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Question 1
Incorrect
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You assess a patient who has been hospitalized with a non-ST elevation myocardial infarction in the ED. They have been administered aspirin 300 mg stat and glyceryl trinitrate spray (2 puffs). As per the latest NICE recommendations, which patients should be given ticagrelor?
Your Answer: Patients who have a history of hypertension, ischaemic heart disease or diabetes mellitus
Correct Answer: All patients
Explanation: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 oxygen therapy if the patient has low oxygen saturation.
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 or unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool. Based on the risk assessment, decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or conservative management.
This summary provides an overview of the NICE guidelines on the management of ACS. However, it is important to note that emergency departments may have their own protocols based on local factors. The full NICE guidelines should be reviewed for further details.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Incorrect
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What is true about jugular venous pulsation (JVP)?
Your Answer: Pressure is assessed relevant to the sternal notch
Correct Answer: Is paradoxical in constrictive pericarditis
Explanation:Impedance of Ventricular Contraction in Constrictive Pericarditis and Cardiac Tamponade
Both constrictive pericarditis and cardiac tamponade can cause impedance of ventricular contraction, which becomes more severe as the diaphragm descends. This results in an increase in venous pressure during inspiration, known as Kussmaul’s sign.
To assess the jugular venous pressure (JVP), the patient should be lying at a 45-degree angle. Normally, the JVP is not palpable except in severe tricuspid regurgitation, and the pressure is assessed relative to the manubrium sterni. In early left ventricular failure, the JVP may be normal, but as fluid retention increases, the veins become congested, leading to congestive cardiac failure (CCF).
In summary, both constrictive pericarditis and cardiac tamponade can lead to impedance of ventricular contraction and an increase in venous pressure during inspiration, which can be assessed through the JVP. Congestion of the veins can also occur in CCF.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Incorrect
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A 56-year-old man presents to his General Practitioner with a 4-month history of shortness of breath on exertion. Recently, he has also started waking at night with shortness of breath, which is relieved by sitting up in bed. On examination, crepitations are heard on auscultation of both lung bases and mild ankle oedema. There is no significant past medical history.
What is the most appropriate next step according to current National Institute for Health and Care Excellence guidance?Your Answer: Referral for echocardiography
Correct Answer: Test for B-type natriuretic peptide (BNP)
Explanation:Appropriate Investigations and Treatment for Suspected Heart Failure
Suspected cases of heart failure require appropriate investigations and treatment. The recommended first-line investigation is B-type natriuretic peptide (BNP) testing, which is released into the blood when the myocardium is stressed. If the BNP level is abnormal, the patient should be referred for specialist assessment and echocardiography. Treatment with angiotensin-converting enzyme (ACE) inhibitors is indicated for patients suffering from heart failure with reduced ejection fraction, but this diagnosis should be confirmed before starting treatment. Referral for echocardiography should be guided by the BNP level, and spirometry is not the most appropriate investigation for patients with classical symptoms of congestive cardiac failure. If treatment is necessary, a loop diuretic such as furosemide is usually started.
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This question is part of the following fields:
- Cardiovascular Health
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Question 4
Correct
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A 65-year-old male is being evaluated for hypertension associated with type 2 diabetes.
Currently, he is taking aspirin 75 mg daily, amlodipine 10 mg daily, and atorvastatin 20 mg daily. However, his blood pressure remains consistently around 160/92 mmHg.
What antihypertensive medication would you recommend adding to improve this patient's hypertension?Your Answer: Ramipril
Explanation:Hypertension Management in Type 2 Diabetes
This patient with type 2 diabetes has poorly controlled hypertension, but is currently tolerating his medication well. The recommended antihypertensive for diabetes is an ACE inhibitor, which can be combined with a calcium channel blocker like amlodipine. Beta-blockers should be avoided for routine hypertension treatment in diabetic patients. Methyldopa is used for hypertension during pregnancy, while moxonidine is used when other medications have failed. If blood pressure control is still inadequate, a thiazide diuretic can be added to the current regimen of ramipril and amlodipine. Proper management of hypertension is crucial in diabetic patients to prevent complications and improve overall health.
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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 67-year-old lady with mitral valve disease and atrial fibrillation is on warfarin therapy. Recently, her INR levels have decreased, leading to an increase in the warfarin dosage. What new treatments could be responsible for this change?
Your Answer: Clarithromycin
Correct Answer: St John's wort
Explanation:Drug Interactions with Warfarin
Drugs that are metabolized in the liver can induce hepatic microsomal enzymes, which can affect the metabolism of other drugs. In the case of warfarin, an anticoagulant medication, certain drugs can either enhance or reduce its effectiveness.
St. John’s wort is an enzyme inducer and can increase the metabolism of warfarin, making it less effective. On the other hand, allopurinol can interact with warfarin to enhance its anticoagulant effect. Similarly, amiodarone inhibits the metabolism of coumarins, which can lead to an enhanced anticoagulant effect.
Clarithromycin, a drug that inhibits CYP3A isozyme, can enhance the anticoagulant effect of coumarins, including warfarin. This is because warfarin is metabolized by the same CYP3A isozyme as clarithromycin. Finally, sertraline may also interact with warfarin to enhance its anticoagulant effect.
In summary, it is important to be aware of potential drug interactions when taking warfarin, as they can either enhance or reduce its effectiveness. Patients should always inform their healthcare provider of all medications they are taking to avoid any potential adverse effects.
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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 who had a stroke 2 years ago is being evaluated. He was prescribed simvastatin 40 mg for secondary prevention of further cardiovascular disease after his diagnosis. A fasting lipid profile was conducted last week and the results are as follows:
Total cholesterol 5.2 mmol/l
HDL cholesterol 1.1 mmol/l
LDL cholesterol 4.0 mmol/l
Triglyceride 1.6 mmol/l
Based on the latest NICE guidelines, what is the most appropriate course of action?Your Answer:
Correct Answer: Switch to atorvastatin 80 mg on
Explanation:In 2014, the NICE guidelines were updated regarding the use of statins for primary and secondary prevention. Patients with established cardiovascular disease are now recommended to be treated with Atorvastatin 80 mg. If the LDL cholesterol levels remain high, it is suitable to consider switching the patient’s medication.
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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This question is part of the following fields:
- Cardiovascular Health
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Question 7
Incorrect
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A 45-year-old man presents with complaints of dyspnea.
On auscultation, you detect a systolic crescendo-decrescendo murmur that is most audible at the right upper sternal border. The murmur is loudest during expiration and decreases in intensity when the patient stands. The second heart sound is faint. The apex beat is forceful but not displaced.
What is the probable diagnosis?Your Answer:
Correct Answer: Aortic sclerosis
Explanation:Aortic Stenosis: Symptoms and Signs
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to reduced blood flow from the heart to the rest of the body. One of the typical features of aortic stenosis is a systolic crescendo-decrescendo murmur that is loudest at the right upper sternal border. This murmur is usually heard during expiration and becomes softer when the patient stands. Additionally, the second heart sound is typically soft, and the apex beat is thrusting but not displaced.
To summarize, aortic stenosis can be identified by a combination of symptoms and signs, including a specific type of murmur, a soft second heart sound, and a thrusting apex beat.
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This question is part of the following fields:
- Cardiovascular Health
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Question 8
Incorrect
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A 57-year-old caucasian woman is diagnosed with stage 2 hypertension. Baseline investigations do not reveal evidence of end-organ damage. She has a history of atrial fibrillation and takes apixaban. Her ECG is normal. Her QRISK3 score is calculated as 12.4%. She has no known drug allergies. Lifestyle advice is given and appropriate follow-up is scheduled. What is the most effective supplementary treatment choice?
Your Answer:
Correct Answer: Atorvastatin and amlodipine
Explanation:According to NICE guidelines, patients who are aged 55 years or over and do not have type 2 diabetes or are of black African or African-Caribbean family origin and do not have type 2 diabetes (of any age) should be prescribed calcium-channel blockers as the first-line treatment for hypertension. In addition, this patient requires a statin for primary cardiovascular disease prevention.
Amlodipine alone is not sufficient as she requires both an antihypertensive agent and lipid-lowering therapy.
Atorvastatin and indapamide (a thiazide-like diuretic) is not the best option as indapamide is only recommended as a second-line antihypertensive agent if a calcium-channel blocker is contraindicated, not suitable or not tolerated.
Atorvastatin and ramipril is also not the best option as ACE inhibitors (or angiotensin-II receptor antagonists) are first-line for patients under the age of 55 and not of black African or African-Caribbean family origin, or those with type 2 diabetes (irrespective of age or family origin).
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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This question is part of the following fields:
- Cardiovascular Health
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Question 9
Incorrect
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A 53-year-old female visits her GP after experiencing a brief episode of right-sided weakness lasting 10-15 minutes. During examination, the GP discovers that the patient has atrial fibrillation. If the patient continues to have chronic atrial fibrillation, what is the most appropriate type of anticoagulation to use?
Your Answer:
Correct Answer: Direct oral anticoagulant
Explanation:When it comes to reducing the risk of stroke in patients with AF, DOACs should be the first option. In the case of this patient, her CHA2DS2-VASc score is 3, with 2 points for the transient ischaemic attack and 1 point for being female. Therefore, it is recommended that she be given anticoagulation treatment with DOACs, which are now preferred over warfarin.
Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.
When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.
For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where 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 Health
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Question 10
Incorrect
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A 68-year-old woman with a history of atrial fibrillation presents for a follow-up appointment. She recently experienced a transient ischemic attack and is currently taking bendroflumethiazide for hypertension. Her blood pressure at the appointment is 130/80 mmHg. As you discuss management options to decrease her risk of future strokes, what is her CHA2DS2-VASc score?
Your Answer:
Correct Answer: 4
Explanation:Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.
When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.
For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where 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 Health
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Question 11
Incorrect
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A 35-year-old woman with familial hypercholesterolaemia presents for a check-up. She is considering starting a family and seeks guidance on medication, as she is currently taking 80 mg of atorvastatin. What would be the most suitable recommendation?
Your Answer:
Correct Answer: Stop atorvastatin before trying to conceive
Explanation:To avoid the possibility of congenital defects, it is recommended that women discontinue the use of statins at least 3 months prior to conception.
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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 12
Incorrect
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A 75-year-old man is found to be in atrial fibrillation during a routine check-up. He reports having noticed some irregularity in his pulse for a few weeks. What is the appropriate management for him?
Your Answer:
Correct Answer: ß-blockers are recommended as first-line treatment
Explanation:Rate Control vs Rhythm Control in Atrial Fibrillation: Recent Trials and Treatment Guidelines
Recent trials have confirmed that for most patients with atrial fibrillation, rate control is superior to rhythm control in terms of survival benefit. However, DC cardioversion may be considered for new onset and younger patients. The National Institute for Health and Care Excellence (NICE) guidelines recommend first-line therapy with ß-blockers or rate-limiting calcium antagonists, or digoxin if these are not tolerated. Verapamil should not be used in combination with a ß-blocker. These guidelines provide a framework for the management of atrial fibrillation and can help clinicians make informed treatment decisions.
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This question is part of the following fields:
- Cardiovascular Health
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Question 13
Incorrect
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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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 14
Incorrect
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A 72-year-old woman is on ramipril, digoxin, metformin, quinine and bisoprolol. She has been experiencing mild ankle swelling lately. Following an echo, she has been urgently referred to cardiology due to moderate-severe aortic stenosis. Which of her medications should be discontinued?
Your Answer:
Correct Answer: Ramipril
Explanation:Moderate to severe aortic stenosis is a contraindication for ACE inhibitors like ramipril due to the potential risk of reducing coronary perfusion pressure and causing cardiac ischemia. Therefore, the patient should stop taking ramipril until cardiology review. However, bisoprolol, which reduces cardiac workload by inhibiting β1-adrenergic receptors, is safe to use in the presence of aortic stenosis. Digoxin, which improves cardiac contractility, is also safe to use unless there are defects in the cardiac conduction system. Metformin should be used with caution in patients with chronic heart failure but is not contraindicated in those with valvular disease. Quinine is also safe to use in the presence of aortic stenosis but should be stopped if there are defects in the cardiac conduction system.
Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.
While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.
Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.
The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.
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This question is part of the following fields:
- Cardiovascular Health
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Question 15
Incorrect
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A 72-year-old man presents with intermittent bilateral calf pain that occurs when walking. He has a medical history of type II diabetes mellitus, hypertension, and a past myocardial infarction (MI). What additional feature, commonly seen in patients with intermittent claudication, would be present in this case?
Your Answer:
Correct Answer: Pain disappears within ten minutes of stopping exercise
Explanation:Understanding Intermittent Claudication: Symptoms and Characteristics
Intermittent claudication is a condition that affects the lower limbs and is caused by arterial disease. Here are some key characteristics and symptoms to help you understand this condition:
– Pain disappears within ten minutes of stopping exercise: The muscle pain in the lower limbs that develops as a result of exercise due to lower-extremity arterial disease is quickly relieved at rest, usually within ten minutes.
– Pain eases walking uphill: Typically, pain develops more rapidly when walking uphill than on the flat.
– Occurs similarly in both legs: Claudication can occur in both legs but is often worse in one leg.
– Pain in the buttock: In intermittent claudication, the pain is typically felt in the calf. A diagnosis of atypical claudication could be made if a patient indicates pain in the thigh or buttock, in the absence of any calf pain.
– Pain starts when standing still: Intermittent claudication is classically described as pain that starts during exertion and which is relieved on rest.
Understanding these symptoms and characteristics can help individuals recognize and seek treatment for intermittent claudication.
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This question is part of the following fields:
- Cardiovascular Health
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Question 16
Incorrect
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A 35-year-old construction worker presents with symptoms of dizziness, blurred vision and difficulty walking after a long day at a construction site. During examination, there is a significant difference in blood pressure between his right and left arms.
Select from the list the most appropriate diagnosis for this clinical presentation.Your Answer:
Correct Answer: Subclavian steal syndrome
Explanation:Understanding Subclavian Steal Syndrome: Symptoms and Causes
Subclavian steal syndrome is a condition that occurs when there is a blockage or narrowing of the subclavian artery, which leads to a reversal of blood flow in the vertebral artery on the same side. While some patients may not experience any symptoms, others may suffer from compromised blood flow to the vertebrobasilar and brachial regions, resulting in paroxysmal vertigo, syncope, and arm claudication during exercise. In addition, blood pressure in the affected arm may drop significantly. Based on the patient’s occupation and the marked decrease in arm blood pressure, subclavian steal syndrome is the most likely diagnosis.
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This question is part of the following fields:
- Cardiovascular Health
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Question 17
Incorrect
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An 80-year-old woman is brought to the clinic by her family members. She has been experiencing increasing shortness of breath and low energy levels for the past 6 weeks. Upon conducting an ECG, it is revealed that she has atrial fibrillation with a heart rate of 114 / min. Her blood pressure is 128/80 mmHg and a chest x-ray shows no abnormalities. What medication should be prescribed to manage her heart rate?
Your Answer:
Correct Answer: Bisoprolol
Explanation:When it comes to rate control in atrial fibrillation, beta blockers are now the preferred option over digoxin. This is an important point to remember, especially for exams. The patient’s shortness of breath may be related to her heart rate and not necessarily a sign of heart failure, as her chest x-ray was normal. For more information, refer to the NICE guidelines.
Atrial fibrillation (AF) is a heart condition that requires prompt management. The management of AF depends on the patient’s haemodynamic stability and the duration of the AF. For haemodynamically unstable patients, electrical cardioversion is recommended. For haemodynamically stable patients, rate control is the first-line treatment strategy, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin are commonly used to control the heart rate. Rhythm control is another treatment option that involves the use of medications such as beta-blockers, dronedarone, and amiodarone. Catheter ablation is recommended for patients who have not responded to or wish to avoid antiarrhythmic medication. The procedure involves the use of radiofrequency or cryotherapy to ablate the faulty electrical pathways that cause AF. Anticoagulation is necessary before and during the procedure to reduce the risk of stroke. The success rate of catheter ablation varies, with around 50% of patients experiencing an early recurrence of AF within three months. However, after three years, around 55% of patients who have undergone a single procedure remain in sinus rhythm.
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This question is part of the following fields:
- Cardiovascular Health
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Question 18
Incorrect
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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.
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This question is part of the following fields:
- Cardiovascular Health
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Question 19
Incorrect
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A worried mother brings her two-week-old baby to the clinic due to poor feeding. The baby was born at 37 weeks gestation without any complications. No central cyanosis is observed, but the baby has a slightly elevated heart rate, rapid breathing, and high blood pressure in the upper extremities. Oxygen saturation levels are at 99% on air. Upon chest auscultation, a systolic murmur is heard loudest at the left sternal edge. Additionally, the baby has weak bilateral femoral pulses. What is the most probable underlying diagnosis?
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:Coarctation of the Aorta: A Narrowing of the Descending Aorta
Coarctation of the aorta is a congenital condition that affects the descending aorta, causing it to narrow. This condition is more common in males, despite its association with Turner’s syndrome. In infancy, coarctation of the aorta can lead to heart failure, while in adults, it can cause hypertension. Other features of this condition include radio-femoral delay, a mid systolic murmur that is maximal over the back, and an apical click from the aortic valve. Notching of the inferior border of the ribs, which is caused by collateral vessels, is not seen in young children. Coarctation of the aorta is often associated with other conditions, such as bicuspid aortic valve, berry aneurysms, and neurofibromatosis.
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This question is part of the following fields:
- Cardiovascular Health
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Question 20
Incorrect
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A 65-year-old lady presents with a brief history of sudden onset severe left lower limb pain lasting for three hours. The pain started while she was at rest and there was no history of injury or any previous leg or calf pain.
Upon examination, her pulse rate is irregular and measures 92 bpm. The left lower limb is cold and immobile with decreased sensation. No pulses can be felt from the level of the femoral pulse downwards in the left leg, but all pulses are palpable on the right. There are no abdominal masses or bruits, and chest auscultation is normal.
What is the probable diagnosis?Your Answer:
Correct Answer: Sciatica
Explanation:Acute Limb Ischaemia: Causes and Symptoms
Acute limb ischaemia is a condition characterized by a painful, paralysed, and pulseless limb that feels perishingly cold with paraesthesia. This condition is usually caused by either an embolus or thrombotic occlusion, which can occur on the background of intermittent claudication (chronic limb ischaemia). In most cases, the likely cause of acute limb ischaemia is an embolism secondary to atrial fibrillation. Other sources of emboli include defective heart valves, cardiac mural thrombi, and thrombus from within an aortic aneurysm.
If a patient presents with a painful, paralysed, and pulseless limb, an echocardiogram, abdominal ultrasound, and duplex of proximal limb vessels are indicated. These tests can help identify the underlying cause of the condition. It is important to note that acute limb ischaemia is a medical emergency that requires immediate attention. Delayed treatment can lead to irreversible tissue damage and even limb loss.
In summary, acute limb ischaemia is a serious condition that requires prompt diagnosis and treatment. Patients with this condition should seek medical attention immediately to prevent irreversible tissue damage and limb loss.
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This question is part of the following fields:
- Cardiovascular Health
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Question 21
Incorrect
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A patient who is 65 years old calls you from overseas. He was recently discharged from a hospital in Spain after experiencing a heart attack. The hospital did not report any complications and he did not undergo a percutaneous coronary intervention. What is the minimum amount of time he should wait before flying back home?
Your Answer:
Correct Answer: After 7-10 days
Explanation:After a period of 7-10 days, the individual’s fitness to fly will be assessed.
The CAA has issued guidelines on air travel for people with medical conditions. Patients with certain cardiovascular diseases, uncomplicated myocardial infarction, coronary artery bypass graft, and percutaneous coronary intervention may fly after a certain period of time. Patients with respiratory diseases should be clinically improved with no residual infection before flying. Pregnant women may not be allowed to travel after a certain number of weeks and may require a certificate confirming the pregnancy is progressing normally. Patients who have had surgery should avoid flying for a certain period of time depending on the type of surgery. Patients with haematological disorders may travel without problems if their haemoglobin is greater than 8 g/dl and there are no coexisting conditions.
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This question is part of the following fields:
- Cardiovascular Health
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Question 22
Incorrect
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An 80-year-old man comes to the clinic complaining of occasional palpitations without any accompanying chest pain, shortness of breath, or lightheadedness. He has no notable medical history and is not taking any medications at present. Physical examination and vital signs are normal except for an irregular heartbeat, which is later diagnosed as atrial fibrillation. What is the suggested preventive therapy for a stroke?
Your Answer:
Correct Answer: Consider an anticoagulant
Explanation:Anticoagulation must be taken into account for individuals with a CHA2DS2-VASC score of 1 or higher if they are male, and a score of 2 or higher if they are female. In this case, the gentleman’s CHA2DS2-VASC score is 1, indicating that he should be considered for anticoagulation after assessing his HAS-BLED score. It is important to note that if his HAS-BLED score is 3 or higher, alternative options to anticoagulation should be considered. Beta-blockers, aspirin, and clopidogrel are not recommended for primary prevention against cerebrovascular accidents. It is incorrect to assume that no treatment is necessary, as the CHA2DS2-VASC score indicates a need for consideration of anticoagulation.
Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.
When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.
For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where 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 Health
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Question 23
Incorrect
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A 62-year-old man has recently started taking a new medication for his hypertension. He has noticed swelling in his ankles and wonders if it could be a side effect of the medication. Which drug is most likely responsible for his symptoms?
Your Answer:
Correct Answer: Amlodipine
Explanation:Understanding Amlodipine: A Calcium-Channel Blocker and its Side-Effects
Amlodipine is a medication that belongs to the class of calcium-channel blockers. It works by inhibiting the inward displacement of calcium ions through the slow channels of active cell membranes. The primary effect of amlodipine is to relax vascular smooth muscle and dilate peripheral and coronary arteries. However, this medication is also associated with some side-effects due to its vasodilatory properties.
Common side-effects of amlodipine include flushing and headache, which usually subside after a few days. Another common side-effect is ankle swelling, which only partially responds to diuretics. In some cases, ankle swelling may be severe enough to warrant discontinuation of the drug. On the other hand, oedema is uncommon with losartan and not reported for any of the other options.
If you experience oedema due to calcium-channel blockers, it is important to manage it properly. Please refer to the external links for more information on how to manage this side-effect.
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This question is part of the following fields:
- Cardiovascular Health
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Question 24
Incorrect
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A 72-year-old man presents as he has suffered two episodes of syncope in the past three weeks and is feeling increasingly tired. On examination, his pulse is 40 bpm and his BP 100/60 mmHg. An ECG reveals he is in complete heart block.
What other finding are you most likely to find?Your Answer:
Correct Answer: Variable S1
Explanation:Characteristics of Complete Heart Block
Complete heart block is a condition where there is no coordination between the atrial and ventricular contractions. This results in a variable intensity of the first heart sound, which is the closure of the atrioventricular (AV) valves. The blood flow from the atria to the ventricles varies from beat to beat, leading to inconsistent intensity of the first heart sound. Additionally, cannon A waves may be observed in the neck, indicating atrial contraction against closed AV valves.
Narrow pulse pressure is not a characteristic of complete heart block. It is more commonly associated with aortic valve disease. Similarly, aortic stenosis is not typically linked with complete heart block, although it can cause reversed splitting of S2. Giant V waves are not observed in complete heart block, but they suggest tricuspid regurgitation. Reversed splitting of S2 is also not a defining feature of complete heart block, but it can be found in aortic stenosis, hypertrophic cardiomyopathy, and left bundle branch block. It is important to note that murmurs may also be present in complete heart block due to concomitant valve disease.
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This question is part of the following fields:
- Cardiovascular Health
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Question 25
Incorrect
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Which beta blocker has been approved for treating heart failure?
Your Answer:
Correct Answer: Acebutolol
Explanation:Heart Failure Treatment Options
According to the 2010 update by the National Institute for Health and Care Excellence (NICE), there are several medications that are indicated for the treatment of heart failure. These medications include bisoprolol, metoprolol succinate, carvedilol, and nebivolol. These drugs are commonly used to manage heart failure symptoms and improve overall heart function. It is important to consult with a healthcare provider to determine the best treatment plan for each individual case of heart failure. With proper medication management, individuals with heart failure can experience improved quality of life and better outcomes.
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This question is part of the following fields:
- Cardiovascular Health
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Question 26
Incorrect
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You are contemplating prescribing enalapril for a patient with recently diagnosed heart failure. What are the most typical side-effects of angiotensin-converting enzyme inhibitors?
Your Answer:
Correct Answer: Cough + anaphylactoid reactions + hyperkalaemia
Explanation:Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.
While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.
Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.
The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.
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This question is part of the following fields:
- Cardiovascular Health
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Question 27
Incorrect
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A 75-year-old man with a history of type II diabetes mellitus presents with worsening dyspnea. His ECG reveals normal sinus rhythm and an echocardiogram confirms the diagnosis of congestive heart failure with reduced left ventricular ejection fraction. Which of the following medications is most likely to decrease mortality in this patient? Choose ONE answer only.
Your Answer:
Correct Answer: Enalapril
Explanation:Treatment Options for Congestive Heart Failure
Congestive heart failure is a serious condition that requires proper treatment to improve survival rates and alleviate symptoms. One of the recommended treatments is the use of angiotensin-converting enzyme (ACE) inhibitors like Enalapril, which have been shown to reduce left ventricular afterload and prolong survival rates. This is particularly important for patients with diabetes mellitus. Antiplatelets like aspirin are only indicated for those with concurrent atherosclerotic arterial disease. Standard drugs like digoxin have not been proven to improve survival rates compared to ACE inhibitors. Diuretics like furosemide provide relief from symptoms of fluid overload but do not improve survival rates. Antiarrhythmic agents like lidocaine are only useful when there is arrhythmia associated with heart failure. It is important to work with a healthcare provider to determine the best treatment plan for each individual case of congestive heart failure.
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This question is part of the following fields:
- Cardiovascular Health
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Question 28
Incorrect
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A 40-year-old man requests a check-up after the unexpected passing of his 45-year-old brother. He denies experiencing any specific symptoms. His blood pressure is 132/88 and heart rate 90 and regular. His cardiovascular system examination is unremarkable. An ECG reveals left bundle branch block and a chest X-ray shows cardiomegaly.
What is the most probable reason for these abnormalities?Your Answer:
Correct Answer: Dilated cardiomyopathy
Explanation:Understanding Cardiomyopathy: Causes, Symptoms, and Diagnosis
Cardiomyopathy is a chronic disease that affects the heart muscle, causing it to become enlarged, thickened, or stiffened. This condition can range from being asymptomatic to causing heart failure, arrhythmia, thromboembolism, and sudden death. In this article, we will discuss the causes, symptoms, and diagnosis of cardiomyopathy.
Causes of Cardiomyopathy
Cardiomyopathy can be caused by a variety of factors, including coronary heart disease, hypertension, valvular disease, and congenital heart disease. It can also be caused by secondary factors such as ischaemia, alcohol abuse, toxins, infections, thyroid disorders, and valvular disease. In some cases, cardiomyopathy may be familial or genetic.Symptoms of Cardiomyopathy
Most cases of cardiomyopathy present as congestive heart failure with symptoms such as dyspnoea, weakness, fatigue, oedema, raised JVP, pulmonary congestion, cardiomegaly, and a loud 3rd and/or 4th heart sound. However, some cases may remain asymptomatic for a long time.Diagnosis of Cardiomyopathy
Diagnosis of cardiomyopathy usually involves an electrocardiogram (ECG) which may show sinus tachycardia, intraventricular conduction delay, left bundle branch block, or nonspecific changes in ST and T waves. Other diagnostic tests may include echocardiography, cardiac MRI, and cardiac catheterization.Conclusion
Cardiomyopathy is a serious condition that can lead to heart failure, arrhythmia, thromboembolism, and sudden death. It is important to understand the causes, symptoms, and diagnosis of this condition in order to manage it effectively. If you suspect that you or a loved one may have cardiomyopathy, seek medical attention immediately. -
This question is part of the following fields:
- Cardiovascular Health
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Question 29
Incorrect
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You are evaluating a 65-year-old new patient to the clinic who has a history of established cardiovascular disease (CVD), having suffered a myocardial infarction 12 months ago.
Previously, he declined taking a statin due to concerns about potential side effects, but he has since researched the topic and is now open to the idea.
He currently takes aspirin 75 mg daily, ramipril 5 mg once daily, and bisoprolol 2.5 mg once daily. He has no other significant medical history. Recent blood tests indicate normal renal, liver, and thyroid function.
What is the most appropriate course of action for management at this stage?Your Answer:
Correct Answer: Offer ezetimibe 10 mg daily
Explanation:Statin Therapy for Those with Pre-existing CVD
All individuals with a history of established cardiovascular disease (CVD) should be offered statin therapy, according to NICE guidelines. While diet and lifestyle modifications are important, they should not delay or withhold statin therapy.
For those with pre-existing CVD (excluding chronic kidney disease), atorvastatin 80 mg daily is recommended. However, for individuals with chronic kidney disease and an eGFR of less than 60 mL/min/1.73m2, a lower dose of atorvastatin 20 mg daily is advised. Lower doses may also be considered for those at higher risk of side effects or due to individual preference.
It is not necessary to use the QRISK2 risk assessment tool for those with pre-existing CVD, as they are automatically considered at high risk of CVD and should be treated accordingly. Overall, statin therapy is an important component of managing CVD and should be considered for all individuals with a history of the disease.
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This question is part of the following fields:
- Cardiovascular Health
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Question 30
Incorrect
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A 28-year-old man comes to the clinic complaining of pain in both lower legs while running. The pain gradually intensifies after a brief period of running, causing him to stop. However, the pain quickly subsides when he is at rest. Upon examination, there are no abnormal findings, and his peripheral pulses are all palpable. What is the probable diagnosis?
Your Answer:
Correct Answer: Osgood-Schlatter's disease
Explanation:Chronic Exertional Compartment Syndrome
Chronic exertional compartment syndrome (CECS) is a condition that causes exertional leg pain due to the fascial compartment being unable to accommodate the increased volume of the muscle during exercise. It is often mistaken for peripheral arterial disease.
If you experience exertional leg pain with tenderness over the middle of the muscle compartment but no bony tenderness, it may be a sign of CECS. This condition should be suspected when there is no evidence of tibial tuberosity pain, which is common in Osgood-Schlatter’s disease.
Referral for pre- and post-exertional pressure testing may be necessary, and if conservative measures are unsuccessful, a fasciotomy may be required.
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This question is part of the following fields:
- Cardiovascular Health
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