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Question 1
Correct
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You are on-call and reviewing a potassium result. The patient's details are as follows:
Na+ 141 mmol/l
K+ 6.4 mmol/l
Bicarbonate 16 mmol/l
Urea 13.1 mmol/l
Creatinine 195 µmol/l
You are uncertain about administering calcium gluconate and decide to seek advice from your senior. She advises you to only give calcium gluconate if there are ECG changes. What ECG changes are most indicative of hyperkalaemia in a patient who is 60 years old?Your Answer: Widening of the QRS complex
Explanation:ECG characteristics of hypokalaemia include a prolonged QT interval, prolonged PR interval, and the presence of U waves.
Understanding Hyperkalaemia: Causes and Symptoms
Hyperkalaemia is a condition characterized by high levels of potassium in the blood. The regulation of plasma potassium levels is influenced by various factors such as aldosterone, insulin levels, and acid-base balance. When metabolic acidosis occurs, hyperkalaemia may develop as hydrogen and potassium ions compete for exchange with sodium ions across cell membranes and in the distal tubule. ECG changes that may be observed in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.
There are several causes of hyperkalaemia, including acute kidney injury, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Certain drugs such as potassium-sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin can also cause hyperkalaemia. It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. On the other hand, beta-agonists like Salbutamol are sometimes used as emergency treatment.
Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes. It is essential to monitor potassium levels in the blood to prevent complications associated with hyperkalaemia. If left untreated, hyperkalaemia can lead to serious health problems such as cardiac arrhythmias and even death.
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This question is part of the following fields:
- Cardiovascular
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Question 2
Incorrect
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A 55-year-old man comes to his GP clinic complaining of palpitations that have been ongoing for the past day. He has no significant medical history. There are no accompanying symptoms of chest pain or difficulty breathing. Physical examination is normal except for an irregularly fast heartbeat. An electrocardiogram reveals atrial fibrillation with a rate of 126 bpm and no other abnormalities. What is the best course of action for treatment?
Your Answer: Beta-blocker + aspirin
Correct Answer: Admit patient
Explanation:Admission to hospital is necessary for this patient as they are a suitable candidate for electrical cardioversion.
Atrial Fibrillation and Cardioversion: Elective Procedure for Rhythm Control
Cardioversion is a medical procedure used in atrial fibrillation (AF) to restore the heart’s normal rhythm. There are two scenarios where cardioversion may be used: as an emergency if the patient is haemodynamically unstable, or as an elective procedure where a rhythm control strategy is preferred. In the elective scenario, cardioversion can be performed either electrically or pharmacologically. Electrical cardioversion is synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced.
According to the 2014 NICE guidelines, rate or rhythm control should be offered if the onset of the arrhythmia is less than 48 hours, and rate control should be started if it is more than 48 hours or is uncertain. If the AF is definitely of less than 48 hours onset, patients should be heparinised and may be cardioverted using either electrical or pharmacological means. However, if the patient has been in AF for more than 48 hours, anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded, patients may be heparinised and cardioverted immediately.
NICE recommends electrical cardioversion in this scenario, rather than pharmacological. If there is a high risk of cardioversion failure, it is recommended to have at least 4 weeks of amiodarone or sotalol prior to electrical cardioversion. Following electrical cardioversion, patients should be anticoagulated for at least 4 weeks. After this time, decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence.
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This question is part of the following fields:
- Cardiovascular
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Question 3
Correct
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A 58-year-old woman comes to the Emergency Department complaining of a painful left leg that has been getting worse for several hours. She has no other symptoms and has a medical history of asthma, hypertension, and a laparoscopic cholecystectomy 8 weeks ago.
During the examination, the left calf diameter is approximately 4 cm larger than the right calf, but there is no oedema.
What would be the most suitable initial investigation?Your Answer: Proximal leg vein ultrasound
Explanation:If the Wells score for a suspected deep vein thrombosis (DVT) is 2 or higher, a proximal leg vein ultrasound scan should be arranged within 4 hours. In this case, the patient’s Wells score is 2 due to recent major surgery within 12 weeks and a calf swelling at least 3 cm larger than the asymptomatic side. It is important to note that a CT angiogram of the leg is not appropriate for diagnosing DVT, and ultrasound is the preferred imaging modality. A CT pulmonary angiogram would only be necessary if the patient had symptoms suggestive of pulmonary embolism. A chest X-ray is not relevant in this scenario. If ultrasound is not possible within 4 hours, a D-dimer test could be performed and interim therapeutic anticoagulation given, but the initial choice is to perform an ultrasound scan as soon as possible.
NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.
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This question is part of the following fields:
- Cardiovascular
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Question 4
Correct
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A 50-year-old woman with a history of hypertension and hypercholesterolaemia presents with sudden shortness of breath one hour after undergoing primary percutaneous intervention for an anterior ST-elevation myocardial infarction. The procedure was successful and radial access was used. She initially appeared stable and a bedside echocardiogram showed normal left ventricular function. However, on examination, she appears unwell with diaphoresis, tachypnea, hypotension (80/42 mmHg), tachycardia (111/minute), and elevated JVP. There are no signs of peripheral oedema or deep venous thrombosis. What is the most urgent intervention that could save her life?
Your Answer: Pericardiocentesis
Explanation:Cardiac tamponade is suggested by the presence of Beck’s triad, which includes falling blood pressure, rising jugular venous pulse, and muffled heart sounds. Therefore, cardiogenic shock is unlikely as the patient underwent successful revascularization and had a normal echocardiogram post-procedure. While inotropes may provide temporary support for low blood pressure, they are not a curative option in this case. Sepsis is not the cause of hypotension as it is typically associated with a fever, bounding pulse, and warm extremities, and the jugular venous pulse would not be elevated. Intravenous antibiotics are therefore not the correct answer. Hypovolemia is also not associated with an elevated jugular venous pulse, so intravenous fluids are not the correct answer. Additionally, the use of radial access makes a retroperitoneal hematoma less likely. The correct answer is pericardiocentesis, as the clinical features suggest cardiac tamponade, which is a known complication of primary percutaneous intervention in myocardial infarction.
Cardiac tamponade is a condition where there is an accumulation of fluid in the pericardial sac, which puts pressure on the heart. This can lead to a range of symptoms, including hypotension, raised JVP, muffled heart sounds, dyspnoea, tachycardia, and pulsus paradoxus. One of the key features of cardiac tamponade is the absence of a Y descent on the JVP, which is due to limited right ventricular filling. Other diagnostic criteria include Kussmaul’s sign and electrical alternans on an ECG. Constrictive pericarditis is a similar condition, but it can be distinguished from cardiac tamponade by the presence of an X and Y descent on the JVP, the absence of pulsus paradoxus, and the presence of pericardial calcification on a chest X-ray. The management of cardiac tamponade involves urgent pericardiocentesis to relieve the pressure on the heart.
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This question is part of the following fields:
- Cardiovascular
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Question 5
Correct
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A 35-year-old woman visits her general practice surgery to discuss her plans to become pregnant. She is taking medication for hypertension but is otherwise fit and well. She has not had any previous pregnancies.
On examination, her blood pressure (BP) is 120/78 mmHg.
Which of the following drugs can this patient continue to take during pregnancy?Your Answer: Nifedipine
Explanation:Nifedipine is a medication that blocks calcium channels and is recommended as a second-line treatment for hypertension during pregnancy or pre-eclampsia if labetalol is not effective or well-tolerated. If a woman is already taking nifedipine and has good blood pressure control, it is advisable to continue this treatment throughout pregnancy, with regular monitoring of blood pressure. Women with chronic hypertension are at risk of developing pre-eclampsia and should take 75-150 mg aspirin daily from 12 weeks gestation.
Bendroflumethiazide and other thiazide diuretics should not be taken during pregnancy as they are associated with various adverse effects on the fetus. Beta-blockers, except for labetalol, increase the risk of intrauterine growth restriction, neonatal hypoglycemia, and bradycardia. Therefore, the use of any beta-blockers during pregnancy, except for labetalol, should be avoided. Angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors are contraindicated in pregnancy as they can cause serious harm to the fetus. Women who become pregnant while taking ARBs or ACE inhibitors should stop taking them immediately and be prescribed a safer alternative antihypertensive medication.
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This question is part of the following fields:
- Cardiovascular
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Question 6
Incorrect
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A 55-year-old woman had a recent acute myocardial infarction (MI).
Which medication has been proven to reduce mortality after an MI?Your Answer: Isosorbide mononitrate (ISMN)
Correct Answer: Bisoprolol
Explanation:Medications for Post-Myocardial Infarction Patients
Post-myocardial infarction (MI) patients require specific medications to prevent further cardiovascular disease and improve their overall health. One of the most important drugs to offer is a beta-blocker, such as bisoprolol, as soon as the patient is stable. This medication should be continued for at least 12 months after an MI in patients without left ventricular systolic dysfunction or heart failure, and indefinitely in those with left ventricular systolic dysfunction. While beta-blockers can reduce mortality and morbidity for up to a year after an MI, recent studies suggest that continuing treatment beyond a year may not provide any additional benefits. Other medications, such as amiodarone, isosorbide mononitrate, and nicorandil, offer symptom relief but do not reduce mortality or morbidity. Calcium-channel blockers, like diltiazem, may be considered for secondary prevention in patients without pulmonary congestion or left ventricular systolic dysfunction if beta-blockers are contraindicated or discontinued. However, current guidelines recommend offering all post-MI patients an ACE inhibitor, dual antiplatelet therapy, beta-blocker, and statin to improve their long-term health outcomes.
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This question is part of the following fields:
- Cardiovascular
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Question 7
Incorrect
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A 50-year-old man comes to the clinic complaining of palpitations that started about 30 minutes ago. He mentions having a stressful day at work, but there doesn't seem to be any other obvious trigger. He denies experiencing any chest pain or difficulty breathing. Upon conducting an ECG, a regular tachycardia of 180 bpm with a QRS duration of 0.10s is observed. His blood pressure is 106/70 mmHg, and his oxygen saturation is 98% on room air. Despite performing the Valsalva manoeuvre, there is no effect on the rhythm. What is the most appropriate next step?
Your Answer: Re-attempt Valsava manoeuvre in 5 minutes
Correct Answer: Intravenous adenosine
Explanation:In cases of haemodynamically stable patients with SVT who do not respond to vagal manoeuvres, the recommended course of action is to administer adenosine.
Understanding Supraventricular Tachycardia
Supraventricular tachycardia (SVT) is a type of tachycardia that originates above the ventricles. It is commonly associated with paroxysmal SVT, which is characterized by sudden onset of a narrow complex tachycardia, usually an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.
When it comes to acute management, vagal maneuvers such as the Valsalva maneuver or carotid sinus massage can be used. Intravenous adenosine is also an option, with a rapid IV bolus of 6mg given initially, followed by 12mg and then 18mg if necessary. However, adenosine is contraindicated in asthmatics, and verapamil may be a better option for them. Electrical cardioversion is another option.
To prevent episodes of SVT, beta-blockers can be used. Radio-frequency ablation is also an option. It is important to work with a healthcare provider to determine the best course of treatment for each individual case.
Overall, understanding SVT and its management options can help individuals with this condition better manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Cardiovascular
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Question 8
Incorrect
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A 30-year-old medical student noticed that he had a murmur when he tested his new stethoscope. On assessment in the Cardiology Clinic, he was found to have a harsh systolic murmur over his precordium, which did not change with inspiration. His electrocardiogram (ECG) showed features of biventricular hypertrophy.
Which of the following is the most likely diagnosis?Your Answer: Hypertrophic cardiomyopathy (HCM)
Correct Answer: Ventricular septal defect (VSD)
Explanation:Common Heart Murmurs and their Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common heart murmurs and their characteristics:
1. Ventricular Septal Defect (VSD): This has a pansystolic murmur, heard loudest at the lower left sternal edge and causing biventricular hypertrophy due to increased strain on both the right and left ventricles.
2. Mitral Regurgitation: This has a pansystolic murmur which is heard loudest at the apex and radiates to the axilla; it is louder on expiration. The ECG can show left ventricular and left atrial enlargement.
3. Aortic Stenosis: This causes a crescendo-decrescendo murmur, heard loudest in the aortic area and radiating to the carotids. It (and all other left-sided murmurs) is louder on expiration.
4. Hypertrophic Cardiomyopathy (HCM): HCM has an early peaking systolic murmur which is worse on Valsalva and reduced on squatting. It is also associated with a jerky pulse. The ECG would show left ventricular hypertrophy.
5. Tricuspid Regurgitation: This has a pansystolic murmur and a brief rumbling diastolic murmur; these are louder on inspiration. The ECG may show right ventricular enlargement.
It is important to note that right-sided murmurs increase with inspiration (e.g. tricuspid regurgitation or TR), whereas left-sided murmurs show no change. The clue to diagnosis is in the ECG finding. Aortic stenosis and mitral regurgitation produce left ventricular hypertrophy; TR produces right ventricular hypertrophy and a VSD produces biventricular hypertrophy.
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This question is part of the following fields:
- Cardiovascular
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Question 9
Incorrect
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A 56-year-old male with no previous medical history presents with a sprained ankle and is incidentally found to be in atrial fibrillation. He denies any symptoms of palpitations or shortness of breath. Despite discussing treatment options, he declines cardioversion. Cardiovascular examination is otherwise normal, with a blood pressure of 118/76 mmHg. As per the most recent NICE guidelines, what is the recommended treatment for this patient if he remains in chronic atrial fibrillation?
Your Answer: Aspirin + dipyridamole
Correct Answer: No treatment
Explanation:NICE recommends using the CHA2DS2-VASc score to determine the need for anticoagulation in patients with any history of AF. The ORBIT scoring system should be used to assess bleeding risk, but anticoagulation should not be withheld solely on the grounds of age or risk of falls. DOACs are now recommended as the first-line anticoagulant for patients with AF, with warfarin used second-line if a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular
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Question 10
Correct
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A 58-year-old man presents for follow-up. He has experienced two episodes of fainting in the past month. The first occurred while he was climbing stairs, and the second occurred last week as he was exiting a swimming pool. There were no warning signs before either episode. Witnesses to the most recent episode reported that he was unconscious for approximately 15 seconds. He reports feeling disoriented for only a few seconds after regaining consciousness. On physical examination, his pulse is 90 beats per minute, blood pressure is 110/86 mmHg, his lungs are clear, and there is a systolic murmur that radiates to the carotid area. Which of the following tests should be ordered first?
Your Answer: Echocardiogram
Explanation:The presence of a systolic murmur could indicate the possibility of aortic stenosis (AS). It is crucial to prioritize ruling out this condition as syncope, which is a late symptom, often occurs during physical activity in patients with AS.
Aortic Stenosis: Symptoms, Causes, and Management
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope, and a characteristic ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can also cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, and left ventricular hypertrophy or failure. The most common causes of aortic stenosis are degenerative calcification in older patients and bicuspid aortic valve in younger patients.
If a patient is asymptomatic, observation is usually recommended. However, if the patient is symptomatic or has a valvular gradient greater than 40 mmHg with features such as left ventricular systolic dysfunction, valve replacement is necessary. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement.
In summary, aortic stenosis is a condition that can cause various symptoms and requires prompt management to prevent complications. The causes of aortic stenosis vary, and treatment options depend on the patient’s age, operative risk, and overall health.
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This question is part of the following fields:
- Cardiovascular
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Question 11
Correct
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Which of the following tests would be most beneficial in diagnosing heart failure?
Your Answer: B-type natriuretic peptide (BNP)
Explanation:Understanding Cardiac Biomarkers: Importance of BNP in Heart Failure Diagnosis
When it comes to diagnosing heart failure, healthcare professionals rely on various cardiac biomarkers to aid in their assessment. Among these biomarkers, B-type natriuretic peptide (BNP) is considered the primary investigation according to the National Institute for Health and Care Excellence (NICE) guidelines.
Unlike other biomarkers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), BNP is specific to heart failure and is not affected by inflammation. On the other hand, troponin T is useful in diagnosing acute coronary syndromes, while creatine phosphokinase is primarily used to detect muscle breakdown and rhabdomyolysis.
It is important to note that certain factors such as obesity and medications like angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) can falsely lower BNP levels. Therefore, if BNP levels are elevated, patients should be referred for an echocardiogram to confirm the diagnosis of heart failure.
In summary, understanding the role of cardiac biomarkers such as BNP in heart failure diagnosis is crucial in providing accurate and timely treatment for patients.
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This question is part of the following fields:
- Cardiovascular
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Question 12
Correct
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A 72-year-old man is being evaluated after being diagnosed with atrial fibrillation during his recent hospitalization. He has a history of mitral stenosis and takes ramipril for hypertension. He was started on warfarin during his admission and was discharged with plans for follow-up in the cardiology clinic. However, he is now found to be in sinus rhythm during his current review. What is the appropriate course of action regarding anticoagulation?
Your Answer: Continue lifelong warfarin
Explanation:Warfarin should be continued indefinitely due to the patient’s risk factors for stroke and history of atrial fibrillation. It is preferred over direct oral anticoagulants due to his valvular heart disease.
NICE recommends using the CHA2DS2-VASc score to determine the need for anticoagulation in patients with any history of AF. The ORBIT scoring system should be used to assess bleeding risk, but anticoagulation should not be withheld solely on the grounds of age or risk of falls. DOACs are now recommended as the first-line anticoagulant for patients with AF, with warfarin used second-line if a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular
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Question 13
Incorrect
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A 67-year-old male experiences a cardiac arrest during coronary angiography in the catheter laboratory. His heart rate is 164 beats per minute and the 12-lead ECG monitor displays ventricular tachycardia. As you begin to assess him, you are unable to detect a pulse and immediately call for assistance.
What is the next appropriate step to take?Your Answer: Give adrenaline 1mg IV
Correct Answer: Deliver a maximum of three successive shocks
Explanation:If a patient experiences cardiac arrest in VF/pulseless VT and is monitored, such as in a coronary care unit, critical care unit, or catheter laboratory, they should receive a maximum of three successive shocks instead of one shock followed by two minutes of CPR. After the shocks, chest compressions should be administered for two minutes. Once compressions restart, adrenaline 1mg IV and amiodarone 300 mg IV should be given for shockable rhythms (VT/pulseless VF). Adrenaline 1mg IV should be given after alternate shocks (every 3-5 minutes). For non-shockable rhythms (pulseless electrical activity/asystole), adrenaline 1mg IV should be given as soon as venous access is achieved and administered alongside CPR. Pulseless electrical activity is a type of cardiac arrest where there is electrical activity (other than ventricular tachycardia) that would normally have an associated pulse. Asystole is a complete cessation of any electrical and mechanical heart activity.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 14
Correct
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A 48-year-old man comes to the emergency department complaining of sudden onset chest pain. The patient has a medical history of hypertension and is currently taking ramipril. His vital signs are as follows: BP 153/90 mmHg in his right arm and 130/80 in his left arm, heart rate 89/minute, temperature 37.2ºC, respiration rate 17/minute, and oxygen saturation 98% on room air. Upon examination, the patient has absent pulses in his right leg and diminished pulses in his left leg.
What is the recommended diagnostic test for this patient's presentation?Your Answer: CT angiography chest/abdomen/pelvis
Explanation:When a patient presents with symptoms of thoracic aortic dissection and is stable, CT angiography is the preferred diagnostic test. This imaging technique provides a clear view of the aorta and helps plan surgical intervention if necessary. In cases of proximal aortic dissection, inter-arm blood pressure measurements may reveal a difference of over 20 mmHg, with the right arm showing higher pressure due to its proximity to the heart. The absence or reduction of femoral pulses on one or both sides is also a common finding. While a chest x-ray may show signs associated with aortic dissection, it is not specific enough for diagnosis. Transesophageal echocardiography (TOE) is used to confirm the diagnosis if CT angiography is inconclusive or if the patient is unstable. Transthoracic echocardiography (TTE) is less sensitive and specific than TOE for detecting aortic dissection.
Understanding Aortic Dissection: Classification, Investigation, and Management
Aortic dissection is a serious medical condition that requires prompt diagnosis and management. It is classified according to the location of the tear in the aorta, with type A affecting the ascending aorta in two-thirds of cases, and type B affecting the descending aorta distal to the left subclavian origin in one-third of cases. The DeBakey classification further divides aortic dissection into type I, which originates in the ascending aorta and propagates to at least the aortic arch, and type II, which is confined to the ascending aorta. Type III originates in the descending aorta and rarely extends proximally but will extend distally.
To diagnose aortic dissection, imaging studies such as chest x-ray and CT angiography of the chest, abdomen, and pelvis are essential. Transoesophageal echocardiography (TOE) may be more suitable for unstable patients who cannot undergo CT scanning. Management of type A aortic dissection requires surgical intervention, but blood pressure should be controlled to a target systolic of 100-120 mmHg while awaiting surgery. Type B aortic dissection can be managed conservatively with bed rest and IV labetalol to reduce blood pressure and prevent progression.
Complications of aortic dissection depend on the location of the tear. Backward tears can lead to aortic incompetence/regurgitation and myocardial infarction, while forward tears can cause unequal arm pulses and blood pressure, stroke, and renal failure. Endovascular repair of type B aortic dissection may have a role in the future. It is important to remember that patients may present acutely and be clinically unstable, so the choice of investigations and management should take this into account.
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This question is part of the following fields:
- Cardiovascular
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Question 15
Incorrect
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A 42-year-old woman who is six weeks pregnant presents to the Cardiovascular Clinic with a swollen right leg. Doppler studies confirm a deep vein thrombosis (DVT). She has no signs or symptoms of a pulmonary embolism (PE) and is haemodynamically stable. What is the most appropriate management choice in this case?
Your Answer: Elastic band compression of her left leg, bedrest, and foot elevation
Correct Answer: Start subcutaneous low molecular weight heparin (LMWH) throughout pregnancy and change to warfarin in the postpartum period
Explanation:Treatment Options for Deep Vein Thrombosis in Pregnancy
Start subcutaneous low molecular weight heparin (LMWH) throughout pregnancy and change to warfarin in the postpartum period: LMWH is recommended for the treatment of DVT during pregnancy. Treatment should be continued for at least three months and until six weeks postpartum. Warfarin can be used after day five of the postpartum period. Both LMWH and warfarin are safe to use while breastfeeding.
Elastic band compression of the affected leg, bedrest, and foot elevation: These measures have no benefit in treating DVT and may even increase the risk of developing a pulmonary embolism (PE) or another DVT.
Commence intravenous (IV) heparin: IV heparin can be used for the treatment of a shocked patient with PE if thrombolysis is not possible. It should not be used for DVT alone.
Oral anticoagulation with warfarin daily throughout pregnancy and the postpartum period: Warfarin is not recommended during pregnancy as it can cross the placenta and increase the risk of congenital malformations and bleeding.
Aspirin 300 mg daily throughout pregnancy and the postpartum period: Aspirin is not effective in treating DVT or PE as it is an antiplatelet drug, not an anticoagulant.
Treatment Options for Deep Vein Thrombosis in Pregnancy
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This question is part of the following fields:
- Cardiovascular
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Question 16
Incorrect
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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: Commence apixaban, perform a transoesophageal echocardiogram, and arrange urgent inpatient electrical cardioversion
Correct 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.
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This question is part of the following fields:
- Cardiovascular
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Question 17
Correct
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A 42-year-old woman with a history of rheumatic heart disease is urgently admitted with a fever, worsening shortness of breath, and a note from her primary care physician confirming the presence of a new heart murmur. During the examination, a harsh pansystolic murmur and early diastolic murmur are detected, and she has a temperature of 38.5 °C with fine basal crepitations in both lungs. Which one of the following should take immediate priority?
Your Answer: Administration of intravenous (IV) antibiotics
Explanation:Prioritizing Interventions in Suspected Infective Endocarditis
When a patient presents with suspected infective endocarditis, prompt intervention is crucial to limit valve destruction and prevent potentially life-threatening complications. The following interventions should be considered, prioritized, and administered as soon as possible:
Administration of intravenous (IV) antibiotics: Empirical treatment with gentamicin and benzylpenicillin may be initiated until microbiological advice suggests an alternative. Antibiotic delivery should take priority over other interventions.
Administration of paracetamol: Fever is a common symptom of infective endocarditis, and paracetamol can provide symptomatic relief. However, it should not take priority over antibiotic delivery.
Echocardiogram (ECHO): An ECHO is an important diagnostic tool for identifying infective endocarditis and detecting complications such as cardiac abscess and pseudoaneurysms. While it should be performed in all suspected cases, it does not take priority over antibiotic administration.
Electrocardiogram (ECG): An ECG can provide additional diagnostic information, including signs of paravalvular extension of infection and emboli in the coronary circulation. It should be part of the initial workup but does not take priority over antibiotic administration.
Throat swab: While a throat swab may be useful in identifying the causative organism of infective endocarditis, it should not take precedence over commencing antibiotics. Careful examination of the patient’s dentition is also crucial to evaluate for a possible infectious source.
In summary, when managing suspected infective endocarditis, prompt administration of IV antibiotics should take priority over other interventions. Other diagnostic and therapeutic interventions should be considered and prioritized based on the individual patient’s clinical presentation and needs.
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This question is part of the following fields:
- Cardiovascular
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Question 18
Correct
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A 35-year-old man is being monitored by his general practitioner for primary prevention of cardiovascular disease. He is a smoker and has a strong family history of premature death from ischaemic heart disease. Following lifestyle modifications, his fasting cholesterol concentration is 7.2 mmol/l. Upon consulting the local guidelines, it is found that his Qrisk2 score is > 17%. What drug therapy would you recommend?
Your Answer: Statin
Explanation:New NICE Guidelines for Lipid Modification: Statins as First-Line Treatment for Cardiovascular Risk
The National Institute for Health and Care Excellence (NICE) has updated its guidelines for lipid modification, recommending statins as the first-line treatment for patients with a cardiovascular risk of over 10%. Atorvastatin 20 mg is the preferred statin for these patients.
Cholestyramine, a previously used medication for hypercholesterolaemia, is no longer recommended. Instead, dietary advice should be offered alongside statin therapy. Fibrates and nicotinic acid may be used as second-line options for patients with high triglyceride levels or those who cannot tolerate multiple statins.
Under the new guidelines, patients with a QRISK2 score of over 10% should be offered statin therapy to reduce their 10-year risk for cardiovascular disease. After three months, lipids should be rechecked, with a focus on non-HDL cholesterol and aiming for a 40% reduction in non-HDL cholesterol.
In addition to medication, patients should be offered interventions to address modifiable risk factors such as smoking cessation, alcohol moderation, and weight reduction where appropriate. These new guidelines aim to improve the management of lipid disorders and reduce the risk of cardiovascular disease.
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This question is part of the following fields:
- Cardiovascular
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Question 19
Correct
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A 70-year-old patient was discovered to have an abdominal aortic aneurysm during a routine medical check-up. The patient is currently receiving treatment for hypertension and high cholesterol but is otherwise healthy and medically capable. The aneurysm was infra-renal and had a diameter of 4.9 cm.
What is the best course of action for managing this patient?Your Answer: Ultrasound scan every three months
Explanation:Screening and Management of Abdominal Aortic Aneurysms
Abdominal aortic aneurysms (AAAs) are screened for initially by an ultrasound scan of the abdomen. Men are invited for an initial ultrasound during the year of their 65th birthday, while women are not routinely screened as AAA is predominantly found in men.
If the initial scan shows an AAA of less than 3 cm, patients are discharged. If it is between 3 and 4.4 cm, they are invited back for yearly screening. If it is between 4.5 and 5.4 cm, patients receive an ultrasound scan every three months. If the aneurysm is above 5.5 cm, patients are referred to a vascular surgeon for consideration for repair.
Elective surgery is recommended for aneurysms larger than 5.5 cm in diameter or those that are growing rapidly, as clinical trials have shown that the risk of rupture is increased when the aneurysm is larger than 5.5 cm. Immediate surgery is only performed on those aneurysms that are leaking or ruptured.
Surveillance is required to ensure the aneurysm remains below 5.5 cm. Patients with an aneurysm over 4.5 cm require an ultrasound scan every three months. Once the aneurysm reaches 5.5 cm, patients are referred for consideration of elective surgery.
Managing Abdominal Aortic Aneurysms: Screening and Treatment Guidelines
Abdominal aortic aneurysms (AAAs) are a serious health concern that require careful management. This article outlines the screening and treatment guidelines for AAAs.
Screening for AAAs is done initially by an ultrasound scan of the abdomen. Men are invited for an initial ultrasound during the year of their 65th birthday, while women are not routinely screened. Patients with an AAA less than 3 cm are discharged, while those with an AAA between 3 and 4.4 cm are invited back for yearly screening. Patients with an AAA between 4.5 and 5.4 cm require an ultrasound scan every three months, while those with an AAA over 5.5 cm are referred to a vascular surgeon for consideration of elective surgery.
Elective surgery is recommended for aneurysms larger than 5.5 cm in diameter or those that are growing rapidly.
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This question is part of the following fields:
- Cardiovascular
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Question 20
Correct
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An 80-year-old woman arrives at the emergency department complaining of chest pain and shortness of breath. Her oxygen saturation is 90%. After receiving oxygen, she experiences ventricular fibrillation and has a GCS of 3. ALS is initiated. The patient has a medical history of type 2 diabetes and multiple pulmonary emboli. What additional medication should be considered for her management during ALS?
Your Answer: Alteplase
Explanation:During CPR, thrombolytic drugs should be considered if a pulmonary embolism (PE) is suspected. Alteplase is a suitable option for advanced life support (ALS) in such cases. This is particularly relevant for patients who present with symptoms suggestive of a PE and have a medical history of previous pulmonary emboli. Thrombolysis can be a life-saving intervention for these patients.
Adenosine is not appropriate for this situation as it is a class 5 antiarrhythmic used mainly for supraventricular tachycardia. Apixaban is an anticoagulant that is useful for long-term treatment and prevention of pulmonary emboli, but it is not suitable for immediate use in a hemodynamically unstable patient requiring advanced life support. Clopidogrel is an antiplatelet medication that is used in peripheral arterial disease and acute coronary syndrome, but it has no role in the acute treatment of a life-threatening pulmonary embolism.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 21
Correct
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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.
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This question is part of the following fields:
- Cardiovascular
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Question 22
Correct
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Sarah is a 60-year-old Caucasian woman who has had hypertension for 3 years. She is not diabetic and there is no other significant medical history. She is currently taking amlodipine at the maximum recommended dose of 10mg.
During her medication review at her GP surgery, her blood pressure remains elevated - it is averaging at 160/98 mmHg over several readings.
What would be the most suitable medication to consider next?Your Answer: Losartan
Explanation:To improve poorly controlled hypertension in a patient already taking a calcium channel blocker, the recommended next step according to NICE guidelines is to add either an ACE inhibitor or an angiotensin receptor blocker or a thiazide-like diuretic. In this scenario, as the options do not include an ACE inhibitor, losartan, an angiotensin receptor blocker, is the correct choice. Beta-blockers like bisoprolol are included in step 4 of NICE guidelines only if diuretic therapy is contraindicated or ineffective, and alpha-blockers like doxazosin are also part of step 4, so they are not the appropriate options for this patient.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 23
Incorrect
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A 65 year old man comes to you with complaints of palpitations. Upon conducting an electrocardiogram, you diagnose him with atrial fibrillation. He has no history of cardiovascular or cerebrovascular disease and his recent blood tests, including a random glucose test, were normal. His BMI is 28 kg/m² and his blood pressure today is 135/82 mmHg. Determine his CHA2DS2 VASc score for stroke risk.
Your Answer: 2
Correct Answer: 0
Explanation:NICE recommends using the CHA2DS2-VASc score to determine the need for anticoagulation in patients with any history of AF. The ORBIT scoring system should be used to assess bleeding risk, but anticoagulation should not be withheld solely on the grounds of age or risk of falls. DOACs are now recommended as the first-line anticoagulant for patients with AF, with warfarin used second-line if a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular
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Question 24
Correct
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A 70-year-old man has been taking warfarin for 2 years due to paroxysmal atrial fibrillation. He recently underwent DC cardioversion and is now in sinus rhythm after consulting with his cardiologist. His CHAD-VASC score is 4. Assuming he remains in sinus rhythm, what is the best course of action for his anticoagulation?
Your Answer: Continue anticoagulation lifelong
Explanation:Anticoagulation should be continued long-term, even if sinus rhythm is maintained, following elective DC cardioversion for AF in high-risk patients. The correct answer is to continue anticoagulation lifelong, with regular evaluation of bleeding risk. The options of continuing anticoagulation for 4 weeks or 6 months then stopping are incorrect for this patient who has a high CHAD-VASC score. One week of low molecular weight heparin is not the appropriate answer in this case, although it may be used for thromboprophylaxis in some post-surgical patients.
Atrial Fibrillation and Cardioversion: Elective Procedure for Rhythm Control
Cardioversion is a medical procedure used in atrial fibrillation (AF) to restore the heart’s normal rhythm. There are two scenarios where cardioversion may be used: as an emergency if the patient is haemodynamically unstable, or as an elective procedure where a rhythm control strategy is preferred. In the elective scenario, cardioversion can be performed either electrically or pharmacologically. Electrical cardioversion is synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced.
According to the 2014 NICE guidelines, rate or rhythm control should be offered if the onset of the arrhythmia is less than 48 hours, and rate control should be started if it is more than 48 hours or is uncertain. If the AF is definitely of less than 48 hours onset, patients should be heparinised and may be cardioverted using either electrical or pharmacological means. However, if the patient has been in AF for more than 48 hours, anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded, patients may be heparinised and cardioverted immediately.
NICE recommends electrical cardioversion in this scenario, rather than pharmacological. If there is a high risk of cardioversion failure, it is recommended to have at least 4 weeks of amiodarone or sotalol prior to electrical cardioversion. Following electrical cardioversion, patients should be anticoagulated for at least 4 weeks. After this time, decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence.
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This question is part of the following fields:
- Cardiovascular
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Question 25
Correct
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An 80-year-old patient is being treated for symptomatic bradycardia. Despite receiving multiple boluses of atropine, the patient's condition remains unchanged with a heart rate of 35 beats per minute, blood pressure of 85/55 mmHg, respiratory rate of 22 breaths per minute, oxygen saturation of 98%, and a temperature of 37.3ºC. The patient is experiencing confusion, sweating, and has cold and clammy extremities. What is the most appropriate course of action for managing this patient?
Your Answer: External pacing
Explanation:Management of Bradycardia in Peri-Arrest Rhythms
The 2015 Resuscitation Council (UK) guidelines highlight the importance of identifying adverse signs and potential risk of asystole in the management of bradycardia in peri-arrest rhythms. Adverse signs indicating haemodynamic compromise include shock, syncope, myocardial ischaemia, and heart failure. Atropine (500 mcg IV) is the first line treatment in this situation. If there is an unsatisfactory response, interventions such as atropine (up to a maximum of 3mg), transcutaneous pacing, and isoprenaline/adrenaline infusion titrated to response may be used. Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.
Furthermore, the presence of risk factors for asystole such as complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, and ventricular pause > 3 seconds should be considered. Even if there is a satisfactory response to atropine, specialist help is indicated to consider the need for transvenous pacing. Effective management of bradycardia in peri-arrest rhythms is crucial in preventing further deterioration and improving patient outcomes.
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This question is part of the following fields:
- Cardiovascular
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Question 26
Incorrect
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A 45-year-old man who was previously healthy comes to the clinic complaining of increasing shortness of breath over the past four to five months. His father passed away a few years ago due to a lung disease. During the examination, the doctor notices an elevated jugular venous pressure and a palpable heave at the left sternal edge.
What is the most probable provisional diagnosis?Your Answer: Pulmonary venous hypertension
Correct Answer: Familial primary pulmonary hypertension
Explanation:Differential Diagnosis for Familial Primary Pulmonary Hypertension
Familial primary pulmonary hypertension is a rare condition that presents with breathlessness, fatigue, angina, or syncope. It has an autosomal dominant pattern of inheritance with incomplete penetrance and physical signs such as elevated JVP, left parasternal heave, pansystolic murmur, right ventricular S4, and peripheral edema. Without treatment, average survival is less than three years. While tricuspid regurgitation may be present, it is best explained in the context of a diagnosis of familial primary pulmonary hypertension. Chronic pulmonary thromboembolism is a more common differential diagnosis that should be considered. Constrictive pericarditis and pulmonary venous hypertension are unlikely diagnoses as they do not run in families. Clinical management requires a specialist with considerable expertise in the field.
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This question is part of the following fields:
- Cardiovascular
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Question 27
Incorrect
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A 50-year-old man presents with intermittent leg pain that worsens with movement and improves with rest. He reports no recent illness or injury. The patient has a history of hypertension and takes amlodipine 5mg daily. He is a smoker with a BMI of 30 kg/m². On examination, there is no visible deformity in his lower limbs, and his calves are soft and nontender bilaterally with no edema. The ankle-brachial pressure index is 0.8. The patient is started on atorvastatin 80 mg daily. What other treatment should be prescribed for this patient?
Your Answer: Aspirin
Correct Answer: Clopidogrel
Explanation:NICE guidelines recommend that patients with peripheral arterial disease should be treated with clopidogrel and atorvastatin. This patient is experiencing intermittent claudication, which is a symptom of peripheral vascular disease caused by atherosclerosis. It is important to differentiate this from critical limb ischaemia, which is characterised by pain at rest. An ankle-brachial pressure index of < 0.9 suggests PAD, with an index < 0.5 suggesting critical limb ischaemia. This patient has several risk factors, including smoking, hypertension and obesity. Aspirin is not the first-line antiplatelet for PAD and should only be used if clopidogrel is not tolerated. Low molecular weight heparin is indicated for deep vein thrombosis, which is characterised by unilateral calf pain and swelling with tenderness along the deep venous system. Metformin is indicated for diabetes mellitus, which cannot be diagnosed without a HbA1c or blood glucose reading. Regular glucose checks are recommended for patients with vascular risk factors. Peripheral arterial disease (PAD) is a condition that is strongly associated with smoking. Therefore, patients who still smoke should be provided with assistance to quit smoking. It is also important to treat any comorbidities that the patient may have, such as hypertension, diabetes mellitus, and obesity. All patients with established cardiovascular disease, including PAD, should be taking a statin, with Atorvastatin 80 mg being the recommended dosage. In 2010, NICE published guidance recommending the use of clopidogrel as the first-line treatment for PAD patients instead of aspirin. Exercise training has also been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions. For severe PAD or critical limb ischaemia, there are several treatment options available. Endovascular revascularization and percutaneous transluminal angioplasty with or without stent placement are typically used for short segment stenosis, aortic iliac disease, and high-risk patients. On the other hand, surgical revascularization, surgical bypass with an autologous vein or prosthetic material, and endarterectomy are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should only be considered for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery. There are also drugs licensed for use in PAD, including naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life. Cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, is not recommended by NICE.
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This question is part of the following fields:
- Cardiovascular
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Question 28
Incorrect
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A 72-year-old man presents for follow-up. He was diagnosed with angina pectoris and is currently prescribed aspirin 75mg once daily, simvastatin 40 mg once daily, and atenolol 100 mg once daily. If his angina symptoms are not adequately managed with this regimen, what would be the most suitable course of action?
Your Answer: Add isosorbide mononitrate MR
Correct Answer: Add a long-acting dihydropyridine calcium-channel blocker
Explanation:When beta-blockers fail to control angina, it is recommended to supplement with a dihydropyridine calcium channel blocker that has a longer duration of action.
Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Cardiovascular
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Question 29
Correct
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A 65-year-old woman presents with difficulty breathing and feeling lightheaded. During the examination, an irregularly irregular pulse is noted. An ECG taken at the time shows the absence of p waves. What medical condition in her past could be responsible for her symptoms?
Your Answer: Hyperthyroidism
Explanation:Common Endocrine Disorders and their Cardiac Manifestations
Endocrine disorders can have significant effects on the cardiovascular system, including the development of arrhythmias. Atrial fibrillation is a common arrhythmia that can be caused by hyperthyroidism, which should be tested for in patients presenting with this condition. Other signs of thyrotoxicosis include sinus tachycardia, physiological tremor, lid lag, and lid retraction. Graves’ disease, a common cause of hyperthyroidism, can also present with pretibial myxoedema, proptosis, chemosis, and thyroid complex ophthalmoplegia.
Hyperparathyroidism can cause hypercalcemia, which may present with non-specific symptoms such as aches and pains, dehydration, fatigue, mood disturbance, and constipation. It can also cause renal stones. Hypothyroidism, on the other hand, may cause bradycardia and can be caused by Hashimoto’s thyroiditis, subacute thyroiditis, iodine deficiency, or iatrogenic factors such as post-carbimazole treatment, radio-iodine, and thyroidectomy. Drugs such as lithium and amiodarone can also cause hypothyroidism.
Cushing syndrome, a disorder caused by excess cortisol production, is not typically associated with arrhythmias. Type 1 diabetes mellitus, another endocrine disorder, also does not typically present with arrhythmias.
In summary, it is important to consider endocrine disorders as potential causes of cardiac manifestations, including arrhythmias. Proper diagnosis and management of these conditions can help prevent serious cardiovascular complications.
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This question is part of the following fields:
- Cardiovascular
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Question 30
Incorrect
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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: 15 l/min via reservoir mask
Correct 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.
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This question is part of the following fields:
- Cardiovascular
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Question 31
Correct
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A 60-year-old man with no significant medical history presents to the Emergency Department with an ECG indicative of an anterior myocardial infarction. Tragically, he experiences cardiac arrest shortly after arrival. What is the leading cause of mortality in patients following a heart attack?
Your Answer: Ventricular fibrillation
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.
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This question is part of the following fields:
- Cardiovascular
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Question 32
Incorrect
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A 35-year-old man presents to the Emergency Department with a sudden onset of central abdominal pain. He claims this is radiating to his back and that it started this afternoon. He is currently still in pain and has been started on some analgesia. His blood pressure is 135/80 mmHg and his heart rate is 100 bpm.
His past medical history includes amputation of the big toe on the left lower limb and femoral-popliteal bypass on the right. He smokes around 20 cigarettes daily.
Which of the following tests should be done urgently to determine the underlying cause of his symptomatology?Your Answer: Computed tomography (CT) scan of the abdomen
Correct Answer: Bedside abdominal ultrasound (US)
Explanation:Bedside Abdominal Ultrasound for Ruptured Abdominal Aortic Aneurysm: Diagnosis and Management
This patient is likely experiencing a ruptured abdominal aortic aneurysm (AAA), a life-threatening medical emergency. Bedside abdominal ultrasound (US) is the best initial diagnostic test for ruling out AAA as a cause of abdominal or back pain, as it provides an instant, objective measurement of aortic diameter. An AAA is a dilatation of the abdominal aorta greater than 3 cm in diameter, with a significant risk of rupture at diameters greater than 5 cm. Risk factors for AAA include smoking and co-existing vascular disease. Symptoms of a ruptured AAA include pain, cardiovascular failure, and distal ischemia. Once diagnosed, a CT angiogram is the gold-standard imaging for planning surgery to repair the aneurysm. Endoscopic retrograde cholangiopancreatography and liver function tests are not indicated in this case, while serum amylase or lipase should be measured in all patients presenting with acute abdominal or upper back pain to exclude acute pancreatitis as a differential diagnosis.
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This question is part of the following fields:
- Cardiovascular
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Question 33
Incorrect
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A 56-year-old female presents with an acutely painful hand. She has a history of hypertension, Raynaud's phenomenon, and has smoked twenty cigarettes a day since she was twenty-two years old. She describes the pain as 'different from her usual Raynaud's,' there has been no relief of symptoms despite wearing gloves and making sure her hands are warm.
Upon examination, her blood pressure is 158/80 mmHg, her right hand is blanched white and feels cold, and the colour of her forearm is normal. The radial pulse is not palpable at the wrist. What is the most likely explanation for her symptoms?Your Answer: Radial artery dissection
Correct Answer: Buerger's disease
Explanation:If a patient with extremity ischaemia is diagnosed with Raynaud’s phenomenon, Buerger’s disease should be considered as a possible underlying condition. Buerger’s disease is a condition where the small and medium arteries in the hands and feet become inflamed and thrombosed, leading to acute or chronic progressive ischaemic changes and potentially gangrene. It is strongly associated with smoking. Osteoarthritis, on the other hand, presents with joint pain and swelling, typically in the wrist, knee, hip, or thumb base, and is more common with age. Radial artery dissection is unlikely in the given scenario as there is no history of traumatic injury. Raynaud’s phenomenon, which is characterised by transient vasospasm of the digits triggered by cold, is usually treated conservatively with warmth and sometimes calcium channel blockers in severe cases. It is mostly idiopathic but can be associated with underlying connective tissue disease.
Understanding Buerger’s Disease
Buerger’s disease, also known as thromboangiitis obliterans, is a type of vasculitis that affects the small and medium-sized blood vessels. This condition is strongly linked to smoking and can cause a range of symptoms, including extremity ischemia, intermittent claudication, ischaemic ulcers, superficial thrombophlebitis, and Raynaud’s phenomenon.
Individuals with Buerger’s disease may experience reduced blood flow to their limbs, which can lead to pain, numbness, and tingling sensations. This can make it difficult to walk or perform other activities, and may even result in the development of ulcers or sores on the skin.
Superficial thrombophlebitis, or inflammation of the veins close to the surface of the skin, is another common symptom of Buerger’s disease. This can cause redness, swelling, and tenderness in the affected area.
Raynaud’s phenomenon, which is characterized by the narrowing of blood vessels in the fingers and toes, is also associated with Buerger’s disease. This can cause the affected areas to turn white or blue and feel cold and numb.
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This question is part of the following fields:
- Cardiovascular
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Question 34
Correct
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A 45-year-old woman had an anterior myocardial infarction. She has a body mass index (BMI) of 30 kg/m2, smokes 10 cigarettes per day and admits to a high-sugar diet and minimal exercise.
Which of the following non-pharmacological interventions will be most helpful in reducing her risk for a future ischaemic event?
Your Answer: Stopping smoking
Explanation:Reducing the Risk of Vascular Events: Lifestyle Interventions
Smoking, high salt intake, poor diet, lack of exercise, and obesity are all risk factors for vascular events such as heart attacks and strokes. However, making lifestyle changes can significantly reduce the risk of these events.
Stopping smoking is the most effective non-pharmacological intervention, as it reduces the risk of heart disease by 2-3 times compared to those who continue to smoke.
Reducing salt intake to 3-6 g/day can also help, as both high and low salt intake can increase the risk of vascular events.
Improving diet by controlling calorie intake can lead to weight loss, improved blood sugar control, and better lipid profiles.
Regular exercise, such as 30 minutes of activity five times a week, can lower the risk of vascular events by 30%.
Finally, weight reduction is important, as obesity increases the risk of heart attacks and strokes at a younger age and can lead to higher mortality rates.
Overall, making these lifestyle changes can significantly reduce the risk of vascular events and improve overall health.
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This question is part of the following fields:
- Cardiovascular
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Question 35
Correct
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A 82-year-old man is admitted to the stroke unit with a left sided infarct. After receiving thrombolysis, he is now stable on the ward. The medical team wants to initiate regular antiplatelet therapy, but the patient has allergies to both aspirin and clopidogrel. What alternative medication can be prescribed for him?
Your Answer: Dipyridamole
Explanation:If aspirin and clopidogrel cannot be used after an ischaemic stroke, MR dipyridamole may be administered as the sole antiplatelet option. Warfarin and rivaroxaban may be considered, but are more suitable for patients with AF. Bisoprolol and enoxaparin are not antiplatelet medications.
The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Cardiovascular
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Question 36
Correct
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A 38-year-old man presents with left-sided pleuritic chest pain and a dry cough. He reports that the pain is alleviated by sitting forward and has been experiencing flu-like symptoms for the past two days. What is the expected ECG finding for a diagnosis of acute pericarditis?
Your Answer: Widespread ST elevation
Explanation:Understanding Acute Pericarditis
Acute pericarditis is a medical condition characterized by inflammation of the pericardial sac that lasts for less than 4-6 weeks. The condition can be caused by various factors such as viral infections, tuberculosis, uraemia, post-myocardial infarction, autoimmune pericarditis, radiotherapy, connective tissue disease, hypothyroidism, malignancy, and trauma. Symptoms of acute pericarditis include chest pain, non-productive cough, dyspnoea, and flu-like symptoms. Patients may also experience pericardial rub.
To diagnose acute pericarditis, doctors may perform an electrocardiogram (ECG) to check for changes in the heart’s electrical activity. Blood tests may also be conducted to check for inflammatory markers and troponin levels. Patients suspected of having acute pericarditis should undergo transthoracic echocardiography.
Treatment for acute pericarditis depends on the underlying cause. Patients with high-risk features such as fever or elevated troponin levels may need to be hospitalized. However, most patients with pericarditis secondary to viral infection can be managed as outpatients. Strenuous physical activity should be avoided until symptoms resolve and inflammatory markers normalize. A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine is typically used as first-line treatment for patients with acute idiopathic or viral pericarditis. The medication is usually tapered off over 1-2 weeks.
Overall, understanding acute pericarditis is important for prompt diagnosis and appropriate management of the condition.
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This question is part of the following fields:
- Cardiovascular
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Question 37
Correct
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A 50-year-old man presents to you with recent blood test results showing a total cholesterol of 6.2 mmol/L. You schedule an appointment to discuss this further and calculate his Qrisk score to be 23%. He has a 20-year history of smoking 10 cigarettes a day and his father died of a heart attack at age 50. He also has a past medical history of asthma. Which medication would you recommend he start taking?
Your Answer: Atorvastatin 20mg
Explanation:To prevent cardiovascular disease, it is recommended to start taking Atorvastatin 20mg, which is a high-intensity statin. Atorvastatin 80 mg is used for secondary prevention. Simvastatin 10mg and 20mg are considered low-intensity statins. It is important to combine statin treatment with lifestyle changes such as increasing physical activity, reducing alcohol consumption, and adopting a heart-healthy diet.
The 2014 NICE guidelines recommend using the QRISK2 tool to identify patients over 40 years old who are at high risk of CVD, with a 10-year risk of 10% or greater. A full lipid profile should be checked before starting a statin, and atorvastatin 20mg should be offered first-line. Lifestyle modifications include a cardioprotective diet, physical activity, weight management, limiting alcohol intake, and smoking cessation. Follow-up should occur at 3 months, with consideration of increasing the dose of atorvastatin up to 80 mg if necessary.
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This question is part of the following fields:
- Cardiovascular
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Question 38
Incorrect
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The medical emergency team is called to an 85-year-old man who has fainted in the cardiology ward whilst visiting a relative. He has been moved to a trolley, where he appears confused and is complaining of dizziness. An A-E examination is performed:
A: Is the airway patent?
B: Is there any respiratory distress? Sats are 98% on air.
C: Is the radial pulse regular? The patient has cool peripheries, blood pressure of 85/55 mmHg, and heart sounds of 1 + 2 + 0.
D: What is the Glasgow Coma Scale (GCS) score? Are the pupils equal and reactive to light?
E: Is the temperature normal? No other findings are noted.
An ECG shows sinus bradycardia with a rate of 42 beats per minute. What is the immediate treatment for his bradycardia?Your Answer: Start transcutaneous pacing
Correct Answer: Give 500 micrograms atropine
Explanation:For patients with bradycardia and signs of shock, the immediate treatment is 500 micrograms of atropine, which can be repeated up to a maximum of 3mg. This is in line with the Resuscitation Council Guidelines. It is important to identify the cause of the bradycardia and check for reversible causes, while also managing the bradycardia to prevent further deterioration and possible cardiac arrest.
It should be noted that 3mg of atropine is the maximum amount that can be given, not the starting dose. If there is an insufficient response to 500 micrograms of atropine, further doses can be given until a total of 3mg has been administered.
Administering 500ml of intravenous fluid stat may temporarily increase cardiac output, but it will not treat the bradycardia causing the patient’s shock.
Transcutaneous pacing is a method of temporarily pacing the heart in an emergency by delivering pulses of electric current through the chest. It may be used as an interim measure if treatment with atropine is unsuccessful, while awaiting the establishment of more permanent measures such as transvenous pacing or permanent pacemaker insertion.
Management of Bradycardia in Peri-Arrest Rhythms
The 2015 Resuscitation Council (UK) guidelines highlight the importance of identifying adverse signs and potential risk of asystole in the management of bradycardia in peri-arrest rhythms. Adverse signs indicating haemodynamic compromise include shock, syncope, myocardial ischaemia, and heart failure. Atropine (500 mcg IV) is the first line treatment in this situation. If there is an unsatisfactory response, interventions such as atropine (up to a maximum of 3mg), transcutaneous pacing, and isoprenaline/adrenaline infusion titrated to response may be used. Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.
Furthermore, the presence of risk factors for asystole such as complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, and ventricular pause > 3 seconds should be considered. Even if there is a satisfactory response to atropine, specialist help is indicated to consider the need for transvenous pacing. Effective management of bradycardia in peri-arrest rhythms is crucial in preventing further deterioration and improving patient outcomes.
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This question is part of the following fields:
- Cardiovascular
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Question 39
Incorrect
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An 80-year-old man has been experiencing recurrent falls due to orthostatic hypotension. Despite trying conservative measures such as increasing fluid and salt intake, reviewing medications, and wearing compression stockings, he still experiences dizziness upon standing. What medication options are available to alleviate his symptoms?
Your Answer: Doxazosin
Correct Answer: Fludrocortisone
Explanation:Fludrocortisone and midodrine are two medications that can be used to treat orthostatic hypotension. However, doxazosin, a medication used for hypertension, can actually worsen orthostatic hypotension. Prochlorperazine is used for vertigo and isoprenaline and dobutamine are not used for orthostatic hypotension as they are ionotropic agents used for patients in shock.
Fludrocortisone works by increasing renal sodium reabsorption and plasma volume, which helps counteract the physiological orthostatic vasovagal reflex. Its effectiveness has been supported by two small observational studies and one small double-blind trial, leading the European Society of Cardiology to give it a Class IIa recommendation.
To manage orthostatic hypotension, patients should be educated on lifestyle measures such as staying hydrated and increasing salt intake. Vasoactive drugs like nitrates, antihypertensives, neuroleptic agents, or dopaminergic drugs should be discontinued if possible. If symptoms persist, compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping can be considered.
Understanding Syncope: Causes and Evaluation
Syncope is a temporary loss of consciousness caused by a sudden decrease in blood flow to the brain. This condition is characterized by a rapid onset, short duration, and complete recovery without any medical intervention. It is important to note that syncope is different from other causes of collapse, such as epilepsy. To better understand syncope, the European Society of Cardiology has classified it into three categories: reflex syncope, orthostatic syncope, and cardiac syncope.
Reflex syncope, also known as neurally mediated syncope, is the most common cause of syncope in all age groups. It can be triggered by emotional stress, pain, or other situational factors such as coughing or gastrointestinal issues. Orthostatic syncope occurs when there is a sudden drop in blood pressure upon standing up, and it is more common in older patients. Cardiac syncope is caused by heart-related issues such as arrhythmias, structural abnormalities, or pulmonary embolism.
To evaluate syncope, doctors may perform a series of tests, including a cardiovascular examination, postural blood pressure readings, ECG, carotid sinus massage, tilt table test, and 24-hour ECG monitoring. These tests help to identify the underlying cause of syncope and determine the appropriate treatment plan. By understanding the causes and evaluation of syncope, patients and healthcare providers can work together to manage this condition effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 40
Correct
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A 40-year-old woman presents to the emergency department complaining of chest pain and shortness of breath for the past 2 days. She denies having a fever or cough. Her medical history includes type 1 diabetes and uterine fibroids that were surgically removed 3 weeks ago.
Upon examination, the patient's heart rate is 103 bpm, and her blood pressure is 122/77 mmHg. Her chest sounds are clear, and her oxygen saturation is 92% on air. She is afebrile.
Laboratory results show a D-dimer level of 1200 ng/mL (< 400) and a troponin level of 24 ng/L (< 14). An ECG reveals sinus tachycardia with T wave inversion in V1-V4.
What is the most appropriate management plan for this patient?Your Answer: Apixaban for 3 months
Explanation:Patients with symptoms of pulmonary embolism, such as chest pain and shortness of breath, are typically treated for 3 months if the PE is provoked. This is especially true for patients who have had recent surgery, as they are at a higher risk for a provoked PE. Clinical signs of a PE include tachycardia, hypoxia, and an elevated D-dimer. ECG changes may include sinus tachycardia, S1Q3T3, and T-wave inversion in the right-sided leads. Patients with right heart strain may also have raised troponin levels. The treatment of choice for a provoked PE is a low-molecular-weight heparin or a direct oral anticoagulant. Apixaban for 6 months is used for unprovoked PEs without risk factors, while apixaban for 12 months is not routinely prescribed. Dual antiplatelet therapy is used for coronary ischaemia, but a raised D-dimer, hypoxia, and ECG changes suggest a PE is more likely.
Management of Pulmonary Embolism: NICE Guidelines
Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.
Anticoagulant therapy is the cornerstone of VTE management, and the guidelines recommend using apixaban or rivaroxaban as the first-line treatment following the diagnosis of a PE. If neither of these is suitable, LMWH followed by dabigatran or edoxaban or LMWH followed by a vitamin K antagonist (VKA) can be used. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation is determined by whether the VTE was provoked or unprovoked, with treatment typically stopped after 3-6 months for provoked VTE and continued for up to 6 months for unprovoked VTE.
In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak.
Overall, the updated NICE guidelines provide clear recommendations for the management of PE, including the use of DOACs as first-line treatment and outpatient management for low-risk patients. The guidelines also emphasize the importance of individualized treatment based on risk stratification and balancing the risks of VTE recurrence and bleeding.
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This question is part of the following fields:
- Cardiovascular
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Question 41
Correct
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A 63-year-old woman complains of unmanageable twitching and cramping in her legs. She has a medical history of heart failure and reports that her symptoms began a few days after starting a new medication prescribed by her cardiologist. As a result, you order routine blood tests that reveal hypokalaemia. Which medication is the probable culprit for her symptoms?
Your Answer: Furosemide
Explanation:Individuals with heart failure and an ejection fraction of 40% or lower should be prescribed an ACE inhibitor, unless there are contraindications or intolerance. This is supported by numerous clinical trials that have shown their efficacy in reducing hospital admissions and mortality rates. The dosage should be started low and gradually increased until the target dose or the highest tolerated dose is achieved, with regular monitoring of renal function and serum electrolytes.
Loop Diuretics: Mechanism of Action and Indications
Loop diuretics, such as furosemide and bumetanide, are medications that inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle. This reduces the absorption of NaCl and increases the excretion of water and electrolytes, making them effective in treating conditions such as heart failure and resistant hypertension. Loop diuretics act on NKCC2, which is more prevalent in the kidneys.
As loop diuretics work on the apical membrane, they must first be filtered into the tubules by the glomerulus before they can have an effect. This means that patients with poor renal function may require higher doses to achieve a sufficient concentration within the tubules.
Loop diuretics are commonly used in the treatment of heart failure, both acutely (usually intravenously) and chronically (usually orally). They are also effective in treating resistant hypertension, particularly in patients with renal impairment.
However, loop diuretics can have adverse effects, including hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, ototoxicity, hypocalcemia, renal impairment (from dehydration and direct toxic effect), hyperglycemia (less common than with thiazides), and gout.
In summary, loop diuretics are effective medications for treating heart failure and resistant hypertension, but their use should be carefully monitored due to potential adverse effects. Patients with poor renal function may require higher doses to achieve therapeutic effects.
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This question is part of the following fields:
- Cardiovascular
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Question 42
Correct
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A 50-year-old man arrives at the emergency department complaining of severe chest pain that radiates to his left arm, accompanied by nausea and sweating. His ECG reveals widespread ST depression with T wave inversion, and his blood tests show a haemoglobin level of 75g/L. What is the appropriate treatment for his anaemia?
Your Answer: Transfusion of packed red cells
Explanation:For patients with ACS, the recommended transfusion threshold is a haemoglobin level of 80 g/L. In this case, the patient is presenting with symptoms of ACS and his ECG confirms this. However, his haemoglobin level is below the threshold, indicating severe anaemia. Therefore, an immediate transfusion is necessary to alleviate the anaemia. Anaemia can exacerbate ischaemia in ACS, leading to increased strain on the heart and reduced oxygen supply. The guidelines suggest aiming for a haemoglobin concentration of 80-100 g/L after transfusion. Oral or IV iron would not provide immediate relief, and IV Hartmann’s solution is not a suitable treatment for anaemia and would not address the underlying issue. This highlights the importance of prompt and appropriate treatment for patients with ACS. This information is based on the NICE guideline [NG24].
Guidelines for Red Blood Cell Transfusion
In 2015, NICE released guidelines for the use of blood products, specifically red blood cells. These guidelines recommend different transfusion thresholds for patients with and without acute coronary syndrome (ACS). For patients without ACS, the transfusion threshold is 70 g/L, while for those with ACS, it is 80 g/L. The target hemoglobin level after transfusion is 70-90 g/L for patients without ACS and 80-100 g/L for those with ACS. It is important to note that these thresholds should not be used for patients with ongoing major hemorrhage or those who require regular blood transfusions for chronic anemia.
When administering red blood cells, it is crucial to store them at 4°C prior to infusion. In non-urgent scenarios, a unit of RBC is typically transfused over a period of 90-120 minutes. By following these guidelines, healthcare professionals can ensure that red blood cell transfusions are administered safely and effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 43
Correct
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A 49-year-old man comes to the emergency department complaining of dizziness and shortness of breath on exertion for the past 3 days. He reports experiencing palpitations during this time but denies any chest pain or cough. The patient has a history of hypertension and angina, for which he takes amlodipine and GTN spray, respectively. Upon examination, he appears alert and oriented, but his vital signs reveal a heart rate of 170 BPM, respiratory rate of 25 breaths/min, and blood pressure of 72/50 mmHg. An ECG shows a narrow complex irregular tachycardia without P waves. What is the most crucial next step in management?
Your Answer: Electrical cardioversion
Explanation:In the case of an acute presentation of atrial fibrillation with signs of haemodynamic instability such as hypotension or heart failure, the correct treatment is electrical cardioversion. This is because the patient is at risk of going into cardiac arrest and needs to be returned to normal sinus rhythm immediately to prevent end organ damage. Giving a bolus of IV saline is not recommended as it will not push more blood into the ventricles and could even be harmful. Starting high dose aspirin or bisoprolol is not appropriate in this situation. Digoxin is only considered as a second line treatment for stable patients, so pharmacologic therapies are not considered until after cardioversion has been attempted and blood pressure returns to normal.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 44
Incorrect
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A 62-year-old female presents to the Emergency Department complaining of central chest pain that has been radiating to her left arm for the past 30 minutes. Upon examination, an ECG reveals ST elevation in leads II, III, and aVF. Which coronary artery is the most probable culprit?
Your Answer: Left anterior descending
Correct Answer: Right coronary
Explanation:Anteroseptal changes in V1-V4 indicate involvement of the left anterior descending artery.
Inferior changes in II, III, and aVF suggest the right coronary artery is affected.
Anterolateral changes in V1-6, I, and aVL indicate the proximal left anterior descending artery is involved.
Lateral changes in I, aVL, and possibly V5-6 suggest the left circumflex artery is affected.
Posterior changes in V1-3 may indicate a posterior infarction, which is confirmed by ST elevation and Q waves in posterior leads (V7-9). This type of infarction is usually caused by the left circumflex artery, but can also be caused by the right coronary artery.
Reciprocal changes of STEMI are typically seen as horizontal ST depression, tall and broad R waves, upright T waves, and a dominant R wave in V2. It is important to note that a new left bundle branch block (LBBB) may indicate acute coronary syndrome.Overall, understanding the correlation between ECG changes and coronary artery territories is crucial in diagnosing acute coronary syndrome. By identifying the specific changes in the ECG, medical professionals can determine which artery is affected and provide appropriate treatment. Additionally, recognizing the reciprocal changes of STEMI and the significance of a new LBBB can aid in making an accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular
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Question 45
Incorrect
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A 42-year-old man presents to the Emergency Department (ED) with a history of fainting. He reports feeling lightheaded while jogging. His father recently passed away suddenly due to a heart condition. Upon examination, he has an irregular pulse, a forceful cardiac impulse, and a mid-systolic murmur.
What is the most probable diagnosis? Choose the ONE best option from the list below.Your Answer: Aortic stenosis (AS)
Correct Answer: Hypertrophic cardiomyopathy (HCM)
Explanation:Hypertrophic cardiomyopathy (HCM) is a genetic disorder with autosomal dominant transmission that is the most common form of inherited cardiomyopathy. It has a prevalence of about 100 per 100,000 and can present with symptoms similar to aortic stenosis, but with a jerky pulse. Sudden death can be the first symptom, especially during or after physical activity. Risk factors for sudden death in HCM include a history of previous cardiac arrest or sustained ventricular tachycardia, recurrent syncope, adverse genotype and/or family history, exercise-induced hypotension, multiple episodes of non-sustained ventricular tachycardia on ambulatory ECG, and a marked increase in the thickness of the left ventricular wall. Dilated cardiomyopathy is the most common form of non-ischaemic cardiomyopathy, but given the patient’s family history, jerky pulse, and collapse on exercise, it is not the most likely cause. Mitral valve prolapse tends to present with palpitations, dyspnoea, low BMI, chest pain, and syncope, with a mid-systolic click followed by a late systolic murmur. Aortic stenosis can cause dizziness, syncope, and angina, but the family history makes HCM more likely than AS. Pericarditis tends to cause central chest pain that is relieved by leaning forward and worsened by coughing or straining.
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This question is part of the following fields:
- Cardiovascular
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Question 46
Correct
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A 63-year-old woman presents for follow-up. She completed a 6 month course of warfarin a year ago after being diagnosed with an unprovoked, proximal deep vein thrombosis. Over the past few weeks, she has been experiencing a sensation of heaviness and aching in the same leg, accompanied by itching and some swelling that subsides each night. Her medical history includes osteoarthritis and type 2 diabetes mellitus. On examination, there are prominent varicose veins on the affected leg, and the skin above the medial malleolus is discolored. The calves have no difference in circumference. Her vital signs are as follows: temperature 36.9ºC, pulse 78/min, and blood pressure 108/82 mmHg. What is the most probable diagnosis?
Your Answer: Post-thrombotic syndrome
Explanation:The symptoms of pruritus and pain that gradually worsen, along with the results of the examination, indicate a high likelihood of post-thrombotic syndrome.
Post-Thrombotic Syndrome: A Complication of Deep Vein Thrombosis
Post-thrombotic syndrome is a clinical syndrome that may develop following a deep vein thrombosis (DVT). It is caused by venous outflow obstruction and venous insufficiency, which leads to chronic venous hypertension. Patients with post-thrombotic syndrome may experience painful, heavy calves, pruritus, swelling, varicose veins, and venous ulceration.
In the past, compression stockings were offered to patients with DVT to reduce the risk of post-thrombotic syndrome. However, current recommendations state that elastic graduated compression stockings should not be used to prevent post-thrombotic syndrome or VTE recurrence after a proximal DVT. This recommendation does not cover the use of elastic stockings for the management of leg symptoms after DVT.
Once post-thrombotic syndrome has developed, compression stockings are a recommended treatment. Other recommendations include keeping the leg elevated. It is important for healthcare providers to recognize the potential complications of DVT and to provide appropriate management to prevent the development of post-thrombotic syndrome.
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This question is part of the following fields:
- Cardiovascular
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Question 47
Correct
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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.
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This question is part of the following fields:
- Cardiovascular
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Question 48
Correct
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A 70-year-old man who takes bendroflumethiazide for hypertension is brought to the Emergency Department. Upon admission, his blood work shows the following:
Na+ 131 mmol/l
K+ 2.2 mmol/l
Urea 3.1 mmol/l
Creatinine 56 µmol/l
Glucose 4.3 mmol/l
What ECG feature is most likely to be observed?Your Answer: U waves
Explanation:ECG Features of Hypokalaemia
Hypokalaemia is a condition characterized by low levels of potassium in the blood. This condition can be detected through an electrocardiogram (ECG) which shows specific features. The ECG features of hypokalaemia include U waves, small or absent T waves, prolonged PR interval, ST depression, and long QT. The U waves are particularly noticeable and are accompanied by a borderline PR interval.
To remember these features, one registered user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT. It is important to detect hypokalaemia early as it can lead to serious complications such as cardiac arrhythmias and even cardiac arrest. Therefore, regular monitoring of potassium levels and ECGs is crucial for individuals at risk of hypokalaemia.
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This question is part of the following fields:
- Cardiovascular
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Question 49
Incorrect
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You assess a 65-year-old man who has recently been discharged from hospital in France following a heart attack. He presents with an echocardiogram report indicating his left ventricular ejection fraction is 38%. Upon examination, his pulse is regular at 76 beats per minute, blood pressure is 126/74 mmHg, and his chest is clear. He is currently taking aspirin, simvastatin, and lisinopril. What is the most appropriate course of action regarding his medication?
Your Answer: Add isosorbide mononitrate
Correct Answer: Add bisoprolol
Explanation:The use of carvedilol and bisoprolol has been proven to decrease mortality in stable heart failure patients, while there is no evidence to support the use of other beta-blockers. NICE guidelines suggest that all individuals with heart failure should be prescribed both an ACE-inhibitor and a beta-blocker.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 50
Correct
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A 48-year-old man comes to the General Practitioner complaining of feeling dizzy and experiencing shortness of breath during physical activity. He has a bicuspid aortic valve and is waiting for valve replacement surgery.
Which of the following murmurs would be the most likely to occur in this patient?Your Answer: Ejection systolic murmur loudest over the 2nd intercostal space, right sternal edge
Explanation:Differentiating Heart Murmurs Based on Location and Type
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate various cardiac conditions. The location and type of murmur can help differentiate between different conditions.
Ejection systolic murmur loudest over the 2nd intercostal space, right sternal edge: This is typical for aortic stenosis, which is more likely to occur in a bicuspid aortic valve. The murmur may radiate to the carotids. Pulmonary stenosis, hypertrophic obstructive cardiomyopathy, and atrial septal defect can also cause this type of murmur, but the location would be different.
Ejection systolic murmur loudest over the 2nd intercostal space, left sternal edge: This location is typical for pulmonary stenosis, not aortic stenosis. The patient’s history indicates symptomatic aortic stenosis, making this finding inconsistent.
Early diastolic murmur loudest over the 3rd intercostal space, left sternal edge: This type and location of murmur is typical for aortic regurgitation, not aortic stenosis. The location is Erb’s point, where S1 and S2 should both be heard.
Mid-diastolic murmur loudest over the apex: This type and location of murmur is typical for mitral stenosis, not aortic stenosis. The apex is the mitral area, located at the 5th intercostal space in the midclavicular line.
Pansystolic murmur loudest over the apex: This type and location of murmur is typical for mitral regurgitation, not aortic stenosis. The apex is the mitral area, located at the 5th intercostal space in the midclavicular line.
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This question is part of the following fields:
- Cardiovascular
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Question 51
Incorrect
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A senior patient presents with congestive heart failure.
Which of the following drugs may be effective in reducing mortality?
Your Answer: Furosemide
Correct 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.
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This question is part of the following fields:
- Cardiovascular
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Question 52
Incorrect
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A 73-year-old male patient with chronic heart failure presented to the cardiology clinic for follow-up after experiencing pulmonary edema. He is currently taking bisoprolol, lisinopril, and spironolactone. During the consultation, you observed that he has an irregularly irregular pulse. The patient reports ongoing breathlessness on exertion since the decompensation episode. What medication would you recommend adding as the next step in managing his symptoms?
Your Answer: Furosemide
Correct Answer: Digoxin
Explanation:If the patient has chronic heart failure along with atrial fibrillation, digoxin is highly recommended. However, if the patient does not have atrial fibrillation, the next step in management would be a combination of hydralazine and a nitrate like isosorbide mononitrate. While furosemide can be used for immediate fluid offloading, it does not have a positive impact on long-term outcomes.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 53
Incorrect
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A 70-year-old man comes to you with complaints of nocturnal dyspnea, intermittent palpitations, and chest tightness. During your examination, you observe a collapsing pulse and a displaced apex beat towards the left. Additionally, you notice his head nodding in sync with his pulse. What do you anticipate hearing upon auscultation of the precordium?
Your Answer: A late diastolic murmur
Correct Answer: An early diastolic murmur
Explanation:Aortic regurgitation is usually accompanied by an early diastolic murmur, along with Corrigan’s pulse and De Musset’s sign. Mitral regurgitation is characterized by a pansystolic murmur, while aortic stenosis is associated with an ejection systolic murmur. A patent ductus arteriosus is indicated by a continuous ‘machinery’ murmur, and mitral stenosis is associated with a late diastolic murmur.
Aortic regurgitation is a condition where the aortic valve of the heart leaks, causing blood to flow in the opposite direction during ventricular diastole. This can be caused by disease of the aortic valve or by distortion or dilation of the aortic root and ascending aorta. In the developing world, rheumatic fever is the most common cause of AR, while in developed countries, calcific valve disease and connective tissue diseases like rheumatoid arthritis and SLE are more common causes. Symptoms of AR include an early diastolic murmur, collapsing pulse, wide pulse pressure, Quincke’s sign, and De Musset’s sign. Echocardiography is used to investigate suspected AR. Management includes medical management of any associated heart failure and surgery for symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunction.
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This question is part of the following fields:
- Cardiovascular
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Question 54
Correct
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An 82-year-old woman presents to the Emergency Department after experiencing a blackout while shopping. Upon examination, she appears alert and oriented, and her vital signs are stable. Her CBG level is 5.8 mmol/l, and her pulse is irregular with a low volume at 89 beats per minute. Her blood pressure is 145/120 mmHg while lying and standing. There is no raised jugular venous pressure, and her apex beat is forceful but undisplaced. Heart sounds reveal a soft S2 and a soft ejection systolic murmur loudest in the right second intercostal space, with a possible fourth heart sound heard. Chest examination reveals occasional bibasal crackles that clear with coughing, and there is no peripheral edema. Based on these findings, what is the most likely cause of her collapse?
Your Answer: Aortic stenosis
Explanation:Understanding Aortic Stenosis and Differential Diagnosis
Aortic stenosis is a condition that presents with symptoms of left ventricular failure, angina, and potential collapse or blackout if the stenosis is critical. A low-volume pulse, narrow pulse pressure, slow-rising carotid pulse, undisplaced, sustained/forceful apex beat, soft or absent A2, ejection systolic murmur + fourth heart sound, and pulmonary edema are significant signs of aortic stenosis.
It is important to differentiate aortic stenosis from other conditions such as mitral regurgitation, aortic regurgitation, mitral stenosis, and mixed mitral and aortic valve disease. Mitral regurgitation causes a pan-systolic murmur radiating to the axilla, while aortic regurgitation causes an early diastolic murmur and a collapsing pulse. Mitral stenosis causes a mid-diastolic murmur with a characteristic opening snap. There is no definitive evidence of mitral valve disease in this clinical scenario.
Understanding the signs and symptoms of aortic stenosis and differentiating it from other conditions is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Cardiovascular
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Question 55
Correct
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A 68-year-old woman with isolated systolic hypertension, who also has urinary tract infections, osteoporosis and diabetes, attends outpatients with a blood pressure reading of 192/88 mmHg. Which of the following medications would you prescribe for this patient?
Your Answer: Valsartan
Explanation:Choosing the Right Medication for Hypertension: A Guide
When it comes to treating hypertension, there are several medications to choose from. The National Institute for Health and Care Excellence (NICE) recommends an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) as first-line treatment for those under 55, while calcium channel blockers (CCBs) are preferred for patients over 55 and those of Afro-Caribbean origin. Beta blockers, once a common choice, are no longer recommended as first-line treatment.
If initial treatment is not effective, a thiazide diuretic can be added to an ACE inhibitor or ARB and CCB. Alpha blockers, such as doxazosin, are no longer commonly used for hypertension and are contraindicated in patients with urinary incontinence. Valsartan, an ARB, is an alternative for patients who cannot tolerate an ACE inhibitor.
For elderly patients with isolated systolic hypertension, a dihydropyridine CCB like amlodipine is the drug of choice, especially if thiazides are not an option. Beta blockers should be used with caution in patients with asthma and are not indicated in this case. By carefully considering the patient’s age, ethnicity, and medical history, healthcare providers can choose the most appropriate medication for treating hypertension.
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This question is part of the following fields:
- Cardiovascular
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Question 56
Correct
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A 62-year-old man visits his GP complaining of recurring central chest pain during physical activity. He reports no chest pain while at rest. The patient was diagnosed with angina six months ago and has been taking verapamil and GTN spray. His medical history includes hypertension, asthma, and osteoarthritis of the right knee. What medication should the doctor prescribe?
Your Answer: Isosorbide mononitrate
Explanation:If a patient with symptomatic stable angina is already on a calcium channel blocker but cannot take a beta-blocker due to a contraindication, the next step in treatment should involve long-acting nitrates, ivabradine, nicorandil, or ranolazine. This scenario involves a 64-year-old man who experiences recurring chest pain during physical activity, which is likely due to poorly controlled stable angina. Although calcium channel blockers and beta-blockers are typically the first-line treatment for stable angina, the patient’s history of asthma makes beta-blockers unsuitable. As the initial treatment has not been effective, the patient should try the next line of therapy. Atenolol, bisoprolol, and diltiazem are not appropriate options for this patient due to their potential risks and lack of effectiveness in this case.
Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Cardiovascular
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Question 57
Correct
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A 43-year-old man, David, visits you after his 72-year-old father passed away due to a heart attack. David has a history of asthma, which he occasionally manages with his salbutamol inhaler, and was diagnosed with type 1 diabetes at the age of 20. His diabetes is well-controlled, and his last cholesterol test, conducted three months ago, was within the normal range. David has been reading about the connection between cholesterol and heart attacks in the news and is curious if he should take medication to lower his cholesterol levels.
Which of the following options is the most appropriate?Your Answer: Start atorvastatin 20mg today
Explanation:For primary prevention of cardiovascular disease, individuals with type 1 diabetes who do not have established risk factors should be prescribed atorvastatin 20mg if they are over 40 years old, have had diabetes for more than 10 years, have established nephropathy, or have other risk factors such as obesity and hypertension. As this patient has had type 1 diabetes for over 10 years, they should be offered statins.
Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.
Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.
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This question is part of the following fields:
- Cardiovascular
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Question 58
Correct
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A 42-year-old woman is brought to the Emergency Room with a 3-day history of flu-like symptoms. She is now experiencing severe central chest pain that worsens with coughing and improves when she sits upright. Upon examination, she has a rapid heart rate and a temperature of 38.5 °C. A third heart sound is heard upon auscultation.
What is the probable cause of this patient's chest pain?Your Answer: Pericarditis
Explanation:Pericarditis is an inflammation of the sac surrounding the heart, causing chest pain that is relieved by sitting forward and worsened by lying flat or coughing. Patients may display signs of infection, and a pericardial friction rub may be heard during examination. Blood tests, electrocardiography, chest X-ray, and echocardiography are used to diagnose pericarditis. Causes include viral, bacterial, and fungal infections, as well as other conditions. Treatment aims to address the underlying cause and may include analgesia and bed rest. Aortic dissection, myocardial ischemia, gastroesophageal reflux disease, and pneumonia are other possible causes of chest pain, but each has distinct symptoms and characteristics.
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This question is part of the following fields:
- Cardiovascular
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Question 59
Incorrect
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A 48-year-old man comes back to the clinic for a blood pressure check following an increase in his ramipril dosage. During the check, his blood pressure is recorded as 152/96 mmHg, and he reports getting similar readings on his home monitor. Which medication would be the most suitable to initiate for this patient?
Your Answer: Bisoprolol
Correct Answer: Amlodipine
Explanation:If a patient in this age group has poorly controlled hypertension despite taking an ACE inhibitor (or angiotensin II receptor blocker), the next step is to consider adding a calcium channel blocker or a thiazide-like diuretic. In this case, adding a calcium channel blocker would be the appropriate choice. Beta blockers are not recommended in the NICE guidelines for hypertension management. While a thiazide-like diuretic could also be an option, furosemide, a loop diuretic, is not suitable. It is important to note that adding another ACE inhibitor is not recommended since the patient is already taking one.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 60
Correct
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A 59-year-old woman comes in for a routine check-up with her primary care physician. She has a history of type 2 diabetes mellitus and is currently taking metformin and sitagliptin. During her last visit, her blood pressure was measured at 161/88 mmHg and she was advised to undergo 7 days of ambulatory blood pressure monitoring.
During this visit, her average ambulatory blood pressure is recorded as 158/74 mmHg. All other observations are stable and her cardiorespiratory examination is unremarkable. Her blood sugar level is 6.2 mmol/L.
What medication would be recommended to manage this patient's blood pressure?Your Answer: Lisinopril
Explanation:Regardless of age, ACE inhibitors/A2RBs are the first-line treatment for hypertension in diabetics.
Blood Pressure Management in Diabetes Mellitus
Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that there was little difference in outcomes between patients who had tight blood pressure control (targets < 130/85 mmHg) and those with more relaxed control (< 140-160/90-100 mmHg), except for a slightly reduced rate of stroke in the former group. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. Further management then follows that of non-diabetic patients. It is important to note that autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. Therefore, the routine use of beta-blockers in uncomplicated hypertension should be avoided, particularly when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.
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This question is part of the following fields:
- Cardiovascular
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Question 61
Incorrect
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As a physician on the night shift cardiac arrest team, you receive an emergency page requesting immediate assistance on the geriatric ward. Upon arrival, you discover the nursing staff performing chest compressions on an unresponsive patient with no carotid pulse. You instruct them to continue compressions while you apply defibrillator pads to the patient's chest. After a brief pause in compressions, the defibrillator monitor displays a monomorphic, broad complex tachycardia. What is the next best course of action?
Your Answer: Immediately give 3 back-to-back defibrillator shocks followed by CPR
Correct Answer: Immediately give 1 defibrillator shock followed by CPR
Explanation:When pulseless ventricular tachycardia (VT) is identified, the immediate and correct treatment is a single defibrillator shock followed by 2 minutes of CPR. This is in contrast to using intravenous adenosine or amiodarone, which are not appropriate in this scenario. The Resuscitation Council (UK) guidelines now recommend a single shock for ventricular fibrillation (VF) or pulseless VT. Administering 3 back-to-back shocks followed by 1 minute of CPR is part of the Advanced Life Support (ALS) algorithm, but it is not the most appropriate next step in management for a delayed recognition of rhythm like in the above case. In contrast, continued CPR with 30 chest compressions to 2 breaths is appropriate in a basic life support scenario where a defibrillator is not yet available.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 62
Correct
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A 24-year-old male is undergoing a medical review at a professional football club when an ejection systolic murmur is found. He is sent for echocardiogram and subsequently diagnosed with hypertrophic obstructive cardiomyopathy (HOCM).
Despite a normal electrocardiogram (ECG) and regular pulse, which complication of this condition is most likely to result in sudden death for this athlete?Your Answer: Ventricular arrhythmia
Explanation:Young athletes with hypertrophic obstructive cardiomyopathy are at risk of sudden death due to ventricular arrhythmia. This is believed to be caused by ventricular tachycardia resulting from ischaemia, which typically occurs during extreme exertion. Unlike myocardial infarction, which is commonly associated with atherosclerosis in the coronary arteries, it is unlikely for a young person to develop this condition. However, cocaine use may increase the risk of MI in young people. Although HOCM may cause a regurgitant mitral valve, valve rupture is not a known complication. While heart block may occur in some cases of HOCM, it is rare and is unlikely to cause sudden death.
Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is caused by mutations in genes encoding contractile proteins. It is characterized by left ventricle hypertrophy, diastolic dysfunction, and myofibrillar hypertrophy with disarray and fibrosis on biopsy. HOCM can be asymptomatic or present with exertional dyspnea, angina, syncope, sudden death, arrhythmias, heart failure, jerky pulse, and systolic murmurs. It is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, non-specific ST segment and T-wave abnormalities, and deep Q waves.
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This question is part of the following fields:
- Cardiovascular
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Question 63
Incorrect
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A 28-year-old male came to the emergency department complaining of shortness of breath during exertion. He had no medical history to report. During the examination, a midsystolic murmur was detected, which was most audible at the left lower sternal border. The murmur became louder when the Valsalva manoeuvre was performed. An echocardiogram revealed mitral regurgitation, asymmetric hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and left ventricular outflow tract obstruction. What medication should be avoided in this patient?
Your Answer: Atenolol
Correct Answer: Ramipril
Explanation:Patients with HOCM should avoid ACE-inhibitors.
The correct answer is Ramipril. In patients with hypertrophic obstructive cardiomyopathy (HOCM) and left ventricular outflow tract (LVOT) obstruction, ACE inhibitors are not recommended. This is because ACE inhibitors can decrease afterload, which may exacerbate the LVOT gradient. The patient in this case has echocardiographic evidence of HOCM, including asymmetric hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and mitral regurgitation.
However, amiodarone, atenolol, disopyramide, and verapamil are all viable treatment options for HOCM.
Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is estimated to have a prevalence of 1 in 500. The condition is caused by defects in the genes that encode contractile proteins.
The management of HOCM involves several approaches. Amiodarone is a medication that can be used to treat the condition. Beta-blockers or verapamil may also be prescribed to alleviate symptoms. In some cases, a cardioverter defibrillator or dual chamber pacemaker may be necessary. It is important to note that certain drugs, such as nitrates, ACE-inhibitors, and inotropes, should be avoided in patients with HOCM. Additionally, endocarditis prophylaxis may be recommended, although the 2008 NICE guidelines should be consulted for specific recommendations.
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This question is part of the following fields:
- Cardiovascular
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Question 64
Correct
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A 35-year-old homeless man is brought to the emergency department after being found unresponsive in a local park. Upon admission, his temperature is 30.2 ºC and an ECG reveals a broad complex polymorphic tachycardia. The patient is diagnosed with torsades de pointes. What is the most suitable course of treatment?
Your Answer: Magnesium sulphate
Explanation:Torsades de pointes can be treated with IV magnesium sulfate.
Torsades de Pointes: A Life-Threatening Condition
Torsades de pointes is a type of ventricular tachycardia that is associated with a prolonged QT interval. This condition can lead to ventricular fibrillation, which can cause sudden death. There are several causes of a prolonged QT interval, including congenital conditions such as Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome, as well as certain medications like antiarrhythmics, tricyclic antidepressants, and antipsychotics. Other causes include electrolyte imbalances, myocarditis, hypothermia, and subarachnoid hemorrhage.
The management of torsades de pointes involves the administration of intravenous magnesium sulfate. This can help to stabilize the heart rhythm and prevent further complications.
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This question is part of the following fields:
- Cardiovascular
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Question 65
Incorrect
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A 75 year old woman comes to the Emergency Department with gradual onset of difficulty breathing. During the examination, the patient displays an S3 gallop rhythm, bibasal crepitations, and pitting edema up to both knees. An ECG reveals indications of left ventricular hypertrophy, and a chest X-ray shows small bilateral pleural effusions, cardiomegaly, and upper lobe diversion.
Considering the probable diagnosis, which of the following medications has been proven to enhance long-term survival?Your Answer: Furosemide
Correct Answer: Ramipril
Explanation:The patient exhibits symptoms of congestive heart failure, which can be managed with loop diuretics and nitrates in acute or decompensated cases. However, these medications do not improve long-term survival. To reduce mortality in patients with left ventricular failure, ACE-inhibitors, beta-blockers, angiotensin receptor blockers, aldosterone antagonists, and hydralazine with nitrates have all been proven effective. Digoxin can reduce hospital admissions but not mortality, and is typically reserved for patients who do not respond to initial treatments or have co-existing atrial fibrillation.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 66
Incorrect
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A 45-year-old woman is admitted with chronic congestive heart failure.
Based on this history, what is the most important factor to consider when prescribing medication for this patient?Your Answer: Digoxin is more effective than angiotensin-converting enzyme (ACE) inhibitors in providing symptomatic relief
Correct Answer: Administration of a β-blocker reduces mortality
Explanation:Treatment Options for Heart Failure: A Summary of Medications and Their Effects
Heart failure is a serious condition that requires careful management to improve symptoms and reduce mortality rates. Two medications that have been found to be effective in reducing mortality are β-blockers and ACE inhibitors. These medications work by reducing afterload and should be offered as first-line treatment according to NICE guidelines. Loop diuretics, on the other hand, have no mortality benefit but can provide symptomatic relief. Digoxin, while effective in providing symptomatic relief, has been found to increase mortality rates and should be used with caution. Spironolactone, however, has been shown to greatly reduce mortality and sudden cardiac death rates and should be added to the treatment. Finally, while angiotensin II receptor antagonists can be used in patients who are intolerant of ACE inhibitors or added to ACE inhibitors and β-blockers if patients remain symptomatic, ACE inhibitors have been found to result in better prognosis. It is important to carefully consider the benefits and risks of each medication when treating patients with heart failure.
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This question is part of the following fields:
- Cardiovascular
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Question 67
Correct
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After expressing discomfort in their chest, a 75-year-old patient suddenly collapses on the surgical ward with no detectable pulse. The medical team initiates cardiopulmonary resuscitation (CPR) and calls for immediate assistance.
Once the defibrillator is connected, the team pauses to check the rhythm. Although there is organised electrical activity, there is still no pulse or signs of life.
In addition to continuing CPR with a ratio of 30 compressions to 2 breaths, what other actions should the team take at this stage?Your Answer: Give intravenous adrenaline
Explanation:In the case of pulseless electrical activity, which is a non-shockable rhythm, the ALS algorithm requires the administration of adrenaline as soon as intravascular access is achieved. This should be done immediately after the rhythm check, following two more minutes of CPR. The recommended dose is 1mg IV, which should be repeated every 3-5 minutes. It is important to note that intramuscular adrenaline is not appropriate for cardiac arrest, and IV amiodarone is not indicated for non-shockable rhythms. While it is correct to avoid shocking the patient, it is incorrect to delay drug administration until the next rhythm check. The most recent Resuscitation Council Guidelines (2021) support the immediate administration of adrenaline in non-shockable rhythms.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 68
Incorrect
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A 61-year-old Caucasian man presents for a routine health check. He has a medical history of asthma and type 2 diabetes mellitus. His most recent HbA1c is 56 mmol/mol (7.3%). During the check-up, his blood pressure is measured at 160/80 mmHg. Subsequently, ambulatory blood pressure monitoring is conducted, which shows an average daytime blood pressure of 150/90 mmHg. What is the appropriate next step in management?
Your Answer: Losartan
Correct Answer: Ramipril
Explanation:For the treatment of hypertension in diabetic patients, the first-line medication should be ACE inhibitors such as ramipril. However, this may not be suitable for individuals of Afro-Caribbean descent or women who may become pregnant. In case of a cough developing with ACE inhibitors, an angiotensin-II receptor antagonist like losartan should be prescribed. If the patient is not diabetic, calcium channel blockers like amlodipine or diuretics such as indapamide would be the preferred initial treatment. Beta blockers like propranolol are not typically the first choice for hypertension treatment, but may be considered for young patients who cannot tolerate ACE inhibitors or women attempting to conceive.
NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines aimed to classify hypertension into stages and recommend the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to accurately diagnose hypertension. This is important because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM allow for a more accurate assessment of a patient’s overall blood pressure and can prevent overdiagnosis.
NICE recommends measuring blood pressure in both arms when considering a diagnosis of hypertension and repeating measurements if there is a difference of more than 20 mmHg between arms. If the blood pressure is >= 140/90 mmHg, NICE suggests offering ABPM or HBPM to confirm the diagnosis. If the blood pressure is >= 180/120 mmHg, referral for specialist assessment is recommended if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms. If target organ damage is identified, antihypertensive drug treatment may be started immediately.
ABPM involves taking at least 2 measurements per hour during the person’s usual waking hours and using the average value of at least 14 measurements. If ABPM is not tolerated, HBPM should be offered. HBPM involves taking two consecutive measurements at least 1 minute apart, twice daily for at least 4 days, and using the average value of all remaining measurements.
Interpreting the results of ABPM/HBPM is important for determining treatment. If the average blood pressure is >= 135/85 mmHg (stage 1 hypertension), treatment may be considered for patients under 80 years of age with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. In 2019, NICE also recommended considering antihypertensive drug treatment for adults under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. If the average blood pressure is >= 150/95 mmHg (stage 2 hypertension), drug treatment should be offered regardless of age.
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This question is part of the following fields:
- Cardiovascular
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Question 69
Correct
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A 30-year-old woman expecting her second child and who is 28 weeks pregnant is referred to the Obstetric Unit with symptoms of headache, blurred vision and nausea.
On examination, her blood pressure (BP) is 160/110 mmHg; her antenatal diary shows consistent systolic readings of 115/125 mmHg and consistent diastolic readings of < 85 mmHg. Her urine dip shows proteinuria.
What is the most appropriate first-line treatment for this patient?
Your Answer: Labetalol
Explanation:Treatment Options for Pre-eclampsia in Pregnancy
Pre-eclampsia is a serious condition that can occur during pregnancy, characterized by high blood pressure, headaches, flashing lights, and vomiting. The following are treatment options for pre-eclampsia:
Labetalol: This beta-blocker is the first-line treatment for pre-eclampsia. According to NICE guidelines, patients should be admitted for monitoring if their blood pressure is above 140/90 mmHg. Labetalol should be used if their systolic blood pressure goes above 150 mmHg or diastolic blood pressure above 100 mmHg. Nifedipine can be used as an alternative if labetalol is contraindicated or not tolerated.
Ramipril: Angiotensin-converting enzyme inhibitors are not recommended during pregnancy due to potential harm to the fetus.
Hydralazine: This vasodilator is reserved for severe pre-eclampsia and requires specialist support.
Methyldopa: This medication is the third-line option if labetalol is ineffective and nifedipine is not tolerated or ineffective.
Nifedipine: This calcium channel blocker is the second-line treatment if labetalol is ineffective or not tolerated.
In conclusion, pre-eclampsia requires prompt treatment to prevent serious complications. Labetalol is the first-line treatment, and other medications can be used if necessary. It is important to consult with a healthcare provider to determine the best course of action for each individual case.
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This question is part of the following fields:
- Cardiovascular
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Question 70
Incorrect
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A 68-year-old man comes to the clinic complaining of central chest pain that started 8 hours ago. The pain is spreading to his left jaw. He has a medical history of hypertension and hyperlipidaemia.
Upon conducting an ECG, it shows ST elevation in leads II, III and aVF. Troponin levels are significantly elevated. The patient is given 300mg of aspirin and sublingual glyceryl trinitrate.
Unfortunately, the nearest hospital that can provide primary percutaneous coronary intervention (PCI) is 4 hours away. What is the most appropriate course of action?Your Answer: Immediately transfer for PCI
Correct Answer: Administer fibrinolysis
Explanation:For the management of STEMI, guidelines recommend primary PCI within 120 minutes of presentation or within 12 hours of symptom onset. As this patient presented with 10 hours of pain and transfer to the nearest hospital for PCI would take 3 hours, fibrinolysis should be offered instead. Giving unfractionated heparin and a glycoprotein IIb/IIIa inhibitor is inappropriate in this case. The patient should not be immediately transferred for PCI, but if the ST elevation is not resolved on a repeat ECG taken 90 minutes after fibrinolysis, then transfer for PCI should be considered. Rechecking troponin in 120 minutes is not necessary, and repeating an ECG in 120 minutes is not the next most important step. Administering fibrinolysis and taking a repeat ECG at the 90-minute mark are the appropriate next steps.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 71
Incorrect
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A 65-year-old man was diagnosed with angina after experiencing chest pain during physical activity. He underwent an exercise test at the cardiology clinic and was prescribed aspirin, bisoprolol, atorvastatin, and a glyceryl trinitrate (GTN) spray.
After six months, he returned with an increase in the frequency of anginal episodes, which were relieved by GTN spray and did not occur at rest.
What medication would be the most suitable addition to his current treatment?Your Answer: Nicorandil
Correct Answer: Amlodipine
Explanation:If a beta-blocker is not effective in controlling angina, it is recommended to add a longer-acting dihydropyridine calcium channel blocker such as amlodipine. Diltiazem and verapamil should not be used in combination with a beta-blocker due to the risk of life-threatening bradycardia and heart failure. Ivabradine and nicorandil can be used as alternatives if a dihydropyridine CCB is not suitable, but should only be initiated under specialist advice.
Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Cardiovascular
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Question 72
Correct
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A 56-year-old man complains of fatigue. During the physical examination, a soft diastolic murmur is detected, which is most audible in the second intercostal space on the right. His blood pressure is measured at 162/65 mmHg. What is the probable reason for the murmur?
Your Answer: Aortic regurgitation
Explanation:The patient exhibits a diastolic murmur that is most pronounced over the aortic valve, along with a wide pulse pressure, indicating a diagnosis of aortic regurgitation. Aortic stenosis, on the other hand, would manifest as a systolic murmur with a narrow pulse pressure. Meanwhile, mitral regurgitation would present as a systolic murmur that is most audible over the mitral valve, while mitral stenosis would produce a diastolic murmur that is loudest over the mitral valve and would not result in a wide pulse pressure.
Aortic regurgitation is a condition where the aortic valve of the heart leaks, causing blood to flow in the opposite direction during ventricular diastole. This can be caused by disease of the aortic valve or by distortion or dilation of the aortic root and ascending aorta. In the developing world, rheumatic fever is the most common cause of AR, while in developed countries, calcific valve disease and connective tissue diseases like rheumatoid arthritis and SLE are more common causes. Symptoms of AR include an early diastolic murmur, collapsing pulse, wide pulse pressure, Quincke’s sign, and De Musset’s sign. Echocardiography is used to investigate suspected AR. Management includes medical management of any associated heart failure and surgery for symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunction.
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This question is part of the following fields:
- Cardiovascular
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Question 73
Correct
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An 83-year-old man who resides in a nursing home arrives at the Emergency Department with symptoms of diarrhoea and vomiting. He has been experiencing 8 watery bowel movements per day for the past 3 days and seems disoriented and dehydrated. The patient has a medical history of atrial fibrillation, type II diabetes, and dementia. His heart rate is elevated at 110/min, and his electrocardiogram displays noticeable U waves. What is the probable reason for his ECG alterations?
Your Answer: Hypokalaemia
Explanation:The ECG changes observed in this scenario are most likely due to hypokalaemia. The patient’s electrolyte balance has been disrupted by vomiting and loose stools, resulting in a depletion of potassium that should be rectified through intravenous replacement. While hypocalcaemia and hypothermia can also cause U waves, they are less probable in this case. Non-ischaemic ST elevation changes may be caused by hyponatraemia. QT prolongation is a common effect of tricyclic antidepressant toxicity.
ECG Features of Hypokalaemia
Hypokalaemia is a condition characterized by low levels of potassium in the blood. This condition can be detected through an electrocardiogram (ECG) which shows specific features. The ECG features of hypokalaemia include U waves, small or absent T waves, prolonged PR interval, ST depression, and long QT. The U waves are particularly noticeable and are accompanied by a borderline PR interval.
To remember these features, one registered user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT. It is important to detect hypokalaemia early as it can lead to serious complications such as cardiac arrhythmias and even cardiac arrest. Therefore, regular monitoring of potassium levels and ECGs is crucial for individuals at risk of hypokalaemia.
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This question is part of the following fields:
- Cardiovascular
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Question 74
Correct
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A 70-year-old man presents to the GP for a blood pressure review after a clinic reading of 154/100 mmHg. He has a medical history of type 2 diabetes and COPD, which are managed with inhalers. His home blood pressure readings over the past week have averaged at 140/96 mmHg. What is the initial intervention that should be considered?
Your Answer: Ramipril
Explanation:Regardless of age, ACE inhibitors/A2RBs are the first-line treatment for hypertension in diabetics.
Blood Pressure Management in Diabetes Mellitus
Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that there was little difference in outcomes between patients who had tight blood pressure control (targets < 130/85 mmHg) and those with more relaxed control (< 140-160/90-100 mmHg), except for a slightly reduced rate of stroke in the former group. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. Further management then follows that of non-diabetic patients. It is important to note that autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. Therefore, the routine use of beta-blockers in uncomplicated hypertension should be avoided, particularly when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.
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This question is part of the following fields:
- Cardiovascular
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Question 75
Incorrect
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A 63-year-old man with angina and breathlessness at rest is found to have severe aortic stenosis. Since he has no prior medical history, he undergoes an open aortic valve replacement and a mechanical valve is implanted. What is the most suitable medication for long-term anticoagulation after the surgery?
Your Answer: Apixaban
Correct Answer: Warfarin
Explanation: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.
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This question is part of the following fields:
- Cardiovascular
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Question 76
Correct
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A 50-year old-man comes to see you saying that his father recently passed away due to an abdominal aortic aneurysm. He inquires if he will be screened for this condition and when should he start screening?
Your Answer: Single abdominal ultrasound at 65
Explanation:Understanding Abdominal Aortic Aneurysms
Abdominal aortic aneurysms occur when the elastic proteins within the extracellular matrix fail, causing dilation of all layers of the arterial wall. This degenerative disease is most commonly seen in individuals over the age of 50, with diameters of 3 cm or greater considered aneurysmal. The development of aneurysms is a complex process involving the loss of the intima and elastic fibers from the media, which is associated with increased proteolytic activity and lymphocytic infiltration.
Smoking and hypertension are major risk factors for the development of aneurysms, while rare causes include syphilis and connective tissue diseases such as Ehlers Danlos type 1 and Marfan’s syndrome. It is important to understand the pathophysiology of abdominal aortic aneurysms in order to identify and manage risk factors, as well as to provide appropriate treatment for those affected. By recognizing the underlying causes and risk factors, healthcare professionals can work to prevent the development of aneurysms and improve outcomes for those affected.
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This question is part of the following fields:
- Cardiovascular
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Question 77
Correct
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A 60-year-old woman has effort-related angina. She has no other cardiac risk factors and no other relevant medical history. Her QRisk is calculated as 12.2%. She has already been prescribed a GTN spray which she can use for immediate relief of her symptoms.
Which of the following is the most appropriate initial treatment?Your Answer: Beta blocker and statin
Explanation:The National Institute for Health and Care Excellence recommends using a β blocker or calcium channel blocker as the first-line treatment for angina, along with a statin. If a patient is intolerant to β blockers or not responding to a CCB alone, a long-acting nitrate can be added. An ACE inhibitor is not indicated for angina treatment. Beta blockers and CCBs can be used together if one alone does not control symptoms, but caution is needed to avoid conduction problems. Long-acting nitrates should only be used in isolation if CCB or β blocker use is contraindicated. Aspirin is recommended for secondary prevention, and short-acting nitrates can be used for symptom relief. The 4S study showed that statins significantly reduce the risk of MI in patients with angina and high cholesterol levels.
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This question is part of the following fields:
- Cardiovascular
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Question 78
Incorrect
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A 68-year-old man comes to the Emergency Department complaining of left-sided chest pain that has been ongoing for 2 hours. He mentions experiencing similar pains that occur during exercise and subside when he rests. The patient appears to be in distress, sweating, and having difficulty breathing. An ECG is conducted, revealing new T-wave inversion in V3-V6. His troponin and d-dimer levels are as follows:
Troponin 223 ng/L (<5)
D-Dimer 932 ng/mL (< 400)
What is the most probable diagnosis?Your Answer: Unstable angina
Correct Answer: Non-ST-elevation myocardial infarction (NSTEMI)
Explanation:Acute coronary syndrome (ACS) is a term that covers various acute presentations of ischaemic heart disease, including ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina. ACS develops in patients with ischaemic heart disease, which is the gradual build-up of fatty plaques in the coronary arteries. ACS can cause chest pain, dyspnoea, sweating, and nausea and vomiting. The two most important investigations for ACS are an ECG and cardiac markers. Treatment for ACS includes preventing worsening of presentation, revascularising the vessel is occluded, and treating pain. Patients who have had an ACS require lifelong drug therapy to reduce the risk of a further event.
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This question is part of the following fields:
- Cardiovascular
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Question 79
Correct
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A 31-year-old pilot comes in for his yearly physical examination. He has no significant medical history, does not take any regular medication, and reports no concerning symptoms. He maintains a healthy lifestyle and enjoys participating in ultramarathons as a runner.
During the physical examination, an ECG is conducted, which was normal during his last check-up the previous year. What would be the most worrisome ECG characteristic?Your Answer: Left bundle branch block (LBBB)
Explanation:A new left bundle branch block on an ECG is always a sign of pathology and not a normal variant. It indicates a delay in the left half of the conducting system, which can be caused by conditions such as aortic stenosis, cardiomyopathy, or ischaemia. However, other findings on an ECG, such as J-waves, left axis deviation, second-degree heart block (Mobitz I), or a short QT interval, may be normal variants in a healthy individual and not a cause for concern unless accompanied by symptoms of arrhythmias.
Left Bundle Branch Block: Causes and Diagnosis
Left bundle branch block (LBBB) is a cardiac condition that can be diagnosed through an electrocardiogram (ECG). The ECG shows typical features of LBBB, including a ‘W’ in V1 and a ‘M’ in V6. It is important to note that new LBBB is always pathological and can be caused by various factors such as myocardial infarction, hypertension, aortic stenosis, and cardiomyopathy. However, diagnosing a myocardial infarction for patients with existing LBBB can be difficult. In such cases, the Sgarbossa criteria can be used to aid in diagnosis.
Other rare causes of LBBB include idiopathic fibrosis, digoxin toxicity, and hyperkalaemia. It is crucial to identify the underlying cause of LBBB to determine the appropriate treatment plan. Therefore, patients with LBBB should undergo further evaluation and testing to determine the cause of their condition. By identifying the cause of LBBB, healthcare professionals can provide appropriate treatment and management to improve the patient’s overall health and well-being.
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This question is part of the following fields:
- Cardiovascular
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Question 80
Correct
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A 65-year-old man is referred by his general practitioner for advice regarding optimisation of secondary prevention. He has a history of non-ST-elevation myocardial infarction (NSTEMI) two years ago. He is on a combination of clopidogrel, atenolol 50 mg once daily and atorvastatin 80 mg once daily. He also has diabetes for which he takes metformin 1 g twice daily. His pulse rate is 70 bpm, and blood pressure 144/86 mmHg. His past medical history includes an ischaemic stroke two years ago, from which he made a complete recovery.
What additional therapy would you consider?
Select the SINGLE most appropriate option from the list below. Select ONE option only.Your Answer: Perindopril
Explanation:The Importance of ACE Inhibitors in Post-MI Patients with Vascular Disease and Diabetes
Following a myocardial infarction (MI), the National Institute for Health and Care Excellence (NICE) recommends the use of angiotensin-converting enzyme (ACE) inhibitors for all patients, regardless of left ventricular function. This is based on evidence from trials such as PROGRESS and HOPE, which demonstrate the benefits of ACE inhibitors in patients with vascular disease. Additionally, for patients with diabetes, the use of ACE inhibitors is preferable. The benefits of ACE inhibition are not solely related to blood pressure reduction, but also include favorable local vascular and myocardial effects. Calcium channel blockers, such as amlodipine and diltiazem, are not recommended for post-MI patients with systolic dysfunction. Nicorandil should also be avoided. Clopidogrel is the preferred antiplatelet for patients with clinical vascular disease who have had an MI and a stroke. Blood pressure should be optimized in post-MI patients, and further antihypertensive therapy may be necessary, including the addition of an ACE inhibitor to achieve the desired level.
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This question is part of the following fields:
- Cardiovascular
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Question 81
Correct
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A 62-year-old man visits his doctor with a complaint of ‘bulging blue veins’ on his legs. During the examination, you observe the presence of twisted, enlarged veins, along with brown patches of pigmentation and rough, flaky patches of skin. The diagnosis is varicose veins.
Which vein is commonly affected in this condition?Your Answer: Long saphenous vein
Explanation:Understanding the Venous System and Varicose Veins
Varicose veins are a common condition that affects the superficial venous system. The long saphenous vein, which ascends the medial side of the leg and passes anteriorly to the medial malleolus of the ankle, is the most common cause of varicose veins. However, it is important to consider alternative diagnoses for limb swelling, such as deep vein thrombosis, which could occur in the popliteal vein, part of the deep venous system.
The cephalic vein, although superficial, is an upper limb vein and is not likely to be affected by varicose veins. Similarly, insufficiencies in the deep venous system, such as the femoral vein, contribute to chronic venous insufficiency but do not cause varicose veins.
Another main vein in the superficial venous system is the short saphenous vein, which ascends the posterior side of the leg and passes posteriorly to the lateral malleolus of the ankle. Insufficiency in this vein can also cause varicose veins, but it is not the most likely distribution.
Understanding the different veins in the venous system and their potential for insufficiency can help in the diagnosis and treatment of varicose veins.
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This question is part of the following fields:
- Cardiovascular
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Question 82
Incorrect
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A 32-year-old woman attends her booking appointment with the community midwife. She is at 14 weeks gestation in her second pregnancy. She has no underlying medical conditions.
Which of the following haemodynamic changes is most likely to present in this patient?Your Answer: A 20% reduction in blood volume and cardiac output
Correct Answer: A 10 mmHg drop in diastolic blood pressure (BP) during the second trimester
Explanation:Physiological Changes in Cardiovascular System During Pregnancy
During pregnancy, the cardiovascular system undergoes significant changes to accommodate the growing fetus. These changes include a drop in diastolic blood pressure by 10 mmHg during the second trimester, circulating blood volume increases by approximately 50%, leading to a dilutional ‘physiological anaemia’ and cardiac output increases most sharply throughout the first trimester.
During pregnancy, heart rate progressively increases until reaching a peak in the third trimester. The overall change in heart rate represents approximately a 20–25% increase from baseline. However, a grade 2/6 diastolic murmur at the mitral area and pulsus alternans are not typical findings in a healthy pregnancy. It is important for healthcare providers to be aware of these physiological changes to properly monitor and manage the health of pregnant individuals.
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This question is part of the following fields:
- Cardiovascular
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Question 83
Correct
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A 45-year-old man with known permanent AF (atrial fibrillation) on warfarin has a fast, irregularly irregular pulse. He has no other past medical history. The ECG confirms AF with a rate of 132 beats/min. He is haemodynamically stable and well. He denies any history of palpitations, shortness of breath or syncope.
Which of the following is the most appropriate intervention?Your Answer: Bisoprolol
Explanation:Treatment Options for Atrial Fibrillation: A Comprehensive Guide
Atrial fibrillation (AF) is a common cardiac arrhythmia that requires prompt and appropriate management to prevent complications. Here are some treatment options for AF:
Rate Control: This is recommended for patients who have had AF for more than 48 hours. Beta-blockers are the first-line treatment unless there is a contraindication such as asthma. Calcium channel blockers can also be used.
Digoxin: This drug can be used as rate control if the patient cannot have beta-blockers or calcium channel blockers. However, it should only be used as a third-line treatment or as an adjunct because it has been shown to increase mortality. It is also only effective in sedentary patients.
DC Cardioversion: This can be used to treat new-onset AF if the patient has had it for less than 48 hours. It can also be considered in patients who have had it for longer than that, once they have been on stable anticoagulation for at least 3 weeks.
Flecainide: This is a class Ic antiarrhythmic drug that can be used as chemical cardioversion in new AF (<48 hours) or if a patient has been anticoagulated for >3 weeks.
Rhythm Control: Nice guidelines advise that rhythm control can be used if AF onset was <48 hours ago, but should be avoided if longer ago because it can increase the risk of stroke from an atrial thrombus. In longer cases, rate control should be used, which is with beta-blockers or rate-limiting calcium channel blockers. Digoxin can be used third line or as an adjunct. In conclusion, the appropriate treatment for AF depends on the duration of the arrhythmia, the patient’s comorbidities, and other factors. It is important to consult with a healthcare professional to determine the best course of action.
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This question is part of the following fields:
- Cardiovascular
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Question 84
Correct
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A 63-year-old male is being seen in the nurse-led heart failure clinic. Despite being on current treatment with furosemide, bisoprolol, enalapril, and spironolactone, he continues to experience breathlessness with minimal exertion. Upon examination, his chest is clear to auscultation and there is minimal ankle edema. Recent test results show sinus rhythm with a rate of 84 bpm on ECG, cardiomegaly with clear lung fields on chest x-ray, and an ejection fraction of 35% on echo. Isosorbide dinitrate with hydralazine was recently attempted but had to be discontinued due to side effects. What additional medication would be most effective in alleviating his symptoms?
Your Answer: Digoxin
Explanation: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.
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This question is part of the following fields:
- Cardiovascular
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Question 85
Incorrect
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A 58-year-old individual is rushed to the Emergency Department via ambulance, experiencing intense chest pain, difficulty breathing, and excessive sweating. The paramedics conducted an ECG on the scene, revealing ST depression in V1-V3 with tall, wide R waves and upward T waves. What should be the next appropriate step to take?
Your Answer: Give IV potassium replacement
Correct Answer: Record a posterior ECG
Explanation:To confirm posterior infarction, a posterior ECG should be recorded when ST elevation and Q waves are present in posterior leads (V7-9). In this case, the patient presented with symptoms suggestive of myocardial infarction and the ECG showed changes that indicated the need for a posterior ECG. This involves placing leads V4-V6 on the patient’s back to make leads V7-V9. ST-elevation and Q waves in these leads confirm posterior infarction, and the patient should be transferred for primary percutaneous coronary intervention as soon as possible. It is important to have a high index of suspicion for posterior MIs and a low threshold for getting a posterior ECG.
Giving IV potassium replacement or calcium gluconate IV would be incorrect in this case. These treatments are used for hypokalaemia and severe hyperkalaemia, respectively, and are not the most likely diagnoses. Ibuprofen and colchicine would be appropriate for pericarditis, which presents with chest pain that is worse on lying flat and has characteristic ECG changes. However, the clinical picture and ECG changes in this case are more consistent with ACS.
A CT aortogram is used to investigate for aortic dissection, which can present with severe chest pain, breathlessness, and sweating. However, it would be best to record a posterior ECG to investigate for posterior MI prior to investigating for an aortic dissection due to the classic features of ACS in the history.
Anteroseptal changes in V1-V4 indicate involvement of the left anterior descending artery. Inferior changes in II, III, and aVF suggest the right coronary artery is affected. Anterolateral changes in V1-6, I, and aVL indicate the proximal left anterior descending artery is involved. Lateral changes in I, aVL, and possibly V5-6 suggest the left circumflex artery is affected. Posterior changes in V1-3 may indicate a posterior infarction, which is confirmed by ST elevation and Q waves in posterior leads (V7-9). This type of infarction is usually caused by the left circumflex artery, but can also be caused by the right coronary artery. Reciprocal changes of STEMI are typically seen as horizontal ST depression, tall and broad R waves, upright T waves, and a dominant R wave in V2. It is important to note that a new left bundle branch block (LBBB) may indicate acute coronary syndrome.
Overall, understanding the correlation between ECG changes and coronary artery territories is crucial in diagnosing acute coronary syndrome. By identifying the specific changes in the ECG, medical professionals can determine which artery is affected and provide appropriate treatment. Additionally, recognizing the reciprocal changes of STEMI and the significance of a new LBBB can aid in making an accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular
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Question 86
Correct
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A 68-year-old man with hypertension has an annual review. He is medicated with amlodipine 10 mg once daily. He has never smoked and does not have diabetes. His past medical history is unremarkable. He has a blood pressure of 126/74 mmHg, total cholesterol:HDL-cholesterol ratio of 6.3, and QRISK2-2017 of 26.1%.
Target blood pressure in people aged <80 years, with treated hypertension: <140/90 mmHg.
Target blood pressure in people aged ≥80 years, with treated hypertension: <150/90 mmHg.
Total cholesterol: HDL-cholesterol ratio: high risk if >6.
You decide to initiate statin therapy for primary prevention of cerebrovascular disease (CVD).
Which of the following drugs is most appropriate for this patient?
Select the SINGLE drug from the slit below. Select ONE option only.Your Answer: Atorvastatin 20mg
Explanation:NICE Guidelines for Statin Use in Primary and Secondary Prevention of CVD
The National Institute for Health and Care Excellence (NICE) provides guidelines for the use of statins in the prevention of cardiovascular disease (CVD). For primary prevention, NICE recommends offering atorvastatin 20 mg to individuals with a 10-year risk of developing CVD ≥10%. Fluvastatin and simvastatin are not recommended as first-line agents for primary prevention.
For secondary prevention in individuals with established CVD, NICE recommends using atorvastatin 80 mg, with a lower dose used if there are potential drug interactions or high risk of adverse effects. Simvastatin 80 mg is considered a high-intensity statin, but is not recommended as a first-line agent for primary or secondary prevention.
NICE guidelines emphasize the importance of assessing CVD risk using a recognized scoring system, such as QRISK2, for primary prevention. All modifiable risk factors should be addressed for individuals with a risk score >10%, including weight loss, tight control of blood pressure, exercise, smoking cessation, and statin use to lower cholesterol.
For secondary prevention, all patients with CVD should be offered a statin. The QRISK2 risk assessment tool is recommended for assessing CVD risk in individuals up to and including age 84 years.
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This question is part of the following fields:
- Cardiovascular
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Question 87
Correct
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A 45-year-old woman presents to the Emergency Department with a 2-day history of pleuritic chest pain. She states that this started in the evening and has gotten worse since then. The pain is central and seems to improve when she leans forward. She has a past medical history of hypertension.
An electrocardiogram (ECG) is performed which shows widespread concave ST-segment elevation and PR interval depression. Extensive investigations reveal no underlying cause.
Given the likely diagnosis, which of the following is the best treatment option?
Select the SINGLE best treatment option from the list below.
Your Answer: NSAIDs until symptomatic resolution along with colchicine for three months
Explanation:Treatment Options for Acute Pericarditis
Acute pericarditis requires prompt treatment to prevent complications such as recurrent pericarditis, pericardial effusions, cardiac tamponade, and chronic constrictive pericarditis. The initial treatment for idiopathic or viral pericarditis involves high-dose non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin in combination with colchicine. The duration of NSAID or aspirin treatment depends on symptom resolution and normalization of C-reactive protein (CRP), while colchicine treatment is continued for three months using a low, weight-adjusted dose. Strenuous physical activity should be restricted until symptom resolution and normalization of inflammatory markers, and gastroprotection with a proton-pump inhibitor is recommended.
If NSAIDs and colchicine are contraindicated, low-dose corticosteroids are the next step in the treatment algorithm, after exclusion of infectious causes. However, when the cause of the pericarditis is known, it must be treated first before starting anti-inflammatory treatment.
Managing Acute Pericarditis: Treatment Options and Considerations
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This question is part of the following fields:
- Cardiovascular
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Question 88
Incorrect
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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.
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This question is part of the following fields:
- Cardiovascular
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Question 89
Correct
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A 72-year-old man has recently been diagnosed with heart failure. He is currently taking ramipril for his high blood pressure. What is the most appropriate medication to help manage his heart failure?
Your Answer: Bisoprolol
Explanation:Comparing Beta Blockers for Heart Failure: Efficacy and Evidence
Beta blockers are a class of medications commonly used in the treatment of heart failure. Among them, bisoprolol and carvedilol have the strongest evidence of efficacy in reducing mortality rates in heart failure patients, according to data from the CIBIS and CASA-2 trials. Atenolol, although cardioselective, has less evidence to support its use in heart failure. Labetalol is primarily used for hypertension in pregnancy, while propranolol has the most evidence of benefit after a myocardial infarction but is not always preferred due to its twice-daily dosing. Sotalol, a first-generation beta blocker, is not cardioselective and is not recommended for heart failure. Overall, the choice of beta blocker for heart failure should be based on the available evidence and individual patient factors.
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This question is part of the following fields:
- Cardiovascular
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Question 90
Correct
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A 65-year-old woman is brought to the Emergency Department (ED) following a fall at home. During examination in the ED, there is no evidence of external bleeding, but her blood pressure is 100/50 mmHg, and her heart rate is 110 bpm. She has distended neck veins and muffled heart sounds. What is the most probable finding on an echocardiogram?
Your Answer: Pericardial effusion
Explanation:Medical Conditions and Trauma: Understanding the Differences
Pericardial Effusion: A Serious Condition
When a patient presents with hypotension, tachycardia, and Beck’s triad (hypotension, distended neck veins, and muffled heart sounds), it is suggestive of pericardial effusion. This condition occurs when fluid accumulates in the pericardial space, compressing the heart and causing low cardiac output. Trauma to the chest is a common cause of pericardial effusion, leading to bleeding into the pericardial space.
Haemothorax, Mitral Regurgitation, Pleural Effusion, and Pneumothorax: Other Trauma-Related Conditions
While haemothorax refers to blood in the pleural space, it would not cause Beck’s triad or be detected on an echocardiogram. Mitral regurgitation could be detected on an echocardiogram, but it would not likely lead to Beck’s triad as blood would remain within the heart chambers. Pleural effusion refers to any fluid in the pleural space and would not cause Beck’s triad, nor would it be detected on echocardiography. Pneumothorax, which refers to air in the pleural space, can also occur with trauma. Tension pneumothorax may cause Beck’s triad, but it would not be detected on an echocardiogram.
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This question is part of the following fields:
- Cardiovascular
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Question 91
Correct
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You are urgently called to the ward where you encounter a 54-year-old woman in ventricular tachycardia. The patient had a syncopal episode while walking to the restroom with nursing staff and currently has a blood pressure (BP) of 85/56 mmHg. Although she is oriented to time, place, and person, she is experiencing dizziness. What is the most suitable approach to managing this patient's ventricular tachycardia?
Your Answer: Synchronised direct current (DC) cardioversion
Explanation:Treatment Options for Ventricular Tachycardia
Ventricular tachycardia is a serious cardiac arrhythmia that requires prompt treatment. The Resuscitation Council tachycardia guideline recommends immediate synchronised electrical cardioversion for unstable patients with ventricular tachycardia who exhibit adverse features such as shock, myocardial ischaemia, syncope, or heart failure. Synchronised cardioversion is preferred over unsynchronised cardioversion as it reduces the risk of causing ventricular fibrillation or cardiac arrest.
In the event that synchronised cardioversion fails to restore sinus rhythm after three attempts, a loading dose of amiodarone 300 mg IV should be given over 10-20 minutes, followed by another attempt of cardioversion. However, in an uncompromised patient with tachycardia and no adverse features, the first-line treatment involves amiodarone 300 mg as a loading dose IV, followed by an infusion of 900 mg over 24 hours.
It is important to note that digoxin and metoprolol are not appropriate treatments for ventricular tachycardia. Digoxin is used in the treatment of atrial fibrillation, while metoprolol is a β blocker that should be avoided in patients with significant hypotension, as it can further compromise the patient’s condition.
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This question is part of the following fields:
- Cardiovascular
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Question 92
Correct
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A 67-year-old man with a history of hypertension comes in for his yearly hypertension check-up. He is currently on a daily dose of ramipril 10 mg and amlodipine 10mg, but his blood pressure readings have been consistently high at an average of 160/110 mmHg. What medication would be the best addition to his treatment plan?
Your Answer: Indapamide
Explanation:To improve the poorly controlled hypertension of this patient who is already taking an ACE inhibitor and a calcium channel blocker, the next step is to add a thiazide-like diuretic. Indapamide is the recommended drug for this purpose, although chlortalidone is also an option. Beta-blockers like bisoprolol and alpha-blockers like doxazosin are not appropriate at this stage of treatment. Combining an angiotensin II receptor blocker with ramipril is not advisable due to the risk of electrolyte imbalance and kidney problems. If the patient has confirmed resistant hypertension, a fourth antihypertensive medication may be added or specialist advice sought. For those with low potassium levels, spironolactone may be considered.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 93
Incorrect
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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: Annual echocardiography, intervention when valve gradient > 75 mmHg
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.
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This question is part of the following fields:
- Cardiovascular
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Question 94
Correct
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What is the primary mode of operation of simvastatin in elderly patients?
Your Answer: Decreases intrinsic cholesterol synthesis
Explanation:The rate-limiting enzyme in hepatic cholesterol synthesis, HMG-CoA reductase, is inhibited by statins.
Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.
Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.
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This question is part of the following fields:
- Cardiovascular
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Question 95
Incorrect
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A 55-year-old man is found to have an irregularly, irregular pulse during a routine check-up. An ECG reveals absent P waves and irregular R-R intervals. The patient has moderate renal impairment. What is the most appropriate treatment option?
Your Answer: Aspirin
Correct Answer: No treatment
Explanation:Understanding Anticoagulation Treatment for Atrial Fibrillation: A CHADS-VASc Scoring System Overview
Atrial fibrillation (AF) is a common rhythm disturbance that can increase the risk of stroke. To determine the appropriate treatment for primary prevention of stroke, healthcare professionals use the CHADS-VASc scoring system. This system assigns points based on various risk factors, including age, sex, hypertension, diabetes, previous stroke or transient ischemic attack, and vascular disease.
This score is based on a point system in which 2 points are assigned for a history of stroke or transient ischemic attack or age 75 years or more and 1 point each is assigned for age 65 to 74 years; a history of hypertension, diabetes, recent cardiac failure, vascular disease (myocardial infarction, complex aortic plaque, and peripheral arterial disease (PAD), including prior revascularization, amputation due to PAD, or angiographic evidence of PAD, etc.); and female gender, resulting in a maximum score of 9 points.
Score Risk Anticoagulation Therapy 0 (male) or 1 (female) Low No anticoagulant therapy 1 (male) Moderate Oral anticoagulant should be considered 2 or greater High Oral anticoagulant is recommended Aspirin is not recommended for primary prevention of stroke in patients with AF, but may be used for secondary prevention after a stroke. Clexane, a low-molecular-weight heparin, is not used for long-term treatment of AF. Dipyridamole may be used in combination with clopidogrel or aspirin for stroke treatment, but not for prevention in AF patients.
It is important to accurately identify AF and assess the patient’s risk using the CHADS-VASc scoring system to determine the appropriate anticoagulation treatment. NOACs are only licensed for non-valvular AF, so patients with valvular AF should be treated with warfarin or seek advice from a specialist.
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This question is part of the following fields:
- Cardiovascular
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Question 96
Correct
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A 65-year-old woman is brought to the emergency department by ambulance due to worsening shortness of breath and palpitations. Upon examination, bilateral crepitations are heard in her lungs and she has bilateral ankle edema. An ECG shows atrial fibrillation with a fast ventricular response, with a heart rate of 157 bpm. A chest x-ray reveals pulmonary edema. Blood tests show normal levels of Hb, platelets, WBC, Na+, K+, urea, creatinine, CRP, magnesium, troponin, and TSH. What is the most appropriate next step in managing this patient?
Your Answer: Synchronised DC cardioversion
Explanation:Patients who exhibit tachycardia along with symptoms of shock, syncope, myocardial ischaemia, or heart failure should be administered up to three synchronised DC shocks. Synchronised DC cardioversion is recommended for tachycardia with haemodynamic instability, signs of myocardial ischaemia, heart failure, or syncope. In this case, the patient is displaying signs of heart failure, and the elevated troponin levels are likely due to tachycardia rather than acute myocardial infarction (MI). Adenosine is not suitable for this situation as it is used to manage supraventricular tachycardia (SVT) that is not associated with shock, syncope, myocardial ischaemia, or heart failure. Amiodarone may be considered in atrial fibrillation with a fast ventricular response if synchronised DC cardioversion is ineffective, but it would not be the most appropriate management option at this time. IV metoprolol (or oral bisoprolol) is used in fast atrial fibrillation not associated with shock, syncope, myocardial ischaemia, or heart failure. However, since this patient is exhibiting signs of heart failure, this is not the correct course of action.
Management of Peri-Arrest Tachycardias
The Resuscitation Council (UK) guidelines for the management of peri-arrest tachycardias have been simplified in the 2015 update. The previous separate algorithms for broad-complex tachycardia, narrow complex tachycardia, and atrial fibrillation have been replaced by a unified treatment algorithm. After basic ABC assessment, patients are classified as stable or unstable based on the presence of adverse signs such as hypotension, pallor, sweating, confusion, or impaired consciousness. If any of these signs are present, synchronised DC shocks should be given, up to a maximum of three shocks.
The treatment following this is based on whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular. For broad-complex tachycardia, a loading dose of amiodarone followed by a 24-hour infusion is given if the rhythm is regular. If the rhythm is irregular, expert help should be sought as it could be due to atrial fibrillation with bundle branch block, atrial fibrillation with ventricular pre-excitation, or torsade de pointes.
For narrow-complex tachycardia, vagal manoeuvres followed by IV adenosine are given if the rhythm is regular. If unsuccessful, atrial flutter is considered, and rate control is achieved with beta-blockers. If the rhythm is irregular, it is likely due to atrial fibrillation, and electrical or chemical cardioversion is considered if the onset is less than 48 hours. Beta-blockers are usually the first-line treatment for rate control unless contraindicated. The full treatment algorithm can be found on the Resuscitation Council website.
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This question is part of the following fields:
- Cardiovascular
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Question 97
Incorrect
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A 59 year old man with a history of aortic stenosis presents to his cardiology clinic with complaints of worsening shortness of breath and fainting episodes. His recent ECHO reveals a mean gradient of 45 mmHg and mild aortic regurgitation, while his ECG shows left ventricular hypertrophy, left bundle branch block, and a prolonged PR interval. What factor is most indicative of the need for valve replacement surgery?
Your Answer: Left bundle branch block
Correct Answer: Presence of symptoms
Explanation:Aortic valve replacement is typically recommended for patients with severe aortic stenosis who are experiencing symptoms such as dyspnea, chest pain, and syncope. Without treatment, these symptoms can lead to a mortality rate of 2-3 years. However, the decision to perform valve replacement on asymptomatic patients is a topic of debate.
Aortic Stenosis: Symptoms, Causes, and Management
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope, and a characteristic ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can also cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, and left ventricular hypertrophy or failure. The most common causes of aortic stenosis are degenerative calcification in older patients and bicuspid aortic valve in younger patients.
If a patient is asymptomatic, observation is usually recommended. However, if the patient is symptomatic or has a valvular gradient greater than 40 mmHg with features such as left ventricular systolic dysfunction, valve replacement is necessary. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement.
In summary, aortic stenosis is a condition that can cause various symptoms and requires prompt management to prevent complications. The causes of aortic stenosis vary, and treatment options depend on the patient’s age, operative risk, and overall health.
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This question is part of the following fields:
- Cardiovascular
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Question 98
Correct
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A 28-year-old female presents to the hospital with palpitations. On ECG, a shortened PR interval and wide QRS complexes are observed, along with a slurred upstroke in lead II. What is the definitive treatment for this condition?
Your Answer: Accessory pathway ablation
Explanation:The definitive treatment for this patient’s Wolff-Parkinson White syndrome is ablation of the accessory pathway.
Understanding Wolff-Parkinson White Syndrome
Wolff-Parkinson White (WPW) syndrome is a condition that occurs due to a congenital accessory conduction pathway between the atria and ventricles, leading to atrioventricular re-entry tachycardia (AVRT). This condition can cause AF to degenerate rapidly into VF as the accessory pathway does not slow conduction. The ECG features of WPW include a short PR interval and wide QRS complexes with a slurred upstroke, also known as a delta wave. The left or right axis deviation depends on the location of the accessory pathway.
WPW syndrome is associated with several conditions, including HOCM, mitral valve prolapse, Ebstein’s anomaly, thyrotoxicosis, and secundum ASD. The definitive treatment for WPW syndrome is radiofrequency ablation of the accessory pathway. Medical therapy options include sotalol, amiodarone, and flecainide. However, sotalol should be avoided if there is coexistent atrial fibrillation as it may increase the ventricular rate and potentially deteriorate into ventricular fibrillation.
In summary, WPW syndrome is a condition caused by a congenital accessory conduction pathway that can lead to rapid degeneration of AF into VF. The ECG features include a short PR interval and a delta wave. WPW syndrome is associated with several conditions, and the definitive treatment is radiofrequency ablation of the accessory pathway. Medical therapy options are available, but sotalol should be avoided in certain cases.
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This question is part of the following fields:
- Cardiovascular
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Question 99
Correct
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A 67-year-old man contacts emergency services due to experiencing central crushing chest pain that spreads to his left arm and jaw. Upon arrival at the emergency department, his heart rate is recorded at 50/min. An ECG is conducted, revealing ST elevation and bradycardia with a 1st-degree heart block. Based on the provided information, which leads are expected to display the ST elevation?
Your Answer: II, III and aVF
Explanation:An ST-elevated myocardial infarction affecting the inferior leads (II, III, aVF) can cause arrhythmias due to the involvement of the right coronary artery, which supplies blood to the AV node. This is evidenced by the patient’s presentation with 1st-degree heart block following the MI.
Anteroseptal changes in V1-V4 indicate involvement of the left anterior descending artery. Inferior changes in II, III, and aVF suggest the right coronary artery is affected. Anterolateral changes in V1-6, I, and aVL indicate the proximal left anterior descending artery is involved. Lateral changes in I, aVL, and possibly V5-6 suggest the left circumflex artery is affected. Posterior changes in V1-3 may indicate a posterior infarction, which is confirmed by ST elevation and Q waves in posterior leads (V7-9). This type of infarction is usually caused by the left circumflex artery, but can also be caused by the right coronary artery. Reciprocal changes of STEMI are typically seen as horizontal ST depression, tall and broad R waves, upright T waves, and a dominant R wave in V2. It is important to note that a new left bundle branch block (LBBB) may indicate acute coronary syndrome.
Overall, understanding the correlation between ECG changes and coronary artery territories is crucial in diagnosing acute coronary syndrome. By identifying the specific changes in the ECG, medical professionals can determine which artery is affected and provide appropriate treatment. Additionally, recognizing the reciprocal changes of STEMI and the significance of a new LBBB can aid in making an accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular
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Question 100
Correct
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A 50-year-old man arrives at the emergency department following a serious car accident resulting in chest injuries. The paramedics had trouble establishing IV access. Upon arrival, he is unresponsive with a ventricular fibrillation ECG. ALS is initiated, but multiple attempts at cannulation fail. However, successful intubation is achieved.
What is the best course of action for administering ALS medications in this scenario?Your Answer: Intraosseous line insertion
Explanation:If it is not possible to obtain IV access in ALS, medications should be administered through the intraosseous route (IO) instead of the tracheal route, which is no longer advised.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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