomenon). Sinus bradycardia refers to a slower than normal heart rate originating from the sinus node, which is the natural pacemaker of the heart. Junctional rhythm occurs when the heart’s electrical impulses originate from the junction between the atria and ventricles, rather than the sinus node. First degree heart block is a delay in the electrical conduction between the atria and ventricles, resulting in a prolonged PR interval on the ECG. Mobitz type 1, also known as Wenckebach phenomenon, is a type of heart block where there is a progressive lengthening of the PR interval until a beat is dropped. These ECG changes are considered normal in athletes and do not necessarily indicate any underlying cardiac pathology.

    • This question is part of the following fields:

      • Cardiovascular
      61.6
      Seconds
  • Question 4 - Which of the following treatments has not been demonstrated to enhance survival in...

    Incorrect

    • Which of the following treatments has not been demonstrated to enhance survival in individuals with persistent heart failure?

      Your Answer: Enalapril

      Correct Answer: Furosemide

      Explanation:

      Although furosemide is effective in treating the symptoms of both acute and chronic heart failure, it does not provide any predictive advantages.

      Drug Management for Chronic Heart Failure: NICE Guidelines

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenza and one-off pneumococcal vaccines are also recommended.

      Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      7.2
      Seconds
  • Question 5 - A 32-year-old taxi driver presents with a frontal headache that has been ongoing...

    Correct

    • A 32-year-old taxi driver presents with a frontal headache that has been ongoing for the past 2 weeks. After taking 3 blood pressure readings, the lowest of which is 168/98 mmHg, a 24-hour tape reveals an average blood pressure reading of 158/88mmHg. The patient is open to starting medication for hypertension but expresses concern about how this diagnosis will affect his job. What advice would you give him?

      Your Answer: Advise him that he may continue driving as long as is blood pressure is not consistently above 180mmHg systolic or above 100mmHg diastolic

      Explanation:

      Drivers of cars and motorcycles are not required to inform the DVLA of their hypertension, but they must refrain from driving if their symptoms would impair their ability to drive safely. The same guidelines apply to bus and lorry drivers, but if their resting blood pressure consistently exceeds 180 mmHg systolic or 100mmHg diastolic, they must cease driving and notify the DVLA.

      DVLA Guidelines for Cardiovascular Disorders and Driving

      The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, for those with Group 2 Entitlement, a resting blood pressure consistently at 180 mmHg systolic or more and/or 100 mm Hg diastolic or more disqualifies them from driving.

      Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must refrain from driving for four weeks. However, if successfully treated by angioplasty, driving is permitted after one week. Those with angina must cease driving if symptoms occur at rest or while driving.

      For individuals who have undergone pacemaker insertion, they must refrain from driving for one week. If they have an implantable cardioverter-defibrillator (ICD) for sustained ventricular arrhythmia, they must cease driving for six months. If the ICD is implanted prophylactically, they must cease driving for one month, and having an ICD results in a permanent bar for Group 2 drivers. Successful catheter ablation for an arrhythmia requires two days off driving.

      Individuals with an aortic aneurysm of 6cm or more must notify the DVLA, and licensing will be permitted subject to annual review. However, an aortic diameter of 6.5 cm or more disqualifies patients from driving. Those who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

    • This question is part of the following fields:

      • Cardiovascular
      57.4
      Seconds
  • Question 6 - A 55-year-old woman with a history of diabetes, obesity, and smoking developed sudden...

    Incorrect

    • A 55-year-old woman with a history of diabetes, obesity, and smoking developed sudden pain in her left foot with a dusky colour change. On examination, in the Emergency Department, she had a cold, blue, painful foot with an absent dorsalis pedis and posterior tibial pulse.
      Which of the following will be the most appropriate investigation for this patient?

      Your Answer: Lower limb Doppler

      Correct Answer: Lower limb angiography

      Explanation:

      Diagnostic Tests for Lower Limb Ischaemia

      Lower limb ischaemia is a medical emergency that requires prompt diagnosis and treatment. Several diagnostic tests can be used to determine the cause and severity of the condition. Here are some of the most common tests:

      1. Lower limb angiography: This test can identify the site of arterial occlusion and help plan the appropriate treatment, such as embolectomy or fasciotomy.
      2. Focused assessment with sonography for trauma (FAST) scan of the abdomen: This test is useful in cases of trauma or suspected abdominal aortic aneurysm rupture.
      3. Ankle-brachial pressure index (ABPI): This quick and easy test can provide an early indication of the severity of ischaemia. A value of 0.9-1.2 is considered normal, while values below 0.3 indicate critical ischaemia.
      4. Echocardiogram: This test can rule out a cardiac source of embolisation, but lower limb angiography is the priority in cases of acute ischaemia.
      5. Lower limb Doppler: This test can be used to assess arterial or venous flow, depending on the suspected cause of ischaemia.

      In summary, a combination of these diagnostic tests can help diagnose and treat lower limb ischaemia effectively.

    • This question is part of the following fields:

      • Cardiovascular
      60.5
      Seconds
  • Question 7 - A 67-year-old man is discharged from the hospital after being treated for a...

    Incorrect

    • A 67-year-old man is discharged from the hospital after being treated for a thrombolysed ST-elevation myocardial infarction. He has a history of depression but no other significant medical history. During his stay in the coronary care unit, he developed dyspnoea and an echo revealed a reduced left ventricular ejection fraction. His cardiorespiratory examination today was normal. In addition to the standard treatment of ACE inhibitor, beta-blocker, aspirin, clopidogrel, and statin, what other type of medication should he be prescribed?

      Your Answer: Loop diuretic

      Correct Answer: Aldosterone antagonist

      Explanation:

      According to the current NICE guidelines, a patient with a reduced left ventricular ejection fraction should be prescribed an aldosterone antagonist. However, a loop diuretic should only be prescribed if there is evidence of fluid overload.

      Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. In 2013, NICE released guidelines on the secondary prevention of MI. One of the key recommendations is the use of four drugs: dual antiplatelet therapy (aspirin plus a second antiplatelet agent), ACE inhibitor, beta-blocker, and statin. Patients are also advised to adopt a Mediterranean-style diet and engage in regular exercise. Sexual activity may resume four weeks after an uncomplicated MI, and PDE5 inhibitors may be used six months after the event.

      Most patients with acute coronary syndrome are now given dual antiplatelet therapy, with ticagrelor and prasugrel being the preferred options. The treatment period for these drugs is 12 months, after which they should be stopped. However, this period may be adjusted for patients at high risk of bleeding or further ischaemic events. Additionally, patients with heart failure and left ventricular systolic dysfunction should be treated with an aldosterone antagonist within 3-14 days of the MI, preferably after ACE inhibitor therapy.

      Overall, the NICE guidelines provide a comprehensive approach to the secondary prevention of MI. By following these recommendations, patients can reduce their risk of further complications and improve their overall health outcomes.

    • This question is part of the following fields:

      • Cardiovascular
      63.7
      Seconds
  • Question 8 - A 65-year-old woman with a history of hypertension and heart failure presents with...

    Incorrect

    • A 65-year-old woman with a history of hypertension and heart failure presents with atrial fibrillation. She is stable with a ventricular rate of 70. Which of the following drug options would be the most suitable for her?

      Your Answer: Digoxin

      Correct Answer: Warfarin or direct oral anticoagulant (DOAC)

      Explanation:

      Treatment Options for Atrial Fibrillation: Warfarin, DOACs, Aspirin, Digoxin, Furosemide, and Lidocaine

      Patients with atrial fibrillation and a CHA2DS2-VASC score of 4 require anticoagulation to reduce the risk of a CVA. The two main options are warfarin and DOACs, but the choice depends on other co-morbidities and patient preference. Before starting warfarin, patients should be referred to the Anticoagulation Clinic and screened for contraindications.

      Aspirin has no benefit in atrial fibrillation, and digoxin should only be used for short-term rate control due to evidence of increased mortality with long-term use. Furosemide can help with symptoms and edema in heart failure but does not improve mortality. Lidocaine is only appropriate for ventricular arrhythmias in unstable patients and requires specialist support.

      In summary, the treatment options for atrial fibrillation vary depending on the patient’s individual circumstances and should be carefully considered by healthcare professionals.

    • This question is part of the following fields:

      • Cardiovascular
      22.1
      Seconds
  • Question 9 - You have just received a 70-year-old man into the resuscitation room who had...

    Correct

    • You have just received a 70-year-old man into the resuscitation room who had a witnessed collapse after complaining of chest pain. There was no pulse, and cardiopulmonary resuscitation (CPR) was performed at the scene. CPR is ongoing upon patient arrival in the Emergency Department. Pulse check demonstrates no palpable central pulse, and there is no respiratory effort. A 3-lead electrocardiogram (ECG) demonstrates no coordinated electrical activity or recognisable complexes, looking very much like a wandering flat line.
      What is the most appropriate management of this patient?

      Your Answer: 1 mg of adrenaline 1 : 10 000 intravenously (IV), and continue CPR

      Explanation:

      Managing Cardiac Arrest: Correct and Incorrect Approaches

      When dealing with a patient in cardiac arrest, it is crucial to follow the correct management protocol. In the case of a patient in asystole, CPR 30:2 (compressions: ventilations) should be initiated, along with 1 mg of adrenaline 10 ml of 1:10 000 IV every other cycle of CPR. Direct current (DC) shock is not indicated for asystole. Adrenaline 1:1000 IM is not appropriate for cardiac arrest situations, as it is used in anaphylaxis. External pacing is unlikely to be successful in the absence of P-wave asystole. Atropine is indicated in severe bradycardia, not asystole. It is essential to follow the correct approach to manage cardiac arrest effectively.

    • This question is part of the following fields:

      • Cardiovascular
      74.8
      Seconds
  • Question 10 - A 49-year-old man is being evaluated at the smoking cessation clinic. Is there...

    Incorrect

    • A 49-year-old man is being evaluated at the smoking cessation clinic. Is there any medical condition that would make it inappropriate to prescribe bupropion for him?

      Your Answer: History of supraventricular tachycardia

      Correct Answer: Epilepsy

      Explanation:

      Reduced seizure threshold is a contraindication for the use of bupropion in patients with epilepsy.

      NICE guidance recommends offering nicotine replacement therapy (NRT), varenicline, or bupropion to patients for smoking cessation, with no preference for one medication over another. NRT should be offered in combination for those with high nicotine dependence or inadequate response to single forms. Varenicline should be started a week before the target stop date and monitored for adverse effects, including nausea and suicidal behavior. Bupropion should also be started before the target stop date and is contraindicated in epilepsy, pregnancy, and breastfeeding. Pregnant women should be tested for smoking and referred to NHS Stop Smoking Services, with first-line interventions being cognitive behavior therapy, motivational interviewing, or structured self-help and support. NRT may be used if other measures fail, but varenicline and bupropion are contraindicated.

    • This question is part of the following fields:

      • Cardiovascular
      13.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular (4/10) 40%
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