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  • Question 1 - A 50-year-old woman has a diastolic murmur best heard in the upper-left 2nd...

    Incorrect

    • A 50-year-old woman has a diastolic murmur best heard in the upper-left 2nd intercostal space.
      What single condition would be part of the differential diagnosis?

      Your Answer: Mitral regurgitation

      Correct Answer: Aortic regurgitation

      Explanation:

      Differentiating Heart Murmurs: Characteristics and Causes

      Heart murmurs are abnormal sounds heard during the cardiac cycle. They can be caused by a variety of conditions, including valve abnormalities, septal defects, and physiological factors. Here are some characteristics and causes of common heart murmurs:

      Aortic Regurgitation: This produces a low-intensity early diastolic decrescendo murmur, best heard in the aortic area. The backflow of blood across the aortic valve causes the murmur.

      Aortic Stenosis: This produces a mid-systolic ejection murmur in the aortic area. It radiates into the neck over the two carotid arteries. The most common cause is calcified aortic valves due to ageing, followed by congenital bicuspid aortic valves.

      Mitral Regurgitation: This murmur is best heard at the apex. In the presence of incompetent mitral valve, the pressure in the left ventricle becomes greater than that in the left atrium at the start of isovolumic contraction, which corresponds to the closing of the mitral valve (S1).

      Physiological Murmur: This is a low-intensity murmur that mainly occurs in children. It can occur in adults particularly if there is anaemia or a fever. It is caused by increased blood flow through the aortic valves.

      Ventricular Septal Defect: This produces a pansystolic murmur that starts at S1 and extends up to S2. In a VSD the murmur is usually best heard over the left lower sternal border (tricuspid area) with radiation to the right lower sternal border. This is the area overlying the VSD.

      Understanding the characteristics and causes of different heart murmurs can aid in their diagnosis and management.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 2 - You are evaluating an 80-year-old patient who has recently been diagnosed with heart...

    Incorrect

    • You are evaluating an 80-year-old patient who has recently been diagnosed with heart failure. Her left ventricular ejection fraction is 55%. She has been experiencing orthopnoea and ankle swelling. The cardiology team has referred her to you for medication initiation.

      During the assessment, her vital signs are blood pressure 120/80 mmHg and heart rate 82/min.

      What should be the initial consideration in her management?

      Your Answer: Enalapril, carvedilol and furosemide

      Correct Answer: Furosemide

      Explanation:

      Furosemide is the appropriate choice for managing symptoms in individuals with heart failure with preserved ejection fraction using loop diuretics. Spironolactone is not recommended for this purpose. In cases of heart failure with reduced ejection fraction, mineralocorticoid receptor antagonists should be considered along with an ACE inhibitor (or ARB) and beta-blocker if symptoms persist.

      Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 3 - A 65-year-old Indian man with recently diagnosed atrial fibrillation is started on warfarin....

    Correct

    • A 65-year-old Indian man with recently diagnosed atrial fibrillation is started on warfarin. He visits the GP clinic after 5 days with unexplained bruising. His INR is measured and found to be 4.5. He has a medical history of epilepsy, depression, substance abuse, and homelessness. Which medication is the most probable cause of his bruising from the following options?

      Your Answer: Sodium valproate

      Explanation:

      Sodium valproate is known to inhibit enzymes, which can lead to an increase in warfarin levels if taken together. The patient’s medical history could include any of the listed drugs, but the question is specifically testing knowledge of enzyme inhibitors. Rifampicin and St John’s Wort are both enzyme inducers, while heroin (diamorphine) doesn’t have any effect on enzyme activity.

      P450 Enzyme System and its Inducers and Inhibitors

      The P450 enzyme system is responsible for metabolizing many drugs in the body. Induction of this system occurs when a drug or substance causes an increase in the activity of the P450 enzymes. This process usually requires prolonged exposure to the inducing drug. On the other hand, P450 inhibitors decrease the activity of the enzymes and their effects are often seen rapidly.

      Some common inducers of the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking. Smoking affects CYP1A2, which is the reason why smokers require more aminophylline.

      In contrast, some common inhibitors of the P450 system include antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, acute alcohol intake, and quinupristin.

      It is important to be aware of the potential for drug interactions when taking medications that affect the P450 enzyme system. Patients should always inform their healthcare provider of all medications and supplements they are taking to avoid any adverse effects.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 4 - A 72-year-old man presents to the General Practitioner with complaints of leg pain...

    Incorrect

    • A 72-year-old man presents to the General Practitioner with complaints of leg pain while walking. Upon examination, his feet appear cool and dusky, with the right foot being more affected than the left. An ankle brachial pressure index is measured at 0.8 on the right and 0.9 on the left. Both femoral pulses are present, but posterior tibial and dorsalis pedis pulses are absent in both legs. His blood pressure is 140/85 mmHg.
      Which of the following medications is LEAST likely to provide relief for his symptoms?

      Your Answer:

      Correct Answer: Amlodipine

      Explanation:

      Treatment options for Peripheral Arterial Disease (PAD)

      Peripheral Arterial Disease (PAD) is a condition that causes intermittent claudication. Antiplatelet therapy is recommended for those with symptomatic disease to reduce major cardiovascular events. Clopidogrel is suggested as the drug of first choice by the National Institute for Health and Care Excellence (NICE). Angiotensin converting enzyme inhibitors have been shown to reduce cardiovascular morbidity and mortality in patients with PAD. However, they should be carefully monitored as more than 25% of patients have co-existent renal artery stenosis. Statins are also recommended as they reduce the risk of mortality, cardiovascular events and stroke in patients with PAD. Naftidrofuryl oxalate is an option for the treatment of intermittent claudication in people with PAD for whom vasodilator therapy is considered appropriate. Amlodipine, a calcium channel blocker, is not indicated for this case.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 5 - A 55-year-old carpenter comes to see you in surgery following an MI three...

    Incorrect

    • A 55-year-old carpenter comes to see you in surgery following an MI three months previously.

      He has made a full recovery but wants to ask about his diet.

      Which one of the following foods should he avoid?

      Your Answer:

      Correct Answer: Pork

      Explanation:

      Tips for a Heart-Healthy Diet after a Heart Attack

      Following a heart attack, it is important to adopt a healthier overall diet to reduce the risk of future heart problems. Unhealthy diets have been attributed to up to 30% of all deaths from coronary heart disease (CHD). While reducing fat intake is important, exercise also plays a crucial role in maintaining heart health.

      Including canned and frozen fruits and vegetables in your diet is just as beneficial as fresh produce. A Mediterranean diet, which includes many protective elements for CHD, is recommended. Replacing butter with olive oil and mono-unsaturated margarine, such as those made from rape-seed or olive oil, is a healthier option. Organic butter is not any better for heart health than non-organic butter.

      To reduce cholesterol intake, it is recommended to eat less red meat and replace it with poultry. Margarine containing sitostanol ester may also help reduce cholesterol intake. Adding plant sterol to margarine has been shown to reduce serum low-density lipoprotein cholesterol. Eating more fish, including oily fish, at least once a week is also recommended.

      Switching to whole-grain bread instead of white bread and eating more root vegetables and green vegetables is also beneficial. Lastly, it is important to eat fruit every day. By following these tips, you can maintain a heart-healthy diet and reduce the risk of future heart problems.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 6 - Which patient with cardiac issues would you deem suitable for air travel? ...

    Incorrect

    • Which patient with cardiac issues would you deem suitable for air travel?

      Your Answer:

      Correct Answer: Patient who had an uncomplicated myocardial infarction (MI) two days ago

      Explanation:

      Understanding Fitness to Fly Guidelines for Medical Conditions

      Fitness to fly can be a complex topic, and it is important to advise patients to consult their airline for specific policies regarding their medical condition. The UK Civil Aviation Authority’s aviation health unit has produced guidelines for healthcare professionals to clarify fitness to fly for various medical conditions. These guidelines provide a concise overview of key points that are commonly encountered in general practice.

      When it comes to cardiovascular contraindications for commercial airline flights, there are several factors to consider. For example, patients who have had an uncomplicated myocardial infarction within the last seven days or a coronary artery bypass graft within the last ten days are not fit to travel. However, patients who have undergone percutaneous coronary intervention/stenting may be fit to travel after a minimum of five days, but they require medical assessment. Additionally, patients with unstable angina or uncontrolled cardiac arrhythmia should not fly.

      It is important to note that different sources may provide slightly different guidance on fitness to fly. However, the CAA guidelines are considered the closest to national guidance and are likely to be used in examination questions. Examining bodies may also choose answers that fall within the reference range of multiple accredited sources to avoid controversial answers. Overall, understanding fitness to fly guidelines for medical conditions is crucial for ensuring the safety and well-being of patients during air travel.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 7 - You are reviewing current guidance in relation to the use of non-HDL cholesterol...

    Incorrect

    • You are reviewing current guidance in relation to the use of non-HDL cholesterol measurement with regards lipid modification therapy for cardiovascular disease prevention.
      Which of the following lipoproteins contribute to 'non-HDL cholesterol'?

      You are reviewing current guidance in relation to the use of non-HDL cholesterol measurement with regards lipid modification therapy for cardiovascular disease prevention.

      Which of the following lipoproteins contribute to 'non-HDL cholesterol'?

      Your Answer:

      Correct Answer: LDL, IDL and VLDL cholesterol

      Explanation:

      The Importance of Non-HDL Cholesterol in Statin Treatment

      NICE guidelines recommend that high-intensity statin treatment for both primary and secondary prevention of cardiovascular disease should aim for a greater than 40% reduction in non-HDL cholesterol. Non-HDL cholesterol includes LDL, IDL, and VLDL cholesterol. In the past, LDL reduction has been used as a marker of statin effect. However, non-HDL reduction is more useful as it takes into account the atherogenic properties of IDL and VLDL cholesterol, which may be raised even in the presence of normal LDL levels.

      Using non-HDL cholesterol also has other benefits. Hypertriglyceridaemia can interfere with lab-based LDL calculations, but it doesn’t impact non-HDL calculation, which is measured by a different method. Additionally, a fasting sample is not required to measure non-HDL cholesterol, making sampling and monitoring easier. Overall, non-HDL cholesterol is an important marker to consider in statin treatment for cardiovascular disease prevention.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 8 - A 41-year-old man is worried about his risk of heart disease due to...

    Incorrect

    • A 41-year-old man is worried about his risk of heart disease due to his family history. His father passed away at the age of 45 from a heart attack. During his medical check-up, his lipid profile is as follows:

      HDL 1.4 mmol/l
      LDL 5.7 mmol/l
      Triglycerides 2.3 mmol/l
      Total cholesterol 8.2 mmol/l

      Upon clinical examination, the doctor notices tendon xanthomata around his ankles. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Familial hypercholesterolaemia

      Explanation:

      Familial hypercholesterolaemia can be diagnosed when there are tendon xanthomata and elevated cholesterol levels present.

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

      Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

      To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected.

      The Simon Broome criteria are used for clinical diagnosis, which includes a total cholesterol level greater than 7.5 mmol/l and LDL-C greater than 4.9 mmol/l in adults or a total cholesterol level greater than 6.7 mmol/l and LDL-C greater than 4.0 mmol/l in children. Definite FH is diagnosed if there is tendon xanthoma in patients or first or second-degree relatives or DNA-based evidence of FH. Possible FH is diagnosed if there is a family history of myocardial infarction below age 50 years in second-degree relatives, below age 60 in first-degree relatives, or a family history of raised cholesterol levels.

      Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate in FH as they do not accurately reflect the risk of CVD. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by the age of 10 years if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 9 - A 68-year-old man visits his General Practitioner for a check-up. He is taking...

    Incorrect

    • A 68-year-old man visits his General Practitioner for a check-up. He is taking warfarin for a mechanical aortic valve and has a history of trigeminal neuralgia, depression, and COPD. During an INR check, his INR is found to be subtherapeutic at 1.5. Which drug is most likely to cause a decrease in his INR if co-prescribed with warfarin therapy? Choose ONE answer.

      Your Answer:

      Correct Answer: Carbamazepine

      Explanation:

      Interactions with Warfarin: Understanding the Effects of Carbamazepine, Alcohol, Clarithromycin, Prednisolone, and Sertraline

      Warfarin is a commonly prescribed anticoagulant medication that requires careful monitoring to ensure its effectiveness and safety. However, several factors can interact with warfarin and affect its metabolism and anticoagulant effect. Here are some examples:

      Carbamazepine is a medication used to manage trigeminal neuralgia, but it is also a hepatic enzyme inducer. This means that it can accelerate the metabolism of warfarin, leading to a reduced effect and a decreased international normalized ratio (INR).

      Alcohol consumption can enhance the effects of warfarin, which can increase the risk of bleeding. Therefore, patients on warfarin should avoid heavy drinking or binge drinking.

      Clarithromycin is an antibiotic that may be prescribed for a COPD exacerbation. However, it is associated with reduced warfarin metabolism and enhanced anticoagulant effect, which can lead to a raised INR.

      Prednisolone is a steroid medication that may also be prescribed for a COPD exacerbation. It is associated with an enhanced anticoagulant effect, which can increase the risk of bleeding when taken with warfarin.

      Sertraline is an antidepressant medication that belongs to the selective serotonin reuptake inhibitor (SSRI) class. SSRIs have an antiplatelet effect, which can also increase the risk of bleeding when taken with warfarin.

      In summary, understanding the interactions between warfarin and other medications or substances is crucial for managing its anticoagulant effect and preventing adverse events. Patients on warfarin should always inform their healthcare providers of any new medications or supplements they are taking to avoid potential interactions.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 10 - A 40-year-old man has a mid-diastolic murmur best heard at the apex. There...

    Incorrect

    • A 40-year-old man has a mid-diastolic murmur best heard at the apex. There is no previous history of any abnormal cardiac findings.
      Select from the list the single most likely explanation of this murmur.

      Your Answer:

      Correct Answer: Physiological

      Explanation:

      Systolic Murmurs in Pregnancy: Causes and Characteristics

      During pregnancy, the increased blood volume and flow through the heart can result in the appearance of innocent murmurs. In fact, a study found that 93.2% of healthy pregnant women had a systolic murmur at some point during pregnancy. These murmurs are typically systolic, may have a diastolic component, and can occur at any stage of pregnancy. They are often located at the second left intercostal space or along the left sternal border, but can radiate widely. If there is any doubt, referral for cardiological assessment is recommended.

      Aortic stenosis produces a specific type of systolic murmur that begins shortly after the first heart sound and ends just before the second heart sound. It is best heard in the second right intercostal space. Mitral murmurs, on the other hand, are best heard at the apex and can radiate to the axilla. Mitral incompetence produces a pansystolic murmur of even intensity throughout systole, while mitral valve prolapse produces a mid-systolic click. A ventricular septal defect produces a harsh systolic murmur that is best heard along the left sternal edge.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 11 - Mrs. Lee attends for her annual medication review. She is on tamsulosin and...

    Incorrect

    • Mrs. Lee attends for her annual medication review. She is on tamsulosin and finasteride for benign prostatic hypertrophy, and paracetamol with topical ibuprofen for osteoarthritis. She says that she was offered treatment for her high cholesterol level at her previous medication review which she declined, but she has decided she would like to start one now after doing some reading about it. It had been offered for primary prevention as her estimated 10-year cardiovascular risk was 22%.

      Her blood results are as below.
      eGFR 62 mmol/L (>90 mmol/L)
      Total Cholesterol 6.6 mmol/L (3.1 - 5.0)
      Bilirubin 10 µmol/L (3 - 17)
      ALP 42 u/L (30 - 100)
      ALT 32 u/L (3 - 40)
      γGT 55 u/L (8 - 60)
      Albumin 45 g/L (35 - 50)

      What medication should be prescribed for Mrs. Lee?

      Your Answer:

      Correct Answer: Atorvastatin 20 mg

      Explanation:

      For primary prevention of cardiovascular disease, the recommended treatment is atorvastatin 20 mg, while for secondary prevention, atorvastatin 80 mg is recommended. Simvastatin used to be the first-line option, but atorvastatin is now preferred due to its higher intensity and lower risk of myopathy at high doses. Before starting statin treatment, it is important to check liver function tests, which in this case were normal. According to the BNF, atorvastatin 20 mg is appropriate for patients with chronic kidney disease. It is not recommended to use ezetimibe or fenofibrate as first-line options for managing cholesterol.

      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.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 12 - A national screening programme exists in the UK for abdominal aortic aneurysms.
    Select the...

    Incorrect

    • A national screening programme exists in the UK for abdominal aortic aneurysms.
      Select the single correct statement regarding this process.

      Your Answer:

      Correct Answer: Screening all men at 65 is estimated to reduce the rate of premature death from ruptured aortic aneurysm by 50%

      Explanation:

      National Screening Programme for Aortic Aneurysm in Men at 65

      The National Screening Programme aims to reduce the rate of premature death from ruptured aortic aneurysm by 50% by screening all men in their 65th year. The prevalence of significant aneurysm in this age group is 4%. Screening will be done through ultrasound, and those without significant aneurysms will be discharged. For those with aneurysms greater than 5.5 cm in diameter, surgery will be offered to 0.5% of men. Those with small aneurysms will enter a follow-up programme. However, the mortality from elective surgery is 5-7%.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 13 - A 56-year-old man is admitted with ST elevation myocardial infarction and treated with...

    Incorrect

    • A 56-year-old man is admitted with ST elevation myocardial infarction and treated with thrombolysis but no angioplasty. What guidance should he receive regarding driving?

      Your Answer:

      Correct Answer: Cannot drive for 4 weeks

      Explanation:

      DVLA guidance following a heart attack – refrain from driving for a period of 4 weeks.

      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, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

      Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

      Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 14 - A 48-year-old man presents to your clinic with concerns about his risk of...

    Incorrect

    • A 48-year-old man presents to your clinic with concerns about his risk of coronary heart disease after a friend recently suffered a heart attack. He has a history of anxiety but is not currently taking any medication. However, he is a heavy smoker, consuming around 20 cigarettes a day. On examination, his cardiovascular system appears normal, with a BMI of 26 kg/m² and blood pressure of 126/82 mmHg.

      Given his smoking habit, you strongly advise him to quit smoking. What would be the most appropriate next step in managing his risk of coronary heart disease?

      Your Answer:

      Correct Answer: Arrange a lipid profile then calculate his QRISK2 score

      Explanation:

      Given his background, he is a suitable candidate for a formal evaluation of his risk for cardiovascular disease through a lipid profile, which can provide additional information to enhance the QRISK2 score.

      Management of Hyperlipidaemia: NICE Guidelines

      Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 15 - Which drug from the list provides the LEAST mortality benefit in chronic heart...

    Incorrect

    • Which drug from the list provides the LEAST mortality benefit in chronic heart failure?

      Your Answer:

      Correct Answer: Digoxin

      Explanation:

      The Role of Digoxin in Congestive Heart Failure Treatment

      Digoxin, a medication commonly used in the past for congestive heart failure, has lost its popularity due to the lack of demonstrated mortality benefit in patients with this condition. However, it has shown a reduction in hospitalizations for congestive heart failure. Therefore, it is recommended to maximize the use of other therapies such as ACE inhibitors, β blockers, and spironolactone before considering digoxin. If the ACE inhibitor cannot be tolerated, an angiotensin II receptor antagonist like candesartan can be used as an alternative. Digoxin should only be considered as a third-line treatment for severe heart failure due to left ventricular systolic dysfunction after first- and second-line treatments have been exhausted.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 16 - A 68-year-old man with lung cancer is diagnosed with deep vein thrombosis. He...

    Incorrect

    • A 68-year-old man with lung cancer is diagnosed with deep vein thrombosis. He is seen in the hospital clinic and prescribed a direct oral anticoagulant (DOAC). What would be the best course of treatment?

      Your Answer:

      Correct Answer: Continue on the DOAC for 3-6 months

      Explanation:

      In 2020, NICE revised their guidance to suggest the use of DOACs for individuals with active cancer who have VTE. Prior to this, low molecular weight heparin was the recommended treatment.

      Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.

      If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).

      The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.

      All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 17 - A 65-year-old gentleman, with stable schizophrenia and a penicillin allergy, had a routine...

    Incorrect

    • A 65-year-old gentleman, with stable schizophrenia and a penicillin allergy, had a routine ECG which showed a QTc interval of 420 ms. He takes oral quetiapine regularly. He was started on a course of clarithromycin for a recently suspected tonsillitis and has now recovered. He reported no new symptoms and was otherwise well. Blood tests including electrolytes were normal.

      Which is the SINGLE MOST appropriate NEXT management step?

      Your Answer:

      Correct Answer: Discuss with the on-call psychiatry team for advice

      Explanation:

      Normal QTc Interval in Patient Taking Quetiapine and Clarithromycin

      The normal values for QTc are < 440 ms in men and <470 ms in women. It is important to monitor the QTc interval in patients taking medications such as quetiapine and clarithromycin, which are known to increase the QTc interval. In this scenario, an ECG was performed and the QTc interval was found to be normal. Therefore, no intervention is necessary at this time. It is important to continue monitoring the patient's QTc interval throughout their treatment with these medications. Proper monitoring can help prevent potentially life-threatening arrhythmias.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 75-year-old man with a history of diabetes, hypertension, hypercholesterolaemia and previous myocardial...

    Incorrect

    • A 75-year-old man with a history of diabetes, hypertension, hypercholesterolaemia and previous myocardial infarction presents to his GP with intermittent abdominal pain that he has been experiencing for two months. The pain is dull in nature and radiates to his lower back. During examination, a pulsatile expansile mass is detected in the central abdomen. The patient had undergone an abdominal ultrasound 6 months ago which showed an abdominal aortic diameter of 5.1 cm. The GP repeats the ultrasound and refers the patient to the vascular clinic. The vascular surgeon reviews the patient's ultrasound report which shows no focal pancreatic, liver or gallbladder disease, trace free fluid, a 5.4 cm diameter abdominal aorta, no biliary duct dilation, and normal-sized and mildly echogenic kidneys.

      What aspect of the patient's medical history suggests that surgery may be necessary?

      Your Answer:

      Correct Answer: Abdominal pain

      Explanation:

      If a patient experiences abdominal pain, it is likely that they have a symptomatic AAA which poses a high risk of rupture. In such cases, surgical intervention, specifically endovascular repair (EVAR), is necessary rather than relying on medical treatment or observation. The abdominal aortic diameter must be greater than 5.5cm to be classified as high rupture risk, which is a close call. The presence of trace free fluid is generally considered normal. Conservative measures, such as quitting smoking, should be taken to address cardiovascular risk factors. An AAA’s velocity of growth should be monitored, and a high-risk AAA would only be indicated if there is an increase of more than 1 cm per year. Ultimately, the decision to proceed with elective surgery is a complex one that should be made in consultation with the patient and surgeon.

      Abdominal aortic aneurysm (AAA) is a condition that often develops without any symptoms. However, a ruptured AAA can be fatal, so it is important to screen patients for this condition. Screening involves a single abdominal ultrasound for males aged 65. The results of the screening are interpreted based on the width of the aorta. If the width is less than 3 cm, no further action is needed. If the width is between 3-4.4 cm, the patient should be rescanned every 12 months. If the width is between 4.5-5.4 cm, the patient should be rescanned every 3 months. If the width is 5.5 cm or greater, the patient should be referred to vascular surgery within 2 weeks for probable intervention.

      For patients with a low risk of rupture (asymptomatic, aortic diameter < 5.5cm), abdominal ultrasound surveillance should be conducted on the time-scales outlined above. Additionally, cardiovascular risk factors should be optimized, such as quitting smoking. For patients with a high risk of rupture (symptomatic, aortic diameter >=5.5cm or rapidly enlarging), referral to vascular surgery for probable intervention should occur within 2 weeks. Treatment options include elective endovascular repair (EVAR) or open repair if unsuitable. EVAR involves placing a stent into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. However, a complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 19 - A study investigated the effectiveness of a new statin therapy in preventing ischaemic...

    Incorrect

    • A study investigated the effectiveness of a new statin therapy in preventing ischaemic heart disease in a diabetic population aged 60 and above. Over a five year period, 1000 patients were randomly assigned to receive the new therapy and 1000 were given a placebo. The results showed that there were 150 myocardial infarcts (MI) in the placebo group and 100 in the group treated with the new statin. What is the number needed to treat to prevent one MI in this population?

      Your Answer:

      Correct Answer: 10

      Explanation:

      Understanding the Number Needed to Treat (NNT)

      When evaluating the efficacy of a treatment, it’s important to look beyond statistical significance and consider the practical impact on patients. The Number Needed to Treat (NNT) is a statistical figure that provides valuable information about the effectiveness of a treatment. For example, if 1000 patients are treated with a new statin for five years and 50 MIs are prevented, the NNT to prevent one MI is 20 (1000/50). This means that by treating just 20 patients, one MI can be prevented over a five-year period.

      The NNT can also be used to calculate cost economic data by factoring in the cost of the drug against the costs of treating and rehabilitating a patient with an MI. By understanding the NNT, healthcare professionals can make informed decisions about the most effective and cost-efficient treatments for their patients.

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      • Cardiovascular Health
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  • Question 20 - Which of the following patients is most likely to have their actual risk...

    Incorrect

    • Which of the following patients is most likely to have their actual risk of cardiovascular disease underestimated by QRISK2?

      Your Answer:

      Correct Answer: A 54-year-old man with a history of schizophrenia who takes olanzapine

      Explanation:

      Patients with a serious mental health disorder and those taking antipsychotics may have their cardiovascular disease risk underestimated by QRISK2.

      Management of Hyperlipidaemia: NICE Guidelines

      Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

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      • Cardiovascular Health
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  • Question 21 - A 72-year-old man visits his GP clinic with a history of hypertension. He...

    Incorrect

    • A 72-year-old man visits his GP clinic with a history of hypertension. He reports experiencing progressive dyspnea on exertion and orthopnea for the past few months. Physical examination reveals no abnormalities. Laboratory tests including full blood count, urea and electrolytes, and CRP are within normal limits. Spirometry and chest x-ray results are also normal. The physician suspects heart failure. What is the most suitable follow-up test to conduct?

      Your Answer:

      Correct Answer: B-type natriuretic peptide

      Explanation:

      According to NICE guidelines, the initial test for patients with suspected chronic heart failure should be an NT-proBNP test. This should be done in conjunction with obtaining an ECG, and is recommended for patients who have not previously experienced a myocardial infarction.

      Diagnosis of Chronic Heart Failure

      Chronic heart failure is a serious condition that requires prompt diagnosis and management. In 2018, the National Institute for Health and Care Excellence (NICE) updated its guidelines on the diagnosis and management of chronic heart failure. According to the new guidelines, all patients should undergo an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation, regardless of whether they have previously had a myocardial infarction or not.

      Interpreting the NT-proBNP test is crucial in determining the severity of the condition. If the levels are high, specialist assessment, including transthoracic echocardiography, should be arranged within two weeks. If the levels are raised, specialist assessment, including echocardiogram, should be arranged within six weeks.

      BNP is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels of BNP are associated with a poor prognosis. The table above shows the different levels of BNP and NTproBNP and their corresponding interpretations.

      It is important to note that certain factors can alter the BNP level. For instance, left ventricular hypertrophy, ischaemia, tachycardia, and right ventricular overload can increase BNP levels, while diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists can decrease BNP levels. Therefore, it is crucial to consider these factors when interpreting the NT-proBNP test.

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      • Cardiovascular Health
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  • Question 22 - During a late-night shift at an urgent care centre, you encounter a 30-year-old...

    Incorrect

    • During a late-night shift at an urgent care centre, you encounter a 30-year-old woman who complains of experiencing pain and swelling in her right leg for the past three days. She denies having chest pain or difficulty breathing and is currently taking the combined oral contraceptive pill.

      Upon examination, you notice that her right leg is swollen and tender to the touch. Her heart rate and pulse oximetry are both normal. After calculating a Wells deep vein thrombosis (DVT) score of 2, you advise her to visit her GP surgery the next morning for urgent blood tests, including a d-dimer, and to be monitored by the duty GP at her practice. You also instruct her to stop taking her contraceptive pill in the meantime.

      What would be the most appropriate course of action to take in this situation?

      Your Answer:

      Correct Answer: Prescribe apixaban

      Explanation:

      If there is suspicion of a DVT and it is not possible to obtain a D-dimer or scan result within four hours, NICE recommends initiating anticoagulation treatment with a DOAC such as apixaban. Low molecular weight heparin is no longer the preferred option. Clopidogrel is not effective in treating DVT. Warfarin, which was previously used, has been largely replaced by DOACs, but may still be used in some cases with low molecular weight heparin until the INR is within target range.

      Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.

      If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).

      The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.

      All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was

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      • Cardiovascular Health
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  • Question 23 - You are contemplating prescribing sildenafil to a patient who is experiencing erectile dysfunction....

    Incorrect

    • You are contemplating prescribing sildenafil to a patient who is experiencing erectile dysfunction. He suffered a heart attack earlier this year but is not presently taking nitrates or nicorandil. What is the duration of time that NICE suggests we wait after a heart attack before prescribing a phosphodiesterase type 5 inhibitor?

      Your Answer:

      Correct Answer: 6 months

      Explanation:

      Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the secondary prevention of MI. Patients who have had an MI should be offered dual antiplatelet therapy, ACE inhibitors, beta-blockers, and statins. Lifestyle changes such as following a Mediterranean-style diet and engaging in regular exercise are also recommended. Sexual activity may resume after four weeks, and PDE5 inhibitors may be used after six months, but caution should be exercised in patients taking nitrates or nicorandil.

      Dual antiplatelet therapy is now the standard treatment for most patients who have had an acute coronary syndrome. Ticagrelor and prasugrel are now more commonly used as ADP-receptor inhibitors. The NICE Clinical Knowledge Summaries recommend adding ticagrelor to aspirin for medically managed patients and prasugrel or ticagrelor for those who have undergone percutaneous coronary intervention. The second antiplatelet should be stopped after 12 months, but this may be adjusted for patients at high risk of bleeding or further ischaemic events.

      For patients who have had an acute MI and have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist such as eplerenone should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy. Proper management and adherence to these guidelines can significantly reduce the risk of further complications and improve the patient’s quality of life.

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      • Cardiovascular Health
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  • Question 24 - A 65-year-old male on long-term warfarin for atrial fibrillation visits the anticoagulation clinic....

    Incorrect

    • A 65-year-old male on long-term warfarin for atrial fibrillation visits the anticoagulation clinic. Despite maintaining a stable INR for the past 3 years on the same dose of warfarin, his INR is found to be 5.4. What is the most probable cause of this sudden change?

      Your Answer:

      Correct Answer: Cranberry juice

      Explanation:

      St John’s Wort induces the P450 enzyme system, which results in a decrease in the INR instead of an increase.

      Understanding Warfarin: Mechanism of Action, Indications, Monitoring, Factors, and Side-Effects

      Warfarin is an oral anticoagulant that has been widely used for many years to manage venous thromboembolism and reduce stroke risk in patients with atrial fibrillation. However, it has been largely replaced by direct oral anticoagulants (DOACs) due to their ease of use and lack of need for monitoring. Warfarin works by inhibiting epoxide reductase, which prevents the reduction of vitamin K to its active hydroquinone form. This, in turn, affects the carboxylation of clotting factor II, VII, IX, and X, as well as protein C.

      Warfarin is indicated for patients with mechanical heart valves, with the target INR depending on the valve type and location. Mitral valves generally require a higher INR than aortic valves. It is also used as a second-line treatment after DOACs for venous thromboembolism and atrial fibrillation, with target INRs of 2.5 and 3.5 for recurrent cases. Patients taking warfarin are monitored using the INR, which may take several days to achieve a stable level. Loading regimens and computer software are often used to adjust the dose.

      Factors that may potentiate warfarin include liver disease, P450 enzyme inhibitors, cranberry juice, drugs that displace warfarin from plasma albumin, and NSAIDs that inhibit platelet function. Warfarin may cause side-effects such as haemorrhage, teratogenic effects, skin necrosis, temporary procoagulant state, thrombosis, and purple toes.

      In summary, understanding the mechanism of action, indications, monitoring, factors, and side-effects of warfarin is crucial for its safe and effective use in patients. While it has been largely replaced by DOACs, warfarin remains an important treatment option for certain patients.

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      • Cardiovascular Health
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  • Question 25 - A 72-year-old woman is being seen for a routine medical check-up at her...

    Incorrect

    • A 72-year-old woman is being seen for a routine medical check-up at her new GP practice. During the examination, her blood pressure is found to be 146/94 mmHg, which is confirmed on a second reading. According to the latest NICE recommendations, what would be the most suitable course of action?

      Your Answer:

      Correct Answer: Arrange ambulatory blood pressure monitoring

      Explanation:

      NICE guidelines from 2011 acknowledge the issue of overtreatment of ‘white coat’ hypertension and recommend the use of ambulatory blood pressure monitoring (ABPM) to address this problem. ABPM is also considered a more reliable predictor of cardiovascular risk compared to clinic blood pressure readings, based on strong evidence.

      NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is 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 provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

      To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

      If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

      ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

      Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

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      • Cardiovascular Health
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  • Question 26 - You review a 54-year-old man who has recently been discharged from the hospital...

    Incorrect

    • You review a 54-year-old man who has recently been discharged from the hospital after receiving thrombolysis for an acute inferior myocardial infarction (MI). He was relatively well post-infarct, and he is here to review his post- discharge medication.

      Other past medical history of note includes type 2 diabetes. Current treatment includes metformin 1g BD, aspirin 75 mg, atorvastatin 10 mg daily and ramipril 10 mg. On examination his BP is 155/92 mmHg, pulse is 75 and regular. His BMI is 29 kg/m2. There are bibasal crackles on auscultation of the chest.

      Investigations reveal:

      Hb 125 g/dL (135-180)

      WCC 5.2 ×109/L (4-10)

      PLT 231 ×109/L (150-400)

      Na 139 mmol/L (134-143)

      K 4.5 mmol/L (3.5-5.0)

      Cr 145 µmol/L (60-120)

      HbA1c 55 mmol/mol (20-46)

      7.2% (<5.5)

      Which of the following is true with respect to the management of his post-MI medication?

      Your Answer:

      Correct Answer: A thiazide diuretic is the most appropriate option for controlling his BP

      Explanation:

      Treatment Recommendations for Patients with Acute MI

      All patients who have experienced an acute MI should be offered a combination of medications, including an ACE inhibitor, beta blocker, aspirin, and statin. Calcium channel antagonists are not typically recommended unless a beta blocker is not tolerated.

      While the DIGAMI study initially suggested that transitioning to insulin therapy may be beneficial for patients with type 2 diabetes, subsequent research has shown a trend towards increased mortality with this treatment. Therefore, it is not routinely recommended.

      Thiazide and nicorandil have not shown convincing post-MI outcome data and may worsen insulin resistance. On the other hand, bisoprolol, a selective beta blocker, has demonstrated positive outcomes in patients with heart failure and hypertension, making it a sensible addition to post-MI therapy.

      In summary, a combination of ACE inhibitor, beta blocker, aspirin, and statin is recommended for all patients with acute MI, with caution advised when considering insulin therapy and thiazide or nicorandil use. Bisoprolol may be a beneficial addition for those with hypertension.

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      • Cardiovascular Health
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  • Question 27 - A 55-year-old man presents to his General Practitioner to discuss the uptitration of...

    Incorrect

    • 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:

      Correct 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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  • Question 28 - What additional action is mentioned in the latest NICE guidance for monitoring blood...

    Incorrect

    • What additional action is mentioned in the latest NICE guidance for monitoring blood pressure in diabetic patients compared to non-diabetic patients?

      Your Answer:

      Correct Answer: Measure BP standing and sitting

      Explanation:

      Monitoring Treatment for Hypertension

      When monitoring treatment for hypertension, it is recommended by NICE to use clinic blood pressure (BP) measurements. However, for patients with type 2 diabetes, symptoms of postural hypotension, or those aged 80 and over, both standing and sitting BP should be measured. Patients who wish to self-monitor their BP should use home blood pressure monitoring (HBPM) and receive proper training and advice. Additionally, for patients with white-coat effect or masked hypertension, ambulatory blood pressure monitoring (ABPM) or HBPM can be considered in addition to clinic BP measurements.

      It is important to note that for adults with type 2 diabetes who have not been previously diagnosed with hypertension or renal disease, BP should be measured at least annually. By following these guidelines, healthcare professionals can effectively monitor and manage hypertension in their patients.

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  • Question 29 - A 48-year-old Caucasian female presents with tiredness to her general practitioner. She has...

    Incorrect

    • A 48-year-old Caucasian female presents with tiredness to her general practitioner. She has gained a little weight of late and during the last year has become increasingly tired. She has a history of asthma for which she takes inhaled salbutamol on an as required basis (usually no more than once a week) and diet-controlled type 2 diabetes.

      Examination reveals a blood pressure of 172/98 mmHg, a body mass index of 29.7 kg/m2, and a pulse of 88 beats per minute. There are no other abnormalities of note. Her blood pressure recordings over the next month are 180/96, 176/90 and 178/100 mmHg.

      Which of the following drugs would you recommend for the treatment of this patient's blood pressure?

      Your Answer:

      Correct Answer: Atenolol

      Explanation:

      Hypertension Treatment in Type 2 Diabetes Patients

      This patient with type 2 diabetes has sustained hypertension and requires treatment. The first-line treatment for hypertension in diabetes is ACE inhibitors. These medications have no adverse effects on glucose tolerance or lipid profiles and can delay the progression of microalbuminuria to nephropathy. Additionally, ACE inhibitors reduce morbidity and mortality in patients with vascular disease and diabetes.

      However, bendroflumethiazide may provoke an attack of gout in patients with a history of gout. Beta-blockers should be avoided for the routine treatment of uncomplicated hypertension in patients with diabetes. They can also precipitate bronchospasm and should be avoided in patients with asthma. In situations where there is no suitable alternative, a cardioselective beta blocker should be selected and initiated at a low dose by a specialist. The patient should be monitored closely for adverse effects.

      Alpha-blockers, such as doxazosin, are reserved for the treatment of resistant hypertension in conjunction with other antihypertensives. It is important to consider the patient’s medical history and individual needs when selecting a treatment plan for hypertension in type 2 diabetes patients.

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  • Question 30 - Mary comes to see you for a medication review. She is a 65-year-old...

    Incorrect

    • Mary comes to see you for a medication review. She is a 65-year-old woman, with a past medical history of chronic kidney disease stage 3, hypertension and gout. Her current medication are amlodipine 10 mg daily and allopurinol 100 mg daily. Her blood pressure today is 151/93 mmHg. A recent urine dip was normal and her blood results are shown in the table below.

      Na+ 137 mmol/L (135 - 145)
      K+ 4.7 mmol/L (3.5 - 5.0)
      Bicarbonate 27 mmol/L (22 - 29)
      Urea 5.6 mmol/L (2.0 - 7.0)
      Creatinine 130 µmol/L (55 - 120)
      eGFR 55 ml/min/1.73m2 (>90)

      What changes should you make to her medications?

      Your Answer:

      Correct Answer: Continue current medications, add ramipril

      Explanation:

      This patient is experiencing poorly controlled hypertension, despite being on the maximum dose of a calcium channel blocker. Additionally, he has established renal disease and his clinic blood pressure readings consistently exceed 140/90. To address this, it is recommended to add either an ACE inhibitor, an angiotensin 2 receptor blocker, or a thiazide-like diuretic to his current medication regimen. Simply relying on lifestyle modifications will not be sufficient to bring his blood pressure under control. Therefore, combination therapy with amlodipine should be continued.

      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 calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

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      • Cardiovascular Health
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular Health (1/3) 33%
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