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Question 1
Incorrect
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A patient who started taking simvastatin half a year ago is experiencing muscle aches all over. What is not considered a risk factor for myopathy caused by statins?
Your Answer: Advanced age
Correct Answer: Large fall in LDL-cholesterol
Explanation:Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Correct
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A 50-year-old woman has been diagnosed with an unprovoked proximal deep vein thrombosis. What are the available treatment options for this condition?
Your Answer: Warfarin or Rivaroxaban or Dabigatran or Apixaban
Explanation:Direct oral anticoagulants (DOACs) are medications used to prevent stroke in non-valvular atrial fibrillation (AF), as well as for the prevention and treatment of venous thromboembolism (VTE). To be prescribed DOACs for stroke prevention, patients must have certain risk factors, such as a prior stroke or transient ischaemic attack, age 75 or older, hypertension, diabetes mellitus, or heart failure. There are four DOACs available, each with a different mechanism of action and method of excretion. Dabigatran is a direct thrombin inhibitor, while rivaroxaban, apixaban, and edoxaban are direct factor Xa inhibitors. The majority of DOACs are excreted either through the kidneys or the liver, with the exception of apixaban and edoxaban, which are excreted through the feces. Reversal agents are available for dabigatran and rivaroxaban, but not for apixaban or edoxaban.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Correct
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A 55-year-old man presents to his General Practitioner to discuss the uptitration of his medication as advised by cardiology. He suffered an anterior myocardial infarction (MI) four weeks ago. His history reveals that he is a smoker (20 per day for 30 years) and works in a sedentary office job, where he often works long days and eats ready meals to save time with food preparation.
On examination, his heart rate is 62 bpm and his blood pressure is 126/74 mmHg, body mass index (BMI) is 31. His bisoprolol is increased to 5 mg and ramipril to 7.5 mg.
Which of the following is the single non-pharmacological intervention that will be most helpful in reducing his risk of a future ischaemic event?
Your Answer: Stopping smoking
Explanation:Reducing Cardiovascular Risk: Lifestyle Changes to Consider
Cardiovascular disease (CVD) is a leading cause of death worldwide, but many of the risk factors are modifiable through lifestyle changes. The three most important modifiable and causal risk factors are smoking, hypertension, and abnormal lipids. While hypertension and abnormal lipids may require medication to make significant changes, smoking cessation is the single most important non-pharmacological, modifiable risk factor in reducing cardiovascular risk.
In addition to quitting smoking, there are other lifestyle changes that can help reduce cardiovascular risk. A cardioprotective diet should limit total fat intake to 30% or less of total energy intake, with saturated fat intake below 7%. Low-carbohydrate dietary intake is also thought to be important in cardiovascular disease prevention.
Regular exercise is also important, with 150 minutes or more per week of moderate-intensity aerobic activity and muscle-strengthening activities on at least two days a week recommended. While exercise is beneficial, stopping smoking remains the most effective lifestyle change for reducing cardiovascular risk.
Salt restriction can also help reduce risk, with a recommended intake of less than 6 g per day. Patients should be advised to avoid adding salt to their meals and minimize processed foods.
Finally, weight reduction should be advised to decrease future cardiovascular risk, with a goal of achieving a normal BMI. Obese patients should also be assessed for sleep apnea. By making these lifestyle changes, individuals can significantly reduce their risk of developing cardiovascular disease.
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This question is part of the following fields:
- Cardiovascular Health
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Question 4
Incorrect
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Which one of the following statements regarding B-type natriuretic peptide is incorrect?
Your Answer: Acts as a diuretic
Correct Answer: The positive predictive value of BNP is greater than the negative predictive value
Explanation:The negative predictive value of BNP for ventricular dysfunction is good, but its positive predictive value is poor.
B-type natriuretic peptide (BNP) is a hormone that is primarily produced by the left ventricular myocardium in response to strain. Although heart failure is the most common cause of elevated BNP levels, any condition that causes left ventricular dysfunction, such as myocardial ischemia or valvular disease, may also raise levels. In patients with chronic kidney disease, reduced excretion may also lead to elevated BNP levels. Conversely, treatment with ACE inhibitors, angiotensin-2 receptor blockers, and diuretics can lower BNP levels.
BNP has several effects, including vasodilation, diuresis, natriuresis, and suppression of both sympathetic tone and the renin-angiotensin-aldosterone system. Clinically, BNP is useful in diagnosing patients with acute dyspnea. A low concentration of BNP (<100 pg/mL) makes a diagnosis of heart failure unlikely, but elevated levels should prompt further investigation to confirm the diagnosis. Currently, NICE recommends BNP as a helpful test to rule out a diagnosis of heart failure. In patients with chronic heart failure, initial evidence suggests that BNP is an extremely useful marker of prognosis and can guide treatment. However, BNP is not currently recommended for population screening for cardiac dysfunction.
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This question is part of the following fields:
- Cardiovascular Health
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Question 5
Incorrect
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A 45-year-old male presents at your clinic following a recent admission at the cardiac unit of the local general hospital. He suffered a myocardial (MI) infarction three weeks ago and has been recovering well physically, but he cries a lot of the time.
You find evidence of low mood, anhedonia and sleep disturbance.
The man feels hopeless about the future and has fleeting thoughts of suicide. He has suffered from depression in the past which responded well to antidepressant treatment.
Which antidepressant would you choose from the following based on its demonstrated safety post-myocardial infarction?Your Answer: Citalopram
Correct Answer: Sertraline
Explanation:Sertraline for Depression in Patients with Recent MI or Unstable Angina
Sertraline is a medication that is both effective and well-tolerated for treating depression in patients who have recently experienced a myocardial infarction (MI) or unstable angina. In addition to its antidepressant properties, sertraline has been found to inhibit platelet aggregation. This makes it a valuable treatment option for patients who are at risk for blood clots and other cardiovascular complications. With its dual benefits, sertraline can help improve both the mental and physical health of patients who have experienced a cardiac event.
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This question is part of the following fields:
- Cardiovascular Health
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Question 6
Incorrect
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A 67-year-old man presents with shortness of breath.
An ECG shows atrial fibrillation (AF).
He takes digoxin, furosemide, and lisinopril.
What further drug would improve this patient's outcome?Your Answer: Clopidogrel
Correct Answer: Abciximab
Explanation:Prophylactic Therapy for AF Patients with Heart Failure
The risk of embolic events in patients with heart failure and AF is high, with the risk of stroke increasing up to five-fold in non-rheumatic AF. The most appropriate prophylactic therapy for these patients is with an anticoagulant, such as warfarin.
According to studies, for every 1,000 patients with AF who are treated with warfarin for one year, 30 strokes are prevented at the expense of six major bleeds. On the other hand, for every 1,000 patients with AF who are treated with aspirin for one year, only 12.5 strokes are prevented at the expense of six major bleeds.
It is important to note that NICE guidelines on Atrial fibrillation (CG180) recommend warfarin, not aspirin, as the preferred prophylactic therapy for AF patients with heart failure.
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This question is part of the following fields:
- Cardiovascular Health
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Question 7
Incorrect
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You are conducting a medication review for a 65-year-old man who has a history of cerebrovascular disease (having suffered a stroke 2 years ago), depression, and knee osteoarthritis. He is currently taking the following medications:
- Clopidogrel 75 mg once daily
- Simvastatin 20 mg once daily
- Amlodipine 5mg once daily
- Ramipril 10 mg once daily
- Diclofenac 50 mg as needed
- Sertraline 50 mg once daily
What changes would you recommend to his medication regimen?Your Answer: Switch clopidogrel to aspirin
Correct Answer: Switch diclofenac for an alternative NSAID
Explanation:The use of diclofenac is now prohibited for individuals with any type of cardiovascular ailment.
Diclofenac and Cardiovascular Risk
The MHRA has updated its guidance on diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), due to a Europe-wide review of cardiovascular safety. While it has been known for some time that NSAIDs may increase the risk of cardiovascular events, the evidence base has become clearer. Diclofenac is associated with a significantly higher risk of cardiovascular events compared to other NSAIDs. Therefore, diclofenac is contraindicated in patients with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, and congestive heart failure (New York Heart Association classification II-IV). Patients should switch from diclofenac to other NSAIDs, such as naproxen or ibuprofen, except for topical diclofenac. Studies have shown that naproxen and low-dose ibuprofen have the best cardiovascular risk profiles of the NSAIDs.
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This question is part of the following fields:
- Cardiovascular Health
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Question 8
Correct
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A 72-year-old man visits his General Practitioner for a medication review for his chronic congestive heart failure. His recent echocardiogram indicates an ejection fraction of 35%. He reports experiencing more shortness of breath, especially when lying down, gaining 2 kg in weight over the past few weeks, and having ankle swelling. What is the appropriate medication class to prescribe for quick relief of symptoms?
Your Answer: Loop diuretics
Explanation:Treatment Options for Symptomatic Heart Failure
Symptomatic heart failure can be managed with various medications. Loop diuretics such as furosemide can provide relief from symptoms of fluid overload. However, it doesn’t alter the prognosis. Aldosterone antagonists may be considered for patients who remain symptomatic despite a combination of loop diuretics, ACE inhibitors, and beta-blockers. ACE inhibitors should be given to all patients with a left ventricular ejection fraction of 40% or less, regardless of symptom severity, as it has been shown to improve ventricular function, reduce mortality, and hospital admission. Beta-blockers should also be used in patients with symptomatic heart failure and a left ventricular ejection fraction ≤ 40%, as long as they are tolerated and not contraindicated. Digoxin is used for rate control but is not recommended for rapid symptom relief.
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This question is part of the following fields:
- Cardiovascular Health
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Question 9
Correct
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A 65-year-old man with known congestive cardiac failure presents to his General Practitioner for his annual review. He reports that his heart failure symptoms have been stable in recent months. On examination his heart rate is 68 bpm but is noted to be irregularly irregular, blood pressure is 136/84 mmHg, respiratory rate 18 breaths per minute and oxygen saturations 95% in air. An electrocardiogram (ECG) confirms atrial fibrillation (AF) with a stable ventricular rate of 72 bpm.
Which single medication from the following list would be most beneficial from the point of view of this patient’s atrial fibrillation?
Your Answer: Warfarin
Explanation:Treatment Options for Atrial Fibrillation: Anticoagulation with Warfarin as Initial Therapy
Atrial fibrillation (AF) patients who are haemodynamically stable have an intermediate risk and require anticoagulation therapy. The initial treatment for such patients is anticoagulation with warfarin, which is also indicated in valvular heart disease and the elderly. Other options for anticoagulation include apixaban, dabigatran etexilate, and rivaroxaban, within their licensed indications. The decision to use anticoagulation in AF is guided by the CHA2DS2-VASc scores, which assess the risk factors for stroke. Patients with a very low risk of stroke (CHA2DS2-VASc score of 0 for men, or 1 for women) should not be offered stroke prevention therapy. Anticoagulation should be offered to people with a CHA2DS2-VASc score of 2 (1 in men) or above, taking bleeding risk into account.
While furosemide is a potential treatment for congestive cardiac failure, it is not urgently required in haemodynamically stable patients. Aspirin is no longer recommended for stroke prevention in any patient with AF. Digoxin is a potential rate-limiting medication in people with non-paroxysmal AF, but rate limitation is not the first priority in this case as the ventricular rate is normal. Sotalol, a cardioselective beta-blocker, is used in rate control for AF with a fast ventricular response, but is not required for this patient.
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This question is part of the following fields:
- Cardiovascular Health
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Question 10
Correct
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A 56-year-old man with a history of smoking, obesity, prediabetes, and high cholesterol visits his GP complaining of chest pains that occur during physical activity or climbing stairs to his office. The pain is crushing in nature and subsides with rest. The patient is currently taking atorvastatin 20 mg and aspirin 75 mg daily. He has no chest pains at the time of the visit and is otherwise feeling well. Physical examination reveals no abnormalities. The GP prescribes a GTN spray for the chest pains and refers the patient to the rapid access chest pain clinic.
What other medication should be considered in addition to the GTN?Your Answer: Bisoprolol
Explanation:For the patient with stable angina, it is recommended to use a beta-blocker or a calcium channel blocker as the first-line treatment to prevent angina attacks. In this case, a cardioselective beta-blocker like bisoprolol or atenolol, or a rate-limiting calcium channel blocker such as verapamil or diltiazem should be considered while waiting for chest clinic assessment.
As the patient is already taking aspirin 75 mg daily, there is no need to prescribe dual antiplatelet therapy. Aspirin is the preferred antiplatelet for stable angina.
Since the patient is already taking atorvastatin, a fibrate like ezetimibe may not be necessary for lipid modification. However, if cholesterol levels or cardiovascular risk remain high, increasing the atorvastatin dose or encouraging positive lifestyle interventions like weight loss and smoking cessation can be helpful.
It is important to note that nifedipine, a dihydropyridine calcium channel blocker, is not recommended as the first-line treatment for angina management as it has limited negative inotropic effects. It can be used in combination with a beta-blocker if monotherapy is insufficient for symptom control.
Angina pectoris can be managed through 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. NICE recommends using either a beta-blocker or a calcium channel blocker as first-line treatment, 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 like amlodipine or modified-release nifedipine should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If initial treatment is ineffective, 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, long-acting nitrate, ivabradine, nicorandil, or ranolazine can be considered. 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.
Nitrate tolerance is a common issue for patients who take nitrates, leading to reduced efficacy. NICE advises patients who take standard-release isosorbide mononitrate to use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. However, this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate.
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This question is part of the following fields:
- Cardiovascular Health
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