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  • Question 1 - An 81-year-old woman arrives at the emergency department after her smartwatch ECG recorder...

    Correct

    • An 81-year-old woman arrives at the emergency department after her smartwatch ECG recorder detected atrial fibrillation for the past three days. She has experienced mild shortness of breath during physical activity in the last 24 hours. Upon examination, her heart rate is irregular, with a rate of 98 bpm, and her blood pressure is stable at 130/72 mmHg. She has no history of atrial fibrillation and only takes amlodipine for her grade I hypertension. What is the most appropriate treatment plan?

      Your Answer: Discharge on bisoprolol and apixaban and arrange cardioversion in four weeks

      Explanation:

      In cases of sudden atrial fibrillation, if the duration is 48 hours or more, the first step is to control the heart rate. If long-term rhythm control is being considered, it is important to wait at least 3 weeks after starting therapeutic anticoagulation before attempting cardioversion.

      Atrial fibrillation (AF) is a condition that requires careful management to prevent complications. The latest guidelines from NICE recommend that patients presenting with AF should be assessed for haemodynamic instability, and if present, electrically cardioverted. For haemodynamically stable patients, the management depends on how acute the AF is. If the AF has been present for less than 48 hours, rate or rhythm control may be considered. However, if it has been present for 48 hours or more, or the onset is uncertain, rate control is recommended. If long-term rhythm control is being considered, cardioversion should be delayed until the patient has been maintained on therapeutic anticoagulation for at least 3 weeks.

      Rate control is the first-line treatment strategy for AF, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin can be used to control the heart rate. However, digoxin is no longer considered first-line as it is less effective at controlling the heart rate during exercise. Rhythm control agents such as beta-blockers, dronedarone, and amiodarone can be used to maintain sinus rhythm in patients with a history of AF. Catheter ablation is recommended for those who have not responded to or wish to avoid antiarrhythmic medication.

      The aim of catheter ablation is to ablate the faulty electrical pathways that are causing AF. The procedure is performed percutaneously, typically via the groin, and can use radiofrequency or cryotherapy to ablate the tissue. Anticoagulation should be used 4 weeks before and during the procedure. It is important to note that catheter ablation controls the rhythm but does not reduce the stroke risk, so patients still require anticoagulation as per their CHA2DS2-VASc score. Complications of catheter ablation can include cardiac tamponade, stroke, and pulmonary vein stenosis. The success rate of the procedure is around 50% for early recurrence within 3 months, and around 55% of patients who’ve had a single procedure remain in sinus rhythm after 3 years. Of patients who’ve undergone multiple procedures, around 80% are in sinus rhythm.

    • This question is part of the following fields:

      • Cardiovascular
      63.7
      Seconds
  • Question 2 - A 52-year-old Caucasian man presents with blood pressure readings of 150/100 mmHg, 148/95mmHg...

    Correct

    • A 52-year-old Caucasian man presents with blood pressure readings of 150/100 mmHg, 148/95mmHg and 160/95mmHg during three consecutive visits to his GP surgery. He refuses ambulatory blood pressure monitoring due to its interference with his job as a construction worker. His home blood pressure readings are consistently above 150/95mmHg. What is the most appropriate initial approach to manage his condition?

      Your Answer: Ramipril

      Explanation:

      For a newly diagnosed patient with hypertension who is under 55 years old and has stage 2 hypertension, it is recommended to add either an ACE inhibitor or an angiotensin receptor blocker. This is in accordance with the NICE guidelines, which suggest that antihypertensive drug treatments should be offered to individuals of any age with stage 2 hypertension. If the patient is 55 years or older, a calcium channel blocker like amlodipine is recommended instead.

      NICE Guidelines for Managing Hypertension

      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 a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

      The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

      NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

      New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

    • This question is part of the following fields:

      • Cardiovascular
      22.3
      Seconds
  • Question 3 - A 72-year-old man presents to the cardiology clinic with symptomatic aortic stenosis. Despite...

    Incorrect

    • A 72-year-old man presents to the cardiology clinic with symptomatic aortic stenosis. Despite his overall good health, he is eager for intervention. What intervention is most likely to be recommended for him?

      Your Answer: Balloon valvuloplasty

      Correct Answer: Bioprosthetic aortic valve replacement

      Explanation:

      Mechanical valves are typically preferred for younger patients as they have a longer lifespan compared to other types of prosthetic heart valves.

      Prosthetic Heart Valves: Options for Replacement

      Prosthetic heart valves are commonly used to replace damaged aortic and mitral valves. There are two main options for replacement: biological (bioprosthetic) or mechanical. Biological valves are usually sourced from bovine or porcine origins and are commonly used in 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 type. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease. Following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis.

    • This question is part of the following fields:

      • Cardiovascular
      19.2
      Seconds
  • Question 4 - A 59-year-old man comes to his General Practitioner complaining of severe dizziness, double...

    Correct

    • A 59-year-old man comes to his General Practitioner complaining of severe dizziness, double vision and tinnitus whenever he lifts weights. He is a non-smoker and is in good health otherwise. During the examination, there is a difference of 35 mmHg between the systolic blood pressure (BP) in his left and right arms. His cardiovascular examination is otherwise unremarkable. His neurological examination is also normal.
      What is the most probable diagnosis?

      Your Answer: Subclavian steal syndrome

      Explanation:

      Differentiating Subclavian Steal Syndrome from Other Conditions

      Subclavian steal syndrome is a condition that occurs when the subclavian artery is narrowed or blocked, leading to reversed blood flow in the vertebral artery. This can cause arm claudication and transient neurological symptoms when the affected arm is exercised. A key diagnostic feature is a systolic blood pressure difference of at least 15 mmHg between the affected and non-affected arms. However, other conditions can also cause discrepancies in blood pressure or similar symptoms, making it important to differentiate subclavian steal syndrome from other possibilities.

      Aortic dissection is a medical emergency that can cause a sudden onset of chest pain and rapidly deteriorating symptoms. Benign paroxysmal positional vertigo (BPPV) is characterized by vertigo triggered by head movements, but does not involve blood pressure differences or diplopia. Buerger’s disease is a rare condition that can cause blood pressure discrepancies, but also involves skin changes and tissue ischemia. Carotid sinus hypersensitivity (CSH) can cause syncope when pressure is applied to the neck, but does not explain the other symptoms reported by the patient.

      In summary, a thorough evaluation is necessary to distinguish subclavian steal syndrome from other conditions that may present with similar symptoms.

    • This question is part of the following fields:

      • Cardiovascular
      44.9
      Seconds
  • Question 5 - A 59-year-old man comes to the hospital complaining of central chest pain that...

    Correct

    • A 59-year-old man comes to the hospital complaining of central chest pain that spreads to his left arm, accompanied by sweating and nausea. In the Emergency Department, an ECG reveals ST elevation in leads V1, V2, V3, and V4, and he is given 300mg of aspirin before undergoing primary percutaneous coronary intervention. After a successful procedure, he is admitted to the Coronary Care Unit and eventually discharged with secondary prevention medication and lifestyle modification advice, as well as a referral to a cardiac rehabilitation program.
      During a check-up with his GP three weeks later, the patient reports feeling well but still experiences fatigue and shortness of breath during rehab activities. He has not had any further chest pain episodes. However, an ECG shows Q waves and convex ST elevation in leads V1, V2, V3, and V4.
      What is the most likely diagnosis?

      Your Answer: Left ventricular aneurysm

      Explanation:

      Complications of Myocardial Infarction

      Myocardial infarction (MI) can lead to various complications, which can occur immediately, early, or late after the event. Cardiac arrest is the most common cause of death following MI, usually due to ventricular fibrillation. Patients are treated with defibrillation as per the ALS protocol. Cardiogenic shock may occur if a significant portion of the ventricular myocardium is damaged, leading to a decrease in ejection fraction. This condition is challenging to treat and may require inotropic support and/or an intra-aortic balloon pump. Chronic heart failure may develop if the patient survives the acute phase, and loop diuretics such as furosemide can help decrease fluid overload. Tachyarrhythmias, such as ventricular fibrillation and ventricular tachycardia, are common complications of MI. Bradyarrhythmias, such as atrioventricular block, are more common following inferior MI.

      Pericarditis is a common complication of MI in the first 48 hours, characterized by typical pericarditis pain, a pericardial rub, and a pericardial effusion. Dressler’s syndrome, which occurs 2-6 weeks after MI, is an autoimmune reaction against antigenic proteins formed during myocardial recovery. It is treated with NSAIDs. Left ventricular aneurysm may form due to weakened myocardium, leading to persistent ST elevation and left ventricular failure. Patients are anticoagulated due to the increased risk of thrombus formation and stroke. Left ventricular free wall rupture and ventricular septal defect are rare but serious complications that require urgent surgical correction. Acute mitral regurgitation may occur due to ischaemia or rupture of the papillary muscle, leading to acute hypotension and pulmonary oedema. Vasodilator therapy and emergency surgical repair may be necessary.

    • This question is part of the following fields:

      • Cardiovascular
      97.6
      Seconds
  • Question 6 - A 55-year-old Caucasian man comes to his GP for a routine check-up. He...

    Correct

    • A 55-year-old Caucasian man comes to his GP for a routine check-up. He works as a lawyer and reports feeling healthy with no recent illnesses. He has a history of hypertension and is currently taking 10mg of ramipril daily. He has no known allergies.
      During his ambulatory blood pressure monitoring, his readings were consistently high at 158/92 mmHg, 162/94mmHg, and 159/93mmHg.
      What would be the most appropriate next step in managing this patient?

      Your Answer: Indapamide

      Explanation:

      For a patient with poorly controlled hypertension who is already taking an ACE inhibitor, the addition of a calcium channel blocker or a thiazide-like diuretic is recommended. In individuals under the age of 55 and of Caucasian ethnicity, the first-line treatment for hypertension is an ACE inhibitor such as ramipril. If the blood pressure remains elevated despite maximum dose of ramipril, a second medication should be added. A calcium channel blocker or thiazide-like diuretic is the preferred choice for second-line therapy in this scenario.

      NICE Guidelines for Managing Hypertension

      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 a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

      The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

      NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

      New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

    • This question is part of the following fields:

      • Cardiovascular
      96.2
      Seconds
  • Question 7 - A 55-year-old man is admitted to Resus with a suspected anterior myocardial infarction....

    Correct

    • A 55-year-old man is admitted to Resus with a suspected anterior myocardial infarction. An ECG on arrival confirms the diagnosis and thrombolysis is prepared. The patient is stable and his pain is well controlled with intravenous morphine. Clinical examination shows a blood pressure of 140/84 mmHg, pulse 90 bpm and oxygen saturations on room air of 97%. What is the most appropriate management with regards to oxygen therapy?

      Your Answer: No oxygen therapy

      Explanation:

      There are now specific guidelines regarding the use of oxygen during emergency situations. Please refer to the provided link for more information.

      Managing Acute Coronary Syndrome: A Summary of NICE Guidelines

      Acute coronary syndrome (ACS) is a common and serious medical condition that requires prompt management. The management of ACS has evolved over the years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of ACS in 2020.

      ACS can be classified into three subtypes: ST-elevation myocardial infarction (STEMI), non ST-elevation myocardial infarction (NSTEMI), and unstable angina. The management of ACS depends on the subtype. However, there are common initial drug therapies for all patients with ACS, such as aspirin and nitrates. Oxygen should only be given if the patient has oxygen saturations below 94%, and morphine should only be given for severe pain.

      For patients with STEMI, the first step is to assess eligibility for coronary reperfusion therapy, which can be either PCI or fibrinolysis. Patients with NSTEMI/unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool to determine whether they need coronary angiography (with follow-on PCI if necessary) or conservative management.

      This summary provides an overview of the NICE guidelines for managing ACS. The guidelines are complex and depend on individual patient factors, so healthcare professionals should review the full guidelines for further details. Proper management of ACS can improve patient outcomes and reduce the risk of complications.

    • This question is part of the following fields:

      • Cardiovascular
      77.6
      Seconds
  • Question 8 - A 65-year-old overweight man presents with worsening shortness of breath and leg swelling...

    Correct

    • A 65-year-old overweight man presents with worsening shortness of breath and leg swelling due to advanced heart failure. His kidney function is normal and his potassium level is 4.2 mmol/l. Which combination of medications would provide the greatest mortality benefit for him?

      Your Answer: Ramipril and bisoprolol

      Explanation:

      There are several medications used to treat heart failure, including ACE inhibitors and beta-blockers, which have been shown to provide a mortality benefit. However, ACE inhibitors can cause hyperkalaemia, so potassium levels should be monitored closely when starting. If ACE inhibitors are not tolerated, angiotensin II receptor antagonists can be used instead. Atenolol is not recommended for use in heart failure, and agents typically used are bisoprolol, carvedilol, or metoprolol. Diuretics like furosemide and bendroflumethiazide provide symptom relief but do not improve mortality. When used together, they have a potent diuretic effect that may be required when patients accumulate fluid despite an adequate furosemide dose. However, this combination provides no long-term mortality benefit. It is important to note that decisions regarding medication management should be made by a specialist.

    • This question is part of the following fields:

      • Cardiovascular
      23.3
      Seconds
  • Question 9 - A 56-year-old man with difficult hypertension comes to the GP clinic for follow-up....

    Correct

    • A 56-year-old man with difficult hypertension comes to the GP clinic for follow-up. His average blood pressure over the past two weeks has been 168/100 mmHg and today in the clinic it is 176/102 mmHg. He is currently taking a combination of telmisartan 80 mg and hydrochlorothiazide 25mg tablets, as well as amlodipine 10mg daily. The latest laboratory results are as follows:

      Na+ 136 mmol/L (135 - 145)
      K+ 3.8 mmol/L (3.5 - 5.0)
      Bicarbonate 25 mmol/L (22 - 29)
      Urea 5 mmol/L (2.0 - 7.0)
      Creatinine 135 µmol/L (55 - 120)

      What would be the most appropriate next step?

      Your Answer: Add spironolactone

      Explanation:

      For a patient with poorly controlled moderate hypertension who is already taking an ACE inhibitor, calcium channel blocker, and thiazide diuretic, the recommended next step would be to add spironolactone if their potassium level is less than 4.5mmol/L. Atenolol may be considered as a fourth-line agent if the potassium level is over 4.5mmol/L, but spironolactone is preferred according to NICE guidelines. Hydralazine should not be used outside of specialist care, and indapamide is not the best option as the patient is already taking a thiazide diuretic. Prazosin is an alternative to spironolactone, but spironolactone is preferred given the lower potassium level.

      NICE Guidelines for Managing Hypertension

      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 a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

      The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

      NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

      New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

    • This question is part of the following fields:

      • Cardiovascular
      27.1
      Seconds
  • Question 10 - A 75 year old man with congestive cardiac failure is seen in cardiology...

    Correct

    • A 75 year old man with congestive cardiac failure is seen in cardiology clinic. He reports persistent shortness of breath with minimal activity. His current medications consist of furosemide, ramipril, bisoprolol, and spironolactone. An ECHO reveals an ejection fraction of 30%, while an ECG shows sinus rhythm with a QRS duration of 150ms. What is the optimal approach to enhance mortality?

      Your Answer: Cardiac resynchronisation therapy

      Explanation:

      Heart failure patients with a left ventricular ejection fraction of less than or equal to 40% and symptoms no more severe than class III according to the New York Heart Association functional classification may benefit from digoxin in terms of reducing hospitalization. However, it does not have an impact on mortality. While increasing the dosage of furosemide may provide relief from fluid overload symptoms, it does not affect mortality.

      Non-Drug Management for Chronic Heart Failure

      Chronic heart failure is a condition that requires long-term management to improve symptoms and reduce hospitalization. While medication is often the first line of treatment, non-drug management options are also available. Two such options are cardiac resynchronization therapy and exercise training.

      Cardiac resynchronization therapy involves biventricular pacing for patients with heart failure and wide QRS. This therapy has been shown to improve symptoms and reduce hospitalization in patients with NYHA class III heart failure. By synchronizing the heart’s contractions, this therapy can improve the heart’s pumping ability and reduce symptoms such as shortness of breath and fatigue.

      Exercise training is another non-drug management option for chronic heart failure. While it may not reduce hospitalization or mortality rates, it has been shown to improve symptoms. Exercise can help improve the heart’s ability to pump blood and increase overall fitness levels. This can lead to a reduction in symptoms such as fatigue and shortness of breath, allowing patients to engage in daily activities with greater ease.

      Overall, non-drug management options such as cardiac resynchronization therapy and exercise training can be effective in managing chronic heart failure. These options can improve symptoms and quality of life for patients, reducing the need for hospitalization and improving overall health outcomes.

    • This question is part of the following fields:

      • Cardiovascular
      106.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular (9/10) 90%
Passmed